Orthopedic Surgeons
35 years of experience

Accepting new patients
Lsu Healthcare Network
200 W Esplanade Ave
Ste 500
Kenner, LA 70065
504-468-6535
Locations and availability (4)

Education ?

Medical School Score Rankings
University of Pittsburgh (1975)
  • Currently 4 of 4 apples
Top 25%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Femoral Fractures
Multiple Trauma
Associations
American Board of Orthopaedic Surgery
Orthopaedic Trauma Association

Affiliations ?

Dr. Riemer is affiliated with 1 hospitals.

Hospital Affilations

Score

Rankings

  • Kenner Regional Medical Center
    180 W Esplanade Ave, Kenner, LA 70065
    • Currently 1 of 4 crosses
  • Publications & Research

    Dr. Riemer has contributed to 27 publications.
    Title The Memory Properties of Cold-worked Titanium Rods in Scoliosis Constructs.
    Date April 2006
    Journal Spine
    Excerpt

    STUDY DESIGN: Time series monitoring changes in titanium and stainless steel rod curvature kept at a constant temperature of 37 C as a function of time. OBJECTIVES: To assess the possibility of loss of curvature in titanium rods after scoliosis surgery. SUMMARY OF BACKGROUND DATA: Titanium rods have gained use in scoliosis surgery due to their excellent biocompatibility, while allowing medical personnel to obtain undistorted magnetic resonance imaging scans following surgery. However, the impression of several clinicians has been that when screw pullout and/or loss of sagittal balance occurs, it may be due to the rods losing some of their curvature. METHODS: Five 6-mm rods of differing compositions and lengths (titanium 300 and 100 mm, stainless steel 300 and 100 mm, prebent titanium 85 mm) were bent at room temperature with a 3-point rod bender, then placed in an incubator at 37 C. Digital photographs were taken every 2 weeks and analyzed to extract the radius of curvature of each rod. RESULTS: The Ti rods had a significantly decreasing curvature with time. The prebent Ti and stainless steel rods did not exhibit significant change in curvature. CONCLUSIONS: Titanium rods bent at room temperature and then exposed to body temperature over time tend to exhibit "metal memory"; they gradually revert to their original shape. This may result in loss of sagittal balance and/or proximal screw pullout.

    Title New Tension Band Material for Fixation of Transverse Olecranon Fractures: a Biomechanical Study.
    Date December 2005
    Journal Orthopedics
    Excerpt

    This study tested the use of braided polyethylene cable as an option for repairing transverse olecranon fractures. Six cadaveric elbows underwent a transverse olecranon osteotomy followed by fixation with tension band constructs using 18-gauge wire and Secure-Strand (U.S. Surgical, North Haven, Conn). Distraction forces up to 450 N were applied to the triceps tendon while measuring fracture displacement with an extensometer. The average maximal fracture gap with the standard AO tension band technique using stainless steel wire was 0.66 +/- 0.43 mm, as opposed to 0.68 +/- 0.45 mm with braided polyethylene cable. A paired t test indicated no significant difference between the two materials. These results support the feasibility of braided polyethylene cable as an alternative to the standard steel-wire tension band.

    Title Vertical Shear Injuries: is There a Relationship Between Residual Displacement and Functional Outcome?
    Date July 1999
    Journal The Journal of Trauma
    Excerpt

    BACKGROUND: Residual vertical displacement is often cited as being related to poor outcome in patients with pelvic injuries. This study attempts to clarify the relationship between residual vertical displacement and functional outcome. METHODS: From 1982 to 1989, over 500 patients with pelvic ring injuries were treated at two Level I trauma centers. Thirty-three patients with vertical shear (Tile C) fractures and residual displacement (2-52 mm) were evaluated. Outcomes were quantified by using SF-36 Short-Form Health Survey (SF-36) and the Iowa Pelvic Score (IPS). RESULTS: There was no correlation between IPS or SF-36 scales and residual vertical displacement. The IPS correlated (p<0.05) with seven of eight SF-36 categories, excluding mental health. Patients reporting limp and leg length discrepancy also correlated with the IPS and select SF-36. CONCLUSION: Pelvic injuries showed no correlation between functional outcome and residual vertical displacement suggesting other factors. The degree of residual vertical displacement does not affect functional outcome.

    Title Ipsilateral Proximal and Shaft Femoral Fractures: Spectrum of Injury Involving the Femoral Neck.
    Date September 1997
    Journal Injury
    Excerpt

    Medical records and radiographs of 52 patients were studied after inclusion/exclusion criteria were met. The anatomical location of proximal femoral fractures that involved the femoral neck were examined after the primary fracture planes were drawn onto templates of the proximal femur. The AO classification is comprehensive and widely accepted. It has not been used in this injury combination in a large series of patients. Therefore, we classified each fracture by the AO method and then the AO classes were tabulated and analysed. Only three patterns of proximal femoral fractures appeared. The inferior aspect of the fracture line clustered in the inferomedial aspect of the femoral neck above an intact lesser trochanter in each separate pattern: 55 per cent were AO B2.1 (basilar); 35 per cent AO B2.3 (intracapsular); and 10 per cent AO A1.2 (pertrochanteric) fractures). Eleven fractures (21 per cent) were not detected initially. None of these were A1.2, eight were B2.1 and three were B2.3. Despite many proximal femoral fracture types reported in the literature only three fracture patterns were noted in this large study group. A new finding of clustering of these fractures in the inferomedial femoral neck was noted. AO class B2.1 fractures were the most common fractures missed at initial presentation and were the most common type seen.

    Title Adult Respiratory Distress Syndrome, Pneumonia, and Mortality Following Thoracic Injury and a Femoral Fracture Treated Either with Intramedullary Nailing with Reaming or with a Plate. A Comparative Study.
    Date July 1997
    Journal The Journal of Bone and Joint Surgery. American Volume
    Excerpt

    Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

    Title Pilon Fractures Treated with an Articulated External Fixator: a Preliminary Report.
    Date March 1997
    Journal Orthopedics
    Excerpt

    Nine high-energy pilon fractures with severe soft tissue injuries were treated by a medial external fixator with an articulated ankle-hinge and limited internal fixation (1.7 screws per case). A 100% union rate was achieved; however, there was a 100% complication rate associated with the fixator. Both B3 fractures required a vertical transarticular pin to maintain reduction. Seven C2 fractures suffered calcaneal screw loosening and drainage, necessitating removal of the fixator prior to union. Due to these complications, the articulated ankle hinge could not be utilized. At a minimum of 6 months follow up, eight of nine fractures had acceptable radiographic and early clinical results.

    Title Management of Humeral Nonunion After the Failure of Locking Intramedullary Nails.
    Date January 1997
    Journal Journal of Orthopaedic Trauma
    Excerpt

    We reviewed 21 cases of humeral nonunion following the failure of "locking" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.

    Title Tibial Diaphyseal Nonunions After External Fixation Treated with Nonreamed Solid Core Nails.
    Date December 1996
    Journal Orthopedics
    Excerpt

    Twenty-nine patients with tibial diaphyseal fractures had external fixators applied to treat their initial fractures and underwent nonreamed solid core nailing for nonunion (> 22 weeks). Fifteen Alta, 11 Lottes, and 3 Rush nails were used. The original fracture grades were: 1 closed, 1 grade I, 7 grade II, 3 grade IIIA, and 17 grade IIIB. The duration of nonunion was 51 weeks (average: 22 to 173). The average duration of external fixation was 19 weeks (range: 9 to 47). The average interval from fixator removal to nail was 32 weeks (range: 0 to 156). Twenty-eight patients were seen at > 12 months' follow up (average: 35; range: 10 to 58) and completion of treatment. Twenty-seven patients' fractures united at an average of 14 weeks (range: 6 to 40). One patient required a reamed exchange nailing at 39 weeks and united 58 weeks post-exchange nailing. One patient had a persistent asymptomatic nonunion. One patient developed a stress fracture 49 months post nail requiring an exchange nailing. Eleven fractures had a pre-nail deformity of 10 degrees or more; 9 were corrected. Eight patients had pre-nail wound and five had pre-nail pin tract infections. Except for two cases, all of these infections were treated successfully with surgical debridement and/or antibiotics prior to nail insertion. Two patients had their nail inserted through active infections that could not be controlled with an unstable fracture. One patient healed uneventfully in 6 weeks. One required two subsequent debridements. There were no other infections. The authors conclude that nonreamed solid core nailing is an acceptable treatment for tibial diaphyseal nonunions following external fixation.

    Title Pelvic Ring Injuries. A Long Term Functional Outcome Study.
    Date October 1996
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    Eighty patients with pelvic fractures, without hip, spine injuries with neurologic deficits, or traumatic cognitive deficits, 61% treated with external fixators, were reviewed with greater than 5 years of followup. The Short Form-36 General Health Survey, the Iowa pelvic scores, and additional questionnaires concerning return to previous sexual function, occupation, and recreation, and a perception of the worst sequelae of their pelvic trauma were administered. Fractures were classified according to Tile as 25 undisplaced Class A, 31 rotationally displaced Class B, and 24 vertically displaced Class C fractures. Injury severity scores, associated injuries, and mechanisms of injuries were similar across Tile classes. Statistical analysis compared Tile Classes A with B with C and Classes A with B and C. Variations by Tile class among the Short Form-36 survey, Iowa pelvic score, or questionnaire result's were not seen. Approximately 75% of patients returned to their previous sexual function and 80% to their previous occupation. Similarities comparing undisplaced with displaced pelvic fractures question whether reduction of pelvic ring injuries can alter patient long term functional outcomes.

    Title Nonreamed Nailing of Closed and Minor Open Tibial Fractures in Patients with Blunt Polytrauma.
    Date December 1995
    Journal Clinical Orthopaedics and Related Research
    Excerpt

    A retrospective comparison of dynamic and static locking mode nonreamed nails in 88 closed, Grades I and II open tibial fractures is presented. Amount of time and number of reoperations required to unite fractures were compared for dynamic (Group 1, n = 31) and static locked (Group 2, n = 13) Winquist I and II fractures, and dynamic (Group 3, n = 14) and static locked (Group 4, n = 30) Winquist III, IV, and segmental fractures. Total reoperations also were compared; Tibias treated with dynamic nails united in an average of 20 weeks, with 3 reoperations; tibias treated with static locked nails united in an average of 30 weeks, with 21 reoperations. Group 1 fractures united in an average of 20 weeks, with 1 reoperation; Group 2 fractures united in an average of 32 weeks, with 4 reoperations. Group 3 fractures united in an average of 20 weeks; Group 4 fractures united in an average of 29 weeks, with 11 reoperations. In the group of tibias treated with dynamic nails, 3 additional operations were done; in the group of tibias treated with static locked nails, 7 additional operations were done. There was 1 infection and 3 deformities. Static locking mode appeared to delay union, especially when Groups 1 and 2 are compared; these fractures can be nailed without locking screws.

    Title Nonreamed Nailing of Tibial Diaphyseal Fractures in Blunt Polytrauma Patients.
    Date May 1995
    Journal Journal of Orthopaedic Trauma
    Excerpt

    The efficacy of nonreamed nailing as the treatment of choice of unstable blunt tibial diaphyseal fractures was studied. From March 1, 1990, through August 31, 1991, 72 patients with 74 fractures that required fixation were treated. One patient died and six were lost to follow-up, leaving 65 patients with 67 fractures. Follow-up averaged 21 months (range 5-43). Fisher's exact and logistic regression analyses were used to compare grades of open fractures, comminution as classified by Winquist, and dynamic and static nailings. The failure rates of 51 titanium and 16 stainless steel nails were compared. Times to union were compared by the log rank statistic method. The average time to union was 32 weeks with 26 (39%) additional operations required to achieve union; 13 dynamizations (12 successful), 12 exchange nailings (11 successful), and one plate and bone graft. The rate of reconstructive procedures to achieve union was a more sensitive indicator of difficulties achieving union than was time to union. Reoperation rates were 33% for closed or grade I and II fractures compared with 46% for grade III fractures (NS). Among closed grade I and II static versus dynamic nailing, times to union were 36 versus 25 weeks (p < 0.01), and the reoperation rates were 44% versus 13% (p < 0.04). Winquist I and II fractures required a 24% reoperation rate versus 53% for grade III and IV and segmental fractures (p < 0.01). Static locked fractures required a 48% reoperation rate versus 12% for dynamic locked fractures (p < 0.01). A logistic regression analysis demonstrated that locking mode was the most important factor in determining reoperation rates. Fifteen additional reoperations for infection, broken or painful implants, or to remodel bones that united with an incomplete circumference of cortex were performed. With an additional 12 elective nail removals, the total reoperations numbered 53 (79%). Titanium alloy nails had a 2% failure rate versus 25% for stainless steel nails (p < 0.01). Two of 28 (7%) grade III fractures became infected. All fractures united within 10 degrees of normal alignment and 1 cm of length. Nine (13%) united with an incomplete cortical circumference, refractory to dynamization and full weight bearing. Thirteen of the 58 (22%) fractures available for an evaluation of ankle motion were symptomatic, with < 10 degrees of dorsiflexion.(ABSTRACT TRUNCATED AT 400 WORDS)

    Title Femur Fractures with Femoral or Popliteal Artery Injuries in Blunt Trauma.
    Date March 1995
    Journal Journal of Orthopaedic Trauma
    Excerpt

    The treatment and results of 13 blunt femoral fractures with an arterial injury were reviewed. Two of the 13 patients (15%) sustained segmental (two levels) arterial injuries. Stabilization of the femur fractures were performed before arterial repair in 10 of the 13 femurs. The results were determined at an average of 4.5 years. For the eight open fractures, two patients had above-knee amputations, no limb regained > 90 degrees of knee motion, four patients required a brace or cane, and three patients have intermittent wound drainage. The five closed fractures all regained full function with full knee motion. Due to the 15% incidence of segmental arterial injury, "wide-field" arteriography is advised for the evaluation of this injury. Femoral stabilization may be performed before arterial repair if the procedure does not encroach on the viability of the limb. The functional results depend on the soft-tissue damage, as illustrated by the poor results seen in open fractures.

    Title Femoral Plating.
    Date October 1994
    Journal The Orthopedic Clinics of North America
    Excerpt

    We have demonstrated that we are able to meet both trauma and orthopedic goals with immediate plate fixation of femoral fractures in patients with blunt polytrauma. Our femoral fracture mortality rate is less than our predicted institutional mortality rate of patients with comparative injury severity scores. Ipsilateral femoral neck and shaft fractures are easily repaired with femoral plating. Infections, even in open fractures and systemically unstable patients, are rare. Implant failures have been infrequent and are easily reconstructed with intramedullary nails. Knee motion has been restored reliably. Stainless steel DCP plate fixation requires primary bone grafting. Achieving union and subsequent knee rehabilitation often requires that patients remain on crutches for up to 6 months. Our experience with titanium LCDCP plates is preliminary, but we are seeing a significant amount of callus formation and, perhaps, earlier union and bearing weight.

    Title Complications of Seidel Intramedullary Nailing of Narrow Diameter Humeral Diaphyseal Fractures.
    Date April 1994
    Journal Orthopedics
    Excerpt

    Forty acute blunt fractures of the humeral diaphysis were treated with Seidel nails (9-mm diameter) between April 1988 and August 1992. Follow up was available for 36 patients. Average Injury Severity Score (ISS) was 22. Forty-eight pelvic and lower extremity fractures necessitated humeral weight bearing in 23 patients. Patients were grouped by canal diameter measured at the point of distal humeral fixation: < or = 9 mm or > or = 10 mm. Data were analyzed with regard to complications, fracture pattern, and time to union. Due to difficulties reaming the humeral canal, five different reaming systems were used. In the < or = 9 mm group (N = 12), there were seven complications (58%). Two patients had iatrogenic comminution distal to the nail. The two open fractures in this group (II, IIIA) developed wound infections, and one, osteomyelitis. Three patients had nonunions: one was lost to follow up at 6 months, and two united at 41 and 74 weeks after exchange nailing and bone grafting. Average time to union was 21 weeks. Six of the seven complications occurred in patients who required reaming of a long, tight segment of distal canal. In the > or = 10 mm group (N = 24), there was one complication of iatrogenic comminution (4%). There were four open fractures (three, grade II; one, IIIB) with no infections. All fractures united (average = 10 weeks). The differences in complications (P = .001) and union (P = .04) between groups were significant. Other complications were not associated with canal diameter or union. There were seven radiographic failures of the distal locking device (19%). Four nails (11%) were left prominent in the shoulder due to technical or equipment failures, and were eventually removed. Four patients (11%) had residual shoulder stiffness (three due to neurologic injury). These primary data suggest use of the Seidel nail is associated with a higher complication rate in humeri with canal diameters < or = 9 mm.

    Title The Anterior Acromial Approach for Antegrade Intramedullary Nailing of the Humeral Diaphysis.
    Date February 1994
    Journal Orthopedics
    Excerpt

    At three institutions, 71 humeral intramedullary nails were inserted into the shoulder; 67 were reviewed at 6 months and at completion of treatment. Fifty-one utilized the anterior acromial approach and 16 were inserted lateral to the acromion. Shoulder motion was rated as: excellent (asymptomatic and within 15 degrees of normal); good (normal daily function within normal motion); and poor. Nails were also inserted into the humeral diaphysis of eight cadaver shoulders. Fifty-one nails were inserted via the anterior acromial incision; 48 were graded as excellent, one as good, and two with traumatic axillary neuropathy and reflex sympathetic dystrophy as poor: Sixteen nails were inserted lateral to the acromion; 8 were rated, 7 good, and 1 poor. Motion returned in an average of 17 weeks (range:0-29). The greatest clinical concern is not ultimate shoulder function, but the rate of return. The authors conclude that either the anterior acromial approach or an extraarticular entry portal must be utilized for antegrade humeral diaphyseal nailing.

    Title Clandestine Femoral Neck Fractures with Ipsilateral Diaphyseal Fractures.
    Date December 1993
    Journal Journal of Orthopaedic Trauma
    Excerpt

    We present a protocol for diagnosis of all femoral neck fractures associated with ipsilateral femoral diaphyseal fractures. A 30% incidence of delayed diagnosis has been reported by other investigators. Between 1982 and 1990, we have treated 32 patients with ipsilateral femoral neck and shaft fractures due to blunt trauma. Only 22 femoral neck fractures were diagnosed on prediaphyseal fixation radiographs. This left the 10 patients in this study who had normal prediaphyseal fixation radiographs and were subsequently found to have femoral neck fractures. The ipsilateral femoral neck fractures were found through a retrospective chart and radiographic review of all 555 femoral diaphyseal fractures identified through our trauma and fracture registries. The clinical and radiologic techniques for diagnosing the femoral neck fractures were presented. The time to union of the femoral shaft and neck was determined, and a preliminary radiologic assessment of the vascularity of the femoral head was made. Ten femoral neck fractures (31%) with normal preoperative radiographs were diagnosed after femoral diaphyseal fixation. One patient did not have a post-diaphyseal fixation radiograph. An incidental radiograph at 6 weeks showed a mildly displaced femoral neck fracture in an asymptomatic patient. At 16 weeks the patient became symptomatic, and a repeat radiograph showed the fracture. Five fractures were diagnosed in asymptomatic patients on routine post-femoral fixation radiographs. Two patients had normal post-femoral fixation radiographs, became symptomatic, and had their femoral neck fractures diagnosed on repeat radiographs at 3 and 7 days. One patient had normal pre- and postfixation radiographs, and on a 25-day routine femoral radiograph, the femoral neck fracture was diagnosed.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Acute Mortality Associated with Injuries to the Pelvic Ring: the Role of Early Patient Mobilization and External Fixation.
    Date December 1993
    Journal The Journal of Trauma
    Excerpt

    PURPOSE: To analyze the effect on mortality of a protocol for early mobilization with external fixation of patients with pelvic ring injuries. METHODS: From 1981 through 1988, 605 patients with pelvic ring fractures and dislocations were treated. In 1982, a protocol for early external fixation of hemodynamically unstable patients and those with structurally unstable pelvic fracture patterns to achieve early mobilization to an upright chest position was initiated. Mortality rates were compared between 1981 (pre-protocol), 1982 (transitional), and 1983 through 1988, after initiation of a protocol of care that included external fixation of the pelvic injury. No statistical changes occurred from 1983 through 1988. RESULTS: Mortality rates in pelvic ring injury patients fell from 26% in 1981, to 6% in 1983 through 1988 (p < 0.001), whereas during the study period the mean injury Severity Score (ISS), 23, did not change. The mortality rate of a group of consecutive patients with comparable ISSs, but without pelvic ring injuries did not change. The mortality rate in patients with systolic blood pressure < 100 mm Hg at admission fell from 41% in 1981 to 21% 1983 through 1988 (p = 0.0001). Mortality in patients with closed head injuries associated with pelvic ring injuries fell from 43% in 1981 to 7% from 1983 through 1988 (p = 0.0001). The proportion of patients undergoing external fixation rose from 3% in 1981 to 31% in 1983 through 1988 (p = 0.0001). CONCLUSIONS: An organized protocol including external fixation and early patient mobilization to an upright chest position reduced mortality associated with injuries of the pelvic ring. Orthopedic stabilization of major skeletal injuries should be viewed as part of patient resuscitation, not reconstruction.

    Title Comparison of Reamed and Nonreamed Solid Core Nailing of the Tibial Diaphysis After External Fixation: a Preliminary Report.
    Date August 1993
    Journal Journal of Orthopaedic Trauma
    Excerpt

    From July 1982 to March 1990, 32 patients had an external fixator applied to treat a tibial diaphyseal fracture and subsequently underwent intramedullary nailing: 16 with reamed and 16 with nonreamed solid core nails. Indications for surgery were 12 atrophic and 1 hypertrophic nonunion in each group. The balance were either planned conversions or inadequate external fixators due to head injuries. All but one were seen by an author at a minimum of 1 year. Among the reamed nails, 3 fractures were grade III B. Two patients had pin tract infections, and there were no prenail wound infections. All infections were clinically inactive at the time of nail insertion. Postnail, 7 patients became infected, requiring 12 debridements and 2 procedures to achieve union. One patient had a plate applied 44 weeks postnail and was lost 48 weeks postnail with a persistent infected nonunion. The average time to union was 26 weeks. In the nonreamed solid core group, 2 fractures were grade III A and 5 grade III B. There were 2 pin and 5 prenail wound infections. One nail was inserted across an active pin tract infection. One tibia became infected postnail (p = .04). The fractures united at an average of 14 weeks postnail (p = .036). Two debridements to control infection but no further procedures to achieve union were necessary (p = .003). When tibial reconstructions following external fixation are required, nonreamed solid core nails are efficacious and may be preferable to reamed nails.

    Title Immediate Plate Fixation of Highly Comminuted Femoral Diaphyseal Fractures in Blunt Polytrauma Patients.
    Date September 1992
    Journal Orthopedics
    Excerpt

    From January 1982 through December 1988, 150 patients with 153 Winquist Class III and IV comminuted diaphyseal femur fractures due to high energy blunt trauma were treated with immediate plate fixation. A total of 260 major general surgical systems were injured in 150 patients. Forty-nine patients did not have adequate preoperative spine radiographs due to positioning or time factors. Nineteen patients had spine fractures; nine were diagnosed post-femoral fixation. The average injury severity score (ISS) was 22.7. Three patients died (2%). Our institution predicted mortality with this ISS for patients without pelvic or femur fractures at 15% (P = .0003). Six patients moved to other states and three were lost to follow up due to noncompliance. One of us reviewed 141 fractures in 138 patients at a minimum of 12 months follow up and completion of treatment. Forty-nine fractures were open; 8 grade I, 25 grade II, 10 grade IIIA, 4 IIIB, 2 IIIC. A total of 153 pelvic or ipsilateral major orthopedic injuries were present in 141 fractures. An additional 188 major associated orthopedic injuries were noted. The average time to union was 17.2 weeks. One plate was applied in 11 degrees of varus. Five plates failed from fatigue and five from repeat traumas. Seven plate failures were rodded and healed within 8 weeks. There was one persistent nonunion. One fracture, open IIIC, became infected after uniting. One patient has 110 degrees of knee motion and 140 fractures have greater than 130 degrees of knee motion. Plate fixation is a safe technique for immediate femoral stabilization in the face of high energy blunt trauma. Failures occur late and are easy to reconstruct. Intramedullary nails are the preferred method of reconstruction. Ultimate knee function is excellent. Infection rates (1/49) in open fractures are acceptably low.

    Title The Risk of Injury to the Axillary Nerve, Artery, and Vein from Proximal Locking Screws of Humeral Intramedullary Nails.
    Date July 1992
    Journal Orthopedics
    Excerpt

    An elderly female cadaver fore-quarter amputation was dissected, and a custom straight intramedullary nail with a 55 degrees oblique downward lateral to medial proximal screw was inserted with a trocar protruding beyond the medial cortex of the humeral surgical neck. The main trunk of the axillary nerve was found to be at risk with any penetration from anterior to posterior and any screw penetration beyond the medial cortex with internal rotation. The axillary artery and vein were at risk with penetration of over 3 cm by a drill point or screw tip whether a transverse or oblique downward screw was used. Transverse screws inserted through the humeral neck from lateral to medial have the potential for damaging a small branch of the axillary nerve laterally, and care must be taken of the lateral humerus while inserting these screws. Screws inserted in a downward direction near the greater tuberosity, if originating above the equator of the humeral head, may cause impingement.

    Title The Abduction Lordotic View of the Clavicle: a New Technique for Radiographic Visualization.
    Date February 1992
    Journal Journal of Orthopaedic Trauma
    Excerpt

    The abduction lordotic view is a previously unreported radiographic technique for visualization of the clavicle. Use of this technique, a simple office procedure, combined with a standard anteroposterior view allows almost 90 degrees visualization of the clavicle. It is recommended particularly for the assessment of clavicular healing.

    Title Harvesting of Autogenous Cancellous Bone Graft from the Proximal Tibial Metaphysis. A Review of 230 Cases.
    Date February 1992
    Journal Journal of Orthopaedic Trauma
    Excerpt

    A study was undertaken to review the results of donor site morbidity of cancellous bone grafts obtained from the proximal tibial metaphysis. Two hundred six patients who underwent 230 proximal tibial bone graft harvestings were reviewed. Patients with lower-extremity fractures or nonunions who required cancellous bone grafts and would be non-weight-bearing for at least 6 weeks were selected to undergo the procedure. Minimum length of follow-up was 4 months, with an average length of follow up of 20.4 months. The proximal tibial metaphysis was found to supply an adequate amount of graft for all procedures involved, with a complication rate related to graft donor site of 1.3%. This compares favorably to a previously published report on bone grafts taken primarily from the iliac crest. The postoperative appearance of the proximal tibia may be permanently altered by the procedure, but weight-bearing after 6 weeks appears safe. The proximal tibial metaphysis is a useful site for obtaining cancellous bone graft and is associated with a low morbidity.

    Title Ipsilateral Femoral Neck and Shaft Fractures: an Overlooked Association.
    Date August 1991
    Journal Skeletal Radiology
    Excerpt

    A total of 304 patients with injuries to the femoral shaft and ipsilateral hip presented between 1984 and 1990. Some 253 of them suffered fractures of the femoral shaft and dislocated hips or fractures of the acetabulum, and 51 of these sustained fractures of the femoral shaft and neck or trochanteric region. Of this latter group, 20 patients had a combination of femoral shaft and neck fractures, and 31 had a combination of femoral shaft and trochanteric fractures. All of the trochanteric injuries were demonstrated on the initial radiographs. However, in 11 of the patients with combined femoral shaft and neck fractures, the diagnosis was delayed by as much as 4 weeks. This delay related to the fact that these fractures tended not to separate in the initial evaluation period and that there was external rotation of the proximal femoral fragment due to the femoral shaft fracture. Good preoperative and, in particular, good postoperative radiography of the hip is essential to make the diagnosis. Although orthopedic surgeons have been aware of this combination of injuries since 1953, radiologists have not.

    Title Seidel Intramedullary Nailing of Humeral Diaphyseal Fractures: a Preliminary Report.
    Date May 1991
    Journal Orthopedics
    Excerpt

    Forty-two humeral diaphyseal fractures in 41 patients were treated at three centers between April 1988 and November 1989. There were 28 acute fractures; four were open. Average time to union was 8 weeks. There were no infections. Six patients with seven pathologic fractures due to metastatic disease died during the course of this study, but the nail had allowed them to be functional with minimal surgical dissection. Five of six nonunions united with one procedure. There was one residual nonunion in a patient with a wide canal and an arthrodesed shoulder above the nonunion. There were three preoperative radial and two preoperative axillary nerve palsies, and no iatrogenic nerve palsies. In all patients with anterior deltoid incisions, shoulder motion returned reliably, but took as long as 6 months. Four rods were left prominent in the rotator cuff and the patients had symptoms of impingement until rod removal. Six patients had restricted shoulder function, one due to a fracture of the humeral head and five from a lateral deltoid incision. This incision was used in 12 cases. There were no stiff shoulders when using an anterior deltoid incision.

    Title Pylon Fractures of the Ankle: a Distinct Clinical and Radiologic Entity.
    Date July 1988
    Journal Radiology
    Excerpt

    Pylon fractures are a distinct clinical and radiologic entity that should not be confused with trimalleolar fractures. Radiographic and clinical comparison of 20 surgically documented pylon and ten trimalleolar fractures revealed four major features of pylon fractures distinguishing them from trimalleolar fractures: (a) the presence of profound distal-tibial comminution, (b) intra-articular extension of tibial fractures through the dome of the plafond, (c) the presence of a fractured talus, and (d) anatomic relationship of the lateral malleolus to the talus at the level of the ankle mortise. With use of clinical history in addition to plain radiography, pluridirectional tomography, and computed tomography, these two fractures can be clearly separated. This distinction carries important surgical and prognostic implications.

    Title Magnetic Resonance Imaging in Acute Tendon Ruptures.
    Date March 1987
    Journal Skeletal Radiology
    Excerpt

    The diagnosis of acute tendon ruptures of the extensor mechanism of the knee or the Achilles tendon of the ankle may usually be made by clinical means. Massive soft tissue swelling accompanying these injuries often obscures the findings, however. Magnetic resonance imaging (MRI) can rapidly demonstrate these tendon ruptures. Examples of the use of MRI for quadriceps tendon, and Achilles tendon rupture are presented.

    Title The Demonstration of a Specific 5'-nucleotidase Activity in Rat Tissues.
    Date January 1976
    Journal Archives of Biochemistry and Biophysics

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