Badri Narayan

Bicondylar tibial fractures: Internal or external fixation?

Bicondylar fractures of the tibia, representing the Schatzker V and VI fractures represent a challenging problem. Any treatment protocol should aim at restoring articular congruity and the metaphyseo-diaphsyeal dissociation (MDD)—both of these are equally important to long-term outcome. Both internal and external fixations have their proponents, and each method of treatment is associated with its unique features and complications. We review the initial and definitive management of these injuries, and the advantages and disadvantages of each method of definitive fixation. We suggest the use of a protocol for definitive management, using either internal or external fixation as deemed appropriate. This protocol is based on the fracture configuration, local soft tissue status and patient condition. In a nutshell, if the fracture pattern and soft tissue status are amenable plate fixation (single or double) is performed, otherwise limited open reduction and articular surface reconstruction with screws and circular frame is performed.

An Unusual Ankle Injury: The Bosworth-Pilon Fracture.

The Bosworth injury occurs when the distal fibula becomes entrapped posterior to the posterior tibial tubercle, usually as a result of a supination external rotation injury. This uncommon occurrence is a recognized cause of an irreducible ankle dislocation. A pilon fracture is usually a high-energy injury caused by the talus being driven upward into the tibial plafond. The resulting bone and soft tissue injuries often require a staged approach to management. The present report is the first in the medical data to describe a Bosworth injury complicating a pilon fracture. We also discuss a management approach for this rare fracture.

Regulation of Bone Formation by Applied Dynamic Loads

In vivo external loads were applied to a functionally isolated avian-bone preparation to evaluate the following data 1. Removal of load-bearing resulted in substantial endosteally bone remodelling, intracortically, and, to a lesser extent, periosteally. The balance of this remodelling was negative – bone mass declined. This suggests that functional load-bearing prevents a remodelling process that would lead to disuse osteoporosis. 2. Four consecutive cycles a day of an externally applied load that prevented physiological strain magnitudes but allowed an altered strain distribution prevented remodelling and was associated with no change in bone mass. A small exposure to, or the fi rst effect of, a suitable dynamic strain regimen appears to be suffi cient to prevent the negatively balanced remodelling that is responsible for disuse osteoporosis. 3. Thirty-six 0.5-Hz cycles per day of the same load routine also prevented intracortical resorption but was associated with substantial periosteal and endosteal new-bone formation. Over a 6 week period, bone mineral content increased to between 133 and 143 % of the original value. Physiological levels of strain applied with an abnormal strain distribution can produce an osteogenic stimulus that is able to increase bone mass. Neither the size nor the nature of the bone changes that were observed were affected by any additional increase in the number of load cycles from 36 to 1,800. The sensitivity of bone remodelling in this model to prevailing mechanical circumstances is apparent. Functional levels of bone mass in patients may only be maintained under the effects of continued load-bearing. The osteogenic effect of an unusual strain distribution suggests that a varied exercise program may provoke a greater hypertrophic response than an exercise program that is restricted. A substantial osteogenic response may be achieved after remarkably few cycles of loading.

Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones. Retrospective and Prospective Analyses

In 673 open fractures of long bones (tibia and fibula, femur, radius and ulna, and humerus) treated from 1955 to 1968 at Hennepin County Medical Center, Minneapolis, Minnesota, and analyzed retrospectively, the infection rate was 12 per cent from 1955 to 1960 and 5 per cent from 1961 to 1968. In a prospective study from 1969to 1973,352 pa tients were managed as follows: débridementand copi ous irrigation, primary closure for Type I and II frac tures and secondary closure for Type III fractures, no primary internal fixation except in the presence of as sociated vascular injuries, cultures of all wounds, and oxacillm-ampicillin before surgery and for three days postoperatively. In 158 of the patients in the prospec tive study the initial wound cultures revealed bacterial growth in 70.3 per cent and the infection rate was 2.5 per cent. Sensitivity studies suggested that cephalospo rin is currently the prophylactic antibiotic of choice. For the Type III open fractures (severe soft-tissue in jury, segmental fracture, or traumatic amputation), the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospective study. Prevention of wound sepsis remains the prime objec tive in the management of open fractures. The reported in fection rates in these fractures, which range from 3 to 25 per cent, are a challenge to every surgeon who treats them 6-8,lO.I4,15,2i,22.26 * Hennepin County Medical Ccnter. Fifth and Portland South. Minneapolis, Minnesota 55415. 1@Universityof Minnesota,Minneapolis. Minnesota. There is universal agreement that open fractures re quire emergency treatment, including adequate débridement and irrigation of the wound. Beyond these two basic tenets, opinions differ as to the following: I . Primary or secondary closure. If the wound is left open and secondary direct skin closure is not possible, when does one do skin-grafting, or create a cross-leg pedi cle flap or a rotational flap? 2. Use of primary internal fixation. What are the in dications for primary internal fixation and if internal fixation is delayed, when is the proper time for open reduc tion and internal fixation? 3. Use of antibiotics. Should they be used routinely? What antibiotics should be used and for how long? In an attempt to answer these questions we carried out retrospective and prospective analyses of a total of I ,025 open fractures of all the long bones treated at Hennepin County Medical Center, Minneapolis, Minnesota, from

The Tension-Stress Effect on the Genesis and Growth of Tissues Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation

To evaluate the optimum conditions for osteogenesis during limb lengthening and to study the changes in soft tissues undergoing elongation, a series of experiments were performed on the canine tibia. The experiments used the transfixionwire, Ilizarov circular external skeletal fixator in configurations of differing stability of fixation in combination with a second variable, i.e., preservation of the periosteum, bone marrow, and medullary blood supply. Both increased fixator stability, and maximum preservation of the periosseous and intraosseous soft tissues enhanced bone formation during limb lengthening. To assess the role that the direction of the elongation vector plays in osteogenesis, canine tibiae were widened rather than lengthened in a second series of experiments using an Ilizarov apparatus modified for lateral distraction. The new bone formed parallel to the tension vector even when perpendicular to the bones mechanical axis. As in longitudinal lengthening, damage to the bone marrow inhibits osteogenesis occurring by the influence of a lateral tension-stress vector. In a third series of experiments, halfand full-circumference cortical defects were created in canine tibiae to study the osteogenic potential of

Classic Papers in Trauma and Fracture Healing: Introduction

A ‘classic paper’ has no specific definition. The number of citations of a paper often reflects quality, but not always. At best therefore, the number of citations is a surrogate marker of how important a paper is and whether the paper is responsible for significant developments in orthopaedics.