Stephen K. Benirschke

Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique

Objectives: Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions. Design: Retrospective clinical review. Setting: Urban level 1 university trauma center. Patients: Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique. Intervention: Dual plating using anterolateral and posteromedial incisions. Main Outcome Measure: Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment. Results: Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width. Conclusions: Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

Talar Neck Fractures: Results and Outcomes

BACKGROUND Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. METHODS We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. RESULTS Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. CONCLUSIONS Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.

Subtalar distraction bone block fusion for late complications of os calcis fractures.

The authors are presenting a new subtalar fusion technique for late complications of calcaneus fractures. These complications include pain, shoe wear difficulties, and foot deformity. The complex pathology includes incongruous subtalar joint, loss of calcaneal body height, and decreased lateral talocalcaneal angle. The latter two factors can result in tibiotalar neck impingement, a deformity that has received little attention in the literature. The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship and regains lost hindfoot height. The clinical series involved 16 feet with an average follow-up of 19 months. Results were satisfactory in 13 feet. Pre- and postoperative radiographic analysis for tibiotalar impingement, lateral talocalcaneal angle, and talonavicular subluxation was performed, with improvement to a normal range seen in the cases analyzed. The results are encouraging but should be considered preliminary based on the length of follow-up.

Fractures of the calcaneus.

Displaced fractures of the calcaneous are relatively common injuries that remain a treatment enigma. Virtually all aspects of the management of calcaneal fractures are a source of debate. Contemporary imaging, reduction, and fixation techniques attempt to improve the long term results of these injuries. The complex fracture fragments displace in predictable patterns. Meticulous surgical technique, restoration of extra- and intra-articular anatomy, and obtaining rigid fracture fixation are critical to obtaining satisfactory operative results. This article extensively reviews the controversies and summarizes the current opinions in the management of displaced calcaneal fractures.

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach.

This is a review of 183 patients with 218 displaced intra-articular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal—88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.

Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.

BACKGROUND Plate fixation of comminuted bicondylar tibial plateau fractures remains controversial. This retrospective study was performed to evaluate the perioperative results and functional outcomes of medial and lateral plate stabilization, through anterolateral and posteromedial surgical approaches, of comminuted bicondylar tibial plateau fractures. METHODS Over a seventy-seven-month period, eighty-three AO/OTA type-41-C3 bicondylar tibial plateau fractures were treated with medial and lateral plate fixation through two exposures. Injury radiographs were rank-ordered according to fracture severity. Immediate biplanar postoperative radiographs were evaluated to assess the quality of the reduction. The Musculoskeletal Function Assessment (MFA) questionnaire was used to evaluate functional outcome. RESULTS Twenty-three male and eighteen female patients (average age, forty-six years) who completed the MFA questionnaire were included in the study group. The mean duration of follow-up was fifty-nine months. Two patients had a deep wound infection. Complete radiographic information was available for thirty-one patients. Seventeen (55%) of those patients had a satisfactory articular reduction (< or =2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87 degrees +/- 5 degrees ), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9 degrees +/- 5 degrees ), and all thirty-one patients demonstrated satisfactory tibial plateau width (0 to 5 mm). Patient age and polytrauma were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When these variables were accounted for, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a better MFA score (p = 0.029). Rank-order fracture severity was also predictive of MFA outcome (p < 0.001). No association was identified between rank-order severity and a satisfactory articular reduction (p = 0.21). The patients in this series demonstrated significant residual dysfunction (p < 0.0001), compared with normative data, with the leisure, employment, and movement MFA domains displaying the worst scores. CONCLUSIONS Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fractures through medial and lateral surgical approaches is a useful treatment method; however, residual dysfunction is common. Accurate articular reduction was possible in about half of our patients and was associated with better outcomes within the confines of the injury severity.

Wound Healing Complications in Closed and Open Calcaneal Fractures

Objectives To determine the rate of serious infection in closed and open calcaneal fractures that were treated with open reduction and internal fixation (ORIF) via an extensile lateral approach. Design Retrospective review. Setting Level 1 trauma center. Patients Two groups of patients with calcaneal fractures treated with ORIF via an extensile lateral approach by the senior author are included. The first group contained 341 closed fractures in patients injured during the period 1994–2000. The second group included 39 open calcaneal fractures in patients injured during the period 1989–2000. Main Outcome Measurements The age, sex, pre-existing medical conditions, compliance history, mechanism of injury, soft tissue status, presence of serious infection, and treatment of the infection were recorded for each patient. Data were gathered by review of patient records and by telephone interview when medical records were incomplete. The rate of serious infection in the closed and open samples was determined. A literature review yielded 15 reports that contained sufficient detail to calculate the rate of serious infection. Results Of patients, 1.8% with closed fractures and 7.7% with open fractures experienced serious infections that required intervention beyond oral antibiotics. All of these feet eventually healed their incisions and fractures. The calculations from data obtained from the literature review indicate rates of serious infection of 0–20% for closed and 19–31% for open calcaneal fractures. Conclusions When done correctly in compliant patients, ORIF for calcaneal fractures via the extensile lateral approach (which allows for restoration of calcaneal anatomy after substantial disruption) does not expose the patient to undue risk of serious infection.

Surgical Treatment of Talar Body Fractures

BACKGROUND Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

Displaced intra-articular fractures of the tarsal navicular.

Between 1980 and 1987, twenty-one patients who had a displaced fracture of the body of the tarsal navicular were treated with open reduction and internal fixation. A classification system was devised on the basis of the direction of the fracture line, the pattern of disruption of the surrounding joints, and the direction of displacement of the foot. In a Type-1 injury, the fracture line is in the coronal plane and there is no angulation of the fore part of the foot. In a Type-2 fracture, the primary fracture line is dorsal-lateral to plantar-medial, and the major fragment and the fore part of the foot are displaced medially. In a Type-3 injury, there is a comminuted fracture in the sagittal plane of the body of the tarsal navicular, and the fore part of the foot is laterally displaced. Satisfactory reduction, which was defined as restoration of more than 60 per cent of the joint surface in the anteroposterior and lateral planes, was achieved in all Type-1 injuries, 67 per cent of the Type-2 fractures, and 50 per cent of the Type-3 fractures. Radiographic evidence of healing was seen at an average of 8.5 weeks after injury. At an average follow-up of forty-four months (range, twelve to 106 months), a good result was noted in fourteen patients (67 per cent); a fair result, in four (19 per cent); and a poor result, in three (14 per cent). Both the type of fracture and the accuracy of the operative reduction directly correlated with the final clinical outcome.

Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation.

Displaced fractures of the glenoid fossa are an uncommon and anatomically diverse group of injuries. Failure to restore anatomy in these fractures results in poor outcome in most cases. The success of a treatment protocol that encompasses appropriate preoperative imaging, injury pattern assessment, prudent approach choice, and a comprehensive reduction and fixation tactic was evaluated. Twenty-seven patients were assessed clinically and radiographically at a mean followup interval of 43 months from surgery. Anatomic reconstruction was achieved in 24 (89%) patients. Three patients had residual joint incongruities measuring 2 mm or less. The only perioperative complication was a partial superficial wound dehiscence. Two additional patients had infraspinatus palsies of indeterminate origin. Functional rating revealed six (22%) excellent, 16 (60%) good, three (11%) fair, and two (7%) poor outcomes. The fair and poor outcomes largely were related to associated injuries. These findings show that anatomic surgical reconstruction with a low complication rate and good functional outcome can be obtained for most patients with glenoid fossa fractures.