Introduction:. Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures. Methods:. All surgically treated adult patients with isolated unstable ankle fracture were included from April 2012 to April 2013 at a MTC in UK. Patients with poly-trauma were excluded. All patients underwent a standard surgical protocol: aim for early definitive surgical fixation (ORIF) within 24 hours however if significantly swollen than temporary stabilization with an external fixation followed by a staged definitive fixation. Results:. In total 172 consecutive unstable ankle fractures were included in one-year study period. Definitive fixation (ORIF) was achieved in 91% patients with only 9% patients required temporary stabilization with external fixation. Fibular locking plates were used in 59(38%) patients compared to conventional one-third tubular plates in 91(60%) patients. In ORIF group 42% (73) patients were operated within 24 hours of admission whilst 58% (83) under went early fixation after 24–72 hours. At one year follow up complications were recorded in 18(11%) patients including metal irritation requiring removal of implant in 6(4%) patients. Wound complications and deep infection leading to a further surgical procedure in 8(5%) patients. There was no statistical difference between complication rates (p=0.016) in early versus delayed fixation groups. Fibular locking plates were associated with higher soft tissue complications (13%) as compared with conventional plates (2%) (p=0.004). Conclusion:. Our study showed that the timing of the surgery has less influence on the complications of the ankle fracture fixation. However choice of implants requires careful consideration and we suggest caution against use of current fibular locking plates

Aims

The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents.

Introduction and Objectives: According to the literature, the prevalence of osteoarthritis in shoulder instability is about 4 to 31%. In these studies we used imaging techniques with little sensitivity to early alterations of cartilage. The aim of this study is to arthroscopically assess the prevalence and distribution of osteoarthritis in shoulder instability and analyze associated risk factors. Materials and Methods: In a group of 64 patients (mean 28.9 years of age, range 15–55) we arthroscopically assessed the degree and distribution of glenohumeral arthritis at the time of surgical stabilization classifying them into 3 groups according to severity. We determined the correlation of the degree of osteoarthritis (Pearson coefficient) with sex, dominance, age, age at the first episode, preoperative sports activities, degree of instability, laxness and number of dislocations and subluxations. Results: 63 patients (98.5%) had chondral or synovial lesions of a degree of severity categorized as slight, moderate or severe in 26 (40.6%), 35 (54.7%) and 3 (4.7%) patients respectively. The most frequent findings were Hill-Sachs type lesions and anteroinferior glenoid fibrillation. We found a significant correlation between degree of severity of the arthritis (p< 0.05) and the age of the patient, age at the first dislocation and number of dislocations. Discussion and Conclusions: The prevalence of osteoarthritis in shoulder instability is greater than has been described. The fact that there is a positive correlation between the number of dislocations suffered and the severity of the arthritis could be a reason for carrying out early stabilization in these patients

Purpose: The optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates earlier mobilization and theoretically reduces associated complications. Method: Consecutive patients requiring stabilization surgery for a spinal fracture, without neurological injury were identified from a prospective institutional database. Patients were stratified by the time to their final surgical stabilization procedure (< 12, 12–24, 24–48, 48–72 and > 72 hours) and outcomes compared. Multivariate analyses were performed to explore potential confounding effects. Results: 76 patients satisfied the inclusion/exclusion criteria. The median time to final surgical spinal stabilization was 71.8 hours. There were significant differences in complications related to prolonged recumbancy (e.g. respiratory failure, thromboembolism, p = 0.016) between the different time frames. Graphical exploration suggested higher complication rates after 48 hours delay. Comparing patients stabilized after 48 hours compared to those within, there was a 6.9 times (p = 0.0085) greater risk of a complication related to prolonged recumbancy. These effects remained significant after multivariate adjustments for age, comorbidity and ISS. There were trends towards longer lengths of stay and lower function (measured using the FIM) at discharge in the surgical delay group. Conclusion: This study demonstrates a strong relationship between surgical delay and complications. The cutoff for this delay appears to occur at 48 hours. This study is limited in that the identified relationship may be related to a number of other confounding factors not measured or inadequately adjusted for because of small numbers. Further study, using this study’s developed algorithms in larger datasets, may help resolve some of these issues

Aims: Functional outcome following pelvic ring fractures is closely correlated with the anatomic results. ORIF is correlated with good anatomic results but with morbidity. Isolated sacro-iliac screws are inadequate. We assessed outcome after complete Minimal-Invasive-Surgery. Methods: Between 1998 and 2001, 21 consecutive patients with unstable pelvic-ring disruptions [15 AO C, 6 AO B] were treated operatively. In a supine position, after close reduction of the fractures, anterior þxation, percutaneous stabilization of the posterior lesions was accomplished using ßuoroscopically-guided ilio-transsacral 7,3 mm cannulated lag-screws inserted through the body of S1 to the opposite sacroiliac joint. Results: Delay from injury to þxation was 4 (0–8) days. 13 anterior þxations and 21 ilio-transsacral cannulated screws were placed. No secondary complications. The main outcome was 2 years; radiographically, 19 anatomic reductions of the posterior fractures and 2 vertical ascensions (5 mm) were achieved. The mean Majeed score was 95. Conclusions: Early stabilization of instable pelvic-fractures in a supine position using percutaneous ilio-transsacral screws and anterior þxation is a technique that lends itself to a variety of unstable pelvic fractures. This diminishes potential blood loss and operative times in multiply injured patients. An obvious limitation in the percutaneous technique is the inability to restore the normal anatomy. Surgical stabilization allows early mobilization of the patients, prevents progressive deformity and obtains good functional results

Introduction: Early stabilization of the skeleton in multiply injured patients has shown to reduce mortality and chest morbidity. Reamed intramedullary nailing is the current method of choice for stablizing femoral and tibial shaft fracture. However several investigators have highlighted the adverse effect of early reamed nailing in polytrauma patients. Intravasation of medullary fat during canal pressurizaton has been suspected to produce a ‘second hit’ and trigger pneumonia and ARDS. The objective of this study is to investigate the effect of a filter placed into the ipsilateral common iliac vein during medullary canal pressurization. Methods: Using an established model of fat embolization, twelve mongrel dogs were randomized into two groups. Under general anaesthesia, cannulations of carotids and jugular veins and transesophageal echo-cardiography were performed in all animals. Under fluoroscopy control, a special filter was inserted percutaneously into the left common iliac vein in half the animals, where as the other half served as controls. In all dogs, the left knee was exposed; the femor and tiiba were sequentially reamed and then pressurized by injection of bone cement and insertion of intramedullary rods. Hemodynamic measurements and trans-esophageal echocardiography images were recorded continuously during the surgical procedure. After 45 minutes from pressurization, the dogs were sacrificed and the lungs and kidneys were harvested and fixed for histological analysis. Results: There was significant difference noticed in the right-sided pressures and oxygen tension between the filter and the control groups. The mean pulmonary artery pressure at 3 minutes of pressurization was 12mm of Hg in the filter group and 28mm of Hg in the control group. Transesophageal echocardiography showed less embolic shower in the filter group and also lesser dilatation of right ventricles. Histomorphometry with special staining demonstrated much less proportion of lungs to be occupied by fat in the filter group as compared to the control group. Discussion and Conclusion: This canine study has demonstrated that mechanical blockade by a venous filter can significantly reduce the emobilic load on the lungs in an established model of fat embolization. A suitable filter with suction system is being designed for possible use in high-risk patients

Early fracture stabilization has been shown to reduce morbidity and mortality in the patient who is multiply injured. Controversy exists in terms of managing multiple trauma patients who sustain thoracic injuries along with femoral shaft fractures. The purpose of the present study was to determine whether the presence and treatment of femoral shaft fractures increases morbidity in patients with pulmonary contusions and to determine the effect of patient and surgical factors on outcome. Patients that suffered chest injuries between January 1987 and April 2006 were identified from the prospectively collected trauma databases at two hospitals. Patient records were reviewed to verify all data. The diagnosis of pulmonary contusion was confirmed with radiologic or post-mortem investigations. All relevant patient and surgical data was collected. Exclusion criteria included severely injured patients (head/abdomen AIS> 3), age sixty years, death twenty-four hours after injuries occurred. A total of 1190 patients with confirmed pulmonary contusions met inclusion criteria; there were 113 femoral shaft fractures (five bilateral). Patients in both the isolated pulmonary contusion and pulmonary contusion with femoral fracture had similar injury severity scores (ISS) and demographic information. Fractures were reduced with intramedullary nailing in 88% of cases. Mean age was thirty-five years. There were significantly more incidences of fat embolism syndrome and acute lung injury (ALI) in patients with femoral factures (twenty-four hours following the injury had significantly greater risk of developing ARDS (p< 0.05). The presence of femoral shaft fractures in patients with pulmonary contusions increases the duration of admittance to hospital and can lead to higher rates of fat embolism syndrome and ALI, however it does not appear to impact overall mortality or contribute to the development of other common respiratory complications. Early reduction of shaft fractures is encouraged to further decrease complications

We have reviewed the patients with vertical shear fractures of the Pelvis and report on our treatment protocol and long-term functional outcome. Methods: Between January 1993 and January 2002, out of 581 pelvic ring injuries treated in our unit, we identified 31 vertical shear fractures in 29 (4.9%) patients (4 female). Data such as age, sex, aetiology, associated injuries, ISS, resuscitation and transfusion requirements were recorded. ICU/HDU stay, surgical stabilization, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome was assessed using the following generic tools: EuroQol EQ-5D, SF36v2, SMFA, Majeed score and VAS. Results: The mean age was 43.5 (16–71). The median ISS was 22 (12–32). Motorcycle accidents were responsible for 27%. Associated injuries included the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 and ruptured viscus was identified in 3 patients. Neurologic deficit was present in 9 cases. Posterior ring was stabilized in 3 (0 – 13) days. 6 patients developed systemic complications – ARDS in 4 (12%) patients, sepsis in 2 (6%). The mean follow up was 39 (12–101) months. Functional outcome using the Majeed score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5- D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes. Conclusion: Prompt resuscitation and early temporarily stabilization of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results, probably due to the extensive pelvic floor trauma seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group

Introduction Rheumatoid arthritis also affects the spine and creates conditions that need surgical treatment. As in other parts of the body, the maintenance of function and reduction of pain are primary goals of surgical treatment, however the additional threat to the neurological structures create an additional dimension in the surgical treatment of the spine. Destructive processes of osteoligamentous structures and severe osteoporosis may be blamed as the principle cause for pain, deformity and subsequent neurological deficit in the rheumatoid patient’s spine. Cervical spine Atlantoaxial instability is the most frequently encountered pathology in the cervical spine of the rheumatoid patient. In order to avoid late appearance of myelopathy, the timing of surgery in the presence of significant atlantoaxial instability (ADD < 5mm) has to be carefully evaluated. The tendency is towards early surgical stabilization since no spontaneous improvement is to be expected in cases with aggressive rheumatoid arthritis. Late surgery not only carries the risk of causing myelopathy by repeated micro-trauma of the myelon, but also the need for extensive surgery including the occiput and the lower cervical spine in case of advanced destructive processes. The subaxial cervical spine has a tendency to disintegrate in the presence of aggressive course of rheumatoid arthritis. The extent of instability and site of compression has to be carefully analyzed, using MRI and neurophysiological examinations. Due to weak bone structures anterior and posterior interventions are often necessary. Lumbar spine The rheumatoid pathology in the lumbar spine is mainly influenced by the degree of osteoporosis. Typical osteoporotic fractures, often on several levels, represent the most frequent pathology, which needs surgical help. In case of persistent pain the relatively new technique of vertebroplasty offers an elegant way to reduce pain. If severe deformities occur, the osteoporotic structure of bone limits the surgical possibility of correction of the deformity. Conclusion “Wait and see”-policy in rheumatoid patients with spinal pathology is often not appropriate (as in other joints of the body) if function and neurology should be preserved and maintained. Early surgery represents usually minor intervention and is better tolerated than extensive corrections. Osteoporosis is the main limitation for surgical treatment in the rheumatoid spine

We have reported that most of lower cervical cord injury patients had either improved or remained the same neurology following early operative stabilization done in our hospital. However, a few patients deteriorated with ascending paralysis in acute stage. Purpose of this paper is to present such cases and discuss the outcomes. Methods: 1) We have analyzed 10 pts of acute lower cervical cord injury who had deteriorated neurologic symptom ascending above C4 and complicated with respiratory quadriplegia. They accounted for 3.7 % out of 271 patients with bony injury. 2) They were 8 males and 2 females, aged 17~76, injury type C5/6 fracture-dislocation (Fx/Dx) in 4, C6/7 Fx/Dx in 4, C7/T1 in 1, and one C5 flexion tear drop Fx. 3) 2 patients were treated conservatively and 8 had operative reduction and fusion with careful technique. Results: 1) All patients had complete quadriplegia. 2) 3 pts could not wean out of ventilator and other 2 of them eventually died. 3) Paralysis started to ascend in 3 days after injury needed ventilator in 24 hours thereafter. 4) 2 out of 10 patients underwent an excessive distraction being treated conservatively. 8 patients had operative fixation for bony injuries, 7 of them obtained solid spine with single operation, but one had redislocated in a few days after the operation and received restabilisation surgery. Conclusion: 1) There are a few patients of acute lower cervical injury with complete quadriplegia deteriorated neurology ascending paralysis with respiratory distress. 2) Comparing to other cases an operative treatment would not a cause of such neurologic deterioration. 3) In most cases paralysis of diaphragm was passing symptom, but quite a few patients(1%) could not wean off ventilator. 4) Cause of ascending paralysis in such injury could not be identified definitely, therefore careful observation and prompt treatment such as tracheotomy should be recommended