David Seligson

Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures.

Internal fixation devices in the form of bone plates have been used for a long time in maxillofacial surgery. As early as 1907, Albin Lambotte of Belgium’ reported the fixation of a mandibular fracture with “a little aluminum plate fixed with two screws.” In North America, Thorna,’ Archer,” Robinson

Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures.

5 Dingman and Natvig,6 Richter and Boyney and Hahn and Corgill’,’ advocated plate or mesh fixation for fractures or in reconstructive surgery of the jaws. These devices and techniques were designed as adjuncts in the management of specific injuries and/or congenital or acquired deformities. Primarily, they were designed to supplement conventional maxillomandibular fixation, contain graft systems, or provide structure and contour. In Europe, Luhr,” Spiessl,” Schilli,12 and Champy et al” developed and/or popularized internal fixation systems involving plates and screws that were designed to avoid or eliminate the need for maxillomandibular fixation in the treatment of maxillofacial injuries and deformities. Their techniques and devices, as well as their philosophy of care, were generally accepted in Europe by the late 1970s and in North America by the late 1980s. The early plating systems were generally large and bulky (other than the Champy system) and fabricated of stainless steel (Spiessl, Champy) or chrome cobalt (Luhr). Removal after they ceased to function was advocated as part of total management. North American surgeons questioned the need for removal, pointing out that patients would not accept a second surgery nor

Antibiotic-leaching from polymethylmethacrylate beads.

Antibiotic-impregnated polymethylmethacrylate (PMMA) beads have been useful in treating orthopedic infections. Local delivery has been reported to establish wound antibiotic levels well above the therapeutic range while avoiding serum levels associated with increased incidence of side effects. After operative debridement, 70 patients with compound fractures were treated prophylactically with tobramycin-impregnated PMMA beads. Observations of antibiotic levels in 27 patients demonstrated antibiotic levels in the wound drainage and clot that were significantly in excess of the usual therapeutic range for tobramycin and simultaneous nontoxic serum levels. Significant levels of tobramycin can be achieved in the extracellular fluid at the fracture site when tobramycin-impregnated PMMA beads are placed in the wound after irrigation and debridement.

Treatment of tibial shaft fractures by percutaneous Kuntscher nailing : technical difficulties and a review of 50 consecutive cases

Aminoglycoside-impregnated polymethylmethacrylate beads, which are used to deliver antibiotic directly to infected sites in the musculoskeletal system, are available as a manufactured product or they can be mold-made by a pharmacy or hand-rolled by the orthopaedist in the operating suite. We investigated the leaching of antibiotic from each of these types of beads. Our hypothesis was that the elutions of antibiotic from the three types of beads are similar. Three study groups (hand-made, mold-made, and manufactured beads), each composed of four five-bead subsets, were formed so that twenty beads of each type were tested. Each bead was leached daily in a two-milliliter aliquot of normal saline solution throughout a sixty-day period, and the aminoglycoside concentration in twenty of these aliquots was determined. Analysis of variance showed no statistically significant differences when the antibiotic elutions within each subset, between the different subsets, and between the three groups were compared. The clinically important finding of this investigation is that the leaching characteristics of the three types of aminoglycoside-impregnated beads are equivalent when the beads have been fabricated out of comparable materials.

Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia

Intramedullary nailing of the tibia is a controversial procedure for fractures of the tibial shaft. Experience with 50 fractures (58% acute, 8% pathologic, and 34% unsuccessfully treated previously by other methods) with an average follow-up period of one year proved that tibial Küntscher nailing is effective. Mean time to clinical union, with patients independently ambulatory and resuming all work activity, was 29 weeks. Union was demonstrated radiographically at 13 weeks. The major complications were delayed union (2 patients), nail protrusion at the knee (2 patients), osteitis (1 patient), and thrombophlebitis (1 patient). Antirotation wires were used in addition to a Küntscher nail for fractures with inherent rotational instability. Blocking screws were used for fractures predisposed to bending. Technical problems arose most often at the nail entrance site, in negotiation of Herzogs curve, and in selection of proper nail length and caliber. With experience and technical skill, even highly complex tibial fractures can be successfully treated by this method.

Inflation osteoplasty: in vitro evaluation of a new technique for reducing depressed intra-articular fractures of the tibial plateau and distal radius.

Numerous reports list predictive criteria to determine whether Gustilio‐type tibial III‐B and III‐C fractures of the tibia are salvageable. What is lacking are long‐term reports of comprehensive functional outcome of these severe injuries. We evaluated the functional outcome of patients with our own seven‐scale score. Fifty‐four patients with 57 types III‐B (n = 41) and III‐C (n = 16) open tibial fractures sustained between 1980 and 1989 were recalled for evaluation. There were 45 men and 9 women (average age, 28.4 years; range, 4–68 years). Follow‐up periods averaged 48.2 months (range, 12–116 months). Salvage rate for the III‐B fractures was 75% (n = 31) and for the III‐C fractures 37% (n = 6). We conclude that the functional score is a simple and complete method for assessing the functional outcome of patients undergoing limb salvage procedures.

Bone graft harvest site options in orthopaedic trauma: A prospective in vivo quantification study

BackgroundAnatomic reduction of intra-articular fractures of the tibial plateau and distal radius can be difficult to achieve. Treatment goals are centered on restoring the native anatomy and articular congruency. Several surgeons in the USA have begun using an inflatable bone tamp to reduce these fracture patterns. The concept is built on the success of the tamp in kyphoplasty of the spine, but it has yet to be tested in the lab for use in the extremities. We performed an investigation into the safety and efficacy of using an inflatable bone tamp for intra-articular fracture reduction of the tibial plateau and distal radius.Materials and methodsPaired cadaveric specimens were obtained for a total of six proximal tibias and six distal radii. Intra-articular depression-type fractures were created in all specimens. The inflatable bone tamp was then used to reduce the depression. For comparison, the tibias were fractured on the medial and lateral side and a conventional metal tamp was used on the contralateral side of the balloon. Fine-cut micro-computed tomography (CT) scans were performed on all intact specimens, which were then fractured, and again after fracture reduction. CT data was used to measure the amount of restoration of the normal anatomy and to compare the effectiveness of the balloon to conventional methods.ResultsThe inflatable bone tamp was equivalent to conventional methods in large, minimally displaced fracture fragments and proved superior when comminution was present at the articular surface. No instances of overreduction or penetration into the joint were encountered with the balloon, whereas this was a common occurrence with conventional metal tamps. The inflatable tamp was successful in reducing all distal radius fractures without complication.ConclusionAnatomic reduction of impacted articular fractures should be the goal of any treating surgeon. In our cadaveric models, we have shown the inflatable bone tamp to be safe and effective in reducing depressed articular fractures around the tibial plateau and distal radius. The balloon offers the advantage of being minimally invasive and creating a symmetric, contained defect to hold bone filler for subchondral support.

The in vivo behavior of gentamicin-PMMA beads in the maxillofacial region.

PURPOSE We compare autologous bone graft volume from three different harvest sites and the associated pain levels at one and four weeks post-harvest. METHODS We prospectively collected a total of 47 consecutive autologous bone grafts in our level I trauma centre between July 2010 and September 2010 - 12 from the anterior iliac crest (AIC), 19 from the olecranon and 16 from the lateral aspect of the proximal tibia. RESULTS The mean ages for each group were 44.8, 41.9 and 42.1, respectively, with no statistically significant differences for age or gender. The mean quantities harvested were, respectively, 6.2 cm(3) (cubic centimetres) from the AIC, 5.7 cm(3) from the olecranon and 7.3 cm(3) from the proximal tibia, with a statistically superior quantity from the proximal tibia when compared to the olecranon and no differences between the other sites. Analysis of the visual analogue scale (VAS) at one week and four weeks post-harvest confirmed statistically that pain was more severe at the AIC site when compared to both the olecranon and proximal tibia sites. There were no infections or neurovascular complications. CONCLUSIONS We conclude that the proximal tibia and olecranon are acceptable alternatives to the anterior iliac crest for autologous bone graft and may be preferred when the location of the primary injury permits.

A measurement of the coefficient of static friction of human long bones

Gentamicin-PMMA beads were placed in maxillofacial wounds of ten dogs, and gentamicin levels from wound drain sites, serum, and urine were measured by radioimmunoassay. The results indicate extremely high wound and modest urine levels (which decrease exponentially) concurrently with negligible serum levels of gentamicin. The results of this study of a highly vascularized area were similar to other studies in which beads were placed in avascular areas.

Clavicular caution: an anatomic study of neurovascular structures.

Abstract The coefficient of static friction for bone-to-bone contacting surfaces has been measured. Unembalmed human cadaveric tibial and femoral bones were cut with three types of surgical saw, two power driven and one hand held, and the bone-to-bone static friction was determined using an in vitro shear method. It was found that both the type of saw and the type of bone affected the coefficient of friction. Greater coefficients of static friction were found with a coarse cutting saw (the hand-held Gigli saw) and tibial bone which is harder than femoral bone. The findings suggest that a rough surface finish to cut bone, in a well-reduced fracture, should promote healing by stabilizing the fracture interface.