Robert Galpin

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management.

Objective To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF). Design Prospective, randomized, multicenter study. Setting Four level I trauma centers. Patients The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998. Interventions Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus. Main Outcome Measurements Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36). Results There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery). Conclusion Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

Long-term follow-up of anterior tibial eminence fractures

Summary Most children who have sustained a tibial eminence fracture have objective evidence of anterior cruciate ligament (ACL) laxity at long-term follow-up, but few have subjective complaints. Clinical signs of anterior instability were noted in 64% of patients (32 of 50) examined at an average follow-up of 4 years. Objective evidence of laxity determined with a KT-1000 arthrometer was noted in 74% of patients (37 of 50). Five patients (10%) complained of pain, but no patient complained of instability at follow-up. Assessment of long-term stability showed that the method of management (open vs. closed methods) had no bearing on eventual outcome.

Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion.

Objective The goal of the current study was to analyze the prospective clinical outcome of patients who failed closed or open treatment of a displaced intra-articular calcaneal fracture. This cohort of patients required a secondary subtalar fusion by distraction bone-block arthrodesis. Design Review of prospective, randomized trial database. Setting Four level I trauma centers. Patients Between April 1, 1991 and December 31, 1997, 424 patients with 471 displaced intra-articular calcaneal fractures were involved in a large, multicenter, randomized trial. Forty-four patients who required subtalar fusion following initial treatment of a displaced intra-articular calcaneal fracture were compared to the population of patients who did not require subtalar fusion. The variables compared between the two groups included Böhler angles, two computed tomography classification systems, and clinical scores including SF-36, visual analogue score, and oral analogue score. Intervention Subtalar distraction bone-block arthrodesis with tricortical bone graft was used in all 45 feet. Main Outcome Measurements The following were examined: x-ray fracture classification, specifically Böhler angles and Essex-Lopresti classification; computed tomography classification, specifically Sanders and Crosby; clinical scores, specifically validated visual analogue score, general health survey scores, oral analogue score, and other factors (i.e., patient demographics including age, sex, profession, smoking history, and Workers Compensation Board involvement. Results Initial treatment of the 44 patients in our study was nonoperative in 37 (84%) patients and operative (open reduction and internal fixation) in 7 (16%) (1 patient had bilateral heel fractures). Patients requiring fusion differed demographically from those patients not requiring fusion. Mean age was 39 years in both the fusion and nonfusion group. The fusion group had 97% males, whereas the nonfusion group had 89% males. Sixty-four percent of the fusion patients were Workers Compensation Board claims, whereas 35% of the nonfusion group were Workers Compensation Board claims. Of those that required fusion, 77% were heavy laborers. On average, the fusion group had a Böhler angle 15° less than the nonfusion group. Forty-six percent of the fusion patients were Sanders-type IV initial fractures. Logistic regression analysis revealed that the primary predictors of requiring fusion were Workers Compensation Board status (odds ratio = 3.03, 95% confidence interval = 1.41–6.57), Sanders-type IV (odds ratio = 5.48, 95% confidence interval = 1.57–19.18), Böhler angle <0° (odds ratio = 10.64–95% confidence interval = 1.33–85.17), and nonoperative initial treatment (odds ratio = 5.86–95% confidence interval = 2.33–14.67). Conclusion These data suggest that the amount of initial injury involved with the calcaneal fracture is the primary prognostic determinant of long-term patient outcome. Böhler angle on presentation of <0° was 10 times more likely to require a secondary subtalar fusion than a Böhler angle on presentation of >15°. Sanders-type IV calcaneal fractures were 5.5 times more likely to be fused than a simple Sanders type II fracture. Workers Compensation Board patients were three times more likely to be fused than non-Workers Compensation Board patients. Nonoperative care was six times more likely to lead to a late fusion as compared to open reduction and internal fixation treatment. Late fusion provided relief from pain and improved function as evidenced by an improvement in visual analogue score postsurgery. This study demonstrates that there is a distinct patient group with a displaced intra-articular calcaneal fracture who are at high risk of subtalar fusion. These include male Workers Compensation Board patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0°. If their initial treatment was nonoperative, the likelihood of requiring late subtalar fusion was significantly increased. Initial open reduction and internal fixation of patients with displaced intra-articular calcaneal fracture minimized the likelihood that subtalar fusion would be required.

Flexible intramedullary nail fixation of pediatric femoral fractures.

The management of pediatric femoral shaft fractures gradually has evolved toward a more operative approach in the past decade. This is because of a desire for more rapid recovery and reintegration of the patients, and a recognition that prolonged immobilization can have negative effects even in children. Economic pressures also favor a treatment that does not require as prolonged a hospitalization as that required with the traditional traction method. External fixation, compression plating, and intramedullary nailing all have been advocated. A restrospective review of the experience with antegrade flexible intramedullary nailing in 25 children was performed. No nonunions or significant malunions were seen. Followup evaluation of limb lengths and proximal femoral morphology showed minor variations of articulotrochanteric distance and neck shaft angle, none of which were clinically significant. Likewise, minor limb length discrepancies were measured (range, -11-+14 mm) with no consistent pattern of overgrowth noted. There was no evidence of a complete trochanteric growth arrest on radiographic followup. Flexible intramedullary nailing seems to be a safe and effective method for the treatment of femoral shaft fractures in the child between 6 and 12 years of age.

Biomechanical analysis of pedicle screw instrumentation systems in a corpectomy model

Five different spinal implants, all using pedicle screw attachment to vertebrae, were examined in a one above/ one below corpectomy model, to determine 1) the relative stiffness of each construct, 2) the stresses generated in the implant during loading, and 3) the relative fatigue susceptibility of each implant. Results indicated that the relative axial and torsional stiffnesses were similar for all the implants tested (DKS/Zielke, VSP/Steffee, AO Fixator Interne, Luque plate, AO Notched plate). Hence, each of the devices impart approximately the same stability to the spine in this highly unstable model. Stresses measured at the root of the pedicle screws were found to exceed the endurance limit of stainless steel in those systems in which the pedicle screws were attached rigidly to the plates (VSP/Steffee, AO Fixator Interne). Good agreement was found between the measured stresses and stresses derived from static calculations. Comparisons between the stresses from each implant gave a relative measure of fatigue susceptibility that was validated by in vitro cyclic testing. Implants with stresses exceeding the endurance limit failed during the cyclic test.

One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening.

We reviewed the results of primary operative treatment in twenty-five patients (thirty-three hips) who were two years or older and had congenital dislocation of the hip. None of the patients had had previous treatment for the dislocation. Preliminary traction was not used in any patient. Femoral shortening and, in twenty-one hips, pelvic osteotomy were performed at the time of open reduction. At the most recent follow-up (average, three years and seven months), according to the radiographic classification system of Severin, there were seven excellent, seventeen good, and eight fair results; one hip had a poor result. Avascular necrosis developed in three of the thirty-three hips. At follow-up, these hips had a radiographic result of excellent, good, and fair, respectively. Twenty-one patients (twenty-eight hips) were reviewed with respect to range of motion and recovery from limb-length discrepancy. According to the rating system of Ferguson and Howorth, there were seventeen excellent, seven good, and three fair results; one hip had a poor result. It was concluded that children who are two years or older and who have a congenital dislocation of the hip can safely be treated with an extensive one-stage operation consisting of open reduction combined with femoral shortening and, often, pelvic osteotomy, without increasing the risk of avascular necrosis. The limb-length discrepancy that is produced by the shortening does not appear to cause a clinical problem.

Intramedullary nailing of pediatric femoral fractures.

This retrospective study reviews our results with intramedullary nail fixation of 37 fractures of the femur in 35 skeletally immature patients. Five of these fractures were open. Twenty-two patients (average age 12 + 9 years) were treated with reamed intramedullary nails. Fifteen patients (average age 9 + 6 years) were treated with nonreamed nails. All fractures united in 6-12 weeks. There were no infections, delayed or nonunions, nor were there any incidences of avascular necrosis. There were very few significant complications. One patient required excision of heterotopic bone to restore hip motion. When surgical treatment of pediatric femur fractures is indicated, we prefer intramedullary nail fixation (either reamed or nonreamed) depending on age, fracture pattern (level, degree of comminution), and size of femoral canal. Experience and careful surgical judgment are required to appropriately individualize treatment for these patients.

Bilateral lower extremity compartment syndromes secondary to intraosseous fluid resuscitation

Intraosseous infusions are reserved for use in life-threatening hypovolemic or cardiogenic shock when intravenous (i.v.) access cannot be readily established. Although minor fluid extravasation is a common problem with this technique, a fully established compartment syndrome has never been reported. We describe a child with severe compartment syndromes of both lower extremities complicating the use of intraosseous fluid resuscitation.

Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results.

The current study is a retrospective clinical and radiographic review of all children treated with intramedullary Steinmann pins for fixation of diaphyseal forearm fractures at one institution. Thirty patients were reviewed. Twenty-five patients had fractures of both bones, three had Monteggia fracture-dislocations, and two had isolated radial fractures. Eight fractures were open. The average age of the patients at the time of surgery was 9 years 3 months (range, 4 years 1 month-14 years 3 months). Time to union averaged 6 weeks but a slightly longer healing time was seen in patients older than 10 years of age. Subjective, objective, and radiographic evaluation at 3 years 6 months average followup revealed no significant side to side differences. There were six complications (two pin site infections, two cases of fracture displacement after pin removal, one extensor pollicus longus tendon rupture requiring repair, and one refracture), none of which affected outcome at followup. When combined with an open reduction, one intramedullary Steinmann pin provides adequate stability in most diaphyseal forearm fractures in children with excellent results and few complications.

The use of the medial head of the gastrocnemius muscle in the posterior cruciate-deficient knee: Indications-technique-results

This review retrospectively analyzes a group of pa tients with chronic posterior cruciate insufficiency who were treated surgically with transfer of the medial head of the gastrocnemius muscle. Our indications, technique, and the results of this surgery are presented. Twenty-one patients (21 knees) over the last 3½ years, from January 1977 to June 1980, were treated by this procedure. Eighteen patients were followed up for more than 8 months after surgery and are included in the review. Subjectively, pain, swelling, reduction of activity, and functional instability were assessed and graded from 0+ to 3+. Postoperative examination showed improvement of these parameters in most patients. Objectively, assessment of effusion, patellofemoral joint symptoms, stability, and recurvatum were tabu lated and compared to preoperative information. Of greatest significance was improvement of the patients overall functional classification in most cases. The posterior sag or drawer sign and patellofemoral com plaints were not altered by the operation. Gait analysis and isokinetic testing were performed as part of the followup on 50% of the patients. We advocate this as a safe, effective reconstructive procedure for the posterior cruciate deficient knee with significant advantages over alternative tech niques.