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SUMMARY Restoration of anatomical alignment while preserving the soft-tissue envelope around the fracture site remains a challenge during distal femur fracture fixation. Although the lateral distal femoral locking plate allows surgeons to achieve adequate bony stability, their application has been associated with malalignment leading to inferior outcomes. We propose a biologically friendly, percutaneous technique that sequentially reduces and aligns distal femur fractures with an anterior external fixator before definitive fixation with a lateral distal femoral locking plate.

To evaluate whether a single proximal interlocking bolt was sufficient during the treatment of extra-articular femur fractures with retrograde medullary nailing.Retrospective comparative study.Academic Level 1 trauma center.The study included 136 patients with extra-articular femur fractures treated with retrograde medullary nailing who met inclusion and follow-up criteria.The intervention included surgical treatment for a femur fracture with retrograde medullary nailing, with comparisons made between those treated with a single proximal interlocking (1 IL) bolt and those treated with 2 proximal interlocking bolts (2 IL).The main outcome measurements were as follows: (1) rate of nonunion and (2) rate of catastrophic implant failure.There was no difference in the rate of nonunion requiring surgical intervention between the 2 groups. There were no catastrophic failures in either group.A single proximal interlocking bolt may be sufficient when using retrograde nailing for the treatment of extra-articular femur fractures.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We present our technique for screw stabilization and our clinical experience treating a series of patients presenting with proximal tibiofibular joint fracture-dislocations.

To compare complications after operatively treated pilon fracture between elderly patients (≥60 years) and younger patients (60 years).Retrospective comparative study.Two Level-1 academic trauma.Of the 740 tibial plafond fractures (OTA/AO 43-B43-C) treated January 2006 through December 2016, 538 patients had a minimum of 1 year follow up.Open reduction-internal fixation (ORIF).Treatment failure defined as either nonunion or arthrosis.A total of 72 patients comprised the elderly group (mean age 66 years) and 466 patients comprised the younger group (mean age 44 years) (P0.001). Besides significantly more tobacco use in the younger group, patient demographics and fracture characteristics did not differ. Locking plates were used significantly more in elderly patients (47% vs. 32%, P = 0.01). Using chi-square analysis, we were unable to detect a difference in treatment failure (elderly 43% vs. young 37%, P = 0.33), infection (elderly 10% vs. young 13%, P = 0.4), or malunion (elderly 3% vs. young 4%, P = 1.0). Using regression analysis, age60 was not associated with treatment failure [odds ratio (OR) 1.2 (0.7-2.1), P = 0.52]. Bone loss (OR 2.7 [1.8-4.1], P0.001), open fracture (OR 1.6 [1-2.5], P = 0.03), and malreduction (OR 4.2 [2.5-7.3], P0.001) were associated with failure.Age60 years is not an independent predictor of surgical treatment failure of pilon fractures as defined by nonunion or arthrosis. This is the largest cohort of pilon fracture in elderly patients and indicates that we should continue to treat elderly patients similar to their younger counterparts using ORIF.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To identify the incidence and fracture characteristics associated with syndesmotic injury in tibial plafond fractures and report the incidence of posttraumatic osteoarthrosis (PTOA). DESIGN Retrospective comparative study. SETTING Two level-1 academic trauma centers. PATIENTS/PARTICIPANTS Of the 735 tibial plafond fractures (OTA/AO 43-B3 and 43-C) treated from January 2006 through December 2015, 108 patients (108/735, 15%) were identified with syndesmosis injury. INTERVENTION Either acute or missed syndesmotic injury. MAIN OUTCOME MEASUREMENT PTOA. RESULTS Fourteen fractures (14/735, 2%) had missed syndesmotic injury. Volkmann fragment of ≤10 mm (P = 0.04) and fibular avulsion fracture (P = 0.05) were significantly more common in missed syndesmosis. Ninety fractures (14/14 missed, 76/94 acute) had greater than 12-month follow-up (mean, 26 months; range, 12-102 months). Nearly all patients with missed syndesmosis injury developed arthrosis (13/14, 93%), and 45% (34/76 fractures) of plafond fractures with acute syndesmosis injury developed arthrosis (P < 0.001). Although controlling for malreduction, patients with missed syndesmosis had significantly more PTOA development (P = 0.018). Controlling for malreduction, patients with syndesmotic fixation and a ≤10-mm Chaput or Volkmann fragment or fibular avulsion fracture (8/31, 26%) were less likely to develop PTOA than if they had a similar fracture pattern without syndesmotic fixation (9/10, 90%) (P = 0.011). CONCLUSIONS Fifteen percent of tibia plafond fractures have a syndesmosis or syndesmotic equivalent injury. Missed syndesmosis injury has a high rate of PTOA development. Patients with a ≤10-mm Chaput or Volkmann fragment and/or fibular avulsion fracture benefit from syndesmotic fixation. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

CASE We present the case of a 40-year-old man with a fracture to the superior angle of the scapula who was treated nonoperatively for 10 months-leading to a symptomatic nonunion. The patient underwent reconstruction of the nonunion for a painful shoulder and was followed clinically for 3 years. He demonstrated major improvement in function and symptoms. CONCLUSION Nonunions of the scapular superior angle can be effectively managed with surgical reconstruction.

Objectives The current literature focuses on wound severity, time to debridement, and antibiotic administration with respect to risk of infection after open fracture. The purpose of this analysis was to determine if either the incidence of posttraumatic infection or causative organism varies with treating institution or the season in which the open fracture occurred. Design Retrospective review. Setting Seven level 1 regional referral trauma centers located in each of the 7 climatic regions of the continental United States (Northwest, High Plains, Midwest/Ohio Valley, New England/Mid-Atlantic, Southeast, South, and Southwest). Patients/participants Five thousand one hundred twenty-seven skeletally mature patients with open extremity fractures treated between 2008 and 2012 at one of the 7 institutions. Intervention Open reduction and internal fixation of fracture following institutional protocol for antibiotic prophylaxis, debridement, and soft-tissue management. Main outcome measurements Seasonal variation on the incidence of infection and the causative organism after treatment for open fracture as recorded by each individual treating institution. Charts were analyzed to extract information regarding date of injury, Gustilo-Anderson type of open fracture, subsequent treatment for a posttraumatic wound infection, and the causative organisms. Patients were placed into one of the 4 groups based on the time of year that the injury occurred: spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Univariate/multivariate analyses and Fisher test were used to assess whether any observed differences were of statistical significance. Results The overall incidence of infection for all open fractures across the 7 different institutions was 7.6% and this did not vary significantly by season. There were, however, significant differences in overall infection rates between the different institutions: Southeast 4.3%, Northwest 13%, Northeast 7.7%, Southwest 9.3%, Midwest/Ohio Valley 5.5%, High Plains 14.6%, and South 7.4%. The following institutions demonstrated a significant seasonal variation in the incidence of infection: Northwest = fall 11% versus winter 18.5%, Southwest = winter 1.5% and fall 17.3%, Northeast = winter 5.2% and spring 9.7%, and Southeast = fall 2.8% and spring 6.0%. The High Plains, Midwest/Ohio Valley, and Southern institutions did not demonstrate a significant seasonal variation in infection rates. Finally, the most commonly encountered causative organism varied not only by region, but by season as well. Staphylococcus aureus (both methicillin sensitive and resistant) continues to be the most prevalent organism in the continental United States. Conclusions A substantial seasonal and institutional variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection after open fractures. Although this may represent a difference in treatment regimens between individual surgeons and institutions, a decades-old general nation-wide empiric antibiotic prophylaxis regimen for all open fractures may in fact be outdated and suboptimal. We recommend that surgeons consult with their infectious disease colleagues to better understand the seasonal variation of infection and causative organism for their individual hospital, and adjust their prophylactic and treatment regimens accordingly. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To identify the incidence and risk factors for development of tibial plafond nonunion. DESIGN Retrospective comparative study. SETTING Two Level 1 academic trauma centers. PATIENTS/PARTICIPANTS Seven hundred forty tibial plafond fractures (OTA/AO 43B3 and 43C) treated January 2006 to December 2015. INTERVENTION Open reduction and internal fixation. MAIN OUTCOME MEASUREMENT Nonunion. RESULTS Five hundred eighteen patients with a mean age of 43 years (range, 18-81 years) and mean follow-up of 27 months (range, 12-115 months) were involved. Seventy-two patients (72/518, 14%) were identified as having a nonunion. Surgical approach was not associated with nonunion in univariate analysis. Multiple regression model 1 identified OTA/AO 43C [odds ratio (OR) = 4.43; 95% confidence interval (CI), 1.01-19.41; P = 0.048], tobacco use (OR = 2.02; 95% CI, 1.10-3.71; P = 0.024), both minimal and substantial bone loss (P = 0.006 and P < 0.001, respectively), and open fracture (OR = 1.96; 95% CI, 1.10-3.48; P = 0.022) as risk factors for tibial plafond nonunion. Model 2 identified locking plate (OR = 1.97; 95% CI, 1.13-3.40; P = 0.016) and failure to treat the medial column (vs. screw P = 0.047, or plate P = 0.038) as risk factors. CONCLUSIONS The tibial plafond nonunion rate was 14%. Bone loss, open fracture, failure to treat the medial column, locking plates, and tobacco use were all significant risk factors for developing tibial plafond nonunion. Equally important, surgical approach was not significantly associated with plafond nonunion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy. Design Retrospective cohort study. Setting Level-1 trauma center. Patients Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy. Intervention Valgus-producing intertrochanteric osteotomy with a blade plate. Main outcome measurements Femoral neck and intertrochanteric osteotomy osseous union. Results Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014). Conclusions Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures.Retrospective cohort review.Regional Level 1 Trauma Center.About 394 patients with 420 pilon fractures treated between January 2005 and November 2011.Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture.Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure.40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%).In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Terrible triad injuries of the elbow, defined as elbow dislocation with associated fractures to the radial head and coronoid, are associated with stiffness, pain, and loss of motion. Studies to date have consisted of small sample sizes and used heterogeneous surgical techniques, which render comparisons difficult and unreliable.In a group of patients treated under a standard surgical protocol, we sought to determine the early dislocation rate, the range of motion in those not undergoing secondary procedures, the frequency and types of secondary surgical interventions required, the difference in motion between those undergoing secondary surgery and those who did not, and the frequency of heterotopic ossification and patient-reported stiffness.Patients underwent a surgical protocol that involved fixing the coronoid, fixing the radial head if possible, otherwise performing radial head arthroplasty, and repairing the lateral ligamentous structures. Patients were excluded if ipsilateral upper extremity fractures from the humerus to the distal forearm were present. Fifty-two patients had a minimum followup of 6 weeks and were included for the early dislocation rate, and 34 of these (65%) had a minimum of 6 months followup and were included for the rest of the data. Eighteen of the 52 (35%) were considered lost to followup because they were seen for less than 6 months postsurgically and were excluded from further analysis. Chart review was performed to determine the presence of early dislocation within the first 6 weeks after surgery, range of motion in patients not requiring a secondary procedure, the frequency and types of secondary procedures required, the range of motion before and after a secondary procedure if it was required, and postoperative stiffness. Postoperative radiographs were analyzed to determine the presence and severity of heterotopic ossification.One of 52 patients sustained a dislocation within the first weeks of surgery (1.9%). Those not undergoing a secondary procedure were able to achieve a flexion arc of 110° and a supination-pronation arc of 148°. Nine of 34 patients (26%) underwent a secondary surgical procedure with stiffness, heterotopic ossification, and ulnar neuropathy being the most common surgical indications. Before secondary surgical procedures, patients had a flexion arc of 57° and a supination-pronation arc of 55°, which was less than those only requiring primary surgery alone (p 0.001). After secondary surgery, patients were able to achieve a flexion arc of 96° and a supination-pronation arc of 124°, which was not different from those who did not undergo reoperation (p = 0.09 and p = 0.08, respectively). Twenty-eight of 34 patients demonstrated evidence of heterotopic ossification on radiographs, whereas 20 patients, including all nine undergoing secondary procedures, reported stiffness at the elbow.Using a standardized surgical protocol, a low early dislocation rate was observed, although stiffness remains a challenge. Many patients who initially do not attain functional range of motion can usually attain this after secondary procedures aimed at removing the heterotopic ossification.Level IV, therapeutic study. See guidelines for authors for a complete description of levels of evidence.

Subtrochanteric femur fractures commonly present with predictable displacement because of the deforming muscle forces acting upon the proximal femur. For this reason, successful closed reduction and femoral nailing can be a technically demanding procedure. Open reduction prior to nail placement has been advocated to improve and maintain anatomic fracture alignment. The purpose of this study was to evaluate the results of patients with closed subtrochanteric femur fractures treated with open reduction and a reamed antegrade statically locked intramedullary nail. An initial query of our database identified 154 patients who had sustained a subtrochanteric femur fracture over the defined study period. Ninety-six patients had adequate radiographic and clinical follow-up. Fifty-six (58%) patients were treated with open reduction and nail placement. There were no wound complications or infections and all patients went on to successful osseous union. There was no loss of reduction and a final coronal and sagittal plane deformity of

The purpose of this study was to assess the impact of variations in angulation of clamp placement to hold syndesmotic reduction and how subsequent syndesmotic screw placement affects malreduction of the syndesmosis. We hypothesized that an anatomic syndesmosis reduction cannot be reliably achieved with a clamp alone; and, inaccurate placement of intraoperative clamps and trans-syndesmotic screws after reduction can malreduce the ankle syndesmosis.After computed tomography scanning of the intact limbs, 14 cadaver legs were dissected; the syndesmosis was completely disrupted in all. Using planned drill holes, clamps were first placed at 0°, 15°, and 30° angles from the fibula, then separate posterolateral, followed by lateral, screws were placed. After each intervention, the limb had a computed tomography scan so the fibular reduction could be evaluated precisely.Clamps placed at 15° and 30° significantly displaced the fibula in external rotation and caused significant overcompression of the syndesmosis. Thirty-degree lateral screws caused significant anteromedial displacement, external rotation, and overcompression of the syndesmosis. The 15° posterolateral screws also caused significant external rotation and overcompression of the syndesmosis.Our study demonstrates that intraoperative clamping and fixation can cause statistically significant malreduction of the syndesmosis. This article should alert clinicians that clamp and screw placement can cause iatrogenic malreduction of the syndesmosis and make them aware that these dangers occur with specific clamp and screw angles in particular.

The distal aspects of the tibia and fibula as well as the associated stabilizing ligamentous structures are collectively known as the ankle syndesmosis. The syndesmosis functions to maintain normal ankle kinematics and provide talar stability through a physiologic range of motion. Disruption of the ligamentous structures can occur in isolation or in the setting of an ankle fracture. The need for recognition and stabilization of syndesmotic instability following ankle trauma is well established. Recently, investigators have reevaluated best practices with regard to the assessment, reduction, and fixation of syndesmotic injuries. The effects of syndesmotic malreduction and failed stabilization have also been examined to a greater degree, resulting in new literature on this topic. The purpose of this article is to present the current evidence on syndesmotic injuries in the setting of an ankle fracture. The ankle syndesmosis comprises four ligamentous structures between the distal aspects of the tibia and fibula. The anterior inferior tibiofibular ligament originates from the anterolateral (Chaput) tubercle of the distal part of the tibia and inserts into the anterior (Wagstaffe) tubercle of the …

The authors have identified a subset of bicondylar tibial plateau fractures with a hyperextension varus deformity (HEVBTP). The radiographic hallmarks of this pattern are (1) sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, (2) tension failure of the posterior cortex, (3) compression of the anterior cortex, and (4) varus deformity in the coronal plan. The purpose of this study was to describe this fracture pattern, to compare the associated injuries with non-HEVBTP fractures, and to suggest treatment strategies that may allow for improved reduction and stabilization.Retrospective Cohort Study.Level 1 trauma center.Preoperative radiographs and CT scans were reviewed in 208 patients who sustained 212 bicondylar tibial plateau fractures (OTA 41C). Twenty-five fractures in 23 patients fulfilled the radiographic criteria for HEVBTP fracture pattern. The remaining 187 bicondylar tibial plateau fractures were used as a control group.Initial spanning external fixation, followed by open reduction internal fixation and bone grafting with/without augmentation.Associated injury rate compared with OTA 41C patients without HEVBTP pattern, nonunion rates, and loss of reduction rates.Thirty-two percent of the HEVBTP fractures demonstrated significant associated injuries compared with 16% in the control group. The incidence of popliteal artery disruption requiring repair was 12% in the HEVBTP group compared with 1% in the control group. Patients with HEVBTP had either partial or complete peroneal nerve injury in 16% of cases (8% in control group) and 12% of patients developed a leg compartment syndrome (10% in control group).The HEVBTP pattern is a unique fracture. The surgeon must recognize the possible associated injuries that accompany this injury. We suggest fixation strategies that address this injury's individual components which may help to avoid failure.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Supracondylar intercondylar distal femur fractures are devastating injuries that frequently have a concurrent coronal plane fracture, which mandates dedicated operative fixation. The purpose of this study was to determine whether small-fragment cortical lag screws oriented in the sagittal plane were sufficient to stabilize coronal plane fractures associated with supracondylar intercondylar distal femur fractures. The authors evaluated short-term radiographic outcomes in 56 coronal plane fractures in 44 knees (27 [61.4%] male, 17 [38.6%] female; mean age, 43 years [range, 19–97 years]) sustaining a supracondylar intercondylar distal femur fracture between January 2001 and November 2013. Coronal plane fractures were stabilized with sagittally oriented small-fragment cortical lag screws measuring 3.5 mm or smaller, and the supracondylar intercondylar component was stabilized with a lateral periarticular plate. Fracture displacement was defined as greater than 2 mm of gapping/translation of the coronal plane fragment on any radiographic view. Thirty-three (75.0%) knees had open injuries. Fifty-five (98.2%) of 56 coronal plane fractures went on to radiographic union with no displacement of the coronal fragment; one knee developed avascular necrosis and required arthrodesis. Fifteen (34.1%) of 44 knees required secondary procedures unrelated to the coronal plane fracture. The reduction of coronal plane fractures associated with supracondylar intercondylar distal femur fractures can be reliably maintained when stabilized with small-fragment cortical lag screws oriented in the sagittal plane. [ Orthopedics. 2016; 39(1):e134–e139.]

To evaluate the prevalence and magnitude of sagittal plane deformity in bicondylar tibial plateau fractures.Retrospective radiographic review.Two Level I trauma centers.Sagittal inclination of the medial and lateral plateau measured in relation to the longitudinal axis of the tibia using computed tomographic reconstruction images.Seventy-four patients (mean age, 49 years; range, 16-82 years; 64% male) with acute bicondylar tibial plateau fractures (Orthopaedic Trauma Association 41C, Schatzker VI) treated from October 2006 to July 2009.The average sagittal plane angulation of the lateral plateau was 9.8° posteriorly (range, 17° anteriorly to 37° posteriorly). The medial plateau was angulated 4.1° posteriorly on average (range, 16° anteriorly to 31° posteriorly). Forty-two lateral plateaus were angulated more than 5° from the "normal" anatomic slope (defined as 5° of posterior tibial slope). Of these, 76% were angulated posteriorly. Forty-three (58%) of the medial plateaus were angulated greater than 5° from normal, of which only 47% were inclined posteriorly (P = 0.019 compared with lateral plateaus). In 68% of patients, the difference between medial and lateral plateaus was greater than 5°; the average intercondylar slope difference was 9° (range, 0°-31°; P0.001). Spanning external fixation did not affect the slope of either the medial or lateral tibial plateau. Intraobserver and interobserver correlations were high for both the medial and lateral plateaus (r0.81, P0.01).Considerable sagittal plane deformity exists in the majority of bicondylar tibial plateau fractures. The lateral plateau has a higher propensity for sagittal angulation and tends to have increased posterior slope. Most patients have a substantial difference between the lateral and medial plateau slopes. The identification of this deformity allows for accurate preoperative planning and specific reduction maneuvers to restore anatomic alignment.

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.

BACKGROUND: The treatment of complex diaphyseal malunions is challenging, requiring extensive preoperative planning and precise operative technique. We have developed a simpler method to treat some of these deformities. METHODS: Ten patients with complex diaphyseal malunions (including four femoral and six tibial malunions) underwent a clamshell osteotomy. The indications for surgery included pain at adjacent joints and deformity. After surgical exposure, the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized along its long axis and was wedged open, similar to opening a clamshell. The proximal and distal segments of the diaphysis were then aligned with use of an intramedullary rod as an anatomic axis template and with use of the contralateral extremity as a length and rotation template. The patients were assessed clinically and radiographically at a mean of thirty-one months (range, six to fifty-two months) after the osteotomy. RESULTS: Complete angular correction was achieved in each case; the amount of correction ranged from 2° to 20° in the coronal plane, from 0° to 32° in the sagittal plane, and from 0° to 25° in the axial plane (rotation). Correction of length ranged from 0 to 5 cm, and limb length was restored to within 2 cm in all patients. All osteotomy sites were healed clinically by six months. While no deep infections occurred, superficial wound dehiscence occurred in two patients along the approach for the longitudinal portion of the osteotomy, emphasizing the importance of careful soft-tissue handling and patient selection. CONCLUSIONS: The clamshell osteotomy provides a useful way to correct many forms of diaphyseal malunion by realigning the anatomic axis of the long bone with use of a reamed intramedullary rod as a template. This technique provides an alternative that could decrease preoperative planning time and complexity as well as decrease the need for intraoperative osteotomy precision in a correctly chosen subset of patients with diaphyseal deformities. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “The Clamshell Osteotomy: A New Technique to Correct Complex Diaphyseal Malunions” (2009;91:314-24).

Background: The sustentaculum tali of the calcaneus is a vital load-bearing structure. Isolated sustentacular fractures are rare and may have implications for future hindfoot function. This retrospective cohort study describes sustentacular fracture patterns and characteristics, associated foot injuries, and a method of surgical treatment via a medial approach to the calcaneus. Materials and Methods: During a 7-year period, 19 surgically-treated sustentacular fractures without calcaneal posterior facet involvement were identified from a prospectively-collected database at a single Level 1 regional trauma center. Of these, 15 underwent open reduction and internal fixation utilizing a medial approach to the calcaneus. Patient charts, plain radiographs, and CT scans were reviewed for injury characteristics/morphology and associated musculoskeletal injuries. Results: Fourteen patients had associated ipsilateral foot/ankle injuries, and nine had other musculoskeletal injuries. Seven patients had intra-articular middle facet involvement, and seven had subtalar joint subluxation or dislocation. The medial approach to the calcaneus involves distal retraction of the neurovascular bundle and toe flexors. This allowed for an accurate indirect articular reduction using the extraarticular medial calcaneal cortex, as well as reduction of any associated subluxations. No complications were related to the surgical approach. Reduction was maintained through fracture healing. Conclusion: Fractures of the sustentaculum tali are rare injuries associated with high energy mechanisms, and associated ipsilateral foot injuries are common. Open reduction and internal fixation of these fractures was reliable and possible through a medial approach involving distal retraction of the digital flexors and neurovascular bundle, allowing for an anatomical extraarticular cortical reduction.Level of Evidence: IV, Retrospective Case Series

Objective Report treatment results of periprosthetic femoral fractures adjacent or at the tip of a stable femoral stem (Vancouver Type B1) using a locked compression plate as the sole method of fracture stabilisation. Design Retrospective case series. Setting Academic Level I Trauma Centre. Patients Patients operatively treated at our institution with locked compression plating for Vancouver Type B1 periprosthetic fractures between 2002 and 2006 with at least 12 weeks of clinical follow-up were included. Patient demographics, hip arthroplasty implant characteristics, and AO/OTA fracture type were recorded. Intervention Open reduction internal fixation using a locked-plate spanning a majority of the femur through a lateral soft-tissue sparing approach. No cortical onlay allografts or cerclage devices (wires or cables) were used. Main outcome measurements Clinical union was defined at a minimum of 12 weeks as ability to walk, with or without the use of a walking aide, without pain at or around the fracture site. Radiographic union was defined by bridging bone spanning two or more cortices on orthogonal radiographs of the femur. Results Ten subjects met the inclusion criteria and were followed for a mean of 27 weeks (range 14–97 weeks). All achieved fracture union at a mean of 17 weeks (range 12–27 weeks). There were no hardware failures or changes in fracture alignment from operative radiographs. There were no major complications that necessitated reoperation. Conclusions Open reduction internal fixation of Vancouver Type B1 periprosthetic femoral fractures using a lateral locked-plate that spans the full extent of the femur as the sole method of stabilisation is a successful treatment method that minimises soft-tissue dissection and provides adequate fixation strength to maintain fracture alignment to fracture union.

Background: Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series. Objective: To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures. Methods: Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review. Main outcome measurements: Post-operative complications, the need for secondary surgery, and the visual analogus pain score. Results: Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0. Conclusion: The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation.

To evaluate the results in patients with open AO/OTA type C3 pilon fractures with segmental bone loss who were treated with a standard treatment protocol.Retrospective case series.Level I trauma center.Of 117 acute open type C pilon fractures treated during the study period, 10 patients with AO/OTA type C3 fractures and segmental metaphyseal bone loss were amenable to treatment with a standard protocol.All patients were treated with immediate debridement and external fixation (stage 1). After a delay of 1-3 weeks, patients with a healthy-appearing soft tissue envelope and no sign of infection underwent open reduction, plate fixation, and antibiotic bead placement (stage 2). Several months later, planned bone grafting was performed (stage 3).The complication rate, additional procedures, and time to bony union were determined.The treatment protocol was able to be completed in all 10 patients. No cases of acute infection or wound necrosis after plate fixation and antibiotic bead placement occurred. Two cases of late infection occurred after delayed bone grafting, one of which was successfully treated and the other resulted in amputation. Nine of the 10 patients healed at an average of 24 weeks.Limb salvage in the most severe open pilon fractures is difficult. In patients with benign soft tissues at several weeks after temporary external fixation, open reduction, antibiotic bead placement, and a delayed bone grafting procedure are associated with a low complication rate and predictable fracture healing.

Objectives: Open wounds occur with calcaneus fracture from direct application of force and from tearing along the medial side of the fracture as the tuberosity displaces laterally. Secondary soft tissue injury can also occur from pressure of the displaced fracture fragments. Tongue-type fractures of the calcaneus lead to variable amounts of displacement of the posterior tuberosity. This displacement may threaten the posterior soft tissue envelope. Because many calcaneus fractures are splinted initially and immobilized for several weeks until swelling resolves, failure to acutely recognize the potential for posterior skin breakdown may lead to severe soft tissue morbidity. The purpose of this study was to determine the incidence of posterior skin involvement in tongue-type calcaneus fractures and to determine the patient and fracture characteristics that lead to high-risk situations. Setting: University level I trauma center. Patients/Participants: All tongue-type calcaneus fractures treated at 1 institution between 2002 and 2007 were identified from a trauma registry. Of 954 patients with calcaneal fractures, 139 tongue-type calcaneus fractures in 127 patients formed the study group. Intervention: Patient demographics, comorbidities, injury mechanism, fracture displacement, and time to presentation were evaluated. Those injuries that were associated with posterior, secondary soft tissue breakdown were identified and compared to those without breakdown. Main Outcome Measurements: Univariate analysis and stepwise multinomial logistic regressions were used to identify significant predictors of posterior soft tissue compromise. Results: Twenty-nine fractures (21%) had some degree of posterior skin compromise at presentation, including 12 with threatened skin, 10 with partial thickness breakdown, and 7 with full thickness breakdown. Six soft tissue coverage procedures and one amputation resulted. Patients with posterior skin compromise were less likely to have a fall mechanism (P = 0.001), had significantly greater fracture displacement (P = 0.007), were more likely to smoke (P = 0.039), and were more frequently referred on a delayed basis (P = 0.007). Those with threatened posterior skin who were treated emergently with percutaneous reduction did not progress to soft tissue compromise. Conclusion: A high incidence (21%) of posterior skin compromise occurs in tongue-type calcaneus fractures. These should be treated with immediate reduction, plantarflexion splinting, and close monitoring. Although mechanism, displacement, and time to presentation were significantly correlated with posterior skin involvement, the surgeon should be aware of this potential complicating factor in all tongue-type fractures.

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.

Objectives: To report the soft tissue complications after fixation of tibial plafond fractures to test the validity of the recommendation that a 7-cm skin bridge represents the minimum safe distance between surgical incisions. Design: Prospective observational cohort. Setting: Level 1 Trauma Center. Patients: A total 42 patients with 46 tibial plafond fractures. Intervention: All injuries had a minimum of 2 surgical approaches for operative management of the tibial plafond and associated fibula fracture (if applicable). Two low-energy injuries had single-stage open reduction internal fixation of the tibia and fibula, and the remaining high- energy fractures had a 2-staged approach to management. Main Outcome Measurements: The surgical approaches used, length of the incisions, distance between the incisions, and overlap between the incisions were recorded. Wound healing was assessed in the outpatient clinic over a 3-month period. Results: Two surgical approaches were used in 32 fractures, and 3 approaches were used in 14 fractures. The mean width of the skin bridge was 5.9 cm. The majority of the skin bridges were 5.0 to 5.9 cm (n = 25) or 6.0 to 6.9 cm (n = 16). Only 17% of the skin bridges were greater than 7.0 cm. Soft tissue complications occurred in 4 (9%) of 46 fractures. Healing of 2 anterolateral incisions was complicated by eschars that ultimately resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection. Conclusions: Despite a measured skin bridge of less than 7 cm in 83% of instances, the soft tissue complication rate was low in this group of tibial plafond fractures. With careful attention to soft tissue management and surgical timing, incisions for tibial plafond fractures may be placed less than 7 cm apart, allowing the surgeon to optimize exposures on the basis of injury pattern.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

Introduction While there is conflicting evidence regarding the importance of anatomic reduction for tibial plateau fractures, there are currently no studies that analyse our ability to grade reduction based on fluoroscopic imaging. The purpose of this study was to determine the accuracy of fluoroscopy in judging tibial plateau articular reduction. Methods Ten embalmed human cadavers were selected. The lateral plateau was sagitally sectioned, and the joint was reduced under direct visualization. Lateral, anterior-posterior (AP), and joint line fluoroscopic views were obtained. The same fluoroscopic views were obtained with 2 mm displacement and 5 mm displacement. The images were randomised, and eight orthopaedic traumatologists were asked whether the plateau was reduced. Within each pair of conditions (view and displacement from 0 mm to 5 mm) sensitivity, specificity, and intraclass correlations (ICC) were evaluated. Results The AP-lateral view with 5 mm displacement yielded the highest accuracy for detecting reduction at 90% (95% CI: 83–94%). For the other conditions, accuracy ranged from (37–83%). Sensitivity was highest for the reduced lateral view (79%, 95% CI: 57–91%). Specificity was highest in the AP-lateral view 98% (95% CI: 93–99%) for 5 mm step-off. ICC was perfect for the AP-lateral view with 5 mm displacement, but otherwise agreement ranged from poor to moderate at ICC = 0.09–0.46. Finally, there was no additional benefit to including the joint-line view with the AP and lateral views. Conclusion Using both AP and lateral views for 5 mm displacement had the highest accuracy, specificity, and ICC. Outside of this scenario, agreement was poor to moderate and accuracy was low. Applying this clinically, direct visualization of the articular surface may be necessary to ensure malreduction less than 5 mm.

In fractures with varying degrees of comminution, it is possible for cortical bone fragments to become entrapped within the intramedullary canal. There have been prior case reports on complications associated with incarcerated fragments; however, there has been no proposed solution. The current case shows how 2 cortical fragments in the distal segment of a comminuted femur fracture impeded passage of the intramedullary reamer and induced deformity at the fracture site during the reaming. The authors describe a simple method of retrieval without having to formally open the fracture site. Recognizing the presence of an incarcerated fragment and appropriately managing it intraoperatively allows for fracture fixation to occur uneventfully. [ Orthopedics. 2016; 39(3):e582–e586.]

Purpose To report results of sacral decompression and lumbopelvic fixation in neurologically impaired patients with highly displaced, comminuted sacral fracture-dislocations resulting in spino-pelvic dissociation. Design Retrospective clinical study. Setting Regional level one trauma center. Patients Nineteen patients with highly displaced, comminuted, irreducible Roy-Camille type 2-4 sacral fractures with spino-pelvic instability patterns and cauda equina deficits were identified over a 6-year period, 18 of which met the 12-month minimum follow-up criterion. Intervention All were treated with open reduction, sacral decompression, and lumbopelvic fixation. Radiographic and clinical results were evaluated. Neurological outcome was measured by Gibbons' criteria. Main outcome measurements Radiographic evaluation with computed tomography scan and antero-posterior, lateral, and oblique views of the pelvis to assess alignment, hardware position and decompression. Clinical evaluation emphasizing neurological outcome as described by Gibbons' criteria. Results Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 43 to 21 degrees. Fifteen patients (83%) had full or partial recovery of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons score improved from 4 to 2.8 at 31-month average follow-up (range: 12 to 57 mo). Wound infection (16%) was the most common complication. Complete recovery of cauda equina function was more likely in patients with continuity of all sacral roots (86% vs. 0%, P = 0.00037) and incomplete deficits (100% vs. 20%, P = 0.024). Although not statistically significant, recovery of bowel and bladder function specifically was more closely associated with absence of any sacral root discontinuity (86% vs. 36%, P = 0.066) than on completeness of the injury (100% vs. 47%, P = 0.21). Conclusions Lumbopelvic fixation provided reliable fracture stability and allowed consistent fracture union without loss of alignment. Neurological outcome was, in part, influenced by completeness of injury and presence of sacral root disruption.

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 (≤2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87° ± 5°), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9° ± 5°), 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. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Objectives To describe the associated injuries, demographic distribution, and management of patients sustaining open clavicle fractures. Design Retrospective case series. Setting A single level-1 trauma center. Patients Twenty patients with open clavicle fractures were identified from a prospectively collected orthopaedic trauma registry. Intervention All patients were managed with surgical irrigation and debridement with or without internal fixation. Results Thirteen patients (65%) had a closed head injury. Fifteen patients (75%) had a significant associated pulmonary injury. In that group, there were 10 patients who had a pneumothorax (7 bilateral). Additionally, 12 patients had rib fractures and 11 had documented pulmonary contusions or effusions. Seven patients (35%) had a cervical or thoracic spine fracture or dislocation. Eight patients (40%) had concomitant scapula fractures. Six patients (30%) had additional ipsilateral upper extremity injuries remote from the shoulder girdle. One patient had a scapulothoracic dissociation. Eleven patients (55%) sustained significant facial trauma including fractures (5 patients), lacerations, and hematomas. Fourteen patients (70%) were treated with open reduction internal fixation. Fifteen patients (75%) were followed to healing (mean: 111 wk, median: 56 wk, range: 13 to 333 wk). There were no other complications related to the operative fixations. There were no known infections or nonunions. Conclusions Open clavicle fractures are a rare injury. Patients often have associated pulmonary and cranial injuries. Ipsilateral upper extremity and shoulder girdle injuries are common, whereas concomitant neurologic and vascular injuries are infrequent. The majority of patients have rapid and uneventful healing of their fractures after surgical treatment.

Objectives: The transolecranon exposure for distal humerus fractures is a suggested technique for improving articular visualization, allowing accurate reduction. Significant osteotomy complications such as nonunion and implant prominence have prompted recommendations for alternate exposures. The purposes of this study are to present the techniques and complications of the olecranon osteotomy for the management of distal humerus fractures, and to evaluate the adequacy of distal humeral and olecranon articular reductions. Design: Retrospective review. Setting: Urban level-1 University trauma center. Patients: One hundred fourteen skeletally mature AO/OTA type 13-C distal humerus fractures were identified from the orthopedic trauma database and formed the study group. Intervention: Seventy fractures (61%), including 42 open injuries, were managed using an intraarticular, chevron-shaped olecranon osteotomy. Osteotomy fixations were performed with an intramedullary screw and supplemental dorsal ulnar wiring, or plate stabilization. In the remaining 44 fractures (39%), soft-tissue mobilizing exposures were performed. Main Outcome Measure: Patient records and radiographs were reviewed to determine injury and operative characteristics, complications, and adequacy of articular reductions. Patient interviews were conducted by telephone to identify any subsequent surgical procedures. Results: The proportion of osteotomies performed increased as fracture complexity increased (P < 0.001). Sixty-seven of 70 patients had adequate follow-up to determine osteotomy union. All osteotomies united. There was 1 delayed union. Sixty-one of 70 patients had adequate follow-up to determine complications associated with ulnar fixations. Five of these patients (8%) underwent elective removal of symptomatic osteotomy fixations. An additional 13 patients had olecranon implants removed in conjunction with other surgical procedures (11 elbow contracture releases, 1 humeral nonunion repair, and 1 chronic draining sinus excision). Symptomatic ulnar fixations in this group could not be reliably ascertained, but may have been present. A total of 18 of 61 patients (29.5%), therefore, had proximal ulna fixations removed. All patients treated using an olecranon osteotomy exposure demonstrated satisfactory radiographic distal humeral articular reductions. Two osteotomies required early revision osteosynthesis secondary to loss of osteotomy reduction. Conclusions: In this study, no osteotomy nonunions were encountered in 67 patients, more than half of which were open injuries. Regardless of which type of fixation is used to secure the osteotomy, secure stabilization must be obtained. Isolated symptomatic olecranon fixation requiring removal occurred in approximately 8% of patients. Although not necessary for all fractures of the distal humerus, the olecranon osteotomy can be useful in the visualization of the complex articular injuries, allowing accurate articular reduction.

It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting. The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60–90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observer’s opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement. Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10–0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51–0.81). During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.

Background: Isolated coronal plane fractures of the distal femoral condyles (Hoffa fractures) occur uncommonly, are difficult to diagnose, and may be challenging to treat. The combination of supracondylar distal femoral fractures and these coronal plane fractures is thought to occur rarely. The purposes of the present study were to identify the frequency of the association between supracondylar-intercondylar distal femoral fractures and coronal fractures of the femoral condyle and to describe the radiographic evaluation of these injuries. Methods: One hundred and eighty-nine patients with 202 supracondylar-intercondylar distal femoral fractures were retrospectively evaluated clinically and radiographically. Results: Coronal plane fractures were diagnosed in association with seventy-seven (38.1%) of the 202 supracondylar-intercondylar distal femoral fractures. Fifty-nine (76.6%) of these coronal fractures involved a single condyle, and eighteen involved both the medial and lateral femoral condyles. Eighty-five percent of the coronal fractures involving a single condyle were located laterally. Patients with an open distal femoral fracture were 2.8 times more likely to have a coronal plane fracture than patients with a closed fracture were (95% confidence interval, 1.54 to 5.25). Coronal plane fractures were diagnosed in 47% of the 102 knees that were evaluated with computerized tomography, compared with 29% of the 100 knees that were not (p = 0.008). Ten coronal plane fractures that had been unrecognized preoperatively were identified only at the time of operative fixation of the distal femoral fracture; none of these fractures occurred in patients who had been evaluated with computerized tomographic scanning preoperatively. Conclusions: Coronal plane fractures frequently occurred in association with high-energy supracondylar-intercondylar distal femoral fractures; in the present study, the prevalence of associated coronal plane fractures was 38%. The lateral condyle was involved more frequently than the medial condyle was. Coronal plane fractures of both condyles were observed commonly, and the majority of coronal plane fractures were associated with open wounds. Since the surgical tactic for the treatment of a supracondylar-intercondylar distal femoral fracture may be altered by the additional diagnosis of a coronal plane fracture component, preoperative computerized tomographic scanning of the injured distal part of the femur, particularly when there is an associated open wound, is strongly recommended. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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.

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 d

The risk of arterial injury with knee dislocation is well known. The most effective method for rapidly and accurately diagnosing arterial injury in this setting remains a topic of debate. Both physical examination and arteriography have been advocated, although each of these methods has its critics. The authors propose that the ankle-brachial index (ABI) can accurately predict whether patients with knee dislocations have sustained vascular injury.A prospective study enrolled 38 patients with knee dislocation to evaluate for potential arterial injury using clinical pulse examination and ABI. Patients with an ABI lower than 0.90 underwent arteriography. Those with an ABI of 0.90 or higher were immobilized and admitted for serial examination and delayed arterial duplex evaluation.Of the 38 patients, 11 (29%) had an ABI lower than 0.90. All 11 had arterial injury requiring surgical treatment. The remaining 27 patients had an ABI of 0.90 or higher. None had vascular injury detectable by serial clinical examination or duplex ultrasonography. The sensitivity, specificity, and positive predictive value of an ABI lower than 0.90 were 100%. The negative predictive value of an ABI that reached 0.90 or higher was 100%.The ABI is a rapid, reliable, noninvasive tool for diagnosing vascular injury associated with knee dislocation. Routine arteriography for all patients with knee dislocation is not supported.

High-energy fractures of the tibial plateau create difficult treatment scenarios. Both osseous and soft tissue injuries can challenge the most experienced trauma surgeon. Because the injury is frequently the result of a crushing mechanism the soft tissues of the proximal leg may initially present an envelope unsuitable for extensile surgical incisions. A closed soft tissue envelope may be associated with marked contusion or significant degloving threatening skin viability, while rapid swelling may prohibit acute surgical wound closure. An open fracture may require multiple debridements, skin grafts, or free tissue transfer to achieve ultimate sterile wound coverage. Still, the vast majority of these fractures benefit from skeletal stabilization with restoration of joint congruity and coronal and sagittal alignment. We routinely deal with this combination of severe bone and soft tissue injury with provisional knee spanning external fixation within 24 hours of injury, aggressive management of open wounds followed by a period of soft tissue rest, then delayed ORIF 2 to 3 weeks after fixator application. Well planned minimal surgical incisions at this time accompanied by meticulous attention to soft tissue handling reproducibly result in successful restoration of alignment and fracture and soft tissue healing.

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.

Background Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity. Methods A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks. Results Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united. Conclusions Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.

Percutaneous pelvic fixation stabilizes pelvic ring disruptions without extensive pelvic dissection. For this reason, these anterior and posterior percutaneous pelvic fixation techniques allow acute and definitive treatment. Successful percutaneous pelvic fixation techniques depend on accurate closed reduction, excellent intraoperative fluoroscopic imaging, and detailed preoperative planning. Early pelvic stability diminishes haemorrhage, provides patient comfort, and allows early patient mobilization from recumbency.

Osteoid osteoma is a common benign bone lesion that affects adolescents and young adults. Spontaneous resolutionof pain is unreliable and may take years to resolve. Relief with non-steroidal anti-inflammatory drugs (NSAIDS) is often unpredictable and requires prolonged administration. Surgical en bloc resection has been the treatment of choice for these tumors. Recently, however, percutaneous radiofrequency thermal ablation, a technique that delivers a discrete, controlled thermal injury to the targeted tissue, has been applied to the treatment of osteoid osteoma, with positive results. This report reviews the pathophysiology and natural history of osteoid osteoma, the basic science of radiofrequency thermal ablation, and our clinical experience of its use in the treatment of osteoid osteoma. Finally, the technique of percutaneous radiofrequency ablation for the treatment of osteoid osteoma is described in detail.