Reamed femoral nailing in patients with multiple injuries. Adverse effects of tourniquet use

Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema. However, the association between femoral nailing followed by tourniquet ischemia and clinical lung injury has not been described. The authors reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation between 1987 and 1993. All femoral shaft fractures were treated with reamed intramedullary nails. Patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with (Group T, 34 patients) or without (Group NT, 38 patients) a tourniquet. Group T was subdivided based on tourniquet time: T1, less than or equal to 90 minutes; T2, greater than 90 minutes. Groups were matched for injury severity. Group NT had fewer ventilator dependent days and intensive care days than Group T (NT: ventilator dependent days, 2.5 +/- 5.2; intensive care days, 3.9 +/- 6.5; T: 5.1 +/- 6.4; intensive care days, 6.7 +/- 6.6). Ventilator dependent days and intensive care days increased with increasing tourniquet time (T1: ventilator dependent days, 3.2 +/- 3.6; intensive care days, 5.4 +/- 4.6; T2: ventilator dependent days, 7.5 +/- 8.5; intensive care days, 8.5 +/- 8.5), suggesting that in patients with multitrauma, combining reamed femoral nailing with fracture fixation under tourniquet control increases pulmonary morbidity. Further investigation to measure pulmonary injury associated with ischemia reperfusion and intramedullary nailing in patients with multitrauma is warranted.     

Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results

Numerous surgical procedures have been proposed for the management of lymphedema. The postoperative results vary, and unfortunately none of the procedures are curative. As a result, some degree of recurrence of leg edema is seen in all patients postoperatively. Reported here is a long-term follow-up of patients with lower extremity lymphedema managed by skin and subcutaneous tissue excision. Thirty-eight patients (6 male; 32 female) with lower extremity lymphedema have been followed up for an average of 14 (3 to 27) years after staged subcutaneous excisions performed beneath skin flaps. Seven patients had been treated previously by other procedures. Of the 38 lymphedema patients, 10 patients developed edema after pelvic or groin ablative surgery, radiation therapy, or both. Results were documented by various methods: physical examination, circumferential measurements, volume displacement, serial photography, lymphoscintigraphy, and patient survey. Of these, it is believed that photographs are the easiest and as representative as any other method, all of which have great variability. Of the 38 patients, 30 patients had significant and long-lasting reduction in extremity size associated with improved function and extremity contour. Episodes of recurrent cellulitis were reduced or completely eliminated. No differences in the long-term results were seen in patients with acquired as opposed to congenital lymphedema. Men did not have as much improvement as women. Two patients had no change in leg swelling, and six patients (three men) had progressive swelling after surgery. Partial wound separation occurred immediately postoperatively in one patient, and three patients had loss (less than 2 cm) of the skin flap, all in the ankle region. None of these instances required further surgery, and no other significant complications were encountered. Staged skin and subcutaneous excision beneath skin flaps appears to provide long-lasting improvement for lower extremity lymphedema, regardless of cause, in the majority of patients treated.     

Oxygen tension of the skin of ischemic legs

Using a Kontron Roche Transcutaneous Oxygen Monitor, we measured oxygen tension on the skin of the legs at three sites in patients with peripheral vascular disease and group of controls. Significant decreases in oxygen tension occurred in the patient groups, which correlated well with ankle systolic pressure, with differences between those with claudication and those with rest pain. These results suggest that in limbs with claudication, significant skin hypoxia may exist during rest in spite of reportedly normal skin and muscle blood flow. The progressive decrease in skin oxygen tension down a limb with occlusive vascular disease may play a significant role in skin healing.     

Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years of experience

The usage of vertical transarticular pin fixation combined with plaster immobilization for severe ankle injuries has been reviewed in 92 consecutive cases over a period of 16 years. Moderately simple in application and without a skin incision, the procedure has been found to provide efficient and reliable short-term stabilization of the ankle and subtalar joints with minimal complications. A new technique is described for accurate placement of the pin and the prevention of its migration. It is a reasonable alternative treatment for certain unstable distal tibial and ankle fractures when open reduction with conventional internal fixation cannot be done. In particular, the method is recommended in treating displaced fractures at the ankle and deltoid ligament ruptures in geriatric patients. It is often useful as a salvage or last-resort procedure in unusually severe ankle injuries with circulatory or neural deficits. In many instances additional trauma to the head, thorax or abdomen may have been sustained. Thus total patient care is essential and priorities must be recognized. The treatment of ankle trauma, furthermore, in a physiologically-aged diabetic patient is often not the same as that for similar injuries in a young healthy adult. The clinical judgement and experience of the operator is the basis for selection of the procedure. The simplest method is often the best. Pin fixation, however, is not for everyone. It should be done only by surgeons qualified to treat bone and joint trauma and even then only for those situations in which its usage is specifically indicated.     

How to reduce the cost of hindfoot fusion

The purpose of this study was to determine whether modification of a surgical practice by using regional anesthesia and local bone grafting would yield the same surgical results as traditional anesthesia and iliac crest bone graft, with a cost reduction. All patients were matched by preoperative disease and were assessed to determine satisfaction and complications. The length of stay for the seven matched pairs of patients undergoing subtalar arthrodesis decreased significantly, as did blood loss, total operating room time, and tourniquet time. The average cost saving was $7844. Similar data were found for the nine matched pairs of patients who underwent triple arthrodesis, blood loss, and tourniquet time. Total cost was again found to be significantly lower by an average of $9302 in the study group. The most dramatic changes between the two groups were demonstrated in the patients who underwent ankle fusions. The 10 matched pairs showed a marked reduction in length of stay, with a decrease in estimated blood loss from 260 mL to 92 mL (P < 0.05). The total operating room time and tourniquet time in these two groups were similar. There was a cost savings in the study group of $9888, with no increase in complications. The use of longacting regional anesthesia and local bone grafting enabled surgeons to perform hindfoot arthrodeses on an outpatient basis, with a significant reduction in cost to the patient and no increase in complications.     

Fasciotomy, chronic venous insufficiency, and the calf muscle pump

OBJECTIVE: To test the hypothesis that fasciotomy may impair the function of the calf muscle pump, which in turn could result in the development of chronic venous insufficiency. DESIGN: A cohort study of patients with a history of lower extremity fasciotomy. SETTING: An urban trauma center. PATIENTS: Seventeen of the 83 patients identified through trauma, vascular, and/or orthopedic registries consented to participation in this study. INTERVENTIONS: Participating patients completed a study questionnaire, and then underwent a complete vascular examination, including air plethysmographic (APG) assessment. Patients with a history of venous injuries were also studied with color flow duplex venous imaging. MAIN OUTCOME MEASURES: Function of the calf muscle pump as measured by APG, and evidence of chronic venous insufficiency as measured by APG, findings on clinical examination, and by venous ultrasonography. RESULTS: Seventeen patients completed the study, including 8 with a history of vascular injuries, 6 with old fractures, and 3 who had undergone fasciotomy for soft tissue infections. The time from injury to examination ranged from 5 months to 20 years. Eight patients had signs or symptoms of venous insufficiency, the severity of which appeared to be time dependent. The APG data showed significant mean differences between fasciotomy and control extremities in ejection fraction (P<.001) and residual volume fraction (P<.001), both measures of calf muscle pump function. There were no significant changes in venous filling index, a measure of venous reflux, or in outflow fraction, which correlates with venous obstruction. There were no differences in APG variables between patients with vascular injuries vs those with orthopedic or soft tissue injuries. CONCLUSIONS: Lower extremity fasciotomy impairs long-term calf muscle pump function, as measured by APG, in patients with and without vascular injuries. These patients are at risk for the long-term development of chronic venous insufficiency following lower extremity trauma.     

Single umbilical artery: correlation of the prognosis and side of the missing artery

Compartment syndrome in association with ankle fracture is extremely rare. The few reported cases involved the deep posterior compartment and were diagnosed late. We show that prompt recognition of this rare problem and early fasciotomy with fracture fixation prevents the long-term sequelae seen in all previously reported cases.     

Midline osteotomy with lag screw stabilization for mandibular swing

Fifteen patients with recurrent inversion ankle sprains and documented lateral ankle instability were treated with an anatomically oriented ligament reconstruction using a split peroneus brevis tendon graft. This reconstruction is designed to augment repair of the anterior talofibular and calcaneofibular ligaments without restricting subtalar motion. Of the 12 patients available for long-term followup, all were functionally improved, with no recurrences of instability. Stress radiographic examination at followup confirmed that mechanical stability had been restored in all ankles. Eversion strength and subtalar joint motion were maintained after surgery. We recommend this procedure in patients who require augmented reconstruction of the lateral ankle ligaments.     

The evaluation of aphasic deficits for the definition of a targetted logotherapeutic treatment

This study evaluated the effects of an occlusive (OpSite Flexigrid) dressing on bacterial growth over excoriated and the surrounding intact skin of eight premature infants. Cultures were obtained before placement and four days after dressing placement. An analysis of variance demonstrated significant increases in coagulase-negative Staphylococcus and overall total skin. No significant differences in bacterial growth occurred between intact skin underneath the dressing and that on the opposite side of the body post-dressing placement. Significant increases were found in bacterial concentrations for both intact and excoriated skin post-dressing placement. Small sample size and no between-subject design hinder generalization to the neonatal population.     

Compartment pressure monitoring during intramedullary fixation of tibial fractures

Twenty-six legs in 25 patients were monitored prospectively for compartment pressures during intramedullary nailing of open and closed tibial shaft fractures. Twenty-three patients were treated within 24 hours of admission. Twenty-three unreamed and three reamed intramedullary rods were utilized. Compartment pressures were measured initially, following fracture reduction, and during reaming. Pressures were also measured at the completion of nailing with the ankle dorsiflexed and at rest (plantar flexed) to determine positional effects on compartment pressures. Nine fractures (35%) were found to have persistently elevated pressures (> 40 mm Hg) and underwent immediate four-compartment fasciotomy. The remaining group of 17 fractures (65%) was monitored throughout the intraoperative period. No patient monitored intraoperatively developed postoperative compartment syndrome.     

Biomechanical consequences of plantar fascial release or rupture during gait: part I--disruptions in longitudinal arch conformation

To examine whether conformational changes induced by plantar fascial division may progress during gait, we loaded the feet of seven cadavers using an apparatus that simulates the actions of the extrinsic plantarflexors. We measured the effects of plantar fasciotomy at two instants in the terminal-stance phase of gait. Radiographic measurements of height of the arch, base length of the arch, and talo first-metatarsal angle were used to assess contributions to arch support made by the plantar fascia, tibialis posterior, peroneus longus and brevis, and digital flexor muscles. Complete fasciotomy caused significant collapse of the arch in the sagittal plane. Early in terminal stance, at the instant after heel-off, mean height of the arch decreased from 47 to 45 mm. Late in terminal stance, at the instant preceding contralateral heel strike, mean height of the arch decreased from 46 to 43. Effects of division of the central band, though significant, were mild. Medial base length of the arch increased from 163 to 167 mm in the absence of tibialis posterior contraction at late terminal stance. Arch-supporting abilities of the other extrinsic muscles were insignificant.     

Does ice immersion influence ankle joint position sense?

The purpose of this study was to determine whether a fifteen minute ice immersion treatment influenced the normal ankle joint position sense at 40% and 80% range of inversion and to establish the length of treatment effect through monitoring the rewarming process. Forty nine healthy volunteers between the ages of 17 and 28 were tested. Subjects were screened to exclude those with a history of ankle injuries. The subject's skin temperature over antero-lateral aspect of the ankle was measured using a thermocouple device during the fifteen minutes ice intervention and thirty minutes post-intervention. Testing of ankle joint position sense using the pedal goniometer was performed before and after a clinical application of ice immersion. The testing required the subject to actively reposition their ankle at 40% and 80% of their total range of inversion. The majority of subjects experienced numbness of the foot and ankle by the fifth or sixth minute during ice immersion. One minute after immersion skin temperatures averaged 15 degrees C + 1.7 degrees C. Skin temperature was seen to rise relatively rapidly for the first ten minutes and then slowed considerably. Subjects had not returned to the pre-test skin temperatures by thirty minutes. A significant difference in ankle joint position sense (p < 0.0499) following fifteen minutes of ice immersion was found. However, the magnitude of this difference (0.5 degree) would not be deemed significant in clinical practice. The research found no significant difference in joint position sense between 40% and 80% of the range of inversion both before and after cryotherapy. These findings suggest that the clinical application of cryotherapy is not deleterious to joint position sense and assuming normal joint integrity patients may resume exercise without increased risk of injury.     

Kindler syndrome. Clinical and ultrastructural findings

BACKGROUND: Kindler syndrome is a genodermatosis that combines clinical features of hereditary epidermolysis bullosa and poikiloderma congenitale. The ultrastructural level of blister formation has not been well characterized. OBSERVATIONS: Two brothers with Kindler syndrome had a history of primarily acral blistering since infancy as well as photosensitivity. Blister formation was found through the basal layer. Marked tonofilament clumping was found in intact keratinocytes adjacent to the blisters. The younger brother (aged 21 years) had actinic keratoses, which have not been previously described in Kindler syndrome. CONCLUSIONS: The findings of basal layer separation in both spontaneous and induced blisters in Kindler syndrome suggest this is the true level of blister formation. The finding of actinic keratoses in a young patient with Kindler syndrome suggests that some patients may be at increased risk for early solar-induced skin disease. The presence of clumped tonofilaments in keratinocytes adjacent to blistered areas suggests an abnormality of keratin 5 or 14 could be present and may play a role in blister formation in patients with Kindler syndrome.     

Oligoribonucleotides containing 8-oxo-7,8-dihydroguanosine and 8-oxo-7,8-dihydro-2''-O-methylguanosine: synthesis and base pairing properties

OBJECTIVE: To test whether a rigid or a flexible ankle orthosis affects postural sway in single-limb stance as quantified by stabilometry. DESIGN: Crossover trial. SETTING: University laboratory. PARTICIPANTS: Twenty-two athletes with functional ankle instability (consecutive sample of patients with recurrent ankle sprains but without mechanical instability) and 22 healthy athletes (control group of volunteers matched to age, height, weight, physical activity). INTERVENTIONS: Stabilometry in single-limb stance on a force platform. Participants were tested on each leg with and without a rigid or a flexible ankle orthosis. The order of test conditions was randomized. MAIN OUTCOME MEASURES: Sway velocities, sway pattern, and sway area as calculated from center of pressure movements. The two groups were compared by Mann-Whitney test, and the different orthoses within each group were compared by Wilcoxon test, paired samples (type I error 5%, Bonferroni adjustment). RESULTS: In athletes with functional ankle instability, both a rigid and a flexible ankle orthosis significantly reduced mediolateral sway velocity. A flexible ankle orthosis also changed sway pattern significantly, by reducing the percentage of linear movements of less than 5 degrees per .01 sec. CONCLUSIONS: In athletes with functional ankle instability, ankle orthoses reduce mediolateral sway velocity, possibly because of improved mediolateral proprioception.     

Early posterior ankle release in the treatment of congenital clubfoot

Eighty-one patients (116 clubfeet) underwent posterior ankle release before the age of two years, following unsatisfactory responses to serial corrective casts applied according to the technique of Kite. Seventy-three per cent of these feet showed no or only mild talar flattening at an average follow-up of 7.5 years. Four years, following posterior ankle release there was a none-mild talar flattening rate of 69 per cent in this group compared to a 40 per cent none-mild rate in ankle release reduces the incidence of recurrent equinus deformity and the necessity for subsequent surgery in comparison to the results obtained with serial plaster casts or with tendo Achillis lengthening alone. Recent trends in clubfoot management have favored increasingly early operative intervention. Denham stated that "In the infant hard tissues (bone and cartilage) should be regarded as soft, and the soft tissues (tendon and ligament) as hard." Our operative experience with posterior ankle release supports this philosophy and indicates that early aggressive surgical management is the treatment of choice for the resistant clubfoot.     

Developing and implementing interprofessional learning in a Faculty of Health Professions

Although medial displacement calcaneal osteotomy has been advocated for treatment of acquired pes planus, no studies have determined the biomechanical consequences at the ankle of such a procedure. The present investigation examined the alteration in ankle motion that resulted from a medial sliding calcaneal osteotomy. In dorsiflexion, the ankle specimens were found to have altered internal rotation and varus alignment. At maximal dorsiflexion, there was a 76% increase in internal rotation (4.4 degrees +/- 2.5 degrees versus 2.5 degrees +/- 1.7 degrees for intact ankles, P < 0.0004) and an increase of 425% in varus (0.42 degrees +/- 0.56 degrees versus 0.08 degrees +/- 0.34 degrees for intact ankles, P < 0.003). There were no significant differences seen in plantar flexion. Based on these results, caution is advised in the indiscriminate use of medial sliding osteotomies, because this procedure may predispose the patient to premature ankle arthritis as a consequence of the altered ankle motions.     

Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.     

The effect of tourniquet release time on the analgesic efficacy of intraarticular morphine after arthroscopic knee surgery

A randomized, controlled study was conducted in patients undergoing elective arthroscopic knee surgery to assess the effects of tourniquet release time on analgesia after intraarticular (I.A.) injection of morphine. Standardized general anesthetic and surgical techniques were used for all patients, including a thigh tourniquet inflated at pressures between 300 and 350 mm Hg. At the conclusion of the arthroscopic procedure, 5 mg morphine in 25 mL saline was administered I.A. Patients were then randomized to one of two treatment groups. In Group 1 (n = 20), the tourniquet was kept inflated for 10 min after I.A. injection, whereas in Group 2 (n = 20), the tourniquet was deflated immediately after I.A. injection. Postoperative pain was assessed using a visual analog scale in the recovery room when the patients were awake and at 2, 4, 6, 8, and 24 h after I.A. injection. Patients who complained of pain in the recovery room received increments of intravenous meperidine 25-50 mg. On discharge from the recovery room, patients received oral mefenamic acid 250-500 mg for pain relief. The time and quantity of analgesics required were recorded. Patients in Group 1 had significantly (P < 0.05) lower pain scores than those in Group 2 at 2, 4, 6, and 8 h postoperatively. These low pain scores were associated with lower requirements of supplementary analgesics. We conclude that, as compared with releasing the tourniquet immediately after I.A. injection of morphine, maintaining the tourniquet inflated for 10 min provides superior analgesia and decreases the need for supplemental analgesics.     

Surgical treatment of Graves' disease in patients younger than 18 years

Eighty-two children and adolescents (18 males, 64 females; median age 14 years) surgically treated for Graves' disease at a single institution between 1979 and 1993 were retrospectively reviewed. Most of the patients (74%) coming to thyroidectomy had been treated medically for a period ranging from 2 to 80 (median 15) months. Bilateral subtotal thyroid resection was the most frequently performed procedure (86%). Postoperatively, no permanent recurrent laryngeal nerve palsy or permanent hypocalcemia occurred. Operative mortality was zero. With a median follow-up of 8.3 years, recurrent hyperthyroidism occurred in five patients (6%), one of whom required reoperation. Most children and adolescents with Graves' disease can be rendered euthyroid by nonsurgical treatment options. However, prolonged and ineffective medical treatment should be avoided in these patients who are in the formative years of their lives. Surgical treatment, when indicated and employed, offers young patients with Graves' disease a safe, rapid, definitive, cost-effective treatment with a high success rate.     

Prenatal dexamethasone causes oligonephronia, sodium retention, and higher blood pressure in the offspring

OBJECTIVES: It is not known whether changes in the biomechanics of elderly gait are related to aging per se, or to reduced walking speed in this population. The goals of the present study were to identify specific biomechanical changes, independent of speed, that might impair gait performance in healthy older people by identifying age-associated changes in the biomechanics of gait, and to determine which of these changes persist at increased walking speed. DESIGN: Stereophotogrammetric and force platform data were collected. Differences in peak joint motion (kinematic) and joint moment and power (kinetic) values between healthy young and elderly subjects at comfortable and increased walking speed were measured. SETTING: A gait laboratory. SUBJECTS: Thirty-one healthy elderly (age 65 to 84 years) and 31 healthy young adult subjects (age 18 to 36 years), all without known neurologic, musculoskeletal, cardiac, or pulmonary problems. MAIN OUTCOME MEASURES: All major peak kinematic and kinetic variables during the gait cycle. RESULTS: Several kinematic and kinetic differences between young and elderly adults were found that did not persist when walking speed was increased. Differences that persisted at both comfortable and fast walking speeds were reduced peak hip extension, increased anterior pelvic tilt, and reduced ankle plantarflexion and ankle power generation. CONCLUSION: Gait performance in the elderly may be limited by both subtle hip flexion contracture and ankle plantarflexor concentric weakness. Results of the current study should motivate future experimental trials of specific hip flexor stretching and ankle plantarflexor concentric strengthening exercises to preserve and potentially improve walking performance in the elderly.