Daniel M. Zinar

Small wire external fixation of high energy tibial plateau fractures.

Open plate osteosynthesis for high energy tibial plateau fractures with dissociation between the metaphysis and diaphysis has been plagued with frequent soft tissue complications. The Harbor-University of California at Los Angeles Medical Centers experience with small wire external fixation supplemented by limited internal fixation is examined. This alternative method of adequate stable fixation offers the advantage of minimal soft tissue compromise. Twenty-four patients with Schatzker Type VI tibial fractures were treated with small wire external fixation. Supplementary limited internal fixation was used with percutaneous screws in 10 patients and with open reduction in one patient. Sixteen patients had isolated fractures, and eight others suffered multiple injuries. Minimum followup was 12 months. All fractures healed. Complications included one septic knee, two infections at screw sites, and one 10° knee flexion contracture. One knee had Grade 3 radiographic arthrosis, five had Grade 2, 10 had Grade 1, and eight showed no arthrosis. The outcomes (Knee Society clinical rating system) of this study compare favorably with outcomes described in reports published previously for this type of fracture, despite inclusion of eight multiply injured patients. This technique preserves the goals of early range of motion and stable fixation for these devastating injuries, while decreasing the observed major wound complications and nonunion rates. However, longer followup may reveal higher arthrosis rates, specifically in those fractures that were not anatomically reduced.

Ipsilateral hip and femoral shaft fractures

Forty-two cases of ipsilateral hip and femoral shaft fractures are reviewed. All patients were treated operatively for both fractures, with the exception of the shaft fracture in one child. Several different methods of fixation were used. The most common method was placement of multiple pins or screws around a previously placed intramedullary rod. Initial rodding of the shaft was not associated with avascular necrosis of the femoral head. Nonunion of the femoral neck occurred in three patients as a result of initial displacement and subsequent malreduction. Delays in operative fixation up to six weeks did not affect the ability to obtain union of the femoral neck. Complications involving the shaft fracture were at least as common as complications involving the femoral neck, suggesting that this component of the double injury should receive equally serious consideration. The hip fracture was initially overlooked in 13 cases (31%) without subsequent nonunion or avascular necrosis. Overall, the prognosis with regard to healing of the femoral neck and avascular necrosis of the femoral head in these combination injuries was found to be superior to that of isolated femoral neck fractures in young adults.

Neurologic injuries in pelvic ring fractures.

Unstable fractures of the pelvic ring are an increasingly frequent outcome of motor vehicle trauma. Neurologic injury after such injuries can be a cause of significant morbidity. The available literature on neurologic injuries was reviewed and compared with a clinical review of 90 unstable pelvic injuries treated during a 3-year period. Eighty-three patients were available for followup examination. Neurologic injuries were seen in 21 % of the patients. Thirty-seven percent of patients had sensory deficits alone whereas the remaining 63% had motor and sensory findings. All patients showed some evidence of neurologic recovery at an average or 24-months followup. At least 1 grade of muscle function improvement was consistently seen and 53% of patients had complete neurologic recovery. Improvement in function was seen as many as 24 months postinjury, but L5 function was least likely to progress to full recovery. The incidence of neurologic injuries and their distribution was similar to that reported in the literature, whereas the prognosis for neurologic recovery was significantly better. This may be related to techniques of early anatomic reduction and stabilization of unstable pelvic ring injuries.

The effect of obesity on early failure after operative syndesmosis injuries.

Objective: The goal of this investigation was to determine if obese patients with syndesmotic injuries have a higher incidence of early postoperative failure compared with nonobese patients. Design: Retrospective cohort study. Setting: Level 1 urban trauma center. Patients and Methods: Two hundred thirteen patients with operative syndesmotic injuries were divided into 2 cohorts: obese and nonobese. All syndesmotic injuries were confirmed by intraoperative stress testing, reduced, and stabilized with internal fixation. Intervention: Fixation of displaced syndesmosis injuries with solid 3.5- and 4.5-mm screws. Main Outcome Measures: The primary outcome was early failure of fixation, defined as revision surgery within 3 months for ankle mortise and/or syndesmosis displacement. Results: Two hundred thirteen patients were identified with operative syndesmosis injuries, of which 102 (48%) were obese and 111 (52%) were nonobese. Fifteen percent (n = 15) of patients in the obese cohort sustained a failure of fixation compared with 1.8% (n = 2) of patients in the nonobese cohort (P = 0.0005). Diabetes mellitus, smoking status, and the type of construct used (eg, screw caliber, number of screws, and number of cortices) were not predictive of loss of reduction. Adjusting for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients (odds ratio = 12.0, P = 0.02). Conclusions: There is a strong association between obesity and loss of reduction after operative treatment of the syndesmosis. Further research is warranted to determine if a stronger mechanical construct or more conservative postoperative protocol can reduce the risk of loss of reduction in obese patients who sustain a syndesmotic injury. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

CT Characterizing the Anatomy of Uninjured Ankle Syndesmosis

Although it is expert opinion that transsyndesmotic screws are placed obliquely 30° from posterolateral to anteromedial in the transverse plane, this has not been formally studied, and there is inconsistency regarding the congruency of the distal tibiofibular joint. Thirty-eight computed tomography (CT) scans of the lower extremity were used to examine the rotational profile of the axis of the syndesmotic joint in relation to the femoral transepicondylar axis and to describe the congruency of this joint. The axis of the distal tibiofibular joint was 32°±6° externally rotated in relation to the transepicondylar axis. The average anterior, central, and posterior widths of the syndesmotic joint space 10 mm superior to the joint line were statistically significantly different: 1.7±0.9 mm, 1.7±0.6 mm, and 2.3±1.1 mm, respectively (P=.004). This study demonstrates that the axis of the uninjured distal tibiofibular joint is approximately 30° externally rotated in relation to the transepicondylar axis. Therefore, reduction clamps and screws should be placed at this angle to avoid malreduction of the syndesmosis. The posterior joint space width is significantly wider than the anterior and central joint spaces. This studys results provide a description of the anatomy of the uninjured distal tibiofibular joint to guide reduction maneuvers and establish a baseline for evaluation of postreduction CT scans.

Diagnosis of occult scaphoid fractures by intrasound vibration.

We investigated a new means of diagnosing occult scaphoid fractures. Eighty-six patients underwent vibratory testing at presentation, while the clinical examination and standard four-view x-ray examination findings were unknown to the persons who performed the vibratory testing of both the injured and uninjured wrists. Thirty-six patients had radiographically confirmed scaphoid fractures and, after their vibratory tests, were eliminated from the study. Fifty patients, 39 men and 11 women, were believed to have scaphoid fractures on the basis of history and clinical examination findings but were included in the occult scaphoid study group because standard four-view x-ray films of the wrists did not reveal a scaphoid fracture. Distinction between the fracture and no-fracture patients was made with a limited two-phase technetium bone scan and delayed x-ray examination. All patients with known scaphoid fractures (36) had positive findings on vibratory examination. Vibratory testing identified all six of the patients with occult scaphoid fractures (sensitivity 100%). Results of two examinations were false-positive, and none were false-negative (specificity 95%). One of the patients with false-positive results had a fracture of the trapezium, and the other had reflex sympathetic dystrophy. The vibratory testing of injured wrists is inexpensive, noninvasive, and easy to perform, and it involves no ionizing radiation.

Internal fixation of diaphyseal fractures of the forearm: a retrospective comparison of hybrid fixation versus dual plating.

Objectives: To compare open reduction and internal fixation using dual plating to a hybrid fixation construct with intramedullary nailing of the ulna and plate fixation of the radius in both-bone forearm fractures. Design: Retrospective comparison study. Setting: Level I trauma center. Patients: A total of 56 skeletally mature individuals treated surgically for acute both-bone forearm fractures between July 2005 and December 2009. Monteggia, Galeazzi, and pathologic fractures, patients treated with external fixation and patients with traumatic brain injuries were excluded. Intervention: Twenty-seven patients were treated with dual plate fixation, and 29 patients were treated using a hybrid fixation construct. Main Outcome Measures: Time to union, range of motion as assessed using a Grace and Eversmann score, and presence of complications. Results: There was no significant difference in either time to union or Grace and Eversmann scores between the 2 groups. There was 1 nonunion in each of the 2 groups. Nine overall complications, outside nonunions, were reported: 5 in the dual plating group and 4 in the hybrid fixation group. Conclusions: Hybrid fixation, using open reduction and internal fixation with a plate-and-screw construct on the radius and closed—or minimally open—reduction and interlocked intramedullary fixation of the ulna, is an acceptable method for treating both-bone diaphyseal forearm fractures in skeletally mature patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs

Anterior Subluxation of the Talus: A Complication of Malreduction of the Ankle Syndesmosis

800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of

Ten year experience with use of Ilizarov bone transport for tibial defects.

50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].