Biomedical subjects
D E Karges
Publications and source records attributed to D E Karges.
Pilon fractures. Treatment protocol based on severity of soft tissue injury.
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.
Comparison of the compression hip screw with the Medoff sliding plate for intertrochanteric fractures.
The Medoff sliding plate was designed to achieve compression along the femoral neck and the longitudinal axis of the femoral shaft theoretically to improve the treatment of intertrochanteric hip fractures. The Medoff sliding plate was compared with a standard compression hip screw in a randomized, prospective study for the fixation of 160 stable and unstable intertrochanteric fractures with an average followup of 9.5 months (range, 6-26 months). Overall, 91 fractures were treated using the compression hip screw and 69 were treated with the Medoff sliding plate. Stable fracture patterns (46) united without complication in both treatment groups. Unstable fractures (114) had an overall failure rate of 9.6%, 14% (nine patients) with the compression hip screw and 3% (two patients) with the Medoff plate; this difference was significantly different. The time to union for the 114 unstable fractures was not significantly different between the two devices. For all patients, no differences in lengths of hospitalization, return to ambulatory status before fracture, postoperative living status, or postoperative pain was observed between the two device groups. Use of the Medoff plate for all fracture types was associated with a significantly higher amount of blood loss and operating time.
Early complications in the operative treatment of patella fractures.
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 patella fractures over a five year period was reviewed. Patients treated nonoperatively or with partial or total patellectomy were excluded. Minimum follow-up to fracture healing (four months) was available in fifty-one fractures. INTERVENTION: Modified tension band wire fixation was used in forty-nine fractures, whereas two fractures were treated with tension band wires threaded through cannulated screws. OUTCOME MEASURES: Early complications such as loss of reduction or fixation, infection, or soft-tissue problems were evaluated. RESULTS: Displacement of > or = 2 mm before healing was noted in eleven fractures. The displacement could be attributed to technical errors in five cases, and to patient noncompliance with postoperative activity restrictions in another five cases. Two cases of superficial infection were documented. Nine patients with symptomatic hardware required hardware removal. CONCLUSIONS: Twenty-two percent of fractures treated with tension band wiring and early motion displaced > or = 2 mm within the early postoperative period. Technical errors or patient noncompliance were identified as factors. The incidence of early complications in operatively treated patella fractures is higher than previously reported.
Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement.
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.
Techniques for reduction and fixation of pelvic ring disruptions through the posterior approach.
Open reduction and internal fixation through the posterior approach has an important role in the management of unstable Type C pelvic ring injuries. Using the described techniques, the goals of anatomic reduction and stable fixation can be attained. However, the potential exists for significant complications. Careful patient selection and attentiveness to detail minimize these risks.
Prophylactic indomethacin for the prevention of heterotopic ossification after acetabular fracture surgery in high-risk patients.
Thirty-seven male patients with acetabular fractures requiring an extensile surgical approach were treated using a uniform protocol that was begun in July 1984. In 1987, prophylactic indomethacin was added to the protocol to study its effects on the prevention of heterotopic ossification. Nineteen patients with at least 12 months' follow-up were operated on prior to, and 16 after the initiation of the indomethacin treatment program. Two patients were lost to follow-up. The severity of heterotopic ossification was evaluated for each of these two patient groups using the Brooker classification and was correlated with hip joint mobility. Statistical analysis revealed that indomethacin was effective in decreasing the overall incidence of heterotopic ossification (p < 0.01). The occurrence of severe heterotopic ossification (Brooker class III and class IV) was also significantly reduced (p < 0.01) and functional results thereby improved. The maximal extent of heterotopic ossification was evident by 6 weeks postoperatively in all patients. In the patients receiving indomethacin, heterotopic ossification did not progress after the drug was discontinued.
Plantar excision of primary interdigital neuromas.
A retrospective study was done of 51 patients (6 males and 45 females) who had 57 primary interdigital neurectomies performed through a plantar incision. The surgical technique is described. The results were divided into three categories, in which 26 feet were judged excellent, 27 feet rated good, and 4 feet were classed as poor. The author concludes that the plantar approach is technically simple and results in a comfortable scar. Poor results occurred in 4 of 57 feet. This failure rate compares favorably with those failure rates in reported series done through a dorsal incision. In the author's opinion, the ability to do a more proximal resection of the nerve--as compared with the dorsal approach--is responsible for the higher rate of success with this method.
Forefoot surgery in rheumatoid arthritis: subjective assessment of outcome.
Forefoot surgical outcomes were evaluated in 26 patients with rheumatoid arthritis. A total of 45 procedures were reviewed with emphasis on first ray intervention. Disease duration and aggressiveness of preceding medical therapy were combined to establish a disease severity index. Patients operated were predominantly in the midrange of disease severity. Subjective data on the relief of pain, callus, and deformity were favorable but this benefit was not long lasting inasmuch as patients were most satisfied in the period immediately following surgery and less so as time elapsed from intervention. Fusion of the first metatarsophalangeal joint seemed better than resection alone, indicating that stability should be the primary goal for surgical intervention of the rheumatoid forefoot.
Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results.
OBJECTIVE: Based on the results of a pilot study indicating the potential value of ultrasound (US) as a diagnostic tool for the early assessment of fracture healing and the related need for secondary operative procedures in patients treated by statically locked intramedullary (IM) nailing without reaming, a protocol was established for a larger scale prospective trial. The purpose of this study was to evaluate the outcome of this follow-up trial. DESIGN/METHODS: All skeletally mature patients admitted to the Henry Ford Hospital (Detroit, Michigan) from January 1993 to August 1994 who had sustained an acute fracture of the tibial shaft and who were treated by statically locked IM nailing, without reaming, were candidates for study. Forty-seven patients with fifty fractures that could be evaluated by US were included. The adopted determinants for fracture healing were complete disappearance of the IM nail on US examination performed at six weeks postoperatively, or progressive disappearance of the nail noted between the initial six-week study and a second nine-week US examination, both in conjunction with periosteal callus formation. Radiographs were obtained to monitor maintenance of reduction and to further evaluate fracture healing. RESULTS: Of thirty-eight fractures with a positive US (thirty-two at six weeks, six at nine weeks), thirty-seven healed uneventfully, a positive predictive value of 97 percent. Radiographic fracture healing was not evident until, on average, nineteen weeks after injury. The single false-positive fracture progressed to nonunion. Of the twelve fractures with negative US studies, ten underwent secondary procedures (nine dynamization, one bone graft), with four progressing to nonunion. Two patients refused secondary surgery; screw failure occurred in both. Otherwise, there were no hardware failures in this series. CONCLUSIONS: The results of this study indicate that US may provide important prognostic information concerning fracture healing after unreamed tibial nailing, upon which subsequent treatment can be based.
Unreamed retrograde intramedullary nailing of fractures of the femoral shaft.
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.