Manual of internal fixation , Manual of internal fixation , کتابخانه دیجیتال جندی شاپور اهواز

Manual of internal fixation

Objective To summarize the surgical experience and clinical results of the first 89 fractures of the proximal tibia treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). Design Retrospective analysis of prospectively enrolled patients into a database. Setting Academic level I trauma center. Subjects/participants Eighty-seven consecutive patients with 89 proximal tibia fractures (AO/OTA type 41 and proximal type 42 fractures) treated by 2 surgeons. Seventy-five patients with 77 fractures were followed until union. The mean follow-up was 14 months (range: 3-35 months). There were 55 closed fractures and 22 open fractures. Intervention Surgical reduction and fixation of fractures, followed by rehabilitation. Main outcome measurements Perioperative and postoperative complications, postoperative alignment, loss of fixation, time to full weight bearing, radiographic union, and range of motion. Results Seventy of 77 fractures healed without major complications (91%). There were 2 early losses of proximal fixation, 2 nonunions, 2 deep delayed infections, and 1 deep peroneal nerve palsy. Other complications included a superficial wound infection and 3 seromas. Postoperative malalignment occurred in 7 patients with 6 degrees to 10 degrees of angular deformity (6 flexion/extension and 1 varus/valgus malalignments), and an eighth patient had a 15 degrees flexion deformity. In 4 patients, the hardware was removed at an average of 13 months because of irritation (5%). The mean time for allowance of full weight bearing was 12.6 weeks (range: 6-21 weeks), and the mean range of final knee motion was 1 degrees to 122 degrees . Conclusions The LISS provides stable fixation (97%), a high rate of union (97%), and a low (4%) rate of infection for proximal tibial fractures. The technique requires the successful use of new and unfamiliar surgical principles to effect an accurate reduction and acceptable rate of malalignment.

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Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures

OBJECTIVE To evaluate the effectiveness of systemic hyperbaric oxygen therapy (s HBOT) in addition to a comprehensive protocol in decreasing major amputation rate in diabetic patients hospitalized for severe foot ulcer. RESEARCH DESIGN AND METHODS From August 1993 to August 1995, 70 diabetic subjects were consecutively admitted into our diabetologic unit for foot ulcers. All the subjects underwent our diagnostic-therapeutic protocol and were randomized to undergo s-HBOT. Two subjects, one in the arm of the treated group and one in the arm of nontreated group, did not complete the protocol and were therefore excluded from the analysis of the results. Finally, 35 subjects received s-HBOT and another 33 did not. RESULTS Of the treated group (mean session = 38.8 ± 8), three subjects (8.6%) underwent major amputation: two below the knee and one above the knee. In the nontreated group, 11 subjects (33.3%) underwent major amputation: 7 below the knee and 4 above the knee. The difference is statistically significant ( P = 0.016). The relative risk for the treated group was 0.26 (95% CI 0.08–0.84). The transcutaneous oxygen tension measured on the dorsum of the foot significantly increased in subjects treated with hyperbaric oxygen therapy: 14.0 ± 11.8 mmHg in treated group, 5.0 ± 5.4 mmHg in nontreated group ( P = 0.0002). Multivariate analysis of major amputation on all the considered variables confirmed the protective role of s-HBOT (odds ratio 0.084, P = 0.033, 95% CI 0.008–0.821) and indicated as negative prognostic determinants low ankle-brachial index values (odds ratio 1.715, P = 0.013, 95% CI 1.121–2.626) and high Wagner grade (odds ratio 11.199, P = 0.022, 95% CI 1.406–89.146). CONCLUSIONS s-HBOT, in conjunction with an aggressive multidisciplinary therapeutic protocol, is effective in decreasing major amputations in diabetic patients with severe prevalently ischemic foot ulcers.

Adjunctive Systemic Hyperbaric Oxygen Therapy in Treatment of Severe Prevalently Ischemic Diabetic Foot Ulcer: A randomized study

Thermal injury to bone: A vital-microscopic description of heat effects

Medullary nails have only been used with reluctance in the treatment of open fractures since reaming interferes with the cortical circulation. The technique of interlocking offers the interesting possibility of inserting a relatively stiff nail which does not necessarily require reaming. The effects of reaming prior to nail insertion upon the cortical circulation was investigated in the canine tibia. Intravital staining with procion red was used to trace areas of disturbed circulation. Nail insertion without reaming provided clear advantages for the bone's blood supply, while reaming disturbed perfusion in two-thirds of the cortical area and regionally extended through the entire thickness of the cortex. The disturbance without reaming was limited to the inner layer of the cortex and involved only one-third of the cortical cross-section.

Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia.

(1969). Reaming of the Medullary Cavity and its Effect on Diaphyseal Bone: A Fluorochromic, Microangiographic and Histologic Study on the Rabbit Tibia and Dog Femur. Acta Orthopaedica Scandinavica: Vol. 40, No. sup128, pp. 1-165.

Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur.

(1970). Intramedullary Nailing after Reaming: An Investigation on the Healing Process in Osteotomized Rabbit Tibias. Acta Orthopaedica Scandinavica: Vol. 41, No. sup134, pp. 1-78.

Intramedullary Nailing after Reaming: An Investigation on the Healing Process in Osteotomized Rabbit Tibias

A study was made of the extent of the intracortical vascular damage occurring on intramedullary reaming in the rabbit tibia with simultaneous reduction of pressure in the distal part of the medullary cavity, and the findings were compared with previously reported results from rabbits in which reaming was performed without such pressure reduction. It was found that reduction of pressure, on reaming, by suction through a separate, peripheral opening in the distal metaphysis, considerably diminished the vascular damage in the cortex. In these cases the primarly avascular part of the cortex began to be revascularized two weeks after the operation, a process which was almost completed after a further two weeks. When the pressure in the medullary cavity was not reduced during the reaming, the degree of intracortical avascularity was considerably greater, and persisted to a large part after an observation time of four weeks.

Intracortical circulation after intramedullary reaming with reduction of pressure in the medullary cavity.

https://www.tandfonline.com/doi/pdf/10.3109/ort.1971.42.suppl-137.01

Fracture Healing in Compression Osteosynthesis: An Experimental Study in Dogs with an Avascular, Diaphyseal, Intermediate Fragment

The maximal isometric muscle strength of hip abduction, knee extension and knee flexion was measured in 23 patients operated on for femur diaphyseal fractures and fitted with a stable intramedullary Kuntscher nail after reaming of the medullary cavity. The trauma, the immobilization and the surgery influenced the musculature of the operated as well as the intact leg. The muscle power recovered in a couple of years, but even after 2-6 years a significantly reduced power was found in the knee extensors, and a probably significant reduction in the power of the knee flexors in the operated leg when the two legs were compared. Malrotation of the fracture seemed to adversely affect the recovery of muscle power.

Göran Danckwardt-Lillieström

Papers

Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur.

Intramedullary Nailing after Reaming: An Investigation on the Healing Process in Osteotomized Rabbit Tibias

Intracortical circulation after intramedullary reaming with reduction of pressure in the medullary cavity.

Fracture Healing in Compression Osteosynthesis: An Experimental Study in Dogs with an Avascular, Diaphyseal, Intermediate Fragment

Postoperative restoration of muscle strength after intramedullary nailing of fractures of the femoral shaft.