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Biomedical subjects

M F Swiontkowski

Publications and source records attributed to M F Swiontkowski.

At least 19 recordsLinked to original sources
PubMed2003

Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices.

The choice between dynamic screw-intramedullary nail (DSIN) devices and dynamic screw-plate (DSP) devices for the fixation of unstable trochanteric fractures remains controversial. This study presents a meta-analysis of fixation failures in unstable trochanteric femoral fractures using DSP devices or DSIN devices. Two independent assessors selected randomised controlled trials using a range of electronic databases, as well as reference lists of selected articles. A study quality checklist was used. The occurrence of fixation failure, in particular cut-out, was the primary subject of analysis using descriptive statistics and random-effect meta-analyses. Seventeen trials were identified. Meta-analyses showed no significant difference in the frequency of implant-related complications between the two types of devices. Iatrogenic femoral fractures associated with the use of DSIN devices represent a rare, but persistent, risk. There was a tendency for less frequent cut-out with intramedullary devices compared with DSP devices.

Bone Nails↗
PubMed2003

The use of a locking custom contoured blade plate for peri-articular nonunions.

A retrospective chart and radiographic review was performed of 37 operative procedures over 7 years period for peri-articular nonunions. This was a consecutive cohort from a single orthopedic trauma service of a Level 1 center. Nonunions of the tibia and humerus were treated with blade plates fashioned from standard compression plates. Twenty-nine operative sites were treated successfully. The average age was 45.0 years; the average follow-up being 5.3 years. The average number of operations before blade plate was 4.0 (range 1-16). Sixteen blade plates were performed in patients with a diagnosis of clinical infection and all progressed to union and resolution of infection. Seven tissue transfers were used as adjunctive therapy. Five other patients with blade plate surgery had persistent nonunion, of which four united after a second custom contoured blade plate procedure. This study illustrates that surgeon contoured blade plates are an option for peri-articular nonunions even in the presence of infection. This technique resulted in a high union rate and a low complication rate compared to other options.

Accidental Falls↗
PubMed2001

Cutaneous metal sensitivity in patients with orthopaedic injuries.

BACKGROUND: Manufactures of orthopaedic fracture implants have turned to titanium in a pure form and an alloy during the past ten to fifteen years. Although primarily because of the biomechanical properties of this metal, concern for allergy to nickel and chromium ions in stainless steel was a factor in these decisions. OBJECTIVES: To document the incidence of baseline sensitivity to metal ions and the incidence of conversion to sensitivity to one of three ions in stainless steel in a population of trauma patients at a Level I trauma center. DESIGN: Prospective, consecutive patient series. SETTING: Level I trauma center. PATIENTS: Patients eighteen years of age and older with no history of metallic implants were recruited for this study between October 1995 and July 1997. Four hundred ninety-three patients had a Finn chamber device with chromium, nickel, and cobalt ions, which were read using a photographic scale on day three. Two hundred forty-two of these patients had placement of a second patch, at a mean interval of 187 days (range 45 to 589 days). INTERVENTION: Internal fixation of fracture or osteotomy with metal implant. MAIN OUTCOME MANAGEMENT: Cutaneous reactivity to metal ions. RESULTS: Prevalence of sensitivity to chromium was 0.2 percent, to nickel 1.3 percent, and to cobalt 1.8 percent. Rates for conversion from a negative to positive status were 2.7 percent for chromium, 3.8 percent for nickel, and 3.8 percent for cobalt. Rates for desensitization (i.e., converting from a positive to negative status) were 2.1 percent for nickel and 3.8 percent for cobalt. CONCLUSION: The prevalence of sensitivity to nickel, cobalt, and chromium is apparently low. Similarly, internal fixation devices composed of stainless steel appear to result in an equal incidence of conversion to metal ionic sensitivity and desensitization to metal ions. It is conceivable that cutaneous sensitivity is not representative of deep immune response.

Adult↗
PubMed2001

Treatment of open fractures of the shaft of the tibia.

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data. One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection. Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails. We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.

External Fixators↗
PubMed2001

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Adolescent↗
PubMed2000

Outcome validation of the AO/OTA fracture classification system.

OBJECTIVES: To determine whether a greater severity of injury as documented by the AO/OTA code would correlate with poor scores of impairment, functional performance, and self-reported health status. DESIGN: Prospective, functional outcome. SETTING: Three Level One Trauma Centers. PATIENTS/PARTICIPANTS: Two hundred patients with unilateral and isolated lower extremity fractures. MAIN OUTCOME MEASUREMENTS: Six- and twelve-month SIP, AMA impairment, and functional performance measures of self-selected walking speed, stair climbing, heel raises, rising from a chair, balance work. RESULTS: At six months post injury, overall impairment was significantly (p < 0.05) higher for patients with Type C versus Type B fractures. A significant difference was found among the A, B, C types and the ROM impairment rating at six months (p = 0.004). Using the Scheffe method, the significant difference was determined to be between the B- and C-type fractures. Overall functional performance scores at six months were shown to have significant (p = 0.01) variation using an ANOVA with the significant variation being between the B and C type. At twelve months, the overall functional performance was significant (p = 0.05). CONCLUSION: Patients with C-type fractures had significantly worse functional performance and impairment compared with patients with B-type fractures but were not significantly different from patients with A-type fractures. AO/OTA code may not be a good predictor of six- and twelve-month functional performance and impairment for patients with isolated unilateral lower extremity fractures.

Analysis of Variance↗
PubMed1999

Musculoskeletal function assessment: reference values for patient and non-patient samples.

Although researchers and clinicians are encouraged to use health-status questionnaires to evaluate, monitor, and modify care, their use is hindered by the lack of reference values. Without reference values, it is difficult to interpret or evaluate questionnaire scores. In this paper, we present reference values for the Musculoskeletal Function Assessment, a 101-item health-status questionnaire designed and validated for patients with a broad range of musculoskeletal disorders. We describe reference values for two samples: non-patients (n = 123) and patients with isolated extremity injuries (n = 274). For the non-patient sample, descriptive statistics are presented by age and gender, measured at one point in time. For the patient sample, descriptive statistics are provided for seven Orthopaedic Trauma Association/AO diagnostic groups, measured at two points in time. Reference values for changes in the Musculoskeletal Function Assessment total score are described for patients 3 and 9 months and 6 and 12 months after injury. The total scores by post-injury interval, across the diagnostic groups, are significantly better at follow-up than at baseline (p = 0.00). Reference values for changes in total scores are also described in terms of these diagnostic groups across post-injury intervals. Musculoskeletal Function Assessment total scores for Orthopaedic Trauma Association/AO diagnostic groups are significantly better at follow-up than at baseline (p < 0.03). Changes in the total score are also tested for responsiveness with use of standardized response means. Large effects are demonstrated for patients completing the Musculoskeletal Function Assessment at 3 and 9 months (1.03), and small effects are demonstrated for those completing it at 6 and 12 months (0.49). Moderate and large effects are demonstrated for Orthopaedic Trauma Association/AO diagnostic groups across post-injury intervals.

Adolescent↗
PubMed1999

A comparison of short- and long-term intravenous antibiotic therapy in the postoperative management of adult osteomyelitis.

The current standard recommendation for antibiotic therapy in the management of chronic osteomyelitis is intravenous treatment for six weeks. We have compared this regime with short-term intravenous therapy followed by oral dosage. A total of 93 patients, with chronic osteomyelitis, underwent single-stage, aggressive surgical debridement and appropriate soft-tissue coverage. Culture-specific intravenous antibiotics were given for five to seven days, followed by oral therapy for six weeks. During surgery, the scar, including the sinus track, was excised en bloc. We used a high-speed, saline-cooled burr to remove necrotic bone, and osseous laser Doppler flowmetry to ensure that the remaining bone was viable. Infected nonunions (Cierny stage-IV osteomyelitis) were stabilised by internal fixation. In 38 patients management of dead space required antibiotic-impregnated polymethylmethacrylate beads, which were exchanged for an autogenous bone graft at six weeks. Free-tissue transfer often facilitated soft-tissue coverage. These 93 patients were compared with 22 consecutive patients treated previously who had the same surgical management, but received culture-specific intravenous antibiotics for six weeks. Of the 93 patients, 80 healed without further intervention. Of the 31 Cierny-IV lesions, 27 healed without another operation, and four fractures required additional bone grafts. No more wound drainage was needed. Treatment was successful in 91% of patients, regardless of the organism involved. There was no difference in outcome in terms of these variables when the series were compared. We conclude that the long-term administration of intravenous antibiotics is not necessary to achieve a high rate of clinical resolution of wound drainage for adult patients with chronic osteomyelitis.

Administration, Oral↗
PubMed1999

Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness.

BACKGROUND: A short questionnaire on functional status was designed for use in community-based outcome studies and in the management of individual patients who have musculoskeletal disease. As most musculoskeletal care is delivered in community practices, short, validated instruments are necessary to perform clinical studies on the effectiveness of treatment in this setting. METHODS: A forty-six-item questionnaire was created as an extension of the work to develop the longer, 101-item Musculoskeletal Function Assessment (MFA) questionnaire. The Short Musculoskeletal Function Assessment (SMFA) questionnaire consists of the dysfunction index, which has thirty-four items for the assessment of patient function, and the bother index, which has twelve items for the assessment of how much patients are bothered by functional problems. The SMFA questionnaire was evaluated for reliability, validity, and responsiveness in a population of 420 patients who had a musculoskeletal disease or injury. RESULTS: The SMFA questionnaire demonstrated excellent internal consistency and stability, with most values greater than 0.90. Content validity for the dysfunction and bother indexes was supported with very little skew (less than 1.00), few ceiling effects (less than 5 percent), and no floor effects. Convergent validity was supported with significant correlations between the SMFA dysfunction and bother indexes and the physicians' ratings of patient function (for example, activities of daily living, recreational and leisure activities, and emotional function [rho > or = 0.40]) and standard clinical measures (for example, grip strength and walking speed [r > or = 0.401). Convergent and discriminant construct validity of the SMFA indexes were demonstrated (p < 0.01) in comparisons with clinical, demographic, Short Form-36 (SF-36), and life-change data. The responsiveness of the SMFA questionnaire to change over time was demonstrated with standardized response means ranging from moderate (0.76) to large (-1.14) for patients who had changes in health status. CONCLUSIONS: The SMFA questionnaire may be used for clinical assessments of the impact of treatment in groups of patients who have musculoskeletal disease or injury. It also may be used in clinical settings to provide reliable and valid assessments of the health status of an individual patient.

Adolescent↗
PubMed1999

In vitro evaluation of a laser Doppler flowmetry implantable fibre system: the effect of flow velocity and concentration on perfusion assessment.

The utility of laser Doppler flowmetry (LDF) is limited by the requirement for placement of the LDF probe directly on the bone surface. A system of implantable and detachable fibres was developed so that repeated non-anaesthetized measurements could be made. Using a specially designed flow chamber and a flow medium of latex particles, we compared the in vitro properties of the implantable fibre and the standard probe, by determining the effect of flow velocity and concentration on perfusion assessment. For both probes, the LDF output increased in response to increasing flow velocities and concentrations of the flow medium. With increasing velocities of the flow medium, both probes responded similarly when assessing perfusion through cortical bone, but differed when measuring flow through cancellous bone. A difference between the probes also existed when determining the effect of concentration on perfusion assessment. With increasing concentrations of the latex particles, the rate of LDF output increased more rapidly when perfusion was measured end on to the direction of flow by the standard probe, compared to the implantable fibre. This situation was reversed when assessing perfusion tangential to the direction of flow. The differences in the properties of the two probe systems are related to the direction of flow assessment and the type of bone through which flow was measured. These factors should be considered when measuring blood flow with either the LDF implantable fibre system or the standard LDF probe.

Animals↗