Unstable pelvic fracture and massive retroperitoneal hematoma from transection of the superior gluteal artery.
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Aged↗
Biomedical subjects
D L Helfet
Publications and source records attributed to D L Helfet.
Presidential Address. From whence we cometh.
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Fractures, Bone↗
Effect of impact load on articular cartilage: cell metabolism and viability, and matrix water content.
Significant evidence exists that trauma to a joint produced by a single impact load below that which causes subchondral bone fracture can result in permanent damage to the cartilage matrix, including surface fissures, loss of proteoglycan, and cell death. Limited information exists, however, on the effect of a varying impact stress on chondrocyte biophysiology and matrix integrity. Based on our previous work, we hypothesized that a stress-dependent response exists for both the chondrocyte's metabolic activity and viability and the matrix's hydration. This hypothesis was tested by impacting bovine cartilage explants with nominal stresses ranging from 0.5 to 65 MPa and measuring proteoglycan biosynthesis, cell viability, and water content immediately after impaction and 24 hours later. We found that proteoglycan biosynthesis decreased and water content increased with increasing impact stress. However, there appeared to be a critical threshold stress (15-20 MPa) that caused cell death and apparent rupture of the collagen fiber matrix at the time of impaction. We concluded that the cell death and collagen rupture are responsible for the observed alterations in the tissue's metabolism and water content, respectively, although the exact mechanism causing this damage could not be determined.
Animals↗
[Avascular femur head necrosis as severe complication after femoral intramedullary nailing in children and adolescents].
Nailing of femoral fractures before closure of the growth plates may lead to avascular necrosis of the femoral head in 3-4% of cases. In addition to the 14 cases described in the literature we present 3 more. Analysis of these cases reveals a common pathogenesis. The nails were all inserted anterograde and were designed for the adult femur. The problem appears to be related to the large diameter of the nail and its entry point in the relatively small femoral neck basis, close to the vessels supplying the femoral head. The role of the open physis remains unclear. Even though the complication of femoral head necrosis is rare, it is a severe complication. Therefore we do not recommend anterograde femoral nailing, using the classic entry point, in children or adolescents. We believe that there is a need for a new design of femoral nail. If both femoral head necrosis and coxa valga are to be avoided, we suggest that the entry point of the nail should be dorsolateral, below the trochanteric physis.
Adolescent↗
Bladder incarceration in a traumatic symphysis pubis diastasis treated with external fixation: a case report and review of the literature.
Fractures of the pelvis constitute a small but significant proportion of skeletal injuries. However, they are associated with significant morbidity and mortality, including damage to the urogenital system, especially the urethra and urinary bladder. We report the rare finding of bladder herniation and entrapment after reduction of a traumatic symphyseal diastasis by external fixation and the diagnosis of these injuries with computed tomography. A comprehensive review of the literature is also performed, to improve understanding and provide guidelines for evaluation and treatment of pelvic injuries with suspected bladder involvement.
Adult↗
Outer gloves in orthopaedic procedures: a polyester/stainless steel wire weave glove liner compared with latex.
OBJECTIVE: To compare the efficacy of traditional double latex gloving with that of a highly cut-resistant polyester/stainless steel wire weave glove (PSSWWG) over a single latex inner glove for the prevention of perforation of the inner latex glove. DESIGN: The primary surgeon and first assistant were involved in a prospective randomized study. Group I consisted of twenty-five procedures in which double latex gloves were used. Group II consisted of twenty-five procedures in which a PSSWWG liner was worn over an inner latex glove. All inner gloves were tested for perforations; all gloves exchanged that were presumed to have a perforation were noted and also tested. The type and length of the procedure were recorded. The dominant hand was recorded for all participants, along with their comments on the PSSWWG liner's performance. SETTING: Orthopaedic Trauma Service, Hospital for Special Surgery. New York. PATIENTS/PARTICIPANTS: Major operative cases, November 1996 to February 1997. MAIN OUTCOME MEASUREMENTS: Inner latex glove perforations. RESULTS: With the use of PSSWWG liners, the percentage of inner gloves found with a perforation dropped from 19 percent in the double latex group to 15 percent in the PSSWWG liner group (not statistically significant, p = 0.4). Two thirds of the perforations were in the primary surgeon's gloves, located in either the index finger or thumb. Nearly 80 percent of all perforations went unrecognized in both groups. Ninety-five percent of all perforations were in gloves that had been in use for more than 120 minutes (statistically significant, p = 0.01). CONCLUSIONS: The particular cut-resistant glove studied (Sceptor) did not significantly reduce the rate of inner glove perforations. Other studies with different cut-resistant glove types and protocols have proven the liners effective. We would still recommend using outer cloth or cut-resistant type gloves when bone fragments are being manipulated or when using sharp implants or saws. At a minimum, surgical gloves should be changed every two hours.
Equipment Design↗
Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture.
The case of a fifty-year-old man who suffered an isolated, associated, both-column fracture of the left acetabulum is presented. He underwent an uncomplicated open reduction and internal fixation through an ilioinguinal approach. A follow-up computed tomographic scan was performed postoperatively, which documented intraarticular fragments. Hip arthroscopy was performed to remove the fragments. During the procedure, arthroscopic fluid extravasated through the fracture site under pump pressure and resulted in an intraabdominal compartment syndrome that presented as cardiopulmonary arrest. An emergent exploratory laparotomy was performed to release the fluid and resume blood flow. Despite prolonged asystole, the patient survived without neurologic sequelae. The literature on compartment syndrome secondary to arthroscopic procedures is reviewed. Because of this previously unreported potentially lethal complication, we do not advocate hip arthroscopic procedures for acute or healing acetabular fractures.
Acetabulum↗
Retrograde intramedullary nailing of supracondylar femoral fractures.
As an alternative to standard AO/Association for the Study of Internal Fixation plate and screw techniques, retrograde intramedullary locked nailing of supracondylar and intracondylar (AO/Association for the Study of Internal Fixation Type 33) fractures is reviewed. This includes a historic review, the technique for knee arthrotomy, fracture reduction and nail insertion, and the reported clinical and biomechanical results. The retrograde intramedullary locked nail is a viable alternative for the treatment of AO/Association for the Study of Internal Fixation Type 33-A and some C supracondylar femoral fractures and should be part of the internal fixation armamentarium, however, it does not replace the standard biologic plate and screw techniques for most fractures.
Bone Nails↗
Minimally invasive plate osteosynthesis of distal fractures of the tibia.
Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.
Adult↗
Practical management of venous thromboembolism following pelvic fractures.
The management of thromboembolic complications remains one of the most controversial issues in the care of patients with pelvic and acetabular fractures. Recent studies have indicated that the incidence of proximal deep vein thrombosis is much higher than was previously believed. These patients should be managed with a formal institutional protocol that includes universal prophylaxis, supplemented in some cases by screening for deep vein thrombosis.
Algorithms↗
Intraoperative monitoring of motor pathways during operative fixation of acute acetabular fractures.
OBJECTIVE: To determine whether intra-operative spontaneous electromyography (EMG) was superior to somatosensory evoked potentials (SSEP) in the prevention of iatrogenic sciatic nerve injury. DESIGN: Prospective, consecutive. SETTING: Tertiary referral, teaching Hospital in New York City. PATIENTS: Seventy-four patients with acutely displaced acetabular fractures. MAIN OUTCOME MEASURE: Group A consisted of 24 patients who underwent intraoperative sciatic nerve monitoring using SSEP only. Group B consisted of 50 patients who underwent monitoring using both SSEP and spontaneous EMG. Motor potentials were recorded from the tibialis anterior, peroneus longus, abductor hallucis, and flexor hallucis longus muscles. All patients had independent preoperative and postoperative evaluations by the same neurologist. RESULTS: One iatrogenic sciatic nerve injury occurred in group A and none in group B. Prolonged sciatic nerve compromise, demonstrated by significant intraoperative SSEP changes, occurred 2.4 times per case in group A and only 0.8 times per case in group B. In group B, spontaneous EMG noted compromise an average of 3.6 times per case (p < 0.0001). CONCLUSIONS: The results of this study support spontaneous EMG as feasible and superior to SSEP monitoring in detecting intraoperative sciatic nerve comprise in acute acetabular fracture surgery. Spontaneous EMG permits earlier detection of intraoperative sciatic nerve comprise, allowing a more rapid response of the surgical team to noxious nerve stimuli. This may prevent permanent neurologic sequellae.
Acetabulum↗
Effect of impact load on articular cartilage: development of an intra-articular fracture model.
OBJECTIVES: To investigate the biological and mechanical effects of a single-impact load on articular cartilage. DESIGN: An in vitro laboratory study was performed using mature bovine cartilage and bone, and isolated cartilage explants. Each specimen was impacted with a single load applied with a specially designed impactor and materials test machine. Chondrocyte metabolic activity and cartilage structural integrity was investigated using force displacement curves, radionuclide labeling, histology, and changes in water content. SETTING: Laboratory for Soft Tissue Research, New York, New York, U.S.A. SPECIMENS: Viable mature bovine cartilage and cartilage and bone explants. MAIN OUTCOME MEASUREMENTS: Mechanical failure, proteoglycan synthesis, water content, histology, radiography, and scanning electron microscopy changes occurring during the twenty-four-hour period immediately following impact. RESULTS: Force/displacement curves for the cartilage and bone explants demonstrated two failure-stress peaks, the first at fifty megapascals, representing cartilage failure, and a second peak at seventy-five megapascals, representing bone failure. Fine grain radiographs, histology, and scanning electron microscopy all confirmed the destruction of the cartilage in the area of direct impact (zone I) and subchondral bone failure and the detachment of the cartilage within the lesser impacted area (zone II). Proteoglycan synthesis was reduced significantly (p < 0.05) in the areas of direct impact (zone I) compared with areas with less or no impact (zones II and III, respectively). Significantly greater water content (p < 0.05) was found within the cartilage of zone I compared with zones II and III. CONCLUSIONS: Significant and possibly irreversible articular cartilage damage occurs after a single high-energy impact load.
Animals↗
The detection and management of proximal deep venous thrombosis in patients with acute acetabular fractures: a follow-up report.
OBJECTIVE: To determine the efficacy of a thromboprophylaxis protocol that included deep venous thrombosis (DVT) prophylaxis (subcutaneous heparin), preoperative screening with magnetic resonance venography (MRV), and therapeutic management (vena caval interruption preoperatively, therapeutic heparin anticoagulation postoperatively) when indicated. DESIGN: Prospective, consecutive. SETTING: Tertiary referral, teaching hospital in New York City. PATIENTS: One hundred one patients with acutely displaced acetabular fractures. MAIN OUTCOME MEASURE: Preoperative MRV was performed to assess vascular structures. Patients with proximal DVT received vena caval filter interruption preoperatively and therapeutic warfarin postoperatively. Patients without proximal DVT received only subcutaneous heparin preoperatively and low-dose warfarin postoperatively. RESULTS: Forty-nine asymptomatic thrombi were identified in thirty-four of 101 patients (34 percent). Location of thrombi were in the popliteal vein in four of forty-nine patients (8 percent), superficial femoral vein in eight of forty-nine (16 percent), common femoral vein in thirteen of forty-nine (27 percent), external iliac vein in six of forty-nine (12 percent), internal iliac vein in fourteen of forty-nine (29 percent), and common iliac vein in four of forty-nine (8 percent). Thrombi were isolated to the injured extremity in twenty-six of thirty-four patients (76 percent), bilateral in four of thirty-four (12 percent), and isolated to the uninjured extremity in four of thirty-four (12 percent). Twenty-six of the thirty-four patients with proximal thrombi received preoperative vena caval filters. As a result of this protocol, only one patient (1 percent) developed a nonfatal pulmonary embolism. CONCLUSION: MRV is a sensitive screening examination that allows the placement of inferior vena caval filters based on documented proximal thrombosis. We anticipate that preoperative DVT screening with MRV will significantly decrease the incidence of fatal pulmonary embolism in this high-risk population.
Acetabulum↗
Thromboembolic complications in patients with pelvic trauma.
Patients with pelvic trauma are known to be at increased risk for the development of thromboembolic complications. The incidence of deep venous thrombosis in patients with pelvic fractures is 35% to 60%. Proximal deep venous thrombosis, which is most likely to result in pulmonary embolism, occurs in 25% to 35% of these patients, and almost 1/2 of all proximal thrombi will be in the pelvic veins. The incidence of symptomatic pulmonary embolism in the pelvic trauma population is 2% to 10% whereas a greater proportion of patients will have clinically silent pulmonary embolism. Fatal pulmonary embolism occurs in 0.5% to 2% of patients with pelvic trauma. The cornerstone of effective management is prophylaxis and the most commonly used forms include low dose heparin, low molecular weight heparin, mechanical devices, and in some studies, inferior vena caval filters. Based on a critical review of the literature, in algorithm is proposed for the management of thromboprophylaxis in this trauma subgroup. This includes prophylaxis, screening, and treatment when proximal thrombosis is identified. Such a systematic approach to this potentially catastrophic problem may decrease the morbidity and mortality associated with thromboembolic complications in these patients.
Fractures, Closed↗
Operative stabilization of fracture dislocations of the sacroiliac joint.
Posterior fracture dislocations of the sacroiliac joint (crescent fracture) represent a subset of lateral compression pelvic fractures. The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the inferior 1/2 of the sacroiliac joint. The posterior superior iliac spine remains firmly attached to the sacrum by the strong posterior ligaments. As a result of this combination of bony and soft tissue injury, the hemipelvis is rotationally unstable, but because the sacrospinous and sacrotuberous ligaments remain intact the involved hemipelvis is stable to vertically applied forces. Operative stabilization is necessary to restore articular congruity of the sacroiliac joint, pelvic stability, and to allow early mobilization of the patient. Stabilization of the pelvis may be achieved through either an anterior or a posterior approach with or without transarticular fixation. A posterolateral approach to the crescent fracture and a method of stabilization using extraarticular fixation, intertable lag screws and outer table antiglide plates are described. The results of using this technique in 22 patients are reviewed.
Fracture Fixation, Internal↗
The crescent fracture: a posterior fracture dislocation of the sacroiliac joint.
Between October 1987 and August 1992, 22 patients with crescent fractures, a posterior fracture-dislocation of the sacroiliac joint, were admitted, treated, and available for review at Tampa General Hospital and The Hospital for Special Surgery. The purpose of the study was twofold: (a) to evaluate the incidence, severity, and pattern of associated injuries, and (b) to determine the efficacy of a treatment protocol using a posterior extrapelvic approach and extraarticular internal fixation. The study population was composed of 13 females and nine males; the average age was 25 years (range 10-52). Despite the fracture pattern resulting in a rotationally unstable hemipelvis, all patients were hemodynamically stable at the time of presentation. Fourteen patients (64%) had other associated injuries, including five (23%) with closed head injury. In all cases a posterior extrapelvic approach was used with an anatomic reduction of the fractured iliac wing and the sacroiliac joint dislocation. Stable extraarticular internal fixation was obtained using intertable lag screws and outer-table neutralization plates. All the fractures were clinically and radiographically healed within 8-10 weeks postoperatively, and there were no acute wound, neurologic, or vascular complications. One patient developed osteomyelitis of the iliac crest 6 months postoperatively.
Adolescent↗
Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery.
Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.
Adolescent↗
Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture.
We performed a prospective, blinded study to assess and compare the values of preoperative contrast venography and magnetic resonance venography in the detection of deep venous thrombosis in the thigh and pelvis of forty-five consecutive patients who had a displaced acetabular fracture. The magnetic resonance venography and contrast venography were performed an average of seven days (range, one to twenty-nine days) after the injury. Twenty-four asymptomatic thrombi were identified with magnetic resonance venography in fifteen (33 percent) of the patients. Four of the thrombi were in the superficial femoral vein, nine were in the common femoral vein, one was in the external iliac vein, seven were in the internal iliac vein, and three were in the common iliac vein. Ten (42 percent) of the twenty-four thrombi were confirmed with contrast venography; nine of them were located in the thigh. The remaining fourteen thrombi (58 percent) that had been noted on magnetic resonance venography could not be seen with contrast venography because they were located either in the deep pelvic veins or in the uninjured extremity. The thrombi in the internal iliac vein were identified only with magnetic resonance venography. Twelve of the fifteen patients who had thrombi had a filter placed in the inferior vena cava preoperatively. In eight of these patients, the filter was placed because of the findings of magnetic resonance venography alone. Magnetic resonance venography resulted in a change in the therapeutic management of ten (22 per cent) of the forty-five patients. There were no pulmonary emboli. We concluded that magnetic resonance venography is superior to contrast venography for the preoperative evaluation of proximal deep venous thrombosis in patients who have an acetabular fracture. Magnetic resonance venography is non-invasive, does not require the use of contrast medium, images the proximal aspects of both lower extremities simultaneously, and, most importantly, allows for the identification of deep venous thrombosis in the pelvis.
Acetabulum↗