Injury Pattern Recognition and Surgical Technique of Pilon Fracture Reduction With Posterior Tibial Tendon Incarceration.

SUMMARY: Pilon fractures occur over a broad spectrum of injury severity and soft-tissue compromise. This article will review a distinct pilon injury variant characterized by posterior tibial tendon incarceration in posteromedial pilon fracture propagation. This injury pattern is vital to recognize preoperatively because failure to mobilize the entrapped posterior tibial tendon (PTT) will result in fracture malreduction and postoperative loss of PTT excursion. In addition, the authors' preferred surgical technique for PTT mobilization and anatomic fracture reduction is described.

Comparing Calcaneus Fracture Radiographic Outcomes and Complications after Percutaneous Pin versus Screw Fixation.

Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Although screws are thought to provide greater stability, limited data exists directly comparing fixation success of these implants. Medical record data from 53 patients (62 total fractures) surgically treated with percutaneous screws (28 fractures) or K-wires (34 fractures) for joint-depression calcaneus fractures at a large tertiary hospital were retrospectively reviewed. Bohler's angle and calcaneal varus were assessed from available radiographs at time of injury, postoperatively, and at final follow-up, and joint congruity was assessed postoperatively and at final follow-up. Complications were also extracted. There were no statistical differences in patient characteristics between surgical groups although a higher proportion of patients treated with K-wires compared to screws had other associated injuries (79% vs 42%, p = .01). A higher proportion of fractures treated with screws compared to K-wires maintained joint congruity at the final follow-up (69% vs 32%, p = .005). However, there were no statistically detectable differences in other postoperative radiographic metrics (p > .05). In conclusion, joint congruity was more often maintained with screw fixation although there was no statistical difference in restoration and maintenance of Bohler's angle or varus alignment. The difference in radiographic metrics was not correlated with secondary procedures, namely subtalar arthrodesis, and may not be clinically significant. Neither group was completely effective in attaining and maintaining reduction, and additional fixation strategies should be considered if feasible based on patient, injury, and soft tissue characteristics.

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography.

OBJECTIVE: To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury. DESIGN: Retrospective cohort. SETTING: ACS Level I trauma center. PATIENTS/PARTICIPANTS: Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period. MAIN OUTCOME MEASUREMENTS: We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement. RESULTS: When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures. DISCUSSION: The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.

Repair of Chronic Tibialis Anterior Tendon Ruptures.

This article presents a novel technique for repair of chronic tibialis anterior tendon ruptures. All chronic tibialis anterior tendon ruptures reviewed were treated with this technique. Patients with chronic tibialis anterior tendon ruptures presenting to the authors' institution from 2006 to 2012 had preoperative and postoperative Foot and Ankle Ability Measure scores. The average follow-up time was 2.1 years. The average Foot and Ankle Ability Measure score was 66.1% preoperatively and 87.1% postoperatively (P=.002). This technique offers theoretical improved strength and may help avoid the need for tendon graft often required by other techniques.

Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures?

OBJECTIVES: Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. METHODS: Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. RESULTS: Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits. CONCLUSIONS: TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.

Effect of off-axis screw insertion, insertion torque, and plate contouring on locked screw strength.

OBJECTIVES: This study quantifies the effects of insertion torque, off-axis screw angulation, and plate contouring on the strength of locking plate constructs. METHODS: Groups of locking screws (n = 6-11 screws) were inserted at 50%, 100%, 150%, and 200% of the manufacturer-recommended torque (3.2 Nm) into locking compression plates at various angles: orthogonal (control), 5-degree angle off-axis, and 10-degree angle off-axis. Screws were loaded to failure by a transverse force (parallel to the plate) either in the same ("+") or opposite direction ("-") of the initial screw angulation. Separately, locking plates were bent to 5 and 10-degree angles, with the bend apex at a screw hole. Locking screws inserted orthogonally into the apex hole at 100% torque were loaded to failure. RESULTS: Orthogonal insertion resulted in the highest average load to failure, 2577 ± 141 N (range, 2413-2778 N), whereas any off-axis insertion significantly weakened constructs (165-1285 N, at 100% torque) (P < 0.05). For "+" loading, torque beyond 100% did not increase strength, but 50% torque reduced screw strength (P < 0.05). Loading in the "-" direction consistently resulted in higher strengths than "+" loading (P < 0.05). Plate contouring of 5-degree angle did not significantly change screw strength compared with straight plates but contouring of 10-degree angle significantly reduced load to failure (P < 0.05). CONCLUSIONS: To maximize the screw plate interface strength, locking screws should be inserted without cross-threading. The mechanical stability of locked screws is significantly compromised by loose insertion, off-axis insertion, or severe distortion of the locking mechanism.

Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study.

BACKGROUND: Treatment of fractures is sometimes performed after normal daytime operating hours and in such instances may be performed under less than ideal conditions. The consequence of performing operations under such conditions is largely unknown and was therefore studied in the context of intramedullary nail fixation of tibial and femoral shaft fractures. METHODS: Two hundred and three consecutive patients with either a femoral or tibial shaft fracture (Orthopaedic Trauma Association classification 32 or 42) treated with intramedullary nail fixation were included in a prospective, multicenter, nonrandomized study. Patients were divided into an after-hours group defined as an operation beginning from 4:00 P.M. to 6:00 A.M. or a daytime group defined as an operation beginning from 6:00 A.M. to 4:00 P.M. These groups were further divided on the basis of the injured bone into the following subgroups: after-hours femoral fracture (fifty-five patients), daytime femoral fracture (forty-four patients), after-hours tibial fracture (forty-eight patients), and daytime tibial fracture (fifty-six patients). The demographic and fracture characteristics were similar among the subgroups. All patients were treated with the same type of femoral antegrade, femoral retrograde, or tibial nail fixation with reaming. Data for fracture-healing, complications, operative time, and fluoroscopy time were collected prospectively. RESULTS: The healing rates were similar between daytime and after-hours surgery groups for both the tibial and femoral nailing. On the basis of univariate analysis, operative times were shorter in the after-hours group compared with the daytime group for both the tibial and femoral nail fixation groups (p < 0.02), but regression analysis failed to identify time of surgery as an independent variable associated with operative time. Radiation exposure was similar for the after-hours group and the daytime group for both tibial and femoral nail fixation (p > 0.05). The after-hours group had more unplanned reoperations than the daytime group (p < 0.02). Removal of painful hardware was more frequent in the after-hours femoral fracture group (27%) than in the daytime femoral fracture group (3%) (p < 0.02), and after-hours surgery was an independent variable associated with the need for removal of painful femoral fracture hardware (p < 0.05). CONCLUSIONS: Rates of nonunion, infectious complications, and radiation exposure are similar for after-hours and daytime surgery for intramedullary nail fixation of both femoral and tibial fractures. After-hours femoral nail fixation was associated with an increased frequency for removal of painful hardware, which may be related to technical errors associated with nonideal conditions and shorter operative times. An increase in the allocated amount of daytime operative time for orthopaedic trauma surgery has the potential to reduce minor complication rates for intramedullary nail fixation.

Intramedullary nailing of femoral shaft fractures: current concepts.

Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.