David L. Helfet

The Measurement and Clinical Importance of Syndesmotic Reduction After Operative Fixation of Rotational Ankle Fractures

BACKGROUND Rotational ankle fractures often have unstable syndesmotic injuries that require reduction and stabilization. Multiple studies have focused on methods to assess syndesmotic reduction; however, the clinical importance of anatomic syndesmotic reduction remains unclear. The purpose of this study was to determine whether the quality of syndesmotic reduction influenced clinical outcomes following operative treatment of ankle fractures with unstable syndesmotic injuries. METHODS Patients were included from an institutional trauma registry if they had sustained rotational ankle fractures with intraoperative evidence of syndesmotic instability requiring syndesmotic reduction and stabilization. Patients with at least twelve months of disease-specific, patient-reported clinical outcomes were included. Computed tomography (CT) imaging of both ankles was performed within two days postoperatively for all patients. Four previously utilized methods of assessing syndesmotic reduction using axial CT images of the operatively treated and the contralateral ankle were used. RESULTS A total of 155 patients met the study inclusion criteria and underwent analysis. The four methods used to assess syndesmotic reduction had reliabilities ranging from moderate to almost perfect (intraclass correlation coefficient [2,1] range = 0.544 to 0.821). Measurements of the uninjured syndesmosis were consistent with those in several previous studies of normal syndesmotic morphology, and the four methods of syndesmotic assessment had strong internal consistency. The mean measurement differences between the injured and normal ankles ranged from 1.32 to 1.88 mm of displacement and averaged 5.75° of rotation. There were no correlations noted between any of the four syndesmotic reduction assessment methods and any Foot and Ankle Outcome Score domains. CONCLUSIONS Within the range of syndesmotic malreductions studied, the quality of syndesmotic reduction did not significantly influence clinical outcomes. These results challenge previous definitions of syndesmotic malreduction and the clinical importance of minor syndesmotic changes. It remains unclear, however, whether greater magnitudes of syndesmotic malreduction than those seen in this cohort would lead to inferior patient-reported outcomes.

Complications Following Treatment of Supination External Rotation Ankle Fractures Through the Posterolateral Approach

Background: The posterolateral approach to the ankle is a valuable approach for the treatment of ankle fractures (SER) ankle fractures. The purpose of this study was to determine the complication rate for ankle fractures treated through the posterolateral approach. We hypothesized that this approach would be associated with a low incidence of complications and good clinical outcomes. Methods: A total of 112 patients with SER ankle fractures treated through a posterolateral approach met inclusion criteria. Prospectively collected data were examined retrospectively from chart review, preoperative plain radiographs, and MRI as well as postoperative radiographs. The mean age was 51.5 (range, 18 to 86) years. The primary outcome of the study was major (surgical debridement, flap, or split thickness skin graft) and minor (epidermolysis requiring local wound care) wound complications. The secondary outcomes included infection, symptomatic hardware, reoperation, loss of reduction, malreduction, nonunion, Foot and Ankle Outcome Scores, range of motion, and other perioperative complications. Results: There were 11 minor wound related complications (9.8%) and 3 major wound complications (2.7%), 1 of which required a split thickness skin graft. The overall postoperative wound infection rate was 4.4% (5 of 112); 2 patients required hardware removal due to deep infection. Of patients, 7% (8 of 112) reported symptomatic lateral sided hardware and thus underwent removal of implants. The overall reoperation rate was 12.5%. The complication rate was 23%. No patients experienced loss of reduction. Conclusions: The posterolateral approach to the ankle was a valuable approach for SER ankle fractures. This series demonstrated many key aspects of this approach including access to the apex of the fibula fracture for posterior antiglide plating, access to the posterior malleolus for fixation, access to the posterior inferior tibiofibular ligament for repair, minimal major wound complications, good functional outcomes, and minimal need for reoperation. Level of Evidence: Level IV, retrospective evaluation of prospectively collected data.

Nonunions around the knee joint.

Nonunions of the distal femur are relatively rare but can occur with or without previous surgery. Many surgical methods have been described for the treatment of these nonunions including external fixation, intramedullary nailing, arthroplasty, and fixed angle plating. While arthroplasty may have a limited role in the elderly patient with osteoporosis and severe communiution, most nonunions can be reliably treated with revision fixation using a fixed angled device, lag screws, and bone grafting as needed. Fixed-angle plating also has the advantage of stabilising a small distal segment where intramedullary nailing has proven to be less effective. Any surgical intervention must include restoration of the normal mechanical axis of the distal femur for a satisfactory clinical outcome. Proximal tibia nonunions are a similarly rare clinical entity due to the excellent blood supply in the metaphysis. Extra-articular proximal tibial nonunions are often due to malreduction during the index surgery resulting in poor bone contact and biomechanical stability. Soft tissue forces and improper use of intramedullary implants often predispose these fractures to malalignment. Revision surgery consisting of deformity correction and at least a lateral tension band plate with lag screws has led to predictable union and good clinical results. Tibial plateau nonunions are exceedingly uncommon but are difficult to treat because of small, often devascularised fragments, post-surgical scarring, and osteopenia. Revision surgery with meticulous soft tissue handling to restore the articular surface and mechanical axis with repair of meniscal pathology gives the patient the best chance of recovering knee function.

Comparison of Clinical Outcome of Pronation External Rotation versus Supination External Rotation Ankle Fractures

Background: A pronation external rotation (PER) ankle fracture is a relatively uncommon injury. The purpose of this study was to examine the immediate and short-term clinical outcomes of operatively treated PER IV ankle fractures and compare them with a similarly treated cohort of supination external rotation IV (SER IV) fractures. Methods: 22 PER IV and 108 SER IV fractures were identified from a single surgeon’s prospectively collected database from 2004 to 2010. All patients were treated with fracture fragment and ligament specific fixation during the same time period by the same surgeon. Postoperative radiographs and bilateral ankle computed tomography (CT) scans were reviewed for articular incongruity, syndesmotic malreduction, and loss of reduction. Clinical outcome measures, including the Foot and Ankle Outcome Score (FAOS) and ankle range of motion (ROM), were collected at latest follow-up visit. Results: There was no difference in the rate of wound complications, fracture nonunion, or loss of reduction between the PER IV and SER IV groups. There was no significant difference in the incidence of postoperative articular incongruity (19% vs 8%, P = .23); however, the PER IV cohort was found to have a significantly higher rate of syndesmotic malreduction (40% vs 18%, P = .04). No clinically or statistically significant differences were detected between the 2 groups in regard to all FAOS domains. Conclusion: In a cohort of operatively treated PER IV fractures, fracture fragment and ligament specific fixation resulted in good short-term outcomes that were comparable to those seen in similarly treated patients with an SER IV fracture pattern. However, a notably greater number of syndesmotic malreductions were noted in the PER IV cohort, and therefore heightened scrutiny is recommended in treating this particular injury pattern. Level of Evidence: Level III, retrospective comparative study.

Manual Stress Ankle Radiography Has Poor Ability to Predict Deep Deltoid Ligament Integrity in a Supination External Rotation Fracture Cohort

Stress ankle radiographs are routinely performed to determine deep deltoid ligament integrity in supination external rotation (SER) ankle fractures. However, variability is present in the published data regarding what medial clear space (MCS) value constitutes a positive result. The purposes of the present study were to evaluate the diagnostic accuracy of different MCS cutoff values and determine whether this clinical test could accurately discriminate between patients with and without a deep deltoid ligament disruption. MCS measurements were recorded for stress ankle injury radiographs in an SER ankle fracture cohort. Preoperative ankle magnetic resonance imaging studies, obtained for all patients, were then read independently by 2 musculoskeletal attending radiologists to determine deep deltoid ligament integrity. The MCS measurements were compared with the magnetic resonance imaging diagnosis using receiver operating characteristic analyses to determine the sensitivity, specificity, and optimal data-driven cutoff values. SER II-III patients demonstrated a mean stress MCS distance of 4.3 ± 0.98 mm compared with 5.8 ± 1.76 mm in the SER IV cohort (p < .001). An analysis of differing MCS positive cutoff thresholds revealed that a stress MCS of 5.0 mm maximized the combined sensitivity and specificity of the external rotation test: 65.8% sensitive and 76.5% specific. Using the receiver operating characteristic curve analysis of the MCS measurement, the calculated area under the curve was 0.77, indicating inadequate discriminative ability for diagnosing SER pattern fractures with or without a deep deltoid ligament tear. Judicious use of additional diagnostic testing in patients with a stress MCS result between 4.0 mm and 5.5 mm is warranted.

Fracture-Dislocations Demonstrate Poorer Postoperative Functional Outcomes Among Pronation External Rotation IV Ankle Fractures.

Background: Pronation external rotation (PER) ankle fractures are relatively uncommon but serious ankle injuries. Although recent studies have demonstrated good outcomes of PER IV fractures after operative treatment, the effect of dislocation on functional outcomes has not yet been evaluated. The objective of this study was to compare short-term functional outcomes in PER IV ankle fractures with and without dislocation. Methods: Our database of ankle fractures surgically treated using an anatomic fixation approach by the senior author from 2003 to 2013 was reviewed. All PER IV ankle fracture patients older than 18 years with a minimum of 12 months of follow-up, including Foot and Ankle Outcome Score (FAOS), were included for analysis. Patient demographics, injury characteristics, FAOS, ankle range of motion (ROM), and rate of postoperative complications were compared in PER IV fractures with and without dislocation. Of the 47 PER IV fractures included for analysis, 20 (43%) were fracture-dislocations and 27 (57%) had no dislocation. Mean age of the study cohort was 49 years (range, 24-91 years). Results: The fracture-dislocation cohort demonstrated significantly poorer FAOS (symptoms, 46 vs 70, P = .002; pain, 56 vs 82, P < .001; activities of daily living, 61 vs 84, P = .002; sports, 37 vs 59, P = .036; quality of life, 25 vs 59, P < .001) than the nondislocation cohort. Articular malreduction (33% vs 14%, P = .147) was also more common in the PER IV dislocation group. Rates of syndesmotic malreduction (44% vs 48%, P = .951) were similar between PER IV fractures with and without dislocation. Conclusion: PER IV fracture-dislocations had higher rates of articular malreduction and demonstrated statistically poorer functional outcomes than PER IV fractures with no dislocation. Dislocation in this select subset of ankle fracture patients likely represents a higher energy injury resulting in substantial articular damage and should spur appropriate preoperative patient counseling by the orthopaedic surgeon concerning functional outcome expectations. Level of Evidence: Level III clinical outcome comparison.

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol

INTRODUCTION This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures. MATERIALS AND METHODS A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented. RESULTS The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score. CONCLUSIONS Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

A Vessel-Preserving Surgical Hip Dislocation Through a Modified Posterior Approach: Assessment of Femoral Head Vascularity Using Gadolinium-Enhanced MRI.

BACKGROUND Surgical hip dislocation allows circumferential access to the femoral head and acetabulum and is utilized in the treatment of intra-articular hip disorders. Surgical hip dislocation is currently performed with a trochanteric osteotomy that reliably preserves the femoral head arterial supply; however, trochanteric nonunion or painful hardware requiring removal may occur. In a cadaveric model, using gadolinium-enhanced magnetic resonance imaging (MRI) and gross dissection, we evaluated whether modifications to the posterior approach preserve the femoral head arterial supply after a posterior surgical hip dislocation. METHODS In eight fresh-frozen pelvic specimens, a surgical hip dislocation was performed through the posterolateral approach with modifications in the tenotomy of the short external rotators and a capsulotomy designed to preserve the medial femoral circumflex artery (MFCA). Modifications included tenotomies of the quadratus femoris, conjoined tendon of the short external rotators, and obturator externus made 2.5 cm medial to their insertion on the greater trochanter and a T-type capsulotomy originating below the cut edge of the obturator externus tendon and continuing circumferentially along the acetabular rim. After hip dislocation, the MFCA was cannulated and MRI scans were acquired before and after gadolinium enhancement for evaluation of femoral head perfusion, with the contralateral hip, which was left intact, used as a control. Anatomic gross dissection was performed after the injection of polyurethane in the MFCA and confirmed MFCA vessel integrity. RESULTS Quantitative MRI showed that the operatively treated hip retained a mean perfusion (and standard deviation) of 95.6% ± 9.7% in the femoral head and 94.7% ± 21.5% in the femoral head-neck junction compared with the control hip (p = 0.66 and p = 0.85, respectively). Dissection after polyurethane injection confirmed that the superior retinacular and inferior retinacular arteries entering the femoral head were intact in all specimens. CONCLUSIONS In a cadaveric model using gadolinium-enhanced MRI, we found that standardized modifications to the posterior approach, specifically with regard to the location of the short external rotator tenotomy and capsulotomy, successfully preserved the femoral head arterial supply after posterior surgical hip dislocation. CLINICAL RELEVANCE While further research is necessary before these modifications can be recommended for widespread clinical use, the results of this study suggest the extracapsular vascular anatomy can be safely preserved during posterior surgical hip dislocation.

The Effect of Soft Tissue Injuries on Clinical Outcomes after Tibial Plateau Fracture Fixation

Objective: To determine if ligamentous and meniscal injuries as determined by initial magnetic resonance imaging altered clinical outcomes after the fixation of tibial plateau fractures. Design: Comparative cohort study. Setting: Academic level I trauma center. Patients/Participants: Eighty-two patients from a prospective database of operatively treated tibial plateau fractures met the inclusion criteria, which consisted of injury radiographs, preoperative knee magnetic resonance imaging (MRI), and a minimum of 12 months of clinical outcomes. Intervention: In addition to radiographs and computed tomography scans for fracture assessment, an MRI was performed to detect tears in the medial and lateral menisci and complete ruptures of the cruciate ligaments (anterior cruciate ligament and posterior cruciate ligament) and collateral ligaments [lateral collateral ligament and medial collateral ligament (MCL)]. Surgical fixation of tibial plateau fractures was performed by a single surgeon based on injury patterns. Main Outcome Measurements: Clinical outcomes included the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, the Short-Form 36, and knee range of motion. Secondary soft tissue surgeries and conversion to arthroplasty were also noted. Results: On injury MRI, 60 patients (73%) had injuries to at least one soft tissue structure. At final follow-up, 2 patients (2%) had a secondary soft tissue surgery and 1 patient (1%) underwent total knee arthroplasty. Patient-reported outcomes and range of motion assessments were not significantly different in patients with and without medial meniscal tears, lateral meniscal tears, and complete MCL ruptures. Conclusions: In this cohort of patients with operative tibial plateau fractures, sutured lateral meniscal tears, untreated medial meniscus tears, and complete MCL ruptures did not significantly affect clinical outcomes. In addition, these data suggest that obtaining a preoperative MRI in patients with tibial plateau fractures to diagnose soft tissue injuries may not alter the surgical treatment or alter patient prognosis for midterm outcomes. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Long-term patient reported outcomes following acetabular fracture fixation

INTRODUCTION Patient reported outcome scores may be the preferred method to assess clinical results following acetabular fracture fixation. However, in current acetabular fracture research, there is a scarcity of studies using these scores and long-term follow-up is lacking. The aim of this study is to describe long-term patient reported outcomes following acetabular fracture surgery and to evaluate the association between reduction quality and these outcome measures. METHODS Patients who received operative fixation for acetabular fractures (1992-2012) were sent questionnaires (short musculoskeletal functional assessment (SMFA) function index and short form (SF)-12), which was returned by 106 patients (22%) (mean age 51 years, 74% male). Mean follow-up was 11.3 years and hip survivorship 78%. Reduction quality was assessed on postoperative CT or plain pelvic radiography (PXR) (3 patients). Reductions were graded as adequate (CT: <1 mm step and <5 mm gap/PXR: ≤3 mm displacement) or inadequate (CT: ≥1 mm step and/or ≥5 mm gap/PXR: >3 mm displacement). Outcome scores between native hip versus total hip arthroplasty (THA) and adequate versus inadequate reduction groups were compared and association between reduction quality and hip survivorship was determined. Subgroup analysis was performed in older patients (≥50 years). RESULTS Patients with native hips reported overall superior relevant outcome scores (SMFA function index (p = 0.047), mobility (p = 0.048) and SF-12 physical component (p = 0.008)) compared to THA patients. Hip survivorship was associated with adequate reductions (p = 0.019). In the native hip group, an adequate reduction was also associated with lower (better) clinical scores (exceeding the minimal clinical important difference) (MCID) specifically for SMFA function index (p = 0.117) and mobility (p = 0.022). In elderly patients, the native hip versus THA group had similar outcomes, and adequate reductions were associated with hip survivorship as well as superior clinical scores (at least exceeding the MCID) in those who retained their native hip. CONCLUSION At long-term follow-up, acetabular fracture surgery is associated with excellent patient reported outcomes. Patients who retain their native hip have overall superior relevant (SMFA and SF-12) function scores compared to those who convert to THA. Adequate reductions (on CT) were associated with both hip survivorship and superior outcome scores in patients who retain their hip.