George Babikian

Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.

Fifty-six blunt multiple trauma patients (HTI-ISS 22-57) were studied for the effects of immediate versus delayed internal fixation of a femur or acetabular fracture on the pulmonary failure septic state. The pulmonary failure septic state may be defined as an alveolar arterial oxygen tension difference greater than 100, plus fever and leukocytosis. These patients were divided into four groups. Group I (N = 20) had immediate internal fixation, postoperative ventilatory support, and was sitting up at 30 hours. Group II (N = 20) had 10 days of femur traction and postoperative ventilatory support. Group III (N = 9) was immediately extubated after surgery and had 30 days of femur traction. Group IV (N = 7) had special circumstances that should increase the duration of the pulmonary failure septic state. These four groups of patients were statistically identical by 20 different criteria on admission except that Group I had more recognized chest injuries than Group II (12 vs. 9). Group I required 3.4 +/- 2.6 days of ventilator support and 7.5 +/- 3.8 intensive care unit (ICU) days; they had 12 +/- 8.8 elevated white counts, 3.8 +/- 4 febrile days, 0.05 positive blood cultures per patient, four fracture complications out of 93 fractures, 59 injections of narcotics, and 23 +/- 8.6 acute care days. Ten days of femur traction doubled the duration of the pulmonary failure septic state relative to Group I at a statistically significant level for nine out of 10 criteria, while increasing the number of positive blood cultures by a factor of 10, the number of fracture complications by a factor of 3.5, and the use of injectable narcotics by a factor of 2. Thirty days of femur traction increased the duration of the pulmonary failure septic state relative to Group I by a factor of 3 to 5 for all criteria at a statistically significant level, while increasing fracture complications by a factor of 17, positive blood cultures by a factor of 74, and the use of narcotics by a factor of 2. Group IV, which had four out of seven immediate internal fixations, behaved similarly to Group II. Femoral shaft traction should be avoided in the blunt multiple trauma patients because it greatly increases the cost of care and the risk of multiple systems organ failure.(ABSTRACT TRUNCATED AT 400 WORDS)

Definitive control of mortality from severe pelvic fracture.

Within a group of 271 patients with pelvic fracture, 69 patients met criteria for severe hemorrhage. Sixty consecutive patients were treated by a combined multispecialty musculoskeletal trauma service using a protocol designed to control bleeding, rapidly diagnose and control associated injuries, as well as to prepare the patient for open reduction of the pelvic fracture, if appropriate. The pneumatic antishock garment, external fixation, and angiography were selectively used to control bleeding. Abdominal injuries were diagnosed using clinical examination and diagnostic peritoneal lavage. When lavage aspirate was grossly bloody, patients had no negative explorations. Microscopically positive lavages were associated with a 50% false-negative rate. Using the protocol, the mortality rate was 5%. Overall mortality rate was 10%. The combination of a trauma team approach and a specifically designed protocol reduces the number of deaths from pelvic fracture.

A High Prevalence of Corrosion at the Head–Neck Taper with Contemporary Zimmer Non-Cemented Femoral Hip Components

Mechanically assisted crevice corrosion (MACC) occurs at metal/metal modular junctions in which at least one of the components is fabricated from cobalt-chromium alloy and may lead to adverse local tissue reaction (ALTR) in patients with metal-on-polyethylene (MoP) total hip arthroplasty. This type of reaction has been previously described in hips with head/neck modularity, but the prevalence is unknown. We found a prevalence of 1.1 percent in a consecutive series of 1356 contemporary Zimmer non-cemented femoral hip components followed for a minimum of 2years. The average time to presentation was 3.7years (range, 9-105months); delay in treatment led to irreversible soft tissue damage in three patients. We recommend usage of ceramic heads until this problem is further understood.

Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts

The use of allograft struts and cerclage wire, possibly augmented by plate fixation, for the treatment of Vancouver type-B1 peri-prosthetic fractures around a total hip replacement has been strongly advocated. We examined our results using plate fixation without allograft struts and compared them with the results of the use of struts alone or when combined with plate fixation. Of 20 consecutive patients with type-B1 fractures treated by open reduction and plate fixation, 19 were available for follow-up. The fractures healed in 18 patients with a mean time to weight-bearing of ten weeks (4 to 19). There were no cases of infection or malunion. Nonunion occurred in one patient and required a second plate fixation to achieve union. Safe, cost-effective treatment of Vancouver type-B1 fractures can be performed by plate fixation without the addition of cortical struts. This procedure may allow earlier weight-bearing than allograft strut fixation alone.

Nonunion of the clavicle treated with plate fixation: A review of forty-seven consecutive cases

Forty-seven consecutive patients underwent superior plating for clavicular nonunion between 1995 and 2005. This retrospective analysis was performed to assess the efficacy of plate fixation and the need for iliac crest bone grafting. Forty-three patients were treated with pelvic reconstruction plates and four with straight dynamic compression plates. Of the patients, 30 were treated with local bone graft only, 14 with demineralized bone matrix, and 3 with distant autogenous bone graft. Of the fractures, 93% united after a single operation. Of the patients, 69% returned the Disabilities of the Arm, Shoulder and Hand questionnaire. The mean Disabilities of the Arm, Shoulder and Hand score was 14.6 (range, 0-53). Plate prominence or sensitivity resulted in removal in 20% of cases. We believe that superiorly applied plate fixation is effective for the treatment of clavicular nonunion. Distant autogenous bone graft is not necessary in most cases to obtain union.

Elevation in compartment pressure following hypovolemic shock and fluid resuscitation: a canine model.

We induced hemorrhagic shock in seven dogs and then resuscitated them with intravenous (IV) lactated ringers. We then monitored anterior leg compartment pressures via a slit catheter during both bleeding and reperfusion. These values were compared with controls that received IV fluids without being bled. Compartment pressures in resuscitated dogs rose well above control values. These values were statistically significant when compared to controls via the paired student t test (P < .01). This model demonstrates that sufficient swelling occurs to significantly elevate compartment pressures, even in the absence of local trauma. While this elevation may not be sufficient enough to cause a compartment syndrome, it reinforces the notion that extremities that have experienced ischemia and reperfusion are at an increased risk for developing compartment syndrome.

Rotational remodeling of malrotated femoral fractures : a model in the rabbit

It is estimated that 20–40% of femoral fractures in children heal in malrotation, yet few patients later complain. To determine if malrotation corrects spontaneously, midshaft osteotomies were made in femurs of 16 rabbits aged 8 weeks and the distal fragments were internally rotated 45°, where they were held with external fixators. The animals were killed between week 0 and week 17. Version of the femoral necks was determined by computed tomography scan (CT). The version altered rapidly toward normal from weeks 0 to 4 and then remained stable, with an average rotational remodeling of 55%.

The Cost and Outcome Effectiveness of Total Hip Replacement: Technique Choice and Volume–Output Effects Matter

BackgroundTotal hip replacement (THR) must be managed in a more sustainable manner. More cost-effective surgical techniques and the centralization/regionalization of services are two solutions. The former requires an assessment of newer minimally invasive and muscle-sparing surgical techniques. The latter necessitates an effective volume–outcome (VO) relationship. Prior studies have failed to evaluate and control for the VO relation.ObjectiveThe objective of this study was to evaluate the relative cost and outcome effectiveness of two minimally invasive and one muscle-sparing techniques while evaluating and controlling for a potentially endogenous VO relation.MethodsAn all payer claims database for all THR performed in Maine in 2011 was used. The cost and outcome effectiveness of newer minimally invasive (modified Hardinge) and muscle-sparing (modified Watson-Jones) techniques were compared with the standard bearer posterior minimally invasive method. Using regression analysis, the outcomes analyzed were as follows: total costs, length of hospital stay, nursing care and home discharges, and use of physical therapy. Regression analysis was also used to evaluate and control for VO effects.Results(1) Newer muscle-sparing and minimally invasive approaches are substantially more effective; (2) irrespective of technique, higher volume surgeons are more effective; (3) technique-specific VO effects for more complex techniques exist and show substantial savings when yearly volume exceeds 30–50; and (4) the anterolateral muscle-sparing technique is accessible to the average surgeon.ConclusionReliance on newer surgical techniques and centralization/regionalization of THR services can reduce costs.