Christopher G. Finkemeier

Bone-Grafting and Bone-Graft Substitutes

The treatment of delayed unions, malunions, and nonunions requires restoration of alignment, stable fixation, and in many cases adjunctive measures such as bone-grafting or use of bone-graft substitutes.Bone-graft materials usually have one or more components: an osteoconductive matrix, which suppor

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.

OBJECTIVES To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. DESIGN Prospective, surgeon-randomized comparative study. SETTING Level One trauma center. PATIENTS Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. INTERVENTION Interlocked IM nail insertion with and without medullary canal reaming. MAIN OUTCOME MEASURES Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. RESULTS For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. CONCLUSION Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.

Operative stabilization of supracondylar femur fractures above total knee arthroplasty ☆: A comparison of four treatment methods

Periprosthetic fractures of the distal femur above a total knee arthroplasty present a challenging surgical problem for orthopedic surgeons. Numerous operative and nonoperative treatment options exist including casting, Rush rods, supracondylar nails, and plate fixation. Potentially significant complications are associated with all current treatment alternatives. Plate or nail constructs frequently achieve limited distal fixation, leading to loss of fixation and varus angulation. This complication was not observed with the Less Invasive Stabilization System (LISS). In addition, our early results demonstrate the superiority of LISS treatment with low infection rates, no requirement for acute bone grafting, and secure fixation allowing for immediate postoperative mobilization. LISS fixation may offer a superior surgical treatment option for periprosthetic distal femur fractures.

Biomechanical comparison of posterior pelvic ring fixation.

Objective To determine relative stiffness of various methods of posterior pelvic ring internal fixation. Design Simulated single leg stance loading of OTA 61-Cl.2, a2 fracture model (unilateral sacroiliac joint disruption and pubic symphysis diastasis). Setting Orthopaedic biomechanic laboratory. Outcome Variables Pubic symphysis gapping, sacroiliac joint gapping, hemipelvis coronal plane rotation. Methods Nine different posterior pelvic ring fixation methods were tested on each of six hard plastic pelvic models. Pubic symphysis was plated. The pelvic ring was loaded to 1000N. Results All data were normalized to values obtained with posterior fixation with a single iliosacral screw. The types of fixation could be grouped into three categories based on relative stiffness of fixation: For sacroiliac joint gapping, group 1—fixation stiffness 0.8 and above (least stiff) includes a single iliosacral screw (conditions A and J), an isolated tension band plate (condition F), and two sacral bars (condition H); group 2—fixation stiffness 0.6 to 0.8 (intermediate stiffness) includes a tension band plate and an iliosacral screw (condition E), one or two sacral bars in combination with an iliosacral screw (conditions G and I); group 3—fixation stiffness 0.6 and below (greatest stiffness) includes two anterior sacroiliac plates (condition D), two iliosacral screws (condition B), and two anterior sacroiliac plates and an iliosacral screw (condition C). For sacroiliac joint rotation, group 1—fixation stiffness 0.8 and above includes a single iliosacral screw (conditions A and J), two anterior sacroiliac plates (condition D), a tension band plate in isolation or in combination with an iliosacral screw (conditions E and F), and two sacral bars (condition H); group 2—fixation stiffness 0.6 to 0.8 (intermediate level of instability) includes either one or two sacral bars in combination with an iliosacral screw (conditions G and I); group 3—fixation stiffness 0.6 and below (stiffest fixation) consists of two iliosacral screws (condition B) and two anterior sacroiliac plates and an iliosacral screw (condition C). Discussion Under conditions of maximal instability with similar material properties between specimens, differences in stiffness of posterior pelvic ring fixation can be demonstrated. The choice of which method to use is multifactorial.

Treatment of Supracondylar Nonunions of the Femur with Plate Fixation and Bone Graft

BACKGROUND The purpose of this study was to review the results of single and double-plate fixation combined with grafting with bone from the iliac crest performed by one surgeon as treatment for supracondylar nonunion of the femur. METHODS We performed a retrospective study of eighteen adult patients in whom a nonunion of the supracondylar region of the femur had been treated with single or double-plate fixation and autologous bone graft. The average time from the initial treatment of the fracture or the osteotomy to the index repair of the nonunion was fifteen months (range, five to thirty-six months), and nine patients had had a total of fifteen operations between the initial treatment and the repair of the nonunion. Two of these patients had had at least three procedures. Thirteen double plates, four single plates, and one interfragmentary screw were used for fixation of the nonunions, with onlay autologous bone graft used in all patients. The average time from the repair of the nonunion to the latest follow-up examination was twenty-six months (range, six to 120 months). RESULTS By the time of the latest follow-up examination, all eighteen nonunions had healed. One patient had needed repeat double-plate fixation and autologous bone-grafting to obtain union. Two patients had had the hardware removed because of pain or infection, one patient had had an implanted electrical bone stimulator removed, and one patient had had a quadricepsplasty to treat restricted motion of the knee. There were only three complications. These included one infection, which resolved with irrigation and debridement and the use of antibiotics; loss of motion of one knee; and one malunion. The average range of motion of the knee at the latest follow-up examination was 101 degrees (range, 10 to 135 degrees). CONCLUSIONS Rigid plate fixation and autologous bone-grafting is an effective technique for the treatment of nonunions of the supracondylar region of the femur.

Treatment of femoral diaphyseal nonunions.

There have been conflicting reports regarding treatment of femoral diaphyseal nonunions using reamed intramedullary nailing. Although high union rates have been reported using this technique, not all orthopaedic surgeons have experienced the same success. A retrospective review of charts and radiographs of 39 adult patients with nonunions of the femoral diaphysis treated at the authors’ institution with reamed intramedullary nailing, compression, and with and without interlocking was done. The time from the index procedure to nonunion repair was 4 to 75 months (average, 19 months). Fifteen patients had 18 procedures between the index operation and nonunion repair. The average followup from nonunion repair to the most recent examination was 22.5 months (range, 3–108 months) with a median of 15 months. At the last followup, the overall union rate was 74% after one procedure and 97% after two or more procedures. There were seven complications including two infections, one pulmonary embolus, one occurrence of a deep venous thrombosis, a hematoma, and one case of malrotation. The data support the use of antegrade reamed nailing as a successful technique for treatment of most femoral diaphyseal nonunions.

Incision placement for intramedullary tibial nailing: an anatomic study.

Objectives For intramedullary nailing of tibial shaft fractures, a recent study has determined that the entry site should be just medial to the lateral tibial spine at the anterior margin of the articular surface. Gaining access to this site is often through a medial parapatellar or transpatellar approach. Several studies have indicated that a transpatellar approach may contribute to anterior knee pain. Our study sought to use anatomic measurement to determine the ideal incision site for insertion of an intramedullary tibial nail. Design Part I: survey of Orthopaedic Trauma Association (OTA) members. Part II: anatomic study. Setting A Level I trauma center in Sacramento, California. Participants Part I: OTA members. Part II: a group of 56 healthy volunteers. Intervention Part I: questionnaire sent to OTA members. Part II: clinical examination and radiographic analysis. Main Outcome Measurements Part I: responses to questionnaire. Part II: anatomic measurements. Results Part I: based on a questionnaire, OTA members use at least one or more approaches to access their preferred tibial nail entry site. Fifty-seven percent use only one type of approach in all cases. Part II: the authors performed a clinical and radiographic study in 56 volunteers (112 knees) to determine the relationship of the lateral tibial spine to the patellar tendon. On the basis of this information, the tendon was divided into thirds to account for the three most common surgical approaches. The entry site was in the lateral zone in 29 knees, the middle zone in 75 knees, and the medial zone in 8 knees. If divided equally into purely a medial or lateral zone to avoid a transpatellar approach, the starting point fell into the medial zone in 42 knees and the lateral zone in 70 knees. Conclusions Individual variations in patellar tendon anatomy should be considered when choosing the proper entry site for tibial nailing. Based on the assumption that the ideal entry point for tibial nailing is just medial to the tibial spine at the anterior margin of the articular surface, a preoperative fluoroscopic measurement before incision can guide the surgeon as to whether a medial parapatellar, transpatellar, or lateral parapatellar approach provides the most direct access to this entry site. The routine use of a single approach for all tibial nails may no longer be justified.

Scapulothoracic dissociation: diagnosis and treatment.

Scapulothoracic dissociation is an important and increasingly common clinical condition resulting from massive traction injury to the anterolateral shoulder girdle with disruption of scapulothoracic articulation. It frequently is accompanied by an acromioclavicular separation, displaced clavicular fracture, or sternoclavicular disruption. Vascular lesions have been reported in 88% of patients and severe neurologic injuries occur in 94% of patients. Many patients have a poor outcome with a flail extremity in 52%, early amputation in 21%, and death in 10%. Early recognition of this injury combined with a logical treatment protocol can help to decrease the substantial morbidity and mortality associated with this condition.

Posterior Wall Fractures

The goal of surgical treatment of posterior wall fractures is to obtain stability of the hip by restoring the normal shape of the acetabulum and to restore the normal pressure distribution within the joint by anatomic reduction of the articular surface. Fractures of the posterior wall are the most common type of acetabular fracture and account for approximately one quarter of all acetabular fractures. These fractures typically occur in young patients as a result of a high-energy trauma, such as motor vehicle collisions. Displaced posterior wall fractures create an incongruity in the articular surface and, in some cases, result in instability of the hip. Diagnosis is made on the anteroposterior pelvis, obturator oblique, and iliac oblique radiographs of the pelvis. Computed tomography (CT) is helpful for identifying subtle marginal impaction and osteochondral fragments. Indications for operative treatment include instability of the hip, marginal impaction, and retained osteochondral fragments. Relative indications include articular fractures that encompass more than 33% of the wall width and minimally displaced fractures that are part of the more complex fracture pattern that require an ilioinguinal approach. Surgical reduction is performed through a Kocher-Langenbeck incision in the prone position with the knee bent to relax the sciatic nerve. Three and one-half mm implants are used for fixation of posterior wall fractures. Good to excellent results can be obtained in up to 80% of fractures that have been anatomically reduced and rigidly fixed. Anatomic reduction is a highly significant predictor of an excellent or a good result. Complications include wound infection, iatrogenic nerve palsy, heterotopic ossification, and thromboembolic complications. Posttraumatic arthritis is the most common late complication that can occur.

RIA: One Community's Experience

The Reamer Irrigator Aspirator (RIA) has three main indications in our community trauma practice. The most common indication for RIA is harvesting of autololgous bone graft from the femur for nonstructural bone graft. The second most common indication is for irrigation and debridement of intramedullary osteomyelitis. The final indication for RIA is for acute nailing of femoral shaft fractures in patients with multiple long bone fractures with or without pulmonary injury. If one pays careful attention to the details of the technique, RIA is a safe and effective method of harvesting autologous bone graft with minimal morbidity. Autologous bone graft harvested with RIA is our graft of choice for nearly all of our bone grafting cases.