Mark J. Anders

Definitive control of mortality from severe pelvic fracture.

Within a group of 271 patients with pelvic fracture, 69 patients met criteria for severe hemorrhage. Sixty consecutive patients were treated by a combined multispecialty musculoskeletal trauma service using a protocol designed to control bleeding, rapidly diagnose and control associated injuries, as well as to prepare the patient for open reduction of the pelvic fracture, if appropriate. The pneumatic antishock garment, external fixation, and angiography were selectively used to control bleeding. Abdominal injuries were diagnosed using clinical examination and diagnostic peritoneal lavage. When lavage aspirate was grossly bloody, patients had no negative explorations. Microscopically positive lavages were associated with a 50% false-negative rate. Using the protocol, the mortality rate was 5%. Overall mortality rate was 10%. The combination of a trauma team approach and a specifically designed protocol reduces the number of deaths from pelvic fracture.

Management strategies for bone loss in tibial shaft fractures.

Fifty open tibial fractures with circumferential cortical bone loss were reviewed. Prospective treatment protocols included fracture stabilization with repeated irrigation and debridement followed by wound coverage. Bony stabilization was accomplished using external fixators, small diameter unreamed interlocking nails, and, in rare instances, plate fixation. Bone graft procedures included posterolateral bone graft, elevation of the free flap or direct anterolateral grafting, bone transport techniques, and free vascularized fibula transfer. Average followup was 18 months (range, 9-40 months). The index graft procedure was used in 30 patients (60%) for fracture healing. The rate of union was 98%, with an average total treatment time of 42.4 weeks (range, 23-80 weeks). Malunion was more likely to develop in patients treated with external fixation and posterolateral bone graft (p = 0.007). Intramedullary nails with direct bone grafting had shorter times to union and shorter total treatment times. The use of free vascular fibular transfers in acute injuries was not successful. Good results were obtained with bone transport techniques. Developing a healthy soft tissue envelope before reconstruction of these injuries is important. Techniques of reconstruction had no correlation to the development of nonunion or infection. They were valuable in determining malunion and total treatment time. These data confirm that carefully staged reconstruction leads to successful outcomes.

Treatment of femoral fractures in the multiply injured patient with thoracic injury.

Early fracture fixation in the multiply injured patient has been shown to reduce morbidity and mortality. This premise recently has been questioned when the multiply injured patient has a pulmonary contusion, and also has a femoral fracture stabilized with a reamed intramedullary nail. This put into question whether early stabilization of femoral fractures, especially with a reamed intramedullary nail, should be performed in patients with a pulmonary contusion. A review of the most recent clinical and animal research was performed to help answer this question. This review has revealed that the incidence of pulmonary failure and adult respiratory distress syndrome in multiply injured patients with thoracic injuries who have femoral fractures treated acutely is less than 3%. The morbidity associated with patients with pulmonary contusions is independent of the treatment of the femoral fracture. No difference in the rate of pulmonary failure is found with reamed nails or plate fixation. The pulmonary failure seems to be secondary to the pulmonary contusion, not to the method of fracture fixation.

Femoral Nerve Block for Diaphyseal and Distal Femoral Fractures in the Emergency Department

BACKGROUND Diaphyseal and distal femoral fractures are painful injuries that are frequently seen in patients requiring a trauma work-up in the hospital emergency department prior to definitive management. The purpose of this study was to determine whether a femoral nerve block administered in the emergency department could provide better pain relief for patients with femoral fractures than currently used pain management practices. METHODS Patients who presented with an acute diaphyseal or distal femoral fracture were identified as potential candidates for this study. Eligible patients were randomized by medical record number to receive either (a) the femoral nerve block (20 mL of 0.5% bupivacaine) along with standard pain management or (b) standard pain management alone (typically intravenous narcotics). The pain was assessed with use of a visual analog scale at the initial evaluation and at five, fifteen, thirty, sixty, and ninety minutes following the initial evaluation. Fifty-four patients were enrolled in the study from April 2005 to May 2006. Thirty-one patients received a femoral nerve block, and twenty-three patients received standard pain management alone. RESULTS Baseline scores on the visual analog pain scale did not differ between the groups at the initial evaluation. The patients who received a femoral nerve block (along with standard pain management) had significantly lower pain scores at five, fifteen, thirty, sixty, and ninety minutes following the block than did the patients who received standard pain management alone (p < 0.001). The score on the visual analog pain scale across these time points was an average of 3.6 points less (on a 10-point scale) for those who received the block. There were no infections, paresthesias, or other complications related to the femoral nerve block. CONCLUSIONS The acute pain of a diaphyseal or distal femoral fracture can be significantly decreased through the use of a femoral nerve block, which can be administered safely in the hospital emergency department.

F-18 Fluoride Positron Emission Tomography of the Hip for Osteonecrosis

AbstractOsteonecrosis (ON) of the femoral head continues to be a devastating disorder for young patients. We evaluated the F-18 fluoride positron emission tomography (PET) imaging modality for use in detection of the bone involved in ON of the hip. We retrospectively reviewed the records of 60 consecutive patients diagnosed with ON and interviewed all by phone. Eleven patients (17 hips) of those interviewed agreed to participate in the study. We classified the ON using the University of Pennsylvania classification system and compared each patient’s plain AP bone scan, single photon emission 3-D computed tomography, and MRI. ON was associated with HIV, alcohol, steroid use, and polycythemia vera in this group. Nine of 17 hips (8 patients) had acetabular increased uptake when using the F-18 fluoride PET scans that were not seen on MRI, single photon emission computed tomography, or bone scans. These data suggest earlier acetabular changes in osteonecrosis may exist that traditional imaging modalities do not reveal. Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Intraoperative monitoring with stimulus-evoked electromyography during placement of iliosacral screws : An initial clinical study

A consecutive series of twenty-seven patients who had thirty acute unstable (type-C) fractures of the pelvic ring was studied prospectively to evaluate the use of stimulus-evoked electromyography to decrease the risk of iatrogenic nerve-root injury during the insertion of iliosacral screws. A prerequisite for inclusion in the study was a normal neurological status preoperatively; somatosensory evoked potentials were monitored to further document the neurological status both before and after insertion of the screw or screws. A total of fifty-one iliosacral screws were inserted, and a current threshold of more than eight milliamperes was selected as the level that indicated that the drill-bit was a safe distance from the nerve root. Four of the fifty-one screws were redirected because of information obtained with stimulus-evoked electromyography. Postoperatively, all patients had a normal neurological status. Computerized tomography, although not accurate for detailed measurements, demonstrated that all of the screws were in a safe, intraosseous position. Monitoring with stimulus-evoked electromyography appears to provide reliable data and may decrease the risk of iatrogenic injury to the nerve roots during operations on the pelvic ring.

Effect of preoperative donation of autologous blood on deep-vein thrombosis following total joint arthroplasty of the hip or knee

The effect of preoperative donation of autologous blood on postoperative deep-vein thrombosis was retrospectively studied in men who had been managed consecutively with elective total joint replacement of the hip or knee because of osteoarthrosis. The patients had, on the average, two of nine considered risk factors for deep-vein thrombosis. Two hundred and thirty-seven patients were evaluated postoperatively with ascending venography, and they form the basis of this study. Fifty-four patients had venographic evidence of deep-vein thrombosis of the lower extremity, with most having asymptomatic clots distal to the knee. The prevalence of deep-vein thrombosis was nineteen (16 per cent) of 116 after total hip arthroplasty, compared with thirty-five (29 per cent) of 121 after total knee arthroplasty (chi square = 4.6, p = 0.03). Deep-vein thrombosis developed in twenty-eight (17 per cent) of the 161 patients who had donated blood preoperatively, compared with twenty-six (34 per cent) of the seventy-six patients who had not donated blood preoperatively (chi square = 7.7, p = 0.006). Through logistic regression analysis, the donation of autologous blood was shown to reduce significantly the development of postoperative deep-vein thrombosis for patients managed with total knee arthroplasty (p < 0.01) but not for patients managed with total hip arthroplasty. Additional neural network analysis showed the donation of autologous blood to be the most important prognostic factor in predicting the absence of postoperative deep-vein thrombosis. In addition to diminishing the need for transfusion of homologous blood after total joint arthroplasty, preoperative donation of autologous blood appears to protect against postoperative deep-vein thrombosis after total knee arthroplasty.

Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series.

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.

Intraoperative stimulus-evoked electromyographic monitoring for placement of iliosacral implants : An animal model

OBJECTIVE A canine model was designed to evaluate the feasibility of stimulus-evoked electromyographic (EMG) monitoring of the lumbosacral nerve roots during the insertion of iliosacral implants. STUDY DESIGN/METHODS Four 2.5-millimeter Kirschner wires (K-wires) were percutaneously inserted under general anesthesia into the S1 body of each of five dog hemipelves using C-arm fluoroscopy image-intensifier control in an actual attempt to compromise the S1 canal and the S1 nerve root. A searching current of twenty milliamperes was initially applied to the K-wire with monitoring electrodes placed in the gastrocnemius muscle. Current thresholds required to evoke an EMG response were recorded for each K-wire. Actual K-wire location was determined by anatomical dissection. RESULTS Evaluation of these twenty wires revealed that current threshold was directly related to the proximity of the K-wire to the nerve root, with a correlation coefficient of 0.94 (p < 0.001). CONCLUSIONS Stimulus-evoked EMG monitoring provided reliable data indicating the proximity of the iliosacral implants to the sacral nerve root. This method of intraoperative nerve monitoring could potentially decrease the risk of iatrogenic nerve root injury during pelvic ring surgery. Further study is warranted.

Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle

For AO 44-B2 ankle fractures of uncertain stability, the current diagnostic standard is to obtain a gravity stress radiograph, but some have advocated for the use of weight-bearing radiographs. The primary aim was to compare measures of medial clear space (MCS) on weight-bearing cone beam computed tomography (CBCT) scans versus gravity stress radiographs for determining the state of stability of ankle fractures classified as AO SER 44-B2 or Weber B. The secondary aim was to evaluate the details offered by CBCT scans with respect to other findings that may be relevant to patient care. Nine patients were enrolled in this cross-sectional study between April 2016 and February 2017 if they had an AO SER 44-B2 fracture of uncertain stability, had a gravity stress radiograph, and were able to undergo CT scan within seven days. The width of the MCS was measured at the level of the talar dome on all radiographs and at the mid coronal slice on CT. Wilcoxon signed-ranks tests were used to compare MCS between initial radiographs, gravity stress radiographs and weight-bearing CBCT scans. MCS on weight-bearing CBCT scan (1.41±0.41 mm) was significantly less than standard radiographs (3.28±1.63 mm, P=0.004) and gravity stress radiographs (5.82±1.93 mm, P=0.02). There was no statistically significant difference in MCS measured on standard radiographs versus gravity stress radiographs (P=0.11). Detailed review of the multiplanar CT images revealed less than perfect anatomical reduction of the fractures, with residual fibular shortening, posterior displacement, and fracture fragments in the incisura as typical findings. Similar to weight-bearing radiographs, weight-bearing CBCT scan can predict stability of AO 44-B2 ankle fractures by showing restoration of the MCS, and might be used to indicate patients for non-operative treatment. None of the fractures imaged in this study were perfectly reduced however, and further clinical research is necessary to determine if any of the detailed weight-bearing CBCT findings are related to patient outcomes.