Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

INTRODUCTION

Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported.

MATERIALS AND METHODS

A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities.

CONCLUSIONS

Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.

[Surgical treatment of acute coronoid process fractures]

OBJECTIVES

This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome.

METHODS

Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months).

RESULTS

A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels.

CONCLUSION

Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

[Reconstruction of the medial collateral ligament of elbow]

OBJECTIVE

To evaluate the clinical effect of excising the radial head, repairing or reconstructing the medial collateral ligament (MCL) in treating comminuted fracture of the radial head accompanying by MCL injury.

METHODS

From September 2000 to April 2006, 18 patients with comminuted fractures of radial head accompanying by MCL injury were treated by excision of the radial head, repair or reconstruction of the MCL. Of them, there were 12 males and 6 females, aged 21 to 57 years. Injury was caused by high falling in 10 cases and by traffic accidents in 8 cases. According to Mason classifications, 13 fractures were of type III and 5 of type IV. Fifteen cases of fresh fractures were operated within 2 weeks, 3 cases of old fractures at 4, 6, and 14 months after injury respectively. Four cases underwent MCL repair and 14 cases underwent MCL reconstruction.

RESULTS

All the 18 cases were followed up 1-5 years (mean 3 years). According to Broberg and Morrey scoring system, 4 patients were rated as excellent, 12 as good, 1 as fair, and 1 as poor. The excellent and good rate was 88.9%. Three patients had light pain of elbow, 1 patient had moderate pain and the other 14 had no pain. The range of elbow motion was from 110 to 140 degrees (mean 130 degrees). The pronation averaged 75 degrees (35-85 degrees). The supination averaged 80 degrees (65-89 degrees). Compared with normal limbs, the grip strength decreased by 3% to 28% (mean 15%); the extension strength decreased by 8% to 39% (mean 30%); the flexion strength decreased by 7% to 29% (mean 18%); the pronation strength decreased by 7% to 31% (mean 20%); the supination strength decreased by 15% to 45% (mean 25%). The X-ray films showed that carrying angle increased by 0 to 11 degrees (mean 5 degrees) under two-newton-meter valgus torque. There were significant differences between injured limbs and normal limbs (P < 0.05).

CONCLUSION

The MCL was the primary valgus stabilizer of the elbow. If the radial head replacement could not be carried out, the repair or reconstruction of the medial collateral ligament was effective.

Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l’extrémité distale du radius

PURPOSE OF THE STUDY

Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint.

MATERIAL AND METHODS

In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively.

RESULTS

The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb.

CONCLUSION

Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.

Low back pain after unstable extracapsular hip fractures: randomized control trial on a specific training

AIM

This study compares the efficacy of a walking recovery rehabilitation program with or without specific back exercises in patients affected by unstable extracapsular hip fractures and secondary back pain. Further, it reports data and images about analysed tomographic changes of the psoas muscle ipsilateral to fractures.

METHODS

A prospective, randomized, parallel treatment trial was carried out. Patients admitted for rehabilitation after fractures were evaluated for secondary back pain. If clinically indicated, patients were further scheduled for a computed tomography (CT) scan of the lumbar spine by which we evaluated cross-sectional changes in density and fibroadipose degeneration of the body of the psoas muscle. When back pain matched cross-sectional changes in psoas density, the patient was eligible for our study, enrolled and randomly assigned to 1 of 2 study groups. Both groups were scheduled for hip rehabilitation and walking training plus a back protocol for the study group only. Pain was evaluated subjectively with a visual analog scale to calculate treatment effectiveness and Harris hip score was used to assess the outcome after surgery.

RESULTS

Thirty-seven patients out of about hundred were enrolled. In all cases CT scans showed age-related changes commonly seen in the lumbar spine and significant fibroadipose degeneration and altered density in the ipsilateral psoas muscles. With back exercises added to the standard rehabilitation protocol, all study patients recovered significantly better than control group patients (P<0.04) in only 4 weeks of treatment.

CONCLUSION

Results show how hip fractures may cause psoas changes that can be of relevance for a more rational choice of physical exercises. Causes of back pain may be more complex than described by the textbooks and prognosis is more favourable following specific back training.

Calcanisation of tibia using Ilizarov fixator in crush injuries of hindfoot: a new method

Crush injuries of the foot are one of the most difficult and challenging tasks for a trauma surgeon to manage in terms of limb salvage and provision of a painless functional foot. Injuries to the foot, especially the hindfoot, account for almost 24.6% of all the warfare injuries in Afghanistan, of which more than 70% end in amputation for various reasons. We devised a method using the principles of Ilizarov's distraction osteosynthesis to salvage limbs with bony defects in the hindfoot which otherwise were candidates for amputation. The procedure is done in two stages. Initially, the ring fixator is applied for the soft tissue reconstruction and infection control, and the next stage consists of percutaneous "inverted L"-shaped osteotomy in the posterior half of the lower tibia. The study included 32 patients with hindfoot crush injuries involving talus, calcaneum, a combination of both, or even involving the adjacent tarsal bones. All these crush injuries were classified using the Gustilo and Anderson classification. The postoperative functional assessment of the feet was done using the Maryland Foot Score system with a minimum follow-up of four years. We had good results in 53%, fair in 34% and failure in 13% of our cases. The complications of this procedure were the same as with the use of the ring fixator elsewhere in the body. This method provides a technique to salvage the foot and produce a painless, stable, fused foot in one of the most difficult settings of a hindfoot crush injury.

Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report

Although extensor pollicis longus tendon ruptures have been noted as a complication of distal radius fractures, flexor tendon ruptures in association with acute fractures of the distal radius are rare. We report a rupture of the flexor carpi radialis tendon as a complication of an acute distal radius fracture that was discovered during operative management of the fracture.

Blow-out fractures in children: six years’ experience

OBJECTIVES

To present and analyze our experience in treating blow-out fractures in children, over a 6-year period.

STUDY DESIGN

The study was retrospective with 16 consecutive cases of blow-out fractures in children aged 5 to 15 years. All patients presented with impairment of eye motility and diplopia together with radiological findings. Treatment included fracture reduction, release of entrapped periorbital soft tissues, and placement of an alloplastic membrane on the orbital floor. Fractures were linear in 11 cases (trapdoor) and severe or comminuted in 5 cases.

RESULTS

Clinical symptoms subsided in all cases. Complete recovery of eye motility was achieved after surgical procedure in 13 cases; 2 patients presented late but had full recovery, and 1 patient, 4 years postoperatively, still had slight motility impairment.

CONCLUSIONS

Surgical treatment of blow-out fractures, including periorbital tissue release and placement of a membrane lining on the orbital floor, presented satisfactory results in our cases.

Ipsilateral dislocation of the shoulder and elbow joints with contralateral comminuted humeral fracture

Ipsilateral dislocation of the shoulder and elbow joints is a rare and complex injury. During the last 25 years, only 3 cases have been reported in the literature. We report a 50-year-old woman who suffered ipsilateral elbow and shoulder dislocation with contralateral comminuted humeral fracture. Both shoulder and elbow joints were reduced, but the elbow was dislocated subsequently at follow-up. The reduction in the elbow was stabilized by a Kirschner wire that was removed at 3 weeks, and the elbow was then stable. A U-shaped coaptation splint was applied for the contralateral comminuted humeral fracture. At 6 months, she had acquired a nearly full range of motion of both shoulder and elbow with complete healing in the contralateral humerus. Although rare and complex, ipsilateral shoulder and elbow dislocation, which is the result of a high-energy trauma, can be treated conservatively.

Prediction of instability in distal radial fractures

BACKGROUND

Effective methods of treating an unstable distal radial fracture are described in the literature, but there is no reliable method of identifying an unstable fracture in time to initiate appropriate treatment. The purposes of this study were to identify the predictors of fracture instability and to construct a method of prospectively predicting the radiographic outcome.

METHODS

Data on approximately 4000 distal radial fractures were prospectively recorded over a 5.5-year period. The database was validated by reexamining a sample of it. Demographic data on the patients and mode of injury, as well as the fracture classification and measurements, were recorded at the time of presentation. Outcome measures consisted of radiographic measurements made at one week and six weeks and assessment of carpal alignment at six weeks. Univariate and multiple logistic regression analyses were performed to identify the significance of the data obtained at presentation in the prediction of early and late instability as well as the risk of malunion and carpal malalignment.

RESULTS

The predictors of early and late instability and malunion differed according to the displacement of the fracture at presentation. Patient age, metaphyseal comminution of the fracture, and ulnar variance were the most consistent predictors of radiographic outcome. Dorsal angulation was not found to be significant in the prediction of radiographic outcome for displaced fractures. The degree to which the patient was independent was predictive of malunion in minimally displaced and displaced fractures. Formulas that are predictive of each of the seven radiographic outcome measurements were constructed.

CONCLUSIONS

The study succeeded in identifying the factors that are prognostic of the radiographic outcome for distal radial fractures. Formulas to predict the radiographic outcome were constructed as the independent prognostic significance of these factors was quantified. These formulas can be used to inform the surgeon's decision about the nature of primary treatment of fractures of the distal aspect of the radius. However, they must be validated by further studies before they are used to impact the management of distal radial fractures.

LEVEL OF EVIDENCE

Prognostic Level I.

Spinal cord–fragment interactions following burst fracture: an in vitro model

Object

The purpose of the study was to develop an in vitro model of the bone fragment and spinal cord interactions that occur during a burst fracture and further the understanding of how the velocity of the bone fragment and the status of the posterior longitudinal ligament (PLL) affect the deformation of the cord.

Methods

An in vitro model was developed such that high-speed video and pressure measurements recorded the impact of a simulated bone fragment on sections of explanted bovine spinal cord. The model simulated the PLL and the posterior elements.

The status of the PLL had a significant effect on both the maximum occlusion of the spinal cord and the time for occlusion to occur. Raising the fragment velocity led to an overall increase in the spinal cord deformation. Interestingly the dura mater appeared to have little or no effect on the extent of occlusion.

Conclusions

These findings may indicate the importance of the dura’s interaction with the cerebrospinal fluid in protecting the cord during this type of impact.

Functional outcome following treatment of transolecranon fracture-dislocation of the elbow

Elbow fracture-dislocations are considered as difficult injuries to treat. Anterior olecranon fracture-dislocation consist an uncommon pattern which is likely to be under-diagnosed. Eight patients identified as anterior fracture-dislocation of the elbow were retrospectively reviewed. There were seven men and one woman with an average age of 35 years (range, 22-58 years). Proximal ulna fracture was comminuted in seven and simple oblique in one patient. Associated fractures were of coronoid in four and radial head in two. Reconstruction plate was used in seven patients and tension band wiring in just one. Nevertheless, tension wiring failed and was successfully revised to plate fixation combined with bone graft. Patients were followed for an average of 37.4 months (range, 10-50 months). The end results were two excellent, five good and one fair, based on Broberg and Morrey scale. An average score of 89 points was obtained using American Shoulder and Elbow Surgeons elbow scoring system. Treatment of anterior olecranon fracture dislocation is mostly satisfactory if contour and dimension of greater sigmoid notch is accurately restored.

Intraarticular distal humerus fracture complicated by osteogenesis imperfecta treated with primary total elbow arthroplasty: a case report

Intraarticular fractures of the distal humerus are challenging problems for the treating surgeon. When these fractures are complicated by severe comminution and poor bone quality, open reduction and internal fixation may lead to poor clinical outcomes when compared with those treated with primary total elbow arthroplasty. The population in which this clinical scenario most often arises is the elderly. An unusual case is presented in which a 38-year-old individual was successfully treated with primary total elbow arthroplasty for a highly comminuted, intraarticular distal humerus fracture with severe osteopenia due to osteogenesis imperfecta in which standard plate osteosynthesis was unlikely to provide sufficient stable fixation.

Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture

PURPOSE

The purpose of this study was to compare intraoperative stress radiography and ankle arthroscopy in the evaluation of distal tibiofibular syndesmosis disruption in acute ankle fracture.

TYPE OF STUDY

Prospective study.

METHODS

We treated 53 Weber type B or C ankle fractures without radiographic evidence of frank syndesmosis diastasis. Intraoperative stress radiography and ankle arthroscopy were performed. Syndesmotic screws were inserted in those patients with syndesmosis diastasis. Screws were removed 12 weeks later and second-look ankle arthroscopy was performed at the same time.

RESULTS

Sixteen cases (30.2%) had positive intraoperative stress radiographs; 35 cases (66.0%) had positive arthroscopic findings of syndesmosis diastasis, including various combinations of coronal, sagittal, and rotational planes of instability. During second-look arthroscopy, 31 of 34 patients with syndesmotic screws showed healing of the syndesmotic ligaments and the syndesmosis became stable.

CONCLUSIONS

Ankle arthroscopy excels intraoperative stress radiography in detecting syndesmosis disruption. It also provides assessment of different planes of instability and assists anatomic reduction of the syndesmosis. Intraoperative radiography still does play an important role in assessing fracture reduction and proper restoration of fibular length and longitudinal orientation of the syndesmosis.

LEVEL OF EVIDENCE

Level 2.

Conservative treatment vs prosthetic replacement surgery to treat 3- and 4-fragment fractures of the proximal epiphysis of humerus in the elderly patient

Several previous studies have revealed a significant difference in the functional results obtained between conservative treatment and prosthetic replacement surgery to treat complex fractures of the proximal end of the humerus. Thus, prosthesis is the gold standard in treatment of such fractures. It is the purpose of this study to analyze the functional results obtained with the conservative treatment of 18 consecutive patients, mean age 78 years, affected with 3- and 4-fragment fractures of the proximal epiphysis of humerus. A comparison of functional results that may be obtained when prosthetic replacement is performed does not show significant differences in this category of patients. Thus, in order to limit complications, when the patient is elderly, complex fracture of the proximal epiphysis of humerus should be treated conservatively.

The metal prosthesis in radial head fracture: indications and preliminary results

Radial head displaced irreparable fracture is an indication for prosthesis; it becomes elective also when there are associated injuries of the skeletal and ligamentous stabilization systems. A retrospective study was conducted to evaluate the functional and radiographic results in 10 patients (mean age 39.6 yrs; minimum 20, maximum 80) submitted to radial head replacement. There were 4 Mason-Johnston type IV Rochwerger subtype "b" fractures, 7 type III fractures (1 associated with an Essex-Lopresti injury and 1 with fracture of the ulnar proximal metaepiphysis). Mean follow-up was 24.6 months (minimum 18, maximum 32). Postoperative functional evaluation of the elbow and ipsilateral wrist was carried out using the ESSSE/SECEC form (mean score 80.7/100; minimum 63, maximum 96) and the PRWE (mean score 11.1; minimum 0, maximum 36) respectively. Radiographically there were postoperative calcifications in 30% of cases and periprosthetic lucency in 40%. The results of this study encourage the use of a metal prosthesis, but a longer follow-up is needed for a better evaluation.

Lumbar burst fracture associated with bowel, bladder, and sexual dysfunction: case study

Lumbar burst fractures occur when unusual force and flexion are placed on the spine, causing the vertebral body to rupture and possibly protrude into the spinal canal. A resulting conus medullaris injury is possible, but not common. In this case presentation, a young man suffered bowel, bladder, and sexual dysfunction after a 25-foot fall that caused a burst fracture of the first lumbar vertebra. The presentation's primary focus is the nursing education needed to care for patients who experience the unusual side effect of conus medullaris injury. The psychosocial aspects attributable to age, developmental stage, and stigma for a young man with these dysfunctions also are explored.

COMMINUTED FRACTURE OF THE DISTAL SESAMOID BONE AND DISTAL RUPTURE OF THE DEEP DIGITAL FLEXOR TENDON

A 10-year-old show jumper was evaluated for an acute severe lameness (grade 4 of 5) of the right foreleg. During weight bearing, the toe of the affected limb rotated dorsally suggesting rupture of the deep digital flexor tendon (DDFT). Upon radiographic examination of the hoof, a severe erosion at the flexor surface and a parasagittal fracture of the distal sesamoid bone were found. Ultrasonographic examination confirmed rupture of the DDFT. These findings were confirmed on post-mortem examination. Prior to the acute lameness, the horse was treated with corticosteroid injections into the podotrochlear bursa. Repeated intra-bursal injections of corticosteroids as a possible cause for DDFT rupture are discussed as well as the possible association between a degenerative distal sesamoid bone, a distal sesamoid bone fracture and a DDFT rupture.

Multisegmental open sacral fracture due to impalement: a case report

We report on an unusual impalement injury to the sacrum in a 15-year-old adolescent patient. This open pelvic fracture resulted in a shattered sacrum with neurologic impairment including clinically absent anal sphincter tone and perineal sensation. Early debridement, wound revision, neural decompression, fracture reduction, and stable fixation using lumbopelvic fixation according to the principles of triangular osteosynthesis resulted in a favorable outcome with primary wound healing, return of bowel and bladder control, as well as immediate patient mobilization.

Complications of intra-articular fractures of the calcaneus

Most complications of calcaneal fractures are due to the combination of the dynamic nature and the mechanism of the injury itself. Complications are usually secondary to three integral parts of this complex fracture pattern: 1) fracture and depression of the subtalar joint, 2) loss of the height of the calcaneal body with varus rotation, and 3) expansion of the lateral wall of the calcaneus. Other complications occur with less frequency. This article describes the complications and sequelae of old, malunited intra-articular calcaneal fractures in relation to the nature and the components of these unique fractures.