James Kellam

Controversy exists regarding management of proximal tibial metaphyseal fractures with severe soft tissue injury. It is unclear whether limb salvage or early amputation results in the best functional and clinical outcomes. We hypothesized that in this group of patients, there is no difference in functional outcomes, complication rates, clinical outcomes, or objective physical function related to the treatment approach. We used the LEAP study database to perform a retrospective comparative review of a subset of patients with proximal tibial metaphyseal fractures (AO/OTA 41A, B, and C) with associated severe soft tissue injuries comparing the outcomes of patients who were treated with either limb salvage or amputation. Although there were major differences in clinical and functional outcomes based on patients' sociodemographics at 2 years, no differences in clinical or functional outcomes were detected regardless of whether amputation or limb salvage was performed. Severity of soft tissue injury was more predictive of outcome than the surgical approach used. Sociodemographics and soft tissue injury severity are more important than treatment approach for predicting clinical and functional outcomes at 2 years in patients with proximal tibia metaphyseal fractures with severe soft tissue injury. Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Objective: To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment. Setting: Level 1 trauma center. Design: A retrospective cohort study. Patients/Participants: There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents. Main Outcome Measurements: The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans. Results: Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans (P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans...

On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria ...

Trabecular bone score (TBS) is a texture parameter that measures the grayscale variation within dual-energy X-ray absorptiometry (DXA) images, and has been shown to significantly correlate with the 3-dimensional bone microarchitecture. The objective of this study was to determine whether TBS is a better clinical tool than traditionally used bone mineral density (BMD) to detect the skeletal deterioration seen in patients with diabetes (DM), patients undergoing oral glucocorticoid (GC) therapy, and patients who are both diabetic and taking steroids (GC + DM). We performed retrospective, cross-sectional study using DXA images of patients who visited UTHealth Department of Internal Medicine DXA clinic in Houston, TX, from May 30, 2014 to May 30, 2016. A total of 477 men and women, who were 55 years or older, were included in the study. Lumbar spine (LS) BMD and TBS were collected. Electronic medical records were reviewed to collect clinical information for each patient. When both men an...

The authors have carried out an interesting study on the predictability of tibial nonunion after intramedullary nailing. The study addresses a pertinent clinical problem. Tibial shaft fractures are common and generally do well after intramedullary nailing. However, delayed union and nonunion are not uncommon, particularly in higher energy injuries and in patients with other risk factors. Early recognition would be very helpful because it would allow timely intervention to achieve union, which would shorten the overall treatment time with obvious functional and socioeconomic advantages for the patient. However, I have some reservations about the methodology of the study and the inference that surgeons can predict tibial nonunion on the basis of the clinical situation at 3 months. The study was based on the analysis of clinical vignettes by 3 fellowship-trained trauma surgeons. This is a small number of surgeons, presumably with a subspecialist expertise in the management of lower limb trauma. This may limit the general applicability of the findings to a more general orthopaedic community, a point the authors concede in the discussion. If a larger group of orthopaedic surgeons had been used, there may well have been a much greater spread of values. The 3 surgeons actually operated on 43% of the cases. I think there is a definite risk of recall bias, particular since the authors have selected a sample of 56 patients who were slow to heal and in 29 cases went on to develop a definite nonunion. I would accept that the 3 surgeons in question might well have a busy orthopaedic practice but since tibial nonunions are not particularly common, the treating surgeon might well be expected to recall specific cases and consequently be more accurate in prediction of nonunion. One other problem with the current design is the failure to test for intraobserver levels of agreement. This was clearly not possible with the methodology used because each surgeon evaluated the clinical vignettes at one single time point. However, there might well be a significant degree of intraobserver variation in decision-making if this was tested by evaluating a sufficiently large sample of clinical vignettes at a sufficient time interval to reduce recall bias. The sensitivity and specificity for prediction of nonunion were 62% and 77%, respectively, and this was associated with positive and negative predictive values for nonunion prediction of 73% and 69%, respectively. These values suggest that judgment at 3 months is not sufficiently accurate to justify a decision to either intervene or withhold treatment at this stage. The percentages of false positives and false negatives would inevitably mean that a number of patients would be subjected to unnecessary interventions and by the same token, a smaller proportion of patients would have no treatment to treat those who would subsequently require surgery. Although the diagnostic accuracy for the entire series was said to be 94%, the key group is the series of 56 patients in whom there is uncertainty about the progress of union at 3 months, and in this group, the diagnostic accuracy is much lower. In the section on callus formation, the authors quote figures in percentages but the actual numbers of cases are very small and do not justify the use of percentages and to do so feigns a precision that simply does not exist with very small sample sizes. The authors make the point that only one unnecessary operation would have occurred based on their results. I would not agree with this. It is true that the surgeons agreed on 1 patient, predicting nonunion when the fracture actually united without intervention. However, it is disingenuous to suggest only one unnecessary intervention would have occurred. For each surgeon, the diagnostic accuracy was in the region of 74%. It is true that they only all agreed on one case in error. However, each individual surgeon would have had a number of other cases that would have been erroneously predicted to go on to nonunion. These cases would have been offered surgery if the decision was in the hands of one orthopaedic surgeon using the criteria applied in the study. If we consider that there were 27 patients who united without intervention, then this 1 false positive would actually give a specificity of 96%. However, the actual specificity quoted by the authors was 77%, which is considerably lower. This lends weight to the conclusion that a lot more patients than the one mentioned would have been offered surgery. I would therefore not agree with the conclusion drawn by the authors that tibial nonunion can be reliably predicted at 3 months postoperatively using clinical and radiographic data in a subset of patients. My own interpretation is that in the very subset of patients in which there is diagnostic doubt at 3 months about progress to union that clinical and radiographic data are not sufficiently reliable to make a decision about surgical intervention. To apply…

The authors have carried out an interesting study on the predictability of tibial nonunion after intramedullary nailing. The study addresses a pertinent clinical problem. Tibial shaft fractures are common and generally do well after intramedullary nailing. However, delayed union and nonunion are not uncommon, particularly in higher energy injuries and in patients with other risk factors. Early recognition would be very helpful because it would allow timely intervention to achieve union, which would shorten the overall treatment time with obvious functional and socioeconomic advantages for the patient. However, I have some reservations about the methodology of the study and the inference that surgeons can predict tibial nonunion on the basis of the clinical situation at 3 months. The study was based on the analysis of clinical vignettes by 3 fellowship-trained trauma surgeons. This is a small number of surgeons, presumably with a subspecialist expertise in the management of lower limb trauma. This may limit the general applicability of the findings to a more general orthopaedic community, a point the authors concede in the discussion. If a larger group of orthopaedic surgeons had been used, there may well have been a much greater spread of values. The 3 surgeons actually operated on 43% of the cases. I think there is a definite risk of recall bias, particular since the authors have selected a sample of 56 patients who were slow to heal and in 29 cases went on to develop a definite nonunion. I would accept that the 3 surgeons in question might well have a busy orthopaedic practice but since tibial nonunions are not particularly common, the treating surgeon might well be expected to recall specific cases and consequently be more accurate in prediction of nonunion. One other problem with the current design is the failure to test for intraobserver levels of agreement. This was clearly not possible with the methodology used because each surgeon evaluated the clinical vignettes at one single time point. However, there might well be a significant degree of intraobserver variation in decision-making if this was tested by evaluating a sufficiently large sample of clinical vignettes at a sufficient time interval to reduce recall bias. The sensitivity and specificity for prediction of nonunion were 62% and 77%, respectively, and this was associated with positive and negative predictive values for nonunion prediction of 73% and 69%, respectively. These values suggest that judgment at 3 months is not sufficiently accurate to justify a decision to either intervene or withhold treatment at this stage. The percentages of false positives and false negatives would inevitably mean that a number of patients would be subjected to unnecessary interventions and by the same token, a smaller proportion of patients would have no treatment to treat those who would subsequently require surgery. Although the diagnostic accuracy for the entire series was said to be 94%, the key group is the series of 56 patients in whom there is uncertainty about the progress of union at 3 months, and in this group, the diagnostic accuracy is much lower. In the section on callus formation, the authors quote figures in percentages but the actual numbers of cases are very small and do not justify the use of percentages and to do so feigns a precision that simply does not exist with very small sample sizes. The authors make the point that only one unnecessary operation would have occurred based on their results. I would not agree with this. It is true that the surgeons agreed on 1 patient, predicting nonunion when the fracture actually united without intervention. However, it is disingenuous to suggest only one unnecessary intervention would have occurred. For each surgeon, the diagnostic accuracy was in the region of 74%. It is true that they only all agreed on one case in error. However, each individual surgeon would have had a number of other cases that would have been erroneously predicted to go on to nonunion. These cases would have been offered surgery if the decision was in the hands of one orthopaedic surgeon using the criteria applied in the study. If we consider that there were 27 patients who united without intervention, then this 1 false positive would actually give a specificity of 96%. However, the actual specificity quoted by the authors was 77%, which is considerably lower. This lends weight to the conclusion that a lot more patients than the one mentioned would have been offered surgery. I would therefore not agree with the conclusion drawn by the authors that tibial nonunion can be reliably predicted at 3 months postoperatively using clinical and radiographic data in a subset of patients. My own interpretation is that in the very subset of patients in which there is diagnostic doubt at 3 months about progress to union that clinical and radiographic data are not sufficiently reliable to make a decision about surgical intervention. To apply…

In the past, before a reamed intramedullary nail was inserted, it was mandatory to exchange the beaded-tip reaming guide wire with a smooth-tip wire. This additional step is optional in most new nail designs. Here we describe 2 cases in which not exchanging the wire led to initial wire incarceration and introduced additional steps that had to be taken before locked nailing could be completed. Intramedullary nail designs that avoid extra steps and thereby promote simplicity and reliability of insertion are potentially advantageous to both patient and surgeon. Eliminating the exchange tube and the smooth wire, however, should be approached with caution, as no time may be saved, and the procedure may be made much more difficult technically.

OBJECTIVE To determine if a position screw will maintain the inter-fragmentary compression force obtained by a reduction clamp across an anatomically reduced cortical bone fracture and determine if this compressive force is equivalent to that generated by a lag screw. METHODS Oblique fractures were created in 6 composite cortical bone models. Inter-fragmentary compression was measured using force sensors within the fracture after reduction with a clamp. A position screw was then placed perpendicular to the fracture and force measurements were repeated with both the clamp and the screw. Finally, the clamp was removed and force measurements were taken with the screw only to measure maintenance of initial compression. Following these measurement, the screw was removed, the near fragment was over-drilled to allow lag screw placement by technique. Compression force measurements were repeated for: clamp only, clamp + screw, and screw only. RESULTS The mean force of clamp alone across all 12 trials was 139.77N. Application of a lag screw increased the compression across the fracture (p=0.01) which was unchanged when the clamp was removed. The position screw had the opposite effect, reducing compression, and the removal of the clamp further reduced the compression (p=0.013). CONCLUSION A reduction clamp will initially compress a fracture to an average of 139N. A lag screw will significantly increase this inter-fragmentary compression. A position screw will not maintain the compression created by the clamp and in fact will significantly decrease inter-fragmentary compression.

Abstract Injuries to the midfoot and forefoot in patients with multiple injuries can be a major source of long-term functional disability. Careful clinical and radiologic assessment is necessary to define the precise injury pattern, which is frequently complex. Treatment of ...

... The surgical management of femoral head fractures occurring with anterior dislocation of the hip. Simpson, Lex A. MD; Kellam, James F. MD; Tile, Marvin MD. Collapse Box Abstract. ... (C) Williams & Wilkins 1986. All Rights Reserved. Close Window. ...

In most birds, the pair bond relationship during the reproductive period is ubiquitous and often necessary for reproductive success. However, trade-offs between the costs and benefits of pair bond maintenance (PBM) make this relationship more variable in the non-breeding season. I determined some of the proximate and ultimate factors that could contribute to inter- and intra-specific variation observed in avian PBM by investigating the trade-off between pair bond benefits and costs experienced by downy woodpeckers (Picoides pubescens) during winter. ^ I evaluated whether individuals' time budgets varied while in the mate's presence. My data showed that, depending on social environment, both competitive foraging costs and anti-predation benefits were important factors that affected the foraging efficiency of downy woodpeckers. Woodpeckers foraging in pairs or in small mixed-species flocks with the mate reduced the amount of time spent vigilant relative to woodpeckers not with the mate. Woodpeckers in large flocks with the mate showed no change in vigilance, and instead spent less time pecking and more time traveling between pecking sites relative to woodpeckers not with the mate. This suggests that individuals might adjust the frequency at which they associate with mate and flock on a short-term basis to minimize both predation risk and long-term loss in foraging efficiency. ^ Testosterone facilitates pair bond behavior during the breeding season, but the function of testosterone in facilitating winter pair bond behavior is not well understood. I used testosterone implants to raise winter testosterone concentrations in experimental males (T-males) to levels near the breeding season maximum. T-males had more widely dispersed activity patterns within their home range compared to control males, and unlike control males, they increased their frequency of mate association when neighboring male intrusions were frequent. These findings indicate that testosterone in winter promotes male mate guarding behavior, which could increase reproductive success. However, female mates of T-males had reduced foraging efficiency relative to other females. It is possible that natural selection favors relatively low male testosterone levels in winter to minimize the impact of testosterone on existing pair bond relationships. ^ My observational and experimental studies have demonstrated how a variety of factors, from predation risk to intrapair competition to hormone levels, affect the strength and character of the non-breeding season avian pair bond. These findings are important because PBM in the non-breeding season can have a significant impact on the reproductive success of individuals in spring. ^

To compare the initial stability of the genucephalic (GSH) intramedullary nail and the 95-degree condylar compression screw and side plate (DCS) for distal femur fractures. Human cadaveric biomechanical study. Twelve matched pairs of fresh frozen human cadaveric femurs. Genucephalic intramedullary nail device (Smith and Nephew Richards, Memphis, TN, U.S.A.) and the 95-degree DCS device (Synthes USA, Paoli, PA, U.S.A.) were compared. Grouped or dispersed screw constructs were tested for each fracture fixation system with progressively more severe simulated fracture patterns. Axial and torsional stiffness values. The DCS plate with the dispersed screw configuration had the greatest torsional stiffness (p < 0.0011). The GSH nail with the grouped screw configuration absorbed more energy (work) during axial loading compared with the plate constructs (p < 0.0007). There were no significant differences in axial or torsional stiffness within treatment groups for fracture patterns of increasing severity. Based on the authors' results, the selection of a GSH nail or a DCS plate should not be determined by the severity of the fracture. If a DCS plate construct is selected, the authors recommend a dispersed screw configuration, including the most proximal hole in the plate, to provide superior stiffness in torsional loading and equal stiffness in axial loading when compared with the GSH nail constructs. If a GSH nail is selected, the authors recommend a grouped screw configuration, which absorbed more energy during axial loading compared with the DCS plate constructs and the nail with the dispersed screw configuration.

Ipsilateral fractures of the femoral neck and shaft present diagnostic difficulties and complex choices as to treatment. A review of the eighty-three cases reported in the literature revealed that one-third of the fractures of the femoral neck were missed initially. No consistent method of treatment can be recommended on the basis of this review. Our present protocol for this double fracture is treatment with immediate internal fixation: the femoral neck fracture is given first priority and is reduced and immobilized with multiple cancellous screws, and the femoral shaft fracture is then treated with retrograde closed intramedullary Küntscher nailing. Appropriate exceptions to the protocol exist. We reviewed the cases of fifteen patients who were treated at Harborview Medical Center and University Hospital from 1971 through 1981. Our experience with the first two patients led to the development of our protocol, which was applied in the thirteen subsequent double fractures. Two of the fifteen femoral-neck fractures were missed initially. All of the fractures had united four months postoperatively. Of the nine patients who were followed for three years or more, two had aseptic necrosis of the femoral head. Compared with other reports, our protocol seems to have produced somewhat better functional results.

In the past two years the closed locked intramedullary nailing system has been used at the Sunnybrook Trauma Unit. This system has equalled the results reported by Hansen in the use of closed intramedullary nailing with conventional indications, and has provided an excellent means of handling complex and difficult shaft fractures of both the tibia and the femur. It appears to provide excellent rates of union with very rapid and early rehabilitation of the patient. It is particularly useful in the multiply injured patient with very difficult high energy femoral and tibial shaft fractures. It has a minimal blood loss and can be done with practice in a reasonable period of time. This technique will add greatly to the armamentarium of the trauma surgeon.

The authors describe the case of a 29-year-old man with multiple trauma who suffered compartment syndromes necessitating bilateral lower limb amputations as a result of the prolonged (9.5 hours) application of a pneumatic antishock garment (PASG). There was no evidence of lower limb trauma before the garment was put on. Despite the apparent benefits of the PASG in traumatized hypovolemic patients, the lowest possible inflation pressures should be used and removal attempted as soon as hemodynamic stability can be assured.

A model-based algorithm for long bone segmentation from digital X-Ray images is introduced. The model is based on statistical variations of anatomical data collected after examining diverse bone shapes. This method extends the centroid to boundary distance shape analysis approach. A bone is modeled by two centroid points, one for each of the two epiphysis, and a range of weighted

One hundred ten fractures due to gunshots were reviewed to examine the medical, social, and financial implants of such injuries. The population was predominantly male (91%), unemployed (56%), and uninsured (79%). Sixty-eight percent were documented substance abusers, and 65% of the injuries appeared to be related to illicit drug activities. There were 94 long bone fractures and 16 intraarticular fractures. Early operative treatment was employed in 64 patients (58%) with formal internal fixation in 31. There was no difference between type of treatment, associated injury variables, and outcome, and no increase in complications with acute operative management employing internal fixation. Medical charges averaged $13,108 per patient, a 1200% increase over injuries treated at this institution in 1972 and a rise far in excess of the medical care inflation rate (334%) during the same period.

With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, th...

Abstract Injuries to the midfoot and forefoot in patients with multiple injuries can be a major source of long-term functional disability. Careful clinical and radiologic assessment is necessary to define the precise injury pattern, which is frequently complex. Treatment of ...

Mechanotransduction is theorized to influence fracture-healing, but optimal fracture-site motion is poorly defined. We hypothesized that three-dimensional (3-D) fracture-site motion as estimated by finite element (FE) analysis would influence callus formation for a clinical series of supracondylar femoral fractures treated with locking-plate fixation. Construct-specific FE modeling simulated 3-D fracture-site motion for sixty-six supracondylar femoral fractures (OTA/AO classification of 33A or 33C) treated at a single institution. Construct stiffness and directional motion through the fracture were investigated to assess the validity of construct stiffness as a surrogate measure of 3-D motion at the fracture site. Callus formation was assessed radiographically for all patients at six, twelve, and twenty-four weeks postoperatively. Univariate and multivariate linear regression analyses examined the effects of longitudinal motion, shear (transverse motion), open fracture, smoking, and...

Malunion of the distal end segment of a fractured femur is a common complication after open reduction and internal fixation when using 95degrees fixed-angle devices. Incorrect positioning of the alignment Kirschner wires can result in implant malposition and subsequent malunion. This article discusses the relevant distal femoral anatomy and the technical points necessary to avoid a malunion when using 95degrees fixed-angle devices.

In a study of 26 distal tibial explosion fractures in 24 patients two fracture patterns were identified: Type A, a rotational pattern; and Type B, a compressive fracture pattern. The rotational pattern was found to be less common than the compressive fracture and to have a substantially better prognosis. Operative treatment of the Type A pattern led to an overall acceptable result of 84%, while the Type B patients had 53% acceptable results. The results of operative treatment were however, superior to the results of nonoperative treatment in both fracture groups. Adequate treatment consists of anatomic reconstruction of the distal tibia, rigid internal fixation, early active motion, and nonweight bearing in 3 to 5 months.