Search PubMed⌕ Search

Biomedical subjects

P Tornetta

Publications and source records attributed to P Tornetta.

At least 37 records · Page 2Linked to original sources
PubMed2000

Hybrid external fixation of tibial pilon fractures.

Although external fixation reduces drastically the number of iatrogenic complications compared with acute open reduction and plate fixation, the prognosis for functional recovery after a pilon fracture remains guarded. Many authors have applied validated patient outcome measures to patients who have had pilon fractures. These studies confirmed that there are significant decreases in general health perceptions, physical and emotional role function, pain, and energy levels in patients who have suffered pilon fractures, regardless of the treatment modality. The high-energy tibial pilon fracture with soft tissue compromise remains a treatment dilemma. Hybrid external fixation with limited open reduction has proved to be a safe, reproducible, and effective treatment modality for this complex fracture.

Ankle Injuries↗
PubMed1999

Pseudosubluxation of the hip joint. A case report.

The case of a 32-year-old man who had a subluxation of his hip joint after open reduction and internal fixation for an acetabular fracture is presented. The subluxation resolved without surgical intervention. It is thought that the subluxation, herein termed pseudosubluxation, is similar to pseudosubluxation seen in the shoulder. The patient had sustained significant trauma to the abductor musculature and lateral hip region with a Morel-Lavelle lesion and a hip fracture coincident with his acetabular fracture. This entity has not been reported previously.

Accidents, Traffic↗
PubMed1999

Intraarticular anatomic risks of tibial nailing.

OBJECTIVE: To identify the risks to intraarticular structures of the knee during tibial portal creation and to identify the safe zone for tibial nail placement. STUDY DESIGN: Cadaveric anatomic. LOCATION: University trauma center. METHODS: Forty fresh frozen cadaveric knees were studied to elaborate the risks of tibial portal creation and nail placement to the intraarticular structures of the knee. Nails were placed through medial and lateral parapatellar approaches, and the distance from the nail portal to the intraarticular structures of the knee was measured. A safe zone for portal placement was determined. RESULTS: The tibial portal location averaged 4.4+/-3 millimeters lateral to the midline of the plateau. Actual intraarticular structural damage occurred in 20 percent of the specimens; however, an additional 30 percent demonstrated the nail to be subjacent to one of the menisci. A lateral paratendinous approach placed the lateral articular surface at most risk, and a medial paratendinous approach placed the medial meniscus at most risk. The safe zone for nail placement was identified and is located 9.1+/-5 millimeters lateral to the midline of the plateau and three millimeters lateral to the center of the tibial tubercle. The width of the safe zone averaged 22.9 millimeters and was as narrow as 12.6 millimeters. CONCLUSION: Damage to the intraarticular structures of the knee is possible during tibial nailing with a superior portal. The safe zone for nail placement is small and can be exceeded if a reamed nail is used. The safest starting point for tibial nailing should be slightly lateral to the center of the tibial tubercle.

Bone Nails↗
PubMed1999

Morbidity and mortality in elderly trauma patients.

BACKGROUND: Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as the Injury Severity Score to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined with regard to complications and mortality. The purpose of this study was to review a large multicenter experience with elderly trauma patients to isolate factors that might predict morbidity and mortality. The potential effect of skeletal long-bone injury was of particular interest. METHODS: The charts of all patients older than 60 years who were admitted to one of four Level I trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were motor vehicle crash, pedestrian struck, fall from a height, and crush injury. Slip-and-fall injuries were excluded. A total of 326 patients met inclusion criteria. Variables studied included age, sex, mechanism of injury, Injury Severity Score (ISS), Revised Trauma Score, Glasgow Coma Scale (GCS) score, blood transfusion, fluid resuscitation, surgery performed (laparotomy, long-bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of adult respiratory distress syndrome, pneumonia, sepsis, myocardial infarction, deep venous thromboembolism, gastrointestinal complications, and death. chi2, logistic regression, t test, and nonparametric analyses were done as appropriate for the type of variable. RESULTS: The average age of the patients was 72.2+/-8 years. Overall, 59 patients (18.1%) died, of whom 52 of 59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4), lower GCS score (11.5 vs. 13.9), greater transfusion requirement (10.9 vs. 2.9 U), and more fluid infused (12.4 vs. 4.9 L). Logistic regression analysis was performed to determine the factors that predicted mortality. They included (odds ratios and p values in parentheses) transfusion (1.11, p = 0.01), ISS (1.04, p = 0.008), GCS score (0.87, p = 0.007), and fluid requirement (1.06, p = 0.06). Regarding surgery, orthopedic surgery alone had an odds ratio of 0.53, indicating that orthopedic patients was less likely to die than patients who did not undergo any surgery. Patients who underwent only a general surgical procedure were 2.5 times more likely to die (p = 0.03) and patients who underwent both general and orthopedic procedures were 1.5 times more likely to die (p = 0.32) than patients who did not require surgery. Early (< or =24 hours) versus late (>24 hours) surgery for bony stabilization did not have a statistical effect on mortality (11% early vs. 18% late). Two patients in need of bony stabilization, however, died before these procedures were performed. With regard to complications, regression analysis revealed that ISS predicted adult respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications; fluid transfusion predicted myocardial infusion; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality. This large series of elderly patients demonstrates that mortality correlates closely with ISS and is influenced by blood and fluid requirements and by GCS score. The institution-specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series. CONCLUSION: Mortality is predicted by ISS and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. (ABSTRACT TRUNCA

Aged↗
PubMed1999

Non-operative management of acetabular fractures. The use of dynamic stress views.

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45 degrees, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients' other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.

Acetabulum↗
PubMed1998

Neurologic and vascular structures at risk during anterior-posterior locking of retrograde femoral nails.

OBJECTIVE: To evaluate the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur. DESIGN: Cadaveric study. MAIN OUTCOME MEASURE: Anatomic relationships. RESULTS: The femoral artery lies medial to the femur, and its branches cross the anterior femur more than four centimeters distal to the lesser trochanter. Branches of the femoral nerve cross the anterior femur proximal to the lesser trochanter and start four centimeters distal to the piriformis fossa. CONCLUSIONS: Risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter.

Bone Screws↗
PubMed1998

Use of an interlocked cephalomedullary nail for subtrochanteric fracture stabilization.

Forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; the most frequent complication was a varus malreduction. The union rate was 100% at an average of 13.5 weeks after surgery; there were no implant failures. Forty-three of 45 (96%) patients regained greater than 120 degrees knee motion. Based on these results it is thought that an interlocked cephalomedullary nail may be the implant of choice for stabilization of Russell-Taylor Type 1B fractures; however, its proper use requires careful intraoperative technique, with particular attention given to avoid a varus malreduction.

Adolescent↗
PubMed1998

Operative treatment of hip fractures in patients with renal failure.

The conditions of a hip fracture and renal failure cause particularly high mortality. Eight patients (average age, 63 years) who had operative treatment for nine hip fractures were studied retrospectively. Three had intertrochanteric fractures fixed with sliding compression screws, and five had femoral neck fractures (bilateral in one patient): two nondisplaced femoral neck fractures were fixed with percutaneous screws, and four displaced femoral neck fractures were treated with arthroplasties in three and percutaneous screws in one. Operative treatment was done when the patient was in medically stable condition (average, 8 days). Full weightbearing was allowed on the injured limb after surgery. Early morbidity analysis showed no wound infections, thromboembolic events, or hemorrhagic complications. The first year mortality was three (38%). Late morbidity included one nonunion and one sliding screw penetration. Total mortality at 6 years was seven (88%) patients, with an average postoperative survival time of 28 months. Preoperative ambulation was preserved in five of seven (71%) patients. One the basis of this study, it appears that a team approach to operative management including nephrologist and surgeon helps to reduce short term complications and mortality and allows such patients to be mobilized and regain ambulation.

Aged↗
PubMed1997

Damage control for devastating pelvic and extremity injuries.

This article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. The authors describe the current approach to the mangled extremity and discuss indications for primary amputation.

Blood Loss, Surgical↗
PubMed1997

The risks of Kirschner wire placement in the distal radius: a comparison of techniques.

A comparison of percutaneous and limited open insertion of Kirschner wires (K-wires) in the distal radius was conducted in an effort to determine which technique has the lower rate of iatrogenic injury. Eighty-eight K-wires were inserted in the distal radii of 44 fresh cadaveric arms: 44 at Lister's tubercle and 44 at the tip of the radial styloid. No incision was used for the percutaneous technique. The limited open technique included a 1.5-cm incision with blunt dissection and use of a soft tissue protector. To define the incidence of nerve or tendon damage secondary to pin placement, the cadaveric wrists were subsequently dissected under 3.5x loupe magnification. The distances from the K-wires to the branches of the superficial radial nerve and to the first 3 extensor compartments were recorded. Structures pierced or displaced by a K-wire were considered potentially injured. Chi-square analysis demonstrated a significantly higher rate of potentially injured nerves and tendons in the percutaneous group. Thus, to reduce the risk of potential injuries, limited open incision, blunt dissection down to bone, and the use of a soft tissue protector for K-wire placement into the distal radius is recommended.

Bone Wires↗
PubMed1997

Open fractures of the humerus treated with external fixation.

Twenty-three patients with open fractures of the humerus who had been treated with immediate external fixation were reviewed retrospectively. Eighteen patients had adequate followup and were included in this study. Four patients (22%) had Gustilo and Anderson Grade I injury; 1 (5%), Grade II; and 13 (72%), Grade III (1 IIIA, 2 IIIB, and 10 IIIC). Fourteen patients (78%) had associated neurologic injury, of which 9 involved multiple nerves. A unilateral external fixation frame with half pins proximal and distal to the fracture site was used in all but 1 case. In 8 patients (44%) with distal humerus fractures, the external fixator crossed the elbow joint. All upper extremities in this series were salvaged. The duration of external fixation averaged 11 weeks. Complications included 3 malunions, 1 delayed union, 8 (44%) pin tract infections, 2 pin tract sequestrum formation, and 2 late fractures after removal of the external fixator. At followup (average, 34 months), function was rated as good or excellent in 12 patients (70%). There were 1 fair and 4 poor results. External fixation of complicated fractures of the humerus allowed associated injuries to the nerves, arteries, and soft tissues to be treated adequately while maintaining skeletal stability.

Adolescent↗
PubMed1997

Compartment pressures during nonreamed tibial nailing without traction.

OBJECTIVE: To assess the intracompartmental pressure changes during the nailing of acute tibia fractures with the extrinsic factors of 90 degrees/90 degrees positioning, posterior thigh posts, continuous traction, and remaining removed. STUDY DESIGN: Prospective case control. METHODS: Fifty-eight acute tibia fractures were nailed using an unreamed technique without leg elevation, thigh post, or continuous traction. Two presented with compartment syndrome and had fasciotomy before nailing. Thirty of the remaining fifty-six tibias had continuous intracompartmental pressure monitoring of the anterior compartment. RESULTS: The highest pressures were routinely seen during manual reduction of the fracture (20-58mms Hg; avg = 34mm Hg) and during nail passage (15-56mms Hg; avg = 26mms Hg). In fifteen tibias, the pressure rose to within 30mmg Hg of the diastolic pressure and in 12 tibias the pressure exceeded 40mmg Hg. The pressures in all cases returned to baseline immediately following nail passage (avg = 13.8mms Hg). No sequelae of compartment syndrome was found in any of the 56 tibias presenting without compartment syndrome. There were no iatrogenic compartment syndromes in the series. CONCLUSION: When extrinsic factors that increase intramedullary pressures are avoided, then intramedullary nailing raises the intramedullary pressure only momentarily. The pressure peaks during manual reduction and nail passage, and then returns to normal before the patient is awakened. Intramedullary nailing performed without reaming or traction is safe with respect to compartment syndromes and continuous pressure is not required.

Adolescent↗
PubMed1997

Intraarticular findings after gunshot wounds through the knee.

OBJECTIVES: To compare the radiographic findings in patients with a low-velocity gunshot wound through the knee with the intraarticular pathology as documented by arthroscopy, and to evaluate arthroscopic management of these injuries. STUDY DESIGN: Retrospective review of a protocol. MATERIALS AND METHODS: Thirty-three patients with low-velocity gunshot wounds through the knee, no significant soft tissue injury, and no fracture requiring repair were studied. Radiographs were evaluated for bullet fragments, loose bodies, and debris. All patients were treated with arthroscopic evaluation and management of intraarticular pathology. The arthroscopic findings were compared with the radiographic findings. RESULTS: Five chondral injuries and fourteen meniscal injuries not suspected on the basis of plain films were found during arthroscopic evaluation. Seven patients had no radiographic evidence of debris, loose bodies, or bullet or bone fragments in the joint. Five of these seven (71%) had debris and meniscal damage. Debridement of all loose bodies was possible using arthroscopy and occasional miniarthrotomy. No patient in the series had an infection. CONCLUSIONS: Patients who sustain a low-velocity gunshot through the knee have soft tissue injuries not visible on plain radiographs in most cases, and therefore operative treatment is warranted. Arthroscopic management of these injuries appears to be a safe and effective method of treatment.

Adolescent↗
PubMed1997

Hip Dislocation: Current Treatment Regimens.

Dislocation of the hip occurs only with high-energy trauma, and concomitant injuries are common. Early diagnosis and institution of treatment are necessary to obtain the best possible results. Treatment protocols include emergent reduction of the femoral head to reestablish perfusion, postreduction radiography and computed tomography to look for associated fractures and to judge the concentricity of the reduction, stability testing, and early mobilization. Open reduction may be required if a concentric reduction cannot be obtained in a closed manner. Despite appropriate management, posttraumatic arthritis and avascular necrosis may occur, with reported rates as high as 15% to 30%. Patients who sustain a hip dislocation should be made aware of these potential complications at the time of initial treatment.

Journal Article↗
PubMed1997

Technical considerations in the surgical management of tibial fractures.

The surgical treatment of tibial shaft fractures is generally successful. However, significant controversy exists regarding the indications for specific types of fixation and the techniques used to apply them. Advances to meet the technical challenges of tibial fracture fixation continue to be made, and orthopaedic surgeons should have these new techniques at their disposal for application to each individual patient's injury.

Humans↗
PubMed1997

Amputation versus limb salvage.

The decision to attempt salvage or to amputate a severely injured leg in among the most difficult that the orthopaedist must face. Even surgeons with tremendous trauma experience cannot agree on standard course of action. In the face of such injuries, physician consultation regarding the treatment decision, including all of those members of the team that are needed for a successful salvage, is necessary. In the best circumstances, the trauma surgeon, vascular surgeon, orthopaedist, and a soft-tissue specialist are all involved. From a psychological perspective, the timing of an amputation is important. Although each patient's case is unique, immediate amputation is often viewed by the patient and family as a result of the injury. Conversely, a delayed amputation may be viewed as a failure of treatment. It is imperative that the surgeon have a detailed discussion with the patient and the family whenever possible before making the decisions. Scoring systems are of some help in estimating the chances of a successful salvage. However, the ultimate decision to amputate or attempt salvage is based on such patient factors as preinjury function and social situation, and of associated injuries, surgeon experience, available resources, projected physical abilities, and the patient's projected physical requirements. These decisions are difficult and tax the judgment and emotions of the patient, family, and physician.

Adult↗