Henry M. Broekhuyse

Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft : A prospective, randomized study

Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not differ significantly between the groups. We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft, although more screws broke when reaming had not been done.

Early Fixation of the Vertically Unstable Pelvis: The Role of Iliosacral Screw Fixation of the Posterior Lesion

OBJECTIVES To evaluate the effectiveness of the use of iliosacral screw fixation in the management of the vertically unstable pelvis. STUDY DESIGN Retrospective analysis with clinical follow-up of patients to assess functional outcome. METHODS Thirty-eight vertically unstable pelvic fractures were treated using iliosacral screw fixation. Anterior fixation was by means of plating in sixteen pelves and by external fixation in fifteen pelves. Four pelves had no anterior fixation. Complications were recorded and radiographs were analyzed to classify fractures and identify screw misplacement and malunion. Twenty-six patients had a functional evaluation. RESULTS Five patients (13 percent) suffered a pulmonary embolus in the early postoperative period, one of which was fatal, a hospital mortality of 2.6 percent. Screw misplacement occurred in five patients but there were no adverse sequelae. In thirty-four cases with radiographic follow-up, malunion was noted in fifteen cases (44 percent). A lower rate of malunion (36 percent) was noted with internal fixation of the anterior lesion. Of twenty-six patients with long-term follow-up, only four (15 percent) had no pain. Sacroiliac fusion for pain was performed in three patients (11 percent). Twelve patients (46 percent) returned to their preinjury occupation, six patients (23 percent) changed occupation, and nine patients (30 percent) had not yet returned to work by last follow-up. CONCLUSIONS Iliosacral screw fixation is a useful method of fixation in the vertically unstable pelvis but needs to be augmented by rigid anterior fixation to minimize malunion.

Surgical treatment of a displaced lateral malleolus fracture: The antiglide technique versus lateral plate fixation

Objectives To assess the outcomes of the surgical management of “isolated” displaced lateral malleolar fractures, comparing the techniques of lateral plating and antiglide plating as described previously. Design This is a retrospective review, being largely a surgeon-randomized comparative study. Setting The study was carried out at a university teaching hospital that serves as a provincial trauma referral service and provides local community care. The senior surgeons are all orthopaedic trauma subspecialists. Patients A total of 193 patients meeting our inclusion criteria, with isolated lateral malleolus fractures surgically treated at the Vancouver General Hospital between 1987 and 1998, were studied. Intervention Eighty-five were treated with antiglide plating, whereas the remaining 108 patients underwent traditional lateral plating. Main Outcome Measures The functional results were evaluated with the ankle scoring system described previously. We also compared the complication rates, including failure of fixation, infection, wound dehiscence, and need for hardware removal. Results Both groups were comparable for age, sex distribution, mechanism of injury, and occupation. There was no difference in ankle score, function, and infection rate. The incidence of wound dehiscence and reoperation for hardware removal was slightly higher in the lateral plate group, but the difference was not statistically significant. Conclusions The outcome of the surgical management of a displaced lateral malleolus fracture is comparable with both techniques. Although few studies have reported some advantages using the antiglide technique, our data do not support one technique over the other.

Biomechanical Evaluation of Proximal Humeral Fracture Fixation Supplemented with Calcium Phosphate Cement

Background: Proximal humeral fractures are common injuries, and numerous surgical methods have been described for their treatment. The biomechanical characteristics of various internal fixation devices that are used to treat these fractures have not been extensively studied, nor has the potential beneficial effect of calcium phosphate cement supplementation. Methods: We used a cadaveric three-part proximal humeral osteotomy model to perform a biomechanical evaluation of three types of internal fixation devices: a cloverleaf plate, an angled blade-plate, and Kirschner wires. The effect of supplementing the fixation with SRS (Skeletal Repair System) calcium phosphate cement was evaluated as well. Eighteen pairs of fresh-frozen humeri were obtained, and the bone-mineral density of each specimen was measured. In each pair, one specimen was secured with internal fixation alone and the contralateral specimen was secured with internal fixation combined with calcium phosphate cement. The specimens were tested cyclically in abduction and in external rotation for 250 cycles to evaluate interfragmentary motion. The specimens were then loaded to failure in external rotation to measure torsional load to failure and torsional stiffness. Results: Overall, there were no significant differences between the specimens treated with the blade and cloverleaf plates, whereas the specimens treated with Kirschner wires demonstrated more interfragmentary motion, less stiffness, and lower torque to failure. In general, supplementation with calcium phosphate cement led to significant improvements in the mechanical performance of all three forms of internal fixation as demonstrated by a significant decrease in interfragmentary motion, a significant increase in torque to failure, and a significant increase in torsional stiffness. The addition of calcium phosphate cement increased the stiffness of even the most osteoporotic specimens to levels that were higher than those of the most osteodense specimens that had been treated with internal fixation alone. Conclusion: The initial biomechanical properties of internal fixation as measured with use of a proximal humeral osteotomy model and three methods of fixation were significantly improved by the addition of calcium phosphate cement. Clinical Relevance: The addition of calcium phosphate cement may augment the mechanical characteristics of internal fixation of difficult, three-part proximal humeral fractures. The ability to stabilize the interface between the implant and cancellous bone, particularly in the presence of osteopenia, may make calcium phosphate cement a valuable clinical tool in the treatment of these difficult fractures.

Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?

Eighty-one open tibial fractures were treated by reamed intramedullary nailing. There were 38 type II, 23 type IIIa and 20 type IIIb injuries. At the end of the nailing procedure the first 26 fractures (15 type II, five type IIIa, and six type IIIb) had antibiotic prophylaxis and delayed closure of the open wound. The subsequent 55 fractures (23 type II, 18 type IIIa, and 14 type IIIb) had identical management but in addition had an antibiotic bead pouch inserted into the open wound following debridement. Three amputations were performed: one (3.8%) in the group treated without a bead pouch and two (3.6%) in the bead pouch group in patients with grade IIIb fractures and severe crushing injuries. Of the remainder, there were four deep infections (16%) in the 25 fractures treated prior to the use of the bead pouch and two (4%) deep infections in the 53 fractures following introduction of the bead pouch. Addition of the bead pouch to the wound management protocol was associated with a worthwhile reduction of deep infection.

Leading 20 at 20: top cited articles and authors in the Journal of Orthopaedic Trauma, 1987-2007.

Objective: To determine the 20 most cited articles and authors in the Journal of Orthopaedic Trauma during the first 20 years of publication, 1987 to 2007. Design: Review. Methods: We used Web of Science “cited reference search” to determine the most cited articles originating in the Journal of Orthopaedic Trauma from 1987 to 2007, the first 20 years of publication. The characteristics of each article were recorded. Next, we manually searched each authors citations for works in the same time period to determine the most cited authors. The number of first authorships for each author was then determined using Medline, and a relative citation impact ratio was calculated. Finally, citation reports for the journal overall were created to evaluate the citation impact of the journal over the last 10 years. Results: The top cited articles ranged from 64 to 566 citations with two articles over 100. Fifteen were clinical articles with the most common topic being tibia fractures (shaft, plateau, and pilon). The top cited authors ranged for 111 to 566 citations, whereas the citations per lead authorship ratio for the authors on that list ranged from 9.5 to 566 citations per lead authorship. The number of citations to the Journal of Orthopaedic Trauma overall over the last 20 years has increased from 181 in 1997 to 3050 in 2007. Conclusions: The influence of the Journal of Orthopaedic Trauma, its articles, and its authors is readily apparent in this review of the most cited articles and authors in the journal over its first 20 years of publication. This journal is a source of highly cited original articles and the work of many highly cited leaders in the field of orthopaedic trauma.

What outcomes are important for patients after pelvic trauma? Subjective responses and psychometric analysis of three published pelvic-specific outcome instruments.

Objective: The measurement of functional outcomes in pelvic fracture patients remains difficult for authors. The authors aimed to test the construct validity, respondent burden, floor and ceiling effects, and patient perception of 3 previously published pelvic outcome questionnaires. Design: Prospective case series. Setting: Level I Trauma Center. Patients: Those with surgically treated Orthopaedic Trauma Association (OTA) B and C pelvic ring disruption at greater than 12 months after treatment. Intervention: None. Main Outcome Measurement: Majeed Pelvic Score, Orlando Pelvic Score, Iowa Pelvis Score, Short Form-36, and Short Musculoskeletal Functional Assessment (SMFA). Results: The authors recruited 38 patients, 15 OTA C and 23 OTA B fractures, who had a mean of 57 months from surgery (13–115 months). Patients cited recreational/mobility difficulty (30), emotional stress and family strain (24), employment and financial difficulty (17), sleep disturbance and anxiety (9), and sexual function (6) as the most important consequences of their injuries. Each of the 3 pelvic outcome questionnaires showed a high correlation with the Physical Component Score of the SF-36, and both indices of the SMFA. None had a high correlation with the Mental Component Score of the SF-36, indicating that these scores do not capture psychologic distress and well-being, social functioning, and overall vitality. All 3 questionnaires demonstrated ceiling effects, with 21%, 18%, and 15% of respondents reporting the highest possible scores on the Iowa, Majeed, and Orlando scores, respectively. The time for completion was 3.6 ± 0.4 minutes for the Iowa score, 7.4 ± 0.4 for the Orlando score (not including radiographic assessment), and 2.6 ± 0.2 for the Majeed score. Fifteen patients preferred the Iowa score, 12 the Orlando score, and 11 the Majeed instrument. Conclusions: Three previously published pelvic outcome instruments were found to have strong construct validity based on correlation with the Physical Component Score of the SF-36 and both indices of the SMFA. Subjects identified mental and emotional outcomes as important consequences of their injury; however, none of the pelvic questionnaires measure these domains, as they all correlate poorly with the Mental Component Score of the SF-36. Ceiling effects limit the utility of the all 3 current instruments, and their reliability and responsiveness over time remain unknown. No currently available outcome instrument seems to captures all of the important consequences of these injuries.

Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures.

Objectives: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening. Design: Retrospective chart review. Setting: Level I trauma centre. Patients/Participants: Sixty-five patients with a median age of 51 years (interquartile range: 42–56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws. Intervention: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw. Main Outcome Measurements: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation. Results: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03). Conclusions: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures.

Objectives: To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position. Design: Retrospective cohort study, single centered. Setting: One level 1 trauma center. Patients: Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006. Intervention: Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position. Outcome Measures: Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score ≥18 and all those with a femur fracture and an Abbreviated Injury Score chest ≥3. Results: Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score ≥18. However, for the subgroup of Abbreviated Injury Score chest ≥3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044). Conclusions: For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.

Incidence, risk factors, and diagnostic evaluation of postoperative fever in an orthopaedic trauma population.

Objectives: To determine the incidence of positive diagnostic evaluations during the management of postoperatively febrile orthopaedic trauma patients. A secondary objective was to describe the incidence and risk factors for postoperative fever. Design: Retrospective study. Setting: The orthopaedic trauma service at a tertiary referral hospital. Patients: Postoperatively febrile orthopaedic trauma patients admitted from 2005 to 2008. Main Outcome Measures: In patients who developed postoperative fever (oral temperature ≥38.5ºC), records were reviewed to determine whether urinalysis, urine cultures, blood cultures, chest radiographs, or wound cultures were performed and subsequent results were recorded. Patient demographics including sex, age, and medical comorbidities were also noted. Results: A total of 106 subjects (18%) developed a postoperative fever, with a mean temperature of 38.8 ± 0.3ºC (range, 38.5–40.0ºC). Overall, 135 diagnostic tests were ordered with 14 being positive (10%). Yields per individual test were as follows: urinalyses, 7 of 34 (21%); urine cultures, 4 of 38 (11%); chest radiograph, 2 of 23 (9%); blood cultures, 1 of 38 (3%); and wound cultures, 0 of 2 (0%). Patients investigated on postoperative day 6 or later had a greater incidence of positive diagnostic evaluations (40%) than patients investigated on postoperative days 0–5 (16%). The single positive blood culture was found on postoperative day 16. Conclusions: Postoperative fever is common among orthopaedic trauma patients. Diagnostic evaluations have a low-positive yield, particularly in the early postoperative period. In the later postoperative period, physicians should be more suspicious for an infective source of fever because a traumatic inflammatory etiology of fever is less likely. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.