Biomedical subjects

William M Ricci

Publications and source records attributed to William M Ricci.

At least 19 recordsLinked to original sources

PubMed2006

Treatment of periprosthetic femoral shaft nonunion.

The purpose of this study is to review the contemporary treatment of periprosthetic femoral shaft nonunions. Thirteen periprosthetic femoral shaft nonunions in 13 patients were reviewed retrospectively. The average follow-up was 48.3 months. Five patients were treated with open reduction and internal fixation, 3 patients were treated with open reduction and internal fixation and prosthesis revision, and 5 were treated with partial femoral replacing prosthesis. Functional outcomes were assessed using a modified Harris hip score. Twelve of 13 nonunions were treated successfully as defined by either radiographic union or a well-functioning prosthesis. Four major complications, 2 requiring reoperation, were noted. These included persistent nonunion, dislocation, and new periprosthetic fracture. Successful treatment of periprosthetic femoral shaft nonunion yielded excellent pain relief, improved function, and patient satisfaction. However, complication and reoperation rates remain high.

Aged↗

PubMed2006

Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty.

OBJECTIVE: New locked plate devices offer theoretical advantages for the treatment of supracondylar femur fractures associated with a total knee arthroplasty (TKA). These devices also can be inserted with relative ease by using minimally invasive techniques, provide a fixed angle construct, and improve fixation in osteoporotic bone. The purpose of this study was to evaluate the results and complications of treating periprosthetic supracondylar femur fractures above a TKA with a locked plate designed for the distal femur. DESIGN: Prospective, consecutive case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-two consecutive adult patients with 24 (2 bilateral) supracondylar femur fractures (OTA 33A) above a well-fixed non-stemmed TKA were treated with the Locking Condylar Plate. One patient who died before fracture healing and 1 who was lost to follow-up were excluded from analysis. All remaining patients (5 males, 15 females, average age, 73 (range, 50-95) years) were available for follow-up at an average of 15 (range, 6-45) months. According to the OTA classification, there were three 33A1, eight 33A2, and eleven 33A3 fractures. All fractures were closed. Indirect reduction methods without bone graft were used in all cases. RESULTS: Nineteen of 22 fractures healed after the index procedure (86%). All 3 patients with healing complications were insulin-dependent patients with diabetes who also were obese (body mass index >30). Two developed infected nonunions and 1 an aseptic nonunion. Postoperative alignment was satisfactory (within 5 degrees ) for 20 of 22 fractures. Fracture of screws in the proximal fragment occurred in 4 patients. In 3 of these cases, there was progressive coronal plane deformity. There was no change in alignment in any other patient. Fifteen of 17 patients who healed returned to their baseline ambulatory status, with 5 requiring additional ambulatory support compared with baseline. CONCLUSIONS: Fixation of periprosthetic supracondylar femur fractures with a locking plate provided satisfactory results in nondiabetic patients. Diabetic patients seem to be at high risk for healing complications and infection.

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PubMed2006

Muscle strength recovery and its effects on outcome after open reduction and internal fixation of acetabular fractures.

OBJECTIVE: To determine the relationship between muscle strength recovery and functional outcome in patients who were treated for an acetabular fracture via an anterior approach. DESIGN: Case series. SETTING: University Medical Center. PATIENTS: Fifteen patients with a displaced acetabular fracture treated via an anterior, ilioinguinal approach were studied. Hip muscle strength of these patients was then compared with the muscle strength of a similar group of patients treated via a Kocher-Langenbeck approach (posterior approach). These patient groups were then combined and muscle strength recovery was compared with the functional outcome. MAIN OUTCOME MEASURE: Primary outcome measures included hip muscle strength, including work (J/min) and maximum torque (Nm/kg) for abductors/adductors and flexors/extensors. Clinical outcome was assessed with the Musculoskeletal Function Assessment (MFA) questionnaire and the results correlated with muscle strength. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, severity of heterotopic ossification, and range of motion of the affected and unaffected hips. RESULTS: At an average follow-up of 44 months, patients treated via an anterior approach had an overall muscle strength deficit of 9%. Hip extension strength was affected to the least extent (6% deficit when compared with the unaffected hip) whereas abduction, adduction, and flexion strength was affected to a greater degree. For each measure the affected side was typically weaker than the unaffected side. The average MFA score for the anterior approach group was 17 (range, 0 to 47) with most patients reporting poorest results in those domains assessing activities of the arms and legs, and those involving life changes and feelings. When MFA scores were compared with the muscle strength, a relationship was found between hip extension/flexion work and maximum torque and hip adduction work and maximum torque and MFA score. For each of these muscle groups, patients reported worsening function with decreased muscle strength. Assessment of the most recent radiographs revealed 9 patients with an excellent radiographic grade, 3 patients with a good grade, 1 patient with a fair grade, and 2 patients with a poor grade. Hip range of motion was not statistically different when the affected hip was compared with the unaffected hip, and none of these variables correlated with outcome. Heterotopic ossification was found in 8 patients; 4 with grade 1, and 4 with grade 2. CONCLUSIONS: Standardized muscle strength determination and completion of an MFA questionnaire provided a thorough evaluation of patients who had undergone open reduction and internal fixation of a displaced acetabular fracture. In these patients, hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. Therefore, in order to maximize the outcome of these patients, particular attention must be paid to postoperative muscle strengthening protocols and accurate and validated methods to assess strength and outcomes.

Acetabulum↗

PubMed2006

A prospective evaluation of patients with isolated orthopedic injuries transferred to a level I trauma center.

PURPOSE: To assess the indications for, the demographics of, and the appropriateness of patient transfers for orthopedic injuries to a level I trauma center. MATERIALS AND METHODS: All patients with isolated orthopedic trauma transferred to our level I trauma center (N = 128) by means of a physician-to-physician referral line during the call period of two surgeons were prospectively evaluated between January 1, 2004 and December 31, 2004. The specific indication for transfer, the specialty of the referring physician, the patient diagnosis, the perceived need for tertiary care referral (as assessed by a visual analog scale [VAS] based on the phone conversation with the transferring physician), and patient insurance status were obtained before the transfer. On patient arrival, each of these factors was reassessed for later comparison. RESULTS: The transferring physician was an emergency department physician in 88 cases (69%), an orthopedic surgeon in 32 cases (25%), and an internist in the other eight cases (6%). In the 77 cases in which we could confirm the presence of an on-call orthopedist, the patient was examined by the orthopedic surgeon before being transferred in only 32 (42%) cases. In 98 cases (76%), the stated indication for transfer was that the case was too complex for care at the referring hospital or that there was a need for a subspecialist. There was no significant difference in pre- versus post-transfer case complexity as assessed by the VAS (P > 0.05). Although the reported insurance data before transfer was inaccurate in 34 patients (27%), the overall payer mixes reported before and after transfers were similar (23% Medicare, 20% HMO/PPO, 14% workers' compensation, 12% uninsured, 5% Medicaid). The insurance type for the transferred patients as a whole was not significantly different from the non-transferred patients treated by our orthopedic trauma service during the same time period (P > 0.05). Twenty transferred patients had a low VAS complexity score (<5), suggesting that their injuries did not necessarily require tertiary care. Fifteen of these 20 had Medicaid, Medicare, or no insurance. This was a significantly different (worse) payer mix than for the typical transferred patient (P < 0.05). CONCLUSIONS: The need for an increased level of care was the predominant stated reason for patient transfer to our level I trauma center. Nonetheless, the orthopedic surgeon on call did not always examine the patient before transfer. Additionally, patients transferred who had a low level of complexity (those believed not to necessarily require tertiary care) had an insurance status that was worse than that of the typical transferred patient.

Adult↗

PubMed2006

Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. Surgical Technique.

BACKGROUND: The application of indirect reduction techniques has improved fracture-healing and reduced the need for bone-grafting compared with the outcomes of older, direct reduction techniques. We investigated the results of such indirect reduction techniques for the treatment of periprosthetic femoral shaft fractures. METHODS: Fifty consecutive patients with a femoral shaft fracture about a stable intramedullary implant (a Vancouver Type-B1 fracture) were treated with a protocol that included open reduction with use of indirect reduction techniques and internal fixation with a single lateral plate without structural allografting or other bone-grafting. Four patients died in the early postoperative period, and five had inadequate follow-up. The remaining forty-one patients (average age, seventy-two years) were evaluated clinically and radiographically at an average of twenty-four months. RESULTS: All fractures healed in satisfactory alignment at an average of twelve weeks (range, seven to twenty-three weeks) after the index procedure. One patient had one fractured cable and two others had one fractured screw, but all of the fractures healed without evidence of implant loosening or malalignment. There was one deep infection in the perioperative period. Thirty of the forty-one patients returned to their baseline ambulatory status. CONCLUSIONS: The results of this study support the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant.

Adult↗

PubMed2006

Distraction external fixation in lateral compression pelvic fractures.

OBJECTIVE: To observe the results and describe the technique of closed reduction and placement of a two-pin supra-acetabular external fixator, followed by immediate weight bearing, in the treatment of displaced vertically stable lateral compression pelvic fractures. DESIGN: Prospective, consecutive. SETTING: Regional trauma center. PATIENTS: A consecutive series of fourteen patients with displaced, vertically stable lateral compression pelvic fractures who were transported to a regional trauma center. INTERVENTION: Surgical treatment with closed reduction and maintenance of the distraction force with a two-pin, single-bar, supra-acetabular external fixator, followed by immediate weight bearing. MAIN OUTCOME MEASUREMENTS: Healing rate and time, operative blood loss and time, quality of reduction, time to full weight-bearing, and incidence of complications, including neurovascular deficits, loss of reduction, nonunion, pin tract infections, and chronic pain. RESULTS: A symmetric reduction of both hemipelves was achieved in all fourteen patients. Time to healing averaged 8.2 weeks (seven to twelve weeks), and no fixator required removal before healing. There were no delayed unions or nonunions, and none of the fractures displaced significantly after initial reduction. Average surgical time was thirty-seven minutes (range, twenty-five to sixty minutes) with an estimated blood loss of less than fifty milliliters. Patients were allowed to bear full weight immediately and were able to do so without ambulatory assistive devices within an average of twelve days (range, three to eighteen days). Complications consisted of three minor pin tract infections, one temporary lateral femoral cutaneous nerve palsy, one late pin tract abscess, and one patient with chronic low-back pain. CONCLUSIONS: Treatment of type B lateral compression injuries of the pelvic ring with anterior distraction external fixation is a highly effective yet relatively simple and minimally invasive treatment method. Surgical time and blood loss are minimal, and patients can be effectively and rapidly mobilized. Based on our experience, we believe this method to be a valuable tool in the treatment of these fractures.

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PubMed2005

Trochanteric nail insertion for the treatment of femoral shaft fractures.

OBJECTIVES: This study was designed to evaluate whether the use of a new femoral nail, specifically designed to be inserted through the greater trochanter, could eliminate the complications previously seen with insertion of straight nails through this entry portal for the treatment of femoral shaft fractures. DESIGN: Prospective, clinical trial. SETTING: Three level I trauma centers. PATIENTS: Sixty-one consecutive patients with femoral shaft fractures (50 closed and 11 open fractures) treated with antegrade nailing with insertion through the greater trochanter. INTERVENTION: All patients were treated in the supine position with a TAN nail (Trigen System, Smith & Nephew, Memphis, TN) inserted through the greater trochanter. MAIN OUTCOME MEASURE: Union, alignment, complications, and hip function. RESULTS: Forty-six of 57 (81%) surviving patients were available for follow-up at a minimum of 12 (range, 12-25) months. Union occurred in all but 1 fracture after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Pain was reported as slight in 6 patients and moderate in 2. Visual and videotaped gate analysis, performed on 24 patients, revealed symmetrical walking in 21. CONCLUSIONS: This study demonstrates that antegrade nailing of femoral shaft fractures with a specially designed nail inserted through a trochanteric starting point provides predictably high union rates and low rates of complications. Ease of entry and utility in patients with a large body habitus are advantages over conventional piriformis fossa entry techniques. Nailing through the greater trochanter with the patient supine is presently our treatment of choice for patients with femoral shaft fractures.

Adolescent↗

PubMed2005

Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant.

Adult↗

PubMed2004

Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system.

OBJECTIVE: Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. The Less Invasive Skeletal Stabilization (LISS) internal fixator system has theoretical advantages (minimally invasive fixed angle construct) for the treatment of these injuries. This report presents clinical results of the LISS system for treatment of complex proximal tibia fractures and illustrates the unique properties of the system. DESIGN: Prospective clinical trial. SETTING: Level I trauma center. PATIENTS: Twenty-eight consecutive patients with comminuted proximal tibia metaphyseal fractures (41A3, 41C2, or 41C3) treated with LISS plates. OUTCOME MEASUREMENTS: Healing, fracture alignment, infectious and implant-related complications, and functional outcome based on the Lower Extremity Measure (LEM). RESULTS: Average follow-up was 23 months (range 12-48). Thirty-seven of 38 patients healed their fracture after the index procedure. The other healed after implant removal without the need for further fracture repair. Postoperative fracture alignment was satisfactory in 37 of the 38 cases and was maintained in all patients at union. There were no infectious complications. The average LEM score was 88. CONCLUSIONS: The LISS internal fixator system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use fixed angle internal fixation plating systems should familiarize themselves with the significant technical differences between these and traditional plating systems to assure satisfactory results.

Adult↗

PubMed2004

Teleradiology in orthopaedics.

Teleradiology is a means of electronically transmitting radiographic image files from one location to another. Technologic advances in digital imaging, telecommunications, digital storage, and viewing technologies have made teleradiology readily available and reasonably affordable. The five components of a teleradiology system include: a sending station, a transmission network, a storage device, a viewing station and, a software package. The advantage of teleradiology is the mobility of digital images. In contrast to plain radiographs that only can be seen in one location at a time, multiple persons who are at different locations can view digital images simultaneously. When applied to orthopaedic trauma applications, when the consulting orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, disposition planning of patients from emergency departments or outlying hospitals, and planning of surgical procedures. These systems also improve the comfort level of consulting orthopaedic surgeons and potentially limit the risk of litigation for incorrect diagnosis. The quality, convenience, and effectiveness of teleradiology systems should improve as the technologies continue to mature. Having radiographic images available on handheld devices, such as cell phones, is likely to be a reality in the near future.

Computer Systems↗

PubMed2004

Acute effects of cartilage impact.

Posttraumatic arthrosis after joint injury occurs as a result of the disruption of the matrix components and chondrocyte death. Matrix components can be disrupted by mechanical and enzymatic means, and proteoglycan loss also has been shown to occur after cartilage injury. Until recently, chondrocyte death has been thought to occur primarily as a result of necrosis. However, new evidence shows that chondrocyte apoptosis can be stimulated to occur as a result of mechanical injury. The role chondrocyte death plays in the development of posttraumatic arthrosis currently is unknown. The development of in vitro cartilage injury models has made it possible to investigate some of the effects of impact load (acute injury) on cartilage. In vivo models of cartilage injury have made it possible to investigate changes in the integrity of the matrix components and of the chondrocytes in response to injury with time. However, considerably more information regarding this process is necessary before improvements in the prevention and treatment of posttraumatic arthrosis can be developed.

Animals↗

PubMed2003

Midline sagittal sacral fractures in anterior-posterior compression pelvic ring injuries.

OBJECTIVE: To evaluate the outcome of an uncommon variant of the anterior-posterior compression pelvic injury, in which the posterior ring injury is a midline sagittal sacral fracture extending into the spinal canal. DESIGN: Prospective, consecutive series. SETTING Two regional trauma centers. PATIENTS: A consecutive series of 10 patients with rotationally displaced, vertically stable anterior-posterior compression pelvic ring fractures (OTA type 61-B1) in which the posterior ring injury is a midline sagittally oriented sacral fracture involving the spinal canal (Denis zone III). This injury pattern comprised 0.6% of pelvic fractures and 1.4% of sacral fractures treated at these two institutions during a 10-year period. INTERVENTION: Patients were treated according to the same principles used in more commonly seen types of anterior-posterior compression pelvic ring injuries. Nine patients were treated with reduction and anterior pelvic stabilization at an average of 5 days after injury, 8 of whom were treated with open reduction and internal fixation and 1 with external fixation. No posterior pelvic fixation was used. One patient with nondisplaced bilateral pubic ramus fractures was treated nonoperatively. Immediate weight bearing was allowed as tolerated. MAIN OUTCOME MEASUREMENTS: Prospectively collected clinical follow-up data emphasized a detailed neurologic examination, whereas radiographic evaluation involved anteroposterior, inlet, and outlet plain radiographic views of the pelvis. RESULTS: An anatomical or near-anatomical reduction of the pelvis was achieved and maintained in all patients. Fractures healed at an average of 10 weeks. At an average follow-up of 31 months (range 20-46 months), there were no objective neurologic deficits that could be attributed to sacral root injury and no significant residual pain or gait disturbance related to the pelvic fracture. Loss of bowel or bladder function, loss of perianal sensation or sphincter tone, and lumbosacral radicular pain or sensorimotor deficit were specifically absent in all patients. Three patients, however, complained of sexual dysfunction at final follow-up. None of these patients had clinical evidence of sacral root/plexus injury secondary to the fracture. One additional patient, who sustained a urethral tear, required a chronic suprapubic catheter because of stricture. Six patients, one of whom had needed repair of a retroperitoneal bladder tear, had no urogenital sequelae. DISCUSSION AND CONCLUSION: Patients who sustain sagittally oriented midline fractures of the sacrum that extend into the spinal canal (Denis zone III) as part of displaced, vertically stable anterior-posterior compression pelvic injuries, have a low incidence of neurologic deficit attributable to sacral root or plexus injury. This is in contrast to the high rate of neurologic deficit (>50%) otherwise reported in zone III sacral fractures, particularly in those associated with a displaced transverse component. In the midline sagittal fracture variant, simultaneous lateral displacement of both bony and neural elements through the midline may protect the sacral roots and plexi from significant traction or shear injury by maintaining the spatial orientation between the sacral foramina and sciatic notch. Long-term sequelae were related to urogenital complaints rather than to musculoskeletal problems, as 4 of the 10 patients in this series had either sexual or urologic dysfunction.

Adult↗

PubMed2003

The significance of anode location for stimulus-evoked electromyography during iliosacral screw placement.

OBJECTIVES: To determine the effect of anode location on the current threshold required to provoke an electromyograph response during stimulus-evoked electromyography for iliosacral screw placement. DESIGN: Prospective cohort. SETTING: Level I trauma center. PATIENTS: Nineteen consecutive patients with 23 unstable posterior pelvic ring injuries treated with iliosacral screws. INTERVENTION: Iliosacral screws were inserted percutaneously over guidewires. Twenty-seven screws were inserted, all into the first sacral vertebrae. The guidewire was used as the cathode for constant-current, stimulus-evoked electromyography for all data collection. Stimulus-evoked electromyographs were obtained with the guidewire at four different stations: at the sacroiliac joint (station I), at the first sacral neuroforamen (station II), in the body of the sacrum (station III), and when the iliosacral screw was in final position over the guidewire (station IV). MAIN OUTCOME MEASURE: Stimulus-evoked electromyographs were obtained with the anode at four different locations for each of the implant stations. Location A had the anode adjacent to the percutaneous insertion site of the guidewire, location B at the ipsilateral anterior superior iliac spine, location C at the midline, and location D at the contralateral anterior superior iliac spine. RESULTS: Moving the anode from midline (location C) toward the entry point of the guidewire increased the current threshold required to provoke an EMG response as much as 67.1% (p < 0.05). Moving the anode from midline to the contralateral anterior superior iliac spine decreased thresholds as much as 3.4% (p > 0.05). In one case, anode placement close to the guidewire insertion site (locations A and B) failed to identify a potentially dangerous implant because current thresholds were >8 mA. With the anode at the midline, current thresholds were <8 mA, indicating unsafe guidewire position leading to redirection of the guidewire. CONCLUSION: The physical location of the anode during stimulus-evoked electromyography monitoring for iliosacral screw placement significantly changes the current thresholds required to provoke an electromyograph response. Current thresholds required to stimulate nerves increase as the anode is moved toward the stimulating electrode. Anode placement ipsilateral to the stimulating electrode may provide a false indication of safe guidewire placement. We recommend anode location at or beyond the midline for stimulus-evoked electromyography monitoring during iliosacral screw placement.

Adolescent↗

PubMed2003

Proximal tibia fracture. Opinion: plate fixation.

Explore the source record for details and available documents.

Adult↗

PubMed2003

Percutaneous treatment of peritrochanteric fractures using the gamma nail. 2000.

Explore the source record for details and available documents.

Bone Nails↗

PubMed2003

Induction of chondrocyte apoptosis following impact load.

OBJECTIVE: To investigate the presence and extent of chondrocyte apoptosis following impact load of articular cartilage in an in vivo model. DESIGN: An in vivo animal model, using a pendulum device and New Zealand White rabbits, was designed to study the effects of impact load on the development of chondrocyte apoptosis. Animals were placed into either a High Impact group or a Low Impact group, and the right medial femoral condyle was impacted with a single impact load. A sham operation was performed on the left limb, and this cartilage served as the control. SETTING: Academic medical center. PARTICIPANTS: New Zealand White rabbits (3 months). INTERVENTION: Impact load to the right medial femoral condyle. MAIN OUTCOME MEASURES: Three different methods were used to assess the presence and extent of chondrocyte apoptosis: 1) light microscopy (hematoxylin and eosin and terminal dUTP nick end labeling staining); 2) transmission electron microscopy; and 3) fluorescent microscopy with Hoechst 33342 staining. Secondary outcome measures included determination of the magnitude of impact force and time to peak force. RESULTS: Light microscopy demonstrated chondrocytes with changes consistent with apoptosis including condensed nuclei, deep eosinophilic cytoplasmic staining, and vacuolization within the impacted specimens. Terminal dUTP nick end labeling staining-stained specimens had a high degree of positively stained cells (60%) in both injured and uninjured specimens. Transmission electron microscopy of the impacted specimens demonstrated numerous chondrocytes with changes characteristic of apoptosis, including nuclear and cellular fragmentation, volume shrinkage, and cytoplasmic vacuolization. Eleven percent of the cells in the High Impact group had changes consistent with apoptosis, versus 3% for the low impact group and <1% for the sham specimens. The High Impact group received a statistically significant greater stress than the Low Impact group. Impact group (P < 0.05), and the average time to peak force was 0.021 seconds for each impact group. CONCLUSIONS: The current data strongly indicate that in vivo chondrocyte apoptosis can be stimulated by the application of a single, rapid impact load and that the extent of chondrocyte apoptosis is related to the amount of load applied. The contribution chondrocyte apoptosis makes to the development of posttraumatic arthritis following joint injury or intra-articular fracture still remains to be determined.

Animals↗

PubMed2003

Treatment of nonunions and osseous defects with bone graft and calcium sulfate.

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.

Calcium Sulfate↗

PubMed2003

A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility.

BACKGROUND: Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with a high complication rate. Diabetic patients with peripheral neuropathy are a particularly difficult group to treat because of their inability to sense deep infection, repeat trauma, and wound complications. The purpose of this study was to evaluate a protocol that included transarticular fixation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in diabetic patients with peripheral neuropathy and loss of protective sensibility. METHODS: The authors retrospectively reviewed the records of 15 patients with diabetes mellitus, unstable ankle fractures (AO classification 44B), and loss of protective sensibility confirmed via testing with a 5.07 Semmes-Weinstein monofilament. Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws in conjunction with standard techniques of open reduction and internal fixation was used. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing status for 12 weeks; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custom-molded ankle-foot orthosis (AFO) or custom total-contact inserts in appropriate diabetic footwear. RESULTS: The major complication rate for all fractures was 25% (4/16) and for closed fractures was 23% (3/13). These are lower than previously reported rates between 30% (3/10) and 43% (9/21) for diabetic patients with and without neuropathy. The amputation rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously reported rates of 10% (2/10) to 20% (2/21). There were no deaths or Charcot malunions in this series. The combination of transarticular fixation and prolonged, protected weightbearing provided 13 of 15 patients with a stable ankle for weightbearing. CONCLUSION: Although these fractures remain a treatment challenge, this study presents a successful, multidisciplinary protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients - those with loss of protective sensibility.

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