We report the functional and socioeconomic long-term
outcome of patients with pelvic ring injuries. We identified 109 patients treated at a Level I trauma centre
between 1973 and 1990 with multiple blunt orthopaedic injuries including
an injury to the pelvic ring, with an Injury Severity Score (ISS)
of ≥ 16. These patients were invited for clinical review at a minimum
of ten years after the initial injury, at which point functional
results, general health scores and socioeconomic factors were assessed. In all 33 isolated anterior (group A), 33 isolated posterior
(group P) and 43 combined anterior/posterior pelvic ring injuries
(group A/P) were included. The mean age of the patients at injury
was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44). At review the mean Short-Form 12 physical component score for
the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score
for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42),
being significantly worse compared with the other two groups (p =
0.004 and p = 0.024, respectively). A total of 42 patients (39%)
had a limp and 12 (11%) required crutches. Car or public transport
usage was restricted in 16 patients (15%). Overall patients in groups
P and A/P had a worse outcome. The long-term outcome of patients
with posterior or combined anterior/posterior pelvic ring injuries
is poorer than of those with an isolated anterior injury. Cite this article:
A wide variety of intra- and extramedullary devices for the treatment of trochanteric fractures has been described. The Percutaneous Compression Plate is a minimally invasive and extramedullary device, which requires two 2–2.5 cm long incisions with minimal dissection oft soft tissue on the lateral aspect of the proximal femur. Earlier studies indicated that internal fixation using the PCCP is associated with a decreased perioperative blood loss, reduced transfusion requirements, with less postoperative pain, more rapid mobilisation, and with a reduced incidence of collapse of the fracture when compared with the standard device Dynamic Hip Screw. Aim of this study is to analyze the risk factors for the occurrence of local complications after internal fixation of intertrochanteric fractures of the femur using a Percutaneous Compression Plate. In a retrospective cohort study patients with trochanteric fractures who underwent internal fixation with a PCCP were included. We investigated the potential risk factors age, gender, experience of the surgeon as indicated by the numbers of surgical procedures with the PCCP device, stability of the fracture according to the AO/OTA classification, and co-morbidities of the patients according to the ASA classification. The operations were performed by ten different surgeons. All local complications which required re-operation were recorded. They included cutting out of the screw, loosening of the screw barrels, local haematoma, and infections. Logistic regression analysis was carried out to determine the risk factors for local complications. The mean age of the 122 patients included in this study was 78.5 years. 87 patients were female (70.7 %), 36 patients were male (29.3 %). With respect to the stability of the fracture 64 trochanteric fractures (52.5%) were classified as stable according to the AO/OTA classification, whereas 58 (47.5%) were considered to be unstable. Of the total of 122 patients with 122 trochanteric fractures eleven underwent re-operation due to local complications (9 %). The most frequent complication was complete or imminent cutting out of the upper cervical screw (N=5; 4 %). In the multivariate logistic regression model the only statistically significant risk factor was the experience of the surgeon (p=0.0316; odds ratio=4.7; CI 1.1–19.4). Our data indicate that the experience of the surgeon is a significant risk factor for the occurrence of local complications. The frequent use of this device seems to lower the re-operation rate.
Aim of this study was to find out which factors influence the outcome after both column fractures of the acetabulum. We performed a retrospective analyse of 115 patients with both column acetabular fractures. The period between the injury and follow-up ranges between 2 and 19 years, 5,7 years on average. The initial displacement, the presence of a dislocation of the hip and fractures of the femoral head were analyzed on the initial radiographs. Postoperative displacement was classified according the classification of Matta. The common classifications of Helfet (posttraumatic arthrosis), Ficat/Arlet (femur head necrosis) and Brooker (periarticular calcification) were used to radiologically classify the long term results. Statistics were performed by the Chi-square-test.Aim of the study
Methods
The additive use of an external modular device may improve dorsal compression forces in pelvic external fixation. This would improve the efficiency of indirect reduction and stabilization with an anterior pelvic external fixator. The purpose of this study was to determine the forces of the posterior pelvis achieved by a new device improving the application of a supraacetabular anterior external fixator compared with other constructs. Synthetic pelvic models were used. Complete pelvic ring instability was created by symphyseal and unilateral sacroiliac joint disruption. Four different constructs of fixation were tested. A pressure-sensitive film was placed in the sacroiliac joint. The constructs were applied in a standardized way. The maximum sacroiliacal compression loads (N) of each trial was recorded. Statistics was performed with the student t-test.Objectives
Material and Method
Overlooked compartment syndrome represents a devastating complication for the patient. Invasive compartment pressure measurement continues to be the gold standard. However, repeated measurements in uncertain cases may be difficult to achieve. We developed a new, noninvasive method to assess tissue firmness by pressure related ultrasound. Decreased tissue elasticity by means of rising compartment pressures was mimicked by infusion of saline directly into the anterior tibial compartment of 6 human specimens post mortem. A pressure transducer (Codman) monitored the pressure of the anterior tibial compartment. A second transducer was located in a saline filled ultrasound probe head to allow a simultaneous recording of the probe pressure provoked by the user. The ultrasound images were generated at 5 and 100mmHg probe pressures to detect the tissue deformity by B-mode ultrasound. The fascial displacement was measured before and after compression (d). Subsequently, increments of 5mmHg pressure increases were used to generate a standard curve (0–80mmHg), thus mimicking rising compartment pressures. The intra-observer reliability was tested using 10 subsequent measurements. A correlation was determined between d and the simulated intacompartmental pressure (ICP) in the compartment. The Pearson correlation coefficient (r) was calculated. The reliability determined by the kappa value and a regression analysis was performed.Background
Methods
The aim of this study was to investigate whether growth factors essential for fracture healing are released in the immediate aftermath following fracture and whether reaming of IM cavity causes increased liberation of these autocoids. Consecutive adult patients with femoral shaft fractures forming two groups (a group who received unreamed nail (n=10) and a second group who received reamed nail (n=10) were recruited for this study. Peripheral blood samples and samples from the femoral canal before and after reaming and before and after the solid nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor I (IGF-I) Transforming Growth Factor beta 1 (TGF-21) and BMP-2 levels was measured.Purpose
Methods
The timing of definitive fixation for major fractures in polytrauma patients is controversial. To clarify this aspect of trauma management, we randomised patients with blunt multiple injuries to either initial definitive stabilisation of the femur shaft with an intramedullary nail or an external fixator which was converted to an intramedullary nail at a secondary procedure and documented the post-operative clinical condition. Multiply injured patients with femoral shaft fractures were randomised to either initial (<24 hours) intramedullary femoral nailing or to initial external fixation and conversion to an intramedullary nail at a later phase. Inclusion criteria: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score >2 points and another injury (Abbreviated Injury Scale score >2 points), and age 18 to 65 years. Exclusion criteria: unstable or patients in extremis. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES: Incidence of acute lung injuries.Purpose
Methods
We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion.Conclusion/Significance
The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. 22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group. The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay >
5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03). Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process.
An increased incidence of systemic inflammatory response syndrome was associated with three variables: presence of borderline condition, hemothorax and requirement of blood transfusion. This may have important treatment implications, including the management of major fractures.
The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months). Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases). In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded. The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients.
The purpose of this study was to assess the effect of human autologous serum on the proliferation and differentiation of MSCs and to analyze the serum growth factor content. Serum was obtained from 8 patients suffering from lower limb long bone fractures requiring surgical intervention. Serum samples were obtained on admission and the 1st-3rd–5th and 7th postoperative day. During the surgical procedure cancellous bone pieces from the fracture were obtained and MSCs were isolated. Cells were cultured with autologous serum from each sample. The cellular potential for proliferation and osteogenic differentiation was assessed. Fetal calf serum (FCS) was used for comparison. The presence of growth factors in the serum was investigated using commercially available colorimetric assays read on Elisa plate reader. We studied the serum content on Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF) and Insulin-like Growth Factor I (IGF-1). The maximal upregulation of cellular proliferation and osteogenic differentiation was noted in cells cultured from serum obtained between third and seventh days. Cellular proliferation in comparison to FCS was increased by 32% with the use of serum from admission, 23% with the use of serum of the 1st day and 37% and 42% with the serum from 3rd and 7th days respectively. Serum analysis revealed an increase of 80% of PDGF between the 1st and 3rd postoperative day and 135% from 3rd–7th postoperative day. IGF-1 was increased by 35% between day 1 and 7. VEGF was increased by 120% during the first two postoperative days and a further increase of 190% occurred between days 3 and 7. Growth factors are released in peripheral circulation and are gradually increased after fracture. MSCs under their influence proliferate faster and up-modulate their osteogenic differentiation. These findings should be considered when using functional assays for tissue regeneration techniques.
Patients with a femoral shaft fracture requiring intra-medullary nailing were recruited to investigate if the femoral canal could be a potential source of inflammatory cytokines, previously implicated in the pathogenesis of life-threatening inflammatory complications. Femoral and peripheral blood samples were obtained at the time of surgery from patients with a femoral shaft fracture requiring intramedullary nailing. The local femoral intramedullary and peripheral release of a group of ten Th1 and Th2 cytokines concentrations (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, GM-CSF, TNF-a and IFN-g) after femoral shaft fracture and intramedullary reaming, if performed, was measured using a Human Cytokine Antibody 10-plex Bead Kit. A control group of patients(n=3) undergoing hip replacement was established to allow comparison with the normal femoral intramedullary cytokine environment. 21 patients with a femoral shaft fracture were recruited. Femoral shaft fracture caused a significant increase in the local femoral concentrations of IL-6 (median 3967pg/ml; range 128–25,689pg/ml) and IL-8 (median 238pg/ml; range 8–8,288pg/ml) compared to the femoral control group(p=0.0005 and p=0.001 respectively). No significant local femoral release of the other cytokines was demonstrated. In the patients who underwent intramedullary reaming of the femoral canal (n=6), a further significant local release of IL-6 (median post-ream 15,903pg/ml; range 1,854–44,922pg/ml) and IL-8 (median post-ream 1,443pg/ml; range 493–3,734pg/ml) was demonstrated (p=0.01 and p=0.03 respectively), thus showing that intramedullary reaming can cause a significant local inflammatory response. Femoral shaft fracture produces a local inflammatory response releasing large amounts of the cytokines IL-6 and IL-8 into the local femoral environment but not of the other Th1 and Th2 cytokines studied. Reaming, produced significant elevation in local femoral IL-6 and IL-8 concentration, suggesting a local femoral response as a result of this procedure. Possibly, local femoral environment may act as a cell-priming or stimulating zone, for circulating inflammatory cells.
Patients with bilateral femur shaft fractures are known to have a higher rate of complications when compared with those who have unilateral fractures. Many contributing factors have been considered responsible, however due to the heterogeneity of the studied populations solid conclusions cannot be substantiated. Patients included in our study were separated according to the presence of a unilateral (group USF) (n=146) versus bilateral femur shaft fracture (group BSF) (n=19)Endpoints of the study included the incidence of systemic (SIRS, Sepsis, Acute Lung Injuries) complications. The perioperative assessment included documentation of clinical and laboratory data assessing blood loss, coagulopathy, wound infection, and pneumonia. Local (wound infection, compartment syndrome etc.) and systemic complications (ALI, MOF, Sepsis) were documented. Statistical analyses were conducted to examine the relation between the occurrence of unilateral versus bilateral femoral fractures and variables indexing patient demographic characteristics and other indicators of initial injury severity. Independent sample t-tests were used to examine treatment group differences for variables that approximated a Gaussian distribution. For non-normal indicators of injury severity Mann-Whitney tests were performed. Pearson chi-square tests were performed for binary indicators of injury severity, except when expected cell counts did not exceed 5 participants. When this occurred, the Fisher exact test was used Evidence indicated that patients who suffered a bilateral femoral fracture were significantly more likely to have hemothorax and receive a blood transfusion upon admission to the hospital in comparison to patients who suffered a unilateral femoral fracture. Bivariate analyses also indicated that patients with bilateral femoral fractures exhibited a longer clinical recovery time and were more likely to experience clinical complications in comparison to those with unilateral fractures. However, there were no significant differences between the fracture groups in terms of the number of hours spent on a ventilator or the occurrence of pneumonia, acute lung injury, acute respiratory distress, sepsis, and multiple organ failure following surgery. Patients in borderline condition spent significantly more time in the ICU in comparison to those in stable condition. The high incidence of posttraumatic complications in poly-trauma patients with bilateral femur shaft fractures is caused by the accompanying injuries rather than by the additional femur fracture itself. It also documents that a thorough preoperative assessment can help differentiate those who have a high like hood of developing systemic complications from those who do not.
The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.
This paper summarises the current knowledge on the effects of medullary reaming of long-bone fractures. Following a review of intramedullary vascular physiology, the consequences for vascularity, the autograft effects, the generation of heat, and fat embolism are outlined. Also, alternative reaming techniques are described.
With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.
