Peter J. O'brien

Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft : A prospective, randomized study

Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not differ significantly between the groups. We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft, although more screws broke when reaming had not been done.

Knee Pain After Tibial Nailing

OBJECTIVE To determine the incidence and natural history of knee pain following tibial nailing. DESIGN A retrospective analysis of patients treated by tibial nailing evaluating a consecutive series of patients with isolated tibial shaft fractures. SETTING A level one trauma center in Vancouver, British Columbia. PATIENTS A group of 107 consecutive patients with 110 tibial fractures treated by interlocking tibial nailing. INTERVENTION Patients were contacted and interviewed by the authors. Clinical records and radiographs were analysed. MAIN OUTCOME MEASUREMENTS Incidence of knee pain; time of onset; relationship of nail position on radiographs to knee pain; relationship to knee pain to site of nail insertion; response to nail removal. RESULTS At a mean follow-up period of thirty-two months (12-58 months), sixty-one (57%) patients (63 of 110 knees) had developed anterior knee pain. There was no correlation between nail protrusion and knee pain. Insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Of patients with knee pain, 80% (49/61) required nail removal. At a mean duration of 16 months following nail removal, pain was completely relieved in 22 patients and partially relieved in 17. In the remaining 10 patients, there was no improvement. CONCLUSIONS Based on this data, we would recommend a parapatellar tendon incision for nail insertion, and nail removal for those patients with a painful knee. The causes of knee pain after tibial nailing are multi-factorial and require further study.

Early Fixation of the Vertically Unstable Pelvis: The Role of Iliosacral Screw Fixation of the Posterior Lesion

OBJECTIVES To evaluate the effectiveness of the use of iliosacral screw fixation in the management of the vertically unstable pelvis. STUDY DESIGN Retrospective analysis with clinical follow-up of patients to assess functional outcome. METHODS Thirty-eight vertically unstable pelvic fractures were treated using iliosacral screw fixation. Anterior fixation was by means of plating in sixteen pelves and by external fixation in fifteen pelves. Four pelves had no anterior fixation. Complications were recorded and radiographs were analyzed to classify fractures and identify screw misplacement and malunion. Twenty-six patients had a functional evaluation. RESULTS Five patients (13 percent) suffered a pulmonary embolus in the early postoperative period, one of which was fatal, a hospital mortality of 2.6 percent. Screw misplacement occurred in five patients but there were no adverse sequelae. In thirty-four cases with radiographic follow-up, malunion was noted in fifteen cases (44 percent). A lower rate of malunion (36 percent) was noted with internal fixation of the anterior lesion. Of twenty-six patients with long-term follow-up, only four (15 percent) had no pain. Sacroiliac fusion for pain was performed in three patients (11 percent). Twelve patients (46 percent) returned to their preinjury occupation, six patients (23 percent) changed occupation, and nine patients (30 percent) had not yet returned to work by last follow-up. CONCLUSIONS Iliosacral screw fixation is a useful method of fixation in the vertically unstable pelvis but needs to be augmented by rigid anterior fixation to minimize malunion.

Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis.

Summary: A prospective, randomized clinical trial in 304 orthopaedic trauma patients with hip and pelvic fractures was conducted to investigate the effectiveness of pneumatic sequential leg compression devices (PSLCDs) for the prevention of thromboembolic disease. The control group received no specific form of prophylaxis. Patients were followed by venous Doppler, duplex scan, and ventilation perfusion lung scans. The study end-point was documented pulmonary embolism and/or deep vein thrombosis. The incidence of a venous thromboembolic event in the control group was 11% and in the experimental group 4%. This difference was statistically significant (p=0.02). These patients were also stratified into hip and pelvic fracture groups. In the hip fracture patients, the control group had a thromboembolic event incidence of 12% and the experimental group 4%. This difference was also statistically significant (p=0.03). In the pelvic fracture group there was a thromboembolic incidence of 11% in the controls, demonstrating this patient population to be at significant risk. In this group, the PSLCDs were not statistically shown to be effective. Pneumatic leg compression devices are effective in reducing the incidence of thromboembolic events in patients with hip fractures

External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol.

Between 1983 and 1989, forty-one open fractures of the tibial shaft were treated with débridement and provisional external fixation, followed by delayed soft-tissue closure and subsequent intramedullary nailing with reaming. The average duration of external fixation was seventeen days (range, six to fifty-two days). The average time between removal of the fixator and intramedullary nailing was nine days (range, zero to twenty-four days). Of thirty-nine patients who had adequate follow-up, two (5 per cent) subsequently had a deep infection. Both infections healed, with retention of the nail and without chronic osteomyelitis. There were two nonunions and one delayed union. Satisfactory alignment was achieved in thirty-seven patients (95 per cent). This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection.

Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty.

&NA; Postoperative periprosthetic femoral fractures around the stem of a total hip arthroplasty are increasing in frequency. To obtain optimal results, full appreciation of the clinical evaluation, classification, and modern management principles and techniques is required. Although periprosthetic femoral fracture associated with a loose stem requires complex revision arthroplasty, fractures associated with a stable femoral stem can be managed effectively with osteosynthesis principles familiar to most orthopaedic surgeons. Femoral fracture around a stable femoral stem is classified as a Vancouver type B1 fracture. The preferred treatment consists of internal fixation, following open or indirect reduction. Emerging techniques, such as percutaneous plating and the use of locking plates, have been used with increasing frequency. Preliminary results of these techniques are promising; however, further prospective comparative studies are required.

Surgical treatment of a displaced lateral malleolus fracture: The antiglide technique versus lateral plate fixation

Objectives To assess the outcomes of the surgical management of “isolated” displaced lateral malleolar fractures, comparing the techniques of lateral plating and antiglide plating as described previously. Design This is a retrospective review, being largely a surgeon-randomized comparative study. Setting The study was carried out at a university teaching hospital that serves as a provincial trauma referral service and provides local community care. The senior surgeons are all orthopaedic trauma subspecialists. Patients A total of 193 patients meeting our inclusion criteria, with isolated lateral malleolus fractures surgically treated at the Vancouver General Hospital between 1987 and 1998, were studied. Intervention Eighty-five were treated with antiglide plating, whereas the remaining 108 patients underwent traditional lateral plating. Main Outcome Measures The functional results were evaluated with the ankle scoring system described previously. We also compared the complication rates, including failure of fixation, infection, wound dehiscence, and need for hardware removal. Results Both groups were comparable for age, sex distribution, mechanism of injury, and occupation. There was no difference in ankle score, function, and infection rate. The incidence of wound dehiscence and reoperation for hardware removal was slightly higher in the lateral plate group, but the difference was not statistically significant. Conclusions The outcome of the surgical management of a displaced lateral malleolus fracture is comparable with both techniques. Although few studies have reported some advantages using the antiglide technique, our data do not support one technique over the other.

Biomechanical Evaluation of Proximal Humeral Fracture Fixation Supplemented with Calcium Phosphate Cement

Background: Proximal humeral fractures are common injuries, and numerous surgical methods have been described for their treatment. The biomechanical characteristics of various internal fixation devices that are used to treat these fractures have not been extensively studied, nor has the potential beneficial effect of calcium phosphate cement supplementation. Methods: We used a cadaveric three-part proximal humeral osteotomy model to perform a biomechanical evaluation of three types of internal fixation devices: a cloverleaf plate, an angled blade-plate, and Kirschner wires. The effect of supplementing the fixation with SRS (Skeletal Repair System) calcium phosphate cement was evaluated as well. Eighteen pairs of fresh-frozen humeri were obtained, and the bone-mineral density of each specimen was measured. In each pair, one specimen was secured with internal fixation alone and the contralateral specimen was secured with internal fixation combined with calcium phosphate cement. The specimens were tested cyclically in abduction and in external rotation for 250 cycles to evaluate interfragmentary motion. The specimens were then loaded to failure in external rotation to measure torsional load to failure and torsional stiffness. Results: Overall, there were no significant differences between the specimens treated with the blade and cloverleaf plates, whereas the specimens treated with Kirschner wires demonstrated more interfragmentary motion, less stiffness, and lower torque to failure. In general, supplementation with calcium phosphate cement led to significant improvements in the mechanical performance of all three forms of internal fixation as demonstrated by a significant decrease in interfragmentary motion, a significant increase in torque to failure, and a significant increase in torsional stiffness. The addition of calcium phosphate cement increased the stiffness of even the most osteoporotic specimens to levels that were higher than those of the most osteodense specimens that had been treated with internal fixation alone. Conclusion: The initial biomechanical properties of internal fixation as measured with use of a proximal humeral osteotomy model and three methods of fixation were significantly improved by the addition of calcium phosphate cement. Clinical Relevance: The addition of calcium phosphate cement may augment the mechanical characteristics of internal fixation of difficult, three-part proximal humeral fractures. The ability to stabilize the interface between the implant and cancellous bone, particularly in the presence of osteopenia, may make calcium phosphate cement a valuable clinical tool in the treatment of these difficult fractures.

Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?

Eighty-one open tibial fractures were treated by reamed intramedullary nailing. There were 38 type II, 23 type IIIa and 20 type IIIb injuries. At the end of the nailing procedure the first 26 fractures (15 type II, five type IIIa, and six type IIIb) had antibiotic prophylaxis and delayed closure of the open wound. The subsequent 55 fractures (23 type II, 18 type IIIa, and 14 type IIIb) had identical management but in addition had an antibiotic bead pouch inserted into the open wound following debridement. Three amputations were performed: one (3.8%) in the group treated without a bead pouch and two (3.6%) in the bead pouch group in patients with grade IIIb fractures and severe crushing injuries. Of the remainder, there were four deep infections (16%) in the 25 fractures treated prior to the use of the bead pouch and two (4%) deep infections in the 53 fractures following introduction of the bead pouch. Addition of the bead pouch to the wound management protocol was associated with a worthwhile reduction of deep infection.

Primary intramedullary nailing of open femoral shaft fractures

The cases of 60 patients with 63 open femoral fractures treated by primary reamed intramedullary nailing were retrospectively reviewed. Twenty-two were classified as Type I open fractures, 26 as Type II and 15 as Type III open fractures by Gustilos classification. All fractures were treated by wound debridement followed by immediate reamed intramedullary nailing. There were five early soft-tissue infections and three late deep infections. Of the late infections, only one was osteomyelitis (1.6%). There were three nonunions and seven malunions. All of the complications were dealt with effectively by standard methods. We concluded that primary reamed intramedullary nailing is an effective alternative for the treatment of Type I and II open femur fractures and for Type III open femur fractures associated with multiple trauma.