Robert N. Meek

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

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.

Comparison of mortality of patients with multiple injuries according to type of fracture treatment—a retrospective age- and injury-matched series

In a retrospective review of 71 patients with multiple injuries matched for age and severity, 28.5 per cent of those whose fractures were treated conservatively died compared with 4.5 per cent of those whose fractures were fixed. Early stable fixation of fractures is recommended in patients with multiple injuries.

Range of motion and complications after postburn heterotopic bone excision about the elbow.

OBJECTIVE To review the results of surgical management of heterotopic ossification about the elbow in burned patients. DESIGN Retrospective analysis with long-term patient follow-up. MATERIALS AND METHODS Eleven patients with 16 elbows requiring surgery were admitted between January 1, 1982 and December 31, 1993. A posterior approach to the elbow with release of the encased ulnar nerve +/- anterior transposition and transolecranon osteotomy to access extensive bone formation in the olecranon fossa was employed. Eight patients (11 elbows) were available for long-term follow-up conducted at mean 50 +/- 13 months after surgery. Long-term follow-up consisted of measurement of range of elbow motion, as well as clinical assessment of ulnar nerve function. MAIN RESULTS For the 11 elbows examined postoperatively, the mean range of motion preoperatively in flexion-extension was 11 degrees +/- 5 degrees compared to 89 degrees +/- 12 degrees postoperatively (p < 0.001). Three patients with poor long-term results had ankylosis of the joint preoperatively. Of four patients with ulnar nerve paresis preoperatively, none had ulnar nerve dysfunction at follow-up. Of 16 elbows operated on, four (25%) had postoperative complications. Two suffered soft-tissue breakdown with hardware exposure requiring abdominal flap closure, one early failure of olecranon fixation, and one late infected hardware. CONCLUSIONS Surgery for both limited range of motion as well as ulnar nerve compression is effective in cases of heterotopic ossification about the elbows of burned patients. Early operative intervention is indicated in progressive disease, particularly ulnar nerve palsy, if soft-tissue quality is adequate. Complications with 25% of elbows suggest that use of olecranon osteotomy for joint access may warrant review.

Intramedullary nailing of the femoral shaft: a prospective, randomized study.

Summary We conducted a prospective, randomized study on 84 consecutive patients with 88 acute, traumatic femoral shaft fractures using 32 Grosse-Kempf nails, 29 Russell-Taylor nails, and 27 Synthes nails. Although total operative times and proximal and distal locking times were similar for the three groups, the procedure was faster with the Grosse-Kempf nail. Three proximal fractures could not be locked with the Synthes nail. At first follow-up, we found no significant difference in terms of pain, limp, range of motion, or time to union; however, we removed fewer Synthes nails to resolve patient complaints of pain. Three delayed unions were attributed to fracture distraction. We conclude that all three nails are suitable for the treatment of almost all femoral shaft fractures. A careful analysis of intraoperative technique and instrumentation indicates that all three nails can be used safely and easily once experience is gained. Clinical outcome is similar regardless of the nail chosen.

The effects of intraoperative positioning on patients undergoing early definitive care for femoral shaft fractures.

Objectives: To determine if there is a difference in morbidity and mortality in orthopaedic trauma patients with femoral shaft fractures undergoing early definitive care with intramedullary (IM) nails in the supine versus the lateral position. Design: Retrospective cohort study, single centered. Setting: One level 1 trauma center. Patients: Nine hundred eighty-eight patients representing 1027 femoral shaft fractures treated with IM nails were identified through a prospectively gathered database between 1987 and 2006. Intervention: Antegrade IM nail insertion with reaming of the femoral canal in either the supine or lateral position. Outcome Measures: Mortality was the primary outcome. Admission to intensive care unit (ICU) was the secondary outcome measure and a surrogate measure of morbidity. Literature review was performed to identify factors shown to contribute to morbidity and mortality in orthopaedic trauma patients. Intraoperative position in either the supine or lateral position was added to this list. Logistic regression analysis was performed to determine the magnitude and effect of the independent variables on each of the study end points. To determine if a more significant trend toward less favorable outcomes was observed with increasing severity of injury, particularly injuries of the chest and thorax, subgroup analysis was performed for all those with a femur fracture and an Injury Severity Score ≥18 and all those with a femur fracture and an Abbreviated Injury Score chest ≥3. Results: Intraoperative position in either the supine or lateral position was not a significant predictor of mortality or ICU admission for the original cohort or the subgroup of Injury Severity Score ≥18. However, for the subgroup of Abbreviated Injury Score chest ≥3, intraoperative positioning in the lateral position had a statistically significant protective effect against ICU admission (P = 0.044). Conclusions: For polytrauma patients with femoral shaft fractures, surgical stabilization using IM nails inserted with reaming of the femoral canal in the lateral position is not associated with an increased risk of mortality or ICU admission.

A feasibility study of pelvic morphology for curved implants.

OBJECTIVES We hypothesize that inserting a curved intramedullary internal fixation device which follows curved osseous fixation paths (OFPs) would be more versatile and mechanically stronger than straight screws for fixation of pelvic ring and acetabular injuries. This study characterizes the dimensions of curved OFPs of the pelvic ring and acetabulum and suggests design parameters for such a curved device. METHODS CT scans of intact pelves of 50 female and 50 male subjects were studied using MIM Maestro™ and Solidworks™ to determine the constriction points (smallest cross sections) and the tightest radii of curvature (RoC) in the anterior column, posterior column, iliosacral and pubic symphysis OFPs. RESULTS The constriction point diameters for the superior pubic ramus and supra-acetabular areas were 13±3mm and 12±3mm, respectively. The anterior column RoC was greater than 65mm in all cases. The minimum observed RoC for the path from one ilium, across the SI joint, the sacrum and to the other ilium was 71mm, with 99% of the cases having a RoC of at least 80mm, in both the inlet and outlet views. CONCLUSION This study shows that if a flexible implant which could be stiffened once in place was available, it would enable the use of larger and longer fixation taking advantage of the pelviss curved intracortical spaces. Even for dysmorphic pelves, accessible tunnels support a long, strong, curved fixation device.

A new technique for heterotopic bone resection in burned elbows

Development of heterotopic bone about the elbow in burn patients, although uncommon, is a problem that carries significant morbidity. We describe a new technique for resection of heterotopic bone at the elbow involving an olecranon osteotomy. The timing of surgery depends upon two factors: the quality of surrounding soft tissues and the presence of ulnar nerve compression.