David C. Templeman

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.

Proximity of iliosacral screws to neurovascular structures after internal fixation

The placement of iliosacral screws for the stabilization of pelvic ring lesions is technically demanding. The postoperative computed tomography scans of 31 patients who had 57 iliosacral screws placed for various indications were studied to determine the proximity of these screws to neurovascular structures. The closest distance of the screws from the S1 foramen averaged 3 mm. (range, 0-10.5 mm); the average closest distance to the anterior cortex of the sacral ala was 4.8 mm (range, 0-15.3 mm). The corridor for the insertion of the screws between the S1 foramen and the anterior cortex of the sacrum averaged 21.7 mm (range, 16.2-28.9 mm). Trigonometric analysis of these dimensions suggests that deviations of the surgeons hand by as little as 4 degrees may direct iliosacral screws either into the S1 foramina or through the anterior cortex of the sacrum.

Intramedullary nailing following external fixation in femoral and tibial shaft fractures.

Background: Intramedullary nailing is the standard of care for the definitive management of lower extremity long bone fractures. Occasionally, temporary external fixation is used in fractures with severe open wounds or vascular injury before definitive intramedullary nailing. Secondary intramedullary nailing following external fixation is somewhat controversial, especially with respect to the duration of external fixation that is allowable before the risk of infection following later nailing becomes too great. Several recent studies have provided further insight into this issue. Objective: The primary objective is to evaluate infection and nonunion rates in patients treated with temporary external fixation and secondary intramedullary nailing for lower extremity long bone fractures. The secondary objective is to evaluate whether the duration of external fixation and the interval time (defined as the time from external fixator removal to intramedullary nailing) influence the risk of infection after intramedullary nailing.

Update on the management of open fractures of the tibial shaft.

A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture care.

Internal fixation of displaced fractures of the sacrum

The results of internal fixation in 30 patients with displaced fractures of the sacrum were retrospectively reviewed. All fractures were displaced at least 1 cm. Neurologic injuries occurred in 40% (12 of 30) patients. In 17 patients who underwent open reduction, the preoperative displacement averaged 24 mm and the postoperative displacement averaged 4 mm. In the 13 patients in whom percutaneous fixation was done, the preoperative displacement averaged 15 mm and the postoperative displacement averaged 5 mm. All 30 fractures united. This review of 30 patients with displaced sacral fractures suggests that open reduction and iliosacral screw fixation leads to better reduction of the fracture site than does closed reduction and percutaneous fixation. Functional assessment indicated that the presence of a neurologic injury is the most important predictor of compromised outcome in patients with displaced sacral fractures.

Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia

Twenty-eight tibial fractures, initially treated with nonreamed interlocking nails, were exchanged to reamed intramedullary nails to promote union. Initially, there were 8 closed fractures with compartment syndromes; 5 Type 2 open fractures; 6 Type 3 A injuries; and 6 Type 3B injuries. Exchange nailing was performed if followup radiographs did not show callus formation between 3 and 5 months after injury. Originally, 16 of the 28 nailings were statistically locked. Twenty-five of 27 fractures united after exchange nailing. In 2 patients with bone loss, additional bone grafting was required. Infection developed in 3 patients after exchange nailing (11%). Exchange nailing is a useful method to promote union of tibial fractures when slow consolidation occurs after initial treatment with a nonreamed nail. This method should be combined with autogenous bone grafting in patients with bone loss. The procedure is safe and effective in closed and minor open fractures; however, caution should be exercised in patients with prior Grade 3B open fractures because of the risk of infection.

Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries.

Objectives: The purposes of this study were to evaluate the relationship between body mass index (BMI) and postoperative complications and to determine the incidence of reoperation after surgical treatment of pelvic ring injuries. Setting: Three Level I trauma centers. Patients/Participants: A retrospective review of 184 consecutive surgically treated pelvic ring injuries (Orthopaedic Trauma Association 61) was performed. Two patients died in the initial postoperative period, and the remaining 182 patients were followed for a minimum of 3 months. Main Outcome Measurements: Complications that were evaluated included wound infection and dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis, pneumonia, and the development of decubitus ulcers. Body mass index was calculated for each patient, and a BMI greater than 30 kg/m2 considered to be obese as defined by the National Institutes of Health. Results: There were 132 males and 50 females with an average age of 36.4 years (range, 14-83 years). There were 48 (26%) patients with a BMI over 30 kg/m2. Complications occurred in 46 of 182 patients (25.3%) with 26 occurring in the 48 patients with BMI greater than 30 kg/m2 (54.2% complication rate) and 20 occurring in the 134 patients with BMI less than 30 kg/m2 (14.9% complication rate). Complications included 20 infections (four superficial wound dehiscence and 16 deep), 23 losses of reduction, five deep vein thromboses, three pulmonary embolus, three pneumonia, two decubitus ulcers, and three iatrogenic nerve injuries. Reoperation was required in 29 of 182 (15.9%) patients with 16 (8.8%) irrigation and débridement, and 17 (9.3%) refixation procedures. All wound complications occurred after open exposures. Open exposures were performed for the anterior pelvic ring in 143 of 182 (78.6%) patients, the posterior pelvic ring in 64 of 182 (35.2%) patients, and percutaneous treatment of the posterior pelvic ring was performed in 80 of 182 (44.0%) patients. Logistic regression modeling analyzing BMI as a continuous variable found a relationship between increasing BMI and complication rate (P < 0.0001) and need for reoperation (P = 0.0013). Odds ratios analysis revealed that obese patients (BMI greater than 30 kg/m2) were 6.87 (95% confidence interval, 3.25-14.49) times more likely to have a complication and 4.68 (95% confidence interval, 2.03-10.76) times more likely to undergo reoperation than patients with BMI less than 30 kg/m2. Conclusions: Body mass index correlates with an increased rate of complications and reoperation after operative treatment of pelvic ring injuries.

Surgical treatment of intertrochanteric hip fractures with associated femoral neck fractures using a sliding hip screw.

Objective: The purpose of this study was to report the results of surgical treatment of a subset of intertrochanteric fractures with posteromedial comminution and extension of the fracture line into the femoral neck using a sliding hip screw. Design: Retrospective review. Setting: Level I county trauma center. Patients: Twenty-nine fractures (8%) with this pattern were identified from 381 intertrochanteric hip fractures treated at a single institution over a 10-year period. Nine patients were excluded (2 died, 7 had incomplete radiographic follow-up), leaving 20 patients for assessment. Intervention: All fractures were treated with a sliding hip screw. Main Outcome Measurements: Radiographs at a mean follow-up of 17 months were recorded as demonstrating: 1) fixation failure; 2) fracture union; or 3) fracture nonunion. The tip-apex distance, amount of lag screw collapse, screw position in the femoral head, and adequacy of reduction were determined. Results: Treatment failed according to these radiographic measures in 5 of 20 (25%) fractures. Failures included fracture nonunion (1 case), lag screw cutout (2 cases), and combined nonunion/lag screw cutout (2 cases). All 5 failures had complete collapse of the lag screw, whereas 4 of the 15 successfully treated fractures had complete collapse. The amount of collapse was significantly greater for the treatment failures (mean, 38 mm) than in the successfully treated hips (mean, 20 mm). There was no significant association between treatment success or failure and tip-apex distance, lag screw position, and adequacy of reduction. Conclusion: We conclude that intertrochanteric hip fractures with associated femoral neck fractures should not be managed with a standard sliding hip screw.

Decision making errors in the use of interlocking tibial nails

Seventy-one fractures of the tibial shaft were treated with interlocking intramedullary nails. None of the fractures were treated with static locking of the intramedullary nails. These 71 fractures were studied to determine whether certain fracture patterns are prone to loss of alignment when static interlocking is not used. Loss of alignment was defined as shortening of 1 cm or more and/or change in angulation of at least 5°. Loss of alignment occurred in eight of the 71 (11%) fractures. Shortening and/or angulation occurred in seven of 22 spiral and short oblique fractures, and in none of 27 transverse fracture patterns. It was concluded that the dynamically locked and nonlocked modes of intramedullary nailing should not be used in the stabilization of spiral and oblique fractures of the tibial shaft.

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Compartment Syndrome Associated with Tibial Fracture*†

Compartment syndrome is a well recognized complication of a fracture of the tibial shaft3,4,6,15,31. Despite attempts to document the pathophysiology of compartment syndrome, the clinical recognition of this disorder is frequently difficult. If left untreated, compartment syndrome not only results in the loss of nerve and muscle function but also may lead to infection, myoglobinuria and renal failure, and even amputation. A closed tibial fracture is one of the conditions most frequently associated with the development of compartment syndrome. Compartment syndrome occurs after both closed and open tibial fractures; the prevalence has ranged from five (1 per cent) of 411 fractures to eighteen (9 per cent) of 198 fractures3. The range probably reflects the varying percentage of high-velocity injuries seen at different medical centers31. Despite an increased sensitivity of clinicians to the diagnosis of compartment syndrome, few criteria are available to serve as guidelines for making the diagnosis. The subjective criteria include pain, sensory changes, motor function, and turgor, but the sole objective criterion is the measurement of intracompartmental pressures. However, even the definition of abnormal tissue pressure is difficult, as anatomical compartments are not homogeneous and an equilibrium of pressure cannot be expected18. Heckman et al.8 measured intracompartmental pressures at multiple sites in patients who had a tibial fracture. They documented localized areas of increased tissue pressure within single compartments. These differences were significant (p < 0.0005) at distances of as little as five centimeters from the site of the fracture. In twenty-four of the twenty-five patients, the highest pressures were found in the anterior and posterior compartments. Those authors recommended the measurement of pressure at multiple sites, especially at the level of the fracture, and the careful assessment of all compartments …