Type III Open Tibia Fractures Treated With Single-Stage Immediate Medullary Nailing and Attempted Primary Closure Yield Low Rates of Flap Coverage.

OBJECTIVE: The purpose of this study was to determine whether type III open high-energy tibia fractures treated with immediate intramedullary nailing (IMN) and primary closure yield low rates of flap coverage. METHODS: Patients with high-energy type IIIA open tibia (OTA/AO42/43) fractures treated with IMN over a 10-year period at a level 1 academic center with at least 90 days of in-person postoperative follow-up were included. Single-stage reamed IMN with acute primary skin closure using Allgower-Donati suture technique was utilized in patients without notable skin loss. The primary outcome was treatment failure of acute primary skin closure requiring subsequent soft-tissue coverage procedures. RESULTS: A total of 111 patients with type IIIA tibia fractures met inclusion criteria. Of 107 of the 111 patients (96%) with skin closure at the index surgery, 95 of the 107 patients (89%) healed their soft-tissue envelop uneventfully. Among the patients who failed primary closure (11%), five required free tissue transfers, five required local rotational flaps, and two underwent split thickness skin grafting only. Patients who failed acute primary closure declared within an average of 8 weeks postoperatively. DISCUSSION: Treatment of type IIIA open high-energy tibia fractures with immediate IMN and primary closure using meticulous soft-tissue handling yields low rates of flap coverage.

Mathematically Directed Single-Cut Osteotomy.

A mathematically directed osteotomy (MDO) is a surgical planning technique for correcting long bone deformities. Using a mathematically derived osteotomy plane, the single-cut correction simultaneously addresses angular deformity, axial malrotation, and minor shortening. This review describes an MDO's indications for use, defines its input and output variables, includes the required graphs for osteotomy planning, and provides intraoperative tips and tricks for successful execution. Finally, the authors present a digital MDO calculator to simplify the complex computations and allow for more precise planning.

Simultaneous Posterolateral and Posteromedial Approaches for Fractures of the Entire Posterior Tibial Plafond: A Safe Technique for Effective Reduction and Fixation.

OBJECTIVE: To determine the short-term results of surgical treatment with dual posterolateral and posteromedial approaches for fractures of the entire posterior tibial plafond and secondarily to identify common fracture characteristics. DESIGN: Retrospective. SETTING: Single academic Level 1 trauma center. PATIENTS: Thirty-five patients with posterior pilon fractures followed until fracture union (minimum 3 months). INTERVENTION: Surgical treatment using simultaneous combined posterolateral and posteromedial exposures for fracture reduction and internal fixation. MAIN OUTCOME MEASUREMENT: (1) Surgical outcomes including rate of wound complications and accuracy of the articular reduction. (2) Fracture characteristics including the incidence of articular impaction, comminution interfering with reduction, syndesmosis injury, and the type of fibula fracture. RESULTS: The rate of wound problems was low (6%), and 94% of patients had an articular reduction with less than 1 mm of step or gap. There were high rates of articular comminution (83%) and posteromedial articular impaction (63%) and a 17% rate of syndesmosis injury requiring repair. CONCLUSIONS: Surgical fixation using simultaneous, combined posterolateral and posteromedial approaches for posterior pilon fractures had a low rate of wound complications and was an effective strategy for obtaining an accurate reduction. The rate of syndesmotic instability requiring fixation was lower than previous work reporting on fixation using a single approach. This may be a useful technique for surgeons who treat these injuries. Careful assessment of the preoperative imaging is required in patients with posterior pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Strategies in Pilon Fixation.

The treatment of tibial pilon fractures has evolved substantially over the past decades due to ever-increasing high-energy injuries. Open reduction and internal fixation of these intra-articular fractures requires an appreciation for a number of basic principles: respect the soft tissues, understand the fracture pattern, use safe surgical approaches, and provide stability that allows for early motion of the ankle. Surgical strategy should be customized based on the fracture pattern, access needed for fracture visualization and reduction, and status of the soft tissues. Given the ability to obtain an accurate stable reduction, smaller implants are typically adequate using multiple small incisions. We view this surgical tactic as continuing the evolution of complex fracture treatment whose origins lie in the influences of pioneers such as Dr Sigvard T. Hansen Jr.

Biomechanical Analysis of the Proximal Femoral Locking Compression Plate: Do Quality of Reduction and Screw Orientation Influence Construct Stability?

OBJECTIVES: To investigate biomechanically in a human cadaveric model the failure modes of the proximal femoral locking compression plate and explore the underlying mechanism. METHODS: Twenty-four fresh-frozen paired human cadaveric femora with simulated unstable intertrochanteric fractures (AO/OTA 31-A3.3) were assigned to 4 groups with 6 specimens each for plating with proximal femoral locking compression plate. The groups differed in the quality of fracture reduction and plating fashion of the first and second proximal screws as follows: (1) anatomic reduction with on-axis screw placement; (2) anatomic reduction with off-axis screw placement; (3) malreduction with on-axis screw placement; (4) malreduction with off-axis screw placement. The specimens were tested until failure using a protocol with combined axial and torsional loading. Mechanical failure was defined as abrupt change in machine load-displacement data. Clinical failure was defined as 5 degrees varus tilting of the femoral head as captured with optical motion tracking. RESULTS: Initial axial stiffness (in N/mm) in groups 1 to 4 was 213.6 ± 65.0, 209.5 ± 134.0, 128.3 ± 16.6, and 106.3 ± 47.4, respectively. Numbers of cycles to clinical and mechanical failure were 16,642 ± 10,468 and 8695 ± 1462 in group 1, 14,076 ± 3032 and 7449 ± 5663 in group 2, 8800 ± 8584 and 4497 ± 2336 in group 3, and 9709 ± 3894 and 5279 ± 4119 in group 4. Significantly higher stiffness and numbers of cycles to both clinical and mechanical failure were detected in group 1 in comparison with group 3, P ≤ 0.044. CONCLUSIONS: Generally, malreduction led to significantly earlier construct failure. The observed failures were cut-out of the proximal screws in the femoral head, followed by either screw bending, screw loosening, or screw fracture. Proper placement of the proximal screws in anatomically reduced fractures led to significantly higher construct stability. Our data also indicate that once the screws are placed off-axis (>5 degrees), the benefit of an anatomic reduction is lost.

Quality of fracture reduction assessed by radiological parameters and its influence on functional results in patients with pilon fractures-A prospective multicentre study.

INTRODUCTION: The management of pilon fractures remains a challenging issue. Due to the complexity of factors that influence the outcome, it has been questioned if anatomical reductions of articular fracture are relevant. The lack of a commonly accepted assessment of quality of fracture reduction compounded the uncertainty of the importance of anatomical reduction in pilon fracture. The current study aimed to define parameters that can better assess the reduction quality and to investigate the influence of reduction quality on functional outcomes. METHODS: Patients with unilateral pilon fracture of the AO/OTA type 43-B or 43-C were consecutively recruited to the study and followed up for 2 years after surgery. Postoperative radiographs of the injured and the contralateral joints were evaluated and 13 radiological parameters measured by 2 independent surgeons. The reliability of the measurements for each parameter was assessed by the Intraclass Correlation Coefficient (ICC), and 4 parameters with the highest ICC scores were deemed most reliable and were selected for further analyses. Functional outcome was assessed by the Foot and Ankle Ability Measure (FAAM) for daily living and sports activities. The 4 most reliable radiologic parameters, together with 3 possible baseline confounders (age, AO/OTA fracture type, and open versus closed injury), were analysed using both univariable and multivariable analysis for their association with the FAAM scores. Secondary outcome measures including pain, ankle range of motion (ROM), quality of life (QoL), and adverse events were also reported. RESULTS: The length of lateral malleolus (LLM), anterior distal tibia angle, anterior talar shift, and length of medial malleolus scored highest on reliability in ICC assessment (ICC=0.76, 0.72, 0.58, and 0.45, respectively). Only LLM exhibited statistical significant association with the 2-year FAAM results. At the 2-year follow-up, the injured joints on average achieved a ROM of 70.7% (95% CI=63.9-77.6) when compared to the contralateral joints, and patients did not regain the pre-injury QoL overall. CONCLUSION: The multivariable analysis showed that LLM (independent of age, AO/OTA fracture type, and open/closed injury) was a reliable indicator of reduction quality and a prognostic factor for patient outcome in pilon fracture surgery.

Intertrochanteric Osteotomy for Femoral Neck Nonunion: Does "Undercorrection" Result in an Acceptable Rate of Femoral Neck Union?

OBJECTIVES: To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy. DESIGN: Retrospective cohort study. SETTING: Level-1 trauma center. PATIENTS: Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy. INTERVENTION: Valgus-producing intertrochanteric osteotomy with a blade plate. MAIN OUTCOME MEASUREMENTS: Femoral neck and intertrochanteric osteotomy osseous union. RESULTS: Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014). CONCLUSIONS: Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Coronal Plane Small-Fragment Fixation in Supracondylar Intercondylar Femur Fractures.

Supracondylar intercondylar distal femur fractures are devastating injuries that frequently have a concurrent coronal plane fracture, which mandates dedicated operative fixation. The purpose of this study was to determine whether small-fragment cortical lag screws oriented in the sagittal plane were sufficient to stabilize coronal plane fractures associated with supracondylar intercondylar distal femur fractures. The authors evaluated short-term radiographic outcomes in 56 coronal plane fractures in 44 knees (27 [61.4%] male, 17 [38.6%] female; mean age, 43 years [range, 19-97 years]) sustaining a supracondylar intercondylar distal femur fracture between January 2001 and November 2013. Coronal plane fractures were stabilized with sagittally oriented small-fragment cortical lag screws measuring 3.5 mm or smaller, and the supracondylar intercondylar component was stabilized with a lateral periarticular plate. Fracture displacement was defined as greater than 2 mm of gapping/translation of the coronal plane fragment on any radiographic view. Thirty-three (75.0%) knees had open injuries. Fifty-five (98.2%) of 56 coronal plane fractures went on to radiographic union with no displacement of the coronal fragment; one knee developed avascular necrosis and required arthrodesis. Fifteen (34.1%) of 44 knees required secondary procedures unrelated to the coronal plane fracture. The reduction of coronal plane fractures associated with supracondylar intercondylar distal femur fractures can be reliably maintained when stabilized with small-fragment cortical lag screws oriented in the sagittal plane.

Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures.

Malleolar ankle fractures associated with syndesmotic injuries are common. Diagnosis of the syndesmotic injury can be difficult and often requires intraoperative fluoroscopic stress testing. Accurate reduction and stable fixation of the syndesmosis are critical to maximize patient outcomes. Recent literature has demonstrated that the unstable syndesmosis is particularly prone to iatrogenic malreduction. Multiple types of malreduction can occur, including translational, rotational, and overcompression. Knowledge of the technical details regarding intraoperative reduction methods and reduction assessment can minimize the risk of syndesmotic malreduction and improve patient outcomes.

What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study.

PURPOSE: Recently, several cases of clinical failure have been reported for the Proximal Femoral Locking Compression Plate (PF-LCP). The current study was designed to explore biomechanically the underlying mechanism and to determine whether the observed failure was due to technical error on insertion or to implant design. METHODS: A foam block model simulating an unstable intertrochanteric fracture was created for 3 study groups with 6 specimens each. Group C was correctly instrumented according to the manufacturer's guidelines. In Group P and Group A, the first or second proximal screw was placed with a posterior or anterior off-axis orientation by 2° measured in the transversal plane, respectively. Each construct was cyclically tested until failure using a test setup and protocol simulating complex axial and torsional loading. Radiographs were taken prior to and after the tests. Force, number of cycles to failure and failure mode were compared. RESULTS: A screw deviation of 2° from the nominal axis led to significantly earlier construct failure in Group P and Group A in comparison to Group C. The failure mode was characterised by loosening of the off-axis screw due to disengagement with the plate, resulting in loss of construct stiffness and varus collapse of the fracture. CONCLUSIONS: In our biomechanical test setup, the clinical failure modes observed with the PF-LCP were reproducible. A screw deviation of 2° from the nominal axis consistently led to the failure. This highlights how crucial is the accurate placement of locking screws in the proximal femur.

Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases.

OBJECTIVES: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN: Retrospective review. SETTING: Three level I or II trauma centers. PATIENTS/PARTICIPANTS: Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers. INTERVENTION: All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS: Risk factors for reoperation to promote union, deep infection, and implant failure. RESULTS: After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS: The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure. LEVEL OF EVIDENCE: Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Salvage of an infected periprosthetic failed fracture fixation in a nonagenarian.

Infected nonunions resulting in segmental bone loss are a devastating complication for patients and a difficult problem for surgeons. Adequate soft tissue coverage, return of mobility, fracture stability, and long-term freedom from infection are all important goals of treatment. Although there are numerous published studies that provide some treatment guidelines, there are patients who require unique and individualized solutions. In this report, we present a case in which an antibiotic-impregnated cement spacer was used as a component of the definitive treatment in a geriatric patient with segmental bone loss of the femur secondary to severe infection as a salvage technique to avoid amputation.

Open reduction and intramedullary stabilisation of subtrochanteric femur fractures: A retrospective study of 56 cases.

Subtrochanteric femur fractures commonly present with predictable displacement because of the deforming muscle forces acting upon the proximal femur. For this reason, successful closed reduction and femoral nailing can be a technically demanding procedure. Open reduction prior to nail placement has been advocated to improve and maintain anatomic fracture alignment. The purpose of this study was to evaluate the results of patients with closed subtrochanteric femur fractures treated with open reduction and a reamed antegrade statically locked intramedullary nail. An initial query of our database identified 154 patients who had sustained a subtrochanteric femur fracture over the defined study period. Ninety-six patients had adequate radiographic and clinical follow-up. Fifty-six (58%) patients were treated with open reduction and nail placement. There were no wound complications or infections and all patients went on to successful osseous union. There was no loss of reduction and a final coronal and sagittal plane deformity of <5 degrees in 55 of 56 (98%) patients. Open reduction of closed subtrochanteric femur fractures followed by intramedullary nailing leads to high union rates with rare complications.

Bicortical fixation of medial malleolar fractures.

Medial malleolar fractures occur commonly and are often treated surgically. For any given fracture, treatment depends on the fracture configuration, and the clinical scenario. Multiple fixation options exist, including cortical or cancellous screws, tension band wiring, plates and screws, and even suture anchors according to some reports. When using screws alone, bicortical fixation of the medial malleolus may be desirable. This is especially true in the population of patients who demonstrate osteopenia. We present a simple technique that facilitates insertion of bicortical screws in the fixation of medial malleolar fractures.

Oblique distraction external pelvic fixation.

Simple anterior pelvic external fixation is a safe and effective strategy for reduction of pelvic ring deformity as well as the provisional or definitive stabilization of selected patterns of pelvic ring disruption. A two-pin oblique anterior pelvic deformity correction frame is a unique frame configuration designed to reduce and stabilize lateral compression pelvic ring disruptions associated with flexion/internal rotation hemipelvic deformities. In a small case series, we demonstrate that the oblique distraction external fixation frame alone or in combination with internal fixation is a simple and safe strategy for reduction and stabilization of unstable multiplanar hemipelvic deformities associated with partial posterior ring stability.

A fragment-specific approach to Type IID Monteggia elbow fracture-dislocations.

OBJECTIVES: To describe the pattern of injury, surgical technique, and outcomes of Monteggia Type IID fracture dislocations. DESIGN: Retrospective review of prospectively collected clinical and radiographic patient data in an orthopaedic trauma database. SETTING: Level I university-based trauma center. PATIENTS/PARTICIPANTS: All patients with Monteggia Type IID fracture-dislocations admitted from January 2000 to July 2005. INTERVENTION: Review of patient demographics, fracture pattern, method of fixation, complications, additional surgical procedures, and clinical and radiographic outcome measures. MAIN OUTCOME MEASUREMENTS: Clinical outcomes: elbow range of motion, complications. Radiographic outcomes: characteristic fracture fragments, quality of fracture reduction, healing time, degenerative changes, and heterotopic ossification. RESULTS: Sixteen patients were included in the study. All fractures united. There were six complications in six patients, including three contractures with associated heterotopic ossification, one pronator syndrome and late radial nerve palsy, one radial head collapse, and one with prominent hardware. CONCLUSIONS: Monteggia IID fracture-dislocations are complex injuries with typical specific fracture fragments. Anatomic fixation of all injury components and avoidance of complications where possible can lead to a good outcome in these challenging injuries.

Fluoroscopically guided hip capsulotomy: effective or not? A cadaveric study.

OBJECTIVE: The purpose of this study was to examine the efficacy of a fluoroscopically guided hip capsulotomy. METHODS: Ten fresh-frozen paired cadaveric hips were injected under fluoroscopic guidance with saline sufficient to generate an intra-articular pressure greater than 58 mmHg. The pressure was monitored continuously using a percutaneous transducer. A limited lateral approach to the proximal femur was performed by one of two senior orthopaedic trauma surgeons. Using a scalpel under fluoroscopic guidance, each surgeon made one attempt at an anterior capsulotomy. Changes in intra-articular pressure were recorded throughout the procedure. The specimens were then dissected to measure the extent of each capsulotomy as well as the distance from the capsulotomy to nearby neurovascular structures. RESULTS: A rapid and substantial decrease in intra-articular pressure was seen in all hips. The mean intra-articular pressure postcapsulotomy was 8.4 mmHg. The capsulotomies averaged 15.1 mm in length. None of the attempts at capsulotomy lasted longer than 90 seconds. The average distance between capsulotomy and the lateral-most branch of the femoral nerve was 19.5 mm. The femoral artery was on average 40.3 mm from the capsulotomy. There was no correlation between the side on which capsulotomy was performed and its extent or proximity to neurovascular structures. CONCLUSIONS: Fluoroscopically guided hip capsulotomy through a small lateral incision appears to be a safe, effective, and expedient method, which may substantially reduce intra-articular pressure after minimally displaced femoral neck fractures.

Reduction strategies through the anterolateral exposure for fixation of type B and C pilon fractures.

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.

Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra.

OBJECTIVES: To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology. DESIGN: Retrospective cohort. SETTING: University Level I trauma center. PATIENTS/PARTICIPANTS: Fifty patients with pelvic computed tomography scans. INTERVENTION: All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane. MAIN OUTCOME MEASUREMENTS: In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared. RESULTS: Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30° versus 21° in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm versus 109 mm, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra. CONCLUSIONS: Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.