Gregory J. Schmeling

Management of complex acetabular fractures through single nonextensile exposures

A review of 127 surgically treated acetabular fractures, treated between August 1986 and January 1991, using single nonextensile surgical exposures and indirect reduction techniques was conducted. There were 31 elementary and 96 associated fractures (Letournel). In 34 cases the fracture involved only one column and in nine cases an extensile or combined exposure was required, therefore these cases were excluded from the study. This left 84 complex fractures (involving two column) for review. In all cases either the anterior (ilioinguinal) or posterior (Kocher-Langenbeck) exposure was used. Indirect reduction of the involved and opposite column was achieved with either the Judet table, lateral trochanteric traction, or the femoral distractor. A satisfactory reduction was obtained in 90.5% (76 of 84) of the cases (concentric, gap < 3 mm, step off < 2 mm). The incidence of acute infection and heterotopic ossification was 0% and 2%, respectively.

The necessity of acute bone grafting in diaphyseal forearm fractures : A Retrospective review

OBJECTIVE To determine the union rate of forearm fractures where acute bone grafting was recommended but not performed. DESIGN Retrospective review. SETTING Regional level one trauma center. PATIENTS The criteria for inclusion in the study were patients with closed growth plates and a diaphyseal fracture of the radius, ulna, or both (including Monteggia and Galeazzi fracture-dislocations) that were treated with plate fixation. Patients were excluded from the study if they were lost to follow-up before radiographic documentation of bone union. The review identified 198 fractures that were eligible for inclusion. Fifteen fractures were excluded. INTERVENTION The method of treatment of each fracture was open reduction and plate fixation with or without bone grafting. MAIN OUTCOME MEASUREMENT Fracture union. RESULTS The overall union rate in comminuted, nongrafted forearm fractures (open and closed) was 98% (99/101; 95% confidence interval: 93-100%). The union rate in closed, comminuted, nongrafted forearm fractures was 97% (74/76; 95% confidence interval; 91-100%). CONCLUSIONS Open reduction and internal fixation of comminuted diaphyseal forearm fractures without bone grafting in this study produced union rates comparable to those reported for open reduction and internal fixation of comminuted forearm fractures with acute bone grafting. This study suggests that routine use of bone grafting in comminuted forearm fractures is not indicated.

Somatosensory evoked potential monitoring in the surgical treatment of acute, displaced acetabular fractures. Results of a prospective study.

A prospective protocol was developed to prevent iatrogenic nerve injury during the surgical treatment of acute, displaced acetabular fractures in 103 patients. The protocol included an independent neurologic evaluation and perioperative somatosensory evoked potential (SEP) monitoring (tibial division only). The incidence of posttraumatic nerve injury was 29% (30/103 patients). The incidence of postoperative nerve injury was 5% (5/103 patients): complete sciatic, 0; tibial division, 0; peroneal division, 5. Somatosensory evoked potential monitoring of the tibial division is effective in preventing injury to this division. If perioperative SEP monitoring is used, independent stimulation of the tibial and peroneal divisions is recommended. High-risk groups for perioperative injury to the sciatic nerve include those patients with significant posterior column or wall displacement or posttraumatic sciatic nerve injury.

Nonreamed Intramedullary Nailing of Open Tibial Fractures.

Abstract The development of small-diameter interlocking intramedullary nails that can be inserted without reaming provides a fìxation option for open tibial-shaft fractures. Nonreamed intramedullary nailing of these injuries facilitates soft-tissue management without an increase in infection or nonunion rates relative to external fìxation. Reaming is not required, which means less injury to the tibial endosteal blood supply. Proximal and distal interlocking maintains better bone alignment than is possible with semirigid or noninterlocking intramedullary nails. The technique of using these devices with static interlocking is described, as are some suggested techniques for avoiding complications.

The use of cervical vertebrae plates for cortical substitution in posterior wall acetabular fractures.

We report a new technique for operative fixation of posterior wall acetabular fractures that require cortical substitution. This technique uses cervical vertebrae plates that are H-shaped as an alternative to the combination of standard locking or nonlocking pelvic reconstruction plates and cortical substitution plates, ie, spring plates. We believe this technique provides a more robust structural support with the plate acting as a cortical substitute in comminuted fracture patterns. Compared with pelvic reconstruction plates, cervical vertebrae plates are almost twice as wide. Additionally, the plate configuration allows more screws per unit length compared with pelvic reconstruction plates, potentially providing more points of fixation. Finally, cost comparison of the two plates shows the cervical vertebrae plates to be less expensive than standard pelvic reconstruction plates. Our series of 23 consecutive patients shows outcomes similar to the published literature for standard pelvic reconstruction plates, and initial results show no early hardware failure.

Stability of unicortical locked fixation versus bicortical non-locked fixation for forearm fractures.

Locking plate fixation is being widely applied for fixation of forearm fractures and has many potential advantages, such as fixed angle fixation and improved construct stability, especially in osteoporotic bone. Biomechanical data comparing locking devices to commonly used Low Contact Dynamic Compression (LCDCP) plates for the fixation of forearm fractures has been lacking. The purpose of this study was to compare the fixation stability of a 3.5-mm unicortical locked plate with bicortical non-locked LCDCP plates. Six matched pairs of fresh frozen cadaveric forearms were randomly assigned to unicortical locked and bicortical unlocked groups. Non-destructive four-point bending and torsional test was performed on the ulna and radius separately, using a servohydraulic testing system to obtain construct stiffness of the intact specimens and specimens after osteotomy and plating. The specimens were then loaded to failure to test the fixation strength. The locked unicortical fixation showed significantly higher bending stiffness than the unlocked bicortical fixation, but with significantly lower stiffness and strength in torsion. Fixation strength was comparable between the two groups under bending, but significantly greater in the bicortical non-locked group under torsion. Findings from this study suggest that postoperative rehabilitation protocols may need modification to limit torsional loading in the early stage when using locked unicortical fixation. The study also points out the potential advantage of a hybrid fixation that combines locked unicortical and unlocked bicortical screws.

The effect of single-pass reaming on tibial nail insertion load and stress

This biomechanical study evaluated and compared the longitudinal and perpendicular stresses generated and the applied load required during the insertion of a tibial nail with three different insertion techniques. Insertion of a narrow-diameter nail using an unreamed technique generated significantly greater stress and required significantly greater applied load than either the single-pass reamed technique or a reamed technique. The single-pass reamed technique and the standard reamed technique were not significantly different from each other. This study biomechanically justifies the use of the single-pass reaming technique during the insertion of a narrow-diameter intramedullary nail in severe open tibial fractures. The use of this technique cannot be advocated until the biologic effect of single-pass reaming is more clearly defined.