Infection and Nonunion After Fasciotomy for Compartment Syndrome Associated With Tibia Fractures: A Matched Cohort Comparison.

OBJECTIVES: The objective was to compare the rates of union and infection in patients treated with and without fasciotomy for acute compartment syndrome (ACS) in operatively managed tibia fractures. DESIGN: This was a retrospective review. SETTING: The study was conducted at both a Level 1 and Level II trauma center. PATIENTS/PARTICIPANTS: Patients operated for tibial plateau fractures (group 1) and tibial shaft fractures (group 3) with ACS requiring fasciotomy were matched to patients without ACS (plateau: group 2, shaft: group 4) in a 1:3 ratio for age, sex, fracture pattern, and open/closed injury. INTERVENTION: Surgical treatment was provided with plates/screws (plateau fractures) or intramedullary rod (shaft fractures). Patients with ACS were treated with a 2-incision 4-compartment fasciotomy. MAIN OUTCOME MEASUREMENTS: Time to union and incidence of deep infection, nonunion, and delayed union. RESULTS: One hundred eighty-four patients were included-group 1: 23 patients, group 2: 69 patients, group 3: 23 patients, and group 4: 69 patients. Time to union averaged 26.8 weeks for groups 1 and 3 and 21.5 weeks for groups 2 and 4 (P > 0.05). Nonunion occurred in 20% for groups 1 and 3 and in 5% for groups 2 and 4 (P = 0.003). Deep infection developed in 20% for groups 1 and 3 and in 4% for groups 2 and 4 (P = 0.001). There was a significant increase in infection in group 1 versus group 2 and nonunion in group 3 versus group 4. There were significantly more smokers for those with fasciotomies (46%) than without (20%, P < 0.001), though all statistical results remained similar after a binary regression analysis. CONCLUSION: Four-compartment fasciotomies in patients with tibial shaft or plateau fractures is associated with a significant increase in infection and nonunion. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Suprapatellar Versus Infrapatellar Tibial Nail Insertion: A Prospective Randomized Control Pilot Study.

PURPOSE: The purpose of this OTA-approved pilot study was to compare the clinical and functional outcomes of the knee joint after infrapatellar (IP) versus suprapatellar (SP) tibial nail insertion. DESIGN: Prospective, randomized. SETTING: Level I trauma center. METHODS: After institutional review board approval, skeletally mature patients with OTA 42 tibial shaft fractures were randomized into either an IP or SP nail insertion group after informed consent was obtained. The SP also underwent prenail and postnail insertion patella-femoral (PF) joint arthroscopy. Patients underwent follow-up (6 weeks, 3, 6, and 12 months) with standard radiographs, as well as visual analog score and pain diagram documentation. At the 6-month and 12-month visits, knee function questionnaires (Lysholm knee scale and SF-36) were completed. Magnetic resonance imaging/image (MRI) of the affected knee was obtained at 12 months. Ten patients in each group were required for a power analysis for the anticipated larger randomized control trial, but enrollment in each arm was not limited because of known problems with patient follow-up over a 12-month period. RESULTS: A total of 41 patients/fractures were enrolled in this study. Of those, only 25 patients/fractures (14 IP, 11 SP) fully complied with and completed 12 months of follow-up. Six of 11 SP presented with articular changes (chondromalacia) in the PF joint during the preinsertion arthroscopy. Three patients displayed a change in the articular cartilage based on postnail insertion arthroscopy. At 12 months, all fractures in both groups had proceeded to union. There were no differences between the affected and unaffected knee with respect to range of motion. Functional visual analog score and Lysholm knee scores showed no significant differences between groups (P > 0.05). The SF-36v2 comparison also revealed no significant differences in the overall score, all 4 mental components, and 3/4 physical components (P > 0.05). The bodily pain component score was superior in the SP group (45 vs. 36, P = 0.035). All 11 SP patients obtained MRIs at 1 year. Five of these patients had evidence of chondromalacia on MRI. These findings did not correlate with either the prenail or postnail insertion arthroscopy. Importantly, no patient in the SP group with postnail insertion arthroscopic changes had PF joint pain at 1 year. CONCLUSIONS: Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up. Based on this pilot study data, larger prospective trial with long-term follow-up is warranted. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients.

OBJECTIVE: To describe the incidence and common patterns of lateral meniscal tears detected intraoperatively and surgically treated based on tibial plateau fracture patterns. DESIGN: Retrospective analysis of a prospective database. SETTING: Level One Regional Trauma Center. METHODS: All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. All operative notes and radiographs were reviewed to determine type of tibial plateau fracture, mechanism of injury, intraoperative detection of a lateral meniscal tear, and operative repair/partial resection of the meniscus itself. Patients were excluded if there was no mention of a submeniscal arthrotomy, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condyle fracture. Statistical analysis was performed using χ analysis and Fisher exact test to determine the overall incidence of lateral meniscal tears and any correlation between meniscal tear and fracture pattern. RESULTS: A total of 602 patients were included in the final analysis. Lateral meniscal tears requiring operative repair were detected intraoperatively in 179 patients (30%). This could be broken down into 12% for pure lateral split fractures, 45% for split depression fractures (P < 0.001), 18% for pure depression fractures, 22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures. Lateral meniscal tears associated with a split depression fracture pattern were most commonly peripheral rim tears (83%). For all other fracture patterns, the type of meniscal injury was evenly distributed between peripheral and radial tear. Young males demonstrated a statistically higher rate of lateral meniscal tears (33%). CONCLUSIONS: In our series, the incidence of a lateral meniscal tear detected intraoperatively requiring repair was 30%. These tears occurred more frequently in young males, with peripheral rim tears most commonly associated with split depression fractures. Based on our data, we believe that preoperative imaging for meniscal injury overstates the true incidence of meniscal tears requiring operative intervention. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.