Bruce J. Sangeorzan

Talar Neck Fractures: Results and Outcomes

BACKGROUND Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. METHODS We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. RESULTS Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. CONCLUSIONS Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.

Modified Lapidus Procedure for Hallux Valgus

A modified Lapidus procedure was introduced at Harborview Medical Center in 1979 for the treatment of symptomatic hallux valgus with hypermobile first ray. The results of the procedures were reviewed retrospectively in 32 patients with 40 feet that were operated on between 1979 and 1984. Preoperative diagnosis was symptomatic hallux valgus complex with hypermobile first ray in 33 and failed bunion surgery in 7. Follow-up ranged from 30 months to 6 1/2 years. Union of the arthrodesis site occurred in 36 (90%). The average preoperative intrametatarsal angle was 14° (range 7.5 to 20°) and the hallux valgus angle was 26° (range 0 to 50°). At healing, the angles were as follows: intermetatarsal angle 6° (range 0 to 18°) and hallux valgus angle 11° (range −3 to 30°). The average change in the length of the first metatarsal was −5 mm for those without bone graft and +4 mm for those with bone graft. Of 33 feet operated on as a primary procedure, successful results were reported in 75% by our rating system. Of 7 feet operated on for failed previous surgery, all were improved. Best results were obtained in those with multiple screw fixation, use of bone graft, and attention to plantarflexion of the first metatarsal.

Fractures of the calcaneus.

Displaced fractures of the calcaneous are relatively common injuries that remain a treatment enigma. Virtually all aspects of the management of calcaneal fractures are a source of debate. Contemporary imaging, reduction, and fixation techniques attempt to improve the long term results of these injuries. The complex fracture fragments displace in predictable patterns. Meticulous surgical technique, restoration of extra- and intra-articular anatomy, and obtaining rigid fracture fixation are critical to obtaining satisfactory operative results. This article extensively reviews the controversies and summarizes the current opinions in the management of displaced calcaneal fractures.

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach.

This is a review of 183 patients with 218 displaced intra-articular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal—88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.

Surgical Treatment of Talar Body Fractures

BACKGROUND Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

The Effect on Ankle Dorsiflexion of Gastrocnemius Recession

Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days post-surgery (range, 37 to 128 days) were performed on 20 legs (15 patients). Results: Average preoperative ankle dorsiflexion with the knee straight was 5.1°. Average preoperative ankle dorsiflexion with the knee bent was 22.8°. Immediately following surgery the average ankle dorsiflexion with the knee straight was 23.2°. The average correction was 18.1° and this increase was significant (p < 0.0001.) In the 15 patients (20 legs) available for follow-up, the increase in ankle dorsiflexion with the knee straight was maintained (average: 24.9°). Patients with gastrocnemius contracture who underwent an isolated gastrocnemius release increased their ankle dorsiflexion (knee straight) by an average of 18.1° with postoperative ankle dorsiflexion (knee straight) being equivalent (23.2 and 22.8°) to preoperative ankle dorsiflexion (knee bent). This correction appears to be maintained (23.2 vs. 24.9°) at short-term follow-up.

Displaced intra-articular fractures of the tarsal navicular.

Between 1980 and 1987, twenty-one patients who had a displaced fracture of the body of the tarsal navicular were treated with open reduction and internal fixation. A classification system was devised on the basis of the direction of the fracture line, the pattern of disruption of the surrounding joints, and the direction of displacement of the foot. In a Type-1 injury, the fracture line is in the coronal plane and there is no angulation of the fore part of the foot. In a Type-2 fracture, the primary fracture line is dorsal-lateral to plantar-medial, and the major fragment and the fore part of the foot are displaced medially. In a Type-3 injury, there is a comminuted fracture in the sagittal plane of the body of the tarsal navicular, and the fore part of the foot is laterally displaced. Satisfactory reduction, which was defined as restoration of more than 60 per cent of the joint surface in the anteroposterior and lateral planes, was achieved in all Type-1 injuries, 67 per cent of the Type-2 fractures, and 50 per cent of the Type-3 fractures. Radiographic evidence of healing was seen at an average of 8.5 weeks after injury. At an average follow-up of forty-four months (range, twelve to 106 months), a good result was noted in fourteen patients (67 per cent); a fair result, in four (19 per cent); and a poor result, in three (14 per cent). Both the type of fracture and the accuracy of the operative reduction directly correlated with the final clinical outcome.

Plate fixation of femoral shaft fractures in multiply injured children

A study was done of twelve patients (seven boys and five girls) who, because of multiple injuries or a head injury, had been managed with compression plating of a unilateral or bilateral femoral-shaft fracture at a level-I trauma center from 1986 through 1990. The patients had a total of fifteen fractures. The average age at the time of the injuries was eight years (range, five years to nine years and eleven months). There were nine closed fractures and six open fractures; three of the open fractures were Grade I; two, Grade II; and one, Grade IIIA, according to the criteria of Gustilo et al. Each patient had an average of three associated injuries. All fifteen fractures had healed clinically and radiographically at an average of eight weeks (range, six to twelve weeks) after the operation. There were no infections. Anatomical alignment was obtained in fourteen limbs. One fracture healed with 13 degrees of anterior angulation. The compression plates were removed at an average of ten months (range, three to twenty-four months) after the index operation. At the latest follow-up evaluation (average, twenty-six months; range, eleven to fifty-seven months), no patient had restriction of activities due to the femoral fracture. Scanograms revealed overgrowth of the injured femur averaging 0.9 centimeter (range, 0.3 to 1.4 centimeters) in seven patients who had an uninjured contralateral femur. We believe that plate fixation of the femur is a good treatment option for children who have a femoral shaft fracture and a major head injury or multiple injuries, or both.

Intramedullary nailing of proximal quarter tibial fractures.

Objective: To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction. Design: Retrospective clinical study. Setting: Level 1 trauma center. Patients: During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions. Main Outcome Measurements: Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane. Results: Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity. Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated. Conclusions: Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.

Triple arthrodesis using internal fixation in treatment of adult foot disorders

Forty adult patients with 44 fused feet were evaluated at an average of 4.9 years after triple arthrodesis. The average age of the patients at operation was 41 years. All operations were performed by a specific technique using rigid internal fixation with screws. Outcome was graded using the clinical criteria of Hallgrimsson as modified by Angus and Cowell. Function was evaluated according to modified Arthritis Impact Measurement Scales (AIMS). Radiographic evaluation included measurement of lateral talocalcaneal angle, lateral talometatarsal angle, and anteroposterior (AP) talometatarsal angle on standing or simulated weight-bearing radiographs. Thirty-four feet had good results, six had fair results, and there were four failures. The average patient could function painlessly on flat surfaces in nonstrenuous activities and had only occasional mild pain with more vigorous activities. In roentgenographic parameters, there was an average improvement of 17 degrees in the lateral talometatarsal angle, 11 degrees improvement in the lateral talocalcaneal angle, and an improvement of 18 degrees in the AP talometatarsal angle. There were two pseudarthroses, no recurrences, and two unsatisfactory corrections. When carefully done, triple arthrodesis can restore an adult patient with a disabling foot disorder to normal function and minimal pain.