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?
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Complications • The only way to avoid all complications • Is • To Not Operate!
Ex- Fix vs ORIF of 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 or 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
Ex fix Plafond Fracture Study Design RCT Consent ORIF joint and ORIF joint and plate tibia Ex-Fix tibia Clinical F/U 3,6 ,12 Clinical F/U 3,6 ,12 mos mos Functional F/U Functional F/U 3,6,12 mos 3,6,12 mos
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 Ankle ROM improved at 3 mos in IMN group No infections in either group
Activity Questionaire at 12-months. Knee Function RETURN OF Open ( 205) Closed (456) Exercise 45% 61% Training 43% 58% Sports 33% 48% 50% 71% Employment
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 3 mos – improved function in IMN group 6 mos. - no differences in any SMFA dom SMFA score lower is better
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
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