Kenneth D. Johnson

Operative Treatment of Fractures of the Tibial Plafond. A Randomized, Prospective Study*

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allgöwer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.

Tibial pilon fractures: a comparison of treatment methods.

OBJECTIVE This retrospective review of surgically treated distal tibia fractures was undertaken to determine whether treatment with open reduction and internal fixation (ORIF) was more efficacious in achieving fracture union than one of two external fixation methods. METHODS Of the 60 study patients with pilon fractures, 21 patients were treated with an ankle-spanning half-pin external fixator, 15 patients with a single-ring hybrid external fixator, and 24 patients with ORIF. The severity of injuries was similar across groups. RESULTS There was no significant difference in complication rates between groups, although two below-knee amputations were required in the ORIF group. A greater (p = 0.03) number of malunions occurred in the fractures treated with external fixation when compared with those treated with ORIF. Fractures in the external fixator groups showed this significant tendency to lose their initial adequate reduction, independent of bone grafting or fibula fixation. There was no significant difference between groups in the need for bone grafting. There was a trend for patients treated with a single ring hybrid frame to require late bone grafting for metaphyseal-diaphyseal nonunion. CONCLUSION External fixation offers advantages in the treatment of the soft-tissue injury associated with pilon fractures, but malunion continues to be a problem with this method of fixation.

Acetabular Fractures: Long-term Follow-up of Open Reduction and Internal Fixation

Summary: Eighty-seven acetabular fractures in eighty-seven patients underwent open reduction and internal fixation at Vanderbilt University Hospital from 1984 to 1989. Fifty-six were treated by orthopaedic traumatologists. Fifty- six patients returned for long-term follow-up (range 24-80 months, average 43). Harris hip ratings were used to clinically grade the results. Poor results were found in 43%. Eighty-three percent of the patients with poor results had satisfactory surgical reductions with < 3 mm of residual displacement. Factors other than surgical reduction contributed significantly to the poor results. These included hip dislocation associated with the fracture, class III or IV heterotopic ossification, development of avascular necrosis, and age > 40 years. These factors in addition to adequacy of surgical reduction allow us to better counsel patients as to long-term prognosis.

Functional Outcomes Following Displaced Talar Neck Fractures

Objectives: To determine the outcome of displaced talar neck fractures at long-term follow-up in terms of functional outcome and secondary reconstructive surgery. Design: Retrospective cohort study. Setting: Academic level 1 trauma center. Patients: Seventy patients with displaced talar neck fractures. Intervention: All patients were treated with open reduction and screw fixation. Main Outcome Measurements: Functional outcome of patients who did not require secondary surgery was assessed using the Short Musculoskeletal Function Assessment, Ankle Osteoarthritis Scale score, and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. The incidence of secondary reconstructive hindfoot surgery, including arthrodesis or talectomy, was measured using life table analysis. Results: Mean Short Musculoskeletal Function Assessment score was 20 ± 18 out of 100, with a lower score indicative of better outcome; mean Ankle Osteoarthritis Scale score was 3.8 ± 2.4 out of 10 (lower score better); and mean Ankle Society Ankle-Hindfoot Score was 71 ± 19 out of 100 points (higher score better). The incidence of secondary reconstructive surgery increased from 24 ± 5% at 1 year to 48 ± 10% at 10 years postinjury. Conclusions: Functional outcome varied and was most dependent upon the development of complications. The incidence of secondary reconstructive surgery following talar neck fractures increased over time and was most commonly performed to treat subtalar arthritis or misalignment.

Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures, with illustrative case presentations

Closed intramedullary nailing is an accepted method of treatment for femoral shaft fractures. Technical complications of the procedure include fracture instability, which may result in proximal nail migration, malrotation, delayed union, and occasionally femoral bursting during,insertion of the nail, sometimes leading to fracture instability as well as shortening. This study defines the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. The most significant factor in the proximal femoral component was found to be the position of the starting hole. Anterior displacement by >6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which resulted in bursting of the proximal femoral component by lifting off the anterior cortex. Hoop stresses at the level of the fracture were less sensitive to lateral or medial placement of the starting hole. Distally, fracture stability was governed by femoral component length and reamed diameter. In the proximal and distal components, fracture stability and the potential for bursting were influenced by the particular nail used. This was due to significant differences in mechanical geometric properties between nails of different manufacturers. Case reports are presented to illustrate these biomechanical principles as they apply to clinical situations.

Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor.

Summary Intramedullary nails were placed prospectively in 25 acute femoral shaft fractures in 25 patients without the use of a fracture table. A femoral distractor was used in 21 of the 25 patients to aid in obtaining and holding a reduction. Our goals were to determine if the technique was safe and effective for insertion of intramedullary nails in a wide spectrum of femoral fractures—with no increase in morbidity when compared to the use of the more familiar fracture table—and to determine the potential complications and pitfalls of using this technique. A retrospective evaluation of the most recent 25 patients with 27 femoral fractures that underwent intramedullary nailing on a fracture table was done to compare operative time, estimated blood loss, complications, and postoperative fracture alignment. In addition to the clinical evaluation, cadaveric dissections were undertaken to determine the exact location of the proximal distractor screw in relation to the contents of the femoral triangle. The femoral nerve was a minimum of 2.5 cm, and the femoral artery a minimum of 3.0 cm from the proximal screw. In comparing the two studies, no significant difference was noted in the age of the patients, fracture types or locations, associated injuries, operative time, estimated blood loss, final fracture reduction, or nail position. No complications were encountered in the placement of the proximal femoral distraction screw. Although the distraction method is technically difficult because the reduction is obtained entirely during the procedure, there are certain situations when this technique could be employed with the benefit of decreasing intraoperative patient manipulation, thereby shortening operative time. These situations include: (a) ipsilateral femoral shaft and acetabular fracture; (b) ipsilateral vertically unstable pelvic fracture; (c) simultaneous operations on both lower extremities; (d) single lower extremity with multiple levels of injury requiring operative intervention; (e) obesity; and (f) unstable spine fracture.

The reconstruction locked nail for complex fractures of the proximal femur.

Summary: Thirty-seven patients with 37 proximal femoral fractures were treated with a reconstruction locked femoral nail. There were four ipsilateral intracapsular femoral neck and shaft fractures, two intertrochanteric fractures, 18 intertrochanteric fractures with diaphyseal extension, eight subtrochanteric fractures with involvement of the lesser trochanter, and five subtrochanteric fractures without involvement of the lesser trochanter. The overall union rate was 92%. Twenty-one complications developed in 13 patients (35%) which included three of the four femoral neck and shaft fractures, and six of 18 intertrochanteric fractures with diaphyseal extension. Of the five intertrochanteric fractures with diaphyseal extension in which anatomic reduction was not achieved, four developed a complication. Of the nine proximal screws in nine fractures, which were placed short (below the subchondral bone of the femoral head), six fractures developed a complication. The complications included three nonunions, one delayed union, two leg-length discrepancies of >2.5 cm, two cases of varus deformity of >10°, two varus deformities <10°, four instances of revision surgery including one broken 13-mm nail, four proximal screws that backed out and required removal, two cases of pudendal nerve palsy, and one case of heterotopic ossification. Seven patients developed more than one complication. Eleven of the 13 patients with complications required a second surgery to treat the complication. We conclude that the reconstruction locked femoral nail is not a good choice for ipsilateral intracapsular neck and shaft fractures. Our recommendation is that anatomic reduction should be achieved for all cases using the reconstruction femoral nail, but it is absolutely required when treating the intertrochanteric fracture with diaphyseal extension. Reconstruction femoral nails have a high rate of complication due to the complex nature of the fracture as well as the device

Intramedullary nailing of acute femoral shaft fractures using manual traction without a fracture table.

Summary: Intramedullary (1M) nails were prospectively placed in 32 consecutive femoral shaft fractures without the use of a fracture table. All fractures were reduced using manual traction. Pathologic and nonacute fractures and those requiring a reconstruction nail were excluded. The results are compared with results of two prior study groups from this institution that underwent IM nailing with or without a fracture table using a femoral distractor. Ten patients had unstable spine or pelvis fractures. Four nailings followed exploratory laparotomy. Twelve patients underwent two or more procedures on the lower extremities under the same preparation and drape. Six fractures were open. Sixty-seven percent of results were anatomic, 27% had <5 mm lengthening/shortening or <5° varus/valgus, and 7% had >5 mm lengthening/shortening or <5° varus/valgus. Average operative time was 95 min. No complications occurred that were attributable to the technique. Compared with the prior study groups, no statistical difference in the fracture types or results was found. However, operative time was significantly less in the manual traction group (p < .05). We feel that this technique is a safe, simple, and effective alternative to using a fracture table. The technique is especially useful in the polytrauma patient, significantly decreasing anesthestic time

Floating knee injuries: ipsilateral fractures of the femur and tibia.

&NA; Ipsilateral fractures of the femur and tibia have been called “floating knee” injuries and may include combinations of diaphyseal, metaphyseal, and intra‐articular fractures. These are often high‐energy injuries and most frequently occur in the polytrauma patient. Many of these fractures are open, with associated vascular injuries. Surgical stabilization of both fractures and early mobilization of the patient and the extremity produce the best clinical outcomes. The use of a radiolucent operating room table and the introduction of retrograde intramedullary fixation of femoral fractures have facilitated surgical stabilization of some floating‐knee fracture patterns. Although treatment planning for each fracture in the extremity should be considered individually to achieve the optimal result, the effect of that decision must be considered in light of the overall injury status of the entire extremity. Collateral ligament and meniscal injuries may also be associated with this fracture complex. Complications (such as compartment syndrome, loss of knee motion, failure to diagnose knee ligament injury, and the need for amputation) are not infrequent. Better results and fewer complications are observed when both fractures are diaphyseal than when one or both are intra‐articular.

Length of Operative Procedures: Reamed Femoral Intramedullary Nailing Performed with and Without a Fracture Table

OBJECTIVES To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation. DESIGN Retrospective. SETTING Level 1 trauma center, Nashville. Tennessee. PATIENTS/PARTICIPANTS Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996. INTERVENTION Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table. MAIN OUTCOME MEASUREMENTS Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared. RESULTS Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled. CONCLUSIONS Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.