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Journal of case reviews from the SIGN Surgical Database.

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Reamers / Irrigator / Aspirator (RIA)

Posted by on Dec 21, 2012 in Journal of Database Reviews | Comments Off on Reamers / Irrigator / Aspirator (RIA)

In the December 5, 2012 Journal of bone and joint, a study comparing reamers/irrigator/aspirator (RIA) bone graft has similar osteogenic properties as graft from the iliac crest. The RIA apparatus is quite expensive. We feel that taking bone graft from the flutes of the SIGN hand reamers during the reaming process is equivalent to iliac crest bone graft also. It may even be better because there is less morbidity to the patient. We therefore encourage the surgeon to save the bone from the flutes of the reamer as well as the fluid that is received when the reamer is withdrawn from the canal and place it into the fracture site.

Orthopedic Truth

Posted by on Sep 27, 2012 in Journal of Database Reviews | Comments Off on Orthopedic Truth

From the 2012 Annual SIGN Conference

Each area of the world uses  different tools and techniques in treating trauma patients. We are grateful to each speaker at the SIGN conference because you added to our knowledge base and  decision making process for treating our patients. Thank you for taking your time to prepare your presentations and attend the conference.

Several concepts emerged in the SIGN conference.

The SIGN Technique Can Be Used In Difficult Situations With Good Results.

Series of large numbers of fractures treated by SIGN technique demonstrate excellent results in stabilizing difficult fractures. These series including comminuted, segmental, previously infected, nonunions, malunions and those treated previously with external fixation. The SIGN technique is being used in bone transport, osteotomies, retrocalcaneal fusions and other reconstructive procedures. Analysis of x-ray reveal SIGN surgeons are achieving excellent alignment of the fractures. Clinical studies with good followup will provide more information about technique and indications.

Open Fractures

We must develop  protocols, and study different antimicrobial dressings, categorize emerging bacteria types as well as risk factors such as diabetes in treating these fractures. Stabilization of open fractures using SIGN implants is being performed earlier in preference to external fixation.

Treatment Of Soft Tissues

Soft tissue treatment using economical negative pressure wound therapy devices and flaps were discussed in San Francisco and at the SIGN conference. We recognize you must be the entire trauma team.

Different Approaches

Retrograde approach to the humerus was discussed.

Varied Orthopedic Trauma

Treatment of shoulder, elbow residuals of trauma, severe ankle fractures, tibia plateau, calcaneus, patella, scapula, proximal humerus, osteosarcoma, spine and pelvic fractures were discussed. We recognize you must treat many different traumatic  injuries.

Surgical Efficiency

Surgical efficiency was discussed by a video showing a 4 minute placement of SIGN nail and screws in the tibia and a 7 minute placement of fin nail into a humerus fracture. This video demonstrated efficiency but sometimes SIGN technique was compromised.

Stabilization Using Other Methods

Use and demonstration of preparation of economical steel rods for forearm, pediatric femur and fibula treat many fractures. Tension band external fixation of patella and olecranon fractures was demonstrated.

Making Stainless Steel and Titanium

There was a consensus that stainless steel and titanium could be used together to stabilize fractures.

New SIGN Implants

Innovative SIGN implants such as the SIGN hip construct and pediatric femoral nail are being used and recorded in centers of excellence. These centers of excellence do many surgeries and have high rates of followup reports. We are pleased with the results so far but we must continually be observant.

Clubfoot Correction

We recognize that pediatric and other deformities must be treated on a timely basis. The Ponseti workshop demonstrated the optimal  treatment of club foot.

Clinical Studies

We can determine orthopedic truth and be guided in our treatment by reading clinical studies of previous treatment. These studies must be well designed to be useful. Collaboration with academic centers in devising these programs will be very helpful. SIGN was invited today to join “Myorthoevidence” which will be run by McMaster is University and we will begin making the necessary arrangements. We will keep you informed.

SIGN Network

Many attendees commented on the mutual respect and friendship displayed by members of the SIGN network. Some refer to the network as a family. I felt this way and I hope you did. People who worked at the Red Lion Inn noticed this and participated by preparing breakfast for the surgeons leaving early in the morning. Many other kindnesses between SIGN surgeons and others were demonstrated.

The SIGN network is moving forward as a unit toward our goal of creating equality of fracture care. This movement is powered by your ideas and recognition that we must validate these ideas in clinical studies. I’m sure this will be reflected in the next annual SIGN conference.

Thank you to all of you who attended the 2012 SIGN conference.

Check Points

Posted by on Sep 10, 2012 in Journal of Database Reviews | Comments Off on Check Points

The Checklist Manifesto by Atul Gawande M.D. is excellent. Below the title on the cover are the words “How to get things right”. This is a universal goal. I also read The Invisible Guerilla by Christopher Chabris and Daniel Simons which has the words “How our intuitions deceive us”. These books are interrelated as we strive to become better surgeons.

The checklist is used in an increasing number of hospitals and has been shown to significantly decrease complications in patient care. The checklist concept recognizes the complexity of surgery and draws attention to preparation in the event that a potentially catastrophic event arises. A copy of the surgical safety checklist as recommended by the WHO which Dr. Gawande helped devise will be included once we have permission to do so.

I hope SIGN programs will consider using the surgical safety checklist. The need for the surgical safety checklist is emphasized in The Invisible Gorilla which describes how we miss events or processes because we are concentrating on the surgery. Checklists as described in the Checklist Manifesto are used to prevent known complications. They should also be used in SIGN surgery.

When operating with SIGN surgeons throughout the world, we are often confronted with challenges that require evaluation. SIGN surgery is unique in that we must place the interlocking screws without the use of C-arm. We therefore must be prepared to deal with situations when we cannot see a C-arm image. As I was revising the technique, I recognized that we should anticipate by having a list of causes and solutions when difficulties arise.

Situation

The nail is placed and when the target arm is applied to the L. handle, the target arm directs the cannula so that it does not hit the bone. This occurs anteriorly in the femur and posteriorly in the tibia.

Checkpoint

  • The nail is bent.

As the nail passes through the isthmus this bend is retained as a nail passes into the wider canal of the distal femur or tibia. Please visualize this.

This is more common when the nail is a smaller diameter or has been hammered during insertion.

  • The locking bolt is loose. This will allow rotation of the target arm
  • Amount of anterior bow of the femur is greater than usual. This is often reflected in the isthmus.
  • The cap screws on the target arm have become loose.

Situation

The guide hole has been drilled into the bone and enlarged by the step drill. The solid slot finder cannot be rotated in the hole.

Checkpoint

  • The bone at the bottom of the hole has not been cleared by the step drill and the slot finder cannot enter. Solution is to use the screw hole broach to remove this bone.
  • The slot finder has entered the slot in the nail obliquely so the slot does not allow motion. Solution is to rotate the nail slightly.

Situation

The solid slot finder will enter the slot and rotates but the cannulated slot finder will not rotate

checkpoint

  • The cannulated slot finder is wider than the solid slot finder. The hole must therefore be enlarged.
  • The cannulated slot finder is bent. Some surgeons are inserting this into the slot and then rotating the nail to determine if the cannulated slot finder is in the slot. This will bend the cannulated slot finder. It is better to rotate the cannulated slot finder to check if it is in the slot of the nail.

Situation

A hole is drilled in the near cortex following the SIGN protocol. This hole is cleared of the bone at the bottom of the hole using the screw hole broach. The nail cannot be found even with the curved slot finder.

Checkpoint

The reduction has slipped after the hole was drilled. If there was a longitudinal displacement over 1 cm, the nail will be proximal to the hole drilled to find the distal slot.

  • The nail subluxed deeper into the insertion hole or came out the insertion hole. Both of these are longitudinal subluxations.
  • Rotational subluxation can occur if the nail rotates after the hole has been drilled in the near cortex.

Situation

The depth gauge will not go through the hole in the far cortex when it is placed through the cannulated slot finder after the hole has been drilled.

Checkpoint

  • The depth gauge is bent and will not pass through the cannulated slot finder or does not pass parallel to the hole in the cannulated slot finder because of the bend. Inexperienced surgeons often bend the depth gauge to try to hook it on the far side of the hole. This does not help the depth gauge pass into the hole and it bends the depth gauge.

Please use the Feedback Form below to submit your ideas about Checkpoints.  Please preface your comments with the word “Checkpoints”.

Hindfoot Nail with SIGN Implant

Posted by on Sep 4, 2012 in Journal of Database Reviews | Comments Off on Hindfoot Nail with SIGN Implant

I wonder if anyone has done a Hindfoot nail with SIGN before?  It’s become more popular elsewhere for certain distal tibia and ankle fractures in less active patients with poor bone.  I did this lady after resection of a GCT distal tibia.  The nail fitted in nicely with 2 locking screws distally in the talus and calcaneum and then a massive bone graft to fill the defect.  It has been done with other nails but I’m not sure about SIGN.  I would do it again in certain circumstances.  Any comments?

Jes Bates

Followup Reports on the Database

Posted by on Aug 29, 2012 in Journal of Database Reviews | Comments Off on Followup Reports on the Database

The percentage of followup reports at most SIGN programs is increasing. Some programs report as high as 80% followup reports. The followup reports on each patient is necessary for all orthopedic surgeons to judge the results of their treatment. Followup reports are necessary so recommendations can be made and surgeons can use these findings to guide decisions regarding treatment. We’ll also eventually modify our database so the results can be queried easily. SIGN is moving toward better clinical studies. We have been sending the followup percentages each month to the  25 busiest SIGN programs and plan to send follow percentages to all programs on a monthly basis after the SIGN conference in Sept. 2012.

We are incorporating the squat and smile pictures as a measure of fracture healing. We are studying the anterior view versus the lateral view as a measure of fracture healing, knee motion, strength and comparing these pictures with x-rays taken at the same time. Please send your recommendations for the proper pose and projection. So far out of 1400 reports that include a squat and smile picture, only one patient who could squat and smile has gone on to need surgery for fracture healing.

The following survey will help us understand how followup reports can continue to increase.

*Increase Followup Survey Available Through Sept. 13th.

New Target Arm Design

Posted by on Aug 22, 2012 in Journal of Database Reviews | Comments Off on New Target Arm Design

SIGN has designed, tested and placed the first radiolucent target arm in Haiti. Jeanne and I just returned and it works very well.

The thighs of the world are getting bigger and therefore we are considering redesigning the new target arm. This new target arm will have a longer(possibly 8 inch) L. handle to accommodate the larger thigh. We are considering options to stabilize the cannula and drill guides. We will devise a survey regarding this. If any of you have suggestions about a new target arm design, please respond in the Feedback form below. We may not respond to each suggestion due to time constraints but we are grateful for your response. This will be a SIGN network brainstorm.

Several SIGN surgeons have requested a longer L-Handle to accommodate the circumference of the thigh in treating femur fractures. This will require many design changes because it involves the cannula, drill guides, alignment pin, drills and L. handle.  Please complete the following survey to assist SIGN in manufacturing decisions regarding this.

*Longer L-Handle Survey Available Through Sept. 13th!