Purpose: Infected nonunion of the forearm bones is a challenge for the orthopedic surgeon on several fronts. The forearm itself is unique as the difficulties include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, and the risk of elbow and wrist stiffness related to prolonged immobilization. The problem of infection is complex due to the presence of bone necrosis, segmental bone loss, sinus tract formation, fracture instability, and scar adhesion of the soft tissues. The ideal management method for these situations is still debated.
Materials and methods: We used the two-stage-induced membrane technique devised by Alain Masquelet for the management of these infected nonunion of 12 forearm bones.
Results: All 12 bones united uneventfully. The bones united in a period ranging from 6 to 12 months with a mean of 7.8 months.
Conclusion: Our results show that this technique addresses several of the challenges pertinent to the forearm nonunion simultaneously and results are uniformly predictable.
Michael A Del Core,
Stephen Blake Wallace,
Background: Femoral head fractures are an uncommon but severe injury. These high-energy injuries typically occur in association with traumatic hip dislocations. Initial treatment includes urgent concentric reduction; however, controversy exists regarding specific fracture management. The well-known complications of avascular necrosis (AVN), posttraumatic arthritis (PTA), and heterotrophic ossification can leave patients with a significant functional loss of their affected hip. The purpose of this study is to evaluate the clinical and radiographic outcomes of femoral head fractures.
Methods: A retrospective review was performed at our institution assessing all patients who presented from 2007 to 2015 with a femoral head fracture associated with a hip dislocation and at least 6 months of clinical and radiographic follow-up. Twenty-two patients met our inclusion criteria. There were 15 males and 7 females with an average age of 36 years (range: 17–55). The average follow-up time was 18 months (range: 6–102). Fractures were classified according to the Pipkin classification. The Thompson and Epstein score was used to determine functional outcomes.
Results: There were five, Pipkin I, 3 Pipkin II, 0 Pipkin III, and 14 Pipkin IV, femoral head fractures. Sixteen patients were successfully closed reduced in the emergency department (ED) and six patients required open reduction after failed reduction in the ED. Four patients (18%) were successfully treated with closed reduction alone and 18 patients (82%) required operative intervention. Of those undergoing operative intervention, one patient underwent excision of the femoral head fragment, seven underwent open reduction internal fixation (ORIF) of the femoral head, nine underwent ORIF of the acetabulum, and one underwent ORIF of the femoral head and the acetabulum. Nine patients (41%) had an uneventful postoperative course. Two patients (9%) developed AVN, both requiring total hip arthroplasty (THA). Five patients (23%) developed PTA, two eventually requiring a THA. Two patients (9%) had sciatic nerve palsy. One patient (5%) developed a postoperative infection and four patients (18%) developed heterotrophic ossification (HO), none requiring operative treatment. Two patients (9%) had persistent anterolateral (AL) thigh numbness. Overall functional results were excellent in six patients (27%), good in six (27%), fair in seven (32%), and poor in three patients (14%). Four patients (18%) required a THA.
Conclusion: Femoral head fractures are a rare injury with well-known complications. Early diagnosis and concentric reduction are the prerequisites for successful treatment. This study adds to the growing literature on femoral head fractures associated with hip dislocations in efforts to define treatment plans and to guide patient expectations.
Ross A Fawdington,
How to cite this article:
Fawdington RA, Lotfi N, Beaven A, Fenton P. Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures?. 2019; 14 (1):11-14.
Aim: The aim of this study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved the radiological outcome and prevented a loss of fracture alignment. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing.
Methods: We searched computerized records at a UK level 1 major trauma center. The joint alignment was measured on the immediate postoperative radiograph and compared to the most recent radiograph. We used a difference of 2° to indicate a progressive deformity.
Results: Thirty patients were included. Twenty patients had no blocking screw and 10 patients had a blocking screw. Six patients had a difference in their coronal plane alignment of 2° or more (3/6 had no blocking screw). The results were analyzed and found to be not statistically significant (p = 0.82). The addition of a blocking screw has also been shown not to have an effect on the time to radiological union (RUST score greater or equal to 10).
Conclusion: We use a 2.5-mm blocking wire to aid in fracture reduction prior to reaming or nail insertion and then remove the wire when the nail has been adequately locked. We no longer routinely replace the wire with a blocking screw and this could lead to a decrease in procedure time, cost, and radiation exposure.
Matheus L Azi,
Marcelo B Teixeira,
Suedson F de Carvalho,
Armando A de Almeida Teixeira,
Ricardo B Cotias
How to cite this article:
Azi ML, Teixeira MB, de Carvalho SF, de Almeida Teixeira AA, Cotias RB. Computed Tomography vs Standard Radiograph in Preoperative Planning of Distal Radius Fractures with Articular Involvement. 2019; 14 (1):15-19.
Introduction: Distal radius fractures with articular involvement are more likely to require surgical management. Treatment decisions are based on parameters which are obtained from plain radiographs. This study aims to determine the differences between computed tomography and standard radiographs in the preoperative planning of distal radius fractures with articular involvement. This was performed by measuring the intraobserver and interobserver reliability between three systems used to interpret the main fracture characteristics and two treatment decisions.
Materials and methods: Forty-three cases of distal radius fractures with articular involvement were included. Fracture displacement was measured using plain radiographic and computed tomography. Five orthopedic surgeons evaluate the images to determine the AO/OTA classification, the articular fragments, the biomechanical columns involved, and recommend a surgical approach and implant for fracture fixation.
Results: An articular step-off was identified in 13 cases (30%) with the standard radiographs and in 22 (51%) cases with the computed tomography (p = 0.00). Interobserver variation for preoperative planning was slight when evaluated using the standard radiographs. Computed tomography improves reliability for AO/OTA classification and articular fragments but not for the biomechanical columns. Intraobserver variation for preoperative planning was slight to moderate for AO/OTA classification and slight to fair for identification of articular fragments and biomechanical columns. With regard to selection of the surgical approach, there was slight to moderate variation and, finally, for fracture fixation it was slight to fair.
Conclusion: Information provided by conventional radiography and computed tomography are sufficiently different as to induce the surgeon to select different treatments for the same fracture.
Gareth P Rogers,
Matheus L Azi,
Hiang B Tan,
Introduction: Segmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators.
Materials and methods: Patients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken.
Results: Eight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications.
Conclusion: Pediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered.
Abdullah A Nada,
Aim: The purpose of this study is to evaluate the results of indirect reduction and fixation of comminuted diaphyseal tibial fractures using temporary simplified external fixator and plate osteosynthesis through a limited incision approach with special consideration of the duration of surgery and rate of complications.
Materials and methods: In this prospective case series study, 41 cases of comminuted diaphyseal tibial fractures were included. Twenty-two were closed fractures, 15 grade I open fractures, and four were grade II open fractures. Patients were evaluated clinically according to the lower extremity functional scale (LEFS).
Results: Of the 41 cases, 38 were followed up for at least 1 year. Using the LEFS, final scores ranged from 67–80 (mean 75). Union was achieved in all cases except one which united after bone grafting. The mean time to radiological healing was 12 weeks. Operative time from skin incision to closure ranged between 65 minutes and 100 minutes (mean of 80 minutes). There were four cases of superficial infection.
Conclusion: Treatment of comminuted tibial fractures through use the of a simplified external fixator to aid and maintain the reduction of comminuted tibial fractures whilst limited incisions are then used for minimally-invasive plate osteosynthesis in an effective and time-saving method with a low complication rate.
Nisarg J Mehta,
How to cite this article:
Mehta NJ, Goldsmith T, Lacey A, Reddy G, Selvaratnam V, Ramakrishnan M. Outcomes of Intramedullary Nailing with Cerclage Wiring in Subtrochanteric Femoral Fractures. 2019; 14 (1):29-33.
Aims: The aim of this study was to compare the outcomes of closed reduction against open reduction with cerclage wires in patients with subtrochanteric fractures treated with intramedullary nailing (IMN).
Materials and methods: We identified 141 patients who had an IMN over a 4-year period. They were classified into three groups based on fracture pattern and whether open or closed reduction was performed. Type I was a transverse fracture, type II, a spiral fracture with an intact posterior and medial wall in the proximal fragment, and a type III fracture without intact posterior or medial walls. The primary outcome measure was a revision surgery for implant failure. Secondary outcome measures were related to fracture reduction and radiological union scores of the hip (RUSH).
Results: There were 35 patients who had a type I fracture, 26 patients with a type II fracture, and 80 patients with a type III fracture. The mean follow-up was 7 months. Closed reduction in type III fractures was associated with a significantly increased risk of mechanical complications (p = 0.005) and unplanned returns to theatre for implant failure (p = 0.04) as compared to open reduction. Open reduction in type III fractures was associated with a significantly higher mean RUSH scores (p = 0.0006). There was no significant difference in mean operative time between open and closed reduction in type III fractures (p = 0.12).
Conclusion: We recommend open reduction with cerclage wiring in type III subtrochanteric fractures in order to reduce the risk of implant failure, nonunion, and need for further surgery.
Peter J Smitham,
W David Goodier,
Peter R Calder
How to cite this article:
Antonios T, Barker A, Ibrahim I, Scarsbrook C, Smitham PJ, Goodier WD, Calder PR. A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation. 2019; 14 (1):34-44.
Introduction: Clinical studies in orthopedics are using patient-reported outcome measures (PROMs) increasingly. PROMs are often being designed for a specific disease or an area of the body with the aim of being patient centered. As yet, none exists specifically for treatment with circular ring external fixation devices.
Aim: The purpose of this study is to provide a comprehensive systematic review of the published literature related to the use of PROMs in patients that underwent treatment with circular frames (Ilizarov or Hexapod Type Fixators).
Methods: An online literature search was conducted for English language articles using the Scopus.
Results: There were 534 published articles identified. After initial filtering for relevance and duplication, this figure reduced to 17, with no further articles identified through searching the bibliographies. Exclusion criteria removed two articles resulting in 15 articles included in the final review. Out of the 15 studies identified, a total of 10 different scoring measures where used. The majority of studies used a combination of joint/limb-specific and generic health PROMs with an average of 2.5 per study. No paper specifically discussed all eight PROMs criteria when justifying which PROMs they used.
Conclusion: Our findings indicate that none of the PROMs analyzed in this systematic review are truly representative of the health outcomes specific to this patient group and, therefore, propose that a PROM specific to this patient group needs to be developed.
Lucian B Solomon
How to cite this article:
Rickman M, Link B, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery—A Systematic Review of the Literature: What is the Modern Evidence Base?. 2019; 14 (1):45-52.
Background: Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes.
Methods: A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data.
Results: There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification.
Limitations: Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias.
Conclusion: A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system.
Introduction: Subtalar dislocations are a rare injury, comprising 1–2% of all large joint dislocations and 15% of all peri-talar injuries. Most subtalar dislocations are managed acutely, with the documented reconstruction of chronic dislocations rare. This case report aims to present our experience with the first documented use of an Ilizarov frame for bony and soft tissue reconstruction in a case of chronic subtalar dislocation.
Materials and methods: A single patient surgically treated for chronic subtalar dislocation was followed over a 2-year period, and retrospectively reviewed.
Results: A 67-year-old lady presented with an over 10-year history of worsening ankle pain and significant varus deformity with skin contractures, limiting ambulation over the past 6 months. Computed tomography confirmed medial dislocations of the subtalar and talonavicular joints with head and neck fractures of the talus and generalized osteoarthritis. A two-stage reconstruction involving an Ilizarov frame and subsequent arthrodesis allowed for correction of soft tissue and bone with the return of independent ambulation.
Conclusion: Although the correction of bony deformities is important in reconstruction, soft tissue management is crucial and must not be overlooked. An Ilizarov frame is ideal for correction of both the bony deformity and soft tissue contractures. Arthrodesis can be performed when the overlying soft tissue is able to accommodate correction of the varus deformity and reduction of the dislocations. While an Ilizarov frame requires both an experienced surgeon and a motivated patient, in the right hands, good functional recovery can be returned.