Evaluation of electromyographic monitoring during insertion of thoracic pedicle screws.
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We prospectively studied the use of intercostal EMG monitoring as an indicator of the accuracy of the placement of pedicle screws in the thoracic spine. We investigated 95 thoracic pedicles in 17 patients. Before insertion of the screw, the surgeon recorded his assessment of the integrity of the pedicle track. We then stimulated the track using a K-wire pedicle probe connected to a constant current stimulator. A compound muscle action potential (CMAP) was recorded from the appropriate intercostal or abdominal muscles. Postoperative CT was performed to establish the position of the screw. The stimulus intensity required to evoke a muscle response was correlated with the position of the screw on the CT scan. There were eight unrecognised breaches of the pedicle. Using 7.0 mA as a threshold, the sensitivity of EMG was 0.50 in detecting a breached pedicle and the specificity was 0.83. Thoracic pedicle screws were accurately placed in more than 90% of patients. EMG monitoring did not significantly improve the reliability of placement of the screw. (+info)
Complications of fracture treatment by traditional bonesetters in southwest Nigeria.
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BACKGROUND: Traditional bonesetters (TBS) practice widely in Nigeria. OBJECTIVE: Our aim was to evaluate the types of complications seen in patients previously treated by TBS and to assess factors that may predispose to the complications. METHODS: We carried out a prospective non-randomized controlled study in a general hospital in southwest Nigeria. All patients brought into the hospital over the 10-month study period with fractures who had been treated previously by a TBS and, as a control, all patients brought directly to and treated by us were studied. Each patient was assessed and prescribed the most appropriate treatment for their fracture: reduction, immobilization (operatively and otherwise) and physiotherapy. Malunion, non-union, delayed union, gangrene, stiffness of joints and loss of joint motion, Volkman's ischaemic contracture and tetanus were all investigated. RESULTS: Over half of the patients in the TBS subgroup had malunion, and a quarter had non-union. Only one out of the 36 (2.8%) had no complaints and was satisfied with the outcome of treatment of his fractures by the TBS. In the orthodox subgroup, there were seven complications as a result of treatment of a total of 49 bones (14%). Most of the complications involved the loss of joint motion. CONCLUSIONS: There were no statistically significant associations between the complications recorded and the ages of the patients, types of bone fractured or the duration of treatment in patients who were in the TBS subgroup. The introduction of a health insurance scheme in Nigeria may make it easier for individuals and families to be able to afford proper fracture treatment in hospitals. (+info)
A new articulated elbow external fixation technique for difficult elbow trauma.
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Articulated external fixation of the elbow allows aggressive elbow range of motion while protecting the joint and periarticular structures from excessive forces. A technique for aligning a monolateral-hinged fixator to the rotational axis of the elbow without the use of an invasive axis pin has been developed. Thirteen patients with acute and chronic post-traumatic elbow problems were treated over a four year period with this technique. An average arc of motion of 84 degrees was achieved in the frame. Frames were removed at an average of 7.6 weeks. Complications were confined to pin tract infections. In 11 patients followed for an average of 35 weeks the average arc of motion was 81 degrees. Further experience is required to determine the role of this device and to identify which elbows achieve the most benefit compared to conventional techniques. (+info)
Drilling efficiency and temperature elevation of three types of Kirschner-wire point.
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An innovative Kirschner (K-) wire point was developed and compared in fresh pig femora in terms of drilling efficiency and temperature elevation with the trochar and diamond points currently used in clinical practice. The tips of thermal couples were machined to the defined geometry and the temperature measured during drilling. Using the same drill speed (rev/min) and feed rate, the new K-wire point produced the lowest thrust force and torque as measured by a Kistler dynamometer. Drill point temperatures were highest with the trochar geometry (129 +/- 6 degrees C), followed by the diamond (98 +/- 7 degrees C). The lowest temperatures were recorded with the Medin K-wire (66 +/- 2 degrees C). On repeated drilling it could be used for up to 30 holes before reaching the less satisfactory drill performance of the diamond tip. The new K-wire provides a better alternative as it requires less effort for insertion, generates less heat and may be re-used. (+info)
The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur.
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In a prospective, randomised study we have compared the pertrochanteric external fixator (PF) with the sliding hip screw (SHS) in 100 consecutive patients who were allocated randomly to the two methods of treatment. Details of the patients and the patterns of fracture were similar in both groups. Follow-up was for six months. Use of the PF was associated with significantly less blood loss, a shorter operating time, reduced postoperative pain, shorter hospitalisation (p < 0.001), earlier mobilisation (p < 0.001) and a reduced rate of mechanical complications (p < 0.01). Superficial infection was significantly more common with the PF (p < 0.01), but without long-term adverse consequences. There were no differences in the healing of the fracture, mortality or final functional outcome. Our results indicate that the external fixator is an effective and safe device for treating pertrochanteric fractures and should be considered as a useful alternative to conventional fixation with the sliding hip screw. (+info)
Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures.
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BACKGROUND: A prospective, randomized controlled trial comparing conventional intraoperative fluid management with two differing methods of invasive haemodynamic monitoring to optimize intraoperative fluid therapy, in patients undergoing proximal femoral fracture repair under general anaesthesia. METHODS: Ninety patients randomized to three groups; conventional intraoperative fluid management (Gp CON, n=29), and two groups receiving additional repeated colloid fluid challenges guided by central venous pressure (Gp CVP, n=31) or oesophageal Doppler ultrasonography (Gp DOP, n=30). Primary outcome measures were time to medical fitness to discharge, hospital stay and postoperative morbidity. RESULTS: The fluid challenge resulted in significantly greater perioperative changes in central venous pressure between Gp CVP and Gp CON (mean 5 (95% confidence interval 3-7) mm Hg) (P<0.0001). Important perioperative changes were also shown in Gp DOP with increases of 49.4 ms (19.7-79.1 ms) in the corrected flow time, 13.5 ml (7.4-19.6 ml) in stroke volume, and 0.9 (0.49-1.39) litre min(-1) in cardiac output. As a result, fewer patients in Gp CVP and Gp DOP experienced severe intraoperative hypotension (Gp CON 28% (8/29), Gp CVP 9% (3/31), Gp DOP 7% (2/30), P=0.048 (chi-squared, 2 degrees of freedom (df). No differences were seen between the three groups when major morbidity and mortality were combined, P=0.24 (chi-squared, 2 df). Postoperative recovery for survivors, as defined by time to be deemed medically fit for discharge, was significantly faster, in comparison with Gp CON, in both the Gp CVP (10 vs 14 (95% confidence interval 8-12 vs 12-17) days, P=0.008 (t-test)), and Gp DOP (8 vs 14 (95% confidence interval 6-12 vs 12-17) days, P=0.023 (t-test). There were no significant differences between groups, for survivors, with respect to acute orthopaedic hospital and total hospital stay. CONCLUSIONS: Invasive intraoperative haemodynamic monitoring with fluid challenges during repair of femoral fracture under general anaesthetic shortens time to being medically fit for discharge. (+info)
Fractures of the calcaneus with displacement of the thalamic portion.
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The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The twp ,aom frag,emts are foxed bu am amtero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild. (+info)
Primary bone grafting does not improve the results in severely displaced distal radius fractures.
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We prospectively randomised 45 patients ages 20-70 years with distal radius fractures of Older type III and IV to one of two treatment groups. One group was treated with closed reduction, primary bone grafting, and external fixation for 3 weeks, followed by a plaster cast that allowed volar flexion, for an additional 3 weeks. The other group was treated with closed reduction and external fixation for 6 weeks. The functional and radiographic results were evaluated. There was no difference between the two groups in either clinical or radiographic outcome. We do not recommend external fixation and primary bone grafting as a routine method in these fractures. (+info)