Background

The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy.

Purpose: Problem: Tibia plateau fractures may lead to end-stage post-traumatic arthritis that requires reconstructive surgery. The incidence of this problem is unknown but has been estimated at 20–40% by studies that were limited by small sample sizes, potential follow-up bias, and the limitations of using radiographic arthritis as a chosen outcome (not correlated to function). The use of administrative data bases to follow the care of a large number patients for robust end points such as surgery, offers an opportunity to address these limitations. Purpose: to determine the minimum ten year incidence of post-traumatic arthritis necessitating reconstructive surgery following tibia plateau fractures.

Method: We queried our prospectively collected Orthopedic Trauma Data base to identify operatively treated patients with tibia plateau fractures. These cases were cross-referenced with the data from our Province’s administrative health database and tracked over time for the performance of reconstructive knee surgery. Each individual’s exposure/follow-up period was limited by end of health plan coverage on record or date of death from vital statistics data. The minimum follow-up was ten years.

Results: Between 1987 and 1994, 378 patients with a tibia plateau fracture were treated at our institution. The average age was 46 years (sd=18, range 14–87), while 56% of patients were males. Seventeen out-of-Province residents were excluded, along with forty-six others whose “Medical Services Plan” numbers could not be identified. Of which seven were WCB patients and one who was affiliated with the military. The study cohort therefore consisted of 311 patients with 314 tibia plateau fractures. Four individuals (1.3%) we treated tibia plateau fractures have required reconstructive knee surgery for end-stage post-traumatic knee arthritis at 10 years. Of these 3 of 4 were type VI fractures and 1 of 4 was open.

Conclusion: Patients who require surgical treatment of tibia plateau fractures may be counseled on their long-term risk of requiring reconstructive knee surgery for endstage knee arthritis based on a clinical study. Based on our findings, the proportion of those who have required a total knee surgery, ten years following their injury, is lower than previously published.

Purpose: To conduct a study to identify differences in complication rates and outcomes between previously recognized sub-groups commonly treated for limb length discrepancies (LLD).

Method: Forty-two males and 13 females were treated for LLD at two level-one trauma centres. Mean LLD was 4.4 cm (range 1.8 to 18cm). There were 44 femoral segments (in 41 patients) and 14 tibia segments lengthened. Forty were post-traumatic, and 18 congenital/ developmental. Objective data regarding complications, length achieved, and lengthening duration was collected from patient records. Two groups were compared for differences: Developmental (congenital and developmental etiology combined; LLD occurred prior to skeletal maturity and treatment involved creating new length) versus post-traumatic (restoration of previously existing length), and tibia versus femoral lengthening.

Results: A mean of 4.4 cm of length was achieved over a mean duration of 83 days, for a mean lengthening index of 18.9 days/cm. Superficial pin tract infections were the most common complication, occurring in 33 segments (56%). Deep infection occurred in six segments (10%). Three of these six had a history of open fracture, and a fourth had a history of infection during initial fracture management. All were successfully treated with irrigation and debridement, and exchange nailing. The developmental group had significantly greater incidence of flexion contracture (13% versus 78%, p< 0.001), and surgical correction for a contracture deformity (5% versus 61%, p< 0.001). The post-traumatic group had a significantly higher rate of painful hardware requiring removal following successful treatment of their LLD (45% versus 16%, p=0.04). Tibia segments had a significantly greater lengthening index (29 d/cm versus 18 d/cm, p=0.03).

Conclusion: Limb lengthening is an involved process with potential for serious complications. Patients who had limb-lengthening for congenital/ developmental discrepancies had a higher rate of adjacent joint contrac-ture and subsequent requirement for surgical release. Patients with post-traumatic lengthening had a higher rate of hardware removal, and the lengthening index was greater for tibiae than femora. Deep infection remains a significant concern. This study provides information for physicians and patients on the rate and type of complications that can be expected both overall, and within specific LLD treatment groups.

To determine if intraoperative positioning in the supine or lateral position affects morbidity and mortality in orthopaedic trauma patients with femur fractures.

Retrospective cohort study of 991 patients representing 1030 femoral shaft fractures admitted to our level one trauma center between the years of 1987 to 2006. Primary outcome measures included mortality and admission to ICU. Secondary outcome measures included length of stay in hospital, length of time admitted to the intensive care unit and discharge disposition. Logistic regression analysis was performed to compare to effect of intraoperative position in addition to other known dependent variables on primary and secondary outcome measures.

Intraoperative position in the supine or lateral position had no effect on morbidity or mortality in orthopaedic trauma patients with femur fractures.

There is no difference in immediate mortality or morbidity between patients with femur fractures treated with IM nails in either the lateral or supine position. We conclude that either position is safe for the surgical stabilization of femur fractures and intraoperative position should be determined by surgeon preference.

The long-term results of patients with multiple knee ligament injuries, i.e. at least 3 ligament ruptures, including both cruciates, in patients entered prospectively onto the trauma database between 1985 and 1999, were reviewed. Forty patients with this injury had modified Lysholm scores at long term follow-up a mean of 8 years post-injury. The mode of operative treatment fell into 3 groups: direct suture or screw fixation of avulsions (Group 1), mid-substance ruptures treated with cruciate reconstruction with hamstring tendons (Group 2), or suture repairs of mid-substance ruptures (Group 3). All operative procedures were undertaken within 2 weeks of injury. Non-operative treatment involved a cast or spanning external fixator (2–4 weeks) followed by bracing. Statistical analysis was performed on the Lysholm scores.

The 40 patients in the study group were predominantly young males, 40% had polytrauma, 33% had isolated injuries. Thirteen patients (33%) had non-operative management, the remainder had early operative treatment of their ligament injuries, tailored to the type of ligament injuries identified.

Long-term patient outcome data shows statistically significant differences (p< 0.05) between the best results, in patients with direct fixation of bony avulsions (mean = 89), followed by those who had early hamstring reconstruction (mean = 79), followed by those who underwent simple ligament repairs (mean = 65). There was a statistically significant difference (p< 0.05) between the overall scores for the operative group (mean = 80) compared with the non-operative group (mean = 50).

Operative treatment of multiple ligament injuries, particularly fixation of avulsions and primary reconstruction of the posterior cruciate ligament appears to yield better results than non-operative or simple repair in the long term follow-up in this group with significant knee injuries.

Fifty-six patients, with a median fourteen years follow-up of isolated tibial shaft fracture treated with an IM nailing, underwent functional evaluation with SMFA and SF-36 questionnaires, as well as an injury specific questionnaire. Thirty-three also underwent clinical and radiological evaluation.

Overall, SF-36 scores (PCS 49.9, MCS 52.0) were near normal. Five (15.2%) had physical findings of venous stasis, while a third reported symptoms A third had at least mild OA on radiographs (knee-seven, ankle-eleven). A third of patients had a loss in ankle dorsiflexion, and more than half reported knee pain that was limiting to at least one activity.

We conducted a study to evaluate the long term functional outcomes and disabilities of patients with an isolated tibial shaft fracture treated with intramedullary nailing.

We identified two hundred and fifty eligible patients from the VGH Orthopaedic Trauma database between 1987 and 1992. A total of fifty-six patients agreed to participate. All were evaluated with the SF-36 and SMFA functional questionnaires, as well as an injury specific questionnaire focusing on knee pain, and symptoms of venous insufficiency. A sub-group of thirty-three patients were evaluated radiographically and by physical examination. We had a median follow-up of fourteen years, with a range from twelve to seventeen years.

The SF-36 scores (PCS 49.9, MCS 52.0) were comparable to population norms. Of the questionnaire group (n=56), fifteen denied knee pain with any activity, while twenty-nine had knee pain that was limiting to at least one type of activity. With respect to swelling, eighteen reported asymmetrical swelling affecting the injured limb. However, in the examination group, only five had objective evidence of venous stasis. Knee range of motion was essentially equivalent to the unaffected side, while thirteen patients had a restricted range of motion of the ankle. Radiographically, seven patients had at least mild OA of at least one knee compartment, while eleven had at least mild OA of the tibio-talar joint, despite near anatomic fracture healing.

At a median fourteen years following tibial nailing of isolated tibial fractures, patients function very well, but objective and subjective evaluation shows not insignificant sequellae.

Purpose: The use of radiology is integral to Orthopaedic Trauma surgery and there has been increasing dependence on image intensifiers in the operating room. A study was undertaken to assess the radiation exposure of the surgeon.

Methods: One full time orthopaedic trauma surgeon has worn a dosimeter on his waist since November 1996, under a lead apron when using a large image intensifier and when using a mini C-arm. Since November 2001, a second dosimeter was worn at the neck, unshielded in all cases. Since June 2005, a ring dosimeter was worn on the dominant ring finger and the all surgical cases were prospectively documented in regard to the type of intensifier used and the amount of fluoroscopy used.

Results: In the nine years of monitoring the truncal dosimeter has never recorded any radiation. In four years of monitoring the neck dosimeter has recorded 5.72 mSv (average 1.4 mSv / yr). In last 2 months (6 months data will be available at the time of presentation), 99 operative cases were done. In 31 cases no intra-operative radiology was used, 33 cases used a mini C-arm and in 35 cases a large C-arm was used. A total of 40.2 minutes of mini fluoro time (average 1.22 minutes / case) and 118.09 minutes of full sized C-arm fluoro time (average 3.37 minutes / case) was used. In these 2 months the ring dosimeter recorded 5.4 mSv of radiation (annualized dose 32.4 mSv).

Conclusions: The International Commission on Radiological Protection annual recommended dose limits for “radiation workers” are: whole body 20 mSv, eyes 150 mSv and skin / hands 500 mSv. For members of the public these limits are 1 mSv, 15 mSv and 50 mSv, respectively. The exposure of an Orthopaedic Trauma surgeon fall well below the annual recommended dose limits in the industry but begin to approach the limits for the public. From this study it would appear to be safe not to use a lead apron for mini C-arm cases. The surgeons hands are exposed to the most radiation and strategies to reduce this exposure should be pursued.

There are a variety of surgical approaches available for open reduction and internal fixation of acetabular fractures. Some centres have avoided the use of the triradiate approach in the belief that it may result in a significantly higher rate of heterotopic ossification. This has not been our experience. In contrast to many centres, acetabular fractures are treated in an emergent manner, with surgery usually undertaken within the first few days post injury. It is the investigators’ belief that this may in part result in a lower rate of heterotopic ossification.

The triradiate approach has fallen out of favour in the treatment of acetabular fractures due to concerns with both wound healing and heterotopic ossification. This approach however has been utilised frequently at the Vancouver General Hospital (VGH) in the treatment of acetabular fractures. The purpose of this study was to review the results and complications of this approach experienced in the large series at VGH.

We concluded that the results of this approach are acceptable with the exposure allowing anatomical fracture reduction in the vast majority of cases. The complication rate was low, as was the rate of heterotopic ossification.

The significance of this study is to highlight that this approach remains extremely useful in the treatment of acetabular fractures, due to its ability to give excellent exposure while still having an acceptably low complication rate. We believe that the ability of our unit to operate on these injuries in an emergent manner may impart the low rate of heterotopic ossification that we have observed.

There were a total of one hundred and sixty-one acetabular fractures that were treated operatively with the triradiate approach over the period 1989 to 2001. Of these, the majority were two column injuries (79 or 49%), T type fractures (34 or 21%) and transverse fractures (17 or 11%). The average age of the patients was thirty-seven years and the average time to surgery was three days. Our early complications included five cases of failure of fixation or loss of reduction of the fracture, two cases of neurovascular injury, two cases of superficial wound infection, one case of deep wound infection and one case of wound breakdown.

The study involved examining patient hospital records and radiographs and included fracture types, patient ages, delay to surgery, post-operative complications and degree of fracture reduction and healing. Grading of heterotopic ossification was performed by reviewing the anteroposterior radiographs and using Gruen’s classification system.

Purpose: To evaluate early and late perioperative complications and long term quality of life outcomes in patients having undergone immediate open reduction and internal fixation of acute high-energy tibial plateau fractures (AO C3).

Methods: Retrospective review of 70 AO C3 tibial plateau fractures managed with immediate open reduction and internal fixation at the Vancouver General Hospital from December 1987 to April 2004. Chart and database review was conducted for early and late perioperative complications, and patients were surveyed using three quality of life instruments: SF36, SMFA, and WOMAC.

Results: 3(4.3%) patients had died at the time of follow-up. Of the remaining 67, 49(73%) could be located and were contacted for follow-up. 28 of the 49 subjects (57%) completed the mail-out surveys (20 male, 8 female). Mean age of respondents at time of follow-up was 45.2±9.0 years. 10(36%) patients were pedestrians or cyclists struck by cars, 9(32%) were injured as a result of a fall, 5(18%) were motor vehicle collisions, 2(7%) were sustained by a direct blow, and 2(7%) were sustained by twisting mechanisms. Mean time from injury to OR was 56.0+84.3 hours. Duration of follow-up was 8.9+5.3 years. 4(14%) patients had open fractures. Fixation methods included immediate ORIF with a single plate in 24(86%) cases, dual plating in 3(11%) cases, and screws alone in one (3%) case. ISS and LOS scores were 11.4+6.8 and 15.7+8.0 respectively. One patient (3%) experienced an early perioperative complication of excessive soft tissue tension post ORIF requiring delayed skin closure. Late perioperative complications included 9(32%) cases of painful hardware, 2(7%) non-unions, 2(7%) superficial infections, 1(3%) osteomyelitis and 1(3%) mal-union. No patients required amputation. SMFA and WOMAC scores were 55.3+9.6 and 29.44+23.22. SF36v scores were 40.6+10.4(PCS) and 45.1+15.8(MCS).

Conclusions: Immediate open reduction and internal fixation with careful attention to soft tissues can be a viable management option for many high energy tibial plateau fractures. Complication rates are comparable to those of delayed definitive management of these injuries.

Introduction and Aims: The use of the triradiate approach has been associated with high rates of wound dehiscence, wound infection and significant heterotopic ossification. This approach has been the favoured extensile exposure at the Vancouver General Hospital for many years. We will review the outcomes of the use of this approach in the treatment of acetabular fractures.

Method: Patients were identified from the database at Vancouver General Hospital who had their acetabular fractures treated through a triradiate approach from the period January 1989 through to December 2001. Patients with a delay of greater than three weeks from injury were excluded. A retrospective review of the hospital and out-patient records and all available radiographs was performed. Patients were contacted to determine if they required any further surgery and to assess their current functional status with appropriate outcome scores. Patients were also invited to undergo repeat radiographic assessment.

Results: Of a total of 407 acetabular fractures treated surgically, 152 open reductions were performed through the triradiate approach. The average age of these patients was 38 years and 114 (75%) of these were male. Patients referred from other hospitals totalled 128 (84%). Wound outcomes were known in 138 cases. Wound complications included five cases of wound dehiscence, of which four resolved with no undue effects. There were three cases of superficial wound infection and five cases of deep wound infection. Two of the patients with deep wound infection had sustained compound acetabular injuries and a further two had significant risk factors for infection (septicaemia from chest infection and significant soft tissue necrosis). Trochanteric osteotomy was performed in 139 (91%) cases. There were only two cases of trochanteric non-union in this series, however 21 cases required removal of painful trochanteric screws. With respect to heterotopic ossification, there was a 15% Broker III/IV incidence. In this group, the injury severity scores were higher, there was a greater delay to surgery and there was a greater need for mechanical ventilation due to multiple injuries. In the group, 24 hip reconstructions were required over the period.

Conclusion: In our centre, we found a low rate of wound dehiscence and deep wound infection associated with the triradiate approach in the treatment of acetabular fractures. Both open acetabular fractures developed deep infection. Trochanteric irritation was a problem in a number of the patients. The rate of significant hetero-topic ossification was low.