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American journal of orthopedics (Belle Mead, N.J.) 09/2012; 41(9):396-412.
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ABSTRACT: Combined vascular and orthopedic injuries requiring repair are rare. However, these injuries have a high amputation rate and significant morbidity. In a retrospective review of lower extremity injuries managed at a level I trauma center over 9 years, we identified 26 patients with combined vascular and orthopedic injuries. We evaluated their rates of amputation and revascularization procedures based on sequence of care and initial intervention. Patients were stratified into 3 groups based on the initial intervention given: definitive vascular repair (n = 17), orthopedic stabilization (n = 4), and temporary shunt (n = 5). Amputation rates were 29% (5/17) in the vascular group and 20% (1/5) in the shunt group; there were no amputations in the orthopedic group (0/4). Revascularization rates were 41% (7/17), 25% (1/4), and 20% (1/5) in the vascular, orthopedic, and shunt group, respectively. Mangled Extremity Severity Scores higher than 6 had an overall relative risk of 5.5 for amputation (P<.05). We conclude that temporary vascular shunting followed by orthopedic stabilization and then definitive vascular repair is the most reasonable sequence of care for minimizing rates of amputation and revascularization procedures in this cohort of patients.
American journal of orthopedics (Belle Mead, N.J.) 04/2012; 41(4):182-6.
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ABSTRACT: The aim of this study was to retrospectively evaluate the clinical and culture-positive infection rates of open Gustilo/Anderson type II and III fractures using a protocol nanocrystalline silver wound dressing and hydrosurgical debridement. Retrospective case series through chart review on all type II and III open fractures were treated using a novel protocol from December 2005 to March 2008 (N = 17). All Gustilo/Anderson grade II and III open fractures were treated with a novel protocol at a Level I trauma centre. Open Gustilo/Anderson grade II and III fractures were acutely stabilised in the trauma centre/emergency department, while a nanocrystalline silver dressing was placed within the wound. Debridement using a hydrosurgical scalpel and gravity irrigation was performed within 6-8 hours of injury. Cultures were obtained prior to definitive fixation. The primary outcome measurements were positive cultures and clinical infection rates. Seventeen patients met inclusion criteria. Mean age (33·5) and injury severity score (12·7) were gathered. There were 4 grade II open fractures (23·5%), 11 grade IIIA (64·7%) and 2 grade IIIB open fractures (11·8%). The mean time to intravenous antibiotics was 61·5 minutes. The mean time to initial debridement/irrigation was 222·1 minutes. The average number of surgical procedures was 2·35 with a mean length of stay of 11·8 days. Six patients developed positive cultures from the traumatic wounds, five were contaminants. One clinical infection was found (methicillin-resistant Staphylococcus aureus). The overall clinical infection rate in this series was 5·9% (1/17). The only infection was in a Gustilo/Anderson grade II fracture. There were no infections in the more high-energy Gustilo/Anderson grade IIIA and IIIB fractures compared with the Gustilo/Anderson control of 4-42%. We conclude that this novel protocol for open-fracture treatment is a promising intervention. A further prospective randomised clinical study is warranted.
International Wound Journal 11/2011; 9(1):7-13. · 1.46 Impact Factor
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ABSTRACT: The standard of care for femoral diaphysis fractures is sequentially reamed, locked, intramedullary nails. However, in the polytraumatized patient perioperative complications such as fat embolism syndrome (FES) and acute respiratory distress (ARDS) are well chronicled. The reamer irrigator aspirator (RIA)has been theorized to minimize such phenomena.
A retrospective study comparing conventional reamed nailing for femur fractures versus those treated with the RIA was conducted. From January 2005 to September 2006, 156 patients treated at our institution with an intramedullary nail met inclusion criteria. There were sixty-six patient treated with conventional reaming (group A) and ninety patients treated with the RIA (group B). The main outcome measures included length of hospital stay, rate of ARDS, pneumonia, ventilatory failure, overall pulmonary complications, healing rate and death.
No significant differences were found between groups with regard to patient demographics, injury severity and the incidence of head/chest trauma. In addition, no differences were found in length of hospital stay, length of ICU stay or mechanical ventilation. Overall pulmonary complications occurred in 11% (group A) and 16% (group B) respectively (p = 0.48). No fatalities were found in group A while there were four in group B, 4% (p = 0.14). No significant differences were found in delayed union versus nonunion rate between groups, while overall healing complications were seen in 7% and 14% of patients (p = 0.35) in groups A and B respectively.
No statistical significance was reached with regard to pulmonary complications, healing rates or death. However, we were unable to demonstrate favorable physiologic lung parameters with RIA use compared to conventional reaming as has been described in previous animal studies. We found a trend toward more healing complications in the RIA group, but this was not statistically significant. Further study is warranted.
Injury 11/2010; 41 Suppl 2:S51-6. · 1.98 Impact Factor
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ABSTRACT: Nonunions of the tibia continue to present some of the most difficult challenges in orthopaedic fracture care. Whether the consequence of the initial presenting injury, co-morbidity or subsequent attempts at fixation, the biological environment is often compromised. Compounding this problem is a lack of consensus on the best approach to addressing nonunited tibia fractures, placing them at risk for multiple, and sometimes ill-informed attempts at nonunion repair. We present nine cases of recalcitrant tibial nonunions which had previously undergone 4 or more attempts at repair treated with a protocol using RIA graft, rh-BMP2 and intramedullary nail fixation.
Injury 11/2010; 41 Suppl 2:S69-71. · 1.98 Impact Factor
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ABSTRACT: The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.
Orthopedic Clinics of North America 04/2010; 41(2):241-7. · 1.25 Impact Factor
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ABSTRACT: The promise of evidence-based medicine is to integrate the highest levels of clinical data with patient outcomes. After framing the question and identifying appropriate studies, evaluating their relevance to clinical practice is highly dependent on the instruments and measures selected to demonstrate outcomes. Currently, there are hundreds of outcomes measures available in the orthopedic literature evaluating these treatments, and it is not uncommon for different measures to produce conflicting results. Consequently, the ability to evaluate an outcomes measure is critical in determining the value of a specific treatment intervention. Similarly, selecting the appropriate outcomes measure for research or clinical purposes is an important decision that may have far reaching implications on reimbursement, surgeon reputation, and patient treatment success. Evidence-based orthopedic surgery is indeed possible, but demands a detailed understanding of why appropriate outcomes selection is important, the difference between clinician-based and patient-reported outcomes (PROs), and potential future directions in orthopedics outcomes research.
Orthopedic Clinics of North America 04/2010; 41(2):139-43. · 1.25 Impact Factor
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The Foot and Ankle Online Journal 09/2009; 30(9):895-9. · 1.22 Impact Factor
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ABSTRACT: With the increased emphasis on evidence-based medicine in orthopaedics, the surgeon is faced with the challenge of evaluating the effectiveness of various treatment interventions. Health care authorities are also interested in measuring competing interventions, but out of concern for controlling costs. The success or failure of an intervention is often determined based on treatment outcomes. There are many outcomes measures available in the orthopaedic literature, and it is not uncommon for different measures to produce conflicting results. The orthopaedic surgeon must have the ability to accurately evaluate an outcomes measure to determine the value of a specific intervention. Similarly, selecting the appropriate outcomes measure for research or clinical purposes is an important decision that may have far-reaching implications on reimbursement and determining treatment success. To best select outcomes measures and to select the appropriate treatment for each patient, the orthopaedic surgeon needs to understand the recommended contents of a quality instrument, the difference between clinician-based and patient-reported outcomes, and how to evaluate outcomes reported in the literature.
The Journal of the American Academy of Orthopaedic Surgeons 04/2008; 16(3):123-9. · 2.66 Impact Factor
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ABSTRACT: Trauma sustained during pregnancy can trigger uncertainty and anxiety for patient and orthopedic surgeon alike. In particular, orthopedic-related injuries raise concerns about preoperative, intraoperative, and postoperative care. In this article, we review common concerns about radiation exposure, leukemia, pain management, anticoagulation, and anesthesia. One finding is that radiation risk is minimal when obtaining x-rays for operative planning, provided that the cumulative dose is within 5 rad. We also address safety concerns about patient positioning and staff radiation exposure. In addition, we found that most anesthetics used in pregnancy are category C (ie, safe). Perioperative opioid use for pain management is recommended with little risk. Regarding anticoagulation, low-molecular-weight heparin and fondaparinux are the safest choices. Last, pregnancy is not a contraindication to operative management of pelvic and acetabular fractures.
American journal of orthopedics (Belle Mead, N.J.) 12/2007; 36(11):E160-6.
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American journal of orthopedics (Belle Mead, N.J.) 12/2007; 36(11):E167-70.
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American journal of orthopedics (Belle Mead, N.J.) 10/2007; 36(9):E133-7.
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ABSTRACT: The objective of this study was to compare the torsional stability of diaphyseal long bone fractures fixed with either a Fixion nail (DiscOTech, Monroe Township, NJ) or a standard locked Zimmer M/DN locked nail (Zimmer, Warsaw, IN).
Two fracture models were used to evaluate the bone-implant constructs. A transverse osteotomy was created in all tibiae, and a spiral fracture was created in all humeri. Paired specimens were randomly assigned to receive either a Fixion or Zimmer M/DN locked nail. Each implanted construct was cyclically loaded in torsion, and construct stiffness for each fracture type and each bone computed from the resulting load-displacement curves.
Performance of the Fixon nail in the tibial transverse model was variable: 2 of 10 implanted constructs failed during testing, and average construct stiffness was significantly greater for the Zimmer nail. No significant difference was found between the stiffness of the Zimmer M/DN and Fixion implanted humeral constructs either with or without the interlock.
Fracture type significantly affected the performance of the Fixion nail. Our results suggest that the Fixion nail is most suitable for use in fractures where torsional loads across the fracture site are shared between the nail and the bony ends of the fracture, as in a spiral fracture.
The Journal of trauma 08/2007; 63(1):103-7. · 2.48 Impact Factor
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American journal of orthopedics (Belle Mead, N.J.) 09/2006; 35(8):353-4.
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ABSTRACT: Understanding the relevant legal context is critical to the safe and successful practice of orthopaedic surgery. Specifically, three areas of liability are relevant to most physicians: medical malpractice, products liability, and the liability of health care organizations. Medical malpractice encompasses the professional physician-patient relationship with its implied contract, consent, fiduciary responsibilities, and duty to provide the standard of care, as well as certain common-law duties pertinent in special circumstances. Orthopaedic surgeons who design implants or who have a relationship with a device manufacturer are at risk for liability for a failed product. In general, the hospital entity is responsible for the actions of its physician-employees. Still unclear is the degree to which a physician is obligated to appeal to a third-party payer on behalf of a patient. Physicians should remember that, above all else, common sense with regard to the treatment, informed consent, and advocacy of patients is essential to avoiding many medical-legal pitfalls.
The Journal of the American Academy of Orthopaedic Surgeons 11/2005; 13(6):397-406. · 2.66 Impact Factor
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ABSTRACT: The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery.
Prospective cohort.
Level I academic medical center.
One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention.
Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging.
Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner.
The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen.
The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.
Journal of Orthopaedic Trauma 03/2005; 19(2):79-84. · 2.13 Impact Factor
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ABSTRACT: Musculoskeletal injuries in the pediatric population are unique and require a thorough evaluation by a trained specialist. Unlike adults, many of the injuries may be treated closed due to the amazing growth and remodeling potential of children. Special consideration should be taken in treating certain fracture patterns to prevent the long-term consequences of growth deformities and protect children from child abuse. It is the goal of this article to outline common orthopedic injuries in the pediatric population to facilitate proper care in the multidisciplinary evaluation and treatment of children.
Seminars in Pediatric Surgery 06/2004; 13(2):119-25. · 2.93 Impact Factor
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ABSTRACT: Fractures of the distal tibia are notoriously difficult to treat, and traditional methods of fixation are often fraught with soft-tissue complications. With recent emphasis on meticulous handling and preservation of the soft-tissue envelope, minimally invasive percutaneous plate osteosynthesis has become a safe and reliable method of treating these fractures. This technique involves conventional open reduction and internal fixation of the fibula and spanning external fixation of the tibia until the soft-tissue swelling subsides. Subsequently, limited open reduction and internal fixation of displaced articular fragments is performed through small incisions based on CT evaluation. This is followed by minimally invasive percutaneous plate osteosynthesis of the tibia, in which the plafond is attached to the tibial shaft using a variety of commercially available plates.
Instructional course lectures 02/2004; 53:471-5.
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American journal of law & medicine 02/2004; 30(2-3):237-43. · 1.44 Impact Factor
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ABSTRACT: Peritalar dislocation is a term that has been described as an injury involving a simultaneous dislocation to both the subtalar and talonavicular joints without a fracture of talar neck or tibiotalar disruption. It often results from high-energy trauma but may also result from sports injuries. It occurs most frequently with a medial dislocation and less frequently with a lateral, anterior, or posterior dislocation. The treatment for most peritalar dislocations is closed reduction, although surgical intervention may be a requirement in cases where reduction is unobtainable. We present a rare lateral peritalar dislocation requiring open reduction. ACFAS Level of Clinical Evidence: 4.
The Journal of Foot and Ankle Surgery 47(1):56-9. · 0.52 Impact Factor
