Amal Khoury

Percutaneous Plating of Distal Tibial Fractures

This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12° and average plantiflexion 18°). Two fractures united with mal-union: one with an 8° valgus deformity and another with a 7° varus deformity. Both cases, which had a metaphyseal component, were treated by means of a “soft” (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either “soft” or “rigid” plates, and type A and C fractures with a metaphyseal component should be fixed with “rigid” plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.

First generation computerized fluoroscopic navigation in percutaneous pelvic surgery.

Percutaneous internal fixation of pelvic fractures has gained popularity allowing rapid mobilization with reduced surgical related morbidity; however, this method depends on conventional fluoroscopy, which exposes the patient and the surgeon to a significant amount of radiation. The use of computerized fluoroscopic navigation systems enables the simultaneous use of several radiographic projections. These preliminary fluoroscopic views are taken when the operating team stands at a distance from the radiation source. No further fluoroscopic radiation is used later during the surgical procedure. Computerized fluoroscopic navigation was used in the percutaneous insertion of 45 cannulated screws in 29 patients, including sacroiliac screws, pubic ramus screws, posterior column screws, and a supraacetabular transverse screw. Fluoroscopic verification of screw placement demonstrated a deviation ≤2 mm and ≤5°. We believe the system saves fluoroscopic radiation time, yet improves the precision of the procedure. We believe that the use of this system is adequate for a selected patient population with pelvic fractures amenable to percutaneous screw fixation.

Stem cell-based therapy for prevention of delayed fracture union: a randomized and prospective preliminary study.

Distal tibial fractures tend towards delayed- or nonunion. The purpose of this study was to evaluate the safety and efficacy of early minimally invasive intervention (MII) in the treatment of these fractures. A total 24 consecutive patients who underwent operative treatment for distal tibial fractures were randomized into a control and an intervention group. MII entailed aspirating iliac crest bone marrow and peripheral blood, yielding mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) respectively, that were mixed with demineralized bone matrix (DBM) and injected under fluoroscopic control into the fracture site. No complications occurred in either group. The median time to union was 1.5 months in the MII group and 3 months in the control group. MII was found to be a safe and efficient procedure.

The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions.

Objective: To determine the effectiveness of closed, intramedullary exchange nailing with reamed insertion for the treatment of femoral shaft nonunions previously treated with an intramedullary nail. Design: Retrospective cohort study. Setting: Academic level I trauma center. Patients: Forty-two patients whose femoral shaft fracture was initially managed with an intramedullary nail, were subsequently treated by closed, intramedullary exchange nailing with reamed insertion for their femoral nonunion in our center. Seven patients had an infected nonunion as proved by intraoperative cultures. Intervention: Closed, intramedullary exchange nailing with reamed insertion of a larger diameter nail. Main Outcome Measurements: Radiographic and clinical evidence of fracture healing. Results: Thirty-six patients (86%) had their fracture heal without further intervention. The average time to achieve union was 4 months after surgery. Of the 6 cases of exchange nailing failure, 3 were aseptic and 3 were septic. All these 6 patients healed after additional procedures. Lack of immediate weight bearing, open fractures, atrophic/oligotrophic nonunions, and infection were associated with treatment failure. A second nail larger by 2 mm or more than the original nail was associated with a higher success rate. Conclusions: Closed, intramedullary exchange nailing with reamed insertion for femoral shaft nonunions previously treated with intramedullary nails has proved to be a successful sole procedure in most cases. A nail at least 2 mm larger in diameter than the first nail should be used if possible. Risk factors of treatment failure should alert the surgeon to consider an alternative treatment to closed exchange nailing.

Femoral neck shortening and varus collapse after navigated fixation of intracapsular femoral neck fractures.

Objective: Assessing femoral neck shortening (FNS) and varus collapse after internal fixation of femoral neck fractures using computerized navigation (CN). Design: Retrospective cohort study. Settings: Academic Level I trauma center. Patients and Methods: Forty-one patients who had healed femoral neck fractures treated with CN between the years 2003 and 2008. Average age was 65 years (range, 14–91 years). Thirty-six patients had nondisplaced fractures and five had displaced fractures. Intervention: Screws were placed using CN in an inverted triangle formation Follow-up films were digitized into a PACS system, calibrated, and analyzed using CAD software. Outcome Measures: The following parameters were recorded: abductor lever arm shortening (termed x), corresponding vertical femur shortening (termed y), and the resultant femoral neck shortening vector (z). Fifteen patients were available for clinical outcome measures by the means of SF-12 survey Results: Significant FNS of the x component (greater than 5 mm) occurred in 30 of 42 (71%) patients with severe shortening (greater than 10 mm) in 25% of the patients. Significant y shortening occurred in 43% of the patients and severe shortening in 17%. Overall (z) femoral neck shortening occurred in 56% of the patients with severe shortening in 22% of patients. Varus collapse (greater than 5°) did not occur in any patient. Screw pullout (greater than 5 mm) occurred in 17 (41%) patients. Seven patients required late (greater than 6 months) arthroplasty postoperatively. FNS did not significantly correlate with fracture type, quality of reduction, age, or neck shaft angle. SF-12 results were negatively correlated with overall FNS. Conclusions: Our results show a high degree of FNS associated with the use of CN for fixation of femoral neck fractures, similar to recently published series using nonnavigated implants. However, no varus collapse occurred in our series. Our preliminary clinical data show a trend toward an adverse effect of FNS on quality-of-life measures.

Computerized navigation for length and rotation control in femoral fractures: a preliminary clinical study.

Objective: Operative treatment of femoral fractures yields a predictably high union rate, but residual malrotation and leg length discrepancy remain a clinically significant problem. The aim of this study was to determine the safety and efficacy of using computerized navigation in controlling the length and rotation in femoral fracture surgery. Design: Prospective consecutive case series of 16 skeletally mature patients with femoral fractures undergoing surgical fixation; 14 were fixed with intramedullary nails and 2 with plates. Setting: An Academic Level I trauma center. Intervention: Computerized navigation was used to determine the length and rotation of the operated extremity as compared with the intact healthy contralateral side. Main outcome measure: All patients underwent postoperative computed tomography scanogram for determining the length and rotation. Results: All fractures healed. Mean rotational difference between the treated and nontreated sides was 3.45 degrees (range, 0–7.7 degrees). Mean length difference between the 2 extremities as calculated by the computed tomography scan was 5.83 mm (range, 0–13 mm). Additional operative time required for computerized navigation was measured in 2 of the cases and totaled ∼30–35 min/case. Conclusion: Computerized navigation was accurate and precise at restoring femoral length and rotation during femoral fracture fixation when the intact contralateral femur was used for reference. Further, large-scale randomized studies are required. Additionally, improvements aimed at decreasing operative time and improving user interface of these systems are recommended. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of the levels of evidence.

The use of computerized navigation in the treatment of gunshot and shrapnel injury

Objective: Trauma surgeons encounter numerous penetrating injuries nowadays. In some cases, missiles causing infection, pain and discomfort, or those retained within joints, bursae and other strategic sites, must be removed. This paper describes an innovative high-tech modality for use in the immediate removal of shrapnel and bullets from strategic anatomical sites. Methods: Surgical computerized navigation based on real-time acquisition of fluoroscopic data was employed. Several fluoroscopic images of the required anatomical site were obtained. The accurate spatial location of the foreign object could be seen on the images displayed on the computer screen. No further fluoroscopic radiation was necessary. During surgery, the infra-red camera tracked the position of a surgical probe on the patients anatomy and continuously updated its three-dimensional position simultaneously on all displayed images until the missiles location was reached. Results: The use of percutaneous fluoroscopic navigation to remove retained metal objects, including bullets and shrapnel, has proved itself in 12 cases as an accurate measure involving reduced exposure to radiation. In contrast to CT- or MRI-based navigation, computerized fluoroscopic navigation does not require long preliminary preparation. Thus, it is highly efficient in the treatment of acute trauma victims. Conclusions: The use of this accurate technique in complex and dangerous situations where the foreign body is located in proximity to blood vessels, nerves and narrow ‘safe-zones’, is promising. This innovative technique reduces surgical time and radiation exposure. In our experience, it has rendered percutaneous missile removal much safer, even in hazardous situations.

Thermal tibial osteonecrosis: A diagnostic challenge and review of the literature

Intramedullary nail (IMN) is a common treatment for tibial shaft fractures. It has been shown that reamed intramedullary nails are advantageous over non-reamed nails in reducing the number of non-union and hardware breakdown. However, soft tissue damage as well as bone injury may occur during the reaming process. These include deep infection, patellar tendon injury and damage to intra-articular structures. In addition, reaming has been associated with increase in the core temperature of the tibial shaft. This may lead to alter the endosteal architecture and eventually can result in thermal necrosis. Ultimately, this complication may lead to devastating clinical results such as recalcitrant non-union and hardware failure. Despite our understanding of the mechanism leading to this devastating complication only a few case reports dealing with this entity were described in the literature mainly dealing with combined soft and osseous tissue complication. We present here a case of an isolated thermal osteonecrosis of the tibia.

Outcome of dorsally comminuted versus intact distal radial fracture fixed with volar locking plates

OBJECTIVE Distal radial fractures are common. Modern trends favour operative treatment in many instances, providing stable fixation and early functional recovery. Recent biomechanical evidence suggests that volar locking plates (VLPs) enable adequate stability for dorsally displaced fractures, both in dorsally intact (DI) and in dorsally comminuted (DC) fractures. The aim of the study was to compare the clinical outcome of these two fracture groups treated with a VLP. METHODS Retrospective case-control analysis of 91 distal radial fractures treated surgically using VLP by a single surgeon between the years 2006 and 2008 was carried out. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthes/Orthopaedic Trauma Association (AO/OTA) classification. Based on initial pre-reduction X-rays and computed tomography (CT) scans, fractures were classified into two groups of DI and DC fractures. The patients were re-evaluated at 2 and 6 weeks, 3 and 6 months and 1 year. RESULTS Forty-one fractures (45%) were dorsally comminuted. Patients in the DC group were significantly older (mean 59 vs. 46 years, p<0.01) and included more female patients, as well as significantly more C3 type fractures than the DI group (p<0.04). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year postoperatively was 6.3±2.3 for the DC group, as compared with 6.6±2.02 for the DI group (p=0.64). Average time to return to work was longer in the DC group (81.2 vs. 63.6 days, p=0.05). Range of motion, volar tilt, and radial inclination were within clinically acceptable values and did not differ significantly among the two groups. CONCLUSIONS VLP fixation of DC distal radial fractures results in the maintenance of reduction and comparable functional and radiographical outcome with respect to DI fractures.

Outcome of delayed primary internal fixation of distal radius fractures: a comparative study.

INTRODUCTION AND AIM Operative fixation of distal radius fractures using fixed-angle devices has become increasingly common. Although good to excellent results have been reported in acute fractures, little is currently known regarding the fixation of healing displaced distal radius fractures that were presented late. The aim of this study was to evaluate the results of internal fixation of distal radius fractures presented late (>21 days) as compared with an acute-care control group. METHODS Forty patients operated on for displaced distal radius fractures, presenting more than 21 days after injury (delayed treatment (DT) group), were compared with 75 age-matched controls with acute fracture repair (≤21 days). The same surgical approach was used in both groups, together with dorsal soft-tissue and brachioradialis release. No osteotomy was required. Direct and indirect reduction aids were used. A fixed-angle device (DVR; Biomet Inc., Warsaw, IN, USA) was used in both groups. Mean follow-up was 3.4 years. Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Short Form 12 scores were used to evaluate outcome, as well as radiographic analysis for Arbeitsgemeinschaft für Osteosynthesefragen(AO)/Orthopaedic Trauma Association(OTA) classification, volar tilt, radial inclination and radial length. RESULTS Average age was 53 years in both groups and male to female (M/F) ratio was similar in the study groups. Mean time to surgery was 30 days in the DT group and 8 days in the control group. There were significantly more type C (91.5% vs. 67.5%) fractures in the control group. The average quick DASH score was 27.1 in the DT group as compared with 6.3 in the control group (p<0.03); however, when controlling for two outlier cases with complications (hardware irritation and a sensory neuropathy) there was no significant difference. Volar tilt, radial inclination and length were similar in both groups and were within normal anatomical values. CONCLUSIONS Delayed primary operative fixation of displaced unstable distal radial fractures is a viable option for cases that were presented late, with predictable, favourable results. Neither extensile approaches nor formal osteotomies are required.