Avoid Complications: Cast Please, Thank You Dr. Sarmiento William - - PowerPoint PPT Presentation

Avoid Complications: Cast Please, Thank You

• Dr. Sarmiento

William T. Obremskey MD MPH MMHC Vanderbilt Orthopedic Trauma

6th Kenneth D. Johnson, M.D. Lectureship 2011 Augusto Sarmiento M.D.

Bare Bones: A Surgeon's Tale 1st Edition by Augusto Sarmiento M.D.

Was Sarmiento Wrong?

• NO!

4

Gus would never treat a severe Distal Tibia in a cast.

When to Ex Fix ONLY?

6/26/17

6/26/17

6/26/17

6/27/17

7/14/17

8/4/17

9/15/17

9/22/17

9/22/17

9/22/17

11/1/17

Complications

• The only way to avoid all complications
• Is
• To Not Operate!

Ex- Fix vs ORIF

• f

Distal Tibia Fractures

Southeast Fracture Consortium

Supported by: OTA Clinical Grant EBI Educational Grant

ORIF vs Ex fix of Pilon Fxs

• Wyrsch, B., et al., Operative treatment of fractures of the

tibial plafond. A randomized, prospective study. J Bone Joint Surg Am, 1996. 78(11): p. 1646-57. - 39 patients

• ORIF – 5 days

– 28% rate of infection – 33% rate of wound sloughing – 10% BKA

• Ex Fix

– 5% rate of infection – 5% rate of wound sloughing

• No differences in joint reduction, rate of union, clinical scores
• r radiographic scores.

Study Design

• Initial bridging Ex-Fix across ankle joint

– ORIF of fibula at surgeon’s discretion – type of Ex-Fix at surgeon’s discretion

Study Design RCT

Ex fix Plafond Fracture ORIF joint and plate tibia ORIF joint and Ex-Fix tibia Clinical F/U 3,6 ,12 mos Clinical F/U 3,6 ,12 mos Functional F/U 3,6,12 mos Functional F/U 3,6,12 mos Consent

Results

Results

No differences b/t groups: smoking or DM

Results - Clinical

• Time in Ex-Fix

– IF – 3.3 weeks (0-12) – XF – 10 weeks (7-17)

• Bone Grafts < 6 weeks

– 7/34 patients in the IF group – 4/26 patients in the EF group – p> 0.05

Results – Clinical – 6 mos

Delayed/ non Union Infection IF 6/34 (18%) 3/34 (8.8%) XF 10/26 (39%) 2/26 (7.7%) P-value 0.0708, Chi-square 0.3561, Fisher's exact test

Power analysis:

If above % are “real” then need 70 in each group for 0.80 power With these #s power is 0.44

Results - Radiographic

• No differences in Articular reduction

– Post op – 6 months – P= 0.74 – Marsh et al JBJS-A, 2003.

• No differences in arthrosis score at 6 months

– P= 0.67 – Domsic and Saltzman 1998

Results - Functional

• 3 months– IF group improved

– Iowa Ankle (p=0.0172) – Range of Motion (p=.0264)

• 6 months IF group - Iowa Ankle

– Functional outcome scores (p=0.0128)

Results – Functional

• No differences b/t scores at 3, 6, 12 mos:

– SMFA – SF-36

• SF-36 Vitality and Social Functioning

– P= 0.04

Conclusions

• XF or IF can attain and maintain articular

reduction

• No difference in arthrosis at 6-12 months
• Risk of nonunion/delayed union > with XF
• Risk of Infection no different
• Funtional Scores better at 3 mos w/ IF
• Functional scores no different at 6, 12 mos

Prospective Treatment of Closed Stable Tibia Shaft Fxs with Cast vs IMN

The Southeast Fracture Consortium

Supported by OTA grant

Hypotheses

• IMNs patients will:`

– RTW sooner – Better early functional outcomes – Better alignment

• Complications – no difference
• Knee pain/function no difference

Results

No differences b/t groups: Age Smoking Diabetes Anticonvulsants NSAIDs

Follow up

3 mos 6 mos Cast 81% 53% |IMN 86% 77%

Results – Clinical ROM

Cast/IMN 3 months 6 months DF 7.4/12.4 12/15 PF 27.5/39 37/33 P value 0.042/0.027 0.26/0,94

No infections in either group Ankle ROM improved at 3 mos in IMN group

Knee Function

RETURN OF Open ( 205) Closed (456) Exercise 45% 61% Training 43% 58% Sports 33% 48% Employment 50% 71%

Activity Questionaire at 12-months.

Knee Pain

• No Differences at 3, 6 or 12 months

Results – Return to Work

3 mos 6 mos Cast 39% 83% IMN 76% 100% P value 0.04 0.48

Patients with IMN more likely to RTW at 3 mos

Results – Radiographic Alignment – 6 months

Malalignment Malunion Cast 3/15 (20%) 1/15 (7%) IMN 1/17 (6%) 0/17 P value 0.22

More malaligned in Cast group, but not significant

Results – Radiographic Union

3 mos 6 mos Cast 29% 80% IMN 50% 94% p value 0.22 0.32

No difference in union at 3 or 6 mos

Results – Functional SMFA – 3 mos

Dysfct Index Bother Index Daily activity Mobility Cast 38 51 58 45 IMN 16 18 18 19 P value 0.008 0.23 0.0093 0.062 SMFA score lower is better

6 mos. - no differences in any SMFA dom 3 mos – improved function in IMN group

Tibia Shaft Fxs - OP vs Non-op

Hooper GJ, et al. JBJS 73B:1991

• 64 pts w/ closed or open G1 displaced tibia fxs

randomized to cast vs IMN

• Cast

IMNp-value

• union

18.3 wks 15.7 wks < 0.05

• RTW

23 wks 13.5 wks < 0.05

• ang.> 10° 15%

0% < 0.05

• short >1 cm15%

0% < 0.05

• infections

0% 0%

Conclusions

• First study to evaluate STABLE tibia fractures

w/ IMN vs cast

• No difference in ankle ROM
• IMN group faster RTW
• IMN Functional Scores better at 3 mos
• Functional scores no different at 6 mos
• Malalignment risk greater in cast group

The Southeast Fracture Consortim

• EBM and Multicenter Trials
• “This could be the beginning of a beautiful

relationship”

– Humpfrey Bogart - Casa Blanca