Stephen H. Sims

The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?

BACKGROUND Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation. METHODS We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups. RESULTS The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation. CONCLUSIONS Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Failure of Exchange Reamed Intramedullary Nails for Ununited Femoral Shaft Fractures

OBJECTIVE To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. DESIGN Retrospective chart review. PATIENTS Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. INTERVENTION Exchange reamed nails to treat ununited femoral shaft fracture. MAIN OUTCOME MEASUREMENTS Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. RESULTS In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. CONCLUSIONS Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.

Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study.

BACKGROUND Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. METHODS A prospective randomized study was conducted at three medical centers. Patients with an intra-articular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventy-two hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. RESULTS This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. CONCLUSIONS This study demonstrated that postoperative single-fraction radiation therapy, when used acutely after elbow trauma for prophylaxis against heterotopic ossification, may play a role in increasing the rate of nonunion at the site of the fracture or an olecranon osteotomy. The clinical efficacy of radiation therapy could not be determined on the basis of the sample size. Further research is needed to determine the role of limited-field radiation for prophylaxis against heterotopic ossification after elbow trauma.

Indometacin as prophylaxis for heterotopic ossification after the operative treatment of fractures of the acetabulum

Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo. We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.

Unstable proximal extraarticular tibia fractures: a biomechanical evaluation of four methods of fixation.

Objective: To compare the biomechanical stability of extraarticular proximal tibia fractures reconstructed using a double-plate construct, locking plate system, hybrid external fixator, and single lateral periarticular plate, all from the same manufacturer. Design: Standardized proximal tibial fractures (AO classification 41-A3.2 and A3.3) in synthetic tibiae were stabilized using one of the four constructs. Load versus proximal fragment translation and rotation were monitored in each case. Fixation was evaluated for moderately unstable and completely unstable fractures simulated by wedge and gap osteotomies of the proximal femur. Setting: Academic medical center biomechanical engineering laboratory. Main Outcome Measurements: Proximal fragment axial displacement, varus rotation, and posterior rotation versus applied load for each of the constructs. Results: The double-plate construct was significantly stiffer than all other constructs with regard to resistance to axial displacement, varus rotation, and posterior rotation for both types of unstable fractures. With regard to axial stiffness, the double-plate construct was statistically similar to an intact tibia for moderately stable fractures. The locking plate and the external fixator were similar for stabilization of moderately unstable fractures, whereas the locking plate and the periarticular plate were significantly stiffer than the external fixator construct for completely unstable fractures. Conclusion: For axial load applied to a wedge or gap osteotomy of the proximal tibia, the double-plate construct provided significantly more rigidity than the other constructs. The locking plate, periarticular plate, and hybrid external fixator tested provided similar rigidity for the wedge osteotomy, but for the gap osteotomy the external fixator could not support 600N without complete closure of the gap.

Subtrochanteric Femoral Fractures

Fractures in the subtrochanteric zone of the proximal femur present complex treatment challenges. These treatment difficulties are related to the anatomic and biomechanic features that are unique to this area. These fractures occur in older patients from low-energy trauma and in younger patients with high-energy trauma, with separate diagnostic and treatment significance. Intramedullary fixation with standard centromedullary nails, as well as cephalomedullary nails, are commonly employed as fixation methods to treat this fracture. The techniques and results of this will be reviewed.

Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection.

Objective: To examine the association between antibiotic timing and deep infection of type III open tibia fractures. Design: Retrospective prognostic study. Setting: Level 1 Trauma Center. Patients: The study population included 137 patients after exclusions for missing data (13), nonreconstructible limbs (9), and/or absence of 90-day outcome data (3). Intervention: An observational study of antibiotic timing. Main Outcome Measurement: Deep infection within 90 days. Results: Age, smoking, diabetes, injury severity score, type IIIA versus 3B/C injury, and time to surgical debridement were not associated with infection on univariate analysis. Greater than 5 days to wound coverage (P < 0.001) and greater than 66 minutes to antibiotics (P < 0.01) were univariate predictors of infection. Multivariate analysis found wound coverage beyond 5 days [odds ratio, 7.39; 95% confidence interval (CI), 2.33–23.45; P < 0.001] and antibiotics beyond 66 minutes (odds ratio, 3.78; 95% CI, 1.16–12.31; P = 0.03) independently predicted infection. Immediate antibiotics and early coverage limited the infection rate (1 of 36, 2.8%) relative to delay in either factor (6 of 59, 10.2%) or delay in both factors (17 of 42, 40.5%). Conclusions: Time from injury to antibiotics and to wound coverage independently predict infection of type III open tibia fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), prehospital antibiotics may substantially improve outcomes for severe open fractures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prospective comparison of contrast-enhanced computed tomography versus magnetic resonance venography in the detection of occult deep pelvic vein thrombosis in patients with pelvic and acetabular fractures.

Objective To determine the rate of pelvic vein thrombosis following acetabular or pelvic fracture identified by enhanced computed tomography venography or magnetic resonance venography. Design Prospective evaluation of computed tomography venography and magnetic resonance venography in patients with pelvic and acetabular trauma as a screening tool for deep vein thrombosis. Setting Level I trauma center. Results Thirty patients with pelvic or acetabular fractures and who met the study criteria were prospectively screened with magnetic resonance venography and computed tomography venography to determine preoperative presence of pelvic venous thrombosis. Pelvic deep vein thrombosis was detected by computed tomography venography in two patients (7%) and by magnetic resonance venography in four patients (13%). Invasive selective pelvic venographies were performed on the five subjects who tested positive on either one or both screening tests. Only one computed tomography venography case was validated by invasive pelvic venography. The false-positive rate for computed tomography venography was 50%, and the false-positive rate for magnetic resonance venography was 100%. Conclusions We cannot recommend the sole use of either computed tomography venography or magnetic resonance venography to screen and direct the treatment of asymptomatic thrombi in patients with fracture of the pelvic ring because of the high false positive rates. If these studies are used as screening tools, confirmation of the presence of thrombosis with selective venography should be performed prior to initiating invasive treatment with a vena cava filter. Clinical decisions based solely on one of these imaging techniques may result in inappropriate aggressive treatment due to the high false-positive rate.

Efficacy of surgical wound drainage in orthopaedic trauma patients: a randomized prospective trial.

OBJECTIVE To study the efficacy of closed suction drainage in clean nonemergent surgical fracture fixation or bone grafting on the extremities or pelvis. DESIGN A prospective randomized trial. SETTING The orthopaedic trauma service of a Level I trauma hospital. PATIENTS Patients were older than age eighteen years and undergoing clean nonemergent surgical fracture fixation or bone grafting procedures on the extremities (excluding hands and feet) or pelvis. INTERVENTION The application of a surgical drain. MAIN OUTCOME MEASUREMENTS Wound drainage, edema, hematoma and erythema, dehiscence, infection, and need for surgery or readmission were followed for six weeks. A univariate analysis with Students t test for continuous variables and chi-squared analysis for all categorical data were used, with a p value of < or = 0.05 considered statistically significant. RESULTS A total of 202 patients were randomized to 102 patients with no drain and 100 patients with a drain. There was no significant difference between the groups with regard to injury severity, systemic disease, age, body weight, physical status, or estimated blood loss. There was no significant difference between the drain and no-drain groups in any of the parameters evaluated. CONCLUSION There is no significant difference between drained and nondrained wounds in clean, nonurgent orthopaedic trauma surgery. It appears that drainage systems can be safely eliminated in this group.

Locked Plating of Supracondylar Periprosthetic Femur Fractures

Fifty periprosthetic supracondylar femur fractures above a total knee arthroplasty were reviewed. Fractures were closed Lewis and Rorabeck type II with a stable prosthesis. Twenty-nine patients (group I), were treated with locked condylar plating. Twenty-one patients (group II) were treated with nonlocked plating systems or intramedullary fixation. Minimum follow-up was 1.7 years. There were 5 malunions (20%) in group I and 9 (47%) in group II (P < .05). There were no nonunions in group I and 3 (16%) in group II. Complication rates were 12% in group I, compared to 42% in group II. Group I patients had less operative blood loss, healed in better alignment, and had greater knee motion. All 7 patients treated with a retrograde intramedullary nail developed a malunion or nonunion. Locked plating is a reliable treatment for periprosthetic supracondylar femur fractures. We experienced a lower complication, revision, malunion, and nonunion rate with locked plating versus conventional treatment options.