Drake S. Borer

Pelvic ring disruptions: Prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality

Objective To determine if age, fracture pattern, systolic blood pressure on arrival, base deficit, or the Revised Trauma Score is predictive of mortality, transfusion requirements, use of pelvic arteriography, later complications, or injuries associated with the pelvic ring disruption. Study Design Retrospective review of a prospectively collected database. Methods All closed pelvic ring disruptions seen between November 1, 1997 and November 30, 1999 were included. Predictive variables and outcome variables were recorded for each patient. Statistical analysis was used to determine if the above variables were predictive. Results Shock on arrival and the Revised Trauma Score were significantly associated with mortality, transfusion requirement, Injury Severity Score, and all the Abbreviated Injury Scores except the one for skin. In addition, the Revised Trauma Score was significantly associated with the use of pelvic arteriography and predicted more complications than did shock on arrival. Age was significantly associated with transfusion requirement, Injury Severity Score, the chest and skin Abbreviated Injury Scores, use of arteriography, and death. The mortality rate among patients who presented in shock was 57 percent. A Revised Trauma Score of less than 11 predicted mortality with a sensitivity and specificity of 58 percent and 92 percent, respectively. Shock on arrival predicted mortality with a sensitivity and specificity of 27 percent and 96 percent, respectively. Age greater than sixty years predicted mortality with a sensitivity and specificity of 26 percent and 91 percent, respectively. In our analysis of the fracture patterns, we were unable to demonstrate consistent, meaningful links between specific fracture classes and the outcome variables. Conclusions Shock on arrival and the Revised Trauma Score are useful predictors of mortality and transfusion requirements, Injury Severity Score, and Abbreviated Injury Scores for the head and neck, face, chest, abdomen, and extremities. In addition, the Revised Trauma Score predicts the use of pelvic arteriography and later complications. Age predicted transfusion requirement, Injury Severity Score, the chest and skin Abbreviated Injury Scores, use of arteriography, and death.

Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal.

Objective The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point. Design Prospective, randomized. Setting Level 1 trauma center. Patients Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled. Intervention Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeons preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used. Main Outcome Measures Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeons assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function. Results There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeons assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion. Conclusions Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome.

The use of a virtual three-dimensional model to evaluate the intraosseous space available for percutaneous screw fixation of acetabular fractures

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning.

The effect of screening for deep vein thrombosis on the prevalence of pulmonary embolism in patients with fractures of the pelvis or acetabulum: a review of 973 patients.

Objectives: In patients with pelvic or acetabular fractures, to compare the prevalence of pulmonary embolism in a time period without screening for deep vein thrombosis to that seen when a screening protocol was in place. Design: Retrospective. Setting: County hospital. Patients: All patients with closed fractures of the pelvis or acetabulum treated during the study periods. Intervention: Prophylaxis for deep vein thrombosis was the same for both groups. From November 1, 1997 though November 31, 1999, a screening protocol for deep vein thrombosis was employed using ultrasound and magnetic resonance venography. From January 1, 2000 through December 1, 2001, no screening was used. Main Outcome Measurement: Pulmonary emboli were recorded. Results: The 1997 to 1999 time period included 486 patients with fractures of the pelvis or acetabulum; the 2000 to 2001 time period included 487. In the period when a screening protocol was in place, 10 patients (2%) were diagnosed with pulmonary embolism by pulmonary arteriogram, autopsy, or ventilation perfusion scan. All but 2 who were diagnosed with pulmonary embolism had undergone screening for deep vein thrombosis, and none of the screening tests were positive. In the 2000 to 2001 time period, when no screening for deep vein thrombosis was done, 7 patients (1.4%) were diagnosed with pulmonary embolism, by pulmonary arteriogram, autopsy, spiral computed tomography scan, or high clinical suspicion. There was no significant difference between the prevalence of pulmonary embolism seen in 1997 to 1999 and that seen in 2000 to 2001 (P = 0.48). Conclusion: Discontinuation of screening for the diagnosis of deep vein thrombosis did not change the rate of pulmonary embolism.

Complications following the T extensile approach: A modified Extensile approach for acetabular fracture surgery-report of forty-three patients

Objective Analyze the prevalence and severity of surgical complications encountered with a modified extended iliofemoral approach, the “T extensile” approach, in the treatment of complex acetabular fractures Study Design Prospective. Methods During a sixteen-month study period, forty-three patients with complex acetabular fractures were treated via the T extensile approach. Perioperative antibiotics were used to prevent infection, and prophylaxis for heterotopic ossification was done with postoperative irradiation. Complications and clinical results were recorded. The patients were followed for an average of thirty months. Results Acceptable reductions were obtained in forty patients. Poor reductions were obtained in three patients. There were no infections or iatrogenic nerve injuries. Brooker Grade 1 heterotopic ossification was seen in nineteen patients, eight had Grade 2, two had Grade 3, and no heterotopic ossification was seen in the other fourteen patients. No patient who received radiation developed heterotopic ossification beyond Brooker Grade 2. Seven patients went on to require total hip arthroplasty. The remaining thirty-six patients had an average Harris Hip Score of 86. Conclusions Extensile exposures to the acetabulum can be safely carried out with limited morbidity, as long as appropriate steps are taken to limit predictable complications.

Technical aspects of limited open reduction and percutaneous screw fixation of fractures of the acetabulum

This article describes a technique for closed or limited open reduction and percutaneous screw fixation of acetabular fractures, indications and rationale for surgery, as well as fluoroscopic imaging techniques and screw pathways. In addition, complications found with the technique are also discussed.

Conflict of Interest, Bias, and Objectivity in Research Articles

To The Editor: We enjoyed the recent Current Concepts Review “The Use of Low-Intensity Ultrasound to Accelerate the Healing of Fractures” (83-A: 259-70, Feb. 2001), by Rubin et al. It sounds like ultrasound is the best thing since sliced bread—and it may be, but we were a little disappointed with the references. The section entitled “The Ability of Ultrasound to Accelerate Fracture-Healing in the Clinical Setting” cited twelve sources. Two of these were articles published in The Journal of Bone and Joint Surgery . The first, by Heckman, Ryaby, McCabe, Frey, and Kilcoyne1, found that ultrasound made tibial fractures heal faster. The second, by Kristiansen, Ryaby, McCabe, Frey, and Roe2, found that ultrasound made distal radial fractures heal faster. Since The Journal requires disclosure of potential conflicts of interest, the reader is told that for both papers, “One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Exogen, Incorporated.”1,2 The articles also show that Ryaby and McCabe are employees of Exogen and that Frey is an employee of Health Products Development, Inc. The reader is not told what form of support Exogen gave, how much support, or to whom it was given. A third article, published in Clinical Orthopaedics and Related Research, by Cook, Ryaby, McCabe, Frey, Heckman, and Kristiansen3 and cited in this section, was apparently a second look at the patients from the aforementioned two studies. Cook et al. showed that ultrasound makes fractures in …