Pin site infections are a common complication of external fixation that places a significant burden on the patient and healthcare system. Such infections increase the number of clinic visits required during a patient's course of treatment, can result in the need for additional treatment including antibiotics and surgery, and most importantly can compromise patient outcomes should osteomyelitis or instability result from pin loosening or need for pin or complete construct removal. Factors that may influence the development of pin site infections include patient-specific risk factors, surgical technique, pin design characteristics, use of prophylactic antibiotics, and the post-operative pin care protocol including cleansing, dressing changes, and showering. Despite numerous studies that work to derive evidence-based recommendations for prevention of pin site infections, substantial controversy exists in regard to the optimal protocol. This review comprehensively evaluates the current literature to provide an overview of factors that may influence the incidence of pin site infections in patients undergoing treatment with external fixators, and concludes with a description of the preferred surgical and post-operative pin site protocols employed by the senior authors (ATF and SRR).
The definitive treatment of paediatric femoral diaphyseal fractures remains controversial. Modalities of treatment vary mostly according to age, with fracture pattern and site having a lesser impact. Current evidence is reflective of this variation with most evidence cited by the American Academy of Orthopedic Surgeons being level 4 or 5. The authors present a review of the most up-to-date evidence relating to the treatment of these fractures in each age group. In an attempt to clarify the current trends, we have produced an algorithm for decision-making based on the experience from our own tertiary referral level 1 major trauma centre.
Subtrochanteric femoral fractures in children are uncommon and have received limited attention in the literature. Its treatment is controversial, and different options are available: traction, spica casting, internal fixation and external fixation. The aim of this study is to present our results with external fixation of subtrochanteric femoral fractures in children using Ilizarov frame. Between January 2012 and January 2014, 14 patients with closed subtrochanteric femoral fractures were treated in Cairo University School of Medicine Teaching Hospital. The average age at the time of injury was 6.4 years (range 3.8–11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Two patients were multiply injured with abdominal injuries (as ruptured spleen). In all cases, a low profile Ilizarov frame was inserted using two half pins inserted proximally from greater to lesser trochanters parallel to the hip joint orientation line (line between tip of greater trochanter and femoral head centre) and secured to an arch, and another three half pins were inserted distally perpendicular to the femoral shaft and secured to an arch that was connected by three rods to the proximal arch. No post-operative spica was used. Average follow-up was 18 months (range 12–36 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6–12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. External fixation with a low profile Ilizarov frame appears as a good treatment option for subtrochanteric femoral fractures in children.
Level of evidence: Level IV.
DOI: 10.1007/s11751-016-0253-7 |
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Maini L, Batra S, Gupta R, Arora S. Evaluation of the muscle morphology of the obturator externus and piriformis as the predictors of avascular necrosis of the femoral head in acetabular fractures. 2016; 11 (2):105-111.
Avascular necrosis (AVN) of femoral head is a recognised complication of fracture dislocation of the hip joint but is not studied frequently in relation to acetabulum fractures. The aim was to establish the relationship between obturator externus and piriformis muscle morphology in acetabulum fractures and potenital development of AVN of the femoral head. Twenty-five fractures were included in this prospective study and were subjected to radiological assessment and computed tomography of the pelvis. Magnetic resonance imaging (MRI) of the hip was performed to assess the morphology of obturator externus and piriformis, and findings were compared intraoperatively (in 15 cases). Serial radiographs were taken at monthly intervals to assess the development of avascular necrosis. The patients with no evidence of AVN on radiographs at 6 months had additional MRI scans to look for such changes. Three patients developed AVN of femoral head and two had complete tears of piriformis and/or obturator externus muscles on the pre-operative MRI with the findings confirmed intraoperatively (p = 0.013). None of the patients without changes of AVN at 6-month follow-up had complete tears of either or both muscles. Of these patients, there was one case each of T-type fracture, isolated posterior wall fracture with hip dislocation, and posterior wall with transverse fracture of the acetabulum. Complete tears of obturator externus and/or piriformis muscles are a strong predictor of future development of AVN of the femoral head.
An intramedullary device has some advantages over external fixation in callus distraction for bone defect reconstruction. There are difficulties controlling motorized intramedullary devices and monitoring the distraction rate which may lead to poor results. The aim of this study was to design a fully implantable and non-motorized simple distraction nail for the treatment of bone defects. The fully implantable device comprises a tube-in-tube system and a wire pulling mechanism for callus distraction. For the treatment of femoral bone defects, a traction wire, attached to the device at one end, is fixed to the tibial tubercle at its other end. Flexion of the knee joint over a predetermined angle generates a traction force on the wire triggering bone segment transport. This callus distraction system was implanted into the femur of four human cadavers (total 8 femora), and bone segment transport was conducted over 60-mm defects with radiographic monitoring. All bone segments were transported reliably to the docking site. From these preliminary results, we conclude that this callus distraction system offers an alternative to the current intramedullary systems for the treatment of bone defects.
Femoral non-unions are difficult to treat even for the experienced orthopaedic trauma surgeon. If the non-union follows failure of modern stable internal fixation, the complexity of the management is further increased. We report two cases of stiff hypertrophic femoral non-unions after failed locking plate fixation that were successfully treated with a new hexapod circular external fixator. In addition to providing the necessary stability for functional rehabilitation and union, the hexapod circular fixator software allows gradual correction of deformities in order to restore the normal mechanical alignment of the limb.
P. M. Stevens,
Christian J. Gaffney,
The purpose is to describe the technique and report the results and complications of percutaneous femoral rotational osteotomy, secured with a trochanteric-entry, locked intramedullary rod, in adolescents with femoral anteversion. Our series comprised an IRB approved, retrospective, consecutive series of 85 osteotomies (57 patients), followed to implant removal. The average age at surgery was 13.3 years (range 8.8–18.3) with a female-to-male ratio of 2.8:1. The minimum follow-up was 2 years. Eighty-three osteotomies healed primarily. Two patients, subsequently found to have vitamin D deficiency, broke screws and developed nonunions; both healed after repeat reaming and rod exchange and vitamin supplementation. Preoperative symptoms, including in-toeing gait, tripping and anterior knee pain or patellar instability, were resolved consistently. We did not observe significant growth disturbance or osteonecrosis. We noted a 12.5 % incidence of broken interlocking screws; this did not affect the correction or outcome except for the two patients mentioned above. This prompted a switch from a standard screw (core diameter = 3 mm) to a threaded bolt (core diameter = 3.7 mm). These results have led this technique to replace the use of plates or blade plates for rotational osteotomies.
Leonard C. Marais,
Theo L. B. Le Roux
Previous classification systems of chronic osteomyelitis have failed to provide objective and pragmatic guidelines for selection of the appropriate treatment strategy. In this study, we assessed the short-term treatment outcome in adult patients with long-bone chronic osteomyelitis prospectively where a modified host classification system was integrated with treatment strategy selection through a novel management algorithm. Twenty-six of the 28 enrolled patients were available for follow-up at a minimum of 12 months. The median patient age of was 36.5 years (range 18–72 years). Fourteen patients (54 %) were managed palliatively, and 11 patients (42 %) were managed through the implementation of a curative treatment strategy. One patient required alternative treatment in the form of an amputation. The overall success rate was 96.2 % (95 % CI 80.4–99.9 %) at a minimum of 12-months follow-up. Remission was achieved in all [11/11] patients treated curatively (one-sided 95 % CI 73.5–100.0 %). Palliative treatment was successful in 92.9 % [13/14] of cases (95 % CI 66.1–99.9 %). In patients with lower limb involvement, there was a statistically significant improvement of 28.3 (95 % CI 21.0–35.7; SD 17.0) in the AAOS Lower Limb Outcomes Instrument score (p value < 0.001). The integrated approach proposed in this study appears a useful guideline to the management of chronic osteomyelitis of long bones in adult patients in the developing world. Further investigation is required to validate the approach, and additional development of the algorithm may be required in order to render it useful in other clinical environments.