Anthony Infante

Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries

Objective To evaluate the results of a vacuum-assisted closure device in patients presenting with open high-energy soft tissue injuries. Design Consecutive nonrandomized clinical study. Setting/Participants From August 1999 through October 2000, 21 patients, with 21 high-energy soft tissue wounds (6 tibial, 10 ankle, and 5 with wounds of the forearm, elbow, femur, pelvis, and a below-knee stump) were treated with a vacuum-assisted closure device at a Level 1 trauma center. Intervention A negative atmospheric pressure device used for the management of complex open injuries. Infected wounds had dressings changed every 48 hours, whereas all others had dressings changed every 72 to 96 hours. Main Outcome Measurements The duration of vacuum-assisted closure use, final wound closure outcome, costs versus standard dressing changes or free flaps, and a list of all complications were recorded. All patients were followed for 6 months postcoverage. Results Patients averaged 4.1 sponge changes, 77% performed at bedside, with the device used an average of 19.3 days. Twelve wounds (57%) required either no further treatment or a split-thickness skin graft, and 9 (43%) required a free tissue transfer. Conclusions The vacuum-assisted closure appears to be a viable adjunct for the treatment of open high-energy injuries. Application can be performed as a bedside procedure but additional soft tissue reconstruction may be needed for definitive coverage. This device does not replace the need for formal debridement of necrotic tissue, but it may avoid the need for a free tissue transfer in some patients with large traumatic wounds.

Open fractures of the calcaneus: soft-tissue injury determines outcome.

BACKGROUND Studies of open calcaneal fractures have been limited and have not analyzed results according to wound location, severity of soft-tissue disruption, fracture type, or treatment method. In this study, results were evaluated on the basis of the hypothesis that early surgical intervention was indicated. METHODS Between 1989 and 1997, 503 calcaneal fractures were treated at our institution, and forty-three of these fractures, in forty-two patients, were open (8.5%). According to the Gustilo classification there were nine type-I, eight type-II, twelve type-IIIA, and thirteen type-IIIB open fractures as well as one type-IIIC open fracture. All fractures were treated according to the same protocol, consisting of intravenous administration of antibiotics chosen on the basis of the wound type, irrigation and débridement in the operating room, temporary wound coverage, and initial stabilization of the limb. Definitive final fixation was performed after the wound was clean, and soft-tissue swelling was minimal. The final follow-up examinations were performed at a minimum of two years after treatment. Clinical results were graded with use of the AOFAS (American Orthopaedic Foot and Ankle Society) score. RESULTS An infection developed at the sites of 37% of the forty-three fractures, with osteomyelitis developing at the sites of 19%. Seven of the nine type-I open fractures were treated with open reduction and internal fixation or with primary fusion, with no major complications and a good-to-excellent short-term result. Three of the eight type-II open fractures were complicated by an infection. Three of the twelve type-IIIA open fractures and ten of the thirteen type-IIIB open fractures were complicated by an infection. Six of the infections associated with a type-IIIB open fracture progressed to osteomyelitis, and three of those cases led to an amputation. Overall, thirteen (50%) of the twenty-six type-III open fractures were complicated by an infection, with osteomyelitis occurring in seven (27%). Thirty-three patients with a total of thirty-four open calcaneal fractures were available for follow-up at a minimum of two years, and an average of fifty-five months. The average AOFAS hindfoot score for the twenty-seven patients who had not undergone amputation was 71 points. CONCLUSIONS Open calcaneal fractures have a high propensity for deep infection despite the use of an aggressive treatment protocol to prevent it. It appears that type-I and type-II open fractures associated with a medial wound can be treated with open reduction and internal fixation. Type-II fractures associated with a wound in another location should be treated with limited or no internal fixation. Type-III open fractures, and especially type-IIIB open fractures, require extensive débridement and prompt soft-tissue coverage as soon as possible. Early internal fixation should be avoided in this subgroup because of the high rates of osteomyelitis and subsequent amputation.

Conservative treatment of isolated fractures of the medial malleolus

Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3 degrees (25 degrees to 82 degrees ) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis. Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion.

Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur

BACKGROUND Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. METHODS Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. RESULTS Forty-three of the forty-four fractures united. All reductions were within 5 degrees of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2 degrees and 5 degrees ). There were no complications. DISCUSSION Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.

Clamp-Assisted Reduction of High Subtrochanteric Fractures of the Femur: Surgical Technique

BACKGROUND Subtrochanteric fractures can be a treatment challenge. The substantial forces that this region experiences and the fact that the proximal fragment is frequently displaced make accurate reduction and internal fixation difficult. The purpose of this study was to evaluate a series of patients who had undergone clamp-assisted reduction and intramedullary nail fixation to determine the impact of this technique on fracture union rates and reduction quality. METHODS Between December 2003 and January 2007, fifty-five consecutive patients with a displaced high subtrochanteric femoral fracture were treated with clamp-assisted reduction and intramedullary nail fixation at two level-I trauma centers. Two patients died, and nine were lost to follow-up. The remaining forty-four patients were followed until union or a minimum of six months. There were twenty-seven male and seventeen female patients with a mean age of fifty-five years. All were treated with an antegrade statically locked nail implanted with a reaming technique as well as the assistance of a reduction clamp placed through a small lateral incision. Nine patients were treated with a single supplemental cerclage cable. Radiographs were evaluated for the quality of the reduction and fracture union. RESULTS Forty-three of the forty-four fractures united. All reductions were within 5° of the anatomic position in both the frontal and the sagittal plane. Thirty-eight (86%) of the forty-four reductions were anatomic. Six fractures had a minor varus deformity of the proximal fragment (between 2° and 5°). There were no complications. DISCUSSION Surgical treatment of subtrochanteric femoral fractures with clamp-assisted reduction and intramedullary nail fixation techniques with judicious use of a cerclage cable can result in excellent reductions and a high union rate. Careful attention to detail is important to perform these maneuvers with minimal additional soft-tissue disruption.

Suprapatellar Versus Infrapatellar Tibial Nail Insertion: A Prospective Randomized Control Pilot Study.

Purpose: The purpose of this OTA-approved pilot study was to compare the clinical and functional outcomes of the knee joint after infrapatellar (IP) versus suprapatellar (SP) tibial nail insertion. Design: Prospective, randomized. Setting: Level I trauma center. Methods: After institutional review board approval, skeletally mature patients with OTA 42 tibial shaft fractures were randomized into either an IP or SP nail insertion group after informed consent was obtained. The SP also underwent prenail and postnail insertion patella-femoral (PF) joint arthroscopy. Patients underwent follow-up (6 weeks, 3, 6, and 12 months) with standard radiographs, as well as visual analog score and pain diagram documentation. At the 6-month and 12-month visits, knee function questionnaires (Lysholm knee scale and SF-36) were completed. Magnetic resonance imaging/image (MRI) of the affected knee was obtained at 12 months. Ten patients in each group were required for a power analysis for the anticipated larger randomized control trial, but enrollment in each arm was not limited because of known problems with patient follow-up over a 12-month period. Results: A total of 41 patients/fractures were enrolled in this study. Of those, only 25 patients/fractures (14 IP, 11 SP) fully complied with and completed 12 months of follow-up. Six of 11 SP presented with articular changes (chondromalacia) in the PF joint during the preinsertion arthroscopy. Three patients displayed a change in the articular cartilage based on postnail insertion arthroscopy. At 12 months, all fractures in both groups had proceeded to union. There were no differences between the affected and unaffected knee with respect to range of motion. Functional visual analog score and Lysholm knee scores showed no significant differences between groups (P > 0.05). The SF-36v2 comparison also revealed no significant differences in the overall score, all 4 mental components, and 3/4 physical components (P > 0.05). The bodily pain component score was superior in the SP group (45 vs. 36, P = 0.035). All 11 SP patients obtained MRIs at 1 year. Five of these patients had evidence of chondromalacia on MRI. These findings did not correlate with either the prenail or postnail insertion arthroscopy. Importantly, no patient in the SP group with postnail insertion arthroscopic changes had PF joint pain at 1 year. Conclusions: Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up. Based on this pilot study data, larger prospective trial with long-term follow-up is warranted. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Wound complications associated with bone morphogenetic protein-2 in orthopaedic trauma surgery.

Objective: To document the incidence of postoperative wound complications associated with the use of rhBMP-2 in a large series of patients for both acute traumatic and reconstructive extremity cases. Design: Retrospective chart and radiographic review. Setting: Level I trauma center. Methods: A retrospective chart and x-ray review was performed on cases between 2002 and 2009, in which rhBMP-2 (Infuse) was used in acute trauma or posttraumatic reconstruction. The following data points were collected: age, surgical site, purpose (acute vs. reconstructive), associated wound factors (open fractures, soft tissue injury requiring coverage, or history of infection), signs of infection (seroma, erythema, prolonged drainage, abscess), reoperation rate secondary to wound complication, culture results, and union. These cases were then compared with a matched cohort without the use of bone morphogenetic protein-2 (matched for age, type of case, anatomic site, and open injury) for statistical analysis. Results: Group 1 was comprised a total of 193 patients whose treatment included rhBMP-2 (155 reconstructive and 38 acute open fractures). Group 2 was comprised 181 patients treated without the use of rhBMP-2 (145 reconstructive and 36 acute open fractures). The incidences of documented wound complications were 31% (60/193) in group 1 and 18% (33/181) in group 2 (P = 0.004). Reoperation rates for wound complications were in 3.1% of group 1 and 8.3% of group 2 (P = 0.04). Age, sex, anatomic site, acute trauma, open fracture, and the need for soft tissue reconstruction did not correlate with the need to return to the operating room for presumed or actual wound infection. The rates of union between rhBMP-2 and control groups were 90% versus 74% (P < 0.001); for acute trauma cases, 94% versus 79% (P = 0.220); and for reconstructive cases, 89% versus 73% (P = 0.002). Conclusions: The use of rhBMP-2 in both acute traumatic and posttraumatic reconstructive extremity surgery may increase the incidence of prolonged postoperative serous wound drainage. However, this does not seem to correlate with an increased incidence of postoperative wound infection or the need for reoperation. The use of rhBMP-2 seems to have a beneficial effect in improving union rates for both acute trauma and posttraumatic reconstruction of the extremities (P = 0.002); however, this and the mechanism for prolonged serous drainage require further study before definitive recommendations can be made. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.