Lisa M. Wild

Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures

BACKGROUND The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.

The use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: Early results of a prospective trial

Objective We sought to evaluate the use of a bioabsorbable, tobramycin-impregnated bone graft substitute (calcium sulfate alpha-hemihydrate pellets) in the treatment of patients with infected bony defects and nonunions. Study Design/Methods Twenty-five patients (15 male and 10 female, mean age 43 years (range 27–69 years) requiring surgical debridement of culture-positive long bone infection (16 with associated nonunion) were entered into an ongoing consecutive, prospective clinical trial. Involved bones included the tibia (15), femur (6), ulna (3), and humerus (1). All defects were posttraumatic in origin, and each patient had had previous surgery at the involved site (mean 4.3 surgeries; range 1–8 surgeries). The duration of infection ranged from 4 months to 20 years (mean 43 months). According to the Cierny-Mader classification system, there was 1 stage I (medullary osteomyelitis), 6 stage III (localized osteomyelitis), and 18 stage IV (diffuse osteomyelitis) lesions. There were 4 normal (A) hosts and 21 locally and/or systemically compromised (B) hosts. Mean bone defect/void was 30.5 cm3 (range 3–192 cm3). Results Mean follow-up was 28 months (range 20–38 months). Radiographically, pellets were resorbed at a mean of 2.7 months postoperatively. Infection was eradicated in 23 of 25 patients (92%). Isolated bony defects healed in all nine patients without further treatment. Fourteen of 16 patients with nonunion achieved union, although nine required autogenous bone grafting. Union was achieved in five of seven nonunion patients treated with bone graft substitute in isolation. Complications included refracture (three), recurrence of infection (two), persistent nonunion (two), and superficial wound necrosis (one). Eight patients developed sterile draining sinuses that healed upon radiographic resorption of the pellets. Conclusions In patients with posttraumatic osteomyelitis, the bone graft substitute was effective in eradicating bone infection in 23 of 25 patients. Isolated bony defects healed reliably (nine of nine) following addition of bone graft substitute alone. The role of the bone graft substitute in isolation in the treatment of nonunion is unclear at present.

A prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunion.

Objectives: We sought to compare the effectiveness of an antibiotic-impregnated bioabsorbable bone substitute (BBS, tobramycin-impregnated medical-grade calcium sulfate) with antibiotic-impregnated polymethylmethacrylate (PMMA) cement beads after surgical débridement in patients with chronic nonhematogenous osteomyelitis and/or infected nonunion. Design: A prospective, randomized clinical trial. Setting: A university-affiliated teaching hospital. Patients/Participants: Thirty patients requiring surgical treatment for chronic long bone infection or infected nonunion were included: BBS (15 patients, mean age 44.1 years) PMMA (15 patients, mean age 45.6 years). Intervention: Patients were randomized to receive either BBS or PMMA to the bone void created by surgical débridement. Main Outcome Measurements: Eradication of infection, new bone growth, rate of union, repeat operative procedures complications. Results: Patients were followed for a mean 38 months (range, 24-60 months). One patient was lost to follow-up in each group. In the BBS group, infection was eradicated in 86% (12 of 14) of patients. Seven of eight patients achieved union of their nonunion, and five patients underwent seven further surgical procedures. In the PMMA group, infection was eradicated in 86% (12 of 14) of patients. Six of eight patients achieved union of their nonunion, and nine patients required 15 further surgical procedures. There were more reoperations in the PMMA group (15 versus seven, P = 0.04), and these procedures tended to be of greater magnitude. Conclusions: The results of this preliminary study suggest that, in the treatment of chronic osteomyelitis and infected nonunion, the use of an antibiotic-impregnated BBS is equivalent to standard surgical therapy in eradicating infection and that it may reduce the number of subsequent surgical procedures. A larger, definitive study on this topic is required.

Femoral intramedullary nailing: comparison of fracture-table and manual traction. a prospective, randomized study.

Background: The purpose of this study was to compare manual traction and fracture-table traction for the reduction and nailing of femoral shaft fractures. We evaluated the quality of the reduction, operative time, complications, and functional status of the patient.Methods: Eighty-seven consecutive adult patients with a unilateral fracture of the femoral diaphysis that did not extend into the knee joint or proximal to the lesser trochanter were enrolled in the study. Patients who were transferred to our institution more than forty-eight hours after injury; those with multiple-system injuries, injury to the ipsilateral lower extremity, or pathological fracture; and those who were unable or unwilling to provide consent or to return for follow-up were excluded. Forty-five patients were randomized to manual traction and forty-two, to fracture-table traction; all were treated in the supine position. The number of surgical assistants, operative and fluoroscopy time, complications, functional scores, and other outcomes were recorded.Results: There were no significant differences between the groups with respect to age, gender, Glasgow Coma Score, Injury Severity Score, side or mechanism of injury, fracture type, or time from injury to treatment. Internal malrotation was significantly more common when the fracture table had been used: twelve (29%) of the forty-two femora were internally rotated by >10° compared with three (7%) of the forty-five treated with manual traction (p = 0.007). Total operative time, from the beginning of the patient positioning to the completion of the skin closure, was decreased from a mean of 139 minutes (range, 100 to 212 minutes) when the fracture table was used to a mean of 119 minutes (range, sixty-five to 180 minutes) when manual traction was used (p = 0.033). There was no significant difference between the two treatment groups with regard to the number of assistants per case (mean two; range, zero to three), fluoroscopy time, other complications including femoral shortening or lengthening, or functional status of the patient at one year.Conclusions: Compared with fracture-table traction with the patient in a supine position, manual traction for intramedullary nailing of isolated fractures of the femoral shaft is an effective technique that decreases operative time and improves the quality of the reduction.

The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction

Objective To determine the effect of smoking on outcome and complication rates following Ilizarov reconstruction. Design We performed a retrospective review of 84 adult patients (86 limbs) who underwent Ilizarov reconstruction. There were 39 “limbs” in nonsmokers and 47 “limbs” in active smokers. Complications and an outcome score based on ASAMI (Association for the Study and Application of the Methods of Ilizarov) criteria were recorded for each patient. Data Analysis and Results There were 35 major complications including 15 malunions/nonunions, 7 refractures, 8 persisting infections, and 5 amputations. Results were measured using the ASAMI outcome scale. There were significantly more poor results in the smoking group than in the nonsmoking group (18/47, 38% versus 4/39, 10%; P = 0.003). Seven of eight patients with persisting infection were smokers (P = 0.049). There was a higher incidence of nonunion in the smoking group (P = 0.031). All five amputations were in smokers (P = 0.035). Conclusion Smokers had a higher percentage of poor results (P = 0.01), due primarily to higher complication rates. Smoking is a significant, potentially remediable risk factor for failure following Ilizarov reconstruction, and cessation strategies are of paramount importance prior to initiating treatment.

Combined Single-stage Osseous and Soft Tissue Reconstruction of the Tibia With the Ilizarov Method and Tissue Transfer

Objective: To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer. Design: A retrospective review. Setting: A university-affiliated, tertiary-care center. Patients/Intervention: We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases). Main Outcome Measurements: Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters. Results: There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result. Conclusion: Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.