Attila Poka

Prospective comparison of retrograde and antegrade femoral intramedullary nailing

Objective:To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures.Design:Prospective, randomized.Setting:Urban Level 1 trauma center.Patients:One hundred consecutive femoral shaft fractures. Fifty-four nails inserted rOBJECTIVEnTo prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures.nnnDESIGNnProspective, randomized.nnnSETTINGnUrban Level 1 trauma center.nnnPATIENTSnOne hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade.nnnINTERVENTIONnTen-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming.nnnOUTCOME MEASUREMENTSnA comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed.nnnRESULTSnKnee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures.nnnCONCLUSIONSnBoth antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.

Induced membrane technique for reconstruction to manage bone loss.

&NA; Multiple surgeries are often required to manage segmental bone loss because of the complex mechanics and biology involved in reconstruction. These procedures can lead to prolonged recovery times, poor patient outcomes, and even delayed amputation. A twostage technique uses induced biologic membranes with delayed placement of bone graft to manage this clinical challenge. In the first stage, a polymethyl methacrylate spacer is placed in the defect to produce a bioactive membrane, which appears to mature biochemically and physically 4 to 8 weeks after spacer placement. In the second, cancellous autograft is placed within this membrane and, via elution of several growth factors, the membrane appears to prevent graft resorption and promote revascularization and consolidation of new bone. Excellent clinical results have been reported, with successful reconstruction of segmental bone defects >20 cm.

Indications and Techniques for External Fixation of the Pelvis

Pelvic ring disruption is often accompanied by severe, multiple injuries to the organs, vessels, and nerves within the true pelvis. Mortality in the acute resuscitative period is usually due to hemorrhage and hemodynamic instability. Establishing rapid, provisional pelvic stability with external fixation is of immediate importance in the hemodynamically unstable patient, because fixation contributes to hemostasis. Orthopaedic surgeons should anticipate the likelihood of hemorrhage in patients with pelvic ring disruption and should apply external fixation immediately to minimize morbidity and mortality.

Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes.

BackgroundSince the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.Questions/purposesWe evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d’Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.MethodsBetween September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9–59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.ResultsMerle d’Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.ConclusionsIn agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Osteomyoplastic and Traditional Transtibial Amputations in the Trauma Patient: Perioperative Comparisons and Outcomes

We hypothesized that patients undergoing transtibial amputation osteomyoplasty would have better functional outcomes than patients undergoing traditional transtibial amputation. We conducted a retrospective review of the medical and radiographic records to evaluate and compare 26 patients who underwent transtibial amputation osteomyoplasty and 10 patients who underwent traditional transtibial amputation, with specific attention to perioperative complications and functional outcomes. At >1 year follow-up, patients who underwent amputation osteomyoplasty had significantly improved rates of return to work and decreased rates of revision than patients who underwent traditional transtibial amputation. Sickness Impact Profile questionnaire results completed at a mean of 28 months postoperatively showed significantly better overall scores and physical and psychosocial dimension scores for amputation osteomyoplasty patients. Based on the results of this study, the outcomes of amputation osteomyoplasty appear to be safe and may be more beneficial than traditional amputation, in terms of improved functional outcomes for patients after severe lower-extremity trauma.

Gritti-stokes amputations in the trauma patient: clinical comparisons and subjective outcomes.

BACKGROUNDnThe Gritti-Stokes amputation procedure is a modification of the traditional transfemoral amputation, with resection of the bone at a supracondylar femoral level and fixation of the patella to the distal part of the femur as an end-cap. Although well-established in patients with vascular compromise, no evidence exists on its use in the trauma setting.nnnMETHODSnFourteen consecutive patients who underwent Gritti-Stokes amputation and fifteen consecutive patients who underwent traditional transfemoral amputation by fellowship-trained orthopaedic traumatologists at a level-I trauma center were evaluated at more than fourteen months postoperatively. The Sickness Impact Profile (SIP) questionnaire was also administered to both patient groups at more than thirty-six months postoperatively to assess patient-reported functional outcomes.nnnRESULTSnDespite the two groups not having significant differences in preoperative variables or demographics, the Gritti-Stokes group had significantly improved SIP questionnaire overall and domain scores. This procedure also left the patients with a significantly longer residual limb (an average of 46.1 cm of residual femoral length versus 34.6 cm for the transfemoral group). The Gritti-Stokes group also had a significantly increased rate of walking without assistive devices (five patients versus none in the transfemoral amputation group).nnnCONCLUSIONSnThe Gritti-Stokes amputation appears to be safe and beneficial when utilized in the trauma population.

Osteomyoplastic transtibial amputation: technique and tips

Treatment of severe lower extremity trauma, diabetic complications, infections, dysvascular limbs, neoplasia, developmental pathology, or other conditions often involves amputation of the involved extremity. However, techniques of lower extremity amputation have largely remained stagnant over decades.This article reports a reproducible technique for transtibial osteomyoplastic amputation.

Osteomyoplastic Transtibial Amputation: The Ertl Technique.

Amputation may be required for management of lower extremity trauma and medical conditions, such as neoplasm, infection, and vascular compromise. The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. Additional research is needed to elucidate the optimal patient population, technique, and postoperative protocol for the Ertl osteomyoplastic transtibial amputation technique.

Perioperative management of foot and ankle trauma

This review covers the perioperative management of trauma to the foot and ankle. The goal when treating these injuries is to return the patient to a sensate, plantigrade, painless, and functioning foot and ankle. Depending on the nature of the trauma, realistic outcomes should be established for the patient, family, and surgeon. The importance of early recognition and treatment of foot and ankle injuries has been established and is paramount for the overall recovery of traumatized patient.

Gritti-Stokes Amputation in the Trauma Patient: Tips and Techniques

IntroductionnThe Gritti-Stokes amputation establishes osseous continuity between the patella and the distal part of the femur with maintenance of the intact prepatellar soft tissues.nnnStep 1 Preoperative PlanningnAs with all orthopaedic surgery, preoperative planning is essential to obtaining an optimal outcome with this procedure.nnnStep 2 Flap DesignnUse an asymmetric flap consisting of the undisturbed prepatellar soft tissues and rotate it posteriorly to achieve closure.nnnStep 3 Soft-Tissue DissectionnKeep soft-tissue dissection subperiosteal or intratendinous to minimize blood loss and postoperative pain.nnnStep 4 Distal Femoral and Patellar CutsnUse a high-speed saw to transect the femur and patella.nnnStep 5 Posterior DissectionnCarry out posterior dissection in a methodical manner, with individual identification and ligation of all neurovascular structures.nnnStep 6 Patellofemoral ArthrodesisnSuture the patella to the distal part of the femur using six drill holes and nonabsorbable suture.nnnStep 7 Soft-Tissue ClosurenClose the remaining soft tissue, including the posterior musculature, subcutaneous layer, and skin, in a layered fashion.nnnStep 8 Postoperative ManagementnPostoperative care should be done in conjunction with a prosthetist to obtain optimal outcomes.nnnResultsnThe Gritti-Stokes amputation technique appears to be a potentially valuable addition to the amputation surgeons armamentarium.nnnWhat to Watch FornIndicationsContraindicationsPitfalls & Challenges.