Ross Leighton

Treatment of acute Achilles tendon ruptures a systematic overview and metaanalysis

A quantitative systematic review of randomized and quasirandomized trials was conducted to determine the effect of surgical versus conservative treatment of acute Achilles tendon ruptures on rates of rerupture. Secondary outcomes included deep infection rates, return to normal function, and minor complaints. A search of computerized databases was conducted to locate clinical studies published from 1969 to 2000. Additional studies were located through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files. Of the 273 citations initially identified, 11 proved potentially eligible, and six met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data. Among the studies, surgical repair revealed a significant reduction in the risk of rerupture when compared with conservative treatment. Alternatively, the risk of infection with surgical repair was significantly increased. Pooled analysis of studies did not reveal any difference in the risk of minor complaints or return to normal function between surgical repair and conservatively treated groups. Surgical treatment significantly reduces the risk of Achilles tendon rerupture, but increases the risk of infection, when compared with conservative therapy. Wide confidence intervals around the estimates of risk reduction suggest a large trial is needed to establish risks and benefits.

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.

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.

Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures.

Objectives: The purpose of this study was to compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa with nails specifically designed for each starting point. Design: Prospective cohort study. Setting: Four level 1 trauma centers. Patients: One-hundred and eight patients treated by 1 of 4 surgeons for a femoral shaft or subtrochanteric fracture with antegrade nailing between January 2001 and April 2003 were included. Four patients who expired early in the postoperative period and 13 with insufficient follow-up were excluded from analysis. Intervention: Patients were treated with either nailing through a greater trochanter starting point with the Trigen TAN nail (GT group) (n = 38) or through a piriformis fossa starting point with the Trigen FAN nail (PF group) (n = 53). Outcome Measures: Operative time, fluoroscopy time, fracture alignment, fracture healing, complications, and functional outcome based on the lower-extremity measure (LEM). Results: Thirty-seven of the 38 fractures from the GT group and 52 of the 53 fractures from the PF group healed after the index procedure. One patient from the GT group had external rotation malalignment of 12 degrees. There were no other malalignments or iatrogenic fracture comminution. There were 2 infectious complications, 1 from each group. The average operative time was 75 minutes for piriformis insertion using the FAN nail and 62 minutes for trochanteric insertion using the TAN nail (P = 0.08). The average fluoroscopy time was 61% greater for the PF group (153 seconds) than for the GT group (95 seconds) (P < 0.05). These differences were magnified in patients who were obese (body mass index > 30) where the operative time was 30% greater (P < 0.05) and the fluoroscopy time was 73% higher in the PF group (P < 0.02). Patients from both groups had a similar initial decline and subsequent improvement in function over time (P > 0.05). Conclusions: A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. The greater trochanter entry portal coupled with an appropriately designed nail represents a rational alternative for antegrade femoral nailing with the benefit of decreased fluoroscopy time and decreased operative time in patients who are obese.

Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study.

Objectives: Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. Design: Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. Setting: Four Level 1 trauma centers. Patients: Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of ≥30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. Intervention: Reamed intramedullary nailing of a femoral shaft fracture. Main Outcome Measures: Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. Results: Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). Conclusions: This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.

Biomechanical testing of new and old fixation devices for vertical shear fractures of the pelvis

Malgaigne fractures of the pelvis have been treated with many different methods of fixation. We developed a plate for use on the anterior aspect of the sacroiliac (SI) joint using information obtained from cadaveric dissections and computed tomography (CT) scans of male (50) and female (50) pelvises. We tested each of six pelvises in the Instron, with five different fixation systems. Our results showed that the weakest system was the anterior quadrilateral frame plus two symphyseal plates. When comparing three posterior screws with the SI joint plate, the difference was not statistically significant. However, in both of these systems, a second symphyseal plate added to the overall stability.

Effect of proximal and distal venting during intramedullary nailing.

During intramedullary manipulation, 2 main phenomena occur. A dramatic rise in intramedullary pressure occurs followed by intravasation of damaged marrow tissue. There are concerns about the development of increased interosseous pressure during reaming and the potential for this to contribute to fat embolism syndrome. The intramedullary pressures generated with various intramedullary devices was determined and the effects of a fracture, with and without proximal and distal venting on these pressures were studied. Pressures generated in 78 embalmed anatomic specimen femurs and tibias were studied, leaving all soft tissues intact. Pressures were recorded for awl, guide rod, reamer, and nail insertion. Venting was done by creating a 4.5-mm hole in the cortex directly opposite the transducer. Proximal venting reduced proximal pressures to 80 mm Hg in the tibia (90% reduction) and 460 mm Hg in the femur (70% reduction). Distal venting reduced distal pressures to 65 mm and 30 mm in the tibias and femurs, respectively (90% reduction in pressures). Intramedullary pressures generated during nail or alignment rod insertion in anatomic specimen bone greatly exceeds the critical thresholds (150 mm Hg) thought to be responsible for fat emboli to the lung in the dogs. The introduction of a vent may reduce the chance of fat embolism. Despite the high association of raised intramedullary pressures and fat emboli in animal studies, there is no known critical threshold for humans. Therefore, although venting seems effective in reducing the intramedullary pressure in anatomic specimen bones, its efficacy in the patient with trauma remains to be determined.

Comparative fixation of tibial plateau fractures using alpha-BSM, a calcium phosphate cement, versus cancellous bone graft.

Objectives: To compare the compressive strength of a bone substitute material (α-BSM™) to cancellous bone when used to fill a defect void in a cadaver model of a Schatzker II split depression fracture of the lateral tibial plateau. Design: Randomized, paired design. Setting: Biomedical engineering laboratory. Patients: Twenty-six human tibias were harvested from 13 cadavers. Three pairs of tibia fractured during preparation and were excluded. The remaining 10 matched pairs were randomized to fixation by using the bone substitute material or cancellous bone. Intervention: A split depression fracture of the lateral tibial plateau was created in each tibia by using reproducible methods. This fracture was stabilized with a stainless steel L-plate and screws and either α-BSM™ or cancellous bone to fill the defect void. Main Outcome Measurements: Stiffness of the elevated fragment in compression, total depression of the joint at 1000 N. Results: The α-BSM™ bone substitute displayed significantly greater stiffness than cancellous bone constructs in Schatzker II split depression fractures of the lateral tibial plateau (P < 0.0001). Plateau defects displaced significantly less at 1000N when using α-BSM™ in comparison to cancellous bone (P < 0.0001). Conclusions: In this cadaveric study, α-BSM™ is an effective bone substitute compared with cancellous bone graft for stabilizing split depression fractures of the lateral tibial plateau.

A Prospective Randomized Controlled Trial of a Bioresorbable Calcium Phosphate Paste (α-BSM) in Treatment of Displaced Intra-Articular Calcaneal Fractures

BACKGROUND Displaced intra-articular calcaneal fractures are devastating injuries and pose a therapeutic challenge. The purpose of this study was to determine whether open reduction internal fixation (ORIF) plus an injectable bioresorbable calcium phosphate paste (alpha-BSM [bone substitute material]) is superior to ORIF alone in the treatment of calcaneal bone voids encountered after operative treatment of displaced intra-articular calcaneal fractures. METHODS We prospectively randomized 47 patients with 52 closed displaced intra-articular fractures necessitating operative fixation to receive ORIF alone (n = 28) or ORIF plus alpha-BSM (n = 24). The maintenance of Böhlers angle was evaluated at follow-up visits for more than 1 year. Secondary outcome measures included the SF-36 and lower extremity measure every 6 months, and the Oral Analog Scale (OAS) score at 2 years. RESULTS There was no difference between the groups in the degree of collapse of Böhlers angle at 6 weeks and 3 months when compared with initial postoperative values. However, at 6 months, the mean collapse of the alpha-BSM and ORIF group was 5.6 degree (SD, 4.5 degree) and ORIF alone was 9.1 degree (SD, 5.8 degree), which was statistically significant (p = 0.03). Final radiographic evaluation after 1 year revealed a Böhlers angle loss of 6.2 degree (SD 5.9 degree) and 10.4 degree (SD 7.1 degree) in alpha-BSM and ORIF and ORIF alone groups, respectively, (p = 0.05). There was no difference between the two groups in regards to secondary outcome measures of general health, limb specific function, and pain past 2 years. CONCLUSION These results support the use of an injectable, in situ hardening calcium phosphate paste to fill the bone void after a displaced intra-articular calcaneal fracture. There was no impact on general health, limb specific function, and pain past 2 years and no associated complications with alpha-BSM use, supporting it safety as an augment to ORIF.

Bilateral Calcaneal Fractures: Operative Versus Nonoperative Treatment:

Background: There is poor information in the literature regarding patients who suffer from bilateral calcaneal fractures. The objective of this study was to analyze demographic characteristics and objective clinical features of patients with bilateral calcaneal fractures as well as subjective outcomes following either operative or conservative management. It was a prospective randomized trial. It was performed at four level 1 trauma centers. Methods: Forty-seven patients sustaining bilateral calcaneal fractures were randomized to either operative (open reduction and internal fixation) or conservative treatment groups. Demographic features and fracture patterns were compared between those sustaining unilateral fractures (large calcaneal database) and those sustaining bilateral fractures. Following treatment, comparison of both objective outcome measures (Bohlers angle and subtalar range of motion) and subjective outcomes, as measured by the previously validated visual analogue scale (VAS) and SF-36 scores, was performed. Outcomes were also compared (with existing data from trauma database) for those treated for unilateral calcaneal fracture. Results: No difference in demographic features was found between individuals suffering unilateral and bilateral calcaneal fractures. Among bilaterally injured patients, initial Bohlers angle was slightly, but significantly, more depressed relative to that in the unilateral comparison data (p < .05). Post-treatment range of motion was significantly better when injury was confined to one side regardless of treatment modality (p < .01). Surgical intervention did not significantly affect subjective patient outcome as measured by either SF-36 or the VAS. This remained true following stratification by Workers Compensation Board (WCB) status. However, those who were treated nonoperatively were significantly more likely to require late subtalar arthrodesis (p < .05). In general, patients whose injury was not associated with a WCB claim demonstrated significantly better subjective outcomes (p < .01 for SF-36 and VAS). Conclusions: Other than demonstrating a slightly more depressed Bohlers angle, patients sustaining bilateral calcaneal fractures are very similar to those in whom the injury is confined to one side. The evidence presented here does not definitively support primary operative intervention for bilateral calcaneal fractures. Neither objective nor subjective functional outcomes are significantly improved following such intervention. However, careful operative patient selection will minimize complications and lessen the need for late subtalar arthrodesis.