Postoperative Compartment Syndrome Research Articles

Outpatient surgery for tibial plateau fractures.

The purpose of this study was to determine the rates of compartment syndrome and other early complications following outpatient open reduction and internal fixation (ORIF) of tibial plateau fractures. This was a retrospective cohort at a single US level I academic trauma centre of patients with tibial plateau fractures managed operatively. Inpatients received their definitive ORIF during their index hospital stay and were admitted post-operatively following ORIF. Outpatients were scheduled for ambulatory surgery during definitive ORIF. Exclusion criteria for outpatient surgery included compartment syndrome, polytrauma, open types IIIb/IIIc, and patients who received any internal fixation during index presentation. The primary outcome measure was post-operative compartment syndrome. Secondary outcomes were return to the 90-day return to the ED, 90-day readmission, surgical wound infection, thromboembolism, and 90-day mortality. An intention-to-treat (ITT) and as-treated (AT) analyses were performed. Totally, 71 inpatients and 47 outpatients were included. There were no cases of post-operative compartment syndrome. In the ITT analysis, there were no differences for inpatients vs outpatients for 90-day re-admission (22.5% vs 12.8%, p = 0.275), 90-day return to the ED (35.2% vs 17.0%, p = 0.052), infection (12.7% vs 2.1%, p = 0.094), DVT (7% vs 4.3%, p = 0.819), or PE 1.4% vs 0.0%, p = 1.000). The AT analysis showed a significantly higher 90-day re-admission (26.9% vs 2.5%, p = 0.003) and 90-day ED visit (38.5% vs 7.5%, p = 0.001) rate in the inpatient group. Appropriately selected patients with isolated tibial plateau fractures can have non-inferior rates of compartment syndrome and post-operative complications when compared to inpatients.

Extra-articular proximal tibia fracture fixation with locked plating versus intramedullary nailing: A meta-analysis

ObjectivesThis study compared outcomes of locked plating (LP) versus intramedullary nailing (IMN) techniques for treatment of extra-articular proximal-third tibia fractures. MethodsData Sources: PubMed, Ovid MEDLINE Study SelectionStudies were included if they compared LP and IMN fixation for proximal one third tibial shaft fractures without articular extension or with simple articular extension into the tibial plateau. Minimum 1 year of clinical and radiographic follow up was used. Data ExtractionOutcomes assessed included operative duration, postoperative knee range of motion (ROM), union outcomes (time to union, nonunion, malunion, delayed union), and incidence of postoperative complications (superficial and deep infection, secondary surgical intervention, compartment syndrome). Data SynthesisSeparate random-effects meta-analyses were conducted for each outcome. For categorical data, relative risks were used whereas the standardized mean difference was used for continuous variables, with corresponding 95 % confidence intervals. Results7 studies were included reporting the outcomes of 319 patients treated with LP and 300 treated with IMN. IMN fixation had significantly shorter time to union (p = 0.049) and lower risk for superficial infection (p = 0.028). However, LP conferred a significantly lower risk for malunion (p = 0.017) and postoperative compartment syndrome (p = 0.018). ConclusionIMN demonstrated significantly shorter time to union and lower risk of superficial infection when treating extra-articular proximal tibia fractures, while LP fixation demonstrated significantly lower risk for malunion and postoperative compartment syndrome. Although successful results can be achieved with good technique in LP and IMN fixation, a significant complication profile exists with these fractures regardless of construct choice. Level of EvidenceTherapeutic Level III

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach

BackgroundIntramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach.PurposeThe aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches.MethodsA total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies.ResultsThe study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups.ConclusionsThe suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.Level of evidence3.

OC-013 INDIVIDUAL STRATEGY FOR PATIENTS WITH ABDOMINAL WALL EVENTRATION – DIFFERENT COMPONENTS SEPARATION TECHNIQUE WITH MESH AUGMENTATION

Abstract Aim To present individual approach for patients with abdominal wall eventration using various anterior component separation techniques (aCST) with mesh augmentation. Materials and Methods Between January 2008 and April 2022, 194 patients with abdominal wall eventration underwent surgery by single surgeon. Surgical treatment consists: a) enlargement of the abdominal cavity using different aCST (Ramirez CST, modified CST in the presence of enterostomies, “open book” modification CST, “method of wide myofascial release” or combination of these techniques); b) mesh augmentation (sublay or onlay hernioplasty); c) prolonged muscle relaxation and mechanical respiratory support in intensive care unit. Results Type of abdominal wall reconstruction: 143 Ramirez CST, 35 modification CST in the presence of enterostomies, 11“open book” CST modification, 5 “method of wide myofascial release”, 159 onlay mesh hernioplasty and 35 sublay mesh hernioplasty. Mean hernia defect size was 255 cm2 (100–750). During the mean follow-up of 31 months, 78 (40%) patients had one or more complications: intraabdominal hypertension 8 (4,1%), seroma 13 (6,7%), hematoma 10 (5,1%), wound/mesh infections 21 (10,8%), skin necrosis 40 (20,6%), pain 3 (1,6%), and recurrence 5 (2,6%). There were 10 (5,1%) postoperative deaths. The cause of dead was significant comorbidity in 8 patients and postoperative compartment syndrome in two. Conclusion Eventration disease is a complex surgical problem and its treatment is associated with significant complications. Individual strategy for each patient based on multidisciplinary approach using different component separation techniques with mesh augmentation may improve postoperative results.

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PurposeThe timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.MethodsLiterature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.ResultsA total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.ConclusionDespite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Hold the Antibiotics: Are Preoperative Antibiotics Unnecessary in the Treatment of Pediatric Supracondylar Humerus Fractures?

Supracondylar humerus (SCH) fracture is the most common elbow injury in children and often treated with closed reduction and percutaneous pinning (CRPP). There is little published evidence supporting or refuting the use of perioperative prophylactic antibiotics for SCH CRPP in the pediatric population. The purpose of this study is to evaluate the rate of surgical site infection for patients with and without preoperative antibiotics. A retrospective chart review was conducted of patients less than or equal to 16 years from 2012 to 2018 who underwent primary CRPP. Open fractures, multilimbed polytraumas, and immunodeficient patients were excluded. Infection rates were compared using a noninferiority test assuming a 3% infection rate and a predefined noninferiority margin of 4%. A total of 255 patients were needed to adequately power the study. Of the 1253 cases identified, 845 met eligibility criteria. A total of 337 received antibiotics, and 508 did not. Preoperative nerve injury (P=0.0244) and sterilization technique (P<0.0001) were associated with antibiotic use: 4 patients developed an infection; there were successfully treated superficial infections, and 1 was a deep infection requiring a formal debridement. There were 8 patients that had a recorded mal-union, and 6 patients required additional procedures; 1 patient had a postoperative compartment syndrome on postoperation day 1. The infection rates among patients treated with and without antibiotics were 0.60% and 0.40%, respectively. The absence of antibiotics was not clinically inferior to using antibiotics (P=0.003). Infection remains a rare complication following CRPP of SCH fractures. According to our current data, not giving perioperative antibiotics was not inferior to using perioperative antibiotics for preventing superficial or deep infection in patients undergoing CRPP of SCH fractures. With the increase in attention to antibiotic stewardship, it is important to eliminate unnecessary antibiotic use while continuing to maintain a low rate of surgical site infection. Level IV-case series. This is a therapeutic study that investigates the results from a case series.

Postoperative extremity compartment syndrome in a cancer center: Incidence and risk factors

ObjectivePostoperative compartment syndrome is a reported complication with known patient- and treatment-specific risk factors. Cancer patients carry unique risk factors associated with their underlying disease and long, complex procedures. While elevated serum lactate in traumatic and intensive care settings portends higher risk, no laboratory parameter has demonstrated utility in postoperative risk stratification. Postoperative extremity compartment syndrome in the study institution's cancer population was examined and whether intraoperative serum lactate correlates with postoperative compartment syndrome risk was investigated. MethodsA 1:2 case-control study was performed, which compared cancer patients with postoperative compartment syndrome to those who underwent similar surgical procedures without this complication. Twelve patients were matched to 24 controls by sex, age, surgical procedures, and duration of surgery. Patient and operative variables were analyzed for prognostic significance. ResultsThe compartment syndrome rate was 0.09% of all cases (n = 13,491); 0.12% of cases ≥ 3 h’ duration (n = 9,979), and 0.25% of cases ≥ 5 h (n = 4,811). Compared with controls, the case group had higher median BMI (31.7 kg/m2 vs. 25.4 kg/m2, P = 0.001), and median intraoperative lactate level (4.05 mmol/L vs. 1.5 mmol/L, P = 0.047). ConclusionOur institutional incidence of postoperative compartment syndrome was similar to that of non-oncologic institutions. While many traditional risk factors did not prove to be influential in our patients, elevated median body mass index and intraoperative serum lactate were identified as risk factors for postoperative compartment syndrome in a cancer population.

Acute postoperative compartment syndrome in a child receiving patient‐controlled analgesia and peripheral nerve block

SummaryPatient‐controlled analgesia and nerve blocks have been implicated in the delayed or missed diagnosis of acute compartment syndrome. We report a case of early successful diagnosis of acute compartment syndrome in a 15‐year‐old male, who received both morphine‐based patient‐controlled analgesia and a femoral nerve block following corrective surgery for patellofemoral instability. Our case demonstrates that multimodal analgesia, combining both patient‐controlled analgesia and a nerve block, does not necessarily prevent the early diagnosis of an evolving compartment syndrome. There must be a high level of clinical awareness amongst medical and nursing staff regarding the serious potential complication of postoperative compartment syndrome and ongoing vigilance to monitor for its symptoms and signs.

Popliteal Artery Pseudoaneurysm After Total Knee Arthroplasty

BackgroundPopliteal artery pseudoaneurysm is a rare complication after total knee arthroplasty. Early recognition is imperative in its management to prevent the subsequent development of compartment syndrome and soft tissue ischemia. The aim of this study was to evaluate the complication rate, recognition, and management of symptomatic popliteal artery pseudoaneurysm after total knee arthroplasty. MethodsBetween January 2004 and October 2014, 7937 consecutive total knee arthroplasties were identified from the Theatre Management (Ormis) System and cross-referenced against 1304 radiology reports containing the key words “popliteal” and “aneurysm’ identified from the Patient Archiving Communication System. ResultsSeven patients (0.088%) were found to have had a symptomatic popliteal artery pseudoaneurysm. The median (range) interval between total knee arthroplasty and the radiological diagnosis of a pseudoaneurysm was 15 (7-27) days. Popliteal artery pseudoaneurysm was diagnosed on duplex imaging (n = 4), arteriogram (n = 2), and computed tomography angiogram (n = 1). Fasciotomies were undertaken in 3 patients. ConclusionThe complication rate of popliteal artery pseudoaneurysm was comparable to the literature. Recognition was identified as a problem. An appreciation of the mechanisms of injury and an awareness of this potential complication among orthopedic surgeons are imperative in reducing the complication rate and interval to diagnosis. Popliteal artery pseudoaneurysm should be included in the differential diagnosis for patients with a clinical presentation of postoperative compartment syndrome or deep vein thrombosis, and examination of the popliteal pulse should be undertaken early.

Survey of compartment syndrome of the lower extremity after gynecological operations

This study was aimed to investigate incidence, circumstances and consequences of acute compartment syndrome (CS) of the lower extremity after gynecological operations in lithotomy position by collecting data from departments of Obstetrics and Gynecology in Germany. Retrospective observational study. Departments of Obstetrics and Gynecology in the area of North Rhine (Germany) A 24-item questionnaire was sent to 168 gynecological departments. In addition, cases anonymously reported to the Expert Committee for Medical Malpractice Claims of the Medical Association of North Rhine between 2002 and 2012 were analyzed. Incidence of acute CS after gynecological operations. A total of 59 questionnaires (35%) were returned for analysis, reporting 21 cases of CS. Based on the collected data, we calculated an incidence of postoperative CS ranging between 0.067% and 0.28%. All reported cases of postoperative CS occurred after surgeries in lithotomy position, 57.1% of cases occurred after laparoscopic procedures and 76.2% after procedures longer than 4h. Overall, 61.0% of departments do not routinely inform about the risk of this complication when they get patients' informed consent. Reported prevention strategies were inconsistent and ranged from none to multiple measures. CS is a complication clearly associated with long lasting gynecological operations in Lithotomy position. Despite a relatively high incidence, so far no guidelines on perioperative management and medicolegal aspects exist and preventive measures are heterogeneous among institutions. The need for guidelines and recommendations by an expert committee has been identified.

A Case of Nonisland Pedicled Foot Fillet Flap for Below-Knee Amputation Stump Wound: Treatment Option for Compartment Syndrome after Fibular Free Flap Surgery

Despite the frequent use of the fibular free flap, there have been no reports of severe compartment syndrome of the donor leg that necessitated limb amputation. A 66-yr-old man had a fibular osseous free flap transfer from the left leg to the mandible that was complicated by postoperative compartment syndrome. An extensive chronic leg wound resulted, which was treated with multiple debridements and finally with below-knee amputation. Successful coverage of the below-knee amputation stump was accomplished with a nonisland pedicled foot fillet flap. Various foot fillet flaps may be used acutely as a free or an island pedicled flap, but dissection of the vascular pedicle may be difficult in a chronically inflamed wound because of inflammation and adhesions to surrounding tissue. The nonisland pedicled foot fillet flap may be considered as a useful option for treatment of a chronically inflamed stump wound after below-knee amputation.

Acute Compartment Syndrome After Intramedullary Nailing of Isolated Radius and Ulna Fractures in Children

There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.

Complications and Outcomes of Diaphyseal Forearm Fracture Intramedullary Nailing

Flexible intramedullary nailing (IMN) has become a popular technique for the management of unstable or open forearm fractures. Recent publications have suggested an increased incidence of delayed union and poor outcomes in older children and adolescents. The objective of this study was to review forearm fractures treated with IMN, comparing the rate of complications and outcomes between the 2 age groups. Our hypothesis was that IMN is an effective technique with a similar rate of complications in both age groups. An Institutional Review Board-approved retrospective review was conducted of pediatric forearm fractures treated from 1998 to 2008 at a single institution. Over the study time period, 4161 pediatric forearm fractures were managed nonoperatively (92%) and 353 were treated operatively with plate, cross-pin, or intramedullary fixation (8%). Patients with inadequate follow-up, cross-pin, or plate fixation were excluded. Medical records were reviewed for indications and complications. Complications were graded with a modification of the Clavien-Dindo classification. Outcomes were judged by a new grading system. A total of 205 forearm fractures treated with IMN in 203 patients were identified. The mean age was 9.7 years (range, 1.7 to 16.2 y) and mean follow-up was 42 weeks. Operative indications were failure of closed treatment in 165 (80%) and open fracture in 40 (20%). Mean time from injury to IMN was 5.9 days (range, 0 to 25 d). Single bone IMN was performed in 40 of 185 both bone fractures (26%); there were 20 single-bone forearm fractures treated with IMN. Open reduction was required in 61/165 (37%) of closed fractures. Asymptomatic delayed union (grade 1 complication) was observed in 9 fractures (4%). More severe complications were noted in 17% (grade 2 to 4 complications). Postoperative compartment syndrome occurred in 3 isolated forearm fractures with a significant younger mean age (6.0 vs. 10 y, P=0.031). Overall, complications were significantly more frequent in children older than 10 years of age (25/101) as compared with younger children (13/104, P=0.031). In particular, delayed union was more common in children over the age of 10 years (9/101 vs. 1/104, OR=9.99, P=0.009). Outcomes were good or excellent in 91% of fractures. There was no statistical association of patient age with a fair or poor outcome. IMN is an effective technique for pediatric forearm fractures with good to excellent outcomes in 91%. Complications are not infrequent with this technique, with complications of grade 2 to 4 severity in 17%. There was a 2-fold increase in the rate of complications in children over the age of 10 years. Compartment syndrome was more common in younger children. Patients and families should be counseled about the risks preoperatively.

Akutes Kompartmentsyndrom des Unterschenkels nach Kniegelenkarthroskopie

This case report describes an acute postoperative compartment syndrome of the lower leg following simple arthroscopy of the knee. The diagnostics as well as the time course of further therapeutic procedures are considered critically. Furthermore, the surgical workflow is analyzed for possible reasons. Retrospectively, an accumulation of irrigation fluid passing through a popliteal cyst into the superficial flexor compartment must be suspected. In summary, even with an optimal perioperative management the subsequent compartment syndrome due to knee arthroscopy cannot be avoided with any certainty. However, immediate causal therapy lies in the urgent dermatofasciotomy to prevent irreversible neuromuscular damage.

Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study

The surgical treatment of large incisional hernias with loss of domain (LIHLD) carries the risk of fascia closure under tension and, thus, abdominal compartment syndrome. We investigated volume measurements as a predictive factor for tension-free fascia closure. From September 2004 to July 2008, we prospectively included 17 patients with LIHLD. The operation was prepared by a progressive preoperative pneumoperitoneum (PPP) technique known as the Goni Moreno procedure. The patient's age and body mass index (BMI), the incisional hernia's width, length and surface area, and the incisional hernia volume (IHV)/peritoneal volume (PV) ratio <20% were evaluated as predictive factors for tension-free fascia closure. A tension-free closure was defined as a closure in which the use of a surgical device for avoiding postoperative compartment syndrome was not required. The mean PPP volume introduced was 12.7±4.4l (range 4.5-19.2) over a period of 11±6days (range 4-24). The mean width, height and surface area of the incisional hernia after PPP were 11.3±4.7cm (range 4.5-19), 13.4±7.8cm (range 4.4-30) and 165±101cm(2) (range 19-304), respectively. The mean IHV after PPP was 2,374±1,356cc (range 517-4,802) and the mean abdominal cavity volume was 9,558±4,106cc (range 4,785-21,782). The mean IHV/PV ratio was 16.3±10.4% (range 4.4-34). In a univariate analysis, the BMI and the IHV/PV ratio were predictive of tension-free fascia closure. In a multivariate analysis, only an IHV/PV ratio <20% was a significant predictive factor. The IHV/PV ratio is predictive of tension-free fascia closure for hernias or incisional hernias with loss of domain. Simplification of the volumetry method is necessary.

Elastic intramedullary nailing of paediatric fractures of the forearm

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%). Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities. Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

Oblique tibial osteotomy revisited

PurposeOblique proximal tibial osteotomy is a useful option for correcting deformity associated with Blount’s disease (tibia vara). Safe, adequate correction depends on technical issues that have evolved since the original description of the procedure.MethodsRetrospective review of surgical experience.ResultsThe refinement of osteotomy plane orientation, based on the distal rather than the proximal tibia, reduces the likelihood of procurvatum after surgery. The stability of the osteotomy is enhanced by an improved screw fixation technique. The risk of compartment syndrome is low if prophylactic partial fasciotomy is performed concurrently. Avoidance of spinal or regional block anesthesia minimizes the possibility of failure to detect post-operative compartment syndrome.ConclusionsImprovements in the technical execution of oblique proximal tibial osteotomy enhances the correction and predictability of the procedure.

Complications Associated With the Use of Bone Morphogenetic Protein in Pediatric Patients

Recombinant human bone morphogenetic protein (rhBMP) has been found to be a powerful adjunct to healing nonunions and obtaining fusions. Despite the apparent clinical efficacy and good safety profile reported with rhBMP use in adults, there is little data regarding the safety of this product in pediatric patients. We evaluated the use of rhBMP-2 in pediatric patients to determine if any complications were associated with its use. We performed a retrospective review of 81 patients, all less then 18 years old, in whom rhBMP-2 was used. Theoretical complications associated with rhBMP-2 use were compiled based on a review of the published literature on rhBMP-2. A review of each patient's chart and radiographs was performed to record the occurrences of complications, which may have been associated with the use of rhBMP-2. A total of 16 complications were found, which may have been attributed to the use of rhBMP-2. There were no incidences of systemic toxicity associated with rhBMP-2 use. Nine patients were noted to have some local operative site problem, 3 deep infections were noted, 1 patient was found to have a postoperative compartment syndrome, 2 patients were found to have neurologic complications (1 with progressive myelopathy and 1 with weakness and dural fibrosis), and 1 patient with neurofibromatosis and previously diagnosed intracranial gliomas was found to have subsequent enlargement of these gliomas. In reviewing these complications, only the case of dural fibrosis and subsequent weakness was thought to possibly be directly related to the use of rhBMP-2. We found few complications in pediatric patients, which were felt to be directly attributable to the use of rhBMP-2. As such, rhBMP-2 use seems to be relatively safe in this young patient population. Due to the current use of this product in pediatric patients in an "off-label" fashion, we recommend a thorough discussion of the possible risks and benefits of this product with the family before its use. Therapeutic studies-Level IV.

Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.

The Lithotomy Versus the Supine Position for Laparoscopic Advanced Surgeries: A Historical Review

Laparoscopic advanced surgery has been taught in many institutions in the United States. Initially, proctoring for the laparoscopic technique was performed by European surgeons; therefore, the lithotomy position was suggested as the preferred approach. Many American and European surgeons have adopted the supine position. Laparoscopy initially entered the clinical realm in the field of gynecology. Albert Decker, at the Knickerbocker and Gouverneur Hospital in New York, performed culdoscopy as early as 1928. This was done in the "knee-chest" position without the use of pneumoperitoneum. Raoul Palmer, at the Hopital Broca in Paris, popularized "colposcopie," utilizing pneumoperitoneum, with the patient in the lithotomy position. Laparoscopy then advanced in Europe to the general surgery arena. As a result, patient positioning for laparoscopic procedures in Europe was performed in what is now referred to as the French position (i.e., lithotomy). Many of these procedures are modified to a side approach, or American position, when performed in the United States. There is a clear association between the dorsal lithotomy position and the development of postoperative compartment syndrome. Compartment syndrome occurs when elevated pressure in an osteofascial compartment compromises local perfusion, and often results in neurovascular damage and permanent disability. Many centers have adopted the lithotomy position for their laparoscopic advanced procedures. At our institution, however, we prefer all procedures be performed in the American position (patient supine and the surgeon at the side of the patient), since this resembles the position used for other, open surgeries. The advantage of this approach is that it eliminates the risks associated with placement of the patient in the lithotomy position.