A Staged Protocol for Treatment of High-Energy Tongue-Type Calcaneus Fractures: Surgical Technique and Case Series.

SUMMARY: Displaced tongue-type calcaneus fractures are frequently associated with severe soft tissue injuries, and urgent relief of the displaced tongue fragment on the posterior soft tissues is essential to preventing soft tissue complications. If there is a complex articular injury, the soft tissue envelope often needs time for swelling to resolve to allow for a safe open anatomic reduction because premature open reduction internal fixation is often associated with increased complications. We have found that in high-energy tongue-type calcaneus fractures with complex articular injuries, a staged protocol consisting of initial percutaneous reduction and fixation with later definitive reconstruction is soft tissue friendly, allows early restoration of calcaneal morphology, and affords extensile approaches for eventual reconstruction. The purpose of this study was to describe our protocol of staged treatment of high-energy tongue-type calcaneus fractures, along with postoperative surgical outcomes, in a case series of 53 patients.Our series of patients had a high rate of intra-articular injury with marked initial displacement (mean Bohler angle -8.4 ± 20.8 degrees). They were treated initially with percutaneous reduction and fixation at median 1 day postinjury (interquartile range [IQR] 0-1) and definitively at median 16 days postinjury (IQR 10-33). In this series, 2 of 53 (3.8%) patients developed a deep wound infection.In high-energy tongue-type calcaneus fractures at risk for soft tissue compromise or with a significantly displaced tongue fragment without initial soft tissue compromise, we found that staged management represents a feasible management strategy to mitigate risk of soft tissue complications and therefore helps facilitate safe definitive open treatment.

Triceps Surae Lengthening in Foot and Ankle Trauma: A Survey of OTA and AOFAS Members.

Background: The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening-grouped as triceps surae lengthening (TSL) procedures-in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma. Methods: A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma. Results: A total of 258 surgeons with median 14 years' experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (ß = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL. Conclusion: Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice. Level of Evidence: Level V, therapeutic.

Prospective Study Investigating the Prevalence and Evolution of Malnourishment in the Acute Orthopaedic Trauma Patient.

Background: Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this study was to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients and determine when and what labs should be ordered. The secondary aim was to determine if malnourished patients had increased complications. Methods: Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritional status over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritional laboratory markers on admission, day 3, day 7, and 6 weeks post-op. Results: 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourished based on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR) as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted based on the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilized at 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12% of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markers throughout the hospital stay. Conclusion: The prevalence of malnourishment, based on serum nutritional markers, in the presence of acute orthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbumin or albumin levels on hospital day 3 to assess nutritional status.

Technique for Open Reduction and Internal Fixation of Lateral Process Talus Fractures.

Lateral process fractures of the talus may occur either in isolation or in combination with a talar neck or body fracture. Screw fixation has been well described as a means of stabilization; however, many patients have multifragmentary fragments, unable to be controlled by isolated screw fixation alone. Plate fixation of the lateral process has been yet to be described in detail with presence of a clinical series. Here, we describe our technique of plate fixation for both isolated lateral process fractures and those that occur in conjunction with talar neck or body fracture.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction.

INTRODUCTION: The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach. METHODS: Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome. RESULTS: The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed. CONCLUSIONS: ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Significance of Lateral Process Fractures Associated With Talar Neck and Body Fractures.

OBJECTIVES: To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures. DESIGN: Retrospective review. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period. INTERVENTION: Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis. MAIN OUTCOME MEASUREMENTS: Radiographic evidence of subtalar arthritis. RESULTS: Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001). CONCLUSION: Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Posteromedial Talus Fractures: Technique Description and Results of 10 Cases.

BACKGROUND: The aim of this study is to describe a surgical technique for successful treatment of posteromedial talar body fractures and establish treatment recommendations for fractures of the posterior aspect of the talus. MATERIALS AND METHODS: Ten patients treated operatively for a posteromedial talar body fractures entering both the subtalar and ankle articulations with a minimum of 1-year followup were identified from a trauma database. Age, mechanism of injury, associated injuries, time to surgery, complications, the range of motion, secondary procedures, and need for arthrodesis were evaluated. RESULTS: Followup averaged 4.8 years (1-10). Eight of ten patients had high-energy mechanisms of injury. Six patients had associated medial subtalar dislocations with two open. Associated injuries were common. No surgical complications occurred. The range of motion was present but decreased. No arthrodesis procedures were performed. CONCLUSIONS: Operative fixation of posteromedial talus fractures with the described surgical technique resulted in acceptable outcomes in this series of patients with improved outcomes when compared to prior reports in the literature.

Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series.

The derangement in calcaneal morphology after a fracture can be significant and is often associated with severe soft tissue envelop problems. Medial calcaneal external fixation is useful for early restoration of calcaneal morphology and the corresponding soft tissue envelop. When performed in a stepwise fashion, external fixation can successfully restore normal calcaneal height, length, width, and coronal plane alignment. For severely displaced joint depression and broken tongue-type calcaneus fractures where open treatment is the preferred strategy, early external fixation restores the normal soft tissue tension, allows a stable environment for soft tissue recovery, and facilitates the definitive operation by restoring and maintaining overall calcaneal architecture. We describe the stepwise approach to calcaneal reduction and external fixation and report a case series demonstrating this method is safe and effective for staged management of severely displaced calcaneus fractures.

Obtaining Correct Ankle Alignment Using Intraoperative External Fixation for Ankle Arthrodesis.

Ankle arthrodesis remains an important treatment option for patients with ankle arthritis. Many methods have been described; however, no consensus has been reached regarding the best technique to achieve both successful fusion and a good position for optimal foot mechanics. Furthermore, as arthroplasty has become more popular, preservation of the fibula to allow for future arthroplasty has become critical. The present report describes an innovative technique in which temporary external fixation at operative fixation is used, along with internal fixation, to achieve both an optimal foot position and high fusion rates, while maintaining the integrity of the fibula. Seventeen patients were identified who met the criteria for inclusion. Their medical records, including pre- and postoperative radiographs, were reviewed retrospectively. Preoperative and postoperative coronal and sagittal alignment was determined. All patients achieved successful fusion, although 1 (5.9%) patient experienced delayed union. The average tibial/talar ratio preoperatively was 21% (range 8% to 33%), demonstrating anterior subluxation. Postoperatively, this ratio improved to 33% (range 26% to 40%), approximating the normal anatomic ratio. Of the 17 patients, 5 (29.4%) had preoperative varus or valgus alignment of the talas >5°. All 5 cases were successfully corrected to within 2° of normal anatomic alignment. This technique allows the surgeon to achieve good visualization of the joint for preparation and to obtain the optimal position of the foot at arthrodesis without compromising the lateral column significance of the fibula. All patients obtained fusion, and minimal complications were associated with the use of this technique.

Gastrocnemius or Achilles Lengthening at Time of Trauma Fixation.

Gastrocnemius equinus is a frequent comorbidity with traumatic injuries of the foot and ankle. Gastrocnemius lengthening at the time of definitive treatment facilitates obtaining and maintaining an anatomic reduction of the injury. The lengthening procedure is accomplished in 5 steps and results in fewer long-term, problematic sequelae.

Treatment of Peripheral Talus Fractures.

Peripheral talus fractures include injuries to the lateral process, posteromedial talar body, and talar head. These injuries are rare and are often missed. Nonunion with conservative treatment is high and excision can lead to joint instability, rapid arthrosis, and earlier need for arthrodesis. Open reduction internal fixation of most peripheral talus fractures is critical to achieving a good outcome. Open reduction leads to more rapid union and ability to mobilize the ankle and subtalar joints, quicker revascularization of the talus, and lower rates of arthrosis. Surgical treatment can lead to substantial functional improvement and a slowing of the degenerative process.

Incidence of Preoperative Deep Vein Thrombosis in Calcaneal Fractures.

OBJECTIVES: This study examined the incidence and risk factors of preoperative deep vein thrombosis (DVT) in patients presenting to an outpatient setting with an isolated calcaneal fracture. DESIGN: Retrospective chart review. SETTING: All patients included in the study presented to the treating surgeon at a Level I trauma center with isolated calcaneal fractures as an outpatient between 2005 and 2013. METHODS: These patients were either referred from outside hospitals, had been evaluated in the emergency department initially and presented for definitive care, or presented initially to the outpatient clinic. Patients included were over the age of 18, had a preoperative duplex ultrasonography of bilateral lower extremities per the treating surgeon's protocol, and had at minimum 6 weeks follow-up. Patients were excluded if they were a polytrauma, had a documented hypercoagulable state, or were on baseline pharmacologic anticoagulation for another condition. All patients had a preoperative duplex ultrasound of both lower extremities to evaluate for DVT at least 7 days after injury. MAIN OUTCOME MEASURE: Patients found to have a preoperative DVT were compared with those who did not have preoperative DVT for possible risk factors. RESULTS: One hundred fifty-nine patients qualified for our study and of these, 19 (12%) were found to have a DVT preoperatively, almost all of which were in distal veins. All risk factors, including age, sex, and body mass index were analyzed as continuous variables. Older age was found to be a risk factor for DVT (P = 0.009, Odds Ratio = 1.06, 95% CI, 1.01-1.11). All other predictor variables, including body mass index (P = 0.05) and sex (P = 0.08), were not statistically significant predictors in our sample. CONCLUSIONS: The incidence of preoperative DVT found here is almost 2 times as high as any previously published examination of lower extremity injuries. Physicians should be aware of this increase so they may counsel patients about the risks of DVTs and the likelihood of any sequelae from developing a DVT that may affect a patient's recovery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Joint-Preserving Osteotomies for Malaligned Intraarticular Calcaneal Fractures.

Intraarticular calcaneal fracture treatments that result in malalignment often require reconstructive surgery. Seven cases are used to demonstrate the intricacies of reconstructive case management. Reestablishment of calcaneal height, length, orientation, and position relative to the other tarsals is necessary to reestablish appropriate foot function. Inherent or acquired gastrocnemius equinus should be treated with recession to reduce destructive forces on the reconstruction.

Open surgical management of high energy ipsilateral fractures of the fibula and calcaneus.

BACKGROUND: Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity. METHODS: A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks. RESULTS: Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united. CONCLUSIONS: Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.

Interobserver Variability in the Measurement of Lower Leg Compartment Pressures.

OBJECTIVES: To determine whether interobserver technical variations and errors in the measurement of compartment pressures may affect measurement accuracy. METHODS: Four above-knee cadaveric specimens were used to create a consistent model of lower leg compartment syndrome. Thirty-eight physicians examined the limbs and measured 4 compartment pressures using the Intra-Compartmental Pressure Monitor (Stryker Orthopaedics). They were observed for correct assembly and use of the monitor. Measurements obtained were compared with known pressures. RESULTS: Of the total number of compartment measurements, 31% were made using the correct technique, 39% were made with lesser errors in technique, and 30% were made with catastrophic errors. Only 60% of measurements made with the correct technique were within 5 mm Hg of the standard pressure. Accuracy dropped to 42% for measurements taken with small errors in technique and 22% when a catastrophic error was committed. CONCLUSIONS: Variations in use of a commercially available pressure monitor exist, and errors are common. Proper use improved accuracy, but even with proper technique, 40% of the measurements were >5 mm Hg from the actual pressure. Based on our data, measurement accuracy with this device should be questioned and viewed within a range. Regular review and education of technique is strongly recommended.

Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures.

BACKGROUND: There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire. METHODS: Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years. RESULTS: The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon's overall impression of severity were significantly associated with functional outcome. CONCLUSIONS: The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon's overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA. LEVEL OF EVIDENCE: Level III, comparative series.

Triple arthrodesis: tips and tricks to navigate trouble.

Triple arthrodesis is a powerful corrector of hindfoot deformity related to trauma, rheumatoid arthritis, and long-standing peritalar subluxation with posterior tibial tendon dysfunction. To avoid the common postoperative complications related to triple arthrodesis, one must be meticulous in preoperative evaluation as well as surgical technique. Presented are some tips and tricks to avoid the common complications and provide the patient with a plantigrade, stable foot, as well as some salvage options for triple arthrodesis in a malunited position.

Entrapped posteromedial structures in pilon fractures.

OBJECTIVES: To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 Trauma Center. PATIENTS/PARTICIPANTS: About 394 patients with 420 pilon fractures treated between January 2005 and November 2011. INTERVENTION: Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture. MAIN OUTCOME MEASUREMENTS: Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure. RESULTS: 40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%). CONCLUSIONS: In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Plantar medial wounds associated with calcaneal fractures.

BACKGROUND: Calcaneal fractures with open wounds are prone to soft tissue complications. We describe a particular subclass of open injury that occurs on the plantar surface of the foot, medial to the anterior process of the calcaneus, the plantar medial wound (PMW). The purpose of this study was to evaluate soft tissue healing and potential complications in open calcaneal fractures that have a PMW. METHODS: We established the time to soft tissue healing and the status of the injured limb of 11 adults with 12 calcaneal fractures with a PMW. This was a retrospective review of prospectively gathered data at a Level I trauma center. RESULTS: Five fractures developed an infection requiring intravenous antibiotics. Two patients required split thickness skin grafts and 1 patient required a free gracilis flap 10 months after injury to treat a chronic open PMW with resolving osteomyelitis and required a below-knee amputation secondary to flap failure. The most commonly associated bony injury with a PMW was a transcalcaneal-talonavicular fracture dislocation (8/13 injuries). Nonunion of the calcaneal fracture occurred in 3 patients. CONCLUSION: Patients with this type of injury-even those with Gustilo Type I open fractures-need to be apprised that their injury is associated with long-term sequelae, including complications with wound healing, high infection rates, and a higher potential for subsequent amputation than other open hind foot wounds. The Tscherne classification of open wounds should be used in the future. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Kirschner wire bending.

Although Kirschner wires are useful implants in many situations, migration of the wire and irritation of the surrounding soft tissues are common complications. Seven steps are described herein, which result in a Kirschner wire that is bent 180° angle, providing a smooth anchor into bone. Use of this technique produces implants that provide stable fixation with few soft tissue complications.