Craig S. Roberts

Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma.

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Pin tract infection with contemporary external fixation: how much of a problem?

Objective To determine the incidence of pin tract infection. Design Retrospective chart review. Setting Level 1 trauma center in an urban community. Patients A total of 285 patients with 285 fractures over a 4-year period (1997–2001). Intervention External fixation. Main Outcome Measurement Incidence of pin tract infection. Results Of 285 fractures, 32 (11.2%) were complicated by infection. The incidence of infection according to montage was 3.9% (3/77) for ring fixators, which was significantly different (P < 0.04) from the 12.9% incidence (23/178) for unilateral fixators and the 20.0% incidence (6/30) for hybrid fixators (P = 0.004). The incidences of pin tract infection for the unilateral fixator group and the hybrid fixator group were not significantly different. Conclusions Patients with hybrid external fixators had a similar risk of pin tract infection as patients who had unilateral fixators. The infection rate in the ring fixator group was significantly lower than the hybrid external and unilateral fixator groups.

Second generation intramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion.

Objectives: To compare fracture site motion between different second-generation intramedullary nails used to fix subtrochanteric fractures of the proximal femur with and without femoral neck fractures. Design: Nondestructive mechanical testing of four types of femoral intramedullary nails was undertaken to evaluate fracture site motion using a model that simulated single-leg and double-leg stance. Methods: Three types of reconstruction nails (the Russell-Taylor Delta [Smith & Nephew, Memphis, TN], the Uniflex [Biomet, Warsaw, IN], Alta CFX [Howmedica-Osteonics, Rutherford, NJ]) and the Long Gamma nail (Howmedica-Osteonics, Rutherford, NJ), each measuring 11 × 380 mm, were inserted in fiberglass composite femurs. Four fracture patterns were studied (transverse subtrochanteric, subtrochanteric with posteromedial wedge comminution, subtrochanteric with one-centimeter gap, and a one-centimeter gap with a subcapital neck fracture). Single- and double-leg stance loading was simulated using a servohydraulic load frame (MTS, Eden Prairie, MN). Two-way analysis of variance and post hoc t tests were used to determine any statistically significant differences between groups. Results: In single-leg stance there were significant differences in coronal plane rotation, shear, and axial translation across the subtrochanteric fracture site between the different nail types and the different fracture patterns (p < 0.001). In double-leg stance there were significant differences in coronal plane rotation and femoral head vertical motion between the different nail types and the different fracture patterns (p < 0.001), and there were significant differences in shear and axial translation between the different fracture patterns (p < 0.001) but not the different nail types (p > 0.05). Conclusions: For simple, well-reduced fractures the choice of implant is not critical. As fracture severity increased (comminution, gap, and combined neck fracture), the choice of implant, particularly with reference to proximal nail dimensions and implant materials, was a significant factor in reducing fracture site motion. Therefore, our laboratory data suggest that when subtrochanteric fractures are unstable (e.g., comminution, segmental bone loss) and early weight bearing is desirable, the choice of implant is critical and should be restricted to implants that allow minimal fracture site motion (Long Gamma and Russell-Taylor).

Effect of ketamine on bispectral index and levels of sedation.

To the Editor: An electroencephalographic (EEG) variable, i.e., bispectral index (BIS), a numerical index ranging from 0 to 100, has been shown to correlate with sedation produced by midazolam, thiopental and propofol [1^3]. However, the relationship between levels of sedation produced by low-dose ketamine and BIS is not known.We assessed the relationship between levels of sedation produced by the administration of low-dose ketamine and BIS, as well as other EEG variables, i.e., relative alpha, beta, theta, and delta powers; and percentile frequencies (f95% and f50%), in 24 adult patients, age 19^46, ASA physical status I^II, scheduled for elective operations under general anesthesia. Informed consent was obtained. Patients with a history of substance abuse, patients taking psychotropic and/or opiate drugs, and those with psychiatric diseases or psychological problems were excluded. Premedication was omitted. Patients were randomly assigned to one of three groups: (1) those receiving ketamine 0.5 mg/kg (n = 8); (2) those receiving ketamine 0.25 mg/kg (n = 8); and (3) those receiving ketamine 0.1 mg/kg (n = 8). In the operating room, patients were asked to keep their eyes closed. After 5 min of quiet rest, ketamine was infused over a period of 20 s. The degree of sedation was assessed 2 min after the administration of ketamine using the observers assessment of alertness/ sedation (OAA/S) scale: 5 = responds readily to name spoken in normal tone; 4 = lethargic response to name spoken in normal tone; 3 = responds only after name is called loudly and/or repeatedly; 2 = responds only after mild prodding or shaking; and 1 = does not respond to mild prodding or shaking. The EEG variables were monitored continuously using an A-1000 EEG Monitor (version 3.0 algorithm) and Zipprep selfprepping disposable electrodes (Aspect Medical Systems, Inc., Natick, MA) in the bifrontal montage (FP1^FPZ and FP2^FPZ) with impedance under 5 K . The data were recorded using a Lifebook-635T (Fujitsu, Tokyo, Japan) until shortly after thiopental induction and endotracheal intubation. Data on EEG variables were analyzed using ANOVA for repeated measures and adjusted p-value for multiple tests using the Holms sequential rejection algorithm, and data on OAA/S scores were analyzed using KruskalWallis test. There was a dose-dependent decrease in the OAA/S score. There was no correlation between BIS and levels of sedation or dose of ketamine (Table 1). However, the relative theta power increased signi¢cantly after injection of ketamine (p < 0.05, adjusted p-value), and there were correlations between levels of sedation and the increase in the relative theta power as well as dose of ketamine (r = ÿ0.57, p < 0.005 and r = ÿ0.61, p < 0.002, respectively). There was a signi¢cant reduction in the relative delta power (p < 0.05). The reduction in the relative delta power correlated with the dose of ketamine (r = 0.43, p < 0.05) but not with the levels of sedation. These results suggest that the levels of sedation after the administration of low-dose ketamine alone do not correlate with the BIS. Our results, however, suggest that, as was shown previously [4], the levels of sedation induced by low-dose ketamine may correlate with the changes in theta power.

Articular step-off and risk of post-traumatic osteoarthritis. Evidence today

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

Percutaneous fixation of the pelvic ring: AN UPDATE

With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.

A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait.

Without an intact anterior cruciate ligament (ACL) to resist anterior tibial translation, it is commonly believed that ACL-deficient patients employ alterations in walking. Although there is no consensus in the literature about the specific kinematic and kinetic adaptations in these patients with ACL tears, the gait adaptation of quadriceps avoidance is perhaps the one most popularized. The purpose of our study was to determine whether quadriceps avoidance is common in patients with ACL-deficiency. We used a video-based motion analysis system and surface electromyography (EMG) to study 18 patients with ACL-deficiency. All patients demonstrated an internal knee extension moment during early mid-stance (similar to normal subjects). Quadriceps EMG activity was noted throughout most of stance. No patients demonstrated an internal knee flexion moment, a decreased internal knee extension moment or a decreased duration of quadriceps EMG activity during stance. The findings of this study would suggest that quadriceps avoidance as a gait adaptation in ACL-deficient patients may be less common than previously reported.

Pregnancy-related pelvic girdle pain: an update

A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndromes symptoms to a fraction of the population of pregnant women.

The role of reduction and internal fixation of Lisfranc fracture–dislocations: a systematic review of the literature

A systematic review of the literature was performed in order to evaluate the role of reduction and internal fixation in the management of Lisfranc joint fracture–dislocations. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfilled. Eleven articles were eligible for the final analysis, reporting data for the management of 257 patients. Injuries of the first three metatarsal rays were treated by closed reduction and internal fixation with screws in 16.3% of the patients, open reduction and internal fixation with screws in 66.5% and open reduction and internal fixation with Kirschner wires (K-wires) in 17.1% of the patients. The preferred method for the stabilisation of the fourth and fifth metatarsal rays was K-wires. Screw-related complications were common and were reported in 16.1% of the cases. The mean American Orthopaedic Foot and Ankle Society midfoot score was 78.1 points. Post-traumatic radiographic arthritis was reported in 49.6% of the patients, but only in 7.8% of them it was severe enough to warrant an arthrodesis. We conclude that open reduction and internal fixation of the first three metatarsal rays with screws is a reliable method for the management of Lisfranc injuries. This can be complemented by K-wires application in the fourth and fifth metatarsal rays if needed.

Compartment syndrome of the thigh: a systematic review.

INTRODUCTION Thigh compartment syndrome is a surgical emergency with risk of high morbidity and mortality rates. The purpose of this study was to review the available evidence regarding the causes of thigh compartment syndrome, techniques of fasciotomy (specifically, one versus two incisions), methods of wound closure, and complications. METHODS This institutional review board-exempt study was performed at a level-one trauma centre. PubMed and Medline OVID databases in the English language were searched for case series of two or more cases of compartment syndrome of the thigh. Cases were reviewed and analysed for causes of thigh compartment syndrome, number of fasciotomy incisions, methods of wound closure, and complications. RESULTS A total of 9 papers met our criteria. All were retrospective case studies comprising a total of 89 patients. The most common cause was blunt trauma (90%). Motor vehicle accidents accounted for 36% of cases whilst motorcycle accidents were involved in 9%. Associated injuries included femur fractures in 48%, other limb fractures, renal, cardiovascular and head insults. Eighty-six percent of fasciotomies were performed through a single incision. Fifty-nine percent of fasciotomy wounds were closed by delayed primary closure, 26% had split-thickness skin grafts, and 15% had primary wound closure. Neurological deficits were the most common complications. CONCLUSION There are limited data on thigh compartment syndrome with respect to cause, use of one versus two incisions for fasciotomy, methods of wound closure, and complication rates. Prospective studies are required to better define these variables in order to optimise the management of this problem.