Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study

Background

To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.

Methods

All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.

Results

In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).

Conclusion

Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.

Trial registration

The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Different outcomes after proximal femoral replacement in oncologic and failed revision arthroplasty patients - a retrospective cohort study

Background

Proximal femoral replacement (PFR) is a technically demanding procedure commonly performed to restore extensive, oncological or non-oncological bone defects in a severely debilitated patient collective. Depending on different indications, a varying outcome has been reported. The aim of the study was to assess the functional outcomes and complication rates of PFR with the modular Munich-Luebeck (MML) femoral megaprosthesis (ESKA/Orthodynamics, Luebeck, Germany), and to highlight outcome differences in patients treated for failed revision total hip arthroplasty (THA) or malignant bone disease.

Methods

A retrospective review of patients treated with PFR for failed THA or malignant tumor disease between 2000 and 2012 was performed. Patient satisfaction, functional outcome (VAS, SF-12, MSTS, WOMAC, TESS), complications and failure types (Henderson’s failure classification) were assessed. A Kaplan-Meier analysis determined implant survival.

Results

Fifty-eight patients (age: 69.9 years, BMI: 26.7 kg/m², mean follow-up: 66 months) were included. The mean SF-12 (physical / mental) was 37.9 / 48.4. MSTS averaged 68% at final follow-up, while mean WOMAC and TESS scored 37.8 and 59.5. TESS and WOMAC scores demonstrated significantly worse outcomes in the revision group (RG) compared to the tumor group (TG). Overall complication rate was 43.1%, and dislocation was the most common complication (27.6%). Implant survival rates were 83% (RG) and 85% (TG; p = n.s.) at 5 years, while 10-year survival was 57% (RG) and 85% (TG, p < 0.05).

Conclusions

PFR is a salvage procedure for restoration of mechanical integrity and limb preservation after extensive bone loss. Complications rates are considerably high.

Functional outcomes and 10-year implant survival rate were worse in the RG compared to the TG. Strict indications and disease-specific patient education are essential in preoperative planning and prognosis.

Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center

Background

The aim of this retrospective monocentric study was to investigate the outcomes of surgically treated intra-articular calcaneus fractures in a maximum care trauma center.

Methods

One hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between 2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries.

Results

Mean follow-up was 91 months (range 12–183). The overall complication rate was 29% (37/129 ft). Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion (18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%) after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70). The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores (p < 0.01).

Conclusions

Our data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary subtalar fusion with caution due to the high revision rate. Smoking status should always be considered.

Level of evidence: Level III, retrospective cohort study.

No difference in radiolucent lines after TKA: a matched-pair analysis of the classic implant and its evolutional design

PURPOSE

Total knee arthroplasty (TKA) designs evolve continuously to improve patient outcomes. However, incidences of radiolucent lines (RLL) in the latest TKA system have recently been reported, raising concerns. The purpose of the current study was to compare radiographic outcomes of this new TKA implant to its predecessor design.

METHODS

A group of 100 patients undergoing TKA using the newer design (Attune) was matched by age and gender to 191 patients with the classic design (LCS). All patients underwent computer-navigated primary TKA by the same surgeon using the same technique. Radiographs were taken before discharge, and 2 and 12 months postoperatively. Radiographic analysis was performed independently by three assessors, using the Modern Knee Society Radiographic Evaluation System and Methodology (MKSRES).

RESULTS

At 12 months postoperatively, the incidence of RLL did not statistically differ between the two implants (14%, n = 14 Attune vs. 8% n = 17 LCS, n.s.). The posterior femoral flange was most commonly affected (12%; n = 12 Attune vs. 7.9%; n = 15 LCS, n.s.) followed by the anterior flange (1%; n = 1 Attune vs. 3.1%; n = 6 LCS, n.s.). The tibial baseplate was only affected in 1% (n = 1) of the Attune and 2.6% (n = 5) of the LCS (n.s.).

CONCLUSION

At 12 months follow-up we found no significant difference in RLL between the two implants. Both Attune and LCS TKA systems showed RLL predominantly at the posterior femoral flange. The reasons for the RLL remain a matter of speculation; however, shortcomings in surgical and cementing techniques seem to be more important than implant-related factors.

LEVEL OF EVIDENCE

III.

[Differential diagnosis of heel pain]

"Heel pain" describes a very common reason for foot orthopedic consultation and the further differential diagnostic investigation is crucial for the choice of correct treatment. In the treatment of frequent underlying diseases, such as plantar fasciitis or insertional tendinopathy of the Achilles tendon, a variety of modern strategies are available. Rarer diseases, such as tumors or nerve entrapment syndromes must be delineated and correctly classified. This article provides the current state of the diagnostics and treatment of the most common entities of heel pathologies.

Compartment syndrome in dislocation and non-dislocation type proximal tibia fractures: analysis of 356 consecutive cases

INTRODUCTION

Dislocation type proximal tibia fractures are associated with the major soft tissue injuries. The main purpose of this study was to analyze the incidence of compartment syndrome (CS) in proximal tibia fractures in relation to the fracture type, i.e., dislocation versus non-dislocation type. We further analyzed CS within the non-dislocation type injuries, initial treatment modality as well as infection rate relative to the treatment policies (one- or two-staged procedures).

PATIENTS AND METHODS

Over an 8.5-year period, prospectively, acquired data of 356 proximal tibia fractures were evaluated. All fractures were classified either according to the AO/OTA or to the Moore (fracture dislocation type) classification system respectively. The appearance of CS in dislocation and non-dislocation type injuries as well as treatment modality, i.e., one- or two-staged procedures was analyzed.

RESULTS

307 (86%) fractures were classified as non-dislocation type and 49 (14%) as fracture dislocation type injuries. Overall 31 (8.7%) CS occurred. All were diagnosed and treated within the initial surgical management. CS was equally distributed in non-dislocation type fractures (24/307) and Moore type fractures (7/49) (Chi-square test, p = 0.4). But a significant difference in the non-dislocation type injuries was observed between AO/OTA B-type (0/166) and non-B type fractures (24/117) (Chi-square test, p < 0.001). 104 fractures were treated in a two-staged procedure with definitive reconstruction after an average of 6.0 days. Initial postoperative surgical site infection remained very low with 0.5%, and did not seem to be related to operative treatment variables including single-stage versus two-stage reconstruction, temporary external fixation and/or compartment fasciotomies.

CONCLUSION

The incidence for CS did not differ between the dislocation and non-dislocation type group, but a significant difference was found comparing the incidence for CS only in the non-dislocation type group.

Operative strategy in postero-medial fracture-dislocation of the proximal tibia

OBJECTIVE

In 1981, Moore introduced a new classification for dislocation-type fractures caused by high-energy mechanisms. The most common medial Moore-type fractures are entire condyle fractures with the avulsion of the median eminence (tibial anterior cruciate ligament (ACL) insertion). They are usually associated with a posterolateral depression of the tibial plateau and an injury of the lateral menisco-tibial capsule. This uniform injury of the knee is increasingly observed in the recent years after skiing injuries due to the high-speed carving technique. This uprising technique uses shorter skis with more sidecut allowing much higher curve speeds and increases the forces on the knee joint. The aim of this study was to describe the injury pattern, our developed operative approach for reconstruction and outcome.

METHODS

A total of 28 patients with 29 postero-medial fracture dislocation of the proximal tibia from 2001 until 2009 were analysed. Clinical and radiological follow-up was performed after 4 years on average (1 year in minimum). Evaluation criteria included the Lysholm score for everyday knee function and the Tegner score evaluating the activity level. All fractures were stabilised post primarily. The surgical main approach was medial. First, the exposure of the entire medial condyle fracture was performed following the fracture line to the articular border. The posterolateral impaction was addressed directly through the main fracture gap from anteromedial to posterolateral. Small plateau fragments were removed, larger fragments reduced and preliminarily fixed with separate K-wire(s). The postero-medial part of the condyle was then prepared for main reduction and application of a buttress T-plate in a postero-medial position, preserving the pes anserinus and medial collateral ligament. In addition, a parapatellar medial mini-arthrotomy through the same main medial approach was performed. Through this mini-arthrotomy, the avulsed anterior eminence with attached distal ACL is retained by a transosseous suture back to the tibia.

RESULTS

We could evaluate 26 patients (93%); two patients were lost to follow-up due to foreign residence. Median age was 51 years (20-77 years). The fractures were treated post primarily at an average of 4 days; in 18 cases a two-staged procedure with initial knee-spanning external fixator was used. All fractures healed without secondary displacement or infection. As many as 25 patients showed none to moderate osteoarthritis after a median of 4 years. One patient showed a severe osteoarthritis after 8 years. All patients judge the clinical result as good to excellent. The Lysholm score reached 95 (75-100) of maximal 100 points and the Tegner activity score 5 (3-7) of maximal 10 points (competitive sports). The patients achieved a median flexion of 135° (100-145°).

CONCLUSION

In our view, it is crucial to recognise the different components of the injury in the typical postero-medial fracture dislocation of the proximal tibia. The described larger medial approach for this type of medial fracture dislocation allows repairing most of the injured aspects of the tibial head, namely the medial condyle with postero-medial buttressing, the distal insertion of the ACL and the posterolateral impaction of the plateau.