Temporary Kirschner Wire Ankle Transfixation and Delayed ORIF: A Staged Operative Treatment for Closed Ankle Fractures with Tibiotalar Dislocations and Soft-Tissue Damage

Abstract : Background and Purpose: : Immediate ORIF (open reduction and internal fixation) is the treatment of choice for displaced ankle fractures. However, definitive treatment may have to be delayed due to compromised soft tissues. The value of temporary Kirschner wire ankle transfixation with staged ORIF for closed displaced ankle fractures with tibiotalar dislocations was determined. Patients and Methods: : In this retrospective case series (1997-2001), 92 patients (mean age 54 years, range 20-86 years) who underwent a staged procedure for isolated and closed displaced ankle fractures with tibiotalar dislocations were studied. Patients were primarily treated by means of immediate closed reduction. For stable fractures and adequate soft tissues a split plaster cast was applied (n = 50). K-wire transfixation was performed for unstable fracture-dislocations and/or critical soft tissues (n = 42). All patients underwent delayed ORIF after recovery of the soft tissues. Results: : In the K-wire group (KWG), local complication rate was 7%. Mean operating time was 30 min (5-65 min). In the plaster cast group (PCG), local complication rate was 10% (p = 0.72, not significant). Three redislocated ankles (6%) had to be transfixed secondarily. A higher grade of soft-tissue injuries in the KWG (p < 0.05) resulted in a longer time interval between primary treatment and staged ORIF (7 vs. 5 days; p < 0.05) and a longer hospital stay (19 vs. 17 days; p < 0.05) for the KWG. Conclusion: : Temporary K-wire ankle transfixation is an effective method for initial treatment of closed displaced ankle fractures with tibiotalar dislocation, if ORIF has to be delayed and immobilization in a split plaster cast is not suitable. Retention is reliable with a low complication rat

Atlanto-occipital dislocation: four case reports of survival in adults and review of the literature

Traumatic atlanto-occipital dislocation (AOD) is a rare cervical spine injury and in most cases fatal. Consequently, relatively few case reports of adult patients surviving this injury appeared in the literature. We retrospectively report four patients who survived AOD injury and were treated at our institution. A young man fell from height and a woman was injured in a traffic accident. Both patients survived the injury but died later in the hospital. The third patient had a motorcycle accident and survived with incomplete paraplegia. The last patient, a man involved in a working accident, survived without neurological deficit of the upper extremities. Rigid posterior fixation and complete reduction of the dislocation were applied in last two cases using Cervifix together with a cancellous bone grafting. Previously reported cases of patients surviving AOD are reviewed, and clinical features and operative stabilisation procedures are discusse

Surgical Treatment of Neer Group VI Proximal Humeral Fractures: Retrospective Comparison of PHILOS® and Hemiarthroplasty

Background: Neer Group VI proximal humeral fractures often are related to persistent disability despite surgical treatment. We retrospectively compared the outcome after open reduction and internal fixation with the PHILOS® plate or primary hemiarthroplasty in patients with Neer Group VI fractures focusing on complications, shoulder function, health-related quality of life (SF-36), and potential risk factors for complications. Questions/purposes: The aim of this study was to compare the PHILOS® plate with primary hemiarthroplasty for treatment of specific Neer Group VI fractures. We asked whether (1) both procedures have comparable clinical and radiologic complication rates; (2) one procedure is superior in terms of revision rate; (3) objective and subjective shoulder function (Constant-Murley score) and health-related quality of life (SF-36) were comparable in both groups at final followup; and (4) there are clinical or radiologic predictors for complications in any group? Methods: Between 2002 and 2007, 44 consecutive patients (mean, 75.2years) with a Neer Group VI proximal humeral fracture were included. Twenty-two patients treated with a PHILOS® plate were compared with 22 patients treated by primary hemiarthroplasty. Both groups were similar in all criteria. At minimum followup of 12months (mean, 30months; range, 12-83months), radiographic control, Constant-Murley score, and SF-36 were performed. Results : Fourteen patients with complications (63.6%) were counted in the PHILOS® plate group, of which 10 (45.4%) needed revision surgery, mostly as a result of avascular necrosis and screw cut-outs. In the primary hemiarthroplasty group, only one patient needed revision surgery (4.5%). Smoking and steroid therapy were substantially associated with complications in the PHILOS® plate group. There were no differences between the two groups regarding Constant-Murley or SF-36 scores. Conclusions : Angular stable open reduction and internal fixation was associated with high complication and revision rates, especially in patients who smoked and those receiving steroid therapy. Primary hemiarthroplasty provides limited function, which had little influence on the quality of life in this elderly collective. There are predictive factors for complications after the treatment of Neer Group VI proximal humeral fractures with the PHILOS® plate. Primary hemiarthroplasty remains a good option, especially when treating elderly patients. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidenc

Prophylactic Insertion of Optional Vena Cava Filters in High-Risk Trauma Patients

Background:: Vena cava interruption is a form of pulmonary embolism prophylaxis that is being used in high-risk patients who do not tolerate pharmacologic prophylaxis. Retrievable prophylactic vena cava filters (VCFs) are of particular interest for severely injured patients where the necessity for VCF is often only temporary. Methods:: In a single-institution case series of consecutive patients who received prophylactic VCFs after polytrauma, between 04/1998 and 07/2004, the demographic data, injury pattern and complications were analysed. Results:: Ninety-five prophylactic VCFs were placed in polytrauma patients (median ISS of 38). Median age was 38 years (range 16-80 years). Median delay between trauma and filter placement was 1 day (range 0-31 days). No complication was seen related to filter insertion or retrieval. Sixty-five VCFs (68.4%) were retrieved after 4-25 days (median 13 days). One filter migration (1.1%) was observed. Retrieval failed in two patients (3.0%). A total of 30 VCFs (31.6%) were left permanently. One non-fatal PE (1.1%) occurred 21 days after filter retrieval despite prophylaxis with LMWH. DVT developed in two patients (2.1%) including one vena caval occlusion (1.1%). Overall mortality was 7.4%. Conclusions:: Early prophylactic placement of VCF in a high-risk trauma patient should be considered when anticoagulation is contraindicated. Filter insertion and retrieval is safe with a low complication rat

Primary Hemiarthroplasty for Proximal Humeral Fractures in the Elderly: Long-Term Functional Outcome and Social Implications

Background:: Primary shoulder hemiarthroplasty is an established treatment modality for complex fractures of the proximal humerus. Long-term functional outcome is often disappointing. However, little is known about social implications particularly in the elderly. Methods:: A single-institution case series of consecutive geriatric patients (age > 70 years) treated with shoulder hemiarthroplasty for complex fractures of the proximal humerus between 1994 and 1997 was analysed. Postoperative morbidity, long-term function, radiological outcome and social implications were evaluated. Results:: Seventy-seven patients fulfilled the study criteria. Median age at the time of operation was 80 years (range 70-93 years). Systemic and local postoperative complications were observed in 8% including 2 patients (3%) with revision surgery. Postoperative mortality was 1%. Forty-eight patients (62%) were available for follow-up (median 49 months, range 25-80 months), 22 (29%) died from causes unrelated to hemiarthroplasty before follow-up and 7 patients (9%) did not attend follow-up examination. Median Constant-Murley score was 41 points (range 17-77 points). Long-term results concerning pain were satisfying. The Oxford shoulder score ranged from 14 to 40 (median 30). Forty-one patients (85%) still lived in their original environment and managed their daily life independently despite poor shoulder function. Four patients (8%) lived in a retirement home and 3 (6%) in a nursery home. Eighty percent of our patients were still able to use public transportation, do the daily shopping and wash their whole body by themselves. Conclusion:: Most patients managed their daily life independently despite poor shoulder functio

Unsecured Intracranial Aneurysms and Induced Hypertension in Cerebral Vasospasm: Is Induced Hypertension Safe?

Background: Induced hypertension is an established therapy to treat cerebral vasospasm (CVS) following subarachnoid hemorrhage (SAH) to prevent delayed ischemic deficits. Currently, there is minimal evidence available assessing the risk of induced hypertension in the presence of unsecured aneurysms. The aim of this study was to investigate the impact of induced hypertension on the rupturing of unsecured aneurysms in treating CVS. Methods: We conducted a retrospective analysis between 1999 and 2009. Patients with unsecured aneurysms treated with induced hypertension were identified and stratified as having (1) additional unruptured unsecured aneurysms or (2) ruptured unsecured aneurysms. Hemodynamic parameters were analyzed and any bleeding recorded. Results: Forty-five patients were included. Of those, 41 had 71 additional unruptured unsecured aneurysms and four patients had four ruptured unsecured aneurysms. The mean size of unsecured aneurysms was: 4.0±1.9mm (additional unruptured) and 5.3±2.2mm (ruptured), respectively. No aneurysm ruptured during therapy. Combining our data with previously published studies, there appears to be no increase of risk for aneurysm rupture by induced hypertension when compared to the natural history (0.5% for group 1, 2.9% for group 2). Conclusion: These data corroborate that induced hypertension may be a safe treatment option to prevent cerebral infarction in CVS, even in the presence of unsecured aneurysms. Our findings suggest that induced hypertension does not increase rupture of unsecured aneurysms. Given the high risk for cerebral infarction in severe CVS, we conclude that induced hypertension should not be omitted due to the presence of unsecured aneurysm

A Quarter Century Experience in Liver Trauma: A Plea for Early Computed Tomography and Conservative Management for all Hemodynamically Stable Patients

Background: Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome. Methods: A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010). Results: 395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P=0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis. Conclusions: Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver traum

Prophylactic Insertion of Optional Vena Cava Filters in High-Risk Trauma Patients

Background:: Vena cava interruption is a form of pulmonary embolism prophylaxis that is being used in high-risk patients who do not tolerate pharmacologic prophylaxis. Retrievable prophylactic vena cava filters (VCFs) are of particular interest for severely injured patients where the necessity for VCF is often only temporary. Methods:: In a single-institution case series of consecutive patients who received prophylactic VCFs after polytrauma, between 04/1998 and 07/2004, the demographic data, injury pattern and complications were analysed. Results:: Ninety-five prophylactic VCFs were placed in polytrauma patients (median ISS of 38). Median age was 38 years (range 16-80 years). Median delay between trauma and filter placement was 1 day (range 0-31 days). No complication was seen related to filter insertion or retrieval. Sixty-five VCFs (68.4%) were retrieved after 4-25 days (median 13 days). One filter migration (1.1%) was observed. Retrieval failed in two patients (3.0%). A total of 30 VCFs (31.6%) were left permanently. One non-fatal PE (1.1%) occurred 21 days after filter retrieval despite prophylaxis with LMWH. DVT developed in two patients (2.1%) including one vena caval occlusion (1.1%). Overall mortality was 7.4%. Conclusions:: Early prophylactic placement of VCF in a high-risk trauma patient should be considered when anticoagulation is contraindicated. Filter insertion and retrieval is safe with a low complication rat

Gridmapping the northern plains of Mars: Geomorphological, Radar and Water-Equivalent Hydrogen results from Arcadia Plantia

A project of mapping ice-related landforms was undertaken to understand the role of sub-surface ice in the northern plains. This work is the first continuous regional mapping from CTX (“ConTeXt Camera”, 6 m/pixel; Malin et al., 2007) imagery in Arcadia Planitia along a strip 300 km across stretching from 30°N to 80°N centred on the 170° West line of longitude. The distribution and morphotypes of these landforms were used to understand the permafrost cryolithology. The mantled and textured signatures occur almost ubiquitously between 35° N and 78° N and have a positive spatial correlation with inferred ice stability based on thermal modelling, neutron spectroscopy and radar data. The degradational features into the LDM (Latitude Dependent Mantle) include pits, scallops and 100 m polygons and provide supporting evidence for sub-surface ice and volatile loss between 35-70° N in Arcadia with the mantle between 70-78° N appearing much more intact. Pitted terrain appears to be much more pervasive in Arcadia than in Acidalia and Utopia suggesting that the Arcadia study area had more wide-spread near-surface sub-surface ice, and thus was more susceptible to pitting, or that the ice was less well-buried by sediments. Correlations with ice stability models suggest that lack of pits north of 65-70° N could indicate a relatively young age (~1Ma), however this could also be explained through regional variations in degradation rates. The deposition of the LDM is consistent with an airfall hypothesis however there appears to be substantial evidence for fluvial processes in southern Arcadia with older, underlying processes being equally dominant with the LDM and degradation thereof in shaping the landscape