James J. Hutson

Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators.

OBJECTIVES To observe the incidence and clinical presentation of infection in periarticular fractures of the tibia and femur treated with tensioned wire external fixators. DESIGN Prospective cohort study. SETTING Level One Trauma Center in urban community. Single surgeon. PATIENTS One hundred thirty-five patients with 145 fractures: seventy tibial plateau, fifty-six pilon, and nineteen distal femur. Five-year treatment period, 1991 to 1995. MAIN OUTCOME MEASUREMENTS The incidence of infection was evaluated. RESULTS Nineteen of 145 fractures (13 percent) were complicated by infection. Infections presented as pin tract inflammation requiring intravenous antibiotics (seven), deep infection requiring debridement and removal (five), septic arthritis (three), deep fracture infection (three), and necrotizing fasciitis (one). CONCLUSIONS Infection is a common complication of juxtaarticular fractures treated with tensioned wire fixators. Excellent pin care is required. Aggressive management of infections with intravenous antibiotics and debridement will resolve infections occurring in patients treated with tensioned wire fixators. Septic arthritis is associated with wires placed less than one centimeter from the subchondral bone. Deep infection is associated with insidious swelling and excessive proliferative callus. Wire infections increase with prolonged frame time.

Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation

OBJECTIVE Evaluate the treatment of C3 distal femur fractures with limited internal fixation and tensioned wire circular external fixation. DESIGN Prospective cohort study, from June 1992 to July 1996. SETTING Urban Level I trauma center. PATIENTS Sixteen fractures in sixteen patients: nine male, seven female. Fractures: C3.1 one, C3.2 one, C3.3 fourteen. Twelve fractures were open: one GI, seven GII, two GIIIA, one GIIIB, and one GIIIC. INTERVENTION Fractures were treated with limited open fixation of the condylar joint surface and tensioned wire circular external fixation of the metaphysis and shaft for axial alignment. Three fractures had acute autologous bone grafts. MAIN OUTCOME MEASUREMENTS The patients extremity function was evaluated by the authors by using the Sanders et al. Distal Femur Functional Evaluation. RESULTS Sixteen of sixteen fractures healed. Two patients had delayed bone grafting for delayed union. Average frame time was twenty-five weeks. Average range of motion was 0 to 92 degrees. Five patients had less than 90 degrees of flexion. Five patients required a quadricepsplasty. Average follow-up was thirty-five months. One patient developed a pintract infection. One patient developed septic arthritis, and another developed osteomyelitis. The average Sanders et al. Function knee score was twenty-eight, with a maximum possible score of forty. CONCLUSIONS C3 fractures of the distal femur are associated with severe soft tissue injuries and bone loss. Loss of function appears to be directly related to these factors. Treatment with limited internal fixation and tensioned wire external fixation has equivalent results to other methods but has a higher incidence of infection and complications. Joint motion is retarded by binding of the soft tissues with fixation wires and pins. The technique is recommended only for salvage of severely comminuted and open fractures of the distal femur with extensive soft tissue injury. Distal femur fractures with moderate comminution and soft tissue injury should be treated with alternate methods.

An alternative method of osteosynthesis for distal humeral shaft fractures.

Treatment of extra-articular distal humerus shaft fractures with plating techniques is often difficult, as traditional centrally located posterior plates often encroach on the olecranon fossa, limiting distal osseous fixation. The use of a modified Synthes Lateral Tibial Head Buttress Plate (Synthes, Paoli, PA) allows for a centrally placed posterior plating of the humeral shaft that angles anatomically along the lateral column to treat far distal humeral shaft fractures. Fifteen patients treated in this manner were followed to radiographic and clinical union. There were no cases of instrumentation failure orloss of reduction.

The Use of Spring Plates in the Internal Fixation of Acetabular Fractures

The spring plate, a modified one third tubular plate, can be a viable and durable option for fixation of periarticular acetabular fractures. The use of the spring plate in acetabular fractures is demonstrated.

Salvage of Pilon Fracture Nonunion and Infection with Circular Tensioned Wire Fixation

Nonunion, malunion, and infection are complications encountered when treating fractures of the distal tibia extending into the joint surface. There is rank order of severity of those complications extending from a varus collapse of the medial column of the distal tibia with a reduced joint surface to an infected nonunion with destruction of the joint surface, segmental bone loss, and damaged soft tissue envelope. Malunion and malposition of nonunion of the distal tibia have a combination of angular deformity, translation, rotational malalignment, and shortening. These deformities require correction in the reconstruction and there are multiple technique pathways to achieving a successful reconstruction.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Lengthening of the femur over an existing intramedullary nail

Leg length discrepancies can occur despite successful union of femur fractures after intramedullary nailing (IMN). Often, the leg length discrepancy can result in significant disability to the patient, altered gait biomechanics, pelvic obliquity, and pain. Therefore, a successful clinical result for such deformities after IMN involves addressing the leg length inequality. Femoral reconstruction with an osteotomy around an existing intramedullary nail was introduced to address axial deformity correction and limb lengthening without changing or removing a previously inserted IMN. This technique uses the principles of lengthening over an IMN. The presence of the nail has minimized the time needed for the external fixator because the nail supports the regenerate bone or osteotomy during the consolidation phase. With this technique, surgery is minimized by avoiding the need for exchange nailing.