Philip Stegemann

External fixation of severely comminuted and open tibial pilon fractures.

Twenty patients with severely comminuted fractures about the ankle, either severely comminuted pilon fractures or open pilon fractures (three Grade II, seven Grade III), were managed with the use of a Delta-framed external fixator across the ankle joint. All fractures had open reduction and internal fixation (ORIF) with either screw fixation or small plates to stabilize the articular surface with minimal soft-tissue dissection. Average external fixator time was 2.5 months, and the time to union averaged 4.5 months. All fractures healed. Three delayed unions required bone grafting and two had plate stabilization. No infection occurred in the 12 open fractures. There was no infection of the closed injuries, no skin sloughs, and only two minor pin tract infections. Follow-up analysis averaged 12 months (range, six to 30 months). Range of motion (ROM) at last follow-up observation was excellent in six patients, good in nine, fair in three, and poor in two. Two patients required ankle arthrodesis because of posttraumatic arthritis. The ROM and outcomes of the severely comminuted or open fractures of the distal intraarticular tibia were very good.

Displaced Isolated Fractures of the Tibial Shaft Treated with Either a Cast or Intramedullary Nailing. An Outcome Analysis of Matched Pairs of Patients

A study of ninety-nine patients who had a unilateral, displaced, isolated closed fracture of the tibial shaft was performed to determine the effect of the type of treatment on the clinical outcome. Forty-seven patients were managed with closed intramedullary nailing with reaming, and fifty-two were managed with closed reduction and a cast. The two groups were comparable with regard to the ages of the patients, the locations and amounts of displacement of the fractures, and the number of patients who had a history of smoking. The time to union was shorter in the patients who had been managed with intramedullary nailing than in those who had been managed with a cast (mean, eighteen compared with twenty-six weeks; p = 0.02). A non-union occurred in one patient (2 per cent) who had been managed with nailing and in five patients (10 per cent) who had been managed with a cast. There were no infections in either group. Removal of the nail was performed electively in twenty-six patients. Twenty-five patients who had been managed with nailing and twenty-five who had been managed with a cast were followed for a mean of 4.4 years. With use of the Iowa Knee Evaluation and the Ankle-Evaluation Rating System, the patients who had had nailing had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for those who had been managed with a cast (p < 0.05). Administration of the Medical Outcomes Study Short Form-36 Health Survey to the twenty-five matched pairs of patients yielded scores that were significantly better after nailing than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p < 0.05). We concluded that the treatment of displaced closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides functional results that are superior to those obtained with use of a cast.

Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails.

Summary: This study was designed to verify whether open tibial fractures treated with an unreamed tibial nail would heal without the placement of a bone graft. Twenty-nine consecutive patients treated with unreamed tibial nails were prospectively followed to study fracture healing patterns. Monthly radiographs were studied for signs of healing without additional surgical intervention until it appeared that the fracture was a delayed union or nonunion. The average patient age was 31 years (range 16-80). Twenty-seven of the fractures were open (16 grade I, 8 grade II, 3 grade IIIA, with two additional fractures with compartment syndrome open by surgical intent. All fractures resulted from high-energy trauma. Twenty-two fractures were comminuted or segmental. Fifteen fractures healed without secondary intervention at an average of 148 days (range 98-243). Fourteen fractures needed additional intervention from between 3 and 7 months postinjury, with an average intervention of 1.9 per fracture. The two groups (primary healing and delayed union) were similar in fracture location, mechanism, and grade of injury. However, 13 of 14 delayed unions had comminuted or segmental fractures and required statically locked nails in 13 of the 14 fractures. Our experience suggests that the union rate is not improved with unreamed nails over that in the historical external fixator literature unless secondary surgical procedures are performed to change the local biology and enhance healing. We suggest early nail dynamization and bone grafting at 6 weeks to enhance and shorten healing time.

Elevation in compartment pressure following hypovolemic shock and fluid resuscitation: a canine model.

We induced hemorrhagic shock in seven dogs and then resuscitated them with intravenous (IV) lactated ringers. We then monitored anterior leg compartment pressures via a slit catheter during both bleeding and reperfusion. These values were compared with controls that received IV fluids without being bled. Compartment pressures in resuscitated dogs rose well above control values. These values were statistically significant when compared to controls via the paired student t test (P < .01). This model demonstrates that sufficient swelling occurs to significantly elevate compartment pressures, even in the absence of local trauma. While this elevation may not be sufficient enough to cause a compartment syndrome, it reinforces the notion that extremities that have experienced ischemia and reperfusion are at an increased risk for developing compartment syndrome.