Management of Acute Ankle Fractures in Patients With Diabetes.

Ankle fractures in patients with diabetes can be difficult to manage, especially when patients present with hyperglycemia. Treatment often requires a combination of both medical and surgical care, especially in patients with poorly controlled diabetes. The goal of any treatment is to obtain a well-aligned ankle fracture that heals without any further displacement and to avoid the development of a Charcot joint. Nonsurgical treatment is usually reserved for nondisplaced fractures. Displaced fractures often require surgical treatment, and there are different options available, including standard fixation, fixation with multiple syndesmotic screw placement, external (thin wire) fixation alone, hybrid or combined internal and external fixation techniques, and primary arthrodesis. It is important to discuss the approach to the evaluation and treatment of these patients.

The LISFRANC JUT: A physical finding of subtle LISFRANC injuries.

INTRODUCTION: Low-energy Lisfranc injuries are uncommon and are often misdiagnosed as sprains. This results in a delay for the definitive treatment. The aim of this study is to discuss the physical finding of a midfoot "jut," that can be used to help diagnose subtle Lisfranc injuries, in patients who present with persistent midfoot pain after low-energy trauma. PATIENTS AND METHODS: Between January 2015 through December 2019, patients previously diagnosed with a sprain, who were at least six weeks after their original injury, and presented with midfoot pain, were identified. All had a bony prominence on the medial border of the first tarsometatarsal joint, defined as a "jut", which produced pain. Standing radiographs demonstrated subluxation of the tarsometatarsal joint(s). RESULTS: Seven patients (5 females/2 males) presented as isolated injuries, with a mean age of 40.4 years. Mechanisms of injury were five falls, one from a sporting event, and one twisting injury. Time to diagnosis, from their date of injury, averaged 9.9 weeks. All underwent fixation. Follow-up averaged 13.7 months. At final follow-up none of the patients developed surgical site infections, wound dehiscence, loosening of implants, loss of reductions or a recurrence of the "jut". None of the patients demonstrated arthrosis and only one patient had a broken screw and declined further surgical intervention. DISCUSSION AND CONCLUSIONS: Patients presenting with a history of low-energy trauma, a diagnosis of sprain, continued complaint of foot pain, and a "jut" on the medial border of the midfoot, should be evaluated for a subtle Lisfranc injury.

Acute management of high-energy lisfranc injuries: A simple approach.

INTRODUCTION: The aims of this study were to (1) describe the use of the K-wire for the initial management of high-energy Lisfranc dislocations or fracture dislocations, (2) to evaluate whether this standalone technique allowed for adequate reduction of these injuries, (3) to evaluate whether reductions were maintained until definitive fixation was performed, (4) and to determine if it contributed to any increase in complications prior to or after definitive fixation. PATIENTS AND METHODS: A retrospective review was performed on all patients who presented with tarsometatarsal injuries from January 2005 through June 2015. Dislocations of the tarso-metatarsal joints were classified as either Type A (total incongruity, homolateral complex), Type B (partial incongruity, homolateral incomplete) or Type C (divergent, total or partial displacement) patterns, with or without associated fractures. For the purposes of this paper, high-energy injuries were defined as patients presenting with either a Type A or Type C (total displacement) dislocations or fracture-dislocation patterns. A total of 176 patients presented with a tarsometatarsal injury. Eighteen patients with divergent or homolateral patterns underwent a staged approach. Fifteen patients were managed exclusively with K-wire fixation. Wound complications, infections or the unexpected need to return to surgery were recorded. RESULTS: All patients demonstrated an improved alignment using K-wires. There were no compartment syndromes, vascular insufficiency, complications to the skin associated with traction or manipulation, or pin site infections. At definitive fixation, no patient demonstrated a loss in the alignment that had been obtained at the index procedure or had an unexpected return to surgery. DISCUSSION AND CONCLUSIONS: This study demonstrates that high-energy Lisfranc injuries are uncommon and that K-wires are a simple and adequate technique that can be used for initial staged approach of these injuries. The use of 2.0mm K-wires were sufficient to obtain and maintain the reduction until definitive fixation has been obtained, without producing any increase risk for complications.

Extensile Lateral Approach for the Operative Management of a Displaced Intra-Articular Calcaneus Fracture.

Calcaneal fractures account for approximately 1.2% of all fractures and 60% of all tarsal bone fractures. Almost 75% present as displaced, intra-articular fractures. Because of the complex articular and osseous anatomy, the vulnerable soft-tissue envelope, and the technically challenging approach needed for fixation, these fractures are often treated nonoperatively, resulting in poor outcomes. These poor outcomes can include entrapment of the posterior tibial and sural nerves, impingement, dislocation or entrapment of peroneal tendons, a widened heel with a loss of height, hindfoot varus or valgus, formation of painful exostoses, development of posttraumatic arthritis of the subtalar and calcaneocuboid joints, and impingement of the ankle joint. The current scientific literature supports fixation of displaced, intra-articular fractures. The principles of surgical fixation consist of reconstructing the height (obtained by improving the Böhler angle), narrowing the width, reconstructing the length, correcting any varus deformity of the tuberosity, and anatomically reducing the joint. However, at the time of initial presentation, there is often substantial swelling, with or without fracture blisters, that needs to be resolved prior to surgical fixation. During this waiting period, radiographic and computed tomography (CT) evaluations should be performed to assess the fracture pattern. Once re-epithelialization of the blisters and wrinkling of the skin are noted, open reduction and internal fixation (ORIF) can be performed. The steps to an ORIF consist of (1) the use of an extensile lateral incision, with a subperiosteal dissection, that develops a full-thickness fasciocutaneous flap; (2) removal of the lateral wall, to allow visualization of the impacted joint; (3) removal of the lateral third or half of the joint to allow visualization of the medial two-thirds or half of the joint; (4) disimpaction of the medial half of the joint to its normal height, along with medialization of the tuberosity; (5) anatomic reduction of the posterior facet and fixation with lag screw(s); (6) possible use of a bone graft and replacement of the lateral wall; (7) spanning the calcaneus with a plate and screws; and (8) closure of the fasciocutaneous flap and skin over a drain.

Assessing leg length after fixation of comminuted femur fractures.

BACKGROUND: Nailing comminuted femur fractures may result in leg shortening, producing significant complications including pelvic tilt, narrowing of the hip joint space, mechanical and functional changes in gait, an increase in energy expenditures, and strains on spinal ligaments, leading to spinal deformities. The frequency of this complication in patients managed with an intramedullary (IM) nail for comminuted diaphyseal fractures is unknown. QUESTIONS/PURPOSES: We therefore determined (1) the frequency of LLDs, (2) whether a specific fracture pattern was associated with LLDs, (3) the frequency of reoperation, and (4) whether revision fixation ultimately corrected the LLD. METHODS: We studied 83 patients with 91 AO/OTA Type B or Type C fractures fixed with either an antegrade or retrograde IM nail from July 2002 through December 2005. There were 60 males and 23 females, with a mean age of 30 years (range, 15-79 years). All underwent a digitized CT scan in the immediate postoperative period. Measurements of both legs were performed. Any fixation producing a discrepancy and requiring a return to surgery was identified. RESULTS: An mean LLD of 0.58 cm was found in 98% of the patients, but only six (7%) patients had an LLD of greater than 1.25 cm. No fracture pattern or the presentation of bilateral injuries demonstrated a greater incidence of LLD. Of the patients with LLD, two patients refused further surgery while the remaining four patients, two Type B and two Type C fractures, ultimately underwent revision fixation. Repeat CT scans after revision surgery of all four patients demonstrated a residual LLD of only 0.2 cm. CONCLUSIONS: Postoperative CT scans appear to be an efficient method to measure femoral length after IM nailing. Although residual LLDs may be common in comminuted femurs treated with IM nails, most LLDs do not appear to be functionally relevant. When an LLD of greater than 1.5 cm is identified, it should be discussed with the patient, who should be told that potential complications may occur with larger LLDs and that sometimes patients may benefit from repeat surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Development and validation of the new international classification for scapula fractures.

OBJECTIVES: Multiple scapula classification systems exist in the literature and were developed using a consensus approach with one or several experts agreeing on a classification without stringent validation. None have gained widespread acceptance. A decision was made by the OTA classification committee and the AO Classification Advisory Group to collaborate on the development of a new validated classification system capable of addressing the limitations of the existing systems. METHODS: A feedback validation process through 4 iterations of revised classifications on radiographs and computed tomography (CT) scans was used. Statistical analyses calculated the proportion of agreement among surgeons and kappa statistics for the assessment of coding reliability. Estimates of classification accuracy were obtained using latent class modeling. RESULTS: Fractures of the scapular neck are rare injuries and were difficult to define and diagnose with kappa values ranging from 0.28 to 0.40. Although fossa fractures could be identified on plain radiographs, specific fracture patterns could only be classified with CT scans. The new classification divides the scapula into 3 segments: fossa, body, and processes. The validation has shown that the classification can be reliable using plain radiographs (kappa 0.66), increasing to kappa of 0.78 when CT scans were added. CONCLUSIONS: This basic coding system allows clinicians to describe and classify scapula fractures with a reasonable degree of reliability. This validated classification that has resulted from this process has been accepted by a disparate group of orthopaedic traumatologists as a better option for clinical communication and research documentation.

Management of high-energy foot and ankle injuries in the geriatric population.

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Pantalar arthrodesis for post-traumatic arthritis and diabetic neuroarthropathy of the ankle and hindfoot.

BACKGROUND: Pantalar arthrodesis is an important salvage option for stabilizing the hindfoot and salvaging the limb following trauma or collapse. This report evaluates the healing rates and complications which occur in diabetics and post-traumatic patients. MATERIALS AND METHODS: Twenty patients presenting with post-traumatic arthritis of the ankle-hindfoot (twelve) or with Type II or Type IIIA Charcot arthropathy (eight) were managed with a pantalar fusion. Followup averaged 46 months. Patients were evaluated using the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Short Musculoskeletal Function Assessment (SMFA) and the Visual Analog Pain Scale (VAS). RESULTS: There were no amputations in either group. Casting averaged 14.9 weeks, full weightbearing was achieved at 25.1 weeks and time to union averaged 44.1 weeks. Average age was 56.3 yrs. and BMI averaged 34.2. Fourteen patients (70%) had their surgery performed in multiple stages. Acceptable outcomes were noted for all patients for the SF-36, AOFAS and SMFA scores. VAS scores averaged 2.2. There were ten complications (50%); four patients (two in each group) required additional surgery. CONCLUSIONS: Pantalar arthrodesis is a reasonable salvage option for patients with severe post traumatic arthropathy and neuropathic arthropathy. Patients should be informed of the increased risks as well as the long periods of postoperative immobilization and nonweightbearing. We believe a pantalar arthrodesis can produce acceptable outcomes regardless of the cause of disability, with a staged or single approach, and whether the surgery is performed with plates and screws or an intramedullary device.

The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly.

OBJECTIVE: The objective of this study was to evaluate acetabular fractures in elderly patients treated with open reduction internal fixation combined with acute total hip arthroplasty during the same anesthetic. DESIGN: The authors conducted a retrospective analysis of a treatment. SETTING: Level I and Level II trauma centers. PATIENTS: Between September 1995 through January 2005, 22 elderly patients were treated using the combined hip procedure. There were nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury. Six patients had hip dislocations and 14 patients demonstrated some impaction. Patients underwent medical evaluations and clearance before surgical intervention. INTERVENTION: Standard open reduction internal fixation techniques followed by immediate total hip arthroplasty during the same anesthesia. Ilioinguinal patients were repositioned and redraped for total hip placement. MAIN OUTCOME MEASUREMENTS: Complications, physical examinations, and Harris hip scores assessed outcomes. Radiographs evaluated union and stability of the femoral and acetabular components, osteolysis, or the development of any heterotopic bone. RESULTS: Follow up averaged 29.4 months. Surgeries averaged 232 minutes with 1163 mL average blood loss. Hospital stays approximated 8 days with full weightbearing occurring at 3 months. Hip motion averaged 102 degrees of flexion, 32 degrees of abduction, and 16 degrees of adduction. Harris hip scores averaged 74. Four patients developed heterotopic ossification, and five underwent revisions as result of osteolysis or multiple hip dislocations. CONCLUSIONS: The combined hip procedure is an option for acetabular fractures in elderly patients. Complications, surgical times, and hospitalizations are consistent with open reductions or belated total hip arthroplasties. Aggressive medical workups may be needed, but a single posterior surgical procedure will avoid the "wait-and-see" approach often used for these patients.

Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases.

OBJECTIVE: To compare extra-articular proximal tibial fractures treated with intramedullary nailing (IMN) or percutaneous locked plating (PLP) and assess the ability of each technique to obtain and maintain fracture reduction. DESIGN: Retrospective clinical study. SETTING: : Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Beginning with the first use of PLP of the proximal tibia at our institution, all skeletally mature patients with surgically treated proximal extra-articular tibial fractures were reviewed. Between August 1999 and June 2004, 29 patients treated with intramedullary nails and 43 patients treated with percutaneous locked plates were identified. Patients with at least 1-year follow-up included 22 IMN and 34 PLP cases, which formed the final study group. MAIN OUTCOME MEASUREMENTS: Final outcomes were assessed for the IMN and the PLP groups by comparing rates of union, malunion, malreduction (defined as >5 degrees angulation in any plane), infection, and removal of implants. RESULTS: The IMN and PLP groups showed similar age and gender demographics. Average length of follow-up was 3.4 years in the IMN group (15-67 months) and 2.7 years in the PLP group (12-66 months). Open fractures made up 55% of the IMN group and 35% of the PLP group. Final union rates (after additional procedures for nonunions after the index procedure) were similar between groups (IMN = 96% and PLP = 97%). Implant removal in the PLP group was 3 times greater than in the IMN group, (P = 0.390), whereas an apex anterior (procurvatum) malreduction deformity occurred twice as frequently in the IMN group (P = 0.103). Additional surgical techniques (eg, blocking screws) were frequently used during reduction within the IMN group and infrequently used within the PLP group (P = 0.0002). Neither technique resulted in a statistically significant loss of final reduction confirming the stability of each construct. CONCLUSIONS: Neither IMN or PLP showed a distinct advantage in the treatment of proximal extra-articular tibial fractures. Apex anterior malreduction however was the most prevalent form of malreduction in both groups. Additional surgical reduction techniques were frequently needed with IMN, whereas removal of implants seems to be more commonly needed with PLP.

Avoiding complications in the treatment of humeral fractures.

Three of the most common complications that may occur after the treatment of humeral fractures are nonunion, loss of fixation, and nerve injury. Nonunion may occur in up to 15% of patients who have been treated surgically. Loss of fixation often is caused by poor quality bone in the osteopenic humeral head. Nerve injury can occur as a result of trauma or from treatment.

Prevention of complications after treatment of proximal femoral fractures.

Two factors are primarily responsible for complications after treatment of proximal femoral fractures. First, the strong deforming forces across the hip joint and proximal femur can make fracture reduction difficult. Second, the placement of the implant affects fracture healing and outcome more dramatically than in other areas of the body. In subtrochanteric fractures, the use of appropriate reduction and stabilization techniques can prevent varus malreduction and subsequent failure of the fixation device. In intertrochanteric fractures, lag screw cutout can be prevented by correct implant positioning. In femoral neck fractures, nonunion can be avoided by careful attention to reduction and hardware positioning.

Prevention of complications after treatment of femoral shaft and distal femoral fractures.

The need for surgical treatment of femoral shaft and distal femoral fractures is undisputed. The treatment options are varied, and often the choice is based on the surgeon's preference rather than orthopaedic science. The decision should be determined by the predicted functional outcome rather than by the type of implant to be used. The entry point for intramedullary femoral nailing is of no consequence, if the nailing is performed correctly and the patient has a good functional outcome. The primary goal of treatment for a supracondylar femoral fracture is to restore limb alignment while preventing angular deformity. Proper technique, not the choice of a nail or plate, is key to recovery.

Avoiding complications in the care of fractures of the tibia.

Tibial fractures are the most common long-bone fractures. Orthopaedic surgeons, regardless of their subspecialty, often must treat these injuries, which range from low-energy, minimally displaced fractures to limb-threatening injuries with neurologic and vascular damage and significant damage to the soft-tissue envelope. Tibial shaft fractures are often prone to complications, such as apex-anterior and valgus malalignments after nailing of the fractures in the proximal one third of the tibia, infection after open fractures, and aseptic nonunions. Understanding the common complications will aid in preventing them and will allow recognition and provide treatment strategies when such problems occur.

Avoiding complications in the treatment of pronation-external rotation ankle fractures, syndesmotic injuries, and talar neck fractures.

Fractures of the foot and ankle are common injuries that often are successfully treated nonsurgically; however, some injuries require surgical intervention. To restore anatomy and avoid the need for additional surgery, surgeons must pay attention to detail and understand common, avoidable complications. The surgeon should have an understanding of the pathologic characteristics of three common injuries of the foot and ankle as well as the potential complications and their prevention.

Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.

OBJECTIVE: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. DESIGN: Consecutive clinical series. SETTING: 3 tertiary care academic trauma centers (Level 1 and 2). PATIENTS: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. INTERVENTION: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. MAIN OUTCOME MEASUREMENTS: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. RESULTS: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. CONCLUSIONS: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.