Nadine C. Pardee

Articular Congruity Is Associated with Short-Term Clinical Outcomes of Operatively Treated SER IV Ankle Fractures

BACKGROUND With regard to supination-external rotation type-IV (SER IV) ankle fractures, there is no consensus regarding which patient, injury, and treatment variables most strongly influence clinical outcome. The purpose of this investigation was to examine the impact of articular surface congruity on the functional outcomes of operatively treatment of SER IV ankle fractures. METHODS A prospectively generated database consisting of operatively treated SER IV ankle fractures was reviewed. Postoperative computed tomography (CT) scans were used to assess ankle joint congruity. Ankles were considered incongruent in the presence of >2 mm of articular step-off, intra-articular loose bodies, or an articular surface gap of >2 mm (despite an otherwise anatomic reduction) due to joint impaction and comminution. Patients with at least one year of clinical follow-up were eligible for analysis. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and ankle motion. RESULTS One hundred and eight SER IV fractures met our inclusion criteria. The average duration of follow-up was twenty-one months. Seventy-two patients (67%) had a congruent ankle joint, and thirty-six (33%) had elements of articular surface incongruity on postoperative CT scanning. These two groups were similar with regard to comorbidities and injury and treatment variables. At the time of the final follow-up, the group with articular incongruity had a significantly worse FAOS with regard to symptoms (p = 0.012), pain (p = 0.004), and activities of daily living (p = 0.038). Those with articular incongruity had worse average scores in the FAOS sport domain as well. No significant differences in ankle motion were found between the two groups. CONCLUSIONS In this population of patients with an operatively treated SER IV ankle fracture, the presence of postoperative articular incongruity correlated with inferior early clinical outcomes. Orthopaedic surgeons should scrutinize ankle fracture reductions and strive for perfection to allow for the best possible clinical outcome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Operative Fixation of Complete Articular Patellar Fractures: Assessment of Functional Impairment

BACKGROUND Patellar fractures are debilitating injuries that compromise the knee extensor mechanism and are frequently associated with poor outcomes. The purpose of this study was to quantify the functional outcomes of operative treatment of patellar fractures. METHODS Functional outcome data on thirty patients with an isolated unilateral patellar fracture were prospectively obtained at three, six, and twelve months postoperatively. RESULTS All fractures healed. There were two complications (7%) related to the surgery (wound dehiscence and refracture), and eleven patients (37%) underwent removal of symptomatic implants. The tibial plateau-patella angle demonstrated patella baja in seventeen (57%) of the patients. Anterior knee pain during activities of daily living was experienced by twenty-four (80%) of the patients. Clinical improvement occurred over the first six months. However, functional impairment persisted at twelve months, with objective testing demonstrating that the knee extensor mechanism on the injured side had deficits in strength (-41%), power (-47%), and endurance (-34%) as compared with the uninjured side. CONCLUSIONS Despite advances in surgical protocols and acceptable radiographic outcomes, functional impairment remains common after treatment of patellar fractures. Rehabilitation strategies following surgical stabilization of these injuries will be a fruitful area for future clinical research.

Quantitative and qualitative assessment of bone perfusion and arterial contributions in a patellar fracture model using gadolinium-enhanced magnetic resonance imaging: a cadaveric study.

BACKGROUND The purpose of the present study was to evaluate the anatomy and contribution of the patellar vascular supply and to quantify the effect of a transverse fracture on patellar perfusion. METHODS In twenty matched pairs of fresh-frozen cadaveric knees, the superficial femoral artery, anterior tibialis artery, and posterior tibialis artery were cannulated. One side of each matched pair was randomly selected to undergo one of two osteotomies: (1) midpatellar osteotomy or (2) distal-pole osteotomy. For volumetric analysis, comparisons were performed between contrast-enhanced magnetic resonance images and precontrast magnetic resonance images as well as between osteotomized patellar bone fragments and the corresponding intact areas on the control side. We then injected a urethane polymer compound and dissected all specimens to examine extraosseous vascularity. RESULTS Magnetic resonance imaging demonstrated that the largest arterial contribution to the patella entered at the inferior pole in 100% of the specimens; in 80% of these specimens, the artery entered inferomedially. It also revealed an overall decrease in contrast enhancement in both transverse osteotomy groups, with an average reduction in enhancement in the proximal fragment of 36%. CONCLUSIONS If possible, surgical interventions about the knee should be carefully planned to preserve the peripatellar ring (the source of the entire patellar blood supply), especially the inferior patellar network. Distal-pole patellectomy should be avoided to retain vascularized bone at the reduced fracture site.

Assessment of femoral head and head-neck junction perfusion following surgical hip dislocation using gadolinium-enhanced magnetic resonance imaging: a cadaveric study.

BACKGROUND The purpose of the present study was to quantify perfusion to the femoral head and head-neck junction using gadolinium-enhanced magnetic resonance imaging following three surgical dislocations of the hip (trochanteric flip osteotomy, standard posterior approach, and modified posterior approach). METHODS The medial femoral circumflex artery was cannulated in fifty fresh-frozen cadaveric hips (twenty-five pelvic specimens). One hip on each pelvic specimen was randomly chosen to undergo one of the three surgical dislocations, and the contralateral hip was used as a control. Gadolinium enhancement on the magnetic resonance imaging scan was quantified in both the femoral head and head-neck junction by volumetric analysis using custom magnetic resonance imaging analysis software. A polyurethane compound was then injected, and gross dissection was performed to assess the extraosseous vasculature. RESULTS Magnetic resonance imaging quantification revealed that the trochanteric flip osteotomy group maintained almost full perfusion (mean, 96% for the femoral head and 98% for the head-neck junction). The standard posterior approach almost completely compromised perfusion (mean, 4% for the femoral head and 8% for the head-neck junction). Six specimens in the modified posterior approach group demonstrated partial perfusion (mean, 32% in the femoral head and 26% in the head-neck junction). Three specimens in the modified posterior approach group demonstrated almost full perfusion (mean, 96% in the femoral head and 97% in the head-neck junction). Gross dissection revealed that all specimens in the standard posterior approach group and seven of ten in the modified posterior approach group sustained disruption of the ascending branch of the medial femoral circumflex artery. All specimens in the standard posterior approach group demonstrated disruption of the inferior retinacular artery. The inferior retinacular artery remained intact in nine of ten specimens in the modified posterior approach group. One specimen in the modified posterior approach group that had disruption of both the ascending medial femoral circumflex artery and inferior retinacular artery demonstrated a substantial decrease in perfusion (7% in the femoral head and 5% in the head-neck junction). CONCLUSIONS The trochanteric flip osteotomy preserves the vascular supply to the femoral head and head-neck junction. The standard posterior approach disrupts the vascular supply and should be completely abandoned for surgical hip dislocation. Despite reduced enhancement, substantial perfusion of the femoral head and head-neck junction was present in the modified posterior approach group, likely because of the preservation of the inferior retinacular artery. The modified posterior approach produced variable results, indicating that improvement to the modified posterior approach is needed. CLINICAL RELEVANCE Our study provides previously unreported quantitative magnetic resonance imaging data on the perfusion to the femoral head and head-neck junction during common surgical approaches to the hip.

Outcomes of Schatzker II tibial plateau fracture open reduction internal fixation using structural bone allograft.

Objectives: The purpose of this study is to report the rate of anatomic reduction, articular subsidence, and clinical outcomes for Schatzker II tibial plateau fractures treated with structural bone allografts. Design: This is a retrospective case series. Setting: Academic Level I Trauma Center. Patients/Participants: A trauma registry was used to identify 77 Schatzker II tibial plateau fractures. Intervention: Schatzker II tibial plateau fracture open reduction internal fixation and structural bone graft using either Plexur P (N = 29) or fibular allograft (N = 48). Main Outcome Measurement: The primary outcome was articular subsidence. Secondary outcomes included fracture malreduction and clinical outcomes including the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, and the Short Form (SF)-36. Results: No patients experienced subsidence > 2mm. This rate is significantly lower than published rates for autogenous iliac crest (30.3%, P < 0.0001) and calcium phosphate cement (8.7%, P = 0.0099). The rate of fracture malreduction was 11.7% (9/77); only 4 had more than 3 mm of residual incongruity. Average outcome scores were the following: Knee Outcome Survey Activities of Daily Living Scale, 81.7; Lower Extremity Functional Scale, 78.5; SF-36 physical component, 48.3; and SF-36 mental component, 53.1. There was no difference between patients treated with Plexur P or fibula with regard to the primary or secondary outcomes. Conclusions: The use of structural allograft resulted in a high rate of anatomic reduction and negligible rate of articular subsidence and good clinical outcomes in the treatment of this population of Schatzker II tibial plateau fractures. This compares favorably with historical results using nonstructural grafts. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of computerized tomography on classification and treatment plan for patellar fractures.

Objective: To evaluate the impact of computerized tomography (CT) scan on both fracture classification and surgical planning of patellar fractures. Design: Prospective study. Setting: Academic level I trauma center. Patients and Methods: Four fellowship-trained orthopaedic trauma surgeons analyzed radiographs of 41 patellar fractures. Each fracture was classified (OTA/AO classification), and a treatment plan was developed using plain radiographs alone. The process was repeated (4–6 weeks later) with addition of CT scan. After 12 months, the 2-step analysis was repeated and interobserver reliability and intraobserver reproducibility were assessed. Results: Suboptimal intra- and interobserver reliability was found for the surgical plan and classification using the OTA/AO system, despite the addition of a CT scan. After addition of CT, reviewers modified the classification in 66% of cases and treatment plan in 49%. CT frequently demonstrated a distinctive and severely comminuted distal pole fracture; this fracture pattern was present in 88% of cases and was unappreciated on plain radiographs in 44% of those cases. This pattern is unaccounted for by the present OTA/AO classification. Conclusions: CT facilitates improved delineation of patellar fracture patterns. Understanding the distal pole fracture pattern is fundamental in choosing a fixation construct. A fracture-specific classification system, based on CT scans, should be developed.

The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation.

Objectives: To examine the impact of preoperative coronal plane deformity on functional and radiographic outcomes on endosteal strut augmentation of proximal humerus fracture fixation. Design: Single surgeon, retrospective analysis of a prospective database. Case series. Setting: Academic level 1 trauma center. Patients/Participants: Seventy-two patients with isolated proximal humerus fractures fulfilled all inclusion/exclusion criteria with a minimum follow-up of 12 months. Intervention: Proximal humerus open reduction internal fixation with a laterally placed proximal humeral locking plate and endosteal placement of an allograft fibula treated through the anterolateral approach. Main Outcome Measurements: Global functional outcome as determined by the Disabilities of the Arm, Shoulder and Hand (DASH) score and Short Form 36 physical function. Shoulder-specific functional outcome as determined by the Constant–Murley and the University of California Los Angeles shoulder scores. Results: The mean age was 62 years old (range, 26–90 years). There were 32 varus fractures (neck-shaft angle, 110.8 degrees) and 40 valgus fractures (neck-shaft angle, 168.9 degrees). There was no significant difference in the initial postoperative (varus: 132.5 degrees, valgus: 135.5 degrees) and final (varus: 129.9 degrees, valgus: 132.2 degrees) neck-shaft angles or change in humeral height (varus: 0.94 mm, valgus: 1.48 mm). There were no significant differences in functional outcomes [Constant (varus: 85.2, valgus: 88.7) DASH (varus: 21.4, valgus: 13.9), University of California Los Angeles (28.6, varus 30.4), and Short Form 36 (varus: 66.8, valgus: 59.1)]. There were 2 patients in the valgus group and 3 patients in the varus group with an asymptomatic humeral head screw penetration (mean Constant 84.5, DASH 9.5). There was 1 deep infection in the varus group and 2 in the valgus group necessitating implant removal after fracture union. There was 1 case of avascular necrosis in the valgus group (DASH 19.4, Constant 73). Conclusions: There were no significant differences in complication rates, radiographic, or clinical outcomes between fractures presenting with preoperative varus coronal displacement compared with those presenting with valgus coronal displacement. The equivalent outcomes may be attributed to the uniform operative technique and fibular strut augmentation used by the primary surgeon. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary Allograft Fibula as a Reduction and Fixation Tool for Treatment of Complex Proximal Humerus Fractures with Diaphyseal Extension.

Summary: In this study, we present a novel technique for reduction and fixation of complex, unstable proximal humerus fractures with diaphyseal extension with the assistance of fibula allograft. We treated 14 patients using this technique since 2009 and found that it improves the reduction and enhances fixation while making the surgical procedure technically more manageable, and allows for early postoperative motion. In the first part of this study, we describe in detail the indications and surgical technique applied to these fractures. In the second part, we review the clinical and radiographic outcomes of these patients. Using this new technique, we have achieved an excellent union rate with minimal incidence of complications when treating these challenging fractures.

Comparison of Supination External Rotation Type IV Ankle Fractures in Geriatric Versus Nongeriatric Populations

Background: Geriatric patients’ (defined as those older than 65 years old) inherent comorbidities, functional limitations, and bone quality present obstacles to successful clinical outcomes for operatively treated supination external rotation (SER) ankle fractures. We retrospectively reviewed a prospectively collected series of SER injuries between 2004 and 2010. This is a comparison of the radiographic and clinical outcomes of our geriatric (27 patients) and nongeriatric (81 patients) populations. We hypothesized that geriatric patients would have worse outcomes when compared to nongeriatric patients. Methods: All SER ankle fractures (176) treated by a single surgeon were enrolled in a prospective database. All patients fulfilled inclusion criteria (108) consisting of 1 year of having clinical follow-up, postoperative radiographs, and Foot & Ankle Outcome Scores (FAOS). The primary outcome evaluated was functional outcome as exhibited by the FAOS. The secondary outcomes included adequacy of reduction, loss of reduction, postoperative complications (wound complications, infection, pain-driven hardware removal), and range of motion. Results: Despite significantly higher rates of diabetes (P < .001) and peripheral vascular disease (P < .001), there were statistically significantly better FAOS outcomes in the symptoms subcategory among the geriatric population. There was no significant difference in the articular reduction, syndesmotic reduction, wound complications, postoperative infections, or range of motion between these groups. Conclusion: Geriatric patients exhibited equivalent complication rates, radiographic outcomes, and functional outcomes compared to nongeriatric patients in this series. Anatomic fixation and soft tissue management counter the inherent risks of operative intervention in geriatric populations that report higher rates of comorbidities. This study supports aggressive fracture- and ligament-specific operative intervention in geriatric patients presenting with unstable SER injuries. Level of Evidence: Level III, retrospective case control study of prospectively collected data.

Defining the lateral and accessory views of the patella: an anatomic and radiographic study with implications for fracture treatment.

Objective: The majority of orthopaedic surgeons rely on a lateral fluoroscopic image to assess reduction during patella fracture osteosynthesis. However, a comprehensive radiographic description of the lateral view of the patella has not been performed previously, and no accessory views to better visualize specific anatomic features have been developed. The purpose of this study was to provide a detailed anatomic description of all radiographic features of the true lateral of the patella, describe reproducible accessory views for assessing specific features of the patella, and demonstrate their utility in a fracture model. Methods: Twelve cadaver knee specimens free of patellofemoral pathology were used, and imaging was performed using standard C-arm fluoroscopy. For each specimen, a true lateral radiographic projection of the patella was obtained and distinct features were noted. Next, an arthrotomy was made and steel wire was contoured and fixed to various anatomic regions of the patella so as to obliterate the radiographic densities on the true lateral projection, thus confirming their anatomic correlation. Ideal views of the lateral and medial facets themselves were determined using radiographic markers and varying amounts of internal or external rotation of the specimen. Last, a transverse osteotomy was created in each patella and the ability of the true lateral and accessory views to detect malreduction was assessed. Results: The true lateral projection of the patella was obtained with the limb in neutral alignment. Constant radiographic features of the lateral view of the patella include the articular tangent, a secondary articular density of variable length, and a dorsal cortical density. The articular tangent was produced by the central ridge between the medial and lateral facets in all specimens. The secondary articular density was created by a confluence of the edge of the lateral and edge of the medial facets in 5 patellas, a confluence of the edge of the lateral facet and the intersection of the odd and medial facets in 6 patellas, and the edge of the lateral facet alone in 1 patella. The edge of the lateral facet gave a constant contribution to the appearance of the secondary articular density in all cases. A distinct accessory view of the tangent of the lateral facet could be seen with an average of 17 degrees of patella external rotation (range, 12–35 degrees), and the tangent of the medial facet with an average of 26.5 degrees of internal rotation (range, 15–45 degrees). These accessory views were better able to visualize malreduction than the single lateral projection in a fracture model in all specimens. Conclusions: Described here is a comprehensive description of the true lateral radiographic view of the patella and accessory views. These views can be used in the evaluation of minimally displaced patella fractures if a computerized tomography is not desired to better assess the true amount of displacement and when assessing intraoperative reduction during patella fracture osteosynthesis.