Friction burns within the tibia during reaming. Are they affected by the use of a tourniquet?

We have carried out a prospective, randomised trial to measure the rise of temperature during reaming of the tibia before intramedullary nailing. We studied 34 patients with a mean age of 35.1 years (18 to 63) and mean injury severity score of 10 (9 to 13). The patients were randomised into two groups: group 1 included 18 patients whose procedure was undertaken without a tourniquet and group 2, 16 patients in whom a tourniquet was used. The temperature in the bone was measured directly by two thermocouples inserted into the cortical bone near the isthmus of the tibial diaphysis. Reaming was carried out to at least 1.5 mm above the required diameter of the nail. Blood loss was assessed by recording the preoperative and postoperative haemoglobin (Hb) level. The minimum clinical follow-up was six months. In group 1 (no tourniquet), the mean Hb dropped 2.8 g/dl from 14.3 +/- 1.02 g/dl to 11.5 +/- 1.04 g/dl (p = 0.0001), whereas with the tourniquet, the mean decrease was 1.3 g/dl from 14 +/- 1 g/dl to 12.7 +/- 1.3 g/dl (p = 0.007). This difference was not statistically significant. The mean initial tibial temperature was 35.6 degrees C (SD 0.6) and rose with reaming to levels between 36.3 degrees C and 51.6 degrees C. The highest temperatures were obtained with the largest reamers (11 and 12 mm, p = 0.0001) and the most rapid rise with the smallest diameters of medullary canal (8 or 9 mm). The rise of temperature was transient (20 s). We were unable to identify any effect of the use of a tourniquet on the temperature achieved. Reamed intramedullary tibial nailing induces a transient elevation of temperature which is directly related to the amount of reaming.     

Secondary effects of femoral instrumentation on pulmonary physiology in a standardised sheep model: what is the effect of lung contusion and reaming?

Intramedullary nailing is the treatment of choice for patients with femoral shaft fractures. However, there is an ongoing debate in multiple trauma patients with associated lung contusion when primary or secondary definitive stabilisation of the long bone fracture should be performed, as nailing is thought to play an important role in the pathogenesis of adult respiratory distress syndrome (ARDS). In a standardised sheep model, this study aimed to quantify the development of acute pulmonary endothelial changes, to assess the activation of polymorphonuclear leucocytes (PMNL) and to observe the effects on the coagulation system associated with the reamed nailing procedure. Furthermore, the effect of coexisting lung contusion in an experimental model was evaluated. The animals were randomly assigned to one of four different groups (6 animals/group). In control groups, only a sham operation (thoracotomy) was performed, whereas in study groups, lung contusion was induced prior to femoral stabilisation either by external fixation or reamed femoral nailing. Using bronchoalveolar lavage (BAL) pulmonary permeability changes were quantified and PMNL activation was assessed by chemiluminescence. Additionally PMNL diapedesis and interstitial lung oedema were determined by histological analysis. All animals were sacrificed 4 h after the start of the femoral instrumentation. Without an associated lung injury, instrumentation of the femoral canal with the reamed nailing technique induced a transient increase in pulmonary permeability. In the face of an induced lung contusion, reamed femoral nailing resulted in significant increases in PMNL activation, pulmonary permeability and interstitial lung oedema, compared with external fixation. Without pulmonary contusion, reaming of the femoral canal was associated with a transient increase in pulmonary permeability. This was exacerbated in the presence of lung contusion along with increased PMNL activation. External fixation did not provoke similar changes. The findings of this study support the view that reaming of the femoral canal should be avoided in polytrauma patients with severe chest trauma as it could act as an additional stimulus for adverse outcome. Temporary external fixation appears to be a safe method for fracture stabilisation until inflammatory and coagulatory disturbances after trauma have been normalized.     

Femoral preparation in cemented total hip arthroplasty: reaming or broaching?

Surgical techniques continue to be refined to improve the results of primary cemented total hip arthroplasty. Although there has been much research in the areas of cementation and implant design, little work has specifically addressed how bone preparation can be optimized on the femoral side. On the basis of available scientific data, it appears that the broach-only system has several potential advantages over the traditional ream-and-broach technique. Broaching is usually faster, leaves behind more bone stock, and may improve both microinterlock and macrointerlock. Additionally, the excess bone resulting from broaching without reaming does not seem to compromise fixation at the bone-cement interface. Such differences may become even more important as the indications for cemented hip arthroplasty broaden to include increasingly younger and more active patients, because revision in these individuals is likely. In most cases, reaming is probably counterproductive, although it may be advantageous when used to open the femoral canal, to prevent varus stem orientation, and to manage sclerosis or deformity of bone due to a preexisting hip disorder or the presence of internal fixation devices. Regardless of which method is chosen, good bone surface cleansing and cement penetration remain paramount. More studies comparing reamed and nonreamed preparation are necessary to resolve this controversial issue definitively.     

Severe glenoid retroversion is best treated with asymmetric reaming in total shoulder arthroplasty–Opposes

Degenerative arthritis of the shoulder is a common orthopaedic condition, and the number of total shoulder arthroplasty procedures is increasing with the aging population. During total shoulder arthroplasty, reconstruction of the glenoid side of the joint can be particularly difficult in the face of posterior wear or excessive retroversion. Treatment options for posterior wear or excessive retroversion of the glenoid include asymmetric reaming of the high anterior side, bone grafting, or posterior augmentation of the glenoid component. A posterior augmented glenoid component allows the surgeon to maintain bone stock while correcting the posterior deficiency of the glenoid and avoiding the potential for medialization of the humeral component with anterior high side reaming. Bone grafting can be beneficial but relies on graft healing to successfully obtain stability.     

Glenoid resurfacing: What are the limits to asymmetric reaming for posterior erosion?

Eccentric posterior glenoid erosion is a common condition in osteoarthritis. No limits have ever been placed on the degree of eccentric erosion that can be corrected while still maintaining sufficient bone stock to implant a glenoid securely. Five cadaveric scapulae were dissected. Posterior glenoid erosion was created to simulate retroversion of 15 degrees or more. A computed tomography (CT) scan confirmed the degree of glenoid retroversion. The glenoid was then reshaped to correct the glenoid retroversion to neutral, and a glenoid component with central and peripheral pegs was inserted. A second CT scan confirmed the correction to neutral and also evaluated the fit of the component into the glenoid. In all 5 experimental cases, at least 1 of the 4 pegs penetrated the glenoid vault. In 1 case, there was a fracture of the anterior rim. Glenoid retroversion of 15 degrees or more cannot be satisfactorily corrected simply by reaming to lower the anterior edge of the glenoid and restore neutral version when using a glenoid component with peripheral pegs.     

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up

OBJECTIVE: To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia. INTERVENTION: Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail. MAIN OUTCOME MEASUREMENTS: Nonunions, time to fracture healing, and rate of malunions. RESULTS: The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements. CONCLUSION: Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails.     

Is there a gluteus medius tendon injury during reaming through a modified medial trochanteric portal? A cadaver study

OBJECTIVES: The purpose of this cadaveric study was to evaluate whether there is any damage to the gluteus medius tendon when reaming through a modified medial trochanteric portal for antegrade intramedullary femoral nailing. METHODS: Ten cadaver hips were used in this study. A guidewire was placed in the modified medial trochanteric portal using the assistance of C-arm fluoroscopy and a 14-mm reamer was advanced over the wire. After the reaming was complete, each hip was dissected and the gluteus medius muscle and tendon were inspected to evaluate the amount of intrasubstance and medial tendon damage. RESULTS: Precise localization of the modified medial trochanteric portal was achieved in 9 of 10 cadaver hips. Of those nine hips, the use of the modified medial trochanteric portal did not result in any visible damage to the tendinous insertion of the gluteus medius or the medial aspect of the tendon in any of the specimens. CONCLUSIONS: There is no damage to the gluteus medius tendon with the use of the modified medial trochanteric portal. Although the clinical implications of this finding are not known with certainty, the use of the modified medial trochanteric entry portal for antegrade femoral nailing could possibly result in less postoperative morbidity because it does not damage the gluteus medius tendon as compared to the traditional more lateral trochanteric portal.     

Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumor

Objective: To evaluate the role of the lung lobectomy in gestational trophoblastic tumor patients with lung metastases. Methods: A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985~2002 at PUMC hospital were retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma. Results: Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage Ⅲa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage Ⅲb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage Ⅳ had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission(63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission(88%). Tuberculosis was found in 2 patients.Conclusions: Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.     

Determination of the optimal frequency of injection of triamcinolone: monitoring change in volume of keloid lesions following injection of 40 mg of triamcinolone

Background

Different dosage protocols may be advocated by different clinicians for the same keloid lesion. The aim of this study was to determine the optimal frequency of injection of triamcinolone for the purpose of reducing the size of keloid, by monitoring volume change in lesions.

Methods

Volume of all lesions was measured, and 40 mg of triamcinolone was injected once. Lesion volume was thereafter monitored weekly for 6 weeks.

Results

Mean pretreatment volume was 6.4 ml. Following triamcinolone injection, mean lesion volume became 5.1, 3.7, 3.6, and 3.6 ml at 1, 2, 3, and 4 weeks postinjection, respectively. The mean lesion volume was 3.7 and 3.9 ml at 5 and 6 weeks postinjection. Mean lesion volume was 1.29 ml lower at 1 week than at pretreatment stage (SD?±?0.8797), 1.35 ml lower in volume at 2 weeks than 1 week (SD?±?1.0386), and 0.138 ml lower in volume at 3 weeks than 2 weeks (SD?±?0.159). Mean lesion volume was 0.0250 ml lower at 4 weeks than at 3 weeks (SD?±?0.3215), 0.1000 ml greater in volume at 5 weeks than 4 weeks (SD?±?0.1713), and 0.2000 ml greater in volume at 3 weeks than 2 weeks (SD?±?0.0418). There is a statistically significant difference between the mean volume at 1 week postinjection and that at pretreatment stage, between 2 and 1 week, and between 3 and 2 weeks (p?≤?0.05). Reduction in volume was found to be most profound and statistically significant within the first 2 weeks postinjection.

Conclusions

This study finds that the optimal frequency of intralesional injection of triamcinolone involves a 2-week injection interval.Level of Evidence: Level IV, therapeutic study

     

Treatment of 209 cases of liver injury

Objective: To summarize the experience of the treatment of traumatic hepatorrhexis. Methods: The clinical data of 209 cases of liver trauma treated in the three affiliated hospitals of the Third Military Medical University from 1989 to 1999 were retrospectively analyzed. Among the 209 patients, 108 (51.7%) had Grade Ⅲ or more severe liver injury. Operative treatment was performed in 186 cases and preservative treatment in 23. Results: In the operated group, 169 patients were cured. The eomplications occurred in 18 patients and 17 of them died. In the non-operated group, the complications occurred in 22 patients and only 1 of them died. Conclusions： Severe injury and delayed treatment are two major factors leading to death from liver injuries.Surgical intervention is still the principal measure to treat traumatic hepatorrhexis. The indications for non-operative treatment should be carefully selected.     

Analysis of urgent reconstruction of electrical injuries

Objective:To summarize the reconstruction experience of the electrical injuries in emergency.Methods:All 309 wounds in 105 patients who suffered from electrical injuries were reviewed during a 10year period from Jan.1st 1986 to Dec.31st,1996.Treatment method,patient data and results were compared and analyzed.A comprehensive urgent reconstruction alternative used in all cases included the followings,1)debriding the wound in emergency,2)preserving the vital tissues as much as possible,even devitalized tissues or local necrosis,3) transplanting these vital tissues during the first surgery if the functional reconstruction required,4) nourishing the wound bed by tissue flaps covering with rich blood supply,5)improving flap survival by continuous irrigation for 24-720 hours beneath the flaps with a compound medicine after surgery.Results:Satisfactory results were obtained with the extremity loss ratio of less than 7% in this group compared with 42.5% which was 10 years before 1984 in the same hospital.Conclusions:This urgent comprehensive reconstruction alternative is an effective and workable method for reducing extremity loss of electrical injuries.     

Comparison of the safety of three methods of lumbar transpedicular screw fixation

Objective: To choose a proper method of lumbar transpedicular screw fixation at different lumbar levels among the three methods (Roy-Camille's method, Magerl's method and Du's method) in the Chinese population. Methods: Three-dimensional ( 3-D ) images were reconstructed with image data of 42 adult lumbar segments that were scanned by Electron Beam CT. The three methods of lumbar pedicle screw fixation were simulated on the 3-D reconstructed images and the parameters of implanting pedicle screws were measured. Results : There was statistically significant difference at the distance from the entrance point to the pedicle axis between the three methods (P<0.001). The distances measured by Du's method were shortest from L1 to L4, and the distances measured by Magerl's method were shortest at L5 (P<0.05). There was no significant difference from L1 to L2 (P >0.05) but significant difference from L3 to L5 at inserting safe ranges of TSA (transverse section angle) was found between the three methods (P<0.05). From L3 to L4, the inserting safe ranges of TSA measured by Du's and Magerl's methods were significantly larger than that measured by Roy-Camille's method (P<0.05), but there was no significant difference between them (P > 0.05). At L5, the inserting safe ranges of TSA measured by Magerl's method were largest among the three methods (P <0.05). Conclusions: Among the three methods, Du's method is the best choice from L1 to L4 because its distance from the entrance point to the pedicle axis is shortest and the safe range of TSA is largest: Magerl's method can be used from L3 to LS and is the best choice at L5; Roy-Camille's method is applicable at L1 and L2.     

Outcome of multimodality treatment of Ewing��s sarcoma of the extremities

Background:

The management of Ewing’s sarcoma family of tumors (ESFT, Ewing’s sarcoma/primitive neuroectodermal tumor) has been established as a multimodality treatment. Advances in imaging and diagnostics, chemotherapy, surgical techniques, radiotherapy and prosthetic technology have resulted in drastic changes in the outcome of this disease, with most of the recent studies having 5-year survival rates of more than 60%. The Indian patients present at a more advanced stage and the compliance of treatment is suboptimal. While there is plenty of data in the world literature on the outcome of Ewing’s sarcoma, there is paucity of data in Indian patients. Therefore, we conducted the present study to analyze the outcome of multimodality treatment of ESFT of the extremities at a tertiary nonprofit institute over a decade.

Materials and Methods:

34 patients who had histopathologically proven diagnosis of Ewing’s sarcoma of the extremities and had received treatment at our institute from 1997 through 2007 were included for analysis. The majority of patients had involvement of the femur (35%), followed by tibia (17%), fibula and foot (15% each), humerus (12%) and soft tissue of thigh (6%). Twenty-nine patients presented with localized disease (Enneking stage II B) while five patients presented with metastases (Enneking stage III). All patients received Vincristine, Actinomycin D, Cyclofosfamide + Ifosfamide and Etoposide (VAC+IE)-based chemotherapy and local treatment was offered to all but three patients having multicentric disease. The local treatment offered were, radiation (n= 15), surgery (n= 12) both surgery and radiation (n=4). All patients were analyzed for oncological outcome (event-free and overall survival, local and systemic relapses) by clinical and imaging evaluation and functional outcome by using the musculoskeletal tumor society (MSTS) score. These outcomes were correlated with age, sex, size of tumor, stage at presentation, modality of local treatment and site of relapse.

Results:

At the final follow-up (mean, 26 months; median, 17 months; range, 3–97 months), the overall and event-free survivals were 47 ± 12% and 34 ± 9%, respectively. Sixty-two percent of the patients presented with a tumor size more than 8 cm. On correlation with age, sex, size of tumor, stage at presentation, modality of local treatment and site of relapse, no correlation of survival was seen with any of the variables except event-free survival with size of the tumor. The functional outcome of all the patients was satisfactory (MSTS score >16 out of 30). No patient underwent amputation.

Conclusion:

Although the demographic profile, stage at presentation and the local and systemic treatment regimen followed in our study was similar to the world literature, the outcome of Ewing’s sarcoma in Indian patients were found to be inferior to that reported in the western literature. Larger multicentric studies with longer follow-up are required to exactly determine the key areas crucial in improving this outcome.     

Treatment of open supracondylar fracture of humerus

Objective: To explore the injury mechanism and treatment principle of open supracondylar fracture of humerus. Methods: The data of 32 patients with open supracondylar fracture of humerus hospitalized in our department in the recent 20 years were analyzed retrospectively. On an average, they were followed up for 30 months. The relationship between the fracture type,situation of wounds, operating time, operating method and time for postoperative functional exercise and final function of elbow joint were evaluated with Flynn scoring standard. Results: Excellent therapeutic effect was found in 14 cases, good in 12 and bad in 6, with the percentage of fine therapeutic effect of 81.25 %. Conclusions:For the patients with open supracondylar fracture of humerus, debridement and internal fixation should be made as early as possible, for thorough debridement and correct internal fixation are the key points to improve the prognosis.     

Does timing of presentation of penile fracture affect outcome of surgical intervention?

Objective

To assess the effect of timing of presentation of cases with penile fracture on the outcome of surgical intervention.

Patients and Methods

Between January 1986 and May 2010, 180 patients with penile fracture were treated surgically in our center. To assess the effect of timing of presentation, patients were classified into 2 groups: group I with early presentation (≤24 hours) and group II with delayed presentation (>24 hours). All patients were contacted by mail or phone and were re-evaluated. All patients were reevaluated by questionnaire and local examination. Patients with erectile dysfunction were evaluated by color Doppler ultrasonography.

Results

Group I included 149 patients (82.8%) and group II included 31 (17.2%). In group I, patients presented to the emergency department from 1-24 hours (mean, 11.8) after occurrence of the penile trauma. Although patients in group II presented from 30 hours to 7 days (mean, 44.7 hours). Both groups were similar regarding etiology of injury, clinical presentation, surgical findings, and incidence of associated urethral injury. Mean follow-up period for group I was 105 months, and for group II it was 113 months. After such long-term follow up, 35 (19.4%) patients had complications; however, there was no statistically significant difference between both groups.

Conclusions

Cases of penile fracture with early or delayed presentation up to 7 days should be managed surgically. Both groups have comparable excellent outcome with no serious long-term complications.     

Effects of repeated administration of human chorionic gonadotropin on the biosynthesis of testostero

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