George V. Russell

Complications of acetabular fracture surgery in morbidly obese patients.

Objectives: To compare the early complications with operative treatment of acetabular fractures in morbidly obese (body mass index ≥40) patients when compared with all other patients. Design: Retrospective review. Setting: University medical center. Patients/Participants: Four hundred thirty-five consecutive patients with acetabular fractures operatively treated by a single surgeon. Forty-one of these patients were morbidly obese (group 1) and were compared with the remaining patients (group 2). Group 2, therefore, included patients who were clinically overweight and obese. Intervention: Operative repair of acetabular fracture. Main Outcome Measurements: Outcome variables included patient positioning time, total operative time, estimated intraoperative blood loss, length of hospital stay, perioperative complications, and late complications. Results: The average total operative time was 293 minutes for group 1 and 250 minutes (P = 0.008) for group 2. The hospital stay for group 1 averaged 26 days versus 15 days in group 2 (P < 0.01). There were 19 (46%) wound complications in group 1 compared with 49 (12%) in group 2 (P < 0.0001). Overall, there were complications in 26 of the 41 patients (63%) in group 1 and in 96 of the 394 patients (24%) in group 2. Group 1s relative risk of having a complication was 2.6 (95% confidence interval = 2.4-2.8) when compared with group 2. Conclusions: Our morbidly obese population had a statistically higher complication rate, longer operative times, and greater estimated intraoperative blood loss. The majority of complications were related primarily to wound healing problems and successfully controlled with aggressive approach to surgical debridement.

Gluteus minimus necrotic muscle debridement diminishes heterotopic ossification after acetabular fracture fixation.

OBJECTIVE The aetiology and pathogenesis of heterotopic ossification (HO) are still obscure. We evaluated the impact of necrotic gluteus minimus muscle (GMM) debridement on the formation of HO after operative treatment of posterior wall (PW) and associated transverse-posterior wall acetabular fracture (Tr/PW) fixations utilizing a Kocher-Langenbeck surgical exposure. METHODS Thirty-one consecutive patients with displaced PW or associated Tr/PW acetabular fracture-dislocations were operatively treated by a single surgeon using a Kocher-Langenbeck surgical exposure. Strict soft tissue technique was observed and self-retaining retractors were not used. Necrotic GMM was debrided in an attempt to diminish ectopic bone formation. RESULTS Twenty-nine patients were available for post-operative clinical and radiographic evaluations. HO occurred in 12 patients. Significant HO (Brooker class III or IV) was noted in only three patients (10%). There were no complications associated with debridement of necrotic GMM. CONCLUSIONS Necrotic GMM resection diminishes HO formation comparably to other reported series in which non-steroidal anti-inflammatory medications were used. Resection of the necrotic GMM from the zone of injury has proved to be an efficient and safe method of preventing significant HO in patients after operative fixation of PW and associated Tr/PW acetabular fractures treated through a Kocher-Langenbeck approach.

Perioperative complications associated with operative treatment of acetabular fractures

BACKGROUND Perioperative complications in a large number of consecutive patients with displaced acetabular fractures treated operatively were evaluated in an effort to elucidate potentially preventable complications. METHODS Perioperative complications were identified and evaluated in 131 consecutive patients with displaced acetabular fractures treated operatively using the Kocher-Langenbeck surgical exposure. The perioperative complications were identified using a registry. RESULTS There were a total of 76 complications related to the acetabular fracture and patient polytrauma. Eighteen complications resulted from technical errors and the patients postoperative course. Obese patients frequently had unusual perioperative complications. CONCLUSION Perioperative complications occur commonly in patients with displaced acetabular fractures treated operatively using a Kocher-Langenbeck surgical exposure. Some of these complications may be avoidable, and are related to polytrauma. Most technical complications should be avoidable. Unusual complications were identified, especially in obese patients.

Operative experience of pelvic fractures in the obese.

BackgroundDisruptions of the pelvic ring may be a significant short- or long-term source of morbidity and mortality. In the obese, temporary stabilization and definitive fixation of the injured pelvis is a much more difficult undertaking, requiring more surgeon expertise and larger surgical approaches. Complications that arise as a result of the operative fixation of pelvic ring injuries may significantly minimize any potential long-term benefits conferred by attempts at fixation.MethodsDuring a continuous 46-month period, 288 patients with pelvic ring injuries were prospectively enrolled into a database. A cohort of 186 nonobese patients (group 1) was compared to the cohort of 102 obese patients (group 2). Injury patterns were classified and outcome variables were grouped into perioperative variables, perioperative complications, and late complications.ResultsInjury patterns differed significantly between the two groups. There was an increase in the perioperative variables. Overall, there were complications in 19% of nonobese patients and 39% of obese patients (p < 0.001). Wound complications dominated in the obese group. There were 64 additional surgeries in 30 (16%) patients that were the direct result of complications in group 1 and 62 additional surgeries in 31 (31%) patients in group 2.ConclusionsIn the obese, the time commitment, postoperative complication rate, and subsequent surgery rate are significantly greater. In this patient population, special attention should be focused on operative and soft tissue techniques in an effort to lessen the infection risk, the most likely cause of morbidity.

Acetabular fracture patterns and their associated injuries

Objectives: Characterize relationships between acetabular fractures patterns and visceral organ injuries. Design: Retrospective review. Setting: University medical center. Patients/Participants: Three hundred twenty-three patients with displaced acetabular fractures identified in a prospectively maintained database. Intervention: Acetabular fractures were classified according to force vector at the time of injury. Posterior wall, posterior column, and posterior column/posterior wall injuries were assumed to have been caused by an axial load. The remaining seven acetabular fracture types were assumed to have resulted from a lateral or trochanteric load. Records were reviewed to establish any relationship between acetabular fracture patterns defined by their force vector and injuries to other skeletal and nonskeletal organ systems. Main Outcome Measurements: Comparison of organ injury end points of additional skeletal injury; bowel, bladder, brain, kidney, liver, spleen, and lung injury; retroperitoneal hematoma; and vascular injury of the pelvis. Data were analyzed using chi-square, with statistical significance defined as P < 0.05. Results: Acetabular fractures resulting from lateral loads had a statistically higher association with retroperitoneal hematomas (P < 0.001), spleen (P < 0.008), liver (P < 0.002), vascular (P < 0.001), kidney (P < 0.001), and bladder (P < 0.001) injuries than did posteriorly directed acetabular fractures. Transverse posterior wall fractures exhibited intermediate characteristics between axial load and the remaining lateral load patterns. Conclusions: Direction of force is important in the etiology of nonskeletal injury patterns. The possibility of additional nonskeletal injury increases from the rates seen in axial load patterns to those in lateral load patterns involving the anterior column.

Management of distal humerus fractures with minifragment fixation.

Minifragment implants provide several advantages for the stabilization of distal humerus fractures. Compared with small fragment implants, minifragment implants may provide enhanced fracture fixation because a greater number of screws can be placed into the distal fragments. In addition, minifragment plates are easier to contour and less prominent. We describe the surgical technique of minifragment fixation.

Is Obesity Protective Against Wound Healing Complications in Pilon Surgery? Soft Tissue Envelope and Pilon Fractures in the Obese

Open treatment of pilon fractures is associated with wound healing complications. A traumatized, limited soft tissue envelope contributes to wound healing complications. Obese patients have larger soft tissue envelopes around the ankle, theoretically providing a greater area for energy distribution and more accommodation to implants. This led us to test 2 hypotheses: (1) ankle dimensions in obese patients are larger than in lean patients, and (2) the increased soft tissue envelope volume translates into fewer wound complications. A consecutive series of 176 pilon fractures treated from March 2002 to December 2007 were retrospectively reviewed. Inclusion criteria were adults who received a preoperative computed tomography (CT) scan and were treated with a staged protocol including plating. Patients with body mass index (BMI) >30 were compared to those with BMI <30 for CT-derived ankle dimensions and wound complications. Comorbidities were evaluated for their role as potential confounders. Thirty-one fractures in obese patients were compared to 83 in lean patients. The average ratio of bone area to soft tissue area at the tibial plafond was 0.35 for the obese group and 0.38 for the lean group (P=.012). There were 8 major wound-healing complications. Four occurred in the obese group (incidence 13%), and 4 in the lean group (incidence 5%) (P=.252). Ankle dimensions in clinically obese patients are larger than in lean patients. Obesity does not appear to be protective of wound-healing complications, but rather there is a trend toward the opposite.

Complicated Femoral Shaft Fractures

The treatment of femoral shaft fractures has become safe and reproducible since the advent of popularization of intramedullary nailing, however, many femoral shaft fractures are complicated by associated fractures, extensive comminution, extensive contamination, and arterial injury compartmental syndrome. Other conditions associated with the use of femoral nailing include femora nonunions, broken hardware, acute fractures with prior implants, and infections. The management of these complex femoral shaft fractures demands special techniques for successful outcome.

Operative Fixation of Acetabular Fractures in the Pregnant Patient

Objective: To describe in utero radiation exposures in pregnant patients undergoing acetabular fracture repair. Design: Retrospective case series. Setting: University-affiliated regional trauma center. Patient/Participants: Eight pregnant patients with acetabular fractures treated over a 6-year period. There were an additional 518 acetabular fractures in nonpregnant patients treated during the same time period. Intervention: Open reduction and internal fixation of the acetabulum fracture. Outcome Measurements: None. This is a descriptive series reporting fetal radiation doses, fetal fluoroscopy exposure times, and fetal viability after treatment. Results: The gestational age of the fetuses at presentation ranged from 5 to 26 weeks. Infant delivery averaged 27 weeks from the time of surgery and all pregnancies reached 36 weeks. Apgar scores were normal each child including 1 twin delivery. There were 4 posterior wall fractures, 3 transverse or posterior wall fractures, and 1 posterior column fracture. Intraoperative pelvic fluoroscopy averaged 39 seconds. There were no operative complications and fracture reductions were anatomic in 7 patients. Computed tomography scan of the pelvis conferred the greatest exposure risk to the fetus and fluoroscopy conferred the least. In each case that required a computed tomography scan of the pelvis, the calculated radiation exposure dose to the fetus was greater than 5 cGy. Conclusions: The results of this study demonstrate that with a team approach and the judicious use of radiographic imaging during the surgical care of a displaced acetabular fracture in the pregnant patient, minimal risk to the baby can be achieved in pursuit of acceptable articular reductions.

Ipsilateral Clavicle Fracture, Sternoclavicular Joint Subluxation, and Long Thoracic Nerve Injury: An Unusual Constellation of Injuries Sustained During Wrestling A Case Report

Shoulder girdle injuries have been well documented after sports-related trauma. Common injuries include acromioclavicular joint disruption or clavicle fractures. Less frequently described are injuries to the sternoclavicular joint and long thoracic nerve. Each of these entities have been discussed in the literature; however, we are unaware of a reported case of all the three aforementioned injuries occurring simultaneously in one extremity. We report the case of a 16-year-old male athlete who sustained an ipsilateral clavicle fracture, sternoclavicular joint subluxation, and long thoracic nerve palsy while wrestling.