Comparing Different Surgical Techniques for Addressing the Posterior Malleolus in Supination External Rotation Ankle Fractures and the Need for Syndesmotic Screw Fixation.

Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.

The effect of early operative stabilization on late displacement of zone I and II sacral fractures.

INTRODUCTION: This study was designed to evaluate the effect on displacement of early operative stabilization on unstable fractures when compared to stable fractures of the sacrum. METHODS: Patient consisted of those sustaining traumatic pelvic fractures that also included sacral fractures of Denis type I and type II classification, who were over 18 at the time of the study. Patients were managed emergently, as judged appropriate at the time and then subsequently divided into two cohorts, comprising those who were either treated operatively or non-operatively. The operative group comprised those treated with either internal fixation or external fixation. RESULTS: Twenty-eight patients had zone II fractures, and 20 had zone I fractures. Zone II fractures showed average displacements of 6.5mm and 6.9mm in the rostral-caudal and anteroposterior directions, respectively, at final follow up. Zone I fractures had average displacements of 6.6mm and 6.1mm in both directions. There were no significant differences between zone I and II sacral fractures (rostral-caudal P=0.74, anteroposterior P=0.24). Average changes in fracture displacement in patients with zone I fractures were 0.6-1.0mm in both directions. Average changes in zone II fractures were 1.8-1.5mm in both directions. There were no significant differences between the average changes in zone I and II fractures in any direction (rostral-caudal P=0.64, anteroposterior P=0.68) or in average displacements at final follow up in any of zone or the entire cohort. Statistically significant differences were noted in average changes in displacement in zone II fractures in the anteroposterior plane (P=0.03) and the overall cohort in the anteroposterior plane (P=0.02). CONCLUSION: Operative fixation for unstable sacral fractures ensures displacement at follow up is comparable with stable fractures treated non operatively.

Occam paradox? A variation of tapia syndrome and an unreported complication of guidewire-assisted pedicle screw insertion.

Study Design Case report. Clinical Question The clinical aim is to report on a previously unknown association between guidewire-assisted pedicle screw insertion and neuropraxia of the recurrent laryngeal nerve (RLN), and how this may overlap with the signs of Tapia syndrome; we also report our approach to the clinical management of this patient. Methods A 17-year-old male patient with idiopathic scoliosis experienced Tapia syndrome after posterior instrumentation and arthrodesis at the level of T1-L1. After extubation, the patient had a hoarse voice and difficulty in swallowing. Imaging showed a breach in the cortex of the anterior body of T1 corresponding to the RLN on the right. Results Otolaryngological examination noted right vocal fold immobility, decreased sensation of the endolarynx, and pooling of secretions on flexible laryngoscopy that indicated right-sided cranial nerve X injury and left-sided tongue deviation. Aspiration during a modified barium swallow prompted insertion of a percutaneous endoscopic gastrostomy tube before the patient was sent home. On postoperative day 20, a barium swallow demonstrated reduced aspiration, and the patient reported complete resolution of symptoms. The feeding tube was removed, and the patient resumed a normal diet 1 month later. Tapia syndrome, or persistent unilateral laryngeal and hypoglossal paralysis, is an uncommon neuropraxia, which has previously not been observed in association with a breached vertebral body at T1 along the course of the RLN. Conclusion Tapia syndrome should be a differential diagnostic consideration whenever these symptoms persist postoperatively and spine surgeons should be aware of this as a potential complication of guidewires in spinal instrumentation.

Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: operative technique and clinical outcomes.

BACKGROUND: A variety of techniques have been developed to improve clinical outcomes and objective knee stability following posterior cruciate ligament (PCL) reconstruction. Additional refinements in surgical and rehabilitation techniques are necessary for improvement of both subjective and objective outcomes. METHODS: All patients studied underwent endoscopic PCL reconstruction with a double-bundle allograft. All of the allografts were placed into the femoral tunnel through a lateral arthroscopic portal, secured by an all-inside method, and were passed distally through a transtibial tunnel. Modified Cincinnati subjective and International Knee Documentation Committee (IKDC) subjective and objective outcome scores and posterior stress radiographs of the knee were made preoperatively and at the time of final follow-up. RESULTS: There were a total of thirty-nine patients, including thirty-three male and six female patients, with an average age of thirty-three years. There were seven isolated PCL reconstructions and thirty-two combined reconstructions of the knee. Eight patients were not available for follow-up at a minimum of two years, leaving a cohort of thirty-one patients. Preoperative Cincinnati and IKDC subjective scores averaged 34.5 and 39.3, respectively. These scores improved significantly to 73.2 and 74.3, respectively, at an average of 2.5 years postoperatively. On posterior stress radiographs, the average posterior tibial translation of the knees was 15 mm preoperatively and improved significantly to 0.9 mm postoperatively. CONCLUSIONS: Patients undergoing double-bundle PCL reconstruction with use of endoscopic placement of femoral tunnels had significant improvements in subjective and objective outcome scores and with objective knee stability.