Syndesmotic Screw Breakage May Be More Problematic Than Previously Reported: Increased Rates of Hardware Removal Secondary to Pain With Intraosseous Screw Breakage.

BACKGROUND: The majority of retained syndesmotic screws will either loosen or break once the patient resumes weight-bearing. While evidence is limited, anecdotal experience suggests that intraosseous screw breakage may be problematic for some patients due to painful bony erosion. This study seeks to identify the incidence of intraosseous screw breakage, variables that may predict intraosseous screw breakage, and whether intraosseous screw breakage is associated with higher rates of implant removal secondary to pain. METHODS: Five hundred thirty-one patients undergoing syndesmotic stabilization were screened, of which 43 patients (with 58 screws) experiencing postoperative screw breakage met inclusion criteria. Patient charts were retrospectively reviewed for demographic data, comorbidities, time to screw breakage, location of screw breakage, and implant removal. Several radiographic parameters were evaluated for their potential to influence the site of screw breakage. RESULTS: Intraosseous screw breakage occurred in 32 patients (74.4%). Screw breakage occurred exclusively in the tibiofibular clear space in the remaining 11 instances (25.6%). Intraosseous screw breakage was significantly associated with eventual implant removal after breakage (P = .034). Screws placed further from the tibiotalar joint were at less risk for intraosseous breakage (odds ratio 0.818, P = .002). Screws placed at a threshold height of 20 mm or greater were more likely to break in the clear space (odds ratio 12.1, P = .002). CONCLUSION: Syndesmotic screw breakage may be more problematic than previously described. Intraosseous breakage was associated with higher rates of implant removal secondary to pain in this study. Placement of screws 20 mm or higher from the tibiotalar joint may decrease risk of intraosseous breakage.Levels of Evidence: Level III: Retrospective study.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization.

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

Peri-implant fractures around hindfoot fusion nails: A systematic literature review and classification system.

BACKGROUND: Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hindfoot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors. METHODS: A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails. The electronic database of PubMed/Medline/Cochrane Library was explored using specific search terms. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded. RESULTS: A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies. CONCLUSION: Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice.

Prevalence of Incidental Benign and Malignant Lesions on Radiographs Ordered by Orthopaedic Surgeons.

BACKGROUND: Radiographs are the most commonly available diagnostic imaging modalities used to evaluate orthopaedic conditions. In addition to suspected findings based on the initial indication to obtain radiographic images, incidental findings may be observed as well, some of which may have notable medical and legal ramifications. This study evaluates the number of incidental findings reported from orthopaedic radiographs ordered in an academic orthopaedic multispecialty group over 1 year. METHODS: A retrospective review was conducted of 13,948 eligible radiographs recorded at our institution over a 12-month period. Reports were categorized based on examination type. Incidental findings were categorized as having concern for possible malignancy versus likely benign conditions. The possibly malignant findings were then further subdivided into either bone or lung malignancies. The benign findings were subcategorized by etiology and anatomic location. RESULTS: Thirteen thousand nine hundred forty-eight radiographs were evaluated, and 289 (2.07%) incidental findings were identified. The three study categories with the highest prevalence of incidental findings were spine (3.96%), leg length alignment (3.94%), and pelvic and hip (2.81%) radiographs. The three most common types of incidental findings identified were for possible malignancy or metastases in bone (30.1%), benign bone disease (24.9%), and gastrointestinal conditions (6.57%). Follow-up was recommended for 122 (42.2%) incidental findings. DISCUSSION: This study describes the prevalence of incidental findings on orthopaedic radiographs in adults. Axial radiographs such as of the spine and pelvis are more likely to report an incidental finding as opposed to appendicular radiographs of distal extremities. The exception is leg alignment radiographs that include the entire lower extremity and pelvis and image a larger area of the body. Nearly one-third of incidental findings were suspicious for possible malignancy or metastases. Additional diagnostic workup with focused imaging is often recommended. This information is useful to orthopaedic surgeons who read their own radiographs (without formal radiologist interpretation) to increase awareness of common, concerning incidental findings that may be missed and warrant additional follow-up. LEVEL OF EVIDENCE: Level III.

High Burden of Associated Injuries Occurring With Major Fractures of the Talus.

BACKGROUND: Talus fractures are severe injuries typically occurring after high-energy trauma. As a result, associated injuries to different anatomic sites and organ systems occur with high frequency. The objective of this study was to determine what injuries occur with high incidence in patients presenting with major fractures of the talus and to identify clinical injury patterns that may warrant special attention in these patients. METHODS: We performed a retrospective review of patients presenting to 3 level 1 trauma centers with fractures of the talar neck, body, or head over a 14-year period. Patient charts were reviewed for associated orthopedic and nonorthopedic injuries identified during the initial patient encounter and hospitalization. RESULTS: In total, 262 fractures in 258 unique patients met criteria for inclusion. Overall, 33.3% of talus fractures occurred in isolation. One or more associated injuries were identified in the remainder of cases (66.7%). The incidence of associated injuries was similar across fracture patterns. Mean total number of injuries per patient was 2.2 (range, 0-15). The ipsilateral foot was the most frequent site of associated orthopedic injury. Noncontiguous injuries occurred in 36% of cases. Lumbar spine injury occurred in 10.5% of cases. Lower extremity vascular injury was uncommon but bore significant association with open talus fractures. CONCLUSION: Talus fractures are commonly associated with injuries to different anatomic sites and organ systems. A similar rate of lumbar spine trauma may occur with major talus fractures as has been historically associated with calcaneal fractures. Thorough evaluation and a high index of suspicion are necessary when evaluating patients with major fractures of the talus to avoid missing concomitant injuries. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Does fracture obliquity in Weber B fibula fractures correlate with mortise instability?

BACKGROUND: The diagnosis of instability in the apparent, isolated distal fibula fracture can be challenging and often necessitates stress radiography. Danis & Weber classified lateral malleolar fractures based on the level of the fracture in relation to the syndesmosis. While Weber B fractures occur at the level of the syndesmosis, some such injuries present with a long, oblique pattern extending well above the syndesmosis. Given the well-established literature demonstrating that fractures above the syndesmosis correlate with a higher level of concomitant syndesmotic and deltoid ligament injury, we hypothesize that increased fracture obliquity, length and height of Weber B fibula fractures similarly correlates with increased mortise instability. METHODS: All patients with isolated Weber B fibula fractures who underwent gravity stress radiography met inclusion criteria. Fracture height was measured on mortise radiographs as: (1) the distance from the distal tip of the fibula to fracture apex, (2) the distance to the fracture apex as measured on a line drawn perpendicular to a line parallel to the plafond, (3) an angle subtended by a line drawn parallel to the plafond and a line drawn to the fracture apex and (4) a ratio of the absolute length as compared to fibular width. RESULTS: 51 patients were included in the study. The group of 39 patients with stable ankles had a mean medial clear space of 3.12 ±â€¯0.65 mm (range, 1.5 mm to 4.0 mm). The group of 12 patients with unstable ankles had a mean medial clear space of 6.29 ±â€¯3.11 mm (range, 4.1 mm to 14.0 mm). These groups showed no significant difference in fracture angle (p = 0.93), fracture height from plafond (p = 0.49), fracture height from tip of fibula (p = 0.42), and as a ratio of absolute length to fibular width (p = 0.85). CONCLUSION: Increased fracture obliquity, length and height of Weber B fibula fractures did not correlate with a higher incidence of mortise instability. Despite the lack of positive correlation, future studies should continue to investigate and identify radiographic parameters of distal fibula fractures that are most predictive of instability.

Screw distraction technique for gaining fibular length.

Shortening of fibular length is most commonly secondary to fracture, especially in cases of malreduction, malunion or nonunion. In the presence of deltoid ligament incompetence, a shortened fibula causes lateral talar shift, widening of the mortise, decreased tibiotalar contact area and increased incidence of post-traumatic arthrosis. Restoring fibular length is important for normal anatomic relationships and kinematics of the ankle joint. While several techniques have been described for restoring length, some limitations exist. We describe an alternative surgical technique that is straightforward and reproducible that allows for restoration of fibular length and rotation.