Purpose

Management of compound fractures, which have a higher infection risk than closed fractures, currently depends on surgeon training and past practice rather than evidence based practice. Some centres use delayed closure involving a second surgery with repeat debridement and wound closure 48 hours after initial debridement and fixation. Other centres use primary closure in the absence of gross contamination or major soft tissue deficits, where debridement, fixation and wound closure occur during the initial surgery. Delayed closure was used at our centre until January 2009 when the standard of care evolved to primary closure where appropriate. Primary closure allows more efficient OR utilization due to fewer OR visits, but it is unknown if primary closure increases the risk of infection, which can, in turn, lead to fracture non-union. The purpose of this pilot study was to complete a safety analysis of infection rates in the first 40 patients undergoing primary closure of a compound fracture; enrolment is ongoing and updated results will be presented.

CT scans of thirty pes planus and eighteen normal feet were obtained in a simulated weight-bearing mode at 50% of body weight. The navicular skin distance was 22% less (1.9vs2.5cm) in the pes planus feet and forefoot supination was only 50% of normal (8.9vs18.6 degrees). Subtalar subluxation was observed in only the most severe pes planus feet. Navicular skin distance relates to medial arch collapse; loss of forefoot supination reflects the rigidity of the forefoot compensation to hindfoot valgus. Severe pes planus results in subtalar subluxation. The radiological indices described have not previously been reported in the literature.

To compare the inter-tarsal relationships of the pes planus foot to the normal foot in the weight-bearing state.

Weight-bearing CT scan of the feet is a practical examination with rapid set-up and minimal patient discomfort. Preliminary results demonstrate differences in the inter-tarsal relationships of pes planus feet compared to normal feet. Better understanding of pes planus deformity will advance clinical evaluation and treatment strategies.

Radiological indices described have not previously been reported in the literature.

Thirty pes planus and eighteen normal feet were imaged. All patients were able to tolerate the six- minute exam at 50% of body weight. Total study time averaged fifteen minutes. The navicular skin distance was 22% less (1.9vs2.5 cm) in pes planus feet compared to normal feet. Pes planus feet had only 50% of the normal forefoot supination (8.9vs18.6 degrees). Lastly, subtalar joint subluxation was observed in only the most severe pes planus feet. Values ranged from 0.2 to 1.1cm.

Axial CT images of 1mm thickness with 0.5mm overlap were obtained at a weight-bearing load of 50% of body weight using the weight-bearing CT device. Coronal and Sagital images were then reconstructed.

Radiological indices obtained can be related to the clinical picture of the pes planus foot. The navicular skin distance reflects medial arch collapse, where as the lack of forefoot supination reflects the rigidity of the forefoot compensation to hindfoot valgus. Severe hindfoot valgus in pes planus results in subtalar sub-luxation.

This study documents the use of bone graft harvested by the RIA system and used in treating segmental bone loss in the femur and tibia following trauma.

Eight patients with segmental defects of the tibia or femur were enrolled in the study. The segmental defects were optimized for bone grafting by repeated debridements and muscle flap coverage as required. Graft was harvested from the ipsilateral femur via a percutaneous technique. Volumes of bone graft were recorded and then placed to the defect site during the same surgical procedure.

The average age of the patients was twenty-nine years (sixteen to forty-one years). In the five tibiae and three femora there were four grade IIIA, three grade IIIB and One grade IIIC injuries. Muscle flap coverage was required in four patients. The average size of defect was 7 cm (1–14.5 cm). The RIA grafting was performed at an average of three months (2.5 – 5 months) post injury. The average bone graft volume obtained was 73cc(45–90 cc). The average hemoglobin drop was 4.4g/dl(2.3 – 8.0 g/dl) and the average hematocrit drop was 12.3%(6–21%). One patient required transfusion. Donor site complications were limited to one post-operative bleed. Defect site complications included one wound dehiscence and two infections. Radiographic union of the defects was achieved at an average time of four months (two to twelve months).

Grafting of large segmental defects using RIA bone graft has resulted in union at an average of four months. This technique represents an alternative to bone transport for treatment of segmental defects.

Reamed Irrigation Aspirator (RIA) allows access to large volumes of bone graft from the femur through percutaneous technique. The grafting technique was utilized to obtain graft for eight segmental defects in the tibia and femur. These healed at an average of four months.

We compared the radiographs, clinical outcomes, and complications of two techniques used for treatment of unstable distal radius fractures in young adults. Fifty patients were randomized to percutaneous pinning or augmented external fixation. At one year follow-up, the external fixator did not improve the parameters of radial length, radial angulation or volar tilt. Reduction of intra-articular steps was slightly improved. No differences in DASH scores or functional outcomes were observed, but more complications were noted with the fixator. While articular restoration can be slightly improved with use of the external fixator, a higher incidence of complications and patient dissatisfaction was noted.

Two common techniques for treatment of unstable distal radius fractures in young adults include percutaneous pinning combined with plaster cast, and application of an external fixator, frequently with adjunctive pinning.

The objective of this study was to:

1. To compare the short and mid-term radiographic and clinical outcomes of these two common fixation techniques.

2. To compare the complications of the two techniques.

Fifty patients (< 65 yrs) with unstable fractures of the distal radius were recruited. Patients were randomized pre-operatively to percutaneous pinning or external fixation. All surgery was performed by one of three surgeons. Patients were followed for one year with radiographs and an independent clinical exam including DASH questionnaires.

86% of fractures were AO classification C2 or C3, with an equal distribution of all types in both treatment groups. Use of an external fixator did not improve the parameters of radial length, radial angulation or volar tilt. However, reduction of intra-articular steps was slightly improved with its’ use. No differences in mean DASH scores, total ROM or grip strength were observed. More pin complications were noted with the fixator, and all three patients diagnosed with RSD received external fixation.

While external fixation represents a popular first line treatment for unstable distal radius fractures, this study suggests that similar gross radiographic and clinical results can be obtained with percutaneous pinning. While articular restoration can be slightly improved with use of the external fixator in highly comminuted fractures, this must be balanced by a higher incidence of complications and patient dissatisfaction.

Funding: Stryker-Howmedica-Osteonics