Corrective Osteotomies for Malunited Tongue-Type Calcaneal Fractures.

Displaced tongue-type fractures of the calcaneus can lead to severe pain and disability if not treated appropriately. Failure to reduce articular displacement may require subtalar joint arthrodesis with subsequent loss of function. The subtalar joint is crucial for normal foot and ankle function. In selected cases, if the malunited joint is still in good condition, it is preserved by corrective osteotomy. A joint-preserving osteotomy with axial realignment is a treatment option for malunited tongue-type calcaneal fractures encountered early on, before the development of subtalar arthrosis in carefully selected patients.

Corrective Osteotomies for Malunited Extra-Articular Calcaneal Fractures.

The most effective way to treat calcaneal malunions is avoidance. With any articular fracture, progressive arthrosis and dysfunction are common. By restoring the anatomy initially through reduction, late reconstructive options become less complicated. Numerous studies have shown that restoration of the anatomic alignment either through percutaneous or open techniques is effective. In patients with no or minimal articular degeneration, extrarticular joint-sparing procedures can be performed. This represents a small select group who may benefit from simple osteotomy procedures with associated soft tissue reconstruction, if needed.

Malunited fractures in the hand.

Posttraumatic deformity of a tubular bone in the hand after malunion can impact function due to alteration in mobility, strength, or associated pain. Surgical intervention is often indicated, with the surgical options based on both the type and location of the deformity, as well as any associated articular, tendon, or soft tissue constraints. This article provides a management approach based on the deformity classification, location, and any associated conditions.

Malunion of the proximal humerus.

Malunion of a proximal humerus fracture is difficult to manage once bone union has been achieved in a wrong position. Malunion may be encountered after conservative treatment or internal fixation of fractures, and also around a joint prosthesis. The malunion can involve the greater and lesser tuberosities, humeral head, bicipital groove, or the entire epiphysis. The nature of the malunion must be precisely characterized. Malunion can affect bone structures and the articular surface; any resulting displacements must be carefully measured. Clinical assessments will help to evaluate the functional repercussions and determine the need for correction. Radiographic imaging and CT scan guide the treatment plan. Arthroscopic surgery (acromioplasty or tuberoplasty) can be used to treat biceps tenosynovitis or impingement syndrome in cases where full correction of the malunion is not required. Corrective surgery of a metaphyseal malunion is used to realign the proximal humeral into the proper position. Tuberosity osteotomy is the main predictor for a poor outcome following secondary arthroplasty.

Accuracy of ICD-9 codes to identify nonunion and malunion and developing algorithms to improve case-finding of nonunion and malunion.

OBJECTIVE: To evaluate the accuracy of using ICD-9 codes to identify nonunions (NU) and malunions (MU) among adults with a prior fracture code and to explore case-finding algorithms. STUDY DESIGN: Medical chart review of potential NU (N=300) and MU (N=288) cases. True NU cases had evidence of NU and no evidence of MU in the chart (and vice versa for MUs) or were confirmed by the study clinician. Positive predictive values (PPV) were calculated for ICD-9 codes. Case-finding algorithms were developed by a classification and regression tree analysis using additional automated data, and these algorithms were compared to true case status. SETTING: Group Health Cooperative. RESULTS: Compared to true cases as determined from chart review, the PPV of ICD-9 codes for NU and MU were 89% (95% CI, 85-92%) and 47% (95% CI, 41-53%), respectively. A higher proportion of true cases (NU: 95%; 95% CI, 90-98%; MU: 56%; 95% CI, 47-66%) were found among subjects with 1+ additional codes occurring in the 12months following the initial code. There was no case-finding algorithm for NU developed given the high PPV of ICD-9 codes. For MU, the best case-finding algorithm classified people as an MU case if they had a fracture in the forearm, hand, or skull and had no visit with an NU diagnosis code in the 12-month post MU diagnosis. PPV for this MU case-finding algorithm increased to 84%. CONCLUSIONS: Identifying NUs with its ICD-9 code is reasonable. Identifying MUs with automated data can be improved by using a case-finding algorithm that uses additional information. Further validation of the MU algorithms in different populations is needed, as well as exploration of its performance in a larger sample.

The outcome of surgically treated traumatic unstable pelvic fractures by open reduction and internal fixation.

BACKGROUND: This study was performed to evaluate functional and radiological results of pelvic ring fractures treatment by open reduction and internal fixation. METHODS: Thirty eight patients with unstable pelvic fractures, treated from 2002 to 2008 were retrospectively reviewed. The mean patients' age was 37 years (range 20 to 67). Twenty six patients were men (4 patients with type B and 22 patients with type C fracture) and 12 women (7 patients with type B and 5 patients with type C fracture). The commonest cause was a road traffic accident (N=37, about 97%). Internal fixation was done by plaque with ilioinguinal and Kocher-Langenbeek approaches for anterior, posterior pelvic wall and acetabulum fracture respectively. Quality of reduction was graded according to Majeed score system. RESULTS: There were 11 type-C and 27 type-B pelvic fractures according to Tile's classification. Thirty six patients sustained additional injuries. The commonest additional injury was lower extremity fracture. The mean follow-up was 45.6 months (range 16 to 84 months).The functional outcome was excellent in 66%, good in 15%, fair in 11% and poor in 7% of the patients with type B pelvic fractures and functional outcome was excellent in 46%, good in 27%, fair in 27% and poor in 0% of the patients with type C pelvic fractures. There were four postoperative infections. No sexual functional problem was reported. Neurologic problem like Lateral cutaneous nerve of thigh injury recovered completely in 2 patients and partially in 2 patients. There was no significant relation between functional outcome and the site of fracture (P greater than 0.005). CONCLUSIONS: Unstable pelvic ring fracture injuries should be managed surgically by rigid stabilization. It must be carried out as soon as the general condition of the patient permits, and even up to two weeks.

Effect of radial head malunion on radiocapitellar stability.

BACKGROUND: Management for Mason type II radial head fractures is controversial. We hypothesized that angulation or depression of a marginal radial head fragment would affect radiocapitellar stability similarly to fragment excision. MATERIALS AND METHODS: A Mason type II radial head fracture was created in 6 cadaveric elbows by excising a segment from the anterolateral quadrant that was 30% of the diameter of the articular surface. Radiocapitellar stability was recorded under 5 sets of conditions: (1) intact radial head (intact), (2) 30% surface area fragment resected (partially excised), (3) anatomic fragment fixation with screws (fixed), (4) fragment fixation with 2 mm of depression relative to the articular surface (depressed), and (5) fragment fixation after a 30° wedge resection (angulated). RESULTS: The forces required to subluxate the joint were greatly reduced after fragment excision (5 ± 1 N; P = .0001) and restored to normal (21 ± 1 N; P = .9) after anatomic fixation of the excised fragment. The peak forces were significantly reduced with fragment depression (4 ± 1 N) and angulation (4 ± 2 N; P = .0001). CONCLUSION: A radial head fracture that is depressed 2 mm or angulated 30° may cause up to an 80% loss of concavity-compression stability of the radiocapitellar joint.

Evaluation of the calori et Al nonunion scoring system in a retrospective case series.

Nonunion is one of the most challenging orthopedic complications. Although current definitions are accepted, they fail to provide a satisfactory definition of nonunion. Different classifications for nonunion have been described, but these systems did not take all required factors and requirements of nonunion treatment into account for fracture healing. Calori et al recently developed a new comprehensive nonunion scoring system, which takes into account the whole fracture personality that influences non-union. The aim of this study is to evaluate the validity of the Calori et al system in the treatment of nonunions. We retrospectively reviewed our database for lower extremity nonunion from 2002 to 2009. The demographic and clinical data, laboratory, and radiological investigations were collected from medical records and phone interviews. Forty cases were identified: 32 men and 8 women. Mean patient age was 39.75 years (range, 6-102 years). Seventeen were femoral and 23 were tibial. Our patients were divided into 3 groups according to the database treatment: group 1 standard treatment (3 patients), group 2 specialized care and treatment (33 patients), group 3 amputations (4 patients). If we apply the recommended management by Calori et al to our patients, they will be divided into groups similar to the database treatments. Statistical analysis showed significant correlation between our actual treatment and those recommended by the Calori system where the P value was <.01. We concluded that the Calori et al scoring system could be valid as a guideline for lower extremity nonunion treatment.

Incorrect osteosynthesis as a cause of bone union disturbances.

BACKGROUND: Treatment of bone union disturbances is one of the most difficult therapeutic challenges in any orthopaedic and trauma department. MATERIAL AND METHODS: An analysis of causes of bone union disturbances in a series of 136 patients treated between 1999 and 2005 at the Orthopaedics and Traumatology Department of Jagiellonian University's Collegium Medicum is presented with particular regard to the type of primary stabilisation. RESULTS: An inappropriate primary stabilisation technique was the cause of bone union disturbances in nearly all of the patients. All errors identified in the series, such as wrong classification of fracture, failure to account for fracture biomechanics, wrong implant choice, incorrect reduction of bone fragments, wrong implant positioning and brutal surgery technique, were associated with primary stabilisation of the fractures. CONCLUSIONS: 1. Operator errors committed during primary fracture stabilization are the most common cause of bone union disturbances. 2. Elimination of errors committed during primary stabilization is the most effective prophylaxis of bone union disturbances.

Fractures of the odontoid process.

We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.

The prognostic value and reproducibility of the radiological features of the fractured scaphoid.

We investigated whether the radiological features of the fractured scaphoid could be reproducibly measured and used to predict the likelihood of union with conservative plaster cast immobilization. We found that the inter- and intra-observer reproducibility of the Compson, Herbert and Russe classification systems were only fair and that none predicted fracture union. Assessments of fracture level, comminution and displacement showed moderate inter- and intra-observer reproducibility but did not predict the likelihood of fracture union. We conclude that the radiological features of acute scaphoid fractures cannot be used to predict the likelihood of fracture union.

Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients.

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5 degrees. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes. Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment. We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised.

Transfibular osteotomy in the correction of ankle joint incongruity.

The mechanics involved in Danis-Weber-types B and C ankle fractures may allow the fibula to seek a shortened and externally rotated position following injury. Residual talar instability secondary to fibular malalignment may ensue if proper anatomic restoration is not achieved at the time of reduction. Evaluation of ankle incongruity may take the form of clinical, radiographic, and diagnostic techniques. Three case studies are presented in which fibular osteotomies were utilized to restore proper anatomic alignment and function to the ankle mortise.

The relationship of angulation to translation in fracture deformities.

We measured both angulation and translation on anteroposterior and lateral roentgenograms of 100 fixed post-traumatic deformities (either malunions or stiff [hypertrophic] non-unions) of long bones. We used trigonometric formulae to calculate the true planes and actual magnitude of both the angulation and the transverse translation of each deformity. We found that the planes of angulation and translation for each osseous deformity were rotated 43 +/- 25 degrees (mean and standard deviation) with respect to each other; in fact, we found almost as many instances in which the planes of angulation and translation of the fragments were within 10 degrees of perpendicular to each other as we did instances in which the angulation and translation were within 10 degrees of being in the same plane. Only seven angular deformities and six translational deformities occurred along either the sagittal or the coronal plane; the remaining deformities were in planes that were oblique to the standard reference planes.

Classification of femoral abnormalities in total hip arthroplasty.

Bony abnormalities of the femur can significantly complicate total hip arthroplasty both for the primary and revision operations. No standard nomenclature exists for the description of these femoral abnormalities. A classification system is presented to standardize nomenclature, assist in preoperative planning, and to assist in the reporting of these defects.