The Treatment of Lisfranc Injuries: Review of Current Literature.

Tarsometatarsal or Lisfranc fracture dislocations (LFD) are rare, easily overlooked, and lead to long-term disability. Recognition of such injuries is important so that adequate treatment can be provided. As many as 20% of LFD are either misdiagnosed or overlooked, and these can be a permanent source of pain in polytraumatic patients after the major fractures have healed. It is important to distinguish pure Lisfranc joint dislocations (LD) from LFD and Chopart-Lisfranc dislocations (CLFD). Here, we discuss the protocols for treating these different types of injury.

Open acute segmental tibial fracture fixation using the Less Invasive Stabilisation System (LISS): study of 23 consecutive cases.

AIM: To evaluate the Less Invasive Stabilisation System (LISS) in the treatment of segmental tibial fractures. METHODS: A prospective series of 23 consecutive open acute segmental tibial fractures were treated with a long LISS plate, in a university hospital. All but three fractures were temporarily fixed with a unilateral external frame. The minimal follow-up was 2 years. RESULTS: Mean age of the casualties was 34 (17-72) years, all but two were male and all were involved in high-energy accidents, had multiple injuries and open fractures. Of the fractures, 4 were grade IIIA, 16 grade IIIB and 3 grade IIIC. It was possible to span the distal fracture with the LISS plate in 20 cases; of these, 3 developed compartment syndrome. Two people with trifocal fractures required additional distal plates, one of which became loose and infected, resulting in a malunion of 8 degrees. Dermatofasciotomy was performed in 13 cases, in 10 of these as a preventive measure and in 3 because of impending compartment syndrome. In five cases a post-fixation neural palsy of the extensor hallucis longus was observed. All except three fractures healed; mean time for union for the proximal fractures was 16 (10-24) weeks and for the distal fractures was 22 (16-44) weeks. CONCLUSION: Use of the LISS plate in fixing these difficult fractures is commended, but immediate fixation should be avoided. A staged sequential procedure with a temporary spanning external fixation and definitive treatment after soft-tissue healing is preferred.

A pyogenic, ruptured Baker's cyst induced by arthroscopic pressure pump irrigation.

Post-steroid septic arthritis can be treated with irrigation pump assisted arthroscopic synovectomy. The high-intra-articular fluid pressures can force the pyogenic fluid into a pre-existing Baker's cyst. The cyst can rupture and with the pre-existing steroid induced immune-suppression, the calf abscess will be hard to control. Therefore, thorough investigation with an ultrasound-guided aspiration followed by an early drainage of the collection is warranted and mandatory. Close monitoring for the development of a deep thrombosis of the popliteal vein is required.

Recurrent anterior shoulder instability. Results of the glenoid based inferior capsular shift.

A total of forty consecutive patients suffering from recurrent traumatic anterior shoulder instability underwent stabilisation with a glenoid based inferior capsular shift. The patients were followed up prospectively by an independent observer (JM) using the Constant-Murley score and objective evaluation of shoulder movement and strength with an isometric dynamometer. The mean follow-up period was 50 months (range, 2 to 6.8 years). Three patients (7.5%) suffered a repeat, high energy, traumatic dislocation following an early return to sports activities. "Cybex" testing documented a minimal average loss of external rotation movement (4.4 degrees) and strength (4.3%) with the arm in neutral, which was higher with the arm at 90 degrees of abduction (i.e., 13.7 degrees and 15.6%, respectively). The deficit in internal rotation strength was similarly lower in neutral position (2%), when compared to the deficit with the arm at 90 degrees of abduction (13.5%). There was no measurable loss of internal rotation motion. Our study supports the use of a glenoid based inferior capsular shift, as there is a low recurrence rate and minimal deficit in shoulder movement and strength.

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.

Pediatric and adolescent tibial eminence fractures: arthroscopic cannulated screw fixation.

BACKGROUND: Fractures of the intercondylar spine of the tibia are enigmatic injuries. The mechanism of injury remains obscure, and appropriate treatment is unclear. METHODS: The authors analyzed a series of 26 cases of displaced fractures of the intercondylar eminence of the tibia treated with an arthroscopically placed, intrafocal screw with spiked washer. The patients were reviewed after a minimum follow-up of 24 months and a maximum of 8 years. RESULTS: Sixteen patients had a type II tibia eminence fracture according to Meyers and McKeever (mean age, 15 years; male/female ratio, 11:5). Ten patients had a type III tibia eminence fracture (mean age, 17 years; male/female ratio, 1:1). We encountered neither stiffness nor iatrogenic chondral abrasion. Only three patients with type II had no laxity. The 13 other patients in this fracture group had a minor laxity without correlation with the clinical result. In four patients with a type III lesion, a residual laxity without functional deficit was noticed. In two cases with a type III lesion, a reconstruction of the anterior cruciate ligament was necessary 3 years after trauma. In four patients with a type III fracture, the fragment remained elevated, with minor impairment of the mobility (extension lag). No mechanical failure or infection was seen in this series. CONCLUSION: The authors found the intrafocal screw fixation for displaced fracture of the intercondylar eminence to be a reliable and safe technique, although complete restoration of the anteroposterior knee stability was seldom seen.

The Gotfried PerCutaneous Compression Plate versus the Dynamic Hip Screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain.

BACKGROUND: The PerCutaneous Compression Plate (PCCP) was developed by Gotfried (Israel, Haifa) for minimal-approach osteosynthesis of pertrochanteric fractures. METHODS: One hundred fifteen patients, aged 60 or more, with intertrochanteric fractures (AO type 31A1 or 31A2) were selected randomly for fixation with either the PCCP (53 patients) or the Dynamic Hip Screw (62 patients). All surviving patients were scheduled for a 1-year follow-up. RESULTS: Less invasive surgical stabilization of pertrochanteric fractures with the PCCP resulted in shorter theater and surgical time and reduced postoperative pain. The PCCP treatment showed a tendency toward a lower transfusion need and a reduction of fracture impaction; however, results were not statistically significant. There was a trend toward a higher mechanical complication rate with the PCCP: anatomic closed reduction without posterior sagging of the fracture and fluoroscopic control of the placement of the first neck screw in two directions are essential to avoid technical complications. CONCLUSION: Minimal invasive treatment of pertrochanteric fractures with the PCCP reduces operation time and postoperative pain.

The "Clip U2", a new device in treating distal radial fractures.

Fracture of the distal radius is one of the most common lesions in the trauma practice. The relation between anatomic reconstruction, early motion and good or excellent clinical outcome, is well known. The "Clip U2", a new elastic pinning device used in the treatment of the distal radius fracture, promised to secure the reduction and to allow early functional treatment with a simple and minimally invasive technique. Convinced of the possible advantages of this technique, as presented to us by the inventor of the technique, we started a prospective trial in the setting of a university teaching hospital. Both the clinical and radiographic results were disappointing, so we were forced to abandon the trial after 14 patients. We present our clinical and radiographic data.