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PubMedDate not supplied

Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures.

OBJECTIVE: To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. DESIGN: Retrospective chart review. PATIENTS: Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. INTERVENTION: Exchange reamed nails to treat ununited femoral shaft fracture. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. RESULTS: In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. CONCLUSIONS: Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.

Adult↗
PubMed1991

[The specialized treatment of the wounded with complications and unfavorable sequelae of gunshot wounds to the extremities].

The article gathers the management experience of 367 cases of complications in gunshot injuries of extremities, including 165 patients with amputation stumps of extremities and 202 patients with complicated gunshot fractures. The analysed group was consisted of the patients with stump diseases, irregular knitting or ununited fractures, defects of bone tissue or heavy purulent complications. Using the modern methods of diagnostic and treatment the authors succeeded in 30.9% of cases: in 59.9% satisfactory results were obtained. Unsatisfactory results were marked at 9.2% of patients.

Arm Injuries↗
PubMed2000

Serology of abnormal fracture healing: the role of PIIINP, PICP, and BsALP.

OBJECTIVE: To determine whether poorly healing tibial shaft fractures exhibit a serological response of bone-specific alkaline phosphatase (BsALP), collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) different from that of normally healing fractures. DESIGN: Prospective. PARTICIPANTS: Twenty consecutive patients with isolated tibial shaft fractures with or without fracture of the fibula. MAIN OUTCOME MEASUREMENTS: Assays of BsALP, PICP, PIIINP, and ICTP were performed with serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. Fracture healing was assessed at five, ten, fourteen, and twenty weeks for clinical and radiological evidence of union. RESULTS: Seventeen fractures united within the twenty-week study period. The three fractures exhibiting delayed union demonstrated significantly lower PICP levels and marginally lower BsALP levels at twenty weeks. PIIINP levels were significantly higher in these three fractures at ten weeks. There was no difference in ICTP between the seventeen united and the three ununited fractures. CONCLUSIONS: This study identified three serological features of a poor healing response in tibial shaft fractures. First, matrix collagen I and III production in the first ten weeks of healing was adequate, with evidence of significantly increased production of type III collagen. Second, there was no serological evidence of a deficient osteoblast response, as indicated by normal levels of BsALP and PICP, during this early period. Third, evidence of a deficient osteoblast response appeared only at twenty weeks after injury.

Adolescent↗
PubMed1980

Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects.

The results of using segmental cortical autogenous bone grafts to reconstruct defects created by resection of tumors were analyzed in forty patients. Thirty-three patients had dual grafts while seven had a single fibular graft. Dual grafts were used for major bones (humerus, femur, and tibia without fibula) while single grafts were used for the radius and for the tibia when the ipsilateral fibula was intact. Thirty patients had good or excellent results; seven, fair; and three, poor results. In twenty-five patients primary union was achieved within tweleve months and in two, in twenty months, while twelve patients required a second, supplementary cancellous graft at the site of non-union to obtain stability. One patient required removal of an infected graft and had a poor result. Stress fractures of the grafts occurred in eighteen of the forty patients after union had occurred. The stress fractures healed in fifteen of these patients: in six with no treatment (the fracture was identified retrospectively), in seven with external immobilization, and in two after bone-grafting of the ununited fracture. There were three persistent non-unions of stress fractures despite bone-grafting, internal fixation, and electrical stimulation, and these account for two of the three poor results. The length of the defect did not affect the incidence of non-union but it did affect the number of fatigue fractures. The shorter grafts (7.5 to twelve centimeters) were associated with a 33 per cent incidence of non-union (four non-unions of twelve grafts) while the longer grafts (twelve to twenty-five centimeters) had a 32 per cent rate of non-union (nine non-unions of twenty-eight grafts). The incidence of fatigue fractures in the longer grafts (58 per cent) was much greater than that in the shorter grafts (17 per cent). The grafts decreased in density during the first six months but gradually regained their mass and were generally comparable to normal cortical bone at two years. As the patients became functiona, most (55 per cent) of the the grafts became more dense than normal, some (34 per cent) remained the same, and a few (11 per cent) became less dense. Similarly, some (32 per cent) hypertrophied, most (58 per cent) remained the same size, and a few (9 per cent) atrophied. There was little morbidity (three of forty patients) associated with graft procurement. In twelve patients an additional graft was implanted experimentally, labeled with tetracycline, and subsequently removed at the time of a secondary procedure. These grafts were analyzed to determine if human grafts were repaired in the same fashion as grafts in experimental animals. The studies showed that human grafts are repaired in the same fashion, but that the sequence takes approximately twice as long as it does in the dog.

Adolescent↗
PubMed1984

The management of type III open tibial fractures.

In extensive type III open tibial fractures, limb salvage is considered worthwhile when there is good distal circulation and nerve function. The use of the external fixator has revolutionized the management of skin and soft tissues. However, the subsequent morbidity is still high. A retrospective study of 17 cases is analysed: the amputation rate was 6 per cent, delayed union 60 per cent, infected non-union 30 per cent and mal-union 40 per cent. The final functional result was good in 13 per cent of cases, satisfactory in 30 per cent, fair in 30 per cent and poor in 27 per cent. All patients preferred a functional limb to a prosthesis. The technique of using external fixation and the subsequent management are discussed. To improve the result, we recommend perfect alignment, fixation of the fracture with semi-rigid external fixation and early cancellous bone grafting for comminuted fractures and bone loss. Secondary internal fixation using implants is not advisable. A radical approach is necessary in infected ununited fractures. This includes excision of dead and contaminated tissue and the insertion of gentamicin methyl methacrylate bead implants. Although the complication rate is high and the rehabilitation period is prolonged, the main aims of limb salvage, viz. to retain a functional leg, are largely fulfilled.

Adolescent↗
PubMed2002

The effect of short-duration, high-intensity electromagnetic pulses on fresh ulnar fractures in rats.

Pulsed electromagnetic fields (PEMFs) have been found to be beneficial to a wide variety of biological phenomena. In particular, PEMFs have been shown to be useful in the promotion of healing of ununited fractures. Conflicting information exists regarding the benefit of using PEMFs to accelerate the healing of fresh fractures. This paper reports on the evaluation of the effect of a new PEMF generator (PAP IMI) on the healing of fresh ulnar fractures in rats. This device is unique by virtue of the extremely high power output of each of the pulses it generates. Ulnar fractures were created in rats by using a bone cutter, thus producing a 2-3 mm bone defect. Rats were then randomly divided into treatment and control groups. The treatment group underwent periodic treatments with the PAP IMI, and the control group received no treatment. Radiographs of rats from both groups were taken at 1-week intervals. Histological evaluation was performed at the end of the study. Radiographic and histopathological evaluations were scored, and scores were used to assess both rate and quality of healing. The radiographic results demonstrated gradual bridging callus formation in both control and treatment groups, however, the healing process was faster in rats that were not treated by PEMF. Histological evaluation demonstrated that the fibrous content of the callus in rats belonging to the treatment group was significantly higher than that in rats belonging to the control group. The results of this study do not support the claim that PEMF generated by the PAP-IMI stimulate osteogenesis and bone healing after the creation of fresh ulnar fractures in rats.

Animals↗
PubMed1984

Ipsilateral fractures of the femur and tibia. A report of fifty-seven consecutive cases.

We treated fifty-seven consecutive ipsilateral fractures of the femur and tibia in fifty-four adults from 1968 through 1978. Twenty-one patients had concomitant life-threatening injuries, and in thirty-three extremities the fractures were open. All but one of the femoral fractures and about half of the tibial fractures were internally fixed. The length of hospitalization averaged five weeks. Local complications included one below-the-knee amputation, three deep infections, and four ununited fractures. A fat embolism syndrome was diagnosed in 13 per cent of the patients. At the last follow-up examination, at an average of 40.5 months after injury, the mean range of motion of the knee was 129 degrees. Over-all, a good or excellent functional result was achieved in about 80 per cent of the patients. The best results were achieved when both fractures were stabilized surgically.

Adolescent↗
PubMed1992

Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.

Fifty open fractures of the tibial shaft that were treated with débridement and interlocking nailing without reaming were followed for an average of twelve months. Most of the fractures were the result of high-energy trauma, and 68 per cent of the fracture wounds were grade III. Forty-eight (96 per cent) of the fifty fractures united at an average of seven months; there were no malunions. There were four infections (8 per cent), all at the sites of grade-III fractures. Locking screws broke in five tibiae (10 per cent), but the breakage did not result in a loss of reduction. Three nails broke, two at the sites of ununited fractures and one at the site of a healed fracture. These results are comparable with, or better than, those obtained with other forms of fixation, including immobilization with a cast, unlocked intramedullary nailing, and external fixation.

Adolescent↗
PubMed1986

Infection following intramedullary nailing of long bones. Diagnosis and management.

In 30 patients (23 femurs and 7 tibias) with infection of long bone fractures following intramedullary (IM) nailing, the follow-up study ranged from eight to 84 months (mean, 20 months). Six patients retained active infection at the time of follow-up examination. Ununited fractures were present in four and sequestra in two patients. Stabilization for fracture healing after irrigation and debridement with appropriate systemic antibiotic therapy was the critical factor in the orthopedic management of this series of patients.

Adult↗
PubMed1981

The treatment of osteitis complicating tibial fractures.

A six-part scheme for the treatment of osteitis complicating tibial fractures is presented: (1) wound excision; (2) external fixation; (3) open irrigation drainage; (4) cancellous bone grafting; (5) split skin grafting; (6) full weight bearing in a plaster cast. Of 20 cases, 14 of which were ununited, remission of the infection was achieved in 17 with in 27 months (mean 10.8 months). All 14 ununited fractures went on to union within 20 months (mean 9.5 months).

Adolescent↗
PubMedDate not supplied

Treatment of ununited femoral shaft fractures associated with locked nail breakage: comparison between closed and open revision techniques.

OBJECTIVES: To investigate and compare closed and open revision techniques in the treatment of ununited femoral shaft fractures associated with locked nail breakage. DESIGN: Retrospective. SETTING: University hospital. METHODS: Ununited femoral shaft fractures associated with locked nail breakage were treated with either closed or open revision (nine or eighteen cases, respectively). The closed technique entailed closed removal of the broken nail and reinsertion of a stable intramedullary nail after reaming the marrow cavity. The open technique included open removal of the broken nail, reinsertion of a stable intramedullary nail or plate, and cancellous bone graft supplementation. Union rate, union period, perioperative course, and complications were compared. RESULTS: Eight closed and fifteen open technique cases were followed for at least one year (median two years). Cases treated with the closed technique had a union rate of 100 percent, a union period of 4.4+/-0.9 months, an operating time of 1.5+/-0.4 hours, no blood transfusion, and no complications. Open technique cases demonstrated a union rate of 100 percent, a union period of 5.7+/-1.5 months (p = 0.033), an operating time of 2.4+/-0.4 hours (p < 0.001), blood transfusion of 1,000+/-500 milliliters (p < 0.001), and no complications. CONCLUSIONS: We recommend the closed revision technique because its union period and operating time are shorter, and it does not require a blood transfusion. Because there is no local wound dissection, infection rates should also be lower. However, the procedure is technically demanding. If it cannot be completed successfully, using the open technique can still achieve a satisfactory outcome.

Adolescent↗
PubMed1978

[Transplantation of periosteum-coated cortical and cancellous bone grafts for treatment of fractures and pseudarthrosis (author's transl)].

Bone grafts are used in the treatment of fractures just as in the treatment of atrophic pseudarthroses of long tube bones. Only autologous bone graft is a reliable transplantation material. The discussion about different values of cancellous grafts and cortical-cancellous grafts is not completed yet. It will be reported about the own results of 110 transplantations of fresh and ununited fractures of long tube bones between 1968--1975. Only the autologous cortical-cancellous periosteum-coated single graft was used.

Femoral Fractures↗
PubMed1991

Autologous marrow injection as a substitute for operative grafting of tibial nonunions.

Autologous marrow injection was used to stimulate healing in 20 ununited tibial fractures over a five-year period. The technique was employed in conjunction with cast immobilization in ten cases and intramedullary nail fixation in ten cases. Marrow stimulated a callus formation sufficient to unite eight of the ten nonunions immobilized with casts and all ten of the fractures immobilized by intramedullary nails. Bone-marrow injection was as effective as past open autologous grafting but with considerably fewer disadvantages. The technique provides a promptly renewable and reliable source of osteogenic stem cells with numerous advantages compared with standard open-grafting techniques.

Adolescent↗
PubMed1996

A retrospective analysis of 36 civilian gunshot fractures.

A critical retrospective analysis was conducted of 36 gunshot fractures admitted from 1985 to 1989 in Finland by using the statistics of the Central Medical Board. The information was analyzed for demographic details and from consumption of hospital resources point of view, with special attention to gunshot injuries to long bones. The fractures were classified by using the grading system of Gustilo et al. into three categories: type A (60%), type B (12.3%), and type C (27.7%). Debridement of wounds was done successfully in two-thirds of the wounds, but was insufficient in nine cases. Fasciotomy was insufficient in seven cases. The fractures were immobilized by external fixation (Hoffmann) in two-thirds of the patients. Primary internal fixation was used in three femoral and one tibial fracture with severe complications. The tibia and femur were the most frequent sites involved, thus accounting for 13 infections. The infection rate, including two septicemias and four cases of osteomyelitis, could have been lower if war surgical principles were accepted or known in the management. The same could be considered in avoiding four compartment syndromes and six ununited fractures.

Adult↗
PubMed2001

Surgical management of delayed union and nonunion of distal radius fractures.

Ten patients with malaligned fractures of the distal radius that demonstrated either delayed healing or the development of an atrophic or synovial nonunion on standard radiographs were treated with surgical realignment, stable internal fixation, and autogenous iliac crest bone grafting. All 10 fractures healed with acceptable radiologic alignment within 3 months of the index procedure. After an average follow-up period of 3 years 6 months (range, 2 years to 8 years 6 months) patients had an average of 105 degrees wrist flexion and extension, 145 degrees forearm rotation, and 73% grip strength compared with the opposite limb. In the treatment of malaligned, ununited fractures of the distal radius, specific techniques and implants must be tailored to the deformity of the distal radius and the shape of the distal fragment. A stable, well-aligned wrist with preservation of at least 50 degrees mobility in flexion and extension was achieved in every patient, but the final result was compromised by associated problems in 3 patients.

Adult↗
PubMed2003

[Therapeutic results of the proximal humeral neck fractures].

Good therapeutic results can be obtained by conservative treatments for the proximal humeral neck fractures. However, surgical treatment is sometimes required in patients with 2- or 3-part fractures (Neer's classification) in whom the reduction of the fracture is unable to be maintained by conservative treatments. In this study, we performed the surgical treatment using anatomical bone plate on these patients and evaluated the therapeutic results. The materials consisted of twenty patients. The surgical procedure was performed plate fixation using anatomical bone plate by delto-pectral approach. The postoperative follow-up period ranged from one year to eight years and six months (mean;three years and two months). No patient showed ununited fracture site or humeral head necrosis. The average range of motion in the shoulder was 172 degrees in elevation, 164 degrees in abduction, and ninth thoracic level in internal rotation. Favorable therapeutic results can be obtained by plate fixation using anatomical bone plate in patients with 2- or 3-part fracture of the proximal humeral neck. However, there is necessary in consideration to treat using anatomical plate in patients with severe osteoporosis.

English Abstract↗
PubMed2002

Morbidity resulting from the treatment of tibial nonunion with the Ilizarov frame.

OBJECTIVE: To determine the sources and magnitude of residual morbidity after successful treatment of tibial nonunion using the Ilizarov device and techniques. DESIGN: A retrospective cohort study. SETTING: A level 1 trauma centre. PATIENTS: Sixteen patients with healed tibial nonunion. INTERVENTION: Application of the Ilizarov device and techniques to obtain union of a previous ununited tibial fracture. MAIN OUTCOME MEASURES: Patient satisfaction and sources of morbidity through clinical review and a visual analogue scale. Two disease-specific outcome measurement scales were used to assess ankle dysfunction. Radiographs were examined to determine the presence of arthrosis. RESULTS: Residual pain was present in over 90% of patients at a mean follow-up of 39 months: in 80% the worst pain was in the ankle, less than 10% felt the worst pain in the knee or at the fracture site. Mean ankle osteoarthritis scores were 3.4 for pain and 4.0 for disability, compared with 0.76 and 0.90 respectively for age-matched controls. Mean ankle-hindfoot scores were between 64 and 100. CONCLUSION: Ankle pain with disability is the major source of residual disability after successful use of the Ilizarov device for the treatment of tibial nonunion.

Ankle Joint↗