Joseph Borrelli

Minimally invasive plate osteosynthesis of distal fractures of the tibia

Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.

Displaced Intra-Articular Fractures of the Distal Aspect of the Radius. Long-Term Results in Young Adults after Open Reduction and Internal Fixation*

The purpose of this retrospective study was to determine the long-term functional and radiographic outcomes in a series of young adults (less than forty-five years old) in whom an acute displaced intra-articular fracture of the distal aspect of the radius had been treated with operative reduction and stabilization. Twenty-six fractures in twenty-six patients met the initial inclusion criteria for the study. Twenty-one patients returned for a physical examination, imaging (plain radiographs and computerized tomography scans), and completion of a validated musculoskeletal function assessment questionnaire at a minimum of 5.5 years. The physical examinations were performed by the same observer, who was not involved in the initial care of the patients. The plain radiographs and computerized tomography scans were assessed in a blinded fashion by two independent observers who measured the radiographic parameters with standardized methods. At an average of 7.1 years, osteoarthrosis of the radiocarpal joint was evident on the plain radiographs and computerized tomography scans of sixteen (76 per cent) of the twenty-one wrists. A strong association was found between the development of osteoarthrosis of the radiocarpal joint and residual displacement of articular fragments at the time of osseous union (p < 0.01). However, the functional status at the time of the most recent follow-up, as determined by physical examination and on the basis of the responses on the questionnaire, did not correlate with the magnitude of the residual step and gap displacement at the time of fracture-healing. All patients had a good or excellent functional outcome irrespective of radiographic evidence of osteoarthrosis of the radiocarpal or the distal radio-ulnar joint or non-union of the ulnar styloid process. It appears prudent therefore to base the indications for salvage operative procedures on the presence of severe symptoms or a loss of function rather than on radiographic evidence of osteoarthrosis of the radiocarpal joint.

Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws.

Objectives: To describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibial shaft. Design: Prospective. Setting: Level I trauma centers. Patients: Twelve consecutive patients treated with intramedullary nailing and blocking screws for fractures of the proximal third of the tibial shaft. Intervention: Patients were treated with intramedullary nails and blocking screws. Main Outcome Measure: The alignment of fractures was determined using standard anteroposterior and lateral radiographs after surgery and at each follow-up examination. One patient was lost to follow-up. All other patients were followed at regular intervals until union or establishment of a nonunion. Changes in alignment and complications were noted. Results: Postoperatively, all patients had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. One patient had postoperative malalignment (6 degrees of valgus), but a lateral blocking screw to control valgus deformity was not used in this patient. One patient was lost to follow-up. Eleven patients were followed up to union (n = 10) or establishment of a nonunion (n = 1). Ten of eleven patients maintained their postoperative fracture alignment at their last follow-up examination (average follow-up of thirty-three weeks). One patient progressed from 6 degrees of valgus immediately after surgery to 10 degrees of valgus at union. This patient did not have a blocking screw to control valgus angulation. Conclusions: Blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.

Treatment of nonunions and osseous defects with bone graft and calcium sulfate

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients’ return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.

Pelvic Fracture and Associated Urologic Injuries

AbstractSuccessful management of patients withnmajor pelvic injuries requires a team approach including orthopedic,nurologic, and trauma surgeons. Each unstable pelvic disruption must bentreated aggressively to minimize complications and maximize long-termnfunctional outcome. Commonly associated urologic injuries includeninjuries of the urethra, corpora cavernosa (penis), bladder, andnbladder neck. Bladder injuries are usually extraperitoneal and resultnfrom shearing forces or direct laceration by a bone spicule. Posteriornurethral injuries occur more commonly with vertically applied forces,nwhich typically create Malgaigne-type fractures. Common complicationsnof urethral disruption are urethral stricture, incontinence, andnimpotence. Acute urethral injury management is controversial, althoughnit appears that early primary realignment has promise for minimizingnthe complications. Impotence after pelvic fracture is predominantlynvascular in origin, not neurologic as once thought.n

A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility.

Background: Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with a high complication rate. Diabetic patients with peripheral neuropathy are a particularly difficult group to treat because of their inability to sense deep infection, repeat trauma, and wound complications. The purpose of this study was to evaluate a protocol that included transarticular fixation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in diabetic patients with peripheral neuropathy and loss of protective sensibility. Methods: The authors retrospectively reviewed the records of 15 patients with diabetes mellitus, unstable ankle fractures (AO classification 44B), and loss of protective sensibility confirmed via testing with a 5.07 Semmes-Weinstein monofilament. Retrograde trans-calcaneal-talar-tibial fixation using large Steinmann pins or screws in conjunction with standard techniques of open reduction and internal fixation was used. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing status for 12 weeks; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custom-molded ankle-foot orthosis (AFO) or custom total-contact inserts in appropriate diabetic footwear. Results: The major complication rate for all fractures was 25% (4/16) and for closed fractures was 23% (3/13). These are lower than previously reported rates between 30% (3/10) and 43% (9/21) for diabetic patients with and without neuropathy. The amputation rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously reported rates of 10% (2/10) to 20% (2/21). There were no deaths or Charcot malunions in this series. The combination of transarticular fixation and prolonged, protected weightbearing provided 13 of 15 patients with a stable ankle for weightbearing. Conclusion: Although these fractures remain a treatment challenge, this study presents a successful, multidisciplinary protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients – those with loss of protective sensibility.

Pilon Fractures: Assessment and Treatment

The treatment of high-energy intra-articular fractures of the tibial plafond involves many potential complications. A protocol has been developed. This protocol recognizes the importance of the surrounding soft tissues and is based on sound principles and thorough clinical experience. This article discusses this protocol and its use and explains why it is now more widely accepted.

Single high‐energy impact load causes posttraumatic OA in young rabbits via a decrease in cellular metabolism

Articular cartilage deterioration commonly occurs following traumatic joint injury. Patients with posttraumatic osteoarthritis (PTA) experience pain and stiffness in the involved joint causing limited mobility and function. The mechanism by which PTA occurs has not been fully delineated. The goal of this study was to determine if a single high‐energy impact load could cause the development of PTA in 3‐month‐old NZ White rabbits. Each rabbit underwent the application of a single, rapid, high‐energy impact load to the posterior aspect of their right medial femoral condyle using a previously validated mechanism. At regular intervals (0, 1, 6 months) the injured cartilage was harvested and analyzed for the presence of PTA. Each specimen was assessed histologically for cell and tissue morphology and chondrocyte metabolism, including BMP‐2 production and synthesis of extracellular matrix (type II procollagen mRNA). Cartilage from the contralateral sham limb, as well as uninjured cartilage from the experimental limb served as internal controls for each animal. Significant changes were found in the morphology of the cartilage including proteoglycan loss along with decreased BMP‐2 and type II procollagen mRNA staining. These findings confirm that a single high‐energy impact load can cause the development of PTA by disrupting the extracellular matrix and by causing a decrease in chondrocyte metabolism.