2006 abstracts presented at Mississippi Orthopedic association annual meeting-April 2006.

Plate Fixation of Unstable Distal Clavicle Fractures

Jason A. Craft; MD and William B. Geissler, MD

Department of Orthopedics and Rehabilitation

University of Mississippi Medical Center 

2500 North State Street

Jackson, Mississippi 39216

Material and Methods

From 10/2003 to 11/2004, 10 patients with unstable distal clavicle fractures, classified as Neer Type II were identified. Seven represented acute fractures and 3 were nonunions from failed conservative management. They were treated with open reduction and internal fixation of the fracture using an anatomically-contoured, low-profile distal clavicle plate and coracoclavicular ligament augmentation with a coracoclavicular cerclage. Six fractures initially occurred via MVC and 4 via a direct fall onto the shoulder. Average age was 45 years with a range from 19 to 70. They were all examined retrospectively for healing, return to activity, and complications--specifically hardware prominence. This paper represents, to our knowledge, the largest series of plate fixation of unstable distal clavicle fractures.

Results

All patients healed with full range of motion and were able to return to prior activity or work at 2 months. One patient complained of tenderness around the scar (not placed over the plate) and one patient with preexisting shoulder pain had plate removal at the time of arthroscopy for impingement. There were no major complications.

Conclusion

Open reduction and internal fixation with an anatomically-contoured, low-profile distal clavicle plate with coracoclavicular cerclage is a reliable method for treatment of unstable Neer Type II distal clavicle fractures. Patients were able to begin early rehabilitation and return to work and normal activities earlier and more reliably than via non-operative treatment. In our series only one patient required hardware removal for irritation about the plate, but this is less than many other series using K-wires and screws.

Morbid Obesity: Is Operative Treatment of Displaced Acetabular Fractures Worth the Risk?

George V. Russell, M.D., Robert C. Dews, Matthew L. Graves, M.D., Scott E. Porter, M.D. and Zhen Qin, M.S.

Department of Orthopedic Surgery and Rehabilitation

University of Mississippi Medical Center 2500 North State Street

Jackson, Mississippi 39216

PURPOSE: Displaced acetabular fractures require operative intervention for optimal results. Obesity and morbid obesity is becoming more prevalent. Morbid obesity is defined as a body-mass index (BMI) [greater than or equal to]40. The purpose of this investigation is to evaluate the early results of operative treatment of acetabular fractures in morbidly obese patients.

METHODS: A prospectively gathered database demonstrated 349 patients who underwent ORIF for acetabular fractures over a 60 month period. Of those patients, 39 were morbidly obese. Patient weights were self reported. There were 15 posterior wall (OTA 62-A1), 10 transverse/posterior wall (OTA 62-B1), 5 T-type (OTA 62-B2), 3 transverse (OTA 62-B1), 3 anterior column/posterior hemi-transverse (OTA 62-B3), 1 anterior column (OTA 62-A3), 1 posterior column/posterior wall (OTA 62-A2), and 1 both column (OTA 62-C3) fractures. Early results of morbidly obese patients (Group 1) were reviewed. Perioperative complications were compared to patients with BMI < 40 (Group 2). Factors evaluated were: estimated blood loss, operative time, length of hospital stay, and overall complication rate (as defined by wound complications or heterotopic ossification requiring subsequent surgery, failure of fixation, nerve palsy, death).

RESULTS: Follow up ranged from 6-48 months. Fracture reductions were perfect in 23, imperfect in 10, and poor in 6. Fixation failure was noted in 9 patients and typically associated with comminuted posterior wall fractures. Eight patients developed deep infections necessitating debridements. Nine patients required secondary surgery for wound healing problems. Of those, 6 required one additional surgery, three required 2, two required 3, one required 5, and one required 12 additional surgeries. Six patients proceeded to THA and two of those required revisions.

The average EBL was 903cc in group 1 versus 630cc in group 2 (p < 0.044). Operative time averaged 293 minutes in group 1 versus 250 in group 2 (p<0.008). Hospital stay for group 1 averaged 26 days versus 15 days in group 2 (p<0.008). Complication rate for group 1 was 67% versus 16% in group 2.

CONCLUSION AND SIGNIFICANCE: This data shows that there is a significant increase in estimated blood loss, operative time, and length of hospital stay. Moreover, the risk of complications should be heavily weighed prior to operative intervention.

Technique for Sacroiliac Joint Arthrodesis: Literature Review and Case Reports

Robert A. McGuire, M.D., D. Kevin Donahoe, M.D. and Gabriel J. Rulewicz, M.D.

Department of Orthopedic Surgery and Rehabilitation

University of Mississippi Medical Center 2500 North State Street

Jackson, MS 39216

Primary low back pain can result in significant disability and loss of a productive lifestyle. The etiology of this program can arise from the disc space, facet joint, and soft tissues about the lumbosacral region. One area often overlooked as a potential pint generator, the sacroiliac joint, has been shown to cause primary low back and/or lower extremity pain in up to 15% of patients with low back pain (Maign, Schwarzer). Most painful conditions in which the sacroiliac joint is the cause of pain can be treated successfully without surgical intervention. The diagnosis of the sacroiliac joint as the cause of pain, requires fluoroscopically guided injections with improvement of symptoms. Occasionally, surgical arthrodesis of the joint is required to alleviate pain and improve patient function. The authors present a technique that can be used for nontraumatic causes of sacroiliac dysfunction which necessitate fusion.

Compression Plating of Midshaft Clavicle Fractures: Short-term Results of the Acumed Precontoured Clavicle Plate.

Matthew L. Graves, M.D., J. Michael Wells, M.D. and William B. Geissler, M.D.

Department of Orthopedic Surgery and Rehabilitation

University of Mississippi Medical Center 2500 North State Street

Jackson, Mississippi 39216

Purpose of Research

To prospectively study the efficacy of compression plating of midshaft clavicle fractures with the new Acumed precontoured clavicle plating system.

Relevant Background and Rationale for Research

Midshaft clavicle fractures have an excellent healing potential with non-operative treatment; however, certain indications exist for open reduction and internal fixation. In the past, compression plating has been achieved with the use of various plating systems, each with certain drawbacks. Biomechanically, the middle third of the clavicle is subjected to significant axial, bending, and torsional stresses. Previous studies have shown that the optimal plate position to overcome these stresses is the superior surface. Traditionally, the most rigid plating system of reasonable size to fit the bone has been the 3.5 DCP plate. Due to the contour of the superior surface of the clavicle, bending of this plate is challenging for surgeons of all skill levels. Bending a plate of that magnitude is a struggle with any instrumentation.

The Acumed precontoured clavicle plate is a breakthrough in the evolution of compression plating of the clavicle. The anatomic fit on the superior surface of the clavicle saves operative time and makes reduction maneuvers simpler.

The rigidity of the plate still allows for the significant forces applied to the clavicle to be neutralized during the healing phase, and allows for early motion. No study has been done to evaluate this method of fixation to date.

Experimental design and Methodology

Patients who present to the University of Mississippi Medical Center and other participating Mississippi Orthopedists who meet the appropriate indications for operative treatment will be enrolled in the study. After fixation, patients will be evaluated for follow-up at approximately 1 week, 6 weeks, 3 months and 6 months. After 6 months, the Constant score will be used as an objective measure of patient outcome. Healing and complications will be recorded.

Use of Carbon Dioxide Insuflation for Anterior Thoracoscopic Release and Fusion

Haber Lawrence, Islam Saleem

Purpose: The purpose of this study was to evaluate C[O.sub.2] insuflation as an aid to deflate and retract the lung during thoracoscopic anterior release and fusion in the prone position. Dual lumen intubation had been the standard method for this, but adds significant time to the case. Laryngeal trauma is a significant risk. Some feel simple prone positioning eliminates the need for deflation of the lung, but difficulty with lung retraction still exists. The purpose of this study was to evaluate prone positioning combined with the use of C[O.sub.2] insuflation in children undergoing anterior/posterior spinal fusion using thoracoscopy.

Materials and Methods

Eleven patients with idiopathic scoliosis were retrospectively reviewed. All patients underwent anterior thoracoscopic release and fusion as part of an anterior/posterior spinal fusion for idiopathic scoliosis. The anterior release was for severe/stiff curves in eight patients and due to skeletal immaturity in three. All cases were done in the prone position. C02 insuflation was used on all cases during the thoracoscopic procedure to collapse the lung and allow visualization of the spine. Results are compared to a control group treated at our institution by the same surgeons using dual lumen intubation and lateral positioning.

Results: Insuflation was successfully used in all cases. Excellent visualization of the anterior spine was attained. There was no need for dual lumen intubation or retractors. Average curve correction was 81%. Average OR time was 338 (248-435) minutes for the entire anterior and posterior procedure. This compares to 546 (447-646) in our control group using lateral positioning and dual lumen intubations.

Conclusions

C[O.sub.2] insuflation is a safe technique to aid in anterior thoracoscopic release and fusion. It gives excellent visualization while in the prone position. There were no problems with C02 retention or oxygenation. Currently manufactured ports provide a good seal, enabling the surgeon to introduce instruments as needed without loosing pressure in the chest. Insuflation dramatically reduced operative times as there is no need for reintubation, repositioning or retraction. Risks of laryngeal trauma due to a large dual lumen tube are eliminated. In several cases, we released insuflation to compare the results to prone positioning alone. In our opinion, use of insuflation provided superior exposure of the spine compared to prone positioning without insuflation. There were no complications related to the insuflation.

Long Term Outcomes of Atlantaxial Fusion with Transarticular Screw Fixation

McGuire RA, Haber LL, Ferguson CA

Purpose: To evaluate the long term results of atlantoaxial transarticular screw fixation.

Methods: Fifty one patients treated between 1991 and 1998 were previously reviewed at 2 year follow up and found to have good results after atlantoaxial transarticular screw fixation. Five of these were diseased and four were lost to follow up, leaving 42 patients available to review long term results. These patients returned for examination to assess cervical range of motion, neurologic status and clinical function. Radiographs of the spine in flexion and extension were taken to assess fusion status and adjacent segment abnormalities.

Results: Average follow up was 6.5 years (3-10). There were 28 males and 14 females with an average age at fusion of 34.5(18-76). All were treated with transarticular screw fixation with iliac crest bone grafting. The original instability resulted from rheumatoid arthritis in nine, os odontoideum in five, Type II nonunions in eight, unstable bursts in seven, transverse ligament rupture in six, Type III ondontoid fractures in five. Two were treated for painful degenerative conditions. Three patients had a neurologic deficit prior to fusion.

In the early (two year) follow up, three patients had malpositioned screws (7%). Two of these patients required repeat surgery for screw repositioning and all healed without sequelae. One patient had a vertebral artery injury (2.4%) without sequelae. There was one guide wire breakage that required a transoral approach in an attempt to retrieve the wire. The fusion rate at 2 years was 100%.

Late follow up revealed two nonunions (4.8%), both in rheumatoid arthritis patients. These were painless and required no further surgery. This gave a 23% (2/9) nonunion rate in the Rheumatoid population. One patient was noted to have screw breakage (2.4%). Mild C2-3 disc space narrowing was seen in four patients (9.5%). There was no evidence of instability and none required further surgery. Range of motion of the cervical spine averaged 40 degrees of flexion, 25 extension and 40 degrees rotation both ways. None of the patients suffered any changes in their daily activities from restricted motion. Eight (19%) utilized NSAIDS or non-narcotic analgesic for intermittent neck pain.

Conclusion: This study reveals good long term results for antlantoaxial transarticular screw fixation. Nonunion rate was 4.8% and occurred only in the rheumatoid population. Screw breakage was 2.4%. No further surgery was required and these patients were asymptomatic. It is felt that the enhanced biomechanical stability provided by the transarticular construct was the reason for the late finding of the nonunions. Adjacent segment degeneration was 9.5%, but none required further surgical treatment. The decreased range of motion from the fusion does not significantly alter lifestyles in this patient population.