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Background It is important to predict the occurrence of deep infection in open fractures when treating such fractures. We tried to develop a new scoring system for predicting the occurrence of deep infection in open upper and lower extremity fractures on the basis of the Hannover Fracture Scale’98 (HFS-98). Methods A total of 394 open upper and lower extremity fractures (351 patients) were retrospectively reviewed in the initial analysis. The relationship between Gustilo’s grade and the eight items on HFS-98 in the open extremity fractures was first investigated by multivariate analysis. By this analysis, we selected significant items that correlated with Gustilo’s grade. Among these cases, 318 patients with 352 open extremity fractures (humerus = 27, forearm = 62, femur = 76, tibia = 187) were used for the following infection analyses. The relationships between the incidence of deep infection and sex (male or female), age (<30, 30–50, <50 years), grade of polytrauma (ISS < 18, 18 ≤ ISS ≤ 30, ISS > 30), site of fracture (humerus, forearm, femur, tibia), existence of fracture line around joint (+ or −) or some significant items in the above initial analysis were further analyzed by multivariate analysis after univariate analysis. We devised a new scoring system of open extremity fractures based on P values in the above analysis. The discrimination of the newly devised scoring system was evaluated with receiver operating characteristic (ROC) curves. Results The following factors: muscle injury (MI, P  = 0.0001); wound contamination (WC, P  = 0.0001); and local circulation (LC, P  = 0.0001) were significant factors affecting the occurrence of deep infection on multivariate analysis. We devised a new scoring system for open extremity fractures (MI: 0–20 points, WC: 0–20 points, and LC: 0–20 points). The cut-off point for occurrence of deep infection in these fractures was 35 by ROC analysis. Conclusions This new scoring system was thought to be useful for predicting the occurrence of deep infection in open extremity fractures. However, further prospective study or multicenter study would be needed to clarify the validity of this scale.

Many animal models of acute and chronic osteomyelitis have been developed. In these models, osteomyelitic lesions are induced using sclerosing agents and foreign bodies with bacterial strains. In the present rat model, these sclerosing agents were not used. We assessed the relationship between inoculation dose and histological, radiological, and microbiological changes in the acute phase (1 week after inoculation) using this rat osteomyelitis model. An experimental rat model of acute osteomyelitis was developed by direct inoculation of the virulent strain BB of Staphylococcus aureus into tibial bone without sclerosants. To examine the relationship between the inoculation dose of the bacteria and the progression of the osteomyelitis, the inoculated lesions were assessed for changes in histological, radiological, and bacteriological parameters at 1 week after infection. Serial dilutions of the bacteria [6 x 10(1) to 6 x 10(5) colony-forming units (CFU)/5 microl] suspended in saline or saline alone were inoculated into the proximal metaphysis of the tibia. Development of significant histological and radiological signs of osteomyelitis required an inoculum of at least 6 x 10(3) CFU/5 microl. The number of viable bacteria at the lesion reached a maximum of 6 x 10(3) CFU/5 microl. These results suggest that strain BB induces the development of acute staphylococcal osteomyelitis with clear infective destruction in the tibia, and that our model may be applied to the identification of virulence factors in studies of posttraumatic osteomyelitis.

The objective of this study is to evaluate significant contributing factors affecting the functional prognosis of floating knee injuries using multivariate analysis. A total of 68 floating knee injuries (67 patients) were treated at Kitasato University Hospital from 1986 to 1999. Both the femoral fractures and the tibial fractures were managed surgically by various methods. The functional results of these injuries were evaluated using the grading system of Karlström and Olerud. Follow-up periods ranged from 2 to 19 years (mean 50.2 months) after the original injury. We defined satisfactory (S) outcomes as those cases with excellent or good results and unsatisfactory (US) outcomes as those cases with acceptable or poor results. Logistic regression analysis was used as a multivariate analysis, and the dependent variables were defined as a satisfactory outcome or as an unsatisfactory outcome. The explanatory variables were predicting factors influencing the functional outcome such as age at trauma, gender, severity of soft-tissue injury in the femur and the tibia, AO fracture grade in the femur and the tibia, Fraser type (type I or type II), Injury Severity Score (ISS), and fixation time after injury (less than 1 week or more than 1 week) in the femur and the tibia. The final functional results were as follows: 25 cases had excellent results, 15 cases good results, 16 cases acceptable results, and 12 cases poor results. The predictive logistic regression equation was as follows: Log 1-p/p = 3.12-1.52 x Fraser type - 1.65 x severity of soft-tissue injury in the tibia - 1.31 x fixation time after injury in the tibia - 0.821 x AO fracture grade in the tibia + 1.025 x fixation time after injury in the femur - 0.687 x AO fracture grade in the femur ( p=0.01). Among the variables, Fraser type and the severity of soft-tissue injury in the tibia were significantly related to the final result. The multivariate analysis showed that both the involvement of the knee joint and the severity grade of soft-tissue injury in the tibia represented significant risk factors of poor outcome in floating knee injuries in this study.

Transcatheter arterial embolization (TAE) can cause gluteal skin and muscle necrosis. However, the ultimate and typical signs of gluteal necrosis resulting from TAE have not yet thoroughly been investigated. From January 1995 to December 2003, 165 pelvic fractures were managed with TAE to control retroperitoneal bleeding at our level 1 trauma center. From these, 12 patients suffered gluteal muscle and skin necrosis. We reviewed the medical records of these 12 patients for age, gender, fracture type, embolic sites, computed tomography (CT) findings, serum creatine kinase level, site of skin necrosis, time from injury to skin necrosis, treatment, and outcome. All 12 patients underwent TAE of the bilateral internal iliac arteries with gelatin sponge slurries. One patient suffered from an infection of the gluteal muscle from an open fracture site. Five patients presented with signs of gluteal soft tissue injuries on admission. Of these, four had skin abrasions and three revealed fluid or air collection under the gluteal skin on CT. The remaining six patients showed no evidence of soft tissue injuries on admission, and the lesions appeared between 2 days and 7 days after their admission. In these six patients, low-density areas (LDAs) of gluteal muscle with a clear border on the CT were observed following the appearance of skin lesion. The skin necrosis was located in the center of either or both buttocks, and signs of ischemia were clearly demarcated from the adjacent normal tissue. Four of 12 patients died from sepsis, three of whom suffered from uncontrollable gluteal infections that had been pointed out as LDAs on the CT. In every patient with gluteal necrosis associated with pelvic fracture following TAE, initial traumatic contusion cannot be ruled out as contributing to the development of the necrosis. However, for patients who undergo TAE of the bilateral internal iliac artery and who show clear-border LDAs on CT, skin necrosis centered on the buttock, and the delayed appearance of a skin lesion, careful attention must be given in the event of an arterial obstruction due to TAE.

Fifty-nine patients with 61 open femoral fractures were treated with immediate locked intramedullary (IM) nailing (group 1; n=15), delayed IM nailing following nonoperative treatment (group 2; n=42), and delayed IM nailing following external fixation (group 3; n=7). Sixteen fractures were Gustilo type I, 28 were type II, 7 were type IIIA, 6 were type IIIB, and 4 were type IIIC open fractures. Four (6.6%) deep infections occurred. Significant differences existed in the deep infection rate (DIR) between types I and II and all type III fractures (2.3% for types I and II versus 17.6% for type III). The deep infection rate did not differ significantly among the nailing groups (13.3%, 2.6%, and 15.3% for groups 1, 2, and 3, respectively), nor did the deep infection rate correlate with the degree of fracture comminution, the existence of polytrauma or polyskeletal trauma, or preexistence of superficial or pin-site infections. Seven (11.7%) of these fractures resulted in nonunion, excluding one secondary amputation; the nonunion rate correlated with fracture location. There were no significant differences in the mean fracture healing times between any of the nailing groups. These results suggest that IM nailing for the treatment of type III open femoral fractures should be considered carefully, regardless of whether it is performed immediately or delayed.

The objective of this study was to evaluate bony healing and predict factors affecting bony healing of femoral fractures treated with interlocking nailing (ILN) in static or dynamic conditions, and in reamed or unreamed procedures. Seventy-four femoral fractures (69 patients) were initially stabilized with ILNs in static condition. Among these fractures, ten static ILNs were dynamized after approximately 6 (median 6.4, range 1–13) months because of poor fracture healing. Reamed ILNs were performed for 55 fractures and unreamed ILNs for 19 fractures. Clinical and roentgenograhic processes were analyzed with emphasis on whether or not ILNs were dynamized. To evaluate any significant contributing factors affecting the nonunion of femoral shaft fractures treated with ILNs, logistic regression analysis was done. The union rates of static ILNs and dynamized ILNs were 92% (59/64) and 70% (7/10) respectively, but there was no significant difference between them. Five nonunions were seen in reamed ILNs and three in unreamed ILNs. The predictive logistic regression equation for nonunion was as follows: Log 1-p/p=1.05 −1.20 × AO/ASIF fracture grade in the femur −3.07 × existence of multiskeletal trauma in lower extremity + 0.06 × age −1.11 × smoking history −0.3 × existence of polytrauma −0.626 × the severity of soft tissue injury (p=0.002; each variable in the above equation was arranged according to the significant order). Among the variables, AO fracture grade (type C) in the femur and existence of multiskeletal trauma in lower extremity were significantly related to nonunion. Static ILN in most femoral shaft fractures does not inhibit the process of fracture healing. The following associated skeletal lesions were our concerns for nonunion and broken nail in static or dynamic ILNs: (1) C-type femoral fracture; and (2) existence of multiskeletal trauma, such as double lesions in the ipsilateral femur, floating knee injury, and bilateral femoral fractures.

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (< or =6 h or >6 h), method of soft-tissue management, skin closure time (< or =1 week or >1 week), existence of polytrauma (ISS< 18 or ISS> or =18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r(2) = 0.263, P = 0.0001). Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.

This is the case report of a boy with congenital pseudarthrosis of the tibia which was treated with free vascularized fibular transfer and had a difficulty with repeated reconstructions for the grafted fibula. It is important for orthopedic surgeons including the authors not to give up or shy away from the challenging treatment for such a cumbersome nonunion after fracture of free vascularized fibular graft for CPT.

We evaluated the functional outcome of 12 femoral fractures treated using retrograde intramedullary nailing via an intercondylar approach. Patients were 9 men and 3 women with an average age of 39.4 years (range, 16–69 years). The follow-up period was 13–185 months, with an average follow-up of 95 months. Functional outcome was assessed by the knee-rating system of the Hospital for Special Surgery (HSS) and Neer's criteria. The average score was 76 points (44 –100 points) by HSS, and 77 points (36–100 points) by Neer's criteria. The outcomes over good results were seen in 67% (8/12) and 58% (7/12), according to respective rating system. Although retrograde nailing for the femoral fractures is useful method, it is still problematic about its efficacy on the basis of our acceptable rate.