Emil H. Schemitsch

Open fractures of the calcaneus: A review of treatment and outcome

Objectives The aim of this study was to evaluate the functional and clinical outcome of patients with open calcaneus fractures and to determine what factors were associated with these outcomes. Design Retrospective review of 2 level 1 prospective databases. Setting/Patients/Participants All patients admitted with an open calcaneal fracture to 2 level 1 trauma units between January 1, 1987 and April 1, 1996 were identified. Data regarding demographics, injury characteristics, and treatment and complications were documented using a standardized data abstraction form. Radiographs were reviewed to document the fracture type according to Essex-Lopresti. For those patients who had computed tomography scans available, the Sanders et al classification was applied and documented. Patients were contacted and asked to return for follow-up evaluation including the American Orthopaedic Foot and Ankle Society ankle/hindfoot score, the Maryland Foot Score, and the Short Form 36 (SF-36). For patients not willing to return for examination, the questionnaires were completed over the telephone, and the objective scoring components were assigned to lowest score possible. Results Of 177 calcaneal fractures in patients treated as inpatients during the study period, we identified 30 open fractures in 29 patients. Twenty-seven patients had associated injuries. Two patients underwent amputation within 24 hours due to severe crush injury. Following urgent debridement, soft tissues were closed primarily (22 fractures) or with split thickness skin grafting (4 fractures) and free flap coverage (2 fractures); temporary spanning external fixation was used in 3 patients. Definitive fracture care was at the discretion of the treating surgeon and consisted of closed reduction without fixation (10 fractures), open reduction and bone grafting (1 fracture), minimal Kirschner wire (K wire) fixation (12 fractures), and formal lateral open reduction and internal fixation (5 fractures). There were no late amputations. There were no deep infections. Twenty-one of the 28 patients with salvaged limbs returned for follow-up evaluation, and 3 additional patients agreed to be interviewed by telephone. The average time to follow-up was 49 months with a range of 25 to 106 months. The overall American Orthopaedic Foot and Ankle Society ankle/hindfoot scores and Maryland Foot Scores were fair to poor. The average SF-36 results were within 1 standard deviation of published Canadian norms. Worse function was observed in patients with plantar wounds. Severely comminuted fractures had the worst function, whereas single joint depression injuries had the best functional outcome. Conclusion Infection is uncommon following open calcaneus fractures treated with aggressive soft tissue management. Patients with plantar wounds and comminuted fractures are expected to have particularly poor functional results.

Biomechanical evaluation of extramedullary versus intramedullary fixation for reverse obliquity intertrochanteric fractures.

Objectives: This study evaluated the 135-degree hip screw, 95-degree hip screw, and intramedullary hip screw (IMHS) for fixation of reverse obliquity intertrochanteric fractures. Methods: Twelve matched pairs of human femora (mean age 64 years) were obtained. Osteotomies were created in left femurs at a 33-degree angle, running inferolaterally from the lesser trochanter to mimic reverse obliquity intertrochanteric fractures. Right femora acted as controls. Three groups of left femora (n = 4 per group) had a 135-degree hip screw, 95-degree hip screw, or IMHS inserted. Strain gages were placed distal to the fracture site to monitor fragment strain. A linearly variable differential transformer measured lateral displacement of the proximal femur. An Instron tester applied vertical loads to the femoral head. Outcome measures of stiffness, strain, and lateral displacement were determined at 25-degree adduction, 25-degree abduction, 25-degree flexion, and 90-degree flexion. A 2-cm bone gap was then created at the fracture site to simulate comminution and the mechanical tests repeated. Failure load was assessed in 25-degree adduction with a bone gap. Results: There was no difference in normalized stiffness between constructs before creation of a gap. After gap creation, stiffness of all constructs was reduced (P = 0.03), and there was a significant difference in adduction (135-degree hip screw, 46.6% ± 3%; 95-degree hip screw, 22.9% ± 2%; and IMHS, 53.7% ± 7.8%) (P < 0.05). Similar results were noted for abduction and flexion. There was no significant difference in lateral displacement between constructs before (P = 0.92) or after (P = 0.26) gap creation. Failure load was significantly different (135-degree hip screw, 1222 ± 560 N; 95-degree hip screw, 2566 ± 283 N; and IMHS, 4644 ± 518 N) (P = 0.02). Conclusions: With bone contact, there were no statistically significant differences in the stiffness between the constructs. With a gap, however, the IMHS bone implant construct was significantly stiffer and had a greater load to failure than the 135-degree and 95-degree constructs.

A prospective, randomized clinical trial comparing tibial nailing using fracture table traction versus manual traction.

OBJECTIVEnWe sought to determine the effectiveness of intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction.nnnSTUDY DESIGNnProspective, randomized clinical trial.nnnMETHODSnEighty-five tibial shaft fractures (in seventy-nine patients) treated by intramedullary nailing were randomized either to manual traction with the leg draped free or to standard fracture table traction applied through a boot attachment.nnnRESULTSnWe found that manual traction provided results, in terms of intraoperative parameters and quality of fracture reduction, similar to those with standard fracture table traction. Manual traction significantly reduced positioning time (twelve minutes versus twenty-five minutes, p = 0.002) and also allowed for multiple simultaneous or sequential procedures in polytrauma patients without the need for re-positioning or re-draping. This saved a further thirty-two minutes (mean) in 37 percent of cases treated by manual traction.nnnCONCLUSIONnManual traction for intramedullary nailing of the tibia is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures. It is especially useful in polytrauma patients with multiple lower-extremity injuries.

Managing bone defects.

The management of bone defects caused by trauma and nonunion continues to represent a substantial clinical challenge in the management of orthopaedic trauma patients. A variety of treatment options have been described and reported in the literature. The relative rarity of these injuries means that high level, comparative evidence to guide their management is sparse. As such, treatment decisions must be based on knowledge of the available evidence, contemporary fracture management principles, and consideration of patient and surgeon factors. This article reviews the available evidence for the different treatment options available for the management of bone defects.

Ideal tibial intramedullary nail insertion point varies with tibial rotation.

Objectives: The aim of the study was to investigate how superior entry point varies with tibial rotation and to identify landmarks that can be used to identify suitable radiographs for successful intramedullary nail insertion. Methods: The proximal tibia and knee were imaged for 12 cadaveric limbs undergoing 5° increments of internal and external rotation. Medial and lateral arthrotomies were performed, the ideal superior entry point was identified, and a 2-mm Kirschner wire inserted. A second Kirschner wire was sequentially placed at the 5-mm and then the 10-mm position, both medial and lateral to the initial Kirschner wire. Radiographs of the knee were obtained for all increments. The changing position of the ideal nail insertion point was recorded. Results: A 30° arc (range, 25°–40°) provided a suitable anteroposterior radiograph. On the neutral anteroposterior radiograph, the Kirschner wire was 54% ± 1.5% (range, 51–56%) from the medial edge of the tibial plateau. For every 5° of rotation, the Kirschner wire moved 3% of the plateau width. During external rotation, a misleading medial entry point was obtained. A fibular bisector line correlated with an entry point that was ideal or up to 5 mm lateral to this but never medial. The film that best showed the fibular bisector line was between 0° and 10° of internal rotation of the tibia. Conclusions: The fibula head bisector line can be used to avoid choosing external rotation views and, thus, avoid medial insertion points. The current results may help the surgeon prevent malalignment during intramedullary nailing in proximal tibial fractures.

Prognostic Factors for Reoperation After Plate Fixation of the Midshaft Clavicle.

Objectives: To determine which prognostic factors were associated with an increased risk for all-cause reoperation in a heterogeneous population of patients treated with primary plate fixation of a midshaft clavicular fracture. Design: Retrospective observational study. Setting: Single university-affiliated tertiary care Level 1 trauma center. Patients: Of 235 consecutive patients with primary plate fixation for a midshaft clavicular fracture. A reviewer extracted data through a retrospective chart review regarding 20 possible prognostic variables and documented reoperations (defined as any surgical procedure after the initial surgery, including implant removal, bone grafts, implant exchanges, or debridement for infection). Intervention: Open reduction and internal fixation of the clavicle using straight and precontoured clavicle plates. Main Outcome Measurements: Complete 2-year follow-up information was available for 153 of 235 patients (65%). Of these 153 patients included in the analysis, 58 (38%) had reoperations. The preoperative risk factors for 3 specific “reoperation outcomes” were examined: (1) reoperation for implant removal alone; (2) reoperation for nonunion, infection, or fixation failure; and (3) multiple reoperations. Results: There was a significant reoperation rate in this patient series (58 of 153 patients, 38%). Although most were for isolated plate removal (42 of 153 patients, 27%), there were a minority of patients who required more complex (16 of 153 patients, 10%) or multiple (8 of 153 patients, 5%) procedures. For these 3 possible outcomes (reoperation for implant removal alone, reoperation for nonunion, infection, or fixation failure, and the need for multiple reoperations), significant risk factors were identified that can assist surgeons in patient selection and predicting reoperation after plate fixation of midshaft clavicle fractures. The significant risk factors for implant removal alone (42 of 153, 27%) were the use of a plate that was not precontoured and patient height <175 cm. The significant risk factors for reoperation for nonunion, infection, or fixation failure (16 of 153, 10%) were illicit drug use, diabetes, and previous surgery of the shoulder. The significant risk factors for multiple reoperations (8 of 153, 5%) were age >55 years and alcohol use >15 drinks per week. Conclusions: The use of precontoured plates can decrease the rate of hardware removal after primary fixation of displaced fractures of the midshaft clavicle. Also, specific preoperative prognostic factors may be used to counsel patients, maximize outcomes, minimize serious complications, and limit revision surgery. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial.

Objectives: The aim of this study was to compare early weightbearing and range of motion (ROM) to nonweightbearing and immobilization in a cast after surgical fixation of unstable ankle fractures. Design: Multicentre randomized controlled trial. Setting: Two-level one trauma centers. Patients: One hundred ten patients who underwent open reduction and internal fixation of an unstable ankle fracture were recruited and randomized. Intervention: One of 2 rehabilitation protocols: (1) Early weightbearing (weightbearing and ROM at 2 weeks, Early WB) or (2) Late weightbearing (nonweightbearing and cast immobilization for 6 weeks, Late WB). Main Outcome Measurements: The primary outcome measure was time to return to work (RTW). Secondary outcome measures included: ankle ROM, SF-36 heath outcome scores, Olerud/Molander ankle function score, and rates of complications. Results: There was no difference in RTW. At 6 weeks postoperatively, patients in the Early WB group had significantly improved ankle ROM (41 vs. 29, P < 0.0001); Olerud/Molander ankle function scores (45 vs. 32, P = 0.0007), and SF-36 scores on both the physical (51 vs. 42, P = 0.008) and mental (66 vs. 54, P = 0.0008) components. There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the Late WB group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%, P = 0.005). Conclusions: Given the convenience for the patient, early improved functional outcome, and the lack of an increased complication rate, we recommend early postoperative weightbearing and ROM in patients with surgically treated ankle fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Ideal Total Hip Replacement Bearing Surface In The Young Patient: A Prospective Randomized Trial Comparing Alumina Ceramic-On-Ceramic With Ceramic-On-Conventional Polyethylene: Fifteen Year Follow-Up

BACKGROUNDnThe optimum bearing surface for total hip arthroplasty remains debatable. We have previously published our outcome at 10 years and this represents the 15-year follow-up.nnnMETHODSnA total of 58 hips (in 57 patients with a mean age of 42 years) were randomized to receive either ceramic-on-ceramic (CoC) or ceramic-on-polyethylene (CoP) total hip arthroplasty. We prospectively followed for survivorship, functional outcomes (using the Harris Hip Score and the St Michaels Hip Score [SMH]), and radiological outcomes.nnnRESULTSnAt a minimum of 15 years, 3 patients had died, but not been revised. Seven were lost to follow-up. Five cases from the CoP group were revised (4 for polyethylene wear and osteolysis). Four from the CoC were revised; one each for head fracture, instability, infection, and trunnionosis. Both groups showed statistically significant improvements in Harris Hip Score scores and SMH functional scores, with no difference between the 2 bearings. For the CoP group, there was an improvement from 15.6 to 21.5 in the SMH and from 48.8 to 88.7 (P > .05); and for CoC, this improvement was 15.8 to 23.5 and 50.3 to 94.6 (Pxa0>xa0.05), respectively. Mean wear rate of the polyethylene was 0.092 mm/y and for the CoC was 0.018 mm/y. Two patients in the CoC group had evidence of acetabular osteolysis vs 3 in the CoP. Six patients had femoral osteolysis in the CoC group and 12 in the CoP group.nnnCONCLUSIONnSurvivorship and function of the 2 bearing groups remains comparable; while the polyethylene wear and osteolysis may represent issues in the future.

An international, cross-sectional survey of the management of Vancouver type B1 periprosthetic femoral fractures around total hip arthroplasties

INTRODUCTIONnThe incidence of periprosthetic femoral fractures around total hip arthroplasties is increasing. Fractures around a stable implant stem (Vancouver type B1) are among the most common of these fractures. Various fixation strategies for Vancouver type B1 periprosthetic fractures have been reported in the literature; however, little high-level evidence exists. This study was designed to determine the current management strategies and opinions among orthopaedic surgeons treating Vancouver type B1 periprosthetic femoral fractures, and to evaluate the need for a large prospective randomized controlled trial for the management of these injuries.nnnMETHODSnOrthopaedic surgeon members of the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the Hip Society were invited to participate in a 51-item web-based survey surrounding the management of periprosthetic femoral fractures around total hip replacements, as well as the perceived need for future research in this area. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training.nnnRESULTSnFor Vancouver type B1 fractures, open reduction and internal fixation (ORIF) with locked plating was favoured slightly over ORIF with cable plating ± cortical strut allograft (51.1% versus 45.5%). When compared to cable plating with cortical strut allograft, respondents believed that isolated locked plating resulted in lower nonunion and reoperation rates, but similar infection and malunion rates. Subgroup analyses revealed that practice type, surgeon age, case volume, and fellowship training influenced surgeons management of periprosthetic femoral fractures and beliefs regarding complications. There is high demand for a large prospective randomized controlled trial for Vancouver type B1 fracture fixation.nnnCONCLUSIONSnConsensus surrounding the management of Vancouver type B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries.

Fretting Corrosion Testing of Total Hip Replacements with Modular Heads and Stems

Abstract Human hip joints with diseased cartilage and bone are commonly replaced using total hip replacements (THRs), which often have modular head and neck components that connect via matching taper, much like nested cones. Fretting corrosion occurs when subtle relative motion (i.e., micromotion) causes abrasion at the head–neck taper connection (i.e., fretting), thus allowing surrounding biofluids to degrade the material (i.e., corrosion). Corrosion then releases toxic metallic debris that causes local tissue lysis and painful inflammation, ultimately leading to revision surgery. However, concern with long-term systemic effects remains as the toxic debris diffuses throughout the body. Modular THRs are susceptible to fretting corrosion; however, they are important to allow intraoperative flexibility to reconstruct the joint with optimized biomechanics. Therefore, this chapter describes a procedure for investigating fretting corrosion of THRs, as well as how to analyze, present, and interpret results.