John T. Gorczyca

Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures

BACKGROUND Fixation of proximal humeral fractures is challenging. Locking plate technology offers mechanical advantages for treating unstable fractures in weak bone. In this study, we assessed the radiographic and clinical results of a single surgeons experience treating proximal humeral fractures with a locked proximal humeral plate. METHODS Fifty-three adult patients with a displaced proximal humeral fracture were treated with a proximal humeral locking plate over a forty-five-month period. A standard postoperative rehabilitation regimen was followed. Radiographs were made at two weeks, six weeks, three months, six months, and one year and were examined for fracture alignment, fracture displacement, hardware position, and healing. Postoperative outcomes were collected with questionnaires. RESULTS Fifty-two (98%) of the fifty-three fractures healed by six months. Nineteen patients (36%) had radiographic signs of a complication, including screw cutout with intra-articular displacement in twelve (23%), substantial (>10 degrees ) varus displacement in thirteen (25%), and osteonecrosis in two (4%). These radiographic signs of a complication occurred in twelve (57%) of twenty-one patients older than sixty years of age and in seven (22%) of thirty-two patients under sixty years of age (p = 0.0015). Screw cutout occurred in nine (43%) of the twenty-one patients older than sixty years. Patients with a complication had worse functional outcomes as measured with the Short Musculoskeletal Function Assessment (p < 0.05) and the Quick Disabilities of the Arm, Shoulder and Hand (p < 0.001) questionnaires. We were unable to demonstrate a relationship between fracture type and complications. Revision surgery was performed in seven (13%) of the fifty-three patients. There were no cases of infection, nerve injury, or hardware failure. CONCLUSIONS The use of locking plates in the surgical treatment of proximal humeral fractures is associated with an unexpectedly high rate of screw cutout and revision surgery, especially in patients older than sixty years who have a three or four-part fracture. The indications for open reduction and internal fixation in these patients require continued analysis.

Tibiotalar contact area : contribution of posterior malleolus and deltoid ligament

Sixteen fresh ankle specimens were tested under physiologic loads to evaluate the effect on the tibiotalar contact area of increasing-size posterior malleolar fracture fragments and disruption of the deltoid ligament. The tibiotalar joint was maintained in a neutral position, and contact areas were recorded on pressure sensitive film. Posterior malleolar fracture fragments of 25%, 33%, and 50% as visualized on lateral radiographs were created. The deltoid ligament was sectioned after the final fracture fragment was made. There was a corresponding decrease of 4%, 13%, and 22% in tibiotalar contact area with the increasingly larger fracture fragments. The final disruption of the deltoid ligament did not alter the contact area. Statistical analyses using Students t-test showed a statistically significant decrease in tibiotalar contact area in the samples with a fracture fragment of 33% and 50% involvement of the joint as compared with the control samples. Transection of the deltoid ligament produced no statistically significant further change in contact area. Displaced posterior malleolus fractures produce a significant decrease in contact area with 33% or greater involvement of the joint, which may predispose the tibiotalar joint to degenerative changes that should be lessened by anatomic reduction and internal fixation. Disruption of the deltoid ligament does not appear to alter contact area further, supporting the concept of repair as optional.

Modified Tibial Nails for Treating Distal Tibia Fractures

Objective: To determine the biomechanical consequences of cutting one centimeter off the tip of a tibial nail when treating distal tibia fractures with intramedullary nails. Design: Randomized laboratory investigation using matched pairs of cadaveric tibias with osteotomies made to resemble distal tibia fractures extending to four and five centimeters from the tibiotalar joints. Intervention: The smaller (four‐centimeter) distal tibias were stabilized using ten‐millimeter diameter tibial nails that had been modified by removing the distal one centimeter of the nail. The five‐centimeter distal tibias were stabilized with standard ten‐millimeter diameter tibial nails. Each tibia was tested in elastic compression, rotation, and compression‐bending on a servohydraulic materials testing machine. Main Outcome Measurements: Stiffness was calculated for each type of loading to compare stability of the modified nail construct to that of the standard nail construct. Results: Four‐centimeter distal tibia fragments stabilized with modified nails have comparable stiffness in compression and in torsion to five‐centimeter distal tibia fragments stabilized with standard tibial nails. The stiffness in compression‐bending was surprisingly low in both groups and differed by only 3.7 percent. Conclusions: Removal of one centimeter from the tip of a tibial nail allows placement of two distal interlocking screws in tibial fractures located four centimeters from the tibiotalar joint. The fixation strength achieved is comparable to that of standard intramedullary nailing of tibial fractures located five centimeters from the tibiotalar joint using two distal interlocking screws. Fixation strength with these distal fractures, however, is not strong enough to resist moderate compression‐bending loads. Thus, patients with distal tibia fractures treated with intramedullary nailing must follow weight‐bearing restrictions until significant fracture healing occurs to prevent coronal plane malalignment of the fracture.

Effect of Acute Reamed Versus Unreamed Intramedullary Nailing on Compartment Pressure When Treating Closed Tibial Shaft Fractures : A Randomized Prospective Study

OBJECTIVE To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures. DESIGN Randomized prospective study. SETTING University Hospital/Level I trauma center. PATIENTS Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury. INTERVENTION After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures. MAIN OUTCOME MEASUREMENTS Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively. RESULTS Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups. CONCLUSION These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.

The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures

This study compares the relative strengths of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures. A vertical sacral fracture was artificially induced by vertical loading in eight pelvises from cadavers, which were then fixed with two 6.5 mm iliosacral lag screws or two 6.4 mm transiliac bars. The pelvises were then loaded again to failure. The mean strength of iliosacral lag screw fixation was 819 newtons and for transiliac bars it was 1066 newtons, but the study was too small for the difference to be judged as statistically significant. Various advantages and disadvantages of each method of fixation are discussed.

A mechanical comparison of subtrochanteric femur fracture fixation.

OBJECTIVE To determine whether the mechanical properties of first-generation interlocking femoral nails are different from those of second-generation interlocking femoral nails in a subtrochanteric femur fracture model. DESIGN Randomized laboratory investigation using a synthetic subtrochanteric femur fracture model. SETTING Simulated stable and unstable fractures were created at three levels in the subtrochanteric region of synthetic femora. Instrumented specimens were tested elastically in a biomaterials testing system. INTERVENTION Synthetic femora were instrumented with either a statically locked first-generation femoral nail or a statically locked second-generation femoral nail. MAIN OUTCOME MEASUREMENTS Elastic stiffness for both the stable and unstable fracture groups was measured in both compression and torsion. Unstable fracture specimens were tested to failure in compression, and load to failure was measured. RESULTS Throughout the subtrochanteric region, second-generation femoral nail constructs were consistently stiffer in compression and torsion than were statically locked first-generation femoral nail constructs. In general, second-generation constructs also withstood larger loads to failure in the unstable fracture model. CONCLUSIONS Second-generation nails provided significantly enhanced mechanical stiffness compared with first-generation femoral nails when used to treat both stable and unstable subtrochanteric femur fractures. Although these results were obtained by using a well-controlled, mechanically consistent model, clinical validation of an increased incidence of fracture unions or of decreased time to union is required before we can recommend that second-generation nails be used routinely to treat subtrochantenic femur fractures.

Lateral extension of the ilioinguinal incision in the operative treatment of acetabulum fractures

The choice of which decision to use for open reduction and internal fixation of complex acetabulum fractures depends on several variables. We report on 26 patients in whom a lateral extension of the ilioinguinal incision was used to achieve fracture reduction and stabilization. The lateral extension allowed visualization of the lateral ilium, in some cases passage of cerclage wires around the anterior and posterior columns, and in some cases placement of lateral to medial lag screws above the dome of the acetabulum. Reduction with a step of 1 mm or less and a gap of 3 mm or less with joint congruence was achieved in 21 patients (81 per cent). No patients had clinically significant heterotopic ossification. One patient had a transient postoperative femoral neuropathy, one a superficial infection, and one a deep infection. We recommend this lateral extension as an option during surgery of complex acetabular fractures through the ilioinguinal incision.

Tibial fractures with infrapopliteal arterial injuries

Tibial fractures with associated infrapopliteal arterial injuries have been inadequately documented in the literature. Eighteen patients with these injuries were admitted to Boston City Hospital during a 10-year period. Three patients required below-knee amputation, and two of these had ischemic intervals of greater than 8 h before vascular treatment. Six patients had delayed diagnoses of arterial injuries, but none required amputation. There were 15 open and three closed tibial fractures. Nine fractures were badly comminuted. Eight of the 14 viable limbs had delayed unions, but only one was associated with local vascular insufficiency. Five patients had complaints attributed to vascular insufficiency without clinical findings. Our conclusion is that the limb with an infrapopliteal arterial insult combined with a tibial fracture can survive with patency of only the anterior tibial or posterior tibial artery. Poor clinical results correlate with the severity of bony injury and not with the particular arterial injury. The incidence of below-knee amputation can best be related to delay in vascular treatment.

Risk Factors for Failure of a Single Surgical Debridement in Adults with Acute Septic Arthritis

BACKGROUND Acute septic arthritis in a native joint may require more than one surgical debridement to eradicate the infection. Our objectives were to determine the prevalence of failure of a single surgical debridement for acute septic arthritis, to identify risk factors for failure of a single debridement, and to develop a prognostic probability algorithm to predict failure of a single surgical debridement for acute septic arthritis in adults. METHODS We collected initial laboratory and medical comorbidity data of 128 adults (132 native joints) with acute septic arthritis who underwent at least one surgical debridement at our institution between 2000 and 2011. Univariate and logistic regression analyses were used to identify potential risk factors for failure of a single surgical debridement. Stepwise variable selection was used to develop a prediction model and identify probabilities of failure of a single surgical debridement. RESULTS Of the 128 patients (132 affected joints) who underwent surgical debridement for acute septic arthritis, forty-nine (38%) of the patients (fifty joints) experienced failure of a single debridement and required at least two debridements (range, two to four debridements). Staphylococcus aureus was the most common bacterial isolate (in sixty, or 45%, of the 132 joints). Logistic regression analysis identified five independent clinical predictors for failure of a single surgical debridement: a history of inflammatory arthropathy (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.4 to 22.6; p < 0.001), the involvement of a large joint (knee, shoulder, or hip) (OR, 7.0; 95% CI, 1.2 to 37.5; p = 0.02), a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L (OR, 4.7; 95% CI, 1.8 to 17.7; p = 0.002), S. aureus as the bacterial isolate (OR, 4.6; 95% CI, 1.8 to 11.9; p = 0.002), and a history of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; p = 0.04). CONCLUSIONS Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus, or a history of diabetes had a higher risk of failure of a single surgical debridement for acute septic arthritis and requiring additional surgical debridement(s).

Open reduction internal fixation after displacement of a previously nondisplaced acromial fracture in a multiply injured patient: case report and review of literature.

SUMMARY A twenty-eight-year-old multiple trauma patient had a nondisplaced acromion fracture that was not detected until after it had displaced. Open reduction internal fixation was performed without complication and the patient achieved excellent shoulder abduction strength. Nondisplaced acromion fractures may displace if not protected. Open reduction internal fixation of displaced acromion fractures should be considered if deltoid muscle strength is important to the patient.