Tatu J. Mäkinen

Contemporary demographics and complications of patients treated for open ankle fractures

Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation.

Periprosthetic supracondylar femoral fractures following knee arthroplasty: a biomechanical comparison of four methods of fixation

PurposeThe aim of this study was to determine the biomechanical properties of four fixation options for periprosthetic supracondylar femoral fractures.MethodsFourth-generation composite femurs were implanted with a posterior-stabilizing femoral component of total knee arthroplasty. All femurs were osteotomized to produce a AO/OTA 33-A3 fracture pattern and four different constructs were tested: (1) non-locking plate; (2) polyaxial locking plate; (3) intramedullary fibular strut allograft with polyaxial locking plate; (4) retrograde intramedullary nail. The composite femurs underwent non-destructive tests to determine construct stiffness in axial and torsional cyclic loading. The final testing consisted of quasi-static axial loading until failure.ResultsUnder cyclic torsional loading, the retrograde intramedullary nail was less stiff than non-locking plate, polyaxial locking plate and intramedullary fibular strut allograft with polyaxial locking plate (p = 0.046). No differences were detected in cyclic axial loading between the different constructs. During quasi-static axial loading to failure, the intramedullary nail achieved the highest axial stiffness while the non-locking plate showed the lowest (p = 0.036).ConclusionsThe intramedullary fibular strut allograft with polyaxial locking plate did not prove to be significantly better to the polyaxial locking plate only in a periprosthetic distal femur fracture model.

Role of Cages in Revision Arthroplasty of the Acetabulum

➤ The outcome of acetabular revision is heavily influenced by the degree of associated bone loss.➤ Uncemented hemispherical acetabular components can be used in the majority of acetabular revisions, although occasionally the degree of bone loss precludes the stability of the hemispherical component at the correct anatomic level or there is minimal bleeding host bone left for biologic fixation.➤ Massive acetabular bone loss resulting in the need for bone grafts or highly porous augments involving more than half of the acetabulum is one of the main indications for the use of cages.➤ The cup-cage reconstruction is based on bone-grafting the deficient acetabulum and securing a hemispherical, highly porous metal component with multiple screws to bridge the discontinuity and off-loading the hemispherical component with a titanium cage spanning from ischium to ilium.➤ In addition to managing pelvic discontinuities, the cup-cage construct can also be used in hips without discontinuity as the hemispherical, highly porous metal component is used to restore bone stock.➤ In situations in which there is not enough bleeding host bone to secure a hemispherical component, a highly porous metal augment can be used to address the osseous deficiency. The augment is also protected with a cage to assist bone ingrowth.

Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures

Background: Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. Methods: A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. Results: The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. Conclusions: Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. Level of Evidence: Level III, retrospective comparative series.

The role of cages in the management of severe acetabular bone defects at revision arthroplasty

An uncemented hemispherical acetabular component is the mainstay of acetabular revision and gives excellent long-term results. Occasionally, the degree of acetabular bone loss means that a hemispherical component will be unstable when sited in the correct anatomical location or there is minimal bleeding host bone left for biological fixation. On these occasions an alternative method of reconstruction has to be used. A major column structural allograft has been shown to restore the deficient bone stock to some degree, but it needs to be off-loaded with a reconstruction cage to prevent collapse of the graft. The use of porous metal augments is a promising method of overcoming some of the problems associated with structural allograft. If the defect is large, the augment needs to be protected by a cage to allow ingrowth to occur. Cup-cage reconstruction is an effective method of treating chronic pelvic discontinuity and large contained or uncontained bone defects. This paper presents the indications, surgical techniques and outcomes of various methods which use acetabular reconstruction cages for revision total hip arthroplasty.

Risk Factors for Deep Infection Following Plate Fixation of Proximal Tibial Fractures.

BACKGROUND The risk factors are unclear for deep surgical site infection after plate fixation of proximal tibial fractures. The objective of this study was to identify the patient and surgical procedure-related risk factors for infection using established criteria for deep surgical site infection. METHODS A total of 655 proximal tibial fractures were treated with open reduction and plate fixation at our center between 2004 and 2013. We identified 34 patients with deep surgical site infection. A control group of 136 patients was randomly selected from the non-infected cohort. Potential risk factors for deep surgical site infection were identified by reviewing surgical, medical, and radiographic records. Independent risk factors for infection were identified from multivariable logistic regression analysis using a stepwise procedure. RESULTS The prevalence of deep surgical site infection was 5.2%, the mean age of affected patients was 55 years (range, 16 to 84 years), and 35% of patients were female. Twenty-eight of 34 deep infections were diagnosed within 2 months (acute onset), and only 6 infections were diagnosed >6 months after the index surgical procedure. Nine of the 28 acute-onset infections were treated with antibiotic therapy and debridement. Seventeen patients (50%) required muscle flap coverage, and 5 patients (15%) eventually required above-the-knee amputation. In the multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), independent predictors of infection were patient age of ≥50 years (OR, 3.6 [95% CI, 1.3 to 10.1]); obesity, defined as a body mass index of ≥30 kg/m(2) (OR, 6.5 [95% CI, 2.2 to 18.9]); alcohol abuse (OR, 6.7 [95% CI, 2.4 to 19.2]); OTA/AO-type-C fracture (OR, 2.8 [95% CI, 1.1 to 7.5]); use of a temporary spanning external fixator (OR, 3.9 [95% CI, 1.4 to 11.1]); and a 4-compartment fasciotomy (OR, 4.5 [95% CI, 1.3 to 15.7]). CONCLUSIONS There is high morbidity associated with deep surgical site infection in plated proximal tibial fractures. Patients who are ≥50 years of age, obese patients, those with a history of alcohol abuse, or those with an OTA/AO-type-C fracture are at high risk for infection. Performing a fasciotomy also increases the risk of deep infection and should be implemented with meticulous technique when deemed necessary. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Revision Total Hip Arthroplasty for Fractured Ceramic Bearings: A Review of Best Practices for Revision Cases

BACKGROUND Total hip arthroplasty revision for a fractured ceramic bearing is rare but offers unique challenges. The purpose of this review was to provide a summary of existing literature on fractured ceramic bearings. METHODS Two authors performed a literature search of the MEDLINE OVID and PubMed databases with the following search terms: ceramic, fracture, total hip arthroplasty, and revision. RESULTS The search identified 228 articles of which 199 were selected for review. CONCLUSIONS It is mandatory to perform a complete synovectomy and thorough debridement of the fractured ceramic fragments. A well-fixed acetabular component should be removed if either the locking mechanism is damaged or the component is malpositioned. If the femoral stem taper is damaged, the femoral stem should be removed. However, if minimal damage is present, the femoral stem may be retained and revised using a fourth generation ceramic head with a titanium sleeve. Metal bearings should be avoided and revision with ceramic bearings should be performed whenever possible.

Preoperative planning of total hip arthroplasty on dysplastic acetabuli.

Background When performing total hip arthroplasty (THA) on a dysplastic hip, proper positioning of the acetabular component may not allow for more than 70% coverage. Structural support in the form of an autograft or a high porosity metal augment may be necessary. The purpose of the study was to investigate the value of pre-operative templating and deformity classification in predicting cup coverage and the need for structural support. Methods 65 cases of THA for DDH were retrospectively analysed. 2 observers independently classified each dysplastic hip according to Hartofilakidis and determined the extent of cup coverage via templating software on pre-operative digital AP pelvic radiographs. Results Weighted kappa interobserver agreement was 0.68 for cup coverage and 0.76 for Hartofilakidis type. Structural support was necessary in 10 hips. No structural support was necessary in Hartofilakidis type 1, dysplasia cases. However, 27-30% of cases with type 2 or type 3 dysplasia required structural support. All cases with templated cup coverage of 65% or less required structural support. Templated coverage within 65-75% and over 75% resulted in 20% and 10% of patients receiving structural augmentation, respectively. Conclusions Pre-Operative planning for THA in the setting of hip dysplasia is crucial and can provide valuable insight to the need for column augmentation. However, the 3-D severity of the deformity may be underestimated in the 2-D radiographs.