John H. Wilber

Impact of Smoking on Fracture Healing and Risk of Complications in Limb-threatening Open Tibia Fractures

Objectives: Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders. Setting: Eight Level I trauma centers. Patients: Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105). Outcome Measure: Time to fracture healing, diagnosis of infection, and osteomyelitis. Methods: Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics Results: After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection. Conclusion: Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.

Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma

BACKGROUND Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system. METHODS Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation. RESULTS Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity. CONCLUSION Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

The Effect of Laparotomy and External Fixator Stabilization on Pelvic Volume in an Unstable Pelvic Injury

OBJECTIVE Determine if laparotomy further destabilizes an unstable pelvic injury and increases pelvic volume, and if reduction and stabilization restores pelvic volume and prevents volume changes secondary to laparotomy. DESIGN Cadaveric pelvic fracture model. MATERIALS AND METHODS Unilateral open-book pelvic ring injuries were created in five fresh cadaveric specimens by directly disrupting the pubic symphysis, left sacroliac joint, and sacrospinous and sacrotuberous ligaments. Pelvic volume was determined using computerized axial tomography for the intact pelvis, disrupted pelvis with both a laparotomy incision opened and closed, and disrupted pelvis stabilized and reduced using an external fixator with the laparotomy incision opened. MEASUREMENTS AND MAIN RESULTS The average volume increase in the entire pelvis (from the top of the iliac crests to the bottom of the ischial tuberosities) between a nonstabilized injury with the abdomen closed and then subsequently opened was 15 +/- 5% (423 cc). The average increase in entire pelvic volume between a stabilized and reduced pelvis and nonstabilized pelvis, both with the abdomen open, was 26 +/- 5% (692 cc). The public diastasis increased from 3.9 to 9.3 cm in a nonstabilized pelvis with the abdomen closed and then subsequently opened. Application of a single-pin anterior-frame external fixator reduced the pubic diastasis anatomically and reduced the average entire and true (from the pelvic brim to the ischeal tuberosities) pelvic volumes to within 3 +/- 4 and 8 +/- 6% of the initial volume, respectively. CONCLUSIONS We believe that the abdominal wall provides stability to an unstable pelvic ring injury via a tension band effect on the iliac wings. Our results demonstrate that a laparotomy further destabilized an open-book pelvic injury and subsequently increased pelvic volume and pubic diastasis. This could potentially increase blood loss from the pelvic injury and delay the tamponade effect of reduction and stabilization. A single-pin external fixator prevents the destabilizing effect of the laparotomy and effectively reduces pelvic volume. These data support reduction and temporary stabilization of unstable pelvic injuries before or concomitantly with laparotomy.

Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity.

BACKGROUND Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay. METHODS Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations. RESULTS Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation. CONCLUSIONS Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries.

BACKGROUND Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications. METHODS Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury. RESULTS Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04). CONCLUSIONS Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.

Gerdy's tubercle osteotomy for the treatment of coronal fractures of the lateral femoral condyle.

Coronal fractures of the femoral condyle (Hoffa fractures) are intraarticular fractures that are commonly treated surgically by open reduction and internal fixation. Surgical fixation is demanding because anatomic reduction is mandatory and adequate exposure is often difficult. Herein we describe a new technique that permits excellent visualization and fixation of lateral Hoffa fractures based on osteotomy of Gerdys tubercle and reflection of the attached iliotibial band.

Functional outcome of bilateral limb threatening: Lower extremity injuries at two years postinjury

Objectives: To describe the functional outcome of bilateral limb-threatening injuries at 2 years postinjury and to evaluate whether a different decision-making process should be used for these patients as opposed to patients with unilateral limb-threatening injury. Design/Setting/Patients: This study population of 32 patients is a subset of 601 patients from a study of 8 level I trauma centers. The patients were prospectively followed through 24 months. Main Outcome Measurements: The principle outcome measure at 2 years was the Sickness Impact Profile, designed to measure physical and psychosocial dimensions. Results: The overall Sickness Impact Profile scores at 2 years demonstrate that all 3 bilateral injury groups (bilateral salvage [n = 14], unilateral salvage/amputation [n = 8], and bilateral amputation [n = 10]) were severely disabled (Sickness Impact Profile >10). The bilateral salvage group had the most dramatic improvement over the 24 months. The 2-year physical subscale Sickness Impact Profile data showed a similar trend. At the 2-year assessment, the bilateral amputation group was recording greater disability (Sickness Impact Profile = 16.3) compared to the bilateral salvage and unilateral amputation/salvage groups (Sickness Impact Profile = 8.5 and 12.6, respectively). The overall Psychosocial Dimension, which started off worst in the bilateral salvage group, ended up similar in all 3 groups (8 to 9). The percent of patients who returned to work was 66.7% in the unilateral salvage/amputation group versus 21.4 and 16% in the bilateral salvage and amputation groups, respectively. Conclusions: The results indicate that treatment judgments should be based upon the results derived from the analysis of the larger unilateral limb cohort data. Patients with severe, bilateral lower extremity injuries should be counseled that regardless of treatment combinations, the function of each limb is similar at 24 months. The unilateral amputation/salvage group had a greater probability of going back to work. This is the major identifiable benefit to undergoing salvage versus amputation.

Blood flow changes to the femoral head after acetabular fracture or dislocation in the acute injury and perioperative periods.

Objectives Acute blood flow to the femoral head has been postulated to be affected negatively by traumatic acetabular fracture or dislocation. To the best of our knowledge, a prospective study that has examined acute changes in blood flow to the femoral head with respect to the timing of reduction and the effect of open reduction and internal fixation after acetabular fracture or dislocations has not been performed. Design and Setting From June 1994 to February 1996, fifty-four consecutive patients with hip dislocations with or without fractures of the acetabulum were entered into this investigation. The patients were categorized into three groups: isolated dislocations, fractures or dislocations requiring open reduction and internal fixation, and isolated acetabular fractures without dislocation but requiring open reduction and internal fixation. Single-photon emission computed tomography (SPECT) scans were obtained after relocations and preoperatively and postoperatively after open reduction and internal fixation of displaced acetabular fractures. Results The median dislocation time for all patients flow was 4.00 hours (range 1 to 24 hours). SPECT scanning showed a low blood flow pattern in five (9.25 percent) patients. A low blood flow pattern was seen in patients with early and late relocation times. Open reduction and internal fixation was not statistically associated with an avascular pattern of blood flow. Forty-two (78 percent) of our patients were available for follow-up, with an average of 24.3 months and a minimum of one year. There was one false-positive, one false-negative, and thirty-eight true-negative scans. Conclusions A global loss of scintillation in the femoral head as determined by SPECT scanning occurs in some patients with hip dislocations and fractures or dislocations of the acetabulum in the early injury period. Changes in blood flow occurred in patients with short (one hour) and long (twenty-four hours) dislocation times. However, the development of avascular necrosis could not be predicted by early SPECT scanning. Until further multicenter studies are performed, SPECT scanning cannot be recommended on an acute or routine basis to predict those patients who will develop avascular necrosis. Operative approaches for open reduction of the hip and internal fixation of acetabular fractures do not appear to affect blood flow to the femoral head. Although a golden time to relocation cannot be fully established from this study, early relocation is advised to decrease the potential risk of vascular spasm, scarring, and subsequent avascular necrosis.

Patterns and complications of femur fractures below the hip in patients over 65 years of age.

Summary This study is a retrospective review of 105 femur fractures below the hip in 99 patients over 65 years of age treated between 1970 and 1986. Problems in medical management and a high complication rate prompted this study, which focused on the fracture patterns and complications associated with these injuries. There were 25 subtrochanteric, 47 shaft, and 33 supracondylar fractures. These were isolated injuries in 89 of the patients. The overall complication rate was 45%; the orthopaedic complication rate was 15%. The mortality rate was 10% within 60 days of injury. Thirty-nine patients (39%) returned to their preinjury functional status or were able to walk with ambulatory assistive devices. Changes in mental status before fracture were associated with an increased rate of complications. Age, sex, preinjury functional status, number of preexisting medical problems, timing of surgery, type of anesthesia, and operative versus nonoperative treatment were not significantly different between survivor and nonsurvivor groups. The development of a new, postinjury medical problem in the acute treatment period was the most significant factor leading to a poor result and death. Successful management of this fracture requires aggressive medical management in the elderly.

Case Report: Irreducible Fracture Dislocation of the Knee

A unique case of an irreducible fracture dislocation of the knee is reported. A review of the literature revealed no previously reported cases of fracture dislocation of the distal femur not amenable to closed reduction.