Julia M. Scaduto

Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries

Objective To evaluate the results of a vacuum-assisted closure device in patients presenting with open high-energy soft tissue injuries. Design Consecutive nonrandomized clinical study. Setting/Participants From August 1999 through October 2000, 21 patients, with 21 high-energy soft tissue wounds (6 tibial, 10 ankle, and 5 with wounds of the forearm, elbow, femur, pelvis, and a below-knee stump) were treated with a vacuum-assisted closure device at a Level 1 trauma center. Intervention A negative atmospheric pressure device used for the management of complex open injuries. Infected wounds had dressings changed every 48 hours, whereas all others had dressings changed every 72 to 96 hours. Main Outcome Measurements The duration of vacuum-assisted closure use, final wound closure outcome, costs versus standard dressing changes or free flaps, and a list of all complications were recorded. All patients were followed for 6 months postcoverage. Results Patients averaged 4.1 sponge changes, 77% performed at bedside, with the device used an average of 19.3 days. Twelve wounds (57%) required either no further treatment or a split-thickness skin graft, and 9 (43%) required a free tissue transfer. Conclusions The vacuum-assisted closure appears to be a viable adjunct for the treatment of open high-energy injuries. Application can be performed as a bedside procedure but additional soft tissue reconstruction may be needed for definitive coverage. This device does not replace the need for formal debridement of necrotic tissue, but it may avoid the need for a free tissue transfer in some patients with large traumatic wounds.

The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly.

Objective: The objective of this study was to evaluate acetabular fractures in elderly patients treated with open reduction internal fixation combined with acute total hip arthroplasty during the same anesthetic. Design: The authors conducted a retrospective analysis of a treatment. Setting: Level I and Level II trauma centers. Patients: Between September 1995 through January 2005, 22 elderly patients were treated using the combined hip procedure. There were nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury. Six patients had hip dislocations and 14 patients demonstrated some impaction. Patients underwent medical evaluations and clearance before surgical intervention. Intervention: Standard open reduction internal fixation techniques followed by immediate total hip arthroplasty during the same anesthesia. Ilioinguinal patients were repositioned and redraped for total hip placement. Main Outcome Measurements: Complications, physical examinations, and Harris hip scores assessed outcomes. Radiographs evaluated union and stability of the femoral and acetabular components, osteolysis, or the development of any heterotopic bone. Results: Follow up averaged 29.4 months. Surgeries averaged 232 minutes with 1163 mL average blood loss. Hospital stays approximated 8 days with full weightbearing occurring at 3 months. Hip motion averaged 102° of flexion, 32° of abduction, and 16° of adduction. Harris hip scores averaged 74. Four patients developed heterotopic ossification, and five underwent revisions as result of osteolysis or multiple hip dislocations. Conclusions: The combined hip procedure is an option for acetabular fractures in elderly patients. Complications, surgical times, and hospitalizations are consistent with open reductions or belated total hip arthroplasties. Aggressive medical workups may be needed, but a single posterior surgical procedure will avoid the “wait-and-see” approach often used for these patients.

Operative Treatment of Calcaneal Fractures in Elderly Patients

BACKGROUND Operative intervention is an accepted treatment for fractures of the calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures of the calcaneus in elderly patients. METHODS Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. RESULTS The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38 degrees of plantar flexion, 10 degrees of dorsiflexion, 16 degrees of inversion, and 11 degrees of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. CONCLUSIONS Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.

Conservative treatment of isolated fractures of the medial malleolus

Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3 degrees (25 degrees to 82 degrees ) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis. Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion.

Iatrogenic nerve injury in acetabular fracture surgery: a comparison of monitored and unmonitored procedures.

Objectives To review our experience with iatrogenic nerve injuries and to evaluate the efficacy of intraoperative monitoring in a large consecutive series of operatively treated acetabular fractures. Design Retrospective, nonrandomized. Setting Level I Trauma Center, January 1, 1992 through December 31, 1998. Patients/Participants A total of 256 consecutive acetabular fractures were operatively treated at our institution; 140 unmonitored procedures and 112 monitored procedures were available for review. The decision to use monitoring was at the discretion of the treating surgeon. Intervention Open reduction and internal fixation of the acetabular fracture. Main Outcome Measurement Preoperative and postoperative neurologic examinations, fracture type, use of traction, dislocation, operative approach, and complications were analyzed. Motor strength, sensation, the need for gait aids, orthoses, and extent of recovery were evaluated. Results Traumatic nerve palsies were present in eleven of 140 (7.9 percent) unmonitored and thirteen of 112 (11.6 percent) monitored fractures (p = 0.314). There were fourteen iatrogenic sciatic nerve palsies in 252 cases (5.6 percent). There were four iatrogenic sciatic palsies (2.9 percent) in the unmonitored group and ten iatrogenic palsies (8.9 percent) in the monitored group (p = 0.037). In the unmonitored group one of eighty-one Kocher-Langenbeck approaches (1.2 percent), two of fifty-two ilioinguinal (3.9 percent), and one of three extended iliofemoral approaches developed a sciatic palsy. In the monitored group six of seventy-seven Kocher-Langenbeck approaches (7.8 percent), three of twenty-five ilioinguinal (12 percent), and one of six combined approaches (16.7 percent) developed a sciatic palsy. In seven of the ten iatrogenic palsies in the monitored group, the intraoperative monitoring was normal. Seventy-six patients were monitored with somatosensory evoked potential alone, and nine had iatrogenic injuries (11.8 percent). Thirty-six patients were monitored with somatosensory evoked potential and electromyography, and one had an iatrogenic injury (2.8 percent) (p = 0.164). Clinical follow-up was available for three of the four patients with iatrogenic injuries in the unmonitored group, with a mean follow-up of twenty-seven months (range 8 to 60 months). Two patients had full motor recovery at a mean of six months, and one had no recovery at fourteen months. Conclusions The use of intraoperative monitoring did not decrease the rate of iatrogenic sciatic palsy. Further study involving larger prospective, randomized methodology appears warranted. Sciatic nerve injury was more common in ilioinguinal approaches in both groups, likely due to reduction techniques for the posterior column performed with the hip flexed, placing the sciatic nerve under tension.

Management of High-Energy Foot and Ankle Injuries in the Geriatric Population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Total Ankle Arthroplasty for the Treatment of Post-traumatic Arthritis

The use of total ankle replacement is a demanding procedure. Patient selection is important, and preoperative discussions should include a discussion of non-operative approaches and the use of other joint-sparing surgical approaches. Regardless of whether a two-component or three-component third-generation system is used equally, good outcomes can be expected. When the decision is made to use a TAR in patients with post-traumatic arthritis, patient positioning, surgical incision and dissection, tibial and talar preparation, positioning of the components, closure, and postoperative care are important points to consider in order to obtain good outcomes. With the use of good surgical techniques, current literature demonstrates good survivorship of TARs at 5 and 10 years.

Failures in Fixation of the Forearm

Summary The forearm is a unique anatomic unit that in the presence of chronic disorders results in a lack of rotation, impairs strength and stability of the hand, and affects functional motion of the wrist and elbow. Despite outstanding results using open reduction techniques, complications and failures continue to occur and can be divided into problems produced during the perioperative surgical period and complications occurring postoperatively. By addressing injuries in a timely manner, using appropriate surgical techniques and implants, and limiting malposition of the fragments, perioperative problems can be controlled. If other postoperative complications are identified, efforts should be made to reduce the length of the patient’s disability. When anatomic reductions are performed, union rates approaching 98% with excellent outcomes can be expected.