Operative Traction Technique for an Intertrochanteric Femur Fracture in a Patient with Transfemoral Amputation: A Case Report.

CASE: A 53-year-old woman with a history of transfemoral amputation presented to the emergency department with an ipsilateral intertrochanteric femur fracture. Standard fracture tables that use a boot to pull traction are not helpful in these cases, which makes achieving adequate traction for reduction difficult. CONCLUSION: We describe a unique technique to manipulate an amputated extremity using 2 Schanz pins attached to a weight through a traction rope. This practical technique provided adequate skeletal traction for reduction and internal fixation in our case and can be performed on a standard radiolucent table without the need for special table attachments.

Secrets of Success in the Management of Lower Extremity Nonunions.

The key to obtaining healing of nonunions in the lower extremity is to provide a balance of biology and stability. To achieve this goal, the surgeon must understand why the bone did not heal with the initial treatment and change the strategy to improve the outcome. Patients need to be optimized before any proposed surgery. Whether the surgeon uses a certain type of internal or external fixation depends on the location on bone, the type (atrophic versus hypertrophic) of nonunion, the local soft tissue, the element of infection, and the health of the host. The mechanical stability of the fixation, especially in the lower extremity, should be robust and allow some early weight bearing. Early weight bearing stimulates healing, decreases osteoporosis, improves the patient's overall health, and allows early return to function. Diagnosis and management of infected nonunions in the lower extremity is also a major key to a successful outcome in this difficult group of patients.

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures.

OBJECTIVE: To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018. METHODS: A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders. MAIN OUTCOME MEASUREMENTS: Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores. RESULTS: There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores. CONCLUSIONS: Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes After Intramedullary Nailing of Intraarticular Distal Tibial Fractures: A Retrospective Review.

The objective of this study was to evaluate the clinical and functional outcomes of intra-articular distal tibial fractures after intramedullary nail (IMN) and independent fixation compared with extra-articular fracture controls. Methods: A retrospective chart review of distal tibial fractures treated with IMN was performed. Clinical outcomes were compared between fractures with and without intra-articular involvement. Outcomes included nonunion, malunion, ankle arthrosis, and infection. Patient-Reported Outcome Measurement System (PROMIS) scores were used to assess subjective outcomes. Results: Of the 135 distal tibial fractures, 87 extra-articular and 48 intra-articular, no significant difference was observed in the rate of ankle arthrosis between intra-articular and extra-articular fractures (2% versus 0%; P = 0.35). Similarly, no difference was observed in the postoperative rates of infection (8% versus 3%; P = 0.25), the rate of nonunion (17% versus 10%; P = 0.29), or the rate of malunion (10% versus 21%; P = 0.17). No notable difference was observed in PROMIS scores between groups. Conclusion: This study suggests that IMN is an acceptable method of fixation in select intra-articular distal tibial fractures. In the intra-articular group, low rates of ankle arthrosis were noted at intermediate follow-up, with no increase in nonunion, malunion, or infection compared with extra-articular fractures. Furthermore, PROMIS scores indicate similar functional outcomes in patients, regardless of intra-articular involvement.

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review.

OBJECTIVE: To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. DESIGN: Retrospective chart review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. METHODS: A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. MAIN OUTCOME MEASUREMENTS: Outcomes included infection and nonunion. RESULTS: The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). CONCLUSIONS: This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

How Can I Get This Bone to Heal?

A nonunion is a reconstructive challenge that may have a devastating effect on a patient's quality of life. To develop an individualized treatment plan, surgeons must carefully assess several factors related to the nonunion, including the involved bone, the existing implants, the presence of infection, the soft-tissue envelope, and the function of the involved extremity, as well as the status of the patient. Essential components of an individualized treatment plan for a patient with a nonunion include management of infection (if present); optimization of the systemic and local biologic environment via management of nutritional and metabolic deficiencies, systemic disease, tobacco use, and medications that interfere with bone healing as well as via supplemental procedures, such as use of biologics or bone grafting; and achievement of mechanical stability via internal or external fixation that allows for early functional active range of motion and weight bearing. The goal in the management of nonunion is to maximize the likelihood of healing in the most expedient manner without further complications.

Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes.

OBJECTIVES: To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight patients with infected nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod external fixator for bone transport. MAIN OUTCOME MEASUREMENTS: Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. RESULTS: The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. CONCLUSIONS: Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hexapod Frame Stacked Transport for Tibial Infected Nonunions With Bone Loss: Analysis of Use of Adjunctive Stability.

OBJECTIVES: The stacked hexapod bone transport technique is an effective treatment for infected tibial nonunions with bone loss. The purpose of this study was to evaluate the patients' risk factors and timing for requiring adjunctive stabilization. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seventy-five patients with infected posttraumatic nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod frame for bone transport. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. Outcomes recorded: removal of frame, below knee amputation, or adjunctive stability. Further analysis evaluated location of nonunion, timing of adjunctive stabilization, and type of fixation. RESULTS: The average patient age was 45.7 ± 12.5 years, 76% patients were men, 11% were diabetic, and 44% were smokers. Forty two percent had soft tissue defects that required a free flap. Thirty-eight patients had removal of frame, whereas 36 patients required adjunctive stability of the hexapod frame. Patient receiving adjunctive stabilization had a longer length of time in the hexapod frame (P = 0.026) and were more likely to require a free flap (P = 0.053). Ninety-three percent docking site nonunions occurred after the removal of the frame (P = 0.032); whereas 79% regenerate nonunions occurred before the hexapod frame was removed (P = 0.029). CONCLUSIONS: The use of a hexapod frame for the infected tibial nonunions with bone loss is an effective method for achieving union and eradicating infection in a difficult orthopaedic patient population. Use of adjunctive stabilization is a reasonable technique to address delayed regenerate and docking site nonunions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Premature Consolidation with Resultant Implant Failure Using PRECICE Femoral Nail Lengthening: A Case Report.

CASE: Posttraumatic limb-length discrepancies secondary to femoral malunion can be treated with a variety of external or internal lengthening systems. The PRECICE nail is an intramedullary device featuring an external remote control to activate a magnetically driven internal distraction mechanism. While this intramedullary system avoids the soft-tissue complications common to external lengthening, it has unique mechanisms of failure that are difficult to diagnose and that require a systematic approach. CONCLUSION: In this case report, we describe a failure to lengthen with the PRECICE femoral nail and the subsequent steps taken to determine the root cause. We believe that this failure represents the first reported case of malfunction of the PRECICE femoral nail distraction mechanism since its 2013 redesign.

Osteocutaneous pedicle flap transfer for salvage of transtibial amputation after severe lower-extremity injury.

BACKGROUND: A conventional transtibial amputation may not be possible when the zone of injury involves the proximal part of the tibia, or in cases of massive tibial bone and/or soft-tissue loss. The purpose of this study was to examine the outcomes of salvage of a transtibial amputation level with a rotational osteocutaneous pedicle flap from the ipsilateral hindfoot. METHODS: Fourteen patients who had an osteocutaneous pedicle flap from the ipsilateral foot were included in the study. Twelve patients were followed for more than twenty-four months (mean, 60.2 months) and were evaluated with use of the Sickness Impact Profile (SIP), Musculoskeletal Function Assessment (MFA), and a 100-ft (30.48-m) timed walking test. RESULTS: There were ten men and four women with mean age of 43.2 years. Thirteen patients had a type-IIIB open tibial fracture, and one had extensive soft-tissue loss secondary to a burn. Four patients were treated for infection after the index procedure. There were no nonunions of the tibia to the calcaneus. Three patients underwent late reconstructive procedures to improve prosthetic fit. No patient required subsequent revision to a more proximal amputation level. Mean knee flexion was 139°. CONCLUSIONS: A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.

Surgical Technique for Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury.

INTRODUCTION: Osteocutaneous pedicle flap transfer from the foot can be used to "salvage" a transtibial amputation level when the severity of an injury precludes a transtibial amputation. STEP 1 PREOPERATIVE ASSESSMENT: If the posterior tibial artery is not palpable, obtain an angiogram to determine the vascular supply distal to the traumatic zone and to prepare for conversion to a composite free microvascular transfer. STEP 2 REMOVE PROVISIONAL IMPLANTS: Remove provisional stabilization implants and minimize surgery about the knee. STEP 3 DEVELOP THE FLAP: The dissection about the tarsal tunnel is the critical portion of the operative technique. STEP 4 CONTOUR THE CALCANEUS: Any deviation from perpendicular will translate to an axial deformity in the reconstructed limb. STEP 5 PREPARE THE PROXIMAL PART OF THE TIBIA AND SURROUNDING TISSUES: Retain viable soft tissues and bone, but resect the fibula obliquely. STEP 6 SECURE THE CALCANEUS TO THE TIBIA: Avoid varus and recurvatum malalignment. STEP 7 REPAIR AND RECONSTRUCT THE SOFT TISSUES: The injured limb is routinely very swollen, and in some cases complete coverage requires split-thickness skin-grafting. STEP 8 POSTOPERATIVE CARE AND REHABILITATION: As the initial reconstruction is sometimes extremely bulbous, continually advise the patient that the shape will improve dramatically over time with shrinkage of the limb. RESULTS: In our original study, ten men and four women with a mean age of 43.2 years (range, twenty-four to sixty-four years) underwent an osteocutaneous pedicle flap transfer with use of the ipsilateral foot for salvage to achieve a transtibial amputation level. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.

BACKGROUND: Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects. METHODS: The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1). RESULTS: Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent. CONCLUSIONS: Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Tibiotalar arthrodesis using a custom blade plate.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of patients who underwent tibiotalar arthrodesis between 1997 and 2003 for tibiotalar arthritis. The cause was predominantly posttraumatic arthritis secondary to tibial plafond fracture (n = 15) or talar body fracture (n = 2). METHODS: We retrospectively evaluated a consecutive series of 20 patients with 21 arthritic tibiotalar joints. Radiographs, clinical notes, scheduled visits, and telephone interviews were used to obtain outcome data after tibiotalar arthrodesis using a custom blade plate. The American Orthopedic Foot and Ankle Society Ankle Hindfoot Score quantified clinical outcomes in this study. RESULTS: Sixteen patients with 17 ankle arthrodeses were available after a mean follow-up period of 37.3 months. There were no postoperative wound complications or infections. There were no nonunions identified within the study. The mean American Orthopedic Foot and Ankle Society Ankle Hindfoot Score was 78.25 (range, 65-92). The average time to fusion was 3.9 months. CONCLUSIONS: Tibiotalar arthrodesis using a custom blade plate and a lateral approach is a reliable therapy for aseptic posttraumatic arthritis.

Results and outcomes after operative treatment of high-energy tibial plafond fractures.

BACKGROUND: The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation. METHODS: A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered. RESULTS: Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment. CONCLUSIONS: Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.

Femoral head avulsion fracture with malunion to the acetabulum: a case report.

The case of a patient who sustained an avulsion fracture of the femoral head (Pipkin Type I) that was unrecognized is described. The patient was referred to the authors' institution four months after injury, and radiographic studies showed a malunited avulsion fracture of the femoral head to the acetabulum. The patient subsequently went on to an excellent result after surgical debridement. The authors recommend additional radiographic studies in cases to exclude unrecognized fractures where a possible hip subluxation may have occurred.