Summary 1 The pathogenesis of infections associated with fracture-fixation devices is related to microorganisms growing in biofilms, which render these infections difficult to treat. These infections are classified as early ( 10 weeks) according to the implant surgery. Most infections are caused by staphylococci and are acquired during trauma (in penetrating injuries) or subsequent fracture-fixation procedures. A combination of clinical, laboratory, histopathology, microbiology, and imaging studies are usually needed to accurately diagnose infection. Magnetic resonance imaging (MRI) and computed tomography (CT) scans are often used to diagnose infection and plan surgical treatment. Positron emission tomography (PET) and PET-CT are promising new tools for diagnosing implant-associated osteomyelitis. The treatment goal is achieving bone consolidation and avoiding development of chronic osteomyelitis. Successful treatment requires adequate surgical procedures combined with 612 weeks of antimicrobial therapy acting on adhering stationary-phase microorganisms. In chronic osteomyelitis, orthopedic and plastic-reconstructive surgery is combined in the same procedure or within a short time span. In this article, pathogenesis, classification, diagnosis, and treatment of infections associated with intramedullary nails, external-fixation pins, plates, and screws are reviewed.

/pdf/diagnosis-and-treatment-of-infections-associated-with-43xs8a4j0d.pdf

Diagnosis and treatment of infections associated with fracture-fixation devices

Background: A new method of fixation for intertrochanteric hip fractures that involves the use of an intramedullary nail that interlocks proximally into the femoral head was introduced in the early 1990s. Anecdotal observation of practice patterns during the Part II (oral) American Board of Orthopaedic Surgery examination suggested that the use of this method had increased substantially in recent years in comparison with the more traditional sliding compression screw technique. A study of the Part II database was undertaken to detect changing patterns of care for intertrochanteric fractures.

Methods: During the process of Board certification, candidates for the Part II (oral) examination submit a six-month surgical case list and patient data into a secure database. The database was searched for all intertrochanteric fractures (International Classification of Diseases, Ninth Revision, code 820.20 or 820.21) over a seven-year period (1999 through 2006). The cases were categorized by intramedullary nail or plate fixation on the basis of surgeon-reported Current Procedural Terminology codes. Relative utilization of the two devices was analyzed according to year and region, and the devices were compared in terms of complications and outcomes.

Results: A dramatic change in practice was demonstrated, with the intramedullary nail fixation rate increasing from 3% in 1999 to 67% in 2006. Regional variation was substantial. The highest rate of utilization of intramedullary nail fixation was recorded by candidates from the South, Southeast, and Southwest, who converted to the new technology faster than those in the Northeast, Northwest, and Midwest. Overall, patients managed with plate fixation had slightly less pain and deformity in comparison with those managed with intramedullary nailing, with no significant differences being identified in terms of function or satisfaction. Patients managed with intramedullary nailing had more procedure-related complications, particularly bone fracture.

Conclusions: From 1999 to 2006, a dramatic change in surgeon preference for the fixation device used for the treatment of intertrochanteric fractures has occurred among young orthopaedic surgeons. This change has occurred despite a lack of evidence in the literature supporting the change and in the face of the potential for more complications.

Nail or Plate Fixation of Intertrochanteric Hip Fractures: Changing Pattern of Practice: A Review of the American Board of Orthopaedic Surgery Database

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.

Supracondylar humeral fractures in children.

Double-blind, prospective, placebo-controlled clinical trials demonstrate that healing times of fresh fractures of the radius and tibia are reduced by up to 40% with the use of low-intensity ultrasound.

Animal studies indicate that low-intensity ultrasound exposure results in stronger and stiffer callus formation and in acceleration of the endochondral ossification process.

Extensive clinical evidence demonstrates that ultrasound represents a safe, noninvasive method of accelerating the healing of fresh fractures of the tibia, the distal aspect of the radius, the scaphoid, and the metatarsals.

Clinical studies indicate that ultrasound reduces the confounding effect of smoking and patient age on the fracture-healing process.

Ultrasound requires a brief, twenty-minute, daily at-home treatment regimen and has no known contraindications.

The effectiveness of low-intensity ultrasound has also been demonstrated in the clinical treatment of delayed unions and nonunions.

Fracture-healing is a complex biological process that involves the spatial and temporal orchestration of numerous cell types, hundreds if not thousands of genes, and the intricate organization of an extracellular matrix, all working toward restoring the bone's mechanical strength and rapid return to full function. It has often been argued that nature has optimized this process and thus it would be difficult to interventionally accelerate or augment fracture-healing. How can science conceivably improve upon 600 million years of vertebrate evolution? Nevertheless, it is just this goal that has inspired an intense effort among basic-science and clinical investigators from a vast array of biotechnology and bioengineering disciplines at academic as well as industrial laboratories, to seek a means of accelerating the healing of fractured bones. In this article, the basic-science and clinical evaluation of the use of low-intensity ultrasound is reviewed and the case is made that nature's process of fracture-healing, while elegant, can be accelerated with respect to achieving the ability to support clinically relevant loads.

The …

The use of low-intensity ultrasound to accelerate the healing of fractures.

Background: There is a lack of consensus among orthopaedic surgeons in the assessment of fracture-healing. We conducted a systematic review of recent clinical studies of long-bone fracture care that were published in three major orthopaedic journals to identify current definitions of fracture-healing.

Methods: MEDLINE and the computerized databases for The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and the Journal of Orthopaedic Trauma were searched from January 1996 through December 2006 with use of title, abstract, keyword, and medical subject headings. Therapeutic clinical studies of long-bone fractures of the appendicular skeleton in adults in which fracture-healing was assessed were selected. Two reviewers independently identified articles and extracted data. Any disagreement was resolved by consensus. We qualitatively and quantitatively summarized the definition of fracture union and the reliability of the assessment of radiographic fracture-healing.

Results: One hundred and twenty-three studies proved to be eligible. Union was defined on the basis of a combination of clinical and radiographic criteria in 62% of the studies, on the basis of radiographic criteria only in 37%, and on the basis of clinical criteria only in 1%. Twelve different criteria were used to define fracture union clinically, and the most common criterion was the absence of pain or tenderness at the fracture site during weight-bearing. In studies involving the use of plain radiographs, eleven different criteria were used to define fracture union, and the most common criterion was bridging of the fracture site. A quantitative measure of the reliability of the radiographic assessment of fracture union was reported in two studies.

Conclusions: We found a lack of consensus with regard to the definition of fracture-healing in the current orthopaedic literature. Without valid and reliable clinical or radiographic measures of union, the interpretation of fracture care studies remains difficult.

/pdf/variability-in-the-assessment-of-fracture-healing-in-49ifnomdz6.pdf

Variability in the Assessment of Fracture-Healing in Orthopaedic Trauma Studies

Objective:To identify and review early complications in the operative treatment of patella fractures.Design:Retrospective review.Setting:Single tertiary care institution with multiple surgeons, including generalists and fellowship trained subspecialists.Patients:A consecutive series of eighty-seven

Early Complications in the Operative Treatment of Patella Fractures

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.

Pilon fractures. Treatment protocol based on severity of soft tissue injury.

A retrospective review of 101 supracondylar humerus fractures in children between the ages of 0 and 11 years identified 15 patients with neural lesions. All were associated with displaced fractures, and 10 (66%) required open reduction for definitive fracture management. Six of these lesions were isolated anterior interosseous nerve palsies and four other patients had an anterior interosseous nerve injury in combination with another nerve injury, producing a sensory deficit. Two patients had a complete median nerve palsy. Only three patients had nerve lesions that did not involve the anterior interosseous nerve. The incidence (15%) of neural lesions in this study is similar to that reported elsewhere, but the incidence of anterior interosseous nerve lesions, particularly those occurring as an isolated injury, is much higher than has been reported previously. Because an anterior interosseous nerve palsy results in motor loss only, this injury may be easily overlooked.

Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children.

Objective: To evaluate the efficacy of intramedullary nailing in diaphyseal tibia fractures with distal intraarticular involvement. Design: Retrospective. Setting: Henry Ford Hospital, a level I trauma center. Patients/Participants: Twenty patients with twenty fractures at an average of twenty-two months of follow-up were evaluated. There were fifteen closed and five open fractures. Intervention: All fractures were stabilized with lag screw fixation (with or without supplemental plates) of the intraarticular-fracture extension or ankle fracture, and intramedullary nailing of the diaphyseal tibia fracture. Main Outcome Measurements: Time to bony union, malunion, knee and ankle range of motion, early arthrosis, and any complications of treatment were assessed. Results: Nineteen fractures healed, with an average time to bony union of seventeen weeks. One nonunion after a grade IIIB open fracture required exchange nailing and healed after sixty-two weeks. Nineteen fractures had excellent alignment after healing. There were no infections. Conclusions: The indications for intramedullary nailing of unstable diaphyseal tibia fractures may be extended to include certain fractures with distal extension into the ankle joint, as well in a tibial shaft fracture occurring in combination with a noncontiguous ipsilateral ankle fracture.

Intramedullary Nailing of Unstable Diaphyseal Fractures of the Tibia with Distal Intraarticular Involvement

Objective: To evaluate the efficacy of unreamed retrograde intramedullary (IM) nailing of fractures of the femoral shaft in a second series of patients using modifications suggested from our initial study. Design: Prospective. Setting: Level I trauma center. Methods: Based on the findings of a previous study, we began a clinical series incorporating changes consisting of (a) inclusion of any patient with a femoral shaft fracture amenable to IM nailing (i.e., closed physes), (b) primary use of a split patellar tendon intercondylar distal femoral entry portal, and (c) the use of a full-length femoral implant having variable size availability and dynamization capability. Over a twelve-month period, thirty-four patients with thirty-five femoral shaft fractures were treated. The protocol called for planned dynamization in statically locked stable fractures and unstable fractures showing minimal healing at six to twelve weeks. Functional outcome was assessed by using the Knee Society clinical rating system. Results: Incorporating the concepts of canal fill and early dynamization, there were only two nonunions (6 percent) in this series as compared with 14 percent in the previously reported series with an overall shorter time to union (12.6 versus 15 weeks). There were no infections or malunions. Postoperative complaints of knee pain were minimal (knee score average: 98 points) and knee function was excellent (knee score average: 97 points). Conclusions: Although not advocated as a replacement for other techniques, unreamed retrograde nailing is presented as a safe and beneficial fracture fixation method that should be added to the orthopaedic surgeon's treatment armamentarium. The operative technique is quick and simple, and blood loss is minimal. Early nail dynamization and early weight-bearing are important in minimizing the risk of nonunion.

Kathryn E. Cramer

Papers

Early Complications in the Operative Treatment of Patella Fractures

Pilon fractures. Treatment protocol based on severity of soft tissue injury.

Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children.

Intramedullary Nailing of Unstable Diaphyseal Fractures of the Tibia with Distal Intraarticular Involvement

Unreamed retrograde intramedullary nailing of fractures of the femoral shaft.