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Reamed against unreamed nailing of the femoral diaphysis: a retrospective study of healing time
244
Injury:
International
Journal
of the Care of the Injured
Vol. 28, No. 3,1997
J. Beavis, S. Harper Frame HV HD MT DM OT OA
Compression (mm) 0.48 1.06 3.15 1.11 0.52 0.62
Torsion (degrees) 1.59 2.23 3.1 0.65 1.66 0.85
Lateral flexion (degrees)
0.77 0.91 3.29 0.78 1.12 1.36
AP flexion (degrees) 0.47 0.67 0.37 0.15 0.34 0.47
Hercegovina Comparative stiffness 2.57 1.72 0.8 3.03 2.47 2.57
Resistanceto Al’ load was found to be greater than that to lateral load for these laterally placed external fixators. This is contrary to the profile of external fixation on a typical long bone where resistanceis greater in the plane parallel to the pins than perpendicular to the pins. This gives these fixators a valuable mechanical advantage for clinical use. There are some specific differences between individual frames. Notably the Orthofix frames and the Vidal frame were very similar in their overall stiffnesswhich in fact was the initial design aim of the Orthofix device. The ankle module was slightly stiffer than the standard Orthofix due to wider pin placementin the hindfoot. The metatarsal frame was the weakest configuration .with useful stiffnessin the AP plane due to its pin orientation. When combined with the delta frame, which was the next weakest frame, the construct became the overall strongest. This is of use in the clinical application as a frame can be constructed with great stiffnessto aid initial soft-tissuehealing, which can be made more flexible later to stimulate bony healing. As the wooden model cannot fully reproduce the specific mechanical subtleties of the ankle joint, further biomechanical testing should be undertaken using cadaveric specimensto validate the findings of this study.
B.B. Joshi (Bombay, India) Joshi’s External Stabilization System (/ESS): a simple mini externalfixator for the management of hand trauma and its sequels
The unique features of this system are its simple design and reliance on readily available materials. It usestransfixing K wires which are bridged together via ‘link joints’. The systemhashad extensive usein the managementof hand injuries. There are five main indications for the use of this external fixator in hand injuries and their sequels: unstable fractures of phalanges or metacarpals (open or closed); intra-articular fractures where ligamentotaxis is utilized for reduction; stabilization of the mutilated hand in functional position; as an adjuvant in the rehabilitation of complex hand injuries; as a distraction tool in the treatment of stiff contracted joints. JESSallows frames of varying rigidity to be readily constructed depending upon the clinical need. K wires are readily available and are less traumatic to soft tissues. Malleable connecting rods obviate the need for complex joints with multiplanar freedom. The construction of standard hand positioning frames allows proper positioning of crushed hands. Subsequentmobilization of the hand with the help of slingsand rubber bands is also possible.With the addition of hinges and distractersthe systemis able to cope with complex problemsaswell.
and R. Salihefendic (Sarajevo, Bosniaand Rochester, UK) Nutrition and way surgery
During the winter of 1993to 1994the blockade of Sarajevo became more intense and the casualtiesrose becauseof increasedbombardment of the population. Food supplies had been adequate during the summer months but fell during the winter. A study of wound infection was undertaken at the State Hospital, Sarajevo, using pin-tracks of the Sarafix external fixator as a model or marker. Wounds, as such, were so heavily contaminated by the injuries and secondarily from open debridement that comparative studies could not be made. Bacteriological studies were rare and uncertain becauseof a lack of basic facilities, including water and electricity. The study depended on assessmentby gross clinical signs. Simultaneousassessmentof food availability to the hospital patients was alsomade. For the months of August and between November and January the food was calculated from figures published by the UNHCR and during January a direct assessment of the food available in the State Hospital was made. Three separate groups of patients were studied for pin-track infection in August, November and January. They were ones who had the fixator inserted at least 2 weeks and not more than 3 months. During this time the infection rate rose from 8 per cent to 30per cent. The intake of food derived from official figures and local assessmentwas inadequate with a particular deficiency noted in calorie provision and of micronutrients such as vitamins C, folate and B6. The actual intake of patients food was probably lessthan calculated due to the recognized effect of food refusal in depressed and sick individuals. The changein the infection rate paralleled the reduction in food intake and while it may not be the only reasonfor the effect - no electricity, poor water suppliesand ‘theatre problems’ can be cited - it is suggestedthat malnutrition was a major feature in the increaseof infection. P.V. Giannoudis, A.J. Furlong, D.A. Macdonald and R.M. Smith (Leeds, UK) Reamed against unreumed nailing of the femoral diaphysis: a retrospective study of healing time
Recently, thin, solid, unreamed nails have been introduced for the fixation of femoral fractures. We have used the A0 unreamed femoral nail (URFN) since March 1994 and despite European claims of rapid healing with unreamed femoral nailing we have noted a different healing pattern. In order to assess this formally we have performed a retrospective control study of reamed femoral nailing (RFN) againstthe healing pattern seenafter URFN. One hundred and forty-seven consecutive patients treated by locked intramedullary nailing were reviewed. After exclusion of pathological fractures, revisions, and fractures outside the femoral diaphysis (A0 32), 51 femoral shaft fractures were available for review. Theseincluded 24 RFN and 27 URFN. Each case was followed by clinical review and radiography until union or death. Both groups were comparablefor all demographicfactors. There was one death in each group from multiple injuries, one non-union in each group at 52 weeks, and no casesof infection, angular deformity or leg-length discrepancy. Two casesrequired early rotational correction and there was a singlebroken distal locking screw in the URFN group. Overall the URFN casestook longer to reach radio-
Proceedings
of the British
Trauma
Society
logical consolidation (mean of 26.9 weeks as opposed to 20.5 weeks for the RFN: P value 0.009). Despite this delay, this did not appear to produce a significant clinical problem. A.J. Furlong, P.V. Giannoudis and R.M. Smith (Leeds, UK) Heterotopic ossification: a comparison between reamed and uureamed femoral nailing Heterotopic ossification in the abductor region of the hip following reamed intramedullary femoral nailing has an incidence as high as 68 per cent. A definitive triggering factor for heterotopic ossification remains obscure, but it has been suggested that there may be both local and systemic influences. Previous work has only been able to show statistical correlation with systemic factors. The A0 unreamed femoral nail has been used in our unit since March 1994. We undertook a retrospective study comparing the unreamed femoral nail with the reamed femoral nails used in our unit prior to March 1994, to determine if there was a difference in the incidence of heterotopic ossification between the two groups. Sixty antegrade femoral nailings vere performed in 58 patients, of which 32 were unreamed. There were no significant differences between the two groups for systemic risk factors known to have statistical correlation with the formation of heterotopic bone. Heterotopic ossification was graded according to the Brumback classification on the final anteroposterior radiograph of the hip at radiological fracture union. The incidence of heterotopic ossification in the reamed nail group was 35.7 per cent and 9.4 per cent in the unreamed nail group (x2 test, P = 0.01). We feel that the difference in the incidence of heterotopic bone formation between the two groups demonstrates that local factors, and particularly the generation of osteogenic reaming debris,’ are important in the pathophysiology of heterotopic ossification in femoral intramedullary nailing. C.W. Oliver, E.R.S. Ross, S. Hollis and D. Pitts (Oxford, UK, Manchester, UK and Lancaster, UK) Impact of distance learning material on trauma surgeons Traditional methods of teaching fracture fixation have mainly been teaching-laboratory based. We have previously shown distance learning material (DLM) to be beneficial. Our previous pilot study of 120 surgeons has now been expanded to assess the effect of DLM in a larger group of surgeons. This study looks at the change of knowledge base and the determination of effect of different modules as a result of DLM. The effect of DLM was assessed in two consecutive Basic Fracture Fixation Courses at The Royal College of Surgeons, London in June and July 1995 for a group of 240 surgeons. There were four DLMs to assess: screws, plates, intramedullary (IM) nails and external fixator modules. Two modules of DLM were issued before the course to one course and two different modules to the other course. Surgeons were tested on the contents of all four modules of the DLM. A pre- and post-test 200-element multiplechoice questionnaire (MCQ) was used to assess the surgeons. The results showed that there was a significant impact of the course itself and the DLM in increasing knowledge. There was a significant decrease in uncertainty on answering the MCQs. Results also showed that there was a significant impact of the DLM on each specific module.
245 Students were more familiar with screws and plates rather than with IM nails and external fixators prior to the course. The impact of DLM was more noticeable with IM nails. These results show there is a significant increase in knowledge of facts that have been attained, acquired and applied. The results do not show the quality of the acquired knowledge or the competence level at which it will be applied. DLM appears to be a useful adjunct to increasing knowledge at fracture fixation courses. H.G. Zadeh and S.A. Sakka (Stanmore, UK) Current attitude of British orthopaedic trainees (BOTA members) towards trauma surgery in the UK We are embarking on major changes in training with the introduction of the continuum training, reduction of on-call hours and increase in the number of consultant posts. Currently the delivery of trauma services in the UK is changing to a consultant-delivered care system with an increasing number of consultants being appointed as either full-time trauma surgeons or expected to devote the main part of their clinical practice to trauma surgery. Similar changes were implemented in the USA over 10 years ago. However recent reports from the USA highlight the fact that these changes have altered the attitude of the current residents in a negative way towards trauma surgery as a career. The purpose of this study is to establish the current trends in UK and establish a baseline for future comparison. The current members of British Orthopaedic Trainees’ Association (BOTA) were contacted using a postal questionnaire. A total of 480 questionnaires were sent and 253 (52 per cent) replies received. The respondents comprised: consultants 37 per cent, senior registrars 34 per cent, career registrars 22 per cent and others 7 per cent. There were 53 per cent working at teaching hospitals, 43 per cent in non-teaching hospitals and 3 per cent in research. 77 per cent are Advanced Trauma Life Support providers and 14 per cent insiructors. Although over 90 per cent of the respondents found trauma surgery enjoyable and exciting, only 55 per cent considered it attractive and rewarding as a career. Even fewer, 39 per cent, foresee a good future prospect for trauma surgery being a major part of their clinical practice; 64 per cent did not think trauma surgery will bring financial rewards in the future. Only 19 per cent expressed trauma surgery as one of their subspecialties of interest. Some of the main reasons for the disaffection shown towards trauma surgery by the respondents are: lack of provisions out of hours (77 per cent), demanding on-call commitments (65 per cent), lack of private patients (58 per cent), HIV risk (58 per cent), poor career structure (49 per cent), excessive work load (42 per cent) and inadequate training (36 per cent). Furthermore, only 20 per cent consider that trauma surgery is given sufficient accreditation or acknowledgement in UK. Other details, including the differences between the three main grades, i.e. consultants, senior registrars, and registrars, was presented. A.G. Sutherland and D.F. Finlayson (Inverness, UK) Image-intensifier screening times in orthopaedic procaiures performed by trainees and consultants There was a perception held in our unit that the imageintensifier screening times during consultant-led procedures was lower than that for trainee-led procedures. This
Injury:
International
Journal
of the Care of the Injured
Vol. 28, No. 3,1997
J. Beavis, S. Harper Frame HV HD MT DM OT OA
Compression (mm) 0.48 1.06 3.15 1.11 0.52 0.62
Torsion (degrees) 1.59 2.23 3.1 0.65 1.66 0.85
Lateral flexion (degrees)
0.77 0.91 3.29 0.78 1.12 1.36
AP flexion (degrees) 0.47 0.67 0.37 0.15 0.34 0.47
Hercegovina Comparative stiffness 2.57 1.72 0.8 3.03 2.47 2.57
Resistanceto Al’ load was found to be greater than that to lateral load for these laterally placed external fixators. This is contrary to the profile of external fixation on a typical long bone where resistanceis greater in the plane parallel to the pins than perpendicular to the pins. This gives these fixators a valuable mechanical advantage for clinical use. There are some specific differences between individual frames. Notably the Orthofix frames and the Vidal frame were very similar in their overall stiffnesswhich in fact was the initial design aim of the Orthofix device. The ankle module was slightly stiffer than the standard Orthofix due to wider pin placementin the hindfoot. The metatarsal frame was the weakest configuration .with useful stiffnessin the AP plane due to its pin orientation. When combined with the delta frame, which was the next weakest frame, the construct became the overall strongest. This is of use in the clinical application as a frame can be constructed with great stiffnessto aid initial soft-tissuehealing, which can be made more flexible later to stimulate bony healing. As the wooden model cannot fully reproduce the specific mechanical subtleties of the ankle joint, further biomechanical testing should be undertaken using cadaveric specimensto validate the findings of this study.
B.B. Joshi (Bombay, India) Joshi’s External Stabilization System (/ESS): a simple mini externalfixator for the management of hand trauma and its sequels
The unique features of this system are its simple design and reliance on readily available materials. It usestransfixing K wires which are bridged together via ‘link joints’. The systemhashad extensive usein the managementof hand injuries. There are five main indications for the use of this external fixator in hand injuries and their sequels: unstable fractures of phalanges or metacarpals (open or closed); intra-articular fractures where ligamentotaxis is utilized for reduction; stabilization of the mutilated hand in functional position; as an adjuvant in the rehabilitation of complex hand injuries; as a distraction tool in the treatment of stiff contracted joints. JESSallows frames of varying rigidity to be readily constructed depending upon the clinical need. K wires are readily available and are less traumatic to soft tissues. Malleable connecting rods obviate the need for complex joints with multiplanar freedom. The construction of standard hand positioning frames allows proper positioning of crushed hands. Subsequentmobilization of the hand with the help of slingsand rubber bands is also possible.With the addition of hinges and distractersthe systemis able to cope with complex problemsaswell.
and R. Salihefendic (Sarajevo, Bosniaand Rochester, UK) Nutrition and way surgery
During the winter of 1993to 1994the blockade of Sarajevo became more intense and the casualtiesrose becauseof increasedbombardment of the population. Food supplies had been adequate during the summer months but fell during the winter. A study of wound infection was undertaken at the State Hospital, Sarajevo, using pin-tracks of the Sarafix external fixator as a model or marker. Wounds, as such, were so heavily contaminated by the injuries and secondarily from open debridement that comparative studies could not be made. Bacteriological studies were rare and uncertain becauseof a lack of basic facilities, including water and electricity. The study depended on assessmentby gross clinical signs. Simultaneousassessmentof food availability to the hospital patients was alsomade. For the months of August and between November and January the food was calculated from figures published by the UNHCR and during January a direct assessment of the food available in the State Hospital was made. Three separate groups of patients were studied for pin-track infection in August, November and January. They were ones who had the fixator inserted at least 2 weeks and not more than 3 months. During this time the infection rate rose from 8 per cent to 30per cent. The intake of food derived from official figures and local assessmentwas inadequate with a particular deficiency noted in calorie provision and of micronutrients such as vitamins C, folate and B6. The actual intake of patients food was probably lessthan calculated due to the recognized effect of food refusal in depressed and sick individuals. The changein the infection rate paralleled the reduction in food intake and while it may not be the only reasonfor the effect - no electricity, poor water suppliesand ‘theatre problems’ can be cited - it is suggestedthat malnutrition was a major feature in the increaseof infection. P.V. Giannoudis, A.J. Furlong, D.A. Macdonald and R.M. Smith (Leeds, UK) Reamed against unreumed nailing of the femoral diaphysis: a retrospective study of healing time
Recently, thin, solid, unreamed nails have been introduced for the fixation of femoral fractures. We have used the A0 unreamed femoral nail (URFN) since March 1994 and despite European claims of rapid healing with unreamed femoral nailing we have noted a different healing pattern. In order to assess this formally we have performed a retrospective control study of reamed femoral nailing (RFN) againstthe healing pattern seenafter URFN. One hundred and forty-seven consecutive patients treated by locked intramedullary nailing were reviewed. After exclusion of pathological fractures, revisions, and fractures outside the femoral diaphysis (A0 32), 51 femoral shaft fractures were available for review. Theseincluded 24 RFN and 27 URFN. Each case was followed by clinical review and radiography until union or death. Both groups were comparablefor all demographicfactors. There was one death in each group from multiple injuries, one non-union in each group at 52 weeks, and no casesof infection, angular deformity or leg-length discrepancy. Two casesrequired early rotational correction and there was a singlebroken distal locking screw in the URFN group. Overall the URFN casestook longer to reach radio-
Proceedings
of the British
Trauma
Society
logical consolidation (mean of 26.9 weeks as opposed to 20.5 weeks for the RFN: P value 0.009). Despite this delay, this did not appear to produce a significant clinical problem. A.J. Furlong, P.V. Giannoudis and R.M. Smith (Leeds, UK) Heterotopic ossification: a comparison between reamed and uureamed femoral nailing Heterotopic ossification in the abductor region of the hip following reamed intramedullary femoral nailing has an incidence as high as 68 per cent. A definitive triggering factor for heterotopic ossification remains obscure, but it has been suggested that there may be both local and systemic influences. Previous work has only been able to show statistical correlation with systemic factors. The A0 unreamed femoral nail has been used in our unit since March 1994. We undertook a retrospective study comparing the unreamed femoral nail with the reamed femoral nails used in our unit prior to March 1994, to determine if there was a difference in the incidence of heterotopic ossification between the two groups. Sixty antegrade femoral nailings vere performed in 58 patients, of which 32 were unreamed. There were no significant differences between the two groups for systemic risk factors known to have statistical correlation with the formation of heterotopic bone. Heterotopic ossification was graded according to the Brumback classification on the final anteroposterior radiograph of the hip at radiological fracture union. The incidence of heterotopic ossification in the reamed nail group was 35.7 per cent and 9.4 per cent in the unreamed nail group (x2 test, P = 0.01). We feel that the difference in the incidence of heterotopic bone formation between the two groups demonstrates that local factors, and particularly the generation of osteogenic reaming debris,’ are important in the pathophysiology of heterotopic ossification in femoral intramedullary nailing. C.W. Oliver, E.R.S. Ross, S. Hollis and D. Pitts (Oxford, UK, Manchester, UK and Lancaster, UK) Impact of distance learning material on trauma surgeons Traditional methods of teaching fracture fixation have mainly been teaching-laboratory based. We have previously shown distance learning material (DLM) to be beneficial. Our previous pilot study of 120 surgeons has now been expanded to assess the effect of DLM in a larger group of surgeons. This study looks at the change of knowledge base and the determination of effect of different modules as a result of DLM. The effect of DLM was assessed in two consecutive Basic Fracture Fixation Courses at The Royal College of Surgeons, London in June and July 1995 for a group of 240 surgeons. There were four DLMs to assess: screws, plates, intramedullary (IM) nails and external fixator modules. Two modules of DLM were issued before the course to one course and two different modules to the other course. Surgeons were tested on the contents of all four modules of the DLM. A pre- and post-test 200-element multiplechoice questionnaire (MCQ) was used to assess the surgeons. The results showed that there was a significant impact of the course itself and the DLM in increasing knowledge. There was a significant decrease in uncertainty on answering the MCQs. Results also showed that there was a significant impact of the DLM on each specific module.
245 Students were more familiar with screws and plates rather than with IM nails and external fixators prior to the course. The impact of DLM was more noticeable with IM nails. These results show there is a significant increase in knowledge of facts that have been attained, acquired and applied. The results do not show the quality of the acquired knowledge or the competence level at which it will be applied. DLM appears to be a useful adjunct to increasing knowledge at fracture fixation courses. H.G. Zadeh and S.A. Sakka (Stanmore, UK) Current attitude of British orthopaedic trainees (BOTA members) towards trauma surgery in the UK We are embarking on major changes in training with the introduction of the continuum training, reduction of on-call hours and increase in the number of consultant posts. Currently the delivery of trauma services in the UK is changing to a consultant-delivered care system with an increasing number of consultants being appointed as either full-time trauma surgeons or expected to devote the main part of their clinical practice to trauma surgery. Similar changes were implemented in the USA over 10 years ago. However recent reports from the USA highlight the fact that these changes have altered the attitude of the current residents in a negative way towards trauma surgery as a career. The purpose of this study is to establish the current trends in UK and establish a baseline for future comparison. The current members of British Orthopaedic Trainees’ Association (BOTA) were contacted using a postal questionnaire. A total of 480 questionnaires were sent and 253 (52 per cent) replies received. The respondents comprised: consultants 37 per cent, senior registrars 34 per cent, career registrars 22 per cent and others 7 per cent. There were 53 per cent working at teaching hospitals, 43 per cent in non-teaching hospitals and 3 per cent in research. 77 per cent are Advanced Trauma Life Support providers and 14 per cent insiructors. Although over 90 per cent of the respondents found trauma surgery enjoyable and exciting, only 55 per cent considered it attractive and rewarding as a career. Even fewer, 39 per cent, foresee a good future prospect for trauma surgery being a major part of their clinical practice; 64 per cent did not think trauma surgery will bring financial rewards in the future. Only 19 per cent expressed trauma surgery as one of their subspecialties of interest. Some of the main reasons for the disaffection shown towards trauma surgery by the respondents are: lack of provisions out of hours (77 per cent), demanding on-call commitments (65 per cent), lack of private patients (58 per cent), HIV risk (58 per cent), poor career structure (49 per cent), excessive work load (42 per cent) and inadequate training (36 per cent). Furthermore, only 20 per cent consider that trauma surgery is given sufficient accreditation or acknowledgement in UK. Other details, including the differences between the three main grades, i.e. consultants, senior registrars, and registrars, was presented. A.G. Sutherland and D.F. Finlayson (Inverness, UK) Image-intensifier screening times in orthopaedic procaiures performed by trainees and consultants There was a perception held in our unit that the imageintensifier screening times during consultant-led procedures was lower than that for trainee-led procedures. This