Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications

In a retrospective study, 58 patients with 60 tibial plafond fractures were treated by internal fixation and reviewed over an average follow-up period of 2.5 years. There were three Reudi Type I, 27 Reudi Type II, and 30 Reudi Type III fractures. Twelve fractures were open, and 60% of the fractures were the result of high-energy trauma. Results were evaluated based on a subjective and objective rating system. There were 15 good and excellent (25%), 15 fair (25%), and 30 poor results (50%). The deep infection rate in Reudi Types I and II fractures was 0%, and in Type III fractures it was 37%. The deep infection rate statistically correlated with the presence of a postoperative wound dehiscence or skin slough but not with the presence of an open fracture. Overall clinical rating correlated with the Reudi classification, quality of reduction, and the presence of a postoperative wound infection. The ankle fusion rate for Reudi Types I and II fractures was 10%, whereas that in Reudi Type III fractures was 26%. The results of this study show that operative treatment of complex intraarticular fractures of the distal tibia remain fraught with difficulty and that the complication rates and need for further reconstructive surgery remains high. If anatomic reduction without soft-tissue complications cannot be predicted preoperatively, consideration should be given to alternative types of treatment.

The management of fixed flexion contractures during total knee arthroplasty

Fifty-one knees in 40 patients with joint surface degeneration accompanied by fixed flexion contractures (FFC) greater than 20 degrees were treated with total knee arthroplasty using a minimally constrained posterior cruciate ligament retaining prosthesis. Special techniques were employed in an attempt to achieve maximal correction at the time of surgery. The residual FFC measured 3.1 degrees at the completion of the arthroplasty, 10.1 degrees at three months, and 7 degrees at two years. At 55 months postoperatively, the FFC for the osteoarthrotic group had improved from 25.5 degrees to 3.6 degrees, whereas the rheumatoid group improved from 28.7 degrees to 8.6 degrees. The average knee score for the osteoarthrotic group was 89 compared with 81 for the rheumatoid group. Knees that were left with greater residual FFC at the completion of the arthroplasty were found to have greater residual FFC at the latest review.

The clinical and roentgenographic results of cementless porous-coated patellar fixation

From May 1980 to July 1988, 522 porous-coated, metal-backed patellar components were implanted without cement in conjunction with the Porous Coated Anatomic (PCA) knee system during primary total knee arthroplasty (TKA). Four different designs were evaluated clinically and roentgenographically. Fixation failure at the bone-prosthesis interface was the most common cause of failure. The addition of a third peg to the metal backing led to a dramatic decrease in the rate of revision for loosening (from 6.1% to 0.6%). Two patellar implants, one two-pegged and one three-pegged (central dome), were revised because of polyethylene wear. The low incidence of polyethylene wear is attributed to careful attention to technique and the high degree of congruency at the femoral articulation. Porous-coated metal-backing offers a viable means of patellar fixation during primary TKA. Design modifications have led to enhanced fixation and improvements in short-term clinical and roentgenographic results.

Primary total knee arthroplasty in patients with severe varus deformity. A comparative study

Varus deformity is a common finding in candidates for total knee arthroplasty (TKA), but very little has been written concerning the problems encountered in correcting these deformities at the time of arthroplasty. Compared to patients without deformities, this group of patients require more attention to the technical aspects of the arthroplasty, especially bony alignment and ligament balancing. Specific operative techniques used to correct severe varus deformities at primary TKA were evaluated, and the clinical and roentgenographic results were compared with those of a control group of patients without preoperative angular deformity. Operative findings and clinical results in 27 knees (20 patients) with a minimum preoperative varus deformity of 20 degrees (average follow-up period, 58.7 months; range, 24-102 months) were compared with those of 40 knees (31 patients) with a preoperative angulatory deformity of less than 5 degrees varus or valgus (average follow-up period, 50.0 months; range, 24-90 months), in whom a minimally constrained, posterior-cruciate-ligament-sparing prosthesis was implanted. Operative time was an average of 30 minutes longer in the varus deformity group. The average knee evaluation score in the varus group was 89 points, and for the nondeformity group it was 92 points (p less than 0.02). There were no fair or poor results in the varus deformity group; there was one poor result in the nondeformity group. Postoperative knee are of motion was 98 degrees in the varus deformity group and 107 degrees in the nondeformity group. After arthroplasty, the average angle between the mechanical axis of the femur and the tibia was 3 degrees varus in the varus deformity group and 0 degree varus in the nondeformity group (p less than 0.006). Postoperative functional scores of patients in the varus deformity group approached, but were not equal to, the nondeformity group. Greater variability in results and longer operative times were needed in the varus deformity group. Postoperative alignment of the varus deformity group tended to be in residual varus.

Treatment of infected total knee arthroplasty. Irrigation and debridement versus two-stage reimplantation

The results of 24 cases of deep wound infection after total knee arthroplasty were reviewed. Twenty-one knees were initially treated with irrigation and debridement. Infection recurred in 15 knees. An increased infection rate occurred after irrigation and debridement in patients in whom the index prosthesis was in place more than 2 weeks. Nine knees (including 7 that had removal after irrigation and debridement) were treated with removal of the infected prosthesis, intravenous antibiotics, and delayed reimplantation. Immediate exchange was done in one knee. There were no recurrences in this group (P less than .001). The final status of the patients included 8 with fusions or resection arthroplasties and 16 with a prosthesis. The average Hospital for Special Surgery knee rating was 41 in patients without a prosthesis and 75 in patients with a prosthesis (P less than .001). The authors conclude that irrigation and debridement is not likely to be successful for treatment of infections when used more than 2 weeks after the initial arthroplasty. Also, two-stage reimplantation for the treatment of infected total knee arthroplasties gives a reliably low recurrence rate and provides a superior clinical result, compared to arthrodesis or resection arthroplasty.

Compartment syndrome: a complication of use of the MAST suit

A case of compartment syndrome following the use of a MAST suit is reported. The most significant factor in its development is prolonged application combined with severe hemodynamic compromise. Amputation was performed or death occurred in 50% of reported cases. Compartment pressure monitoring should be done in patients who require a MAST suit for more than 4 h.