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A laboratory study was performed to compare the stability and ultimate strength of three standard fixation techniques for split-type lateral tibial plateau fractures. The three methods of fixation were (a) three 6.5-mm cancellous lag screws with washers; (b) two 6.5-mm cancellous lag screws with washers and an additional antiglide 4.5-mm cortical screw with washer; and (c) six-hole L-shaped buttress plate. Twelve pairs of embalmed mildly osteopenic lower extremities were used. Simulated split-type lateral tibial plateau fractures were created, reduced, and then instrumented in a matched pair design. The instrumented specimens were axially loaded to determine resistance to displacement, cyclically loaded to 10,000 cycles to determine dynamic stability, and then loaded to failure. There were no statistically significant differences found between resistance to displacement or failure strength as a function of either fragment size or sample bone density. On the basis of biomechanical stability, there appears to be no difference between the three fixation techniques tested. The results of this study suggest that use of an antiglide screw or buttress plate does not offer an advantage over lag screw fixation alone for the treatment of split type lateral tibial plateau fractures.

Between October 1987 and August 1992, 22 patients with crescent fractures, a posterior fracture-dislocation of the sacroiliac joint, were admitted, treated, and available for review at Tampa General Hospital and The Hospital for Special Surgery. The purpose of the study was twofold: (a) to evaluate the incidence, severity, and pattern of associated injuries, and (b) to determine the efficacy of a treatment protocol using a posterior extrapelvic approach and extraarticular internal fixation. The study population was composed of 13 females and nine males; the average age was 25 years (range 10-52). Despite the fracture pattern resulting in a rotationally unstable hemipelvis, all patients were hemodynamically stable at the time of presentation. Fourteen patients (64%) had other associated injuries, including five (23%) with closed head injury. In all cases a posterior extrapelvic approach was used with an anatomic reduction of the fractured iliac wing and the sacroiliac joint dislocation. Stable extraarticular internal fixation was obtained using intertable lag screws and outer-table neutralization plates. All the fractures were clinically and radiographically healed within 8-10 weeks postoperatively, and there were no acute wound, neurologic, or vascular complications. One patient developed osteomyelitis of the iliac crest 6 months postoperatively.

A biomechanical cadaver study was performed to compare the stability of three standard distal femoral fixation techniques. Eighteen mildly osteoporotic femurs were selected, based on a dual-energy x-ray absorption scanning bone density of 0.3-0.5 g/cm2 and a Singh index of III-IV. After initial mechanical characterization of these intact femurs, a distal femoral osteotomy was created, reduced, and stabilized under compression using random assignment to one of three methods of fixation: (a) six-hole 95 degrees supracondylar plate, (b) retrograde inserted statically locked supracondylar intramedullary nail, and (c) antegrade inserted statically locked Russell-Taylor nail. The instrumented femurs were mechanically tested, a 1-cm gap created, and the femurs retested. The specimens were finally loaded to failure in A-P three-point bending. The 95 degrees plate provided significantly stiffer fixation than the supracondylar intramedullary nail or Russell-Taylor nail in both a compressed transverse and gap distal femoral osteotomy model. The Russell-Taylor nail provided the least rigid fixation. The 95 degrees plate and Russell-Taylor nail had statistically significant greater loads to failure than the supracondylar intramedullary nail. These results support the use of a 95 degrees plate when maximum rigidity of fixation or maximum compression is desired.

We prospectively studied 367 patients who had a fracture of the hip, to determine the effect of an operative delay on postoperative complications and on the one-year mortality rate. All of the patients were at least sixty-five years old, cognitively intact, living at home, and able to walk before the fracture. An operative delay was defined as an interval of three calendar days or more between the time of admission to the hospital and the operation. The operation was performed within two calendar days after admission in 267 (73 per cent) of the patients. When the factors of the patient's age and sex and the number of pre-existing medical conditions were controlled, it was found that an operative delay beyond this period approximately doubled the risk of the patient dying before the end of the first postoperative year. When the patient's age and sex and the severity of pre-existing medical conditions were controlled, there was also an increase in mortality associated with an operative delay, although this was not significant. With the numbers studied, an operative delay beyond two calendar days did not have a significant effect on the prevalence of complications during hospitalization. We concluded that an operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients who have a fracture of the hip and who are cognitively intact, able to walk, and living at home before the fracture. Optimally, such patients should have the operation within two calendar days after admission to the hospital.

As the elderly population grows, a concomitant increase in polytrauma in the geriatric sector is predicted. Diminished physiologic reserve and deficiencies in management contribute to higher rates of morbidity and mortality in the elderly patient with trauma as compared with the young patient with equivalent trauma. Currently, traditional trauma scoring systems are insufficient in directing triage and predicting survival for these elderly patients. This may be related to the effects of aging and associated comorbidities. Age, therefore, should be considered in contemporary scoring systems and treatment algorithms. The benefits of prompt identification and treatment of musculoskeletal, neurologic, abdominal, and cardiopulmonary trauma, and maintenance of adequate nutritional status are well established in the polytrauma setting, in general. For the elderly patient with polytrauma, early invasive hemodynamic and cardiac monitoring are advisable to identify occult shock, limit end organ hypoperfusion, prevent multiorgan failure, and ultimately improve survival.

A biomechanical study was performed to examine a proposed mechanism of fracture blister formation. Sixty cadaver ankle skin specimens were subjected to several levels of uniaxial strain and examined histologically. Dermal-epidermal separation patterns similar to those found histologically in previous studies of biopsied fracture blisters were seen in specimens strained 152% and greater. These findings support the hypothesis that fracture blisters can result from strain developed in the skin during initial fracture deformation.

Ten nonunions of the distal tibial metaphysis were treated by using the Ilizarov circular external fixator. Original fractures were classified in terms of the Association for the Study of Internal Fixation as AO type A (4 cases), type B (5 cases), and type C (1 case). Six patients had a history of osteomyelitis. Bifocal compression-distraction lengthening osteosynthesis was performed in all cases. Proximal metaphyseal corticotomy was combined with resection and compression of the distal nonunion site in five cases, and compression alone in three patients. Ankle arthrodesis, in addition to nonunion resection, was performed in two patients. Follow-up averaged 48 months (range, 26 to 81). Eight nonunions healed (80%). Limb length was completely corrected in five cases; angular and rotational alignment was corrected to within 5 degrees in seven patients (70%). Based on an objective and subjective scale, the results were considered good-to-excellent in seven cases and poor in three. Despite the high complication rate and relatively low success rate (70%), the use of the circular frame with small-diameter, tensioned wires may provide an alternative method for the treatment of the very difficult problems associated with complex low distal tibial metaphyseal nonunions.

From June 1987 to January 1993, 53 fractures complicated by overlying blisters were identified and prospectively followed. Data concerning the mechanism of injury, time course in the development of the fracture blisters, clinical characteristics of the blister, fracture type and management, and soft-tissue treatment and outcome were collected. Clinically, two types of blisters were identified: clear fluid filled and blood filled. Methods used to treat the skin blister were: aspiration of the blister, deroofing of the blister with subsequent application of Silvadene cream or coverage with a nonadherent dressing, and leaving the blister intact and covered by a loose gauze or exposed to the air. No significant difference was found in the outcome of the skin injury treated with the various modalities. Nineteen patients underwent early open reduction and internal fixation in the presence of intact fracture blisters. In 17 cases the incision healed within 3 days, sealing off the deeper structures, and reepithelialization of the blister bed then occurred at a later date. Two of the patients who had incisions pass through blood-filled blisters developed wound healing complications. Although there was no significant difference in the outcome of the soft-tissue treatment techniques, our present practice is to leave all fracture blisters intact. If the blisters rupture spontaneously, they are deroofed and covered with a nonadherent dressing. Early surgery is contemplated in patients with intact blisters and without severe swelling.

An instrumented traction post was used to determine the magnitude and direction of the countertraction force applied to the perineum of 15 awake volunteers for a series of 12 positions used in fracture surgery and compared with their corresponding neutral position controls. The results demonstrated that adduction of the affected limb and abduction of the contralateral limb applied the greatest force to the perineum with ipsilateral and contralateral placement of the fracture post. These two maneuvers increased the perineal countertraction force 80% above their respective neutral readings. Abduction of the affected limb reduced the traction force by 50% with ipsilateral and contralateral placement of the fracture post. Flexion-abduction-external rotation of the contralateral leg reduced the forces applied to the perineum by 60% when the fracture post was placed contralateral to the affected limb. Contralateral placement of the post decreased the perineal countertraction force 46% below the value for ipsilateral post placement for this maneuver. Internal and external rotation of the affected limb had no effect on the perineal countertraction force for either placement of the post. There was a significant decrease in the perineal forces for the neutral positions after adduction of the affected limb and abduction of the contralateral limb with ipsilateral placement of the post, indicating that the volunteers shifted on the fracture table in response to pain. There was no significant difference in the direction of the countertraction force for the various positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-six hemiarthroplasties were performed for acute three- and four-part proximal humerus fractures between March 1986 and December 1991. Postoperative pain, active range of motion, and function were evaluated in 22 patients at a mean follow-up period of 30 months (range 12 to 66 months) with the American Shoulder and Elbow Surgeons evaluation form. Seventy-three percent of patients reported only slight or no pain. Active forward elevation averaged 107 degrees, external rotation averaged 31 degrees, and the average internal rotation was to the second lumbar vertebra. Strength and stability were rarely problematic. Seventy-three percent of patients reported difficulty with at least three of 15 functional tasks tested. Lifting, carrying a weight, and using the hand at or above shoulder level were the most common limitations. This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

The goal of tibial plateau fracture management is a stable, well-aligned, congruent joint, with a painless range of motion and function. Minimally displaced stable fractures should be treated with protected mobilization. The treatment of displaced tibial plateau fractures, however, remains controversial. Surgical reduction and stabilization of displaced tibial plateau fractures, when indicated, requires careful evaluation of both the "personality" of the fracture and the soft-tissue envelope. The timing of surgery and the handling of the soft tissue in this region are critical to treatment success. After restoration of a congruent joint surface, bone grafting and buttress plating are usually needed to allow early range of motion and optimize treatment outcome.

Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.

Three hundred thirty-six community-dwelling, previously ambulatory, geriatric patients with hip fracture were observed prospectively to determine ambulatory ability at a minimum followup of 1 year. One hundred thirty-seven (41%) patients maintained their prefracture ambulatory ability at a minimum followup of 1 year; 134 (40%) patients remained ambulatory but became more dependent on assistive devices; 39 (12%) previous community ambulators became household ambulators, and 26 (8%) patients became nonfunctional ambulators. Analysis was performed to determine which pre- and postinjury factors were predictive of failure to recover ambulatory capacity 1 year after fracture. Potential predictor variables analyzed included age, gender, number of comorbid conditions, prefracture ambulatory ability, prefracture living situation, fracture type, American Society of Anesthesiologists rating of operative risk, type of surgery, and number of postoperative complications. Multiple logistic regression analysis identified significant contributions of age, prefracture ambulatory ability, American Society of Anesthesiologists rating of operative risk, and fracture type to ambulatory recovery.

Between January 1, 1987, and December 31, 1992, 140 community-dwelling geriatric patients > or = 65 years of age with a displaced femoral neck fracture (Garden III-IV) underwent primary prosthetic replacement and were followed prospectively for a minimum of 1 year. Overall, 92 patients received a cemented bipolar prosthesis and 48 patients received a cemented modular unipolar prosthesis. There were no statistically significant differences between the two groups with respect to preinjury characteristics (age, sex, and number and severity of medical comorbidities) and functional ability. There were no statistically significant differences between the two groups with regard to the number of postoperative complications, length of stay, and 1 year mortality rate. An in-depth functional evaluation was obtained as follows: level of ambulation, independence in basic activities of daily living (feeding, bathing, dressing, toileting), and independence in instrumental activities of daily living (food shopping, food preparation, banking, laundry, housework, and use of public transportation). At 1 year follow-up, no statistically significant differences in functional ability were identified between the unipolar and bipolar groups. Furthermore, at a minimum of 1 year follow-up, there were no statistically significant differences between the two groups with regard to the need for revision surgery or the incidence hip pain. Based on the results of this study, there does not appear to be any advantage to the use of bipolar endoprosthesis for the treatment of femoral neck fractures in the elderly patient. The lower cost of modular unipolar prostheses compared with bipolar prostheses provides additional support for their use.

Fracture of the anterior iliac crest following bone grafting is an extremely rare occurrence. Five cases have been reported in the literature, none of which were internally stabilized. We are reporting a sixth case. Of the six cases, our harvest site is the furthest posterior from the anterior superior iliac spine. The fracture resulted in a large displaced anterior fragment that required open reduction and internal fixation with plates and screws. Osteoporosis increases the risk of anterior iliac crest fractures following bone grafting, but preventive procedures can be performed.

Between March 1989 and August 1993, 16 distal femoral nonunions (16 patients) were treated using the supracondylar intramedullary nail. The time between the initial event and retrograde nailing averaged 33 months. The nonunion level was infraisthmal in four patients and supracondylar in 12. Operative technique involved retrograde insertion of a reamed supracondylar intramedullary nail through the intercondylar notch. Follow-up was available on all patients and averaged 20 months (range 9-46). Four nonunions (25%) united with a single surgery at an average of 17 months. A fifth nonunion united at 21 months after nail dynamization and subsequent nail breakage. The nonunions of two additional patients united after exchange of a broken retrograde nail. Additional surgical procedures were performed in six of the remaining nine patients in an attempt to gain union. At an average follow-up of 16 months (range 9-23), none of the nine had united. Nine nails fractured at an average of 11 months, all through a screw hole near the nonunion. Based on these results, we cannot recommend use of the supracondylar intramedullary nail in its present form for the treatment of distal femoral nonunions.

The orthopaedic surgeon has a multitude of internal fixation devices and techniques available for use in the treatment of subtrochanteric fractures of the proximal femur. The successful use of second-generation locking nails is technically demanding. Close attention to positioning of the patient, reduction of the fracture, placement of the guide-wire, and insertion of the nail and of the proximal and distal locking screws is mandatory. The newer, high-strength hip-screws allow good fixation of a fracture that extends into the piriformis fossa. If medial comminution is present, this technique is best performed in conjunction with indirect reduction and bone-grafting. With proper technique, these devices allow the surgeon to manage predictably a complex subtrochanteric fracture that previously had to be treated with traction or extensive dissection and with (frequently inadequate) internal fixation.

A clinical and histological study was performed on fracture blisters found in association with 13 surgically treated ankle fractures. The timing of surgery was dependent upon soft tissue swelling; the status of the blister did not affect this aspect of the decision making process. The average time from injury to surgery was 2.1 days (range, 1-3 days). At the time of surgery all blisters were intact. Skin biopsies were obtained from the edge of the incision in proximity to the blister, and from the bed of the blister when the incision was made through the blister. Clinically, 2 blister types were identified: (1) clear fluid filled, and (2) blood filled. Histologically, both blister types demonstrated a cleavage injury at the dermoepidermal junction. However, the dermis of the clear fluid filled blister retained occasional epithelial cells, while the dermis of blood filled blisters was completely devoid of epidermis. Minimal to no evidence of dermal injury was found in histologic sections from the blister beds or from the skin in close proximity to blisters. All incisions made through and around skin blisters went on to heal without evidence of infection or wound breakdown. Delayed wound healing occurred in 1 patient in whom an incision was placed through a blood filled blister. The blood filled blister appears to represent a slightly deeper injury than the clear fluid blister and had a higher risk of poor healing of surgical incisions.

A biomechanical cadaver study was performed to compare the stability and ultimate strength of 3 standard fixation techniques used for treatment of basicervical hip fractures. Twenty one pairs of mildly osteoporotic femurs were selected, based on a computed tomography bone density reading of 40-50 Hounsfeld units and a Singh index of III. After initial mechanical characterization of intact femurs, basicervical femoral neck fractures were created, reduced, and then instrumented with random assignment to 1 of 3 methods of fixation: (1) 3 parallel 6.5-mm cannulated cancellous screws; (2) a 135 degrees sliding hip screw with a 4 hole side plate; and (3) a 135 degrees sliding hip screw with a 4 hole side plate and a 6.5-mm cannulated cancellous screw placed proximal and parallel to the sliding screw. Nine pairs were tested to failure in axial loading, 6 pairs in lateral bending, and 6 pairs in torsion. The group instrumented with the multiple cancellous screws had a significantly (p < 0.01) lower ultimate axial load to failure than either sliding hip screw group. However, the multiple screws demonstrated significantly (p < 0.01) less fracture displacement. There were no statistically significant differences in lateral bending or torsional testing behavior between the 3 fixation methods. Use of the sliding hip screw is recommended rather than use of multiple cancellous screws for treatment of basicervical femoral neck fractures. Although a superiorly located cancellous screw may provide rotational control during sliding hip screw insertion, it provides no incremental fixation after the sliding hip screw is placed.

Fifty embalmed human tibias were osteotomized to create a simulated vertical shear (supination-adduction) fracture of the medial malleolus and were stabilized using one of five internal fixation techniques. In offset axial testing, which simulated supination-adduction loading, the fixation strength of tibias stabilized with either cortical or cancellous lag screws placed perpendicular to the osteotomy was over five times greater than the strength of those treated with an antiglide plate and nearly two and a half times greater than those treated with cancellous lag screws placed oblique to the osteotomy. The tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy exhibited twice the fixation strength of the tibias stabilized with an antiglide plate and distal lag screw. The tibias stabilized with an antiglide plate and distal lag screw and perpendicularly placed cortical or cancellous lag screws demonstrated three times greater resistance to displacement to the applied supination-adduction load than those stabilized with an antiglide plate alone. In offset transverse testing, to simulate loading in external rotation, the mean failure load of the tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy was over two and a half times greater than those stabilized with an antiglide plate and distal lag screw. No significant differences were observed in the resistance to displacement for these tests. These results support the use of lag screws placed perpendicular to the fracture surface for stabilization of vertical shear fractures of the medial malleolus and indicate that the use of an antiglide plate, with or without a distal lag screw, does not offer any advantage over lag screw fixation.

Hip fractures remain a major source of morbidity and mortality in the elderly, and their incidence is increasing as the population ages. Surgical management followed by early mobilization is the treatment of choice for most patients with hip fractures. However, all comorbid medical conditions, particularly cardiopulmonary and fluid- electrolyte imbalances, must be evaluated and stabilized prior to operative intervention. Nondisplaced femoral-neck fractures should be stabilized with multiple parallel lag screws or pins. The treatment of displaced femoral-neck fractures is based on the patient's age and activity level: young active patients should undergo open reduction and internal fixation; older, less active patients are usually treated with hemiarthroplasty, either uncemented or cemented. Regardless of treatment method, the goal is to return the patient to his or her prefracture level of function.

Surgical stabilization followed by early mobilization is the treatment of choice for both nondisplaced and displaced intertrochanteric fractures. Fracture stability is dependent on the status of the posteromedial cortex. The sliding hip screw is the device mostly commonly used for fracture stabilization. The most important aspect of its insertion is secure placement within the femoral head. Although the sliding hip screw allows postoperative fracture impaction, it is essential to obtain an impacted reduction at the time of surgery. If there is a large posteromedial fragment, an attempt should be made to internally fix the fragment with a lag screw or cerclage wire. Although intramedullary hip screws have not been shown to be superior to the sliding hip screw, they may have selected indications.

The problem of osteomyelitis has, to date, not been completely resolved. Recent research has provided additional insight into the pathogenesis of bone infection. Advances in pharmacology and in surgical techniques have enhanced our ability to treat such infections. Despite these advances, successful treatment of posttraumatic tibial osteomyelitis depends on adherence to several basic principles: complete debridement of necrotic and infected tissue, obtaining bony stability, the elimination of dead space, and the provision of durable soft tissue coverage. Armed with this new knowledge and surgical ability, treatment results have improved. We do not know, however, whether osteomyelitis can ever be "cured," since infections become manifest many years after injury or treatment.

Unstable intertrochanteric hip fractures are characterized by comminution of the posteromedial cortex, resulting in a fragment of variable size containing the lesser trochanter. Controversy exists as to whether it is necessary to perform reduction and fixation of this fragment. This case lends further support to the practice of fixating the lesser trochanteric fragment in unstable intertrochanteric fractures.

A prospective study was performed comparing modified Knowles pins to cannulated cancellous screws for the treatment of nondisplaced and impacted femoral neck fractures. Forty-five impacted or nondisplaced fractures were identified: twenty-five were stabilized with modified Knowles pins and twenty with cannulated cancellous screws. Patient follow-up averaged twenty-four months (range 12 to 46 months) or until reoperation. Six patients (13%) required reoperation; these failures were evenly divided between the two groups. The remainder of patients (twenty-two patients (88%) in the Knowles pin group and seventeen patients (85%) in the cannulated screw group) were comparable with regard to functional outcome.

There are 23 cases in the literature of fracture table-induced pudendal nerve palsy. The majority of these patients had full sensory return; however, return of sexual function was unpredictable. The relevant anatomy, etiology, and incidence of this complication are discussed, and suggestions are made for its prevention.

No doubt all experienced clinicians have observed cases in which a hip fracture dramatically diminished the independence and quality of life of an elderly person. This difficult problem requires a concentrated, multidisciplinary effort. More than 800 patients have now been treated using our interdisciplinary approach. A recent review of the data shows that results in this larger group compare favorably with those in the followup group described in this article. We believe that our approach shows promise as a model for the future. Further, comparisons with current practices may lead in some situations to significant improvements in hip fracture rehabilitation. Primary care physicians play a key role in this process of review and modification and in contributing to the overall restorative effort.

Although computed tomography (CT) scanning has revolutionized the treatment of calcaneal fractures, simple studies such as Böhler's view still have a role in the diagnosis and management of these fractures. This article reviews the benefits and limitations of these imaging techniques for calcaneal fractures.

Two hundred fifty consecutive intertrochanteric fractures treated with a sliding hip screw (SHS) over a three year period were reviewed and specific types of technical pitfalls identified. Most pitfalls were technique dependent and potentially preventable with proper attention to the principles of fracture reduction and insertion of the device. Pitfalls encountered with the use of the SHS occurred as a result of either poor fracture reduction or implant insertion. Problems related to fracture reduction included poor radiographic visualization, posterior sag, varus angulation, and internal rotation of the femoral shaft in relation to the femoral neck. Potential pitfalls encountered during SHS insertion included superior guide wire placement, guide wire breakage or penetration into the hip joint or pelvis, loss of reduction during lag screw insertion, improper screw-barrel relationship, and improper plate application. Finally, the SHS may not be the implant of choice for all extracapsular hip fractures (i.e., the reverse obliquity fracture). This paper identifies the various pitfalls that may occur with the use of the SHS for the fixation of intertrochanteric hip fractures. Illustrative cases are provided and guidelines for avoiding these surgical pitfalls suggested.

Fifteen two-part surgical neck fractures of the humerus in 14 patients were treated with a modified-tension band wiring technique. In this technique, one wire is placed through the greater tuberosity and supraspinatus tendon, and the other wire is placed through the lesser tuberosity and subscapularis tendon. Each wire is connected to the shaft in a similar figure-of-eight technique. This places the wires approximately 90° apart from each other, with neither wire crossing over the biceps tendon. Four (26.7%) fractures had early loss of fixation, and one patient was lost to follow-up. Follow-up evaluation in the remaining 10 fractures (nine patients) averaged 33.4 months (range 26 to 53 months). Clinically, there were three (30%) excellent results, five (50%) satisfactory results, one (10%) unsatisfactory result, and one (10%) failure with the rating scale described by Neer. Based upon these results we cannot recommend the tension band wiring technique used. We consider the high incidence of loss of fixation (26.7%) reported in this series to be unacceptable., (Copyright © 1993 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

A prospective study of sixty-five orthopaedic procedures performed with fluoroscopic assistance was undertaken to determine the risk to the primary orthopaedic surgeon with regard to radiation. Radiation was monitored with the use of a universal film badge placed outside the collar of a lead apron, and a gas-sterilized thermoluminescent dosimeter ring worn on each hand. The rings were changed with every operation, but the same film badge was transferred from surgeon to surgeon. The hand dominance of the surgeon, the duration of the operative procedure, the type of operation, and the total time that fluoroscopy had been used were noted. The study was conducted during twenty-one intramedullary nailing procedures (thirteen involving distal locking), forty open reductions with internal fixation (plates and screws), and four external-fixation procedures. All of the badges and rings were submitted for a report regarding radiation exposure. No relationship was found between a ring with a positive reading for exposure to radiation and the duration of the operation. Similarly, there was no correlation between a positive reading and the surgeon's hand dominance. The mean duration of the fluoroscopy was 2.3 minutes for the group for which the rings did not show a positive reading and 4.7 minutes for the group for which the rings did show a positive reading. This was a significant difference (p < 0.0001). There was no positive reading for exposure to radiation from any ring that had been worn during a procedure in which the fluoroscope had been used for less than 1.7 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) polytrauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122 degrees; only two knees had an extensor lag of > 5 degrees. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

The treatment of 25 tibias in 25 patients with posttraumatic chronic osteomyelitis was reviewed. The approaches to soft tissue management fell into three groups: 1) muscle flap coverage; 2) primary closure with suction irrigation; and 3) open cancellous bone grafting. Treatment success was judged by the presence or absence of drainage and the local signs or symptoms of infection, and by the status of the tibial nonunion. Overall, 19 of 25 tibias (76%) had successful treatment. We found flap coverage to have a higher success rate (80%) than either primary closure with suction irrigation (45.5%) or open cancellous bone grafting (40%). These results further attest to the refractory nature of chronic osteomyelitis.

Indirect reduction and percutaneous screw fixation were attempted in 20 displaced tibial plateau fractures in 20 patients. Closed, indirect reduction was successful in 18 fractures; two others, both Schatzker type II fractures, required open reduction. The 18 fractures were followed for an average of 16.2 months (range, 12-24 months). Of the fractures successfully reduced with indirect techniques, 13 were reduced anatomically (72.2%), and five were considered nonanatomic (27.8%). Four of the five fractures with a nonanatomic reduction were type II fractures. Clinically, there were six excellent (33%), 10 good (56%), and two fair (11%) results. No fracture lost reduction; no patient developed an infection. Indirect techniques could effectively reduce only split fragments. Depressed fragments could not be reduced reliably with either ligamentotaxis or percutaneous elevation with a tamp. There was no correlation between radiographic reduction and clinical outcome. It did not matter whether two, three, or four screws were used to stabilize the fracture.

A retrospective review of 60 acute fractures of the tibia treated with reamed intramedullary nailing was undertaken to document the spectrum of complications associated with this procedure. Forty-five tibial fractures were followed to radiographic union; follow-up averaged 25 months (range, 10-63 months). Complications were categorized into intraoperative, early postoperative, and late postoperative groups. Intraoperative complications occurred in 6 of the 60 (10%) fractures and included propagation of the tibial fracture into the insertion site of the nail in four cases. In each of two other fractures, at least one of the proximal interlocking screws was documented to have poor bony purchase. These complications did not affect final fracture alignment or clinical result. Early complications included soft-tissue complications, complications of fixation, and neurologic complications. Four patients developed hematomas at the nail insertion site. Eight fractures were stabilized in greater than 5 degrees of varus or valgus. Neurologic deficits directly related to the procedure were documented in 18 patients (30%). The majority were minor sensory neuropraxias of the peroneal nerve. Sixteen (89%) of these nerve palsies were transient, resolving within 3-6 months. Two patients had persistent nerve deficits at 1-year follow-up. In the late complications group, 10 of the 45 (22%) tibial fractures followed to union developed patellar tendinitis. Nonunion developed in two fractures, both of which required additional surgical procedures to obtain fracture union. Two deep infections occurred, both of which resolved after local wound care, fracture union, and nail removal. Overall, 26 of the 45 tibial fractures available for follow-up (58%) developed some complication attributable to the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Sixty patients (eighty hips) who had slipped capital femoral epiphysis were treated by epiphyseodesis with a cannulated-screw technique. Forty-nine patients (sixty-seven hips) were available for follow-up, forty-four (sixty hips) of whom were followed for a minimum of two years. Thirty-five patients (forty-six hips) were followed until the hardware was removed. Of seventy-two hips in which contrast medium was injected, arthrographic results were obtained in three. In these three hips, there was evidence of pre-existing narrowing of the joint space. Four patients (six hips) who did not have evidence of penetration by a screw or guide-wire had evidence of either pre-existing chondrolysis or osteoarthrosis. Chondrolysis did not develop postoperatively in any patient who had no evidence of it preoperatively.

Rotational displacement of the distal tibial physis occurred in a 12-year-old boy. A review of the literature indicates that long-term follow-up is necessary to determine whether premature physeal closure will occur.