Simultaneous Internal Fixation Research Articles

Simultaneous internal fixation and latissimus dorsi pedicle flap coverage: A reliable regimen for open fractures with accompanying sizable soft tissue loss of the upper extremities

BackgroundThe optimal treatment protocol for open fractures with accompanying sizable soft tissue defect of the upper extremities has not been specifically delineated. The authors described the concurrent use of internal fixation and latissimus dorsi (LD) pedicle flap coverage in managing such complex fractures. MethodsTwenty patients with open fractures accompanied by large soft tissue defect of the upper extremities (8 clavicle fractures and 12 humeral fractures) were treated by fix & LD pedicle flap. The dimension of the defect, time to fix & flap, post-operative complications, time to union and clinical measurements were recorded. ResultsThe mean size of the defect was 132.45 cm2 (range 6–12 x 2–20 cm2). The average time to fix & flap was 9.9 days (range 7–14). Fractures union was achieved in all patients with an average duration of 18.5 weeks (range 14–28). Regarding post-operative complications, distal flap necrosis occurred in 3 patients, retained seroma in 3 and heterotopic ossification in 1. By the Mayo Elbow Performance (MEP) score, 3 cases were considered to be excellent, 6 were good, 7 were fair and 4 were poor. By the University of California–Los Angeles (UCLA) shoulder score, 2 cases were considered to be excellent, 7 were good, 7 were fair and 4 were poor. The average Disabilities of Arm, Shoulder and Hand (DASH) score was 31.29 (range 12.5–58.3). ConclusionFix & LD pedicle flap is a reliable regimen for open fractures with sizable soft tissue defect of the clavicle and humerus.

Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft

The role of internal fixation and local muscle flaps for open tibial fractures is still not specifically determined. We describe the integration of internal fixation and soleus muscle flap for open fractures complicated with soft tissue loss of the tibial shaft. Twenty-seven patients with Gustilo IIIB open fractures of the tibial shaft were operated on by internal fixation and soft tissue coverage by soleus muscle flaps and variances. Data were collected on types of implants, types of flaps, union time, postoperative complications, and objective clinical measurement. Regarding implants for fixation, plates and screws were selected in 22 patients, and intramedullary nails in 5. Proximally based soleus flap was used in 17 patients, hemisoleus in 6, and reversed hemisoleus in 4. All flaps survived and all fractures were united with a mean union time of 21.8weeks (range 14-30). One patient had unplanned reoperations due to delayed union and equinus deformity of the ankle. All patients had good-to-excellent Puno functional score results. Internal fixation and soft tissue coverage, frequently referred to as 'fix and flap', by a local soleus muscle flap is safe and effective for open fractures accompanied with small-to-medium size soft tissue defect of the tibial shaft.

Allograft Bone as Antibiotic Carrier.

The treatment of chronic bone and joint infections is characterized by obstinate persistency of the causing microorganisms and resulting long term disability to patients, associated with remarkable costs for the health care system. Difficulties derive from biofilm formed on dead bone and eventual implants, with resistance against immunological defences and antimicrobial substances. Biofilm embedded bacteria require up to 1000 times the antibiotic concentration of planktonic bacteria for elimination. Systemic antibiotic treatment alone cannot provide the concentrations required and surgical intervention is always prerequisite for potentially providing a cure. A second issue is that osseous defects are almost always present after surgical debridement, and it is difficult to address their reconstruction. One option is to use bone grafts, either from the patient´s own body or from foreign donors (allografts). Grafts are usually unvascularized and are prone to colonization with bacteria. Loading of allografts with antibiotics may not only protect grafts from bacterial adhesion but, using appropriate processing methods, may also provide high local antibiotic concentrations that may eliminate remaining sessile pathogens. For efficient action as antibiotic carriers, the release of antibiotics should be above the minimum biofilm eradication concentration (MBEC) for a prolonged period of time. Cleaning the bone from bone marrow opens a large reservoir for storage of antimicrobial substances that, after implantation, may be released to the surrounding in a sustained mode, possibly eliminating remaining biofilm remnants. Removal of bone marrow, leaving a pure matrix, provides increased safety and improved revascularization of the graft. Local provision of antibiotic concentrations above the MBEC may enable simultaneous internal fixation with osteosynthetic material and single stage exchange of infected endoprostheses, resulting in shorter hospital stays with reduced pain and faster rehabilitation of patients.

Identification et traitement les lesions intra-carpiennes

High energy injuries of the wrist may cause perilunate dislocations and fracture-dislocations that may develop in a spectrum of injuries of different severity affecting bone and ligaments, or ligaments alone even without dislocation (PLIND injuries). The use of arthroscopic assistance in treating wrist trauma has allowed the finding of association between bone and intracarpal ligament injuries in high percentage of cases. The aim of this study is to evaluate the results of treatment of multiple intracarpal ligament injuries with without simultaneous internal fixation of carpal bones. Twelve patients were treated since 2008. Of those, eight patients affected by simultaneous scaphoid fracture and SL ligament lesions and four patients with associated scapholunate (SL) and lunotriquetral (LT) ligaments. All were males and the mean age was 34 years old (21–65). All patients were examined under arthroscopy and lesions classified according to Geissler and EWAS Classifications. The scaphoid fractures were treated by screw fixation with or without a graft and the ligaments injuries by capsulodesis open or arthroscopic. The patients were evaluated at a mean follow-up of 11 months (5 months–8 years). The Mayo and DASH scores were used for evaluation at follow-up. Scapho-lunate injuries were Geissler stage III in 8 patients (EWAS IIIC 6 cases, IIIB 2 cases, IIIA 1 case) and a Geissler EWAS stage II in 3 patient. At follow-up, X-rays documented healing of the fracture in all cases. The results were excellent and good according to the Mayo Wrist Score. Grip strength was comparable to contralateral side and patients returned to previous work. One patient reported occasional pain under load at follow-up at 5 months. Two patients treated with dorsal capsulodesis had a slight reduction of flexion. The diagnosis of ligamentous lesions has been evolving in the last years with the diffusion of wrist arthroscopy that allows their direct identification. Nowadays, we know that a spectrum of different ligament lesions can occur and that they can be associated in different ways, still under definition. Our preliminary results are excellent and good and a longer follow-up is needed to correctly evaluate the results in the long term. The increased use of arthroscopic examination of the wrist is advisable in wrist trauma in order to establish a correct diagnosis, prognosis and treatment of all the patient's lesions, possibly preventing degenerative arthritis.

Treatment of Chronic Bone Infection

The treatment of chronic osteomyelitis depends on the obstinate persistence of the offending micro-organism(s) and often results in long-term patient disability causing remarkable costs to the health care system. Difficulties of treating chronic osteomyelitis derive from biofilm-forming pathogens that resist the host immunologic defense and antimicrobial substances, and the need to treat osseous defects that result from the disease itself and eventual previous interventions. Established surgical techniques require multiple costly operations with extended periods of disablement and impairment of the patients, sometimes making the therapy worse than the disease. This article suggests a new operative approach to address biofilm-adapted antimicrobial therapy and reconstruction of bony defects using antibiotic-impregnated allograft bone. The technique is applicable to all stages of the Cierny-Mader classification, and detailed description of specifications for the respective procedure is provided. Local use of high antibiotic concentrations enable simultaneous internal fixation with osteosynthetic material and minimize the need for using systemic antibiotics. This treatment results in short hospital stays, reduced pain, and faster rehabilitation for patients, markedly reducing their burden and the costs of treatment. Recurrences may occur in 10% of cases, but may be treated by repeating the procedure.

End-Stage Hindfoot Arthrosis: Outcomes of Tibiocalcaneal Fusion Using Internal and Ilizarov Fixation

End-stage post-traumatic pantalar arthrosis from ankle, pilon, and talus fractures has often been complicated by infection, bone loss, and a soft tissue deficit. Patients can present with neuropathy, diabetes, tobacco use, and previously failed arthrodesis. Fusion in this population has been challenging, with nonunion rates up to 30%, often leading to amputation. We reviewed the results of a standardized protocol that combined simultaneous internal fixation with the Ilizarov technique to achieve fusion in high-risk patients. With institutional review board approval, a retrospective review of the patients treated with simultaneous internal fixation and an Ilizarov frame was undertaken. The records and radiographs allowed identification of the comorbidities and the presence or absence of successful fusion. Complications were acknowledged and treated. Fifteen patients had undergone the procedure. The mean follow-up period was 27.9 (range 9 to 67) months. Thirteen patients (86.67%) had had previous fusion failure. Twelve patients (80%) had developed post-traumatic arthrosis, 5 (33.33%) of whom had open injuries. All patients had 1 comorbidity, and 10 (66.67%) had multiple, including rheumatoid arthritis, diabetes (types 1 and 2), and smoking. Four patients (26.67%) presented with deep infection and bone loss. Union was achieved in 11 (73.33%), with 12 (80%) patients experiencing profound pain relief. Seven patients (46.67%) required symptomatic hardware removal. Three patients (20%) eventually underwent below-the-knee amputation for recalcitrant nonunion. Statistically significant correlations were found between smoking and wound infection and revision and between nonunion and amputation. Our results have indicated that combined internal fixation with Ilizarov application can provide a strong surgical option for the management of end-stage, pantalar arthritis. More studies are needed to compare the cohort outcomes and gait analysis in these patients with those who have chosen below-the-knee amputation.

Urethral realignment and simultaneous internal fixation for pelvic fracture associated with posterior urethral disruption

Objective To investigate the outcome of the urethral realignment simultaneous internal fixation in treatment of pelvic fracture associated with posterior urethral disruption. Methods The study included 33 patients with pelvic fracture associated with posterior urethral disruption treated simultaneously by urethral realignment and internal fixation from December 2003 to August 2009. According to AO classification, two patients were with type A2 fracture, six with type B1 ,seven with type B2,five with type B3 ,six with type C1 ,four with type C2 and three with type C3. All the patients were found with complete posterior urethral disruption. Primary urethral realignment combined with emergency open reduction and internal fixation of pelvic fracture were performed in 12 patients. Due to unstable condition, 21 patients underwent primary suprapubic cystostomy and external fixation, sequentially delayed urethral realignment and internal fixation.Results The mean follow-up time of all patients was 37 months ( range, 3-63 months). Of all the patients, 25 patients (76%) regained good without urethral dialation or needed only short term urethral dilatation, and eight patients (24%) suffered from urethral stricture and needed further complex surgery. The incidences of urinary incontinence and erectile dysfunction were 6%(2/33) and 18% (6/33). The erectile dysfunction of two patients was ascribed to sacral nerve injury.At the final follow-up, the mean score was 90.3 points (range, 66-100) according to the Majeed' s scoring system, which showed that the result was excellent in 24 patients, good in eight and fair in one.Conclusions Urethral realignment and simultaneous internal fixation can attain good clinical results for pelvic fracture associated with posterior urethral disruption. It takes advantages of minor surgical trauma,short treatment cycle, good outcome and low complication rate. Key words: Pelvis; Fracture fixation, internal; Urethra; Disruption

Ununited fracture of the olecranon in a rheumatoid elbow: is total elbow replacement and simultaneous internal fixation the answer?

Transverse fractures of the olecranon can be reliably treated with tension band wiring. However, complications have been reported with this procedure [1–3]. The scope for complications is increased in the presence of pre-existing disease such as rheumatoid arthritis. We report a case of failure of fixation of an oblique fracture of the olecranon in a patient with rheumatoid arthritis of the elbow treated with tension band wiring. This was subsequently successfully treated with total elbow replacement. The elbow was approached through the ununited fracture of the olecranon using an olecranon osteotomy type of approach. Following the total elbow replacement the olecranon was fixed using the tension band wiring technique. To our knowledge such a case has not been reported.