Master Techniques in Orthopaedic Surgery Fractures Third Edition [3 ed.]

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EDITOR Donald A. Wiss MD Director of Orthopaedic Trauma Cedars-Sinai Medical Center Los Angeles, California P.vii

Contributors Amr A. Abdelgawad, M.D. Assistant Professor Department of Orthopaedic Surgery and Rehabilitation Texas Tech University Health Sciences Center in El Paso El Paso, Texas David P. Barei, M.D., F.R.C.S.C. Associate Professor Department of Orthopaedic Surgery University of Washington Orthopaedic Traumatology Harborview Medical Center Seattle, Washington Craig S. Bartlett, III M.D. Associate Professor of Orthopaedics Medical Director of Orthopaedic Trauma The University of Vermont Burlington, Vermont Andrea S. Bauer, M.D. Orthopaedic Surgeon Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, Massachusetts Michael R. Baumgaertner, M.D. Professor Department of Orthopaedics and Rehabilitation Yale University School of Medicine Chief, Orthopaedic Trauma Service Yale—New Haven Hospital New Haven, Connecticut Daphne M. Beingessner, B.Math, B.Sc., M.Sc., M.D., F.R.C.S.C. Associate Professor Department of Orthopaedics University of Washington Orthopaedic Traumatology

Harborview Medical Center Seattle, Washington Michael J. Beltran, M.D. Chief Resident Orthopaedic Surgery San Antonio Military Medical Center San Antonio, Texas Stephen K. Benirschke, M.D. Professor Department of Orthopaedics University of Washington Harborview Medical Center Seattle, Washington Pascal Boileau, M.D. Head Department of Orthopaedics Department of Orthopaedics and Sports Traumatology University of Nice-Sophia-Antipolis Nice, France Sreevathsa Boraiah, M.D. Westchester Medical Center Valhalla, New York Matthew R. Camuso, M.D. Orthopaedic Trauma and Fracture Care Maine Medical Center Portland, Maine Kyle F. Chun, M.D. Resident Department of Orthopaedics and Sports Medicine University of Washington Harborview Medical Center Seattle, Washington Michael P. Clare, M.D. Director of Fellowship Education Foot and Ankle Fellowship Florida Orthopaedic Institute Tampa, Florida P.viii

Peter A. Cole, M.D. Chief of Orthopaedic Surgery Regions Hospital Professor University of Minnesota St. Paul, Minnesota Cory A. Collinge, M.D. Director of Orthopaedic Trauma Harris Methodist Fort Worth Hospital Clinical Staff John Peter Smith Hospital Fort Worth, Texas Brett D. Crist, M.D., F.A.C.S. Associate Professor Co-Director, Orthopaedic Trauma Service Co-Director, Orthopaedic Trauma Fellowship Associate Director, Joint Preservation Service Department of Orthopaedic Surgery University of Missouri Columbia, Missouri Kenneth A. Egol, M.D. Professor and Vice Chairman Department of Orthopaedic Surgery NYU Hospital for Joint Diseases Langone Medical Center New York, New York Christopher G. Finkemeier, M.D., M.B.A. Co-director Orthopaedic Trauma Surgeons of Northern California Granite Bay, California Thomas Fishler, M.D. Instructor Department of Orthopaedics and Rehabilitation Yale University School of Medicine New Haven, Connecticut Paul T. Fortin, M.D. Associate Professor Oakland University School of Medicine William Beaumont Hospital Royal Oak, Michigan

John T. Gorczyca, M.D. Professor Chief, Division of Orthopaedic Trauma Department of Orthopaedics and Rehabilitation University of Rochester Medical Center Rochester, New York James A. Goulet, M.D. Professor of Orthopaedic Surgery The University of Michigan Medical School The University of Michigan Health System Ann Arbor, Michigan George J. Haidukewych, M.D. Professor of Orthopaedic Surgery University of Central Florida Academic Chairman and Chief Orthopaedic Trauma and Adult Reconstruction Orlando Health Orlando, Florida David L. Helfet, M.D. Professor of Orthopaedic Surgery Weill Medical College of Cornell University Director, Orthopaedic Trauma Service Hospital for Special Surgery/New York-Presbyterian Hospital New York, New York Daniel S. Horwitz, M.D. Chief, Orthopaedic Trauma Geisinger Health Systems Danville, Pennsylvania James J. Hutson, Jr. M.D. Orthopaedic Surgeon Orthopaedic Trauma Department of Orthopaedics and Rehabilitation University of Miami Miami, Florida Clifford B. Jones, M.D. Clinical Professor Michigan State University Orthopaedic Associates of Michigan Grand Rapids, Michigan

Jesse B. Jupiter, M.D. Hansjorg Wyss/AO Professor Harvard Medical School Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts Enes M. Kanlic, M.D., F.A.C.S. Professor Department of Orthopaedic Surgery and Rehabilitation Texas Tech University Health Sciences Center in El Paso El Paso, Texas Matthew D. Karam, M.D. Clinical Assistant Professor Department of Orthopaedics and Rehabilitation University of Iowa Hospitals and Clinics Iowa City, Iowa James C. Krieg, M.D. Associate Professor Department of Orthopaedics and Sports Medicine University of Washington Harborview Medical Center Seattle, Washington P.ix Sumant G. Krishnan, M.D. Director Shoulder Fellowship Baylor University Medical Center Attending Orthopaedic Surgeon Shoulder Service The Carrell Clinic Dallas, Texas Erik Noble Kubiak, M.D. Assistant Professor Department of Orthopaedics University of Utah Salt Lake City, Utah Lionel E. Lazaro, M.D. Orthopaedic Surgeon Orthopaedic Trauma Service

Weill Medical College of Cornell University Hospital for Special Surgery and New York-Presbyterian Hospital New York, New York Mark A. Lee, M.D. Associate Professor Department of Orthopaedic Surgery Director Orthopaedic Trauma Fellowship University of California, Davis Sacramento, California Ross Leighton, M.D. Professor of Surgery QEII Health Sciences Centre Dalhousie University Halifax, Nova Scotia, Canada Wai-Yee Li, M.D., Ph.D. Plastic Surgical Resident University of Southern California Los Angeles, California Dean G. Lorich, M.D. Chief Department of Orthopaedics at New York-Presbyterian Associate Director Orthopaedic Trauma Service at Hospital for Special Surgery Associate Professor of Orthopaedic Surgery Weill Cornell Medical Center New York, New York Jason A. Lowe, M.D. Assistant Professor Orthopaedic Trauma Surgery Director Fragility Fracture Program Department of Orthopaedic Surgery University of Alabama at Birmingham Birmingham, Alabama Arthur L. Malkani, M.D. Orthopaedic Trauma Surgeon Chief of Adult Reconstruction Service Professor of Orthopaedic Surgery

Department of Orthopaedics University of Louisville School of Medicine Department of Orthopaedic Surgery The University of Louisville Louisville, Kentucky Joel M. Matta, M.D. Founder and Director Hip and Pelvis Institute at St. John's Health Center Santa Monica, California Elaine Mau, M.D., M.Sc. Resident Division of Orthopaedic Surgery University of Toronto St. Michael's Hospital Toronto, Ontario, Canada Michael D. McKee, M.D. F.R.C.S. (C) Professor of Orthopaedic Surgery Division of Orthopaedic Surgery University of Toronto St. Michael's Hospital Toronto, Ontario, Canada Berton R. Moed, M.D. Professor and Chairman Department of Orthopaedic Surgery Saint Louis University School of Medicine Saint Louis, Missouri Steven J. Morgan, M.D. Mountain Orthopaedic Trauma Surgeons Swedish Medical Center Englewood, Colorado Rafael Neiman, M.D. Co-director Orthopaedic Trauma Surgeons of Northern California Roseville, California Xavier Ohl, M.D. Orthopaedic Surgeon Department of Orthopaedics and Sports Traumatology L'Archet 2 Hospital Nice, France

Robert F. Ostrum, M.D. Director of Orthopaedic Trauma Cooper University Hospital Professor Department of Surgery Cooper Medical School of Rowan University Camden, New Jersey P.x Kagan Ozer, M.D. Clinical Associate Professor of Orthopaedic Surgery The University of Michigan Medical School The University of Michigan Health System Ann Arbor, Michigan Guy D. Paiement, M.D. Residency Director for Orthopaedic Surgery Cedars-Sinai Medical Center Los Angeles, California William H. Paterson, M.D. Orthopaedic Surgeon Shoulder Service The Carrell Clinic Dallas, Texas Hamid R. Redjal, M.D. Fellow Hip and Pelvis Institute St. John's Medical Center Santa Monica, California Mark C. Reilly, M.D. Assistant Professor of Orthopaedics Co-Chief, Orthopaedic Trauma Service University of Medicine & Dentistry of New Jersey New Jersey Medical School Newark, New Jersey David Ring, M.D. Associate Professor of Orthopaedic Surgery Harvard Medical School Director of Research Hand and Upper Extremity Service Department of Orthopaedic Surgery

Massachusetts General Hospital Boston, Massachusetts Melvin P. Rosenwasser, M.D. Robert E. Carroll Professor of Orthopaedic Surgery Columbia University College of Physicians and Surgeons Director, Orthopaedic Trauma Service New York Presbyterian Hospital Director, Hand and Microvascular Service New York-Presbyterian Hospital New York, New York Milton L. Chip Routt, Jr. M.D. Professor of Orthopaedic Surgery University of Washington Harborview Medical Center Seattle, Washington Adam P. Rumian, M.D., F.R.C.S.(Tr&Orth) Consultant Orthopaedic Surgeon Department of Trauma and Orthopaedics East and North Hertfordshire NHS Trust Hertfordshire, England Nicholas Sama, M.D. Orthopaedic Trauma Surgeon Center for Bone & Joint Surgery of the Palm Beaches Royal Palm Beach, Florida Hospital for Special Surgery New York, New York Roy W. Sanders, M.D. Chief, Department of Orthopaedics Tampa General Hospital Director, Orthopaedic Trauma Services Florida Orthopaedic Institute Clinical Professor of Orthopaedic Surgery University of South Florida Tampa, Florida Bruce J. Sangeorzan, M.D. Professor University of Washington Harborview Medical Center Seattle, Washington

Milan K. Sen, M.D., F.R.C.S.C. Chief Orthopaedic Trauma Service Department of Orthopaedic Surgery The University of Texas Health Science Center at Houston Houston, Texas Benjamin Service, M.D. Orthopaedic Resident Orlando Health Orlando, Florida Babar Shafiq, M.D. Director of Orthopaedic Trauma Howard University Hospital Washington, District of Columbia Randy Sherman, M.D. Vice Chair Department of Surgery Cedars Sinai Medical Center Los Angeles, California Jodi Siegel, M.D. Assistant Professor Department of Orthopaedics University of Massachusetts Medical School UMass Memorial Medical Center Worcester, Massachusetts James P. Stannard, M.D. J. Vernon Luck Sr. Distinguished Professor & Chairman Department of Orthopaedic Surgery University of Missouri Columbia, Missouri P.xi Benjamin W. Stevens, M.D. Springfield Clinic Springfield, Illinois Rena L. Stewart, M.D., F.R.C.S.(C) Associate Professor, Orthopaedic Surgery Chief, Section of Orthopaedic Trauma Division of Orthopaedics Department of Surgery

University of Alabama at Birmingham Birmingham, Alabama J. Charles Taylor, M.D. Orthopaedic Surgeon Specialty Orthopaedics, P.C. Memphis, Tennessee David C. Templeman, M.D. Associate Professor of Orthopaedic Surgery University of Minnesota Department of Orthopaedic Surgery Hennepin County Medical Center Minneapolis, Minnesota Frederick Tonnos, D.O. Assistant Clinical Professor Michigan State University East Lansing, Michigan Sutter Rosevale Medical Center Roseville, California Mercy San Juan Medical Center Carmichael, California Paul Tornetta, III M.D. Professor and Vice Chairman Department of Orthopaedic Surgery Director of Orthopaedic Trauma Boston, Massachusetts J. Tracy Watson, M.D. Professor of Orthopaedic Surgery Chief, Orthopaedic Traumatology Department of Orthopaedic Surgery St. Louis University School of Medicine Saint Louis, Missouri Neil J. White, M.D., F.R.C.S.(C) Fellow, Hand and Microvascular Service New York-Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, New York Patrick J. Wiater, M.D. Attending Orthopaedic Surgeon Department of Orthopaedic Surgery

William Beaumont Hospital Beverly Hills, Michigan Donald A. Wiss, M.D. Director of Orthopaedic Trauma Cedars-Sinai Medical Center Los Angeles, California Brad Yoo, M.D. Assistant Professor Department of Orthopaedic Surgery University of California, Davis Sacramento, California Bruce H. Ziran, M.D. Director, Orthopaedic Trauma Orthopaedic Surgery Residency Program Atlanta Medical Center Atlanta, Georgia Navid M. Ziran, M.D. Orthopaedic Surgeon Department of Orthopaedic Surgery Santa Clara Valley Medical Center San Jose, California

2013 Lippincott Williams & Wilkins Philadelphia 530 Walnut Street, Philadelphia, PA 19106 USA 978-1-4511-0814-9

Acquisitions Editor: Robert Hurley Product Manager: Elise M. Paxson Production Manager: Alicia Jackson Senior Manufacturing Manager: Benjamin Rivera Marketing Manager: Lisa Lawrence Design Coordinator: Doug Smock Production Service: SPi Global Copyright © 2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Fractures / editor, Donald A. Wiss. — 3rd ed. p. ; cm. — (Master techniques in orthopaedic surgery) Includes bibliographical references and index. ISBN 978-1-4511-0814-9 I. Wiss, Donald A. II. Series: Master techniques in orthopaedic surgery. [DNLM: 1. Fractures, Bone—surgery. 2. Fracture Fixation, Internal—methods. WE 185] 617.1′5—dc23 2012007461 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth

in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1

Dedication To My Beloved Mother Dorothy Zuckerman Wiss Who Passed Away As This Book Was Going To Press A lasting bond, a quiet trust, a feeling like no other. A gratitude that fills the heart, A son's love for his mother.

Series Preface Since its inception in 1994, the Master Techniques in Orthopaedic Surgery series has become the gold standard for both physicians in training and experienced surgeons. Its exceptional success may be traced to the leadership of the original series editor, Roby Thompson, whose clarity of thought and focused vision sought “to provide direct, detailed access to techniques preferred by orthopaedic surgeons who are recognized by their colleagues as ‘masters’ in their specialty,” as he stated in his series preface. It is personally very rewarding to hear testimonials from both residents and practicing orthopaedic surgeons on the value of these volumes to their training and practice. A key element of the success of the series is its format. The effectiveness of the format is reflected by the fact that it is now being replicated by others. An essential feature is the standardized presentation of information replete with tips and pearls shared by experts with years of experience. Abundant color photographs and drawings guide the reader through the procedures step-by-step. The second key to the success of the Master Techniques series rests in the reputation and experience of our volume editors. The editors are truly dedicated “masters” with a commitment to share their rich experience through these texts. We feel a great debt of gratitude to them and a real responsibility to maintain and enhance the reputation of the Master Techniques series that has developed over the years. We are proud of the progress made in formulating the third edition volumes and are particularly pleased with the expanded content of this series. Six new volumes will soon be available covering topics that are exciting and relevant to a broad cross section of our profession. While we are in the process of carefully expanding Master Techniques topics and editors, we are committed to the now-classic format. The first of the new volumes is Relevant Surgical Exposures, which I have had the honor of editing. The second new volume is Essential Procedures in Pediatrics. Subsequent new topics to be introduced are Soft Tissue Reconstruction, Management of Peripheral Nerve Dysfunction, Advanced Reconstructive Techniques in the Joint, Sports Medicine, and Orthopaedic Oncology and Complex Reconstruction. The full library thus will consist of 16 useful and relevant titles. I am pleased to have accepted the position of series editor, feeling so strongly about the value of this series to educate the orthopaedic surgeon in the full array of expert surgical procedures. The true worth of this endeavor will continue to be measured by the ever-increasing success and critical acceptance of the series. I remain indebted to Dr. Thompson for his inaugural vision and leadership, as well as to the Master Techniques volume editors and numerous contributors who have been true to the series style and vision. As I indicated in the preface to the second edition of The Hip volume, the words of William Mayo are especially relevant to characterize the ultimate goal of this endeavor: “The best interest of the patient is the only interest to be considered.” We are confident that the information in the expanded Master Techniques offers the surgeon an opportunity to realize the patient-centric view of our surgical practice. Bernard F. Morrey, MD

Preface American medicine remains in the midst of a profound and wrenching transformation. The government, the insurance industry, Wall Street, and patients have demanded improved medical care at lower cost. Better medicine (orthopaedics) occurs when doctors practice medicine consistently on the basis of the best scientific evidence available, set up systems to measure performance, analyze results and outcomes, and make this information widely available to patients and the public. Reduced costs have been achieved partly through a wholesale shift to health maintenance organizations, capitation, and managed care. Trauma is a complex problem where initial decisions often dramatically determine the ultimate outcome. Death, deformity, and medicolegal entanglements may follow vacillation and error. When treatment is approached with confidence, planning, and technical skill, the associated mortality rate, preventable complications, permanent damage, and economic loss may be significantly reduced. Uncertainty, inactivity, and inappropriate intervention by physicians are all detrimental to patient care. Certain traditional concepts and fixation techniques need to be abandoned and new approaches learned. This text attempts to address society's mandate to our profession: better orthopaedics at reduced cost. It provides both residents and practitioners with surgical approaches to 46 common but often problematic fractures that, when correctly done, have proven to be safe and effective. It is my hope that the third edition of this textbook remains a valuable fixture in the catalog of literature on fracture management. Donald A. Wiss, M.D.

Acknowledgments The modern scientific world is drowning in information. We have more data than we can possibly use or absorb in our professional lifetimes. There is an avalanche of scientific journals, books, videos, and CME courses competing for our attention. The Internet has allowed anyone with a computer to search the World Wide Web for virtually any topic in any field including orthopaedics and fracture care. So why another textbook about fractures? First, the tremendous success of the two previous editions of this text is strong testimony to the fact that students, house-staff, and practicing orthopaedic surgeons still desire a highly organized, informative, and readable textbook to guide treatment of patients with difficult fractures. Second, our specialty continues to relentlessly change in terms of imaging modalities, reduction techniques, and fixation devices. Thus a third edition was undertaken to fill these perceived needs. My role as Editor is to extract meaning from reams of data, yet remain selectively and self-consciously blind knowing what to ignore, what is extraneous, and what is critical to improve our knowledge base. I could not have devoted 30 years of my life to the study of fractures and nonunions without a passion for this problem and the lessons they offer patient care. I have spent thousands of hours reading, studying, attending courses, reviewing cases, analyzing data, and of course operating, trying to understand fracture management. No sane person would devote such labor, let alone so much of one's life to the pursuit of questions that did not touch one's heart and soul while stimulating the mind. The third edition of Master Techniques in Orthopaedic Surgery: Fractures was 2 years in the making. Anyone undertaking such a work will incur debts of gratitude to a number of people who worked on the project with considerable commitment and little public recognition. I am enormously grateful to my wife Deborah for her unwavering support and love while working on this project often in the evenings and weekends “stealing” our precious family time. In a textbook on surgical techniques, the illustrations and artwork take on primary significance. I am particularly appreciative of the masterful work of the book's medical illustrator, Bernie Kida. His knowledge of musculoskeletal anatomy, beautiful illustrations, and experience provided a crucial visual correlation with the text, often allowing a near operating room experience. I would like to acknowledge and extend my gratitude to Pamela Swan, my Practice coordinator of 20 plus years. She assisted me with the manuscript preparation for virtually every chapter in the book during the inevitable revision process. This book would have been considerably more difficult without her editorial and organizational talents. Special thanks are due to Eileen Wolfberg, the contact person between the authors, myself, and publisher. For the record, Eileen has worked with me on all three editions of the Master Techniques in Orthopaedic Surgery: Fracture text. Her 30 years of experience in the publishing field and previous professional relationships with many of the contributors to the book made for an unbelievably smooth transition. Eileen, I could not have done this book without you! The contributions of Elise Paxson, Robert Hurley, Brian Brown, and the entire publishing team at Wolters-Kluwer were crucial to the success of this project. I am particularly indebted to Robert Hurley who “adjusted the budget” to make this such a beautiful book. Finally, my heartfelt thanks and appreciation to the each of the contributing authors who answered the “bell” once again with yet another academic request for their precious time. Their willingness to share their considerable expertise and to explain the details and nuances of fracture care will unequivocally benefit orthopaedic surgeons everywhere who treat patients with musculoskeletal trauma. Donald A. Wiss, M.D.

Editor

1 Clavicle Fractures: Open Reduction and Internal Fixation Donald A. Wiss

INTRODUCTION Clavicle fractures are common injuries and account for approximately 35% to 40% of fractures in the shoulder region. Most occur in the midshaft, and the majority are treated nonoperatively. Nonsurgical management of this injury was based on historic, retrospective, surgeon, or radiographic studies that equated union with success. These early studies concluded that the residual shoulder deformity was primarily cosmetic and that shoulder and upper limb function were satisfactory. In the past 15 years, there has been a paradigm shift in the evaluation and treatment of clavicle fractures because contemporary studies have reported that nonoperative treatment of widely displaced fractures in adults is associated with persistent anatomical deformity, residual shoulder pain and weakness, and subtle neurologic impairment. Furthermore, recent randomized clinical trials comparing nonoperative with surgical treatment of widely displaced clavicle fractures in adults have shown a 15% rate of nonunion and symptomatic malunion, respectively, in nonoperatively treated patients. These newer studies also used patient-oriented limb-specific outcome measures such as the Constant, Dash, or ASES scores and demonstrated statistically significant improvement in validated patient outcome measures following internal fixation. These studies lend support for the use of internal fixation in selected patients with widely displaced clavicle fractures in adults to decrease the incidence of nonunion and malunion. Surgery has proven to be safe and effective with the most common complication being prominent hardware necessitating removal. Most classification schemes for clavicle fractures divide them into three basic categories. Group I are middle third fractures, Group II are lateral third fractures, and Group III are medial fractures. Neer et al. further subdivided Group II fractures into three distinct subgroups based on associated soft-tissue and ligamentous injuries. In type I injuries, the coracoclavicular ligaments remain intact; in type II injuries, this ligamentous complex is disrupted allowing superior displacement of the lateral fragment; and type III injuries that involve the articular P.2 surface of the acromial-clavicular joint. Several epidemiological studies show that approximately 80% of all clavicle fractures occur in the middle one-third, 15% in the lateral third, and only 5% occur medially. The AO/OTA classification of clavicle fractures is seen in Figure 1.1.

FIGURE 1.1 AO/OTA classification of clavicle fractures.

ANATOMY A thorough knowledge of the osseous, soft-tissue, and neurovascular anatomy of the shoulder is important if surgery is planned. The clavicle is an S-shaped bone and has an anterior convex to concave curvature when viewed from medial to lateral. The lateral end of the clavicle flattens while the medial end remains cylindrical. The midportion is densely cortical with a short and narrow medullary canal particularly in young adults (Fig. 1.2). Laterally, the clavicle is anchored to the scapula by the relatively weak acromioclavicular ligaments and the more robust coracoclavicular ligaments (conoid and trapezoid). Medially, the clavicle articulates with the sternum and is supported by the thick and strong sternoclavicular, costoclavicular, and interclavicular ligaments. Although the clavicle is predominately a subcutaneous structure, the deltoid muscle arises from the anterior-inferior portion of the lateral clavicle while the trapezius muscle arises posterior and superior in its midportion. Several other upper limb muscles take all or part of their origin from the clavicle including the subclavius, sternocleidomastoid, and pectoralis major (Fig. 1.3). From a mechanical point of view, the clavicle functions as a strut between the shoulder girdle and the thorax, and it suspends the upper limb from the chest wall. The clavicle also provides significant protection to the subclavian vessels and the brachial plexus that lie in close proximity (Fig. 1.4).

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY Most clavicle fractures in adults are managed nonoperatively. Nonsurgical treatment is indicated when fracture displacement is 45 degrees as seen on a scapular Y radiograph of the shoulder (Fig. 2.6A,B) Lateral border offset >15 mm plus angular deformity >30 degrees Glenopolar angle (GPA) 10 mm (Fig. 2.8A,B) Complete acromioclavicular dislocation and scapula fracture displaced >10 mm

We also advocate operative management of displaced scapular fractures in patients with complex ipsilateral upper extremity injuries particularly in younger highly active patients, when two or more of the above criteria are met (Fig. 2.9). Contraindications to scapula surgery include extra-articular scapular fractures that are displaced 45 degrees, which we still follow today. Isolated fractures of the greater tuberosity should be reduced and stabilized when displacement is >5 mm in any direction. Not all proximal humeral fractures that require surgery are amenable to internal fixation. Strong indications for hemiarthroplasty include head-splitting fractures (with the exception of some young patients with healthy bone) anatomic neck fractures, and displaced three- and four-part fractures in patients with either comminution or osteoporosis that would not support internal fixation. Preexisting chronic rotator cuff deficiency with arthropathy is better treated nonoperatively or with shoulder arthroplasty. P.49

PREOPERATIVE PLANNING History and Physical Examination Seriously injured patients should undergo initial evaluation according to Advanced Trauma Life Support (ATLS) protocols to ensure a thorough evaluation and to prevent missed injuries. In the multiply injured patient with a shoulder fracture, injuries to the head, neck, chest wall, and upper extremity commonly occur. Proximal humeral fractures that occur in elderly patients following lower energy falls may be associated with injuries to the head, face, or wrist. When possible, a careful history may reveal substantial medical comorbidities such as hypertension, coronary artery disease, or diabetes. The patient's medication record should be scrutinized with particular reference to anticoagulation medication. Other important factors include hand dominance, occupation, and living status, which may play an important role in decision making. All patients should have a complete physical examination. The extremity should be examined for swelling, ecchymosis, peripheral pulses, and neurologic impairment. Any questions regarding the vascular integrity warrant further evaluation, with an ankle-brachial index, Doppler evaluation, or angiography. If any abnormality is identified, vascular surgical consultation should be obtained. A thorough neurologic examination of the entire upper extremity must be performed and documented. Evaluation of the axillary nerve can be difficult in a swollen painful shoulder, but should be tested by asking the patient to contract the deltoid muscle whenever possible. Range of motion of the shoulder is typically limited due to pain. It is also important to evaluate the elbow, forearm, wrist, and hand performed in order to avoid missing a more distal injury.

Radiographic Evaluation The proximal humerus consists of four parts: The humeral head, the greater and lesser tuberosities, and the humeral shaft (Fig. 3.2). In order to optimally visualize these four parts, all patients with a shoulder injury should have an anteroposterior view, a transscapular lateral (“Y”) view, and an axillary lateral view (Fig. 3.3A-C). The axillary lateral, while challenging to obtain in the trauma setting, often provides crucial information. It is frequently the best view to rule out a coronal plane head-splitting fracture, a glenoid rim fracture, as well as a glenohumeral joint subluxation or dislocation. It is important to remember that if the x-ray beam is not orthogonal to the axis of the humeral shaft (which is often the case), then any measurement of fracture angulation will be exaggerated. Thus, the transscapular lateral radiograph provides a better view for accurately measuring fracture angulation. In patients with complex fracture patterns, a computed tomographic (CT) scan can be helpful to evaluate fragment size and displacement and can reveal nondisplaced fracture lines (Fig. 3.4A,B). The thickness of the humeral head seen on the CT scan should be carefully assessed when considering internal fixation. If the head is too small or thin, stable fixation may not be achieved and cut out of the screws is more likely. In addition to the axial, sagittal, and coronal P.50 reconstructions, 3D imaging provides detailed topographic views which may allow a clearer appreciation of the fracture geometry (Fig. 3.4C). In some cases, the scapula can be “subtracted” giving even more information about the fracture morphology. Based on the physical exam, x-rays of the cervical spine, clavicle, ribs, elbow, or forearm may be indicated.

FIGURE 3.2 The pathoanatomy of proximal humeral fractures.

FIGURE 3.3 A. Anterior-posterior view. B. Trans-scapula lateral view. C. Axillary lateral view.

Timing of Surgery The majority of displaced proximal humerus fractures can be managed in a semielective fashion without compromising the quality of the outcome. A patient with an isolated closed, proximal humeral fracture seen in the emergency room can be discharged to home or to a suitable location if the pain is controlled and their social circumstances permit. These patients are seen in the office or clinic several days later and scheduled for surgery if indicated. On the other hand, if the pain is poorly controlled, the social circumstances are not optimal, or the patient has other injuries, patients are typically admitted to the hospital for earlier surgery. Fortunately, there are relatively few indications for emergent surgery. However, an open fracture, a fracture with a vascular injury, an irreducible fracture with impending skin compromise, or an irreducible fracture dislocation require immediate intervention. In these cases, surgery should be performed as soon as an operating room becomes available and a surgical team can be assembled. P.51

FIGURE 3.4 A. The CT scan allows determination of the “thickness” of the humeral head available for fixation. B. Axial CT cut of a valgus impacted fracture demonstrates displacement of the greater and lesser tuberosities. C. A 3D CT image of a complex proximal humerus fracture.

Surgical Tactic The most important step in preoperative planning is for the surgeon to carefully evaluate the x-rays and CT scan and answer two questions. First, does this fracture require surgery, and second, what is the optimal implant if surgery is required. Despite good preoperative planning, there is a small group of patients where the final decision between internal fixation and arthroplasty cannot be made until the time of surgery. If any doubt exists, the patient should be consented for both types of surgery, and the equipment and implants must be in the operating room at the beginning of the case. Surgery can be performed with the patient in either the beach chair position or supine on a flat-top radiolucent table. There are advantages and disadvantages with each technique. In the supine position, the patient should be P.52

positioned at the edge of the table with the arm supported on a hand board or a Mayo stand to allow shoulder abduction. Properly positioned, this setup will not interfere with the use of the C-arm. The patient's head is supported on a gel “donut” or a rolled-up stockinet, and the patient's eyes should be protected during the case (Fig. 3.5).

FIGURE 3.5 Intraoperative setup for open reduction and internal fixation of a proximal humerus fracture with the patient in the supine position. The patient's head is supported on a gel “donut” and the patient's eyes are protected with plastic shields. Prior to prepping and draping, the C-arm should be moved into position to ensure high quality anteroposterior and axillary lateral images can be obtained (Fig. 3.6A-D). In most operating rooms, this is easiest if the surgical table is rotated 90 degrees. I prefer the C-arm to come in from the cranial side, slightly oblique to allow visualization of the entire humeral head and the edge of the glenoid when an axillary lateral view is obtained. It is wise to rehearse these moves so that the radiology technician can change from an AP to an axillary lateral views easily without the need to move the arm or shoulder. The spot for the C-arm is marked with tape on the floor in order to re-create the intraoperative position of the fluoroscopy unit during surgery (Fig. 3.7).

Surgery Surgery is most commonly performed under general anesthesia, which allows optimum control of the patient's blood pressure and muscle paralysis. Regional nerve blocks are most useful for postoperative pain control. A helpful technique is to position and tape the endotracheal tube on the side opposite the fracture. Maintaining the mean arterial pressure close to 70 mm Hg helps minimize bleeding, and muscle paralysis or relaxation is helpful to lessen the forces required for muscle retraction and fracture reduction. A cepholsoporin antibiotic is given for P.53 prophylaxis within 1 hour of surgery. A Foley catheter, arterial line, central venous pressure (CVP) monitoring, or Swan-Ganz catheters are used when the patient's medical comorbidities or physiologic status dictates.

FIGURE 3.6 A. The patient is positioned with the involved shoulder at the edge of the table and the arm supported in approximately 60 degrees of abduction with a Mayo stand. B. An AP fluoroscopic x-ray is obtained.

FIGURE 3.6 (Continued) C. The C-arm is rotated to obtain an axillary lateral view with abduction and mild traction. D. An axillary lateral must show the entire head and the glenoid. The entire upper extremity, shoulder, chest wall, and neck are prepped and draped in the usual orthopedic fashion. A surgical time-out is called, and all members of the surgical, nursing, and anesthesia teams must agree on the patient's name, medical record number, and correct side and site of surgery.

Techniques—Isolated Greater Tuberosity Fractures The patient is positioned, prepped, and draped as outlined above. For isolated greater tuberosity fractures, I prefer a deltoid-splitting approach rather than a deltopectoral incision. The challenge is to reduce and stabilize the fracture through a small incision that must not extend more than 5 cm distal to the acromion to avoid injury to the axillary nerve. For most greater tuberosity fractures, I do not identify the axillary nerve rather proceed in a stepwise fashion to reduce and stabilize the greater tuberosity through the deltoid split. The skin incision, and the deltoid muscle split, start proximally at the anterior-lateral edge of the acromion and

extend straight distally for 5 cm. The muscle is split through a relatively avascular plane in the deltoid raphe. A loose suture can be placed through the deltoid muscle fibers 5 cm distal to the acromion to prevent further muscle separation with injury to the axillary nerve.

FIGURE 3.7 The position of the C-arm base is marked on the floor with tape. P.54 Deep to the muscle is the hemorrhagic subdeltoid bursa, which should be evacuated and excised to improve visualization. With internal and external rotation of the shoulder, the fracture lines will be appreciated. The fracture should be mobilized to expose the undersurface of the greater tuberosity and the defect in the proximal humerus. With the shoulder in internal rotation, a no. 2 or no. 5 heavy nonabsorbable suture is passed twice through the supraspinatus tendon at its insertion on the tuberosity capturing bone and tendon. I prefer a no. 5 ethibond suture with a large cutting needle, which can be gradually worked through the hard cortical bone by grasping the needle close to its point and rotating it back and forth like the tip of an awl. In younger patients with hard bone, a small drill bit can be utilized. Due to the posterior and proximal displacement of the greater tuberosity by the retracted supraspinatus and infraspinatus muscles, the first suture is often placed too far anteriorly. If this is the case, the first suture is used to pull the greater tuberosity anteriorly and distally in order to place two additional sutures in a better position. After this, the first suture can be removed. A curette is used to remove clotted blood and debris from the cancellous underside of the greater tuberosity. The greater tuberosity sutures are gradually pulled to reduce the greater tuberosity into the defect in the proximal humerus. Two drill holes are made approximately 1 cm anterior and distal to the defect along the vector of the sutures used to reduce the greater tuberosity. Following this, the needle end of each suture is passed from within the fracture site out through the drill hole. The sutures are pulled tight is placed on the sutures to remove slack, and the greater tuberosity is held with digital pressure or with a blunt probe and provisionally fixed with one or two K-wires. Ideally, the guide wires for 3.5 or 4.0 mm partially threaded cannulated screws are used, and passed obliquely to engage the medial cortex of the humeral shaft followed by an appropriate length screw (Fig. 3.8A-D). It should be emphasized that in the soft bone of the proximal humerus, both internal fixation and suture augmentation are necessary to prevent early fixation pull-out. The screw(s) ensure anatomic reduction of the tuberosity, but are not strong enough alone to allow physiologic shoulder motion. The sutures provide a more durable fixation of the greater tuberosity and resist tensile forces better. However, suture fixation alone can result in a malunion of the tuberosity if positioned too distally, which can compromise shoulder strength and motion. On

the other hand, retraction of the cuff with posterior and proximal displacement of the tuberosity is also a risk when suture repair is performed alone. After placing one or two partially threaded screws across the fracture and into the medial cortex, the suture ends are tightened and tied with a smaller, absorbable suture. In order to prevent loosening of the knot, the two ends of suture above the knot can be tied together. The fracture reduction and screw position is confirmed with fluoroscopy and stability is checked with gentle shoulder motion. Finally, the rotator cuff is inspected for any sign of tear or deficiency. If a supraspinatus or infraspinatus tear is present, it is carefully repaired with nonabsorbable sutures. The deltoid fascia is closed with absorbable suture, the subcutaneous tissues are approximated, and staples or sutures are placed in the skin. After application of a sterile dressing, the arm is placed in a shoulder immobilizer.

Techniques—ORIF of Two- to Four-Part Fractures in Adults Virtually all displaced two-, three-, and four-part fractures of the proximal humerus that require suture ends are approached through a deltopectoral incision. The incision starts just distal to the coracoid process and extends 12 to 17 cm toward the lateral side of the biceps tendon depending on how much exposure is needed. The cephalic vein is identified, protected, and retracted. The deltopectoral interval is developed digitally, down to the clavipectoral fascia, which is then incised as far proximally as its confluence with the coracoacromial ligament. The space between the lateral aspect of the proximal humerus and the deltoid is developed by careful blunt dissection, and a Hohman retractor is placed between the two. Abduction of the shoulder to 45 degrees or more facilitates mobilization of the deltoid. Approximately one-third of the anterior deltoid insertion is released on the shaft to improve exposure and space for the plate. In three- and four-part fractures, the greater and lesser tuberosities are identified and tagged with two nonabsorbable sutures passed through each of the tuberosities (i.e., total four sutures) where the cuff inserts into the bone. As described in the description of isolated greater tuberosity fracture repair, the first suture in the greater tuberosity is often used for traction that allows optimal placement of one or two additional sutures for secure fixation. After the tuberosities are secured by the sutures, the sutures can be used to manipulate the tuberosities into a reduced position. Attention is now directed to the head fragment. In the uncommon event that the head fragment is dislocated, it can be reduced using a thin periosteal elevator to lift the head over the edge of the glenoid. Alternatively, one or two 2.0-mm terminally threaded K-wires can be drilled into the head fragment and used as joy sticks to help manipulate and reduce the head fragment. In some cases, the head is impacted on the shaft. In most patients, it should be disimpacted to allow reduction of the tuberosities using an osteotome or a thin periosteal elevator. The fracture line between the impacted humeral head and the metaphysis can usually be recognized visually when the split between the greater and lesser tuberosities is separated with an instrument or lamina spreader. It is important to preserve bone stock on the head fragment by gradually freeing it around the periphery before attempting to reduce it (Fig. 3.9). In young patients with dense bone and large tuberosity fragments, the stability of the humeral head usually improves after reduction of the tuberosities. Once the reduction has been verified fluoroscopically, the tuberosities and head fragment are provisionally stabilized with K-wires, which do not interfere with subsequent plate placement. P.55

FIGURE 3.8 A. AP radiographic showing a greater tuberosity fracture dislocation. B. Postreduction radiograph demonstrates reduction of the glenohumeral joint with persistent displacement of the greater tuberosity. C. AP xrays show anatomic reduction of the tuberosity following internal fixation and tension band suture augmentation. D. Axillary lateral radiograph. P.56

FIGURE 3.9 Reduction of an impacted humeral head fragment. By placing an instrument in the fracture line between the greater and lesser tuberosities, the surgeon first develops a plane between the head and the tuberosities, then gently lifts the head from the metaphysis. P.57

FIGURE 3.10 A. The humeral head and shaft are reduced with the aid of a long thin periosteal elevator. The elevator is used to lever the shaft posteriorly and laterally into a reduced position relative to the head. B. Intraoperative fluoroscopic view shows the position of the elevator. Unfortunately, most patients with displaced proximal humeral fractures are elderly and have soft osteoporotic bone, which invariably has some component of crushing and comminution. In these patients, the ability to maintain an adequate reduction of the humeral head by provisional fixation of the tuberosities alone is very limited. In these cases, the greater tuberosity fragment should be carefully evaluated. If it is small or multifragmentary, its reduction and stabilization should be postponed until after the head and shaft are reduced and stabilized. On the other hand, if the greater tuberosity fragment is large, it should be reduced and provisionally stabilized to the head using multiple K-wires outside the plane of the proposed plate. If the lesser tuberosity is fractured and unstable, it is also reduced and held with K-wires. The humeral shaft, which is typically displaced anteriorly and medially, is then reduced to the head with traction and the aid of a periosteal elevator (Fig. 3.10A,B). The shaft is provisionally stabilized to the head with one or two oblique K-wires directed from P.58 anterior-lateral-distal to posterior-medial-proximal (Fig. 3.11A). If the K-wires are able to hold the reduction, fluoroscopy is used to assess the reduction prior to plate placement. The plate is positioned directly laterally so that the anterior edge of the plate is located lateral to the long head of the biceps tendon (Fig. 3.11B).

FIGURE 3.11 A. Intraoperative photo shows heavy sutures placed in the greater and less tuberosities and the head and shaft reduced and held with K-wires. B. The plate is placed on the lateral aspect of the proximal humerus and fixed to the humerus under fluoroscopic control. The tuberosity sutures are tied to the plate. Unfortunately, due to comminution and poor bone quality, K-wires and reduction clamps alone will not usually hold the reduction in the poor bone of the humeral head. In this case, the greater and lesser tuberosities are reduced to the humeral head, and the plate is fixed to the proximal fragment with K-wires through the perimeter of the plate. Fluoroscopy is used to verify plate position and the overall reduction. The plate is reduced to the shaft, thereby indirectly reducing the shaft to the head. Care must be taken to ensure that the superior aspect of the greater tuberosity will end up 8 to 10 mm distal to the superior edge of the humeral head after final plate positioning. With the plate pushed firmly against the bone, two locking screws are placed through the most proximal holes into the humeral head. Screw position is checked on AP and lateral fluoroscopy. One or two additional locking screws are placed more inferiorly into the humeral head, and the position is again confirmed fluoroscopically. The next step is to fix the plate to the shaft. The plate is held against the shaft with direct pressure, and the shaft is pushed proximally toward the head in an attempt to maximize bony contact and create a load-sharing construct. There is a tendency for the shaft to displace anteromedially by the pull of the pectoralis major muscle. This deformity should be corrected before the plate is fixed to the shaft. Typically, one or two nonlocking screws are placed in the distal fragment to secure the plate against the bone with the remaining holes filled with 3.5-mm locking screws. Another scenario commonly encountered is the challenge of restoring the correct angular and rotational relationships between the humeral head, shaft, and the glenoid. This generally occurs when there is significant comminution of surgical neck allowing the head to collapse or rotate into varus or retroversion. The metaphyseal defect will not support the head fragment in its normal alignment or version. This usually requires placement of bone graft material (allograft, autograft, or substitute) into the metaphyseal void to buttress the head and provide mechanical support for fracture reduction. Another alternative is to reduce and temporarily pin the humeral head into the glenoid. If the greater tuberosity fragment is large (which is usually not the case in this scenario), it is reduced to the head using traction sutures, and a plate is positioned laterally, held with K-wires, checked on fluoroscopy, and fixed to the head and greater tuberosity with two proximal locking screws as described previously. After confirmation of an adequate reduction and plate position fluoroscopically, two additional locking screws are placed in the head, and the plate is reduced and fixed to the shaft. If the greater tuberosity fragment is small or multifragmentary, the plate is positioned and provisionally secured to the head fragment with K-wires. Reduction and plate position are verified fluoroscopically, as poorly placed screws in the humeral head that have to be removed and replaced will further compromise fixation in the osteopenic humeral head. These are typically

the fractures with thin head fragments for which arthroplasty is often a treatment option. The head and shaft are reduced and stabilized with screws. Locking screws are placed in any of the remaining holes that will provide purchase into bone. No screw tip should be closer than 5 mm from articular surface. Next, the sutures placed in the tuberosities are used to reduce them to the humeral head, and they are secured to the plate. The sutures can be passed through one or more holes along the periphery of the plate or even as a cerclage around the entire plate. Whatever technique is chosen, it is crucial that the tuberosities are anatomically reduced and securely fixed. The sutures should not be passed through locking holes in the plate if possible, as the threaded edge of the hole may abrade or transect the suture. Some surgeons prefer to pass the sutures through the holes in the plate prior to positioning of the plate, which makes passage of the sutures easier. The disadvantage with this technique is keeping the sutures out of the way during the remainder of the procedure, and the preselected position of the sutures in the plate may not be at the ideal vector for tuberosity reduction or fixation. Following internal fixation, the rotator cuff should be evaluated, and any tears should be repaired with nonabsorbable suture. The wounds are copiously irrigated and meticulous hemostasis obtained with cautery. The wound is closed in layers.

Postoperative Care The surgical incision is inspected at 48 hours prior to hospital discharge When the wound is clean and dry, pendulum exercises and gentle active range of shoulder motion is initiated. Patients are instructed in six exercises they can perform at home independently: 1. Clockwise shoulder rotation—performed while leaning forward, starting initially with small rotations, and gradually increasing the size of rotation as comfort improves. 2. 2. Counterclockwise shoulder rotation—as above, different direction of rotation. 3. Tight fist—the patient makes a tight fist, and then fully extends all fingers. 4. Thumb to shoulder—the patient flexes the elbow in an attempt to touch the anterior shoulder with the thumb, and then gradually extends the elbow as far as possible, then repeats. 5. Front-assisted lift—the patient uses a 1 inch dia. wooden dowel (broomstick), and, grasping it with both hands spaced 6 inches apart, slowly lifts it forward with the contralateral uninjured arm, while the injured arm follows with minimal active contraction of the deltoid. The arm is lifted (shoulder flexed) to the point of mild discomfort, at which point the arm is gently lowered to the resting position. 6. Side-assisted lift—the same dowel is used, the hands are placed a shoulder's width apart, and the uninjured arm pushes the dowel to the opposite side, and the contralateral shoulder abducts with minimal active contracture (i.e., active-assisted). P.59

FIGURE 3.12 Range of shoulder motion in a 30-year-old male 5 months following internal fixation of a displaced proximal humerus fracture. The patient performs 10 repetitions of each exercise and does these exercises three times per day. When not performing exercises or bathing/showering, the patient protects his arm/shoulder in a sling or shoulder immobilizer. Patients are seen for follow-up at 2 weeks and at 6 weeks where AP and axially lateral radiographs of the shoulder are obtained to confirm fracture reduction and to assess fracture healing. At 6 weeks, patients begin independent range of motion exercises with gravity resistance. If at 6 weeks, the patient is unable to forward flex the shoulder to 90 degrees independently, referral to a physical therapist is recommended. At 3 months, the fracture should be healed, and the patient may perform passive stretching and resistive exercises without restriction (Fig. 3.12). Once good shoulder motion has been restored, upper limb strengthening using progressive weights or bands is instituted. Independent passive stretching can be performed by “walking the fingers up the wall” anteriorly and at the side as well as external rotation using the dowel for terminal stretch. If motion is not adequate, the patient should be referred to a physical therapist for assistance with the passive stretching and resistive strengthening exercises.

Complications The most common problem after a proximal humerus fracture is shoulder stiffness (Fig. 3.13). It is unusual for a patient to regain normal shoulder motion after internal fixation of a displaced fracture. Fortunately,

most patients are able to perform activities of daily living with mild or moderate shoulder stiffness. In order to minimize the risk of more significant shoulder stiffness, the surgeon must achieve stable fracture fixation including the fixation of the tuberosities and initiate early motion. If the patient is unable to perform independent exercises, or is not making progress independently, a physical therapist should be involved in the rehabilitation

Screw cut-out or penetration through the subchondral bone into the glenohumeral joint occurs most commonly in elderly patients, but it occurs in younger patients as well (Fig. 3.14). Methods to minimize this risk are (a) placing screws into the subchondral bone without having drilled the entire screw path, (b) checking the position of the screw tips with multiple fluoroscopic projections, to ensure that the screw tips are at least 5 mm from the subchondral bone, and (c) manually pushing the shaft proximally prior to plate fixation in order to increase bone contact and lessen the tendency for the humeral head to collapse. Some authors recommend the use of a custom fit fibular allograft to mechanically support the humeral head. Many forms of fixation failure can occur after open reduction and internal fixation of proximal humerus fractures. Displacement of the tuberosities can occur due to failure of the suture or as a result of the suture cutting through the tuberosity and cuff (Fig. 3.15). Proper positioning and placement of the suture at the insertion P.60 of the rotator cuff, use of a heavy suture, passage of the suture through smooth holes in the plate (i.e., avoiding locking screw holes), and securing the suture with detailed attention to knot tying will minimize this risk. Fixation failure by plate or screw breakage usually occurs as a result of fracture nonunion, but may also occur if the patient is not compliant with postoperative activity restrictions.

FIGURE 3.13 Seven months following internal fixation of a three-part proximal humerus fracture, this 59-

year-old female still has significant loss of forward elevation and shoulder abduction.

FIGURE 3.14 A 61-year-old male referred to our institution for treatment of failed fixation and screw penetration into the joint. P.61

FIGURE 3.15 Loss of reduction of the greater tuberosity following internal fixation.

Aseptic necrosis may occur after a proximal humerus fracture (Fig. 3.16A,B). In the past, the fear of its occurrence led many surgeons away from open reduction and internal fixation toward nonoperative treatment or arthroplasty for these fractures. There is increasing recognition that when aseptic necrosis occurs, it is not always associated with a poor result. In many cases, patchy aseptic necrosis occurs without head collapse and relatively few symptoms. However, if aseptic necrosis with head collapse occurs and the patient is symptomatic, they may benefit from shoulder arthroplasty. In order to reduce the risk of aseptic necrosis, unnecessary soft-tissue stripping should be avoided. Intraoperative manipulation and reduction of the head and shaft should be performed “from within” the fracture, taking care to use: (a) long periosteal elevators to lever the shaft and head into position; (b) heavy sutures to assist with fracture reduction without elevation of soft tissues; and (c) K-wires for provisional fixation whenever possible.

Results/Outcomes Most studies report that 70% to 75% of patients obtain satisfactory outcomes following locked plating of proximal

humeral fractures. The reported 1-year mortality rate is elevated although it returns to the age-expected level after the first year. Although there is a common belief that the results of internal fixation have improved since the advent of locked plate fixation, this has not been clearly established. There are P.62 few randomized controlled trials comparing locked plating with nonoperative treatment or other treatment modalities.

FIGURE 3.16 AP (A) and lateral (B) radiographs of a patient with avascular necrosis and collapse of the humeral head following internal fixation of a proximal humerus fracture. The use of locked plates to treat proximal humerus fractures has significantly increased in number over the past decade. However, this is a challenging surgical procedure, fraught with potential complications, and the results can be less than satisfactory. Proper and thorough evaluation of the patient and the fracture, preoperative preparation, careful technique, and realistic expectations of surgical results remain essential in order to achieve good results. Nevertheless, it is an important tool in the armamentarium of the fracture surgeon.

RECOMMENDED READING Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007;21:676-681. Badman BL, Mighell M. Fixed-angle locked plating of two-, three-, and four-part proximal humerus fractures. J Am Acad Orthop Surg 2008;16(5):294-302. Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br 1997;79:857-865. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14(3):183-190.

Fankhauser F, Schippinger G, Weber K, et al. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop 2005;430:176-181. Gardner MJ, Boraiah S, Helfet DL, et al. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22(3):195-200. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185-191. Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg 2004;12(4):205-212. Hernigou P, Germany W. Unrecognized shoulder joint penetration during fixation of proximal fractures of the humerus. Acta Orthop Scand 2002;72(2):140-143. Herscovici D, Saunders DT, Johnson MP. Percutaneous fixation of proximal humeral fractures. Clin Orthop 2000;375: 97-104. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427-433. Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 1992;74:505-515. Jakob RP, Miniaci A, Anson P, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Am 1991;73:295-298. Kannus P, Palvanen M, Niemi S. Increasing number and incidence of osteoporotic fractures of the proximal humerus in elderly people. Br Med J 1996;313:1051-1052. P.63 Koval KJ, Gallagher MA, Marsicano JG, et al. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207. Meier RA, Messmer P, Regazzoni P, et al. Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma 2006;20:253-260. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089. Olsson C, Petersson CJ. Clinical importance of comorbidity in patients with a proximal humerus fracture. Clin Orthop Relat Res 2006;442:93-99. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87-92.

Rietveld AB, Daanen HA, Rozing PM, et al. The lever arm in glenohumeral abduction after hemiarthroplasty. J Bone Joint Surg Br 1988;70:561-565. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am 2003;85:1647-1655. Rowkles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus: an anatomic study. J Bone Joint Surg Am 2001;83(11):1695-1699. Soete PJ, Clayson PE, Costenoble VH. Transitory percutaneous pinning in fractures of the proximal humerus. J Shoulder Elbow Surg 1999;8:569-573. Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg 1984;100:249-259. Sudkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009;91:1320-1328. Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84:1919-1925. Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury 1998;29: 349-352.

4 Proximal Humerus Fractures: Hemiarthroplasty William H. Paterson Sumant G. Krishnan

INTRODUCTION Proximal humeral fractures are common injuries representing 4% to 5% of all fractures in clinical practice, but they account for nearly half of all shoulder girdle injuries (1). After the hip and distal radius, fractures of the proximal humerus are the third most common fracture in the elderly, with a strong female predominance (2). In this age group, mechanical ground-level falls are the most common cause of fragility fractures of proximal humerus, and there is a strong correlation with the presence of osteoporosis. Early evaluation and management of these injuries is important in optimizing treatment and functional outcomes. There are a bewildering number of treatment alternatives for managing proximal humeral fractures. Nevertheless, there is universal agreement that nondisplaced and minimally displaced fractures are best managed nonoperatively. Percutaneous fixation, plate osteosynthesis, intramedullary nailing, and arthroplasty are the most common methods of treatment for displaced and unstable fractures in adults. A recent Cochrane database review of interventions for treating proximal humeral fractures in adults showed that no single method of treatment was preferable (3). This may be due to the limited number of patients stratified to individual techniques as well as the wide variety of injury patterns and treatments. Arthroplasty is most commonly advocated for the primary treatment of displaced three- and four-part fractures in osteoporotic bone in the elderly. However, it is technically demanding, and numerous studies have documented unpredictable outcomes (4). Notwithstanding, recent advances in surgical technique and prosthetic designs have led to more successful outcomes (5, 6, 7, 8 and 9). Improved outcomes have been documented when soft-tissue dissection is minimized and there is restoration of the “gothic arch” and anatomic reconstruction of the tuberosities (5).

INDICATIONS AND CONTRAINDICATIONS Age, bone quality, fracture pattern, and timing of surgery are important factors that influence the surgical procedure, implant selection, and the functional and radiographic outcome. Utilizing these specific variables, we have devised an “evidence-based” treatment algorithm (Table 4.1) (10).

Age One of the most important considerations in selecting a method of treatment in proximal humeral fractures is the chronological and physiologic age of the patient. Most female patients when they reach the sixth decade of life have some degree of osteoporosis, and many have impaired neuromuscular control as well. These factors may compromise osteosynthesis by increasing the risk of fixation failure, postoperative fracture displacement, nonunion, and/or avascular necrosis (11). Fractures in patients aged 65 years or less appear to be more amenable to humeral head preservation techniques. P.66

TABLE 4.1 Factors Affecting Treatment Choice

Age

Is the patient greater or less than 60 years old?

Bone quality

Will the bone support fixation?

Fracture pattern

Is the humeral head viable? Is the fracture pattern stable?

Timing of surgery

Is the injury acute (4 wk)?

Bone Quality Similar to age, a patient's bone quality can affect the success of humeral head preserving fixation techniques. Despite improved fixation strength in osteoporotic bone afforded by locking plate technology, complications continue to be higher in these patients after open reduction and internal fixation (12).

Fracture Pattern Hertel et al. (13) investigating perfusion of the humeral head after an intracapsular fracture was able to prospectively correlate radiographic fracture morphology with intraoperative humeral head vascularity. Radiographic criteria predictive of humeral head ischemia included a posteromedial metaphyseal fragment extending 2 mm. When these two preoperative radiographic findings were present in conjunction with an anatomic neck fracture, there was a 97% positive predictive value for humeral head ischemia. Even when the humeral head is vascular and amenable to preservation, the ability to maintain adequate fracture stability is necessary for successful fracture healing. The medial calcar of the humerus must be intact or restored at the time of surgery for a “stable” reduction. Comminution in this region increases the risk of a varus fracture reduction.

Timing of Surgery The delay between injury and definitive surgery is the final variable that may affect functional outcomes following surgical management of proximal humeral fractures. For example, a fracture amenable to percutaneous fixation techniques may become impossible to reduce closed and pin percutaneously after 7 to 10 days or when early callus forms that prevents closed reduction. It is also clear that the outcomes following early arthroplasty for proximal humeral fractures are significantly improved compared to arthroplasty more than 4 weeks after injury (14). We believe that optimal surgical timing for shoulder fracture arthroplasty is 6 to 14 days after injury to allow for partial resolution of the soft-tissue swelling (assuming no acute neurovascular injury or other situation necessitating an earlier intervention) (15). Very rarely, glenohumeral arthritis may preexist in a patient with a displaced proximal humerus fracture. If the degenerative changes are mild or moderate, conventional hemiarthroplasty is still indicated. If end-stage glenoid arthrosis is present, a total shoulder arthroplasty with insertion of a glenoid component should be strongly considered. As experience with reverse shoulder arthroplasty increases, the indications for utilizing this prosthesis in the initial treatment of proximal humerus fractures have become better defined. We typically use a reversed prosthesis when the patient is older than 75 years, when the greater or lesser tuberosity cannot be reconstructed, or the patient has ipsilateral lower extremity fractures that require crutches or a walker. In the infrequent situation in which a patient with a proximal humerus fracture has a concomitant irreparable rotator cuff tear or cuff tear arthropathy, a reversed prosthesis should be considered. Contraindications to shoulder fracture arthroplasty are typically related to severe medical comorbidities that

prevent surgical management in general. Nonoperative treatment may be a better treatment alternative for geriatric patients with complex medical comorbidities, extremely low functional demands, and minimal pain at the time of presentation. Other contraindications for arthroplasty are a history of infection, severe contracture of the shoulder girdle, open epiphysis, or fractures amenable to other fixation techniques.

PREOPERATIVE PLANNING Clinical Evaluation Marked edema and ecchymosis, which can extend down the arm and into the chest, are often seen in patients with proximal humeral fractures. Many elderly patients with these injuries are on anticoagulation therapy. Evaluation for concomitant injuries or associated medical conditions is important in these elderly patients. A cardiac or neurologic event may be the predisposing cause of the fall. Most of these patients require a careful medical evaluation by an appropriate specialist particularly if surgery is contemplated. P.67 Subtle neurologic injury occurs in a large number of patients with proximal humeral fractures (15). Utilizing electromyography, Visser et al. (15) documented neuropraxia of the axillary and/or suprascapular nerves in 50% of patients. Clinical appreciation and documentation of this finding is important for both prognostic evaluation and preoperative counseling, as eventual recovery may take up to 12 to 18 months after surgery (6). These may be very difficult to identify clinically in a patient with a painful swollen shoulder following fracture.

Radiographic Evaluation Radiographs should include anteroposterior, scapular “Y,” and/or axillary views. As part of our protocol, we obtain full-length scaled radiographs of both humeri using a ruler of defined length for preoperative planning (Fig. 4.1). If plain radiographs do not allow a clear understanding of the fracture morphology, a computed tomography scan with three-dimensional reconstructions may be a helpful. Neer's classic four-part description of proximal humerus fractures has endured by virtue of its simplicity. Despite this, interobserver reliability and intraobserver reproducibility have been reported to be only poor to fair (16). A “comprehensive binary” description of these fractures based upon Codman's original concept of fracture planes has also been described (Fig. 4.2) (13). In this classification, there are 12 possible fracture patterns: 6 patterns resulting in 2 fracture fragments, 5 patterns resulting in 3 fracture fragments, and 1 pattern resulting in 4 fracture fragments. In the original study by Hertel et al., ischemia was observed only in types 2, 7, 8, 9, 10, and 12. This system has demonstrated improved interobserver reliability as well as better intraobserver reproducibility.

Restoring the “Gothic Arch” Anatomic restoration of humeral height, correct prosthetic version, and tuberosity reconstruction play critical roles in determining functional outcome (5). Many studies have shown that poor functional results correlate closely with prosthesis and/or tuberosity malposition. Boileau et al. (4) described the “unhappy triad,” in which the prosthesis is cemented “proud” and retroverted and the greater tuberosity has been positioned too low. This P.68 combination is associated with persistent pain and stiffness and poor function. Careful attention to the restoration of the proximal humeral anatomy is crucial in obtaining good results following shoulder fracture arthroplasty.

FIGURE 4.1 A scaled ruler is placed on the patient's arm during the radiograph to calculate magnification.

FIGURE 4.2 Hertel's binary (LEGO) proximal humerus fracture description system. HH, humeral head; GT, greater tuberosity; LT, lesser tuberosity. (Modified from Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427-433.) We use the term “gothic arch” to describe the architectural anatomy of the proximal shoulder girdle as seen on

an anteroposterior radiograph (5). The arch is formed by tracing a line along the medial border of the proximal humeral calcar to the articular surface and joining this with a line along the lateral border of the scapula to the articular surface. The result is a classical “vaulted” or “gothic” arch shape seen in medieval period architecture (Fig. 4.3). This simple concept allows for a highly reproducible surgical technique for restoration of proper humeral height, which improves the potential for anatomic tuberosity reconstruction. Using the scaled preoperative radiographs, we first measure the entire length of the intact contralateral humerus from a line perpendicular to the medial epicondyle to the top of the humeral head (N) (Fig. 4.4A). On the injured side, the length of the fractured humerus (F) (Fig. 4.4B) is determined by measuring from a line perpendicular to the medial epicondyle to the fracture line at the humeral metadiaphysis. Humeral height for the prosthesis that must be restored (H) is calculated by subtracting F from N (Fig. 4.4C). In addition, we measure the length of the greater tuberosity fragment (G) (Fig. 4.4D), which should be within 5 mm of H to ensure that humeral prosthetic height will allow for anatomic tuberosity reconstruction. These steps are vital and cannot be overlooked. Fulllength scaled radiographs of both humeri can even be done in the operating room immediately prior to surgery, using digital radiography with markers for precise preoperative measurements.

FIGURE 4.3 The “gothic arch” of the normal shoulder is formed by (1) a line drawn along the medial humeral shaft and calcar and (2) a line drawn along the lateral scapular border, which intersect at (3) the inferior articular margin. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.) P.69

FIGURE 4.4 A. Length of normal humerus (N) is the distance along the humeral shaft from a line perpendicular to the medial epicondyle to the top of the humeral head, corrected for magnification. B. Length of fracture (F) is the distance along the humeral shaft from a line perpendicular to the medial epicondyle to the fracture line at the humeral metadiaphysis, corrected for magnification. C. The amount of humeral height to be restored (H) is the value of N minus F. D. Greater tuberosity length (G) should be within 5 mm of humeral head height (H). (A through D reprinted with permission from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66.) As a final check, the preoperative value G is compared with the length of the greater tuberosity fragment measured intraoperatively (Fig. 4.5). This is important because the greater tuberosity should be positioned 3 to 5 mm below the prosthetic head.

SURGICAL TECHNIQUE General hypotensive anesthesia, without the use of a regional nerve block, is preferred. The patient is positioned supine on the operating room table in a modified beach-chair position using a bean bag for scapula support (Fig. 4.6). The head of the table is elevated 20 to 30 degrees. If desired, the table may now be turned 90 degrees to allow for a C-arm to be brought in directly perpendicular to the patient. A sterile articulated arm holder is utilized (McConnell Arm Holder, McConnell Orthopedic Manufacturing Company, Greenville, TX). The extremity, shoulder, chest wall, and neck are prepped and draped

with the affected arm free. If there is no contraindication, appropriate preoperative and perioperative intravenous antibiotics are administered (cephalosporin or vancomycin) for a 24-hour total duration. A 5- to 7.5-cm deltopectoral approach is used. The incision is placed in the deltopectoral interval and starts at the medial tip of the coracoid paralleling the path of the cephalic vein (Fig. 4.7). A mobile soft-tissue window will allow the procedure to be performed through a relatively small incision. Prior to making the incision, the skin and subcutaneous tissue are infiltrated with 0.25% bupivicaine with epinephrine. The cephalic vein is retracted medially with a small strip of the deltoid. By blunt dissection, the deltopectoral interval is developed down to the clavipectoral fascia. Small Hohmann retractors are placed under the deltoid proximally and over the coracoacromial ligament. A self-retaining retractor is then placed beneath the deltoid and conjoint tendon (Fig. 4.8). The biceps tendon is identified in the intertubercular groove, tagged, and divided at its insertion for later tenodesis. Typically, the fracture line can be located with an elevator or osteotome between the tuberosities, just posterior to the bicipital groove. The greater tuberosity is identified and mobilized. Four nonabsorbable horizontal mattress nonabsorbable sutures (No. 5 Ethibond, Ethicon, a Johnson and Johnson Company, New Brunswick, NJ) are placed separately in the greater tuberosity at the bone-tendon junction (two in the infraspinatus and two in the teres minor). Similarly, the lesser tuberosity is identified and mobilized. Two nonabsorbable sutures are placed around the lesser tuberosity at the subscapularis bone-tendon junction (Fig. 4.9). The tuberosities are gently retracted to gain access to the humeral head. Dissecting scissors are used to divide the rotator cuff in line with the tuberosity fracture plane. The head fragment is carefully removed and measured with a caliper. If the humeral head measurement is intermediate between sizes, the smaller size should be selected. The humeral head is saved and used to procure three structural cancellous bone grafts, which will be placed into and around the humeral component (Fig. 4.10). Loose bony fragments are removed from around the glenoid, and the joint is copiously irrigated and inspected for signs of damage or arthrosis. P.70

FIGURE 4.5 Intraoperative measurement of greater tuberosity should be within 5 mm of humeral head height (H). (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.) P.71

FIGURE 4.6 Modification of the beach-chair position.

FIGURE 4.7 Modified deltopectoral incision. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

FIGURE 4.8 Retractor placement. (1) Over the coracoacromial ligament, (2) on top of the acromion, (3) selfretaining retractor placed under the deltoid and conjoint tendon. The humeral shaft is mobilized and delivered into the wound. The medullary canal is prepared by hand using cylindrical reamers and fracture-specific trial implants of increasing diameter (Aequalis Fracture Prosthesis, Tornier, St. Ismier, France) until the appropriate trial implant and head size are determined. The smallest reamer that demonstrates cortical contact is chosen, and since we recommend a cemented stem, we do not attempt to “ream up” to a larger implant stem diameter. If desired, a trial stem and head may now be placed into the humerus. Fracture jigs are available to allow for stable trial implant height and retroversion during a trial reduction. If a trial reduction feels too loose or tight, one must reassess whether the anatomy has been properly restored using the “gothic arch” technique as described below. If the medial calcar is fractured, it is provisionally stabilized using cerclage wire or heavy suture fixation with the last broach used in the medullary canal (Fig. 4.11). P.72

FIGURE 4.9 Four separate heavy nonabsorbable sutures are placed at the greater tuberosity bone-tendon junction. Two temporary stay sutures are placed at the lesser tuberosity bone-tendon junction. The next step is to restore the proximal humeral “gothic arch” anatomy. Unlike other described techniques, we do not reference the reconstruction using the lateral humeral metadiaphysis. The appropriate diameter fracturespecific prosthetic stem is opened, and the preselected size trial head is placed on the definitive implant with the eccentric head offset rotated into the most lateral position (Fig. 4.12). We systematically place the humeral head offset in this most lateral position as this decreases the amount of “medial overhang” of the humeral head and increases the lateral room under the prosthetic head for bone graft and anatomic positioning of the greater tuberosity. Using the preoperative radiographic calculations as previously described, a mark corresponding to length H is placed on the prosthetic implant by measuring from the top of the trial humeral head (see Fig. 4.4D). During provisional placement of the prosthesis inside the medullary canal, the mark should be visible at the fracture line of the humeral shaft. The line of the “gothic arch” (medial calcar of the humerus up to the inferior margin of the anatomical neck down the lateral scapular border) should be unbroken (Fig. 4.13). This is confirmed visually and by using an instrument such as a freer elevator to trace a smooth line from the top of the prosthetic humeral head inferiorly to the medial calcar. Appropriate retroversion of the prosthesis is confirmed by rotating the forearm to a neutral position and facing the prosthetic humeral head toward the glenoid (Fig. 4.14). This step ensures that the patient's own retroversion is restored and is approximately 20 degrees relative to the transepicondylar axis of the elbow. The greater tuberosity is measured and noted to be within 5 mm of the measured humeral head height (H) (Fig. 4.5). The “gothic arch” anatomy of the proximal humerus is consistently recreated intraoperatively using this

method. If there is any concern, intraoperative fluoroscopy can be utilized to confirm restoration of the gothic arch with the prosthetic stem and head. If the arch is not “restored,” then either 1. Prosthetic height may be incorrect (it is usually too high) 2. Medial calcar is fractured and has not yet been restored 3. Head size is either too large or has not been rotated into the most lateral offset position (Fig. 4.12) P.73

FIGURE 4.10 This osteotome is included in the prosthetic instrumentation set and is used to fashion structural bone graft from the humeral head.

FIGURE 4.11 A fractured medial calcar is stabilized using cerclage wire or heavy suture fixation. P.74

FIGURE 4.12 Appropriate prosthetic humeral head placement is in the most laterally offset position. Once the arch has been established, the implant is removed, and two drill holes are placed in the proximal humeral shaft on either side of the bicipital groove. Two heavy nonabsorbable sutures (No. 5 Ethibond, Ethicon, a Johnson and Johnson Company, New Brunswick, NJ) are placed in a horizontal mattress fashion through these holes to be used as “tension band” sutures during the final tuberosity fixation (Fig. 4.15). A cement restrictor is placed 2 cm distal to the distal tip of the prosthesis. Taking care to ensure that the previous “gothic arch” anatomy is restored (Fig. 4.16), the prosthetic stem is cemented into the canal in slight valgus using thirdgeneration cementation technique. The humeral canal is thoroughly irrigated, and a small diameter suction tube is placed into the canal to vent blood during cementation. The cement is mixed using a vacuum centrifugation device and injected into the humeral canal using a large syringe. Gentle pressurization of the cement is performed using a separate wet glove, adding a small amount of cement each time. The vent tube is removed during the third (final) pressurization. One to two centimeters of proximal cement is removed from the intramedullary canal to allow for placement of bone graft. Final tightening of the wire or suture used to fix the medial calcar fracture (if present) is performed. The final head of predetermined size is gently impacted into the appropriate position. Three structural cancellous bone graft wedges (obtained from the humeral head) are then placed as follows: (a) in the “window” of the fracture-specific prosthesis; (b) under the greater tuberosity at the “lateral” fin of the prosthesis; and (c) under the anteromedial edge of the prosthetic head between the head and neck of the implant (Fig. 4.17). P.75

FIGURE 4.13 With the prosthesis placed inside the medullary canal, the “gothic arch” is unbroken. Restoration of humeral head height is confirmed with the ruler. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

FIGURE 4.14 Appropriate version is determined by rotating the prosthetic humeral head to face the glenoid with the forearm in neutral rotation at the patient's side.

FIGURE 4.15 Two heavy nonabsorbable sutures are placed through drill holes on either side of the intertubercular groove.

FIGURE 4.16 Restoration of the “gothic arch” with the final prosthesis in place. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.) P.76 With the humeral prosthesis reduced into the glenoid, tuberosity osteosynthesis is now performed. The medial limbs of the sutures previously placed at the greater tuberosity bone-tendon junction are passed around the prosthetic neck (Fig. 4.18). With the greater tuberosity in a reduced position, two of these sutures are tied over the structural bone graft (Fig. 4.19). The remaining two greater tuberosity sutures (medial limbs) are placed through the subscapularis bone-tendon junction from posterior to anterior and tied down while the lesser tuberosity is held reduced (Fig. 4.20). Sutures previously placed through drill holes in the humeral shaft are then

used to create a vertical “tension band.” One suture is placed from anterior to posterior through the subscapularis tendon, rotator interval, supraspinatus, and superior infraspinatus tendons (anterosuperior cuff). The other is passed from posterior to anterior through the teres minor and infraspinatus, superior supraspinatus, and leading edge of subscapularis tendons (posterosuperior cuff) (Fig. 4.21). The biceps is tenodesed within the bicipital groove or rotator interval to soft tissue (Fig. 4.22). The shoulder is taken through a full range of motion, to ensure there is no motion of the tuberosity fragments. Passive intraoperative range of motion should be at least 160 degrees of elevation, 40 degrees of external rotation at side, 60 degrees of external rotation in 90degree abducted position, and 70 degrees of internal rotation in a 90-degree abducted position. Closure of the wound is performed. Postoperative x-rays should demonstrate anatomic reconstruction of the proximal humerus (Fig. 4.23). P.77

FIGURE 4.17 Three structural cancellous bone graft wedges are then placed: (a) in the “window” of the fracturespecific prosthesis; (b) under the greater tuberosity at the “lateral” fin of the prosthesis; and (c) under the anteromedial edge of the prosthetic head between the head and neck of the implant.

FIGURE 4.18 Medial limbs of sutures previously placed at the greater tuberosity bone-tendon junction are passed around the prosthetic neck.

FIGURE 4.19 Two sutures previously placed at the greater tuberosity bone-tendon junction tied down around the prosthesis. P.78

FIGURE 4.20 The two remaining sutures previously placed at the greater tuberosity bone-tendon junction are placed through the lesser tuberosity bone-tendon junction and tied down.

FIGURE 4.21 Sutures placed through drill holes in the humeral shaft (gray, light blue) are used for vertical “tension band” fixation. Additional simple sutures are used to reinforce rotator interval closure (purple).

FIGURE 4.22 Soft-tissue biceps tenodesis. P.79

FIGURE 4.23 A. Four-part proximal humeral fracture with broken “gothic arch.” B. Restoration of the “gothic arch” and tuberosity anatomy. C. Two years after surgery. (A and B reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57-66, with permission.)

POSTOPERATIVE MANAGEMENT Patients are placed into a Smart Sling orthosis (Innovation Sports/Ossur, Foothill Ranch, CA) for 6 weeks (Fig. 4.24). Passive motion with the patient supine is begun the day after surgery. Passive supine limits of 90 degrees of forward flexion and 30 degrees of external rotation are maintained for the first 4 postoperative weeks. During weeks 5 to 6, passive supine forward flexion is full, and external rotation is maintained at 30 degrees. At 7 weeks after surgery, active motion is allowed, and resistance exercises begin 10 weeks postoperatively. P.80

FIGURE 4.24 The Smart Sling orthosis.

COMPLICATIONS Many complications can be avoided by proper patient selection, meticulous attention to detail, and careful surgical technique. 1. Component Malposition. A prosthesis placed too high can over tension the superior rotator cuff, resulting in pain and limited elevation. Incorrect prosthetic height or version also makes initial anatomic reduction of the tuberosities difficult and will increase the risk of later tuberosity displacement and/or nonunion (6). This can be avoided by following the criteria for restoring the “gothic arch” anatomy of the proximal humerus as described. 2. Tuberosity Malposition. Even when the implant is placed correctly, fixing the tuberosities in a nonanatomic position can result in a poor outcome. The proximal greater tuberosity should be 3 to 5 mm below the top of the prosthetic head. Placing the greater tuberosity too low will have a similar effect to placing the prosthesis too proud. An intraoperative AP radiograph should be obtained if there is any question about the adequacy of reduction. 3. Failure of Tuberosity Fixation. A key technical point is passing the sutures used in tuberosity fixation around the prosthetic neck. This provides superior stability by compressing the tuberosity to the prosthetic neck (10). 4. Stiffness. In an effort to reduce the risk of early tuberosity migration, the surgeon may be concerned about starting early postoperative shoulder motion. However, the excellent initial fixation afforded by this technique allows for early protected motion as described. Other causes of stiffness include pain as the result of poor prosthesis or tuberosity position or patient inability to participate in a structured therapy program.

5. Other. Less common complications include infection, intraoperative humeral fracture, heterotopic ossification, nerve injury, complex regional pain syndrome, prosthetic loosening, rotator cuff failure, and glenoid arthritis.

RESULTS/OUTCOMES We performed a retrospective review of 170 consecutive patients treated by a single surgeon (SGK) with this technique of proximal humeral hemiarthroplasty and tuberosity osteosynthesis between 2001 and 2006 (6). The mean age was 72 years and follow-up was 24 to 56 months. Between September 2001 and March 2004, 58 standard humeral prosthetic stems (STD) were implanted. From April 2004 through May 2006, 112 fracturespecific prosthetic stems (FX) were used. Differences between groups in age, mean time to surgery, and P.81 visual analog pain scores were not significant. The mean ASES score was higher in the FX group (72 vs. 55, p < 0.0001), and mean goniometric active elevation was better in the FX group (129.8 vs. 95.4, p < 0.0001). Overall, 127/170 (75%) greater tuberosities healed to the humeral shaft. Tuberosity healing was noted to be 89/112 (79%) in the FX group and 38/58 (66%) in the STD group ( p = 0.03). The FX group had a higher percentage of patients 77/112 (69%) with active elevation >120 degrees when compared to the STD group 28/58 (48%), this was significant ( p = 0.007). These results appear to support improved outcomes associated with the fracturespecific stem compared to the standard stem.

REFERENCES 1. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4(2):107-112. 2. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87-92. 3. Handoll HHG, Ollivere BJ. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2010;12: Art. No.: CD000434. DOI: 10.1002/14651858.CD000434.pub2 4. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11(5):401-412. 5. Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch”. Tech Shoulder Elbow Surg 2005;6(2):57-66. 6. Krishnan SG. Shoulder arthroplasty for fractures of the proximal humerus: where are we in 2010? AAOS Instructional Course Lectures, New Orleans, March 2010. 7. Castricini R, De Benedetto M, Pirani P, et al. Shoulder hemiarthroplasty for fractures of the proximal humerus. Musculoskelet Surg April 19, 2011 [Epub ahead of print]. 8. Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop Traumatol Surg Res 2010;96(6):683-694.

9. Esen E, Dogramaci Y, Gultekin S, et al. Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients. Injury 2009;40(12):13361341. 10. Lin K, Krishnan SG. Shoulder Trauma: Bone, Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008. 11. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg Am 2008;90(2):233-240. 12. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009;91(6):1320-1328. 13. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427-433. 14. Sperling JW, Cuomo F, Hill JD, et al. The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results. In: Marsh JL, Duwelius PJ, eds. Instructional course lectures. Vol. 56. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:45-57. 15. Visser CP, Coene LN, Brand R, et al. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg 2001;10(5): 421-427. 16. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am 1993;75(12):1745-1750.

5 Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Pascal Boileau Adam P. Rumian Xavier Ohl

INTRODUCTION Although Neer reported favorable results following hemiarthroplasty for proximal humeral fractures in 1951, a large number of subsequent studies have been unable to duplicate his functional and radiological outcomes. In fact, most reports of shoulder hemiarthroplasty for fractures of the proximal humerus in the United States document a high incidence of shoulder pain and stiffness (1,2). Many authors have documented that the results of hemiarthroplasty are closely related to the accuracy of reduction and healing of the tuberosities, particularly the greater tuberosity (3). If the greater tuberosity heals in a malunited position or migrates because of fixation failure, a poor outcome is predictable. The critical role of the greater tuberosity is explained by the fact that three of the four rotator cuff muscles insert directly onto it: the supraspinatus, infraspinatus, and teres minor. If the greater tuberosity does not heal properly, then the function of these muscles will be compromised, leading to shoulder dysfunction. Furthermore, malunion or nonunion of the tuberosity can lead to bony impingement with decreased range of shoulder motion, pain, and stiffness. In reverse shoulder arthroplasty (RSA), the center of rotation of the shoulder joint is medialized and the humerus is lowered, resulting in an increased lever arm with improved function of the deltoid for abduction. The prosthesis is designed to compensate for deficiencies of the rotator cuff, particularly the supraspinatus (4). A RSA is a semiconstrained prosthesis, and insufficiency of the greater or lesser tuberosity will not cause instability of a properly positioned prosthesis. This makes it an attractive option for arthroplasty in fracture cases where successful reconstruction and osteosynthesis of the proximal humerus and tuberosities are problematic. However, its use should be restricted to more elderly patients (i.e., over 70 years of age) as long-term results with this implant are not available, and preliminary studies report deterioration of function after a few years (5). Although RSA can compensate for cuff deficiency as described above, the surgical goal should include reduction, fixation, and healing of the greater tuberosity to preserve the external rotation function of the shoulder whenever possible (6).

INDICATIONS AND CONTRAINDICATIONS RSA for fracture is reserved for comminuted osteoporotic fractures in elderly patients that are unsuitable for osteosynthesis or conventional hemiarthroplasty. These include four-part fractures and fracture dislocations of the proximal humerus, head-splitting fractures, some three-part fracture dislocations, and three-part fractures without valgus impaction of the humeral head (7,8). Factors that would favor the use of a RSA rather than hemiarthroplasty include age over 70 years, severe osteopenic bone or metabolic bone disease, marked comminution of the fracture, preexisting rotator cuff disease, inflammatory arthritis, heavy smoking, and the use of systemic steroid medication. Contraindications to RSA include age under 70 years, active infection, a complete axillary P.84 nerve deficit, inadequate glenoid bone stock to support a glenoid implant, and inability or unwillingness of the patient to comply with postoperative rehabilatation. RSA for fractures is a technically demanding procedure and should not be performed by inexperienced surgeons without specialized training.

PREOPERATIVE PLANNING Preoperative planning is essential to obtain a successful outcome after RSA for fracture and to prevent avoidable complications. A detailed history should be obtained, and a careful physical examination should be performed. The motor and sensory function of the axillary nerve must be accurately assessed because a significant number of patients with proximal humeral fractures have subtle injuries to the nerve. While neurological dysfunction tends to recover slowly, it may delay recovery and rehabilitation. This is especially important since RSA relies on the deltoid muscle to be the prime driver of shoulder movement. In our opinion, RSA should not be performed in a patient with a complete axillary nerve palsy. Radiographic evaluation should include anteroposterior (AP), scapular Y, and axillary lateral views as well as a CT scan to classify the fracture, and determine fracture displacement and evaluate the status of the tuberosities. The CT also allows some evaluation of the rotator cuff as to the degree of fatty infiltration and muscular atrophy as well as the ability to assess the glenoid bone stock to support a glenoid component (9). We believe that the ideal timing of surgery is at 3 to 7 days after injury, which avoids operating through acutely injured and edematous soft tissues and lessens the risk of wound complications. Surgery after a delay of more than 3 weeks becomes technically difficult due to fracture callus that results in difficulty mobilizing the tuberosity fragments and requires a more extensive soft-tissue dissection. Preoperative radiographic planning is very important if successful outcome is to be consistently achieved. The normal anatomical landmarks that are used as reference points to position the humeral prosthesis are displaced or compromised as a result of the fracture. Correct positioning of the humeral prosthesis, especially in terms of vertical height, is crucial as implanting the prosthesis too deep or too proud in the humeral canal can lead to a poor result (10). In our opinion, it is not acceptable to rely on “eyeballing” the height of the prosthesis at the time of surgery as this leads to unpredictable, unreproducible, and often unacceptable results. Scaled AP radiographs of both humeri should be obtained. The length of the normal humerus is measured along the prosthetic axis as shown in Figure 5.1. On the fractured side, the length of the remaining distal humeral shaft P.85 fragment is measured from the lateral edge of the fracture (Fig. 5.1). The difference between these two measurements, adjusted for the magnification factor, gives the distance above the lateral edge of the distal humeral shaft fragment that the top of the prosthesis needs to be implanted to achieve the correct humeral length.

FIGURE 5.1 A,B. Evaluation of the humeral length on the fracture side and the controlateral side.

Patient Setup Surgery can be performed under a general or regional anesthesia. Antibiotic prophylaxis should be administered at the time of anesthetic induction according to local protocols. We perform surgery in a laminar airflow room. A beach-chair position is used with the arm draped free. We routinely perform a prescrub with diluted antiseptic scrub lotion before definitively prepping the arm as the patient has often had their arm immobilized for a few days and has been unable to perform adequate hygiene in the axillary region due to pain. The arm must be draped free to allow for intraoperative manipulation to aid in exposure and prosthesis implantation. A sterile adhesive antimicrobial incise drape (Ioban, 3M) is applied to the surgical field after marking the incision to lessen the risk of wound contamination. We use the Aequalis Reversed Fracture Prosthesis (Aequalis RSAFx, Tornier, Inc.) system. This specifically designed reverse fracture stem has a low-profile monobloc design, proximal hydroxyapatite coating to promote bone healing, a fenestration to accept proximal bone graft, and a smooth polished neck to prevent abrasion of sutures used for tuberosity osteosynthesis (Fig. 5.2). It is also modular as it can accept either a 36 or a 42 polyethylene cup.

Approach Although we routinely use the deltopectoral approach for elective RSA, we utilise the superolateral deltoidsplitting approach for fracture cases as it allows better access to the greater tuberosity fragments and improves glenoid exposure. A vertical incision centered at the anterior edge of the acromion is made in Langer's lines, 1

cm medial to its lateral border (Fig. 5.3). Full-thickness skin flaps are raised, exposing the underlying deltoid muscle and anterolateral acromion (Fig. 5.4). The deltoid is split in the avascular tendinous raphe between the anterior and middle portions of the deltoid. This split should not extend more than 5 cm distally to avoid damaging the axillary nerve. Proximally, the split is extended up over the superior surface of the anterior acromion, and we detach 2 cm of the anterior deltoid muscle with a thin piece of bone to improve healing of the deltoid after reattachment (Fig. 5.5). A deep self-retaining retractor is used for improved visualization.

FIGURE 5.2 Aequalis Reversed Fracture stem. P.86

FIGURE 5.3 Surgical approach.

FIGURE 5.4 Exposure of the deltoid muscle and anterolateral acromion.

Fracture Exposure The hemorrhagic subacromial bursa and fracture haematoma are carefully removed, exposing the fracture site. The key to understanding the anatomy is to identify the long head of biceps tendon, which lies between the greater and lesser tuberosities and marks the rotator interval. The rotator cuff interval is opened or extended if torn, and the biceps tendon is identified, tagged, and divided at its origin from the supraglenoid tubercle. We excise its intra-articular portion to aid exposure, facilitate fracture reduction, and remove a source of postoperative pain. A soft-tissue tenodesis below the rotator cuff interval of the remaining tendon is performed. The fractured humeral head is now removed and saved to be used as bone graft in and around the definitive prosthesis (Fig. 5.6).

Tuberosity Mobilization and Preparation The supraspinatus tendon is identified and mobilized up to the glenoid rim. In many patients, its attachment to the greater tuberosity is already torn, and any adhesions between the rotator cuff muscles and deltoid should be freed. The greater tuberosity fragment is grasped with an atraumatic specifically designed grasping clamp to allow suture placement (Aequalis, Tornier, Inc.; Fig. 5.7). We pass one green and one blue heavy nonabsorbable braided sutures through the infraspinatus tendon and one green and one blue sutures through the teres minor tendon (Fig. 5.8). These four strong nonabsorbable sutures (two green, two blue) will be used as horizontal cerclages for tuberosity fixation and must be placed at the bone-tendon junction of the greater tuberosity. Sutures of different colours are helpful to aid in suture management. We use a combination of Orthocord (Depuy Orthopaedics, Inc.), Fiberwire (Arthrex, Inc.), or Force Fiber (Tornier Inc.). Likewise, two sutures are passed around the lesser tuberosity fragment through the subscapularis tendon. Using a shuttling suture or a crimping needle, two doubled-over lengths of suture are passed through the superior portion and two of a different color through the inferior portion of the infraspinatus at its junction with the bone. Sutures should not be passed through the bone itself to avoid causing comminution of the tuberosity fragment. Once this step is completed, our attention is turned to the glenoid (Fig. 5.9).

FIGURE 5.5 Detachment of the anterior deltoid.

FIGURE 5.6 Removal of the fractured humeral head. P.87

FIGURE 5.7 Specific atraumatic grasping clamp is used to manipulate the greater tuberosity.

FIGURE 5.8 Four horizontal cerclages. One green and one blue through the infraspinatus tendon and one green and one blue through the teres minor tendon.

Glenoid Exposure and Implantation To expose the glenoid, a flat lever forked retractor (Kolbel retractor) is placed over the anterior glenoid neck to retract the subscapularis muscle anteriorly. The anterior and inferior labrum is excised and an anterior juxtaglenoid capsulotomy performed. Similarly, a forked retractor is placed posteriorly and the posterior labrum excised and posterior capsulotomy performed. The glenoid exposure is completed by placing a retractor inferiorly to depress the humeral diaphysis and expose the inferior rim of the glenoid. The centerpoint of the glenoid is identified by the intersection of the superoinferior and mediolateral bisecting lines. It is desirable to place the glenoid baseplate slightly inferiorly on the glenoid. The circular glenoid guide is placed flush to the inferior rim of the glenoid and used to insert a threaded guide wire. In fracture cases without glenoid wear, it is not necessary to correct glenoid version. The guide wire can be inserted in a neutral position or with 10 degrees of inferior tilt (Fig. 5.10). Any superior tilt of the glenoid implant should be avoided to prevent instability and inferior scapular notching. Gentle reaming of the glenoid surface is performed using the cannulated reamers over the guide wire. The reamer should be started before contacting the bone to lessen the risk of fracturing the glenoid (Fig. 5.11). The aim of reaming is to provide a flat, smooth surface, but it is important to preserve most of the strong subchondral bone to provide support for the glenoid implant. Depending on the size of the glenoid, a 25- or 29-mm baseplate will be selected. Additional reaming with a second reamer is needed to accept the glenoid sphere. There are two sizes of glenoid sphere: 36 and 42 mm. We tend to ream to accept the 42-mm implant in all but the smallest P.88 patients as this improves stability of the prosthesis. Finally, an 8mm hole is drilled over the guide wire to receive the central peg of the glenoid baseplate, which is impacted until fully seated.

FIGURE 5.9 Technique for placement of the sutures.

FIGURE 5.10 Exposure of the glenoid with retractors and glenoid guide with wire inserted with 10 degrees of inferior tilt.

FIGURE 5.11 Glenoid reaming. Next, the baseplate is secured with screws (Fig. 5.12). The anterior and posterior conventional cortical screws are positioned first to optimize compression of the baseplate. The anterior hole is drilled using a guide at a trajectory that is superior and toward the middle of the baseplate, exiting through the posterior scapular cortex. The hole is measured, and the screw is inserted although not yet tightened fully to avoid rocking the baseplate. The posterior hole is then drilled at a trajectory that is inferior and toward the middle of the baseplate, exiting through the anterior scapular cortex. The hole is measured, and the screw is inserted, and tightened fully, after which the anterior screw is tightened. The aim of these screws is to achieve secure cortical fixation—the holes should be redrilled in a different direction if this is not accomplished. The superior and inferior locking screws are inserted next. The drill guide is positioned into the threaded holes of the baseplate and orientated to achieve the desired trajectory. For the superior screw, this is approximately 20 degrees superior and 10 degrees anterior so that the screw engages the cortical bone at the base of the coracoid process. For the inferior screw, this is approximately 20 degrees inferior in the axis of the glenoid so that the screw engages the cortical bone of the scapular pillar. The inferior screw is inserted and tightened first. The final position of the baseplate is verified, which should be fully seated onto bone in a slightly inferior position, up to but not overhanging the inferior edge of the glenoid, and with a neutral or slightly inferior tilt and correct version. Although we tend to impact and screw the definitive glenoid sphere implant onto the baseplate at this stage, a trial implant can be screwed onto the baseplate instead if desired (Fig. 5.13).

Preparation of the Humerus The glenoid retractors are removed, and access to the medullary canal of the humeral shaft can be improved by pushing up on the elbow, delivering it into the wound. The medullary canal is progressively reamed until the last reamer used contacts cortical bone, which determines the size of the humeral stem. During reaming, one hand should be positioned under the elbow during reaming to guide the direction of the reamers, control rotation, and prevent excess traction on the tissues that could result in a neuropraxia (Fig. 5.14).

FIGURE 5.12 Baseplate secured with two standard-headed screws and two locking screws.

FIGURE 5.13 Implantation of the definitive glenoid sphere. P.89

FIGURE 5.14 Reaming of the humeral shaft. Two holes are drilled lateral and posterior to the bicipital groove 1 cm below the fracture site. Two doubledover strands of nonabsorbable suture of different colors are passed through the holes for use as vertical cerclage in the tuberosity repair (Fig. 5.15).

Positioning the Trial Stem It is important that the humeral stem be implanted in the correct retroversion and at the correct height above the fracture site. A trial stem is mounted on the holder and introduced into the medullary canal. The retroversion of the prosthesis is provided by the use of the alignment rod, which is inserted into the holder and the stem is rotated until the retroversion rod is parallel to the patient's forearm with the elbow flexed to 90 degrees (Fig. 5.16). This will position the humeral implant at the desired 20 degrees of retroversion with respect to the forearm (i.e., ∽10 degrees with respect to the epicondylar axis). Using electrocautery or sterile marker, a mark is made on the bone adjacent to the lateral fin of the trial stem that will be used to guide the position of the definitive implant. The height of the prosthesis is determined by reducing the greater tuberosity around the humeral component and onto the shaft. With proper reduction of the greater tuberosity, the most superior part of the trial implant will be at or just above the top of the tuberosity. The height of the prosthesis can also be determined or confirmed from the preoperative planning stage. The distance is set on the height gauge on the implant holder (Fig. 5.17). The foot of the height gauge rests on the cortical rim on the lateral side of the humeral diaphysis, thus positioning the implant at the correct height. If the trial stem is too loose in the medullary canal to allow sufficient

stability for the tuberosity reduction, then a larger-size trial stem should be used. If there is a disparity between the preoperatively determined height and that required to achieve correct positioning of the implant relative to the tuberosity, then the situation should be reassessed. If the greater tuberosity fragment is relatively intact and the reduction verified to be anatomical with respect to the diaphysis, then the tuberosity should be used as the guide for prosthesis height and a new measurement determined from the calibrated height gauge. Conversely, if P.90 the greater tuberosity is comminuted with some degree of bone loss, or anatomical reduction cannot be verified, then the preoperatively templated height should be respected. If the trial stem is stable, a trial reduction can be performed with a spacer; however, we do not routinely perform this step to avoid iatrogenic fracture.

FIGURE 5.15 Two sutures are passed through the humeral shaft under the fracture site.

FIGURE 5.16 Retroversion control with the trial stem.

FIGURE 5.17 Height control with the trial stem.

Humeral Stem Implantation The definitive humeral implant is mounted on the holder. The bone graft cutting instrument provided with the set is used to harvest shaped cancellous graft from the humeral head and is placed into the designated window in the humeral stem (Fig. 5.18). The low-profile fracture stem combined with the bone graft increases the chance for successful tuberosity healing. A cement restrictor is placed in the humeral shaft 2 cm below the tip of the trial stem. The medullary canal is irrigated and dried, and a small bore surgical drain is placed into the humeral canal and attached to suction. Cement is injected using a large syringe, and the small drain is gradually withdrawn as the cement advances. Very little cement is necessary as it is only needed for fixation of the distal prosthetic stem. The proximal canal and prosthesis must be free of cement to allow for bony ingrowth. The definitive implant is inserted, using the mark previously made on the bone to guide retroversion and height (Fig. 5.19). Excess cement is removed with a curette. There should be no cement within 5 mm of the fracture. Any remaining space around the prosthesis in this area is packed with more bone graft harvested from the humeral head to promote tuberosity healing. The diameter of the polyethyelene humeral insert is determined by the size of the glenoid sphere. The thickness of the humeral insert is determined by performing a trial reduction to ensure stability. If the glenoid and humeral components have been implanted properly, a 6-mm humeral insert is usually appropriate. If pistoning of the humerus is present on reduction, or deltoid tension is insufficient, then a thicker insert (9 or 12 mm) may necessary. The prosthesis is dislocated, and the definitive insert is impacted into the humeral component.

Tuberosity Reduction and Fixation Four doubled-over strands of suture previously passed through the bone-tendon junction of the infraspinatus and teres minor are used for horizontal cerclage for the tuberosity repair. The ends emerging from the deep surface of the tendon are passed around the neck of humeral implant (so-called lasso manoeuvre), which is polished to prevent abrasion. The prosthesis is then reduced into the joint (Fig. 5.20).

FIGURE 5.18 Definitive humeral stem with the harvest cancellous autograft.

FIGURE 5.19 Implantation of the definitive humeral stem with height and retroversion control. P.91

FIGURE 5.20 Passage of the four horizontal cerclages around the neck of the prosthese: the “lasso” maneuver.

FIGURE 5.21 Reduction and fixation with two sutures of the greater tuberosity. Arm in external rotation. At this point, it is crucial to place the arm in external rotation while the greater tuberosity is reduced onto the prosthesis and the proximal humerus by pulling it anteriorly with the specific tuberosity grasper. A common mistake is to try and reduce the tuberosity with the arm internally rotated, which will lead to the tuberosity being fixed too far posteriorly, leading to loss of external rotation and posterior impingement. Two cerclages, one superior (green) and one inferior (blue), are then tightened and tied to fix the greater tuberosity in position (Fig. 5.21). The use of doubled-over strands of suture enables the surgeon to use a specific sliding knot—the “Nice knot”—which can gradually be adjusted and tensioned before being finally locked, thereby optimizing tuberosity fixation (see Appendix). Gentle range of motion of the shoulder will verify that the greater tuberosity has been fixed securely. The remaining two cerclages emerging from around the neck of the prosthesis are now passed through the deep surface of the subscapularis tendon—lesser tuberosity bone interface, one superiorly (blue) and one inferiorly (green), using a crimping needle or suture shuttle. The lesser tuberosity is now reduced into position, with the arm in internal rotation. The reduction is maintained with a clamp, and the cerclage sutures are again tied using the sliding Nice knot. Thus, at the end of this step, both tuberosities are reduced and securely fixed to the prosthetic neck (Fig. 5.22). The fixation is reinforced by the two vertical tension-band sutures (one anterosuperior through the subscapularis tendon and one posterosuperior through the infraspinatus tendon) previously prepared that provide solid fixation of the tuberosities onto the humeral diaphysis (Figs. 5.23 and 5.24).

Final Assessment The arm is internally and externally rotated both at the side and in 90 degrees of abduction to check for security of tuberosity fixation, prosthetic stability, and range of movement. The arm is abducted and forward elevated to check range of movement and verify that there is no impingement against the acromion, and adduction is performed to check that there is no impingement against the scapular pillar.

FIGURE 5.22 Reduction of the lesser tuberosity. Both tuberosities are perfectly reduced and stabilized.

FIGURE 5.23 Fixation of the tuberosities on the humeral shaft with two vertical tension-band (anterosuperior and posterosuperior). P.92

FIGURE 5.24 Final aspect of the tuberosities reconstruction around the stem.

Closure A surgical drain is placed in the subacromial space to prevent hematoma formation, which is common in fracture cases. The anterior deltoid is reattached securely using interrupted nonabsorbable transosseous sutures, and the skin is closed in a standard manner (Fig. 5.25).

POSTOPERATIVE REHABILITATION If the soft tissues are of poor quality or there is any doubt about the security of the anterior deltoid repair, we place the patient into an abduction splint for 4 weeks. During this period, the patient is allowed to take the arm out of the splint to perform passive pendular exercises several times a day to prevent stiffness (5 minutes, five times a day, as a rule). Otherwise, a standard broad arm sling in neutral rotation is used with passive- and active-assisted exercises for 4 weeks. Full active and isometric strengthening exercises can be initiated after 6 to 8 weeks once a good passive range of motion has been obtained.

RESULTS To date, few studies have been published of the results of RSA for fracture. Bufquin et al. (11) and Klein et al.(12) reported good pain relief and range of motion of approximately 110 degrees of abduction, 120 degrees of forward elevation, and 10 degrees of external rotation with the arm at the side, which compares favorably with the results of hemiarthroplasty in similar patients. Restoration of internal rotation is more variable. Radiological follow-up has shown a high incidence of progressive radiolucent lines and notching especially around the glenoid component, although frank loosening is uncommon, reinforcing again that use of RSA should be reserved for the elderly (13). Patients should be counselled that improvement continues for up to a year postoperatively and that some limitation in internal and external rotation is to be expected. The most common complications are infection and instability (14). Instability of the prosthesis is often related to technical errors of implantation, especially not adequately restoring the humeral length or implanting the glenoid too high.

FIGURE 5.25 Transosseous repair of the anterior deltoid. P.93 Nonunion or fixation failure of the tuberosities after a Reversed Shoulder Arthroplasty for acute proximal humerus fractures in elderly patients (>70 years) has been reported to occur in up to 50%. This is thought to be related to severe osteopenia/osteoporosis as well as the bulky prosthesis, which impedes anatomic reduction of the tuberosities. Based on the good results observed with the Aequalis Hemi-Arthroplasty Fracture prosthesis, we have designed a novel RSA specifically designed for anatomic tuberosity positioning, fixation, and bone grafting of the proximal humerus: the Aequalis RSAFx. We have evaluated

the radiological and early to midterm functional results of this prosthesis in a prospective cohort study of 38 patients (average age, 78 years) operated (Fig. 5.26). Radiographs and CT scan at last follow-up were used to assess bone healing of the tuberosities and eventual radiolucent lines around the implants. Mean follow-up was 12 months (6 to 34 months). The tuberosities healed in anatomic position in 87% (33/38) of the cases (Fig. 5.27): three patients had partial lysis of the greater tuberosity and two had migration with final malposition and a hornblower sign. P.94 P.95 No implant loosened, became infected, or dislocated, and no patient required reoperation. At the last followup, the average forward elevation was 116 degrees (80 to 150 degrees), external rotation 26 degrees (0 to 50 degrees), and average internal rotation was L5 (buttock-D10; Fig. 5.28). The mean Constant score was 58 points (23 to 79 points), and the adjusted Constant score was 88% (33% to 118%). The subjective shoulder value was 70%.

FIGURE 5.26 A-C. Case of a 72-year-old woman. Four-parts fracture of the right humeral head.

FIGURE 5.27 A-C. The same case than Figure 5.26. CT scan at 3 months shows union of the greater tuberosity and integration of the allograft through the window of the stem. Radiographic control at 9 months shows correct position of the greater tuberosity and good union.

FIGURE 5.28 A-C. The same woman at 1 year. No pain, 140 degrees of forward elevation, 50 degrees of external rotation, and she can reach the 12th dorsal vertebrae in internal rotation.

CONCLUSION In conclusion, a specifically designed reverse shoulder prosthesis is an attractive option for treating complex proximal humerus fractures in the elderly, because it allows (a) better tuberosity healing, (b) active external rotation (useful for ADLs), and (c) reduces the risk of complications. We have found a specifically designed RSA for fractures is a valuable option for treatment of difficult proximal humeral fractures in the elderly where other options are likely to lead to a poor result. Strict attention needs to be paid to the technical aspects of the surgery to optimize the outcome and prevent complications.

REFERENCES 1. Neer CS II. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52(6):1090-1103. 2. Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop

Traumatol Surg Res 2010;96(6):683-694. 3. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11(5):401-412. P.96 4. Boileau P, Watkinson DJ, Hatzidakis AM, et al. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg 2005;14(1 Suppl S):147S-161S. 5. Guery J, Favard L, Sirveaux F, et al. Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006;88(8):1742-1747. 6. Sirveaux F, Favard L, Oudet D, et al. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br 2004;86(3):388-395. 7. Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52(6): 1077-1089. 8. Neer CS II. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg 2002;11(4):389-400. 9. Goutallier D, Postel JM, Bernageau J, et al. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;(304):78-83. 10. Ladermann A, Williams MD, Melis B, et al. Objective evaluation of lengthening in reverse shoulder arthroplasty. J Shoulder Elbow Surg 2009;18(4):588-595. 11. Bufquin T, Hersan A, Hubert L, et al. Reverse shoulder arthroplasty for the treatment of three- and fourpart fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br 2007;89(4):516-520. 12. Klein M, Juschka M, Hinkenjann B, et al. Treatment of comminuted fractures of the proximal humerus in elderly patients with the Delta III reverse shoulder prosthesis. J Orthop Trauma 2008;22(10):698-704. 13. Cazeneuve JF, Cristofari DJ. Delta III reverse shoulder arthroplasty: radiological outcome for acute complex fractures of the proximal humerus in elderly patients. Orthop Traumatol Surg Res 2009;95(5):325329. 14. Farshad M, Gerber C. Reverse total shoulder arthroplasty-from the most to the least common complication. Int Orthop 2010;34(8):1075-1082.

Appendix

The Nice Knot Introduction Knot tying is an essential skill in both open and arthroscopic surgery. Traditionally, flat nonsliding knots, such as surgeon's knots and square knots, have been used in open surgery, as they have been perceived to be more secure than sliding knots, while the development of arthroscopic and endoscopic surgery has resulted in the description of many “new” sliding knots, due to the technical challenges of tying intracorporeal flat knots. A knot should be easy to learn and tie, have good loop and knot security, and allow accurate control of the tension applied.

Technique Pass a single doubled-over suture around the tissues to be opposed. This results in a doubled suture running around the tissues, with two free ends on one side, and a loop on the other (Fig. 5.A1). Throw a simple half hitch (Fig. 5.A2) and then pass the two free ends of the suture through the loop (Fig. 5.A3). Dress the knot that is now ready to be tightened (Fig. 5.A4). Tighten the knot by pulling the two free ends apart from each other, which results in the knot sliding down (Fig. 5.A5). Alternatively, to tighten the knot, the free ends can be pulled alternatively, or the knot can be slid down as with other sliding knots. Finally secure the knot by throwing three alternating half hitches (Fig. 5.A6).

FIGURE 5.A1

FIGURE 5.A2 P.97

FIGURE 5.A3

FIGURE 5.A4

FIGURE 5.A5

FIGURE 5.A6 This knot has several specific characteristics: First, it uses a doubled-over strand of suture. This immediately results in effective doubling of the strength of the suture, as the tension in each strand is halved, so reducing the risk of breakage. The doubling of the suture also results in increased internal friction, giving excellent loop and knot security. Second, tightening the knot by pulling the free ends apart results in a very similar feel to when tying a flat surgeon's or square knot, allowing accurate tensioning of the suture. Third, the tightening process can be stopped and resumed at any stage as the good loop security of the knot prevents it from slipping. Thus, when repairing any tissue under tension, two or more sutures can be placed in position and the knots prepared on each suture. Provisional tightening can then be performed, and the tissue repair can be adjusted as required before final tightening and locking of the Nice knots. This is in stark contrast to when tying a flat knot, which either requires constant tension on the post strand or immediate locking of the knot.

6 Humeral Shaft Fractures: Open Reduction Internal Fixation Bruce H. Ziran Navid M. Ziran

INTRODUCTION The humerus, like the femur, is a single large tubular bone protected by a large circumferential muscle envelope. Fractures of the humerus are common injuries and account for 2% to 3% of all fractures seen in clinical practice. They follow a classic bimodal distribution with lower-energy injuries in the elderly and higher-energy fractures in younger patients. The humerus is designated as number 1 in the AO/OTA classification, with fractures of the proximal, middle, or distal third assigned a second numeral one, two, or three, respectively. The classification is further subdivided based on articular involvement or complexity into A, B, and C patterns (Fig. 6.1). Most fractures of the humerus occur in the middle one-third and are managed nonoperatively with initial splinting and conversion to a functional brace 10 to 14 days after injury. With nonoperative treatment, nonunion rates are 70 years of age) patient population with displaced and comminuted intra-articular fractures (Fig. 9.2A,B). Within this population, other factors favoring TEA include complex articular fractures in patients with preexisting elbow arthritis (6), advanced age with reduced life expectancy, severe osteoporosis, or pathologic bone. Occasionally, younger patients (1 cm, initial radial shortening >5 cm, intraarticular disruption, associated ulna fracture, and severe osteoporosis (Table 14.3).

Relative Contraindications Patients with medical conditions that prohibit the use of anesthesia, with poor compliance, or with local softtissue problems, such as active infection or complex regional pain syndrome, may not benefit from internal fixation of their fracture (Table 14.4). Additionally, low-demand elderly patients with fracture displacement but good

alignment of the carpus on the forearm may not achieve functional improvement with ORIF, despite radiographic improvement (7). The surgeon must keep in mind that anticipated functional loading, rather than chronological age, should be used to guide treatment decisions. P.255

FIGURE 14.2 The column theory of the distal radius.

TABLE 14.1 Definite Indications for ORIF Radiocarpal subluxation or dislocation Displaced fracture of the radial styloid Rotated fracture of the volar lunate facet Displaced intra-articular fractures seen late (after 3 wk)

TABLE 14.2 Relative Indications for ORIF Bilateral displaced fractures Fractures associated with ipsilateral limb trauma Fractures in the setting of polytrauma Fractures associated with excessive swelling or nerve dysfunction

Open fractures Fractures associated with DRUJ instability Unstable fractures that failed cast immobilization

TABLE 14.3 Radiographic Signs of Instability Dorsal comminution >50% Palmar metaphyseal comminution Dorsal tilt >20 degrees Fragment translation >1 cm Radial shortening >5 cm Intra-articular disruption Associated ulna fracture Severe osteoporosis

TABLE 14.4 Relative Contraindications to ORIF Patients with medical conditions that prohibit anesthesia use Poor patient compliance Poor local soft-tissue conditions or complex regional pain syndrome

P.256

PREOPERATIVE PLANNING As with any musculoskeletal injury, a careful evaluation of the patient's overall condition, as well as that of the involved limb and hand, must be made before a decision is rendered to proceed with operative intervention. The fracture characteristics are not always easily appreciated before the fracture is reduced and repeat x-rays are taken. Furthermore, additional x-ray views, including oblique views that focus on the articular surface or computed tomography (CT) scanning, may further influence the decision about treatment (8). A thorough evaluation of the imaging studies preoperatively helps in determining which reduction maneuvers may be necessary, and whether fixation of the fracture will require a special exposure or additional equipment. For particularly complex fractures, a preoperative template may be useful (Fig. 14.3). When the fracture involves impacted articular fragments and/or extensive metaphyseal comminution, the potential for autogenous, allogeneic, or bone-substitute grafts should be noted in the preoperative plan. In these cases, the patient should also be informed that bone grafting may be necessary.

OPERATIVE TECHNIQUES ORIF of the distal radius is generally performed as outpatient surgery with regional anesthesia, pneumatic tourniquet control, and the involved limb extended on a hand table. A parenteral antibiotic, usually cefazolin, is given at least 30 minutes prior to incision as prophylaxis against surgical site infection. A surgeon-operated miniC-arm fluoroscopy unit is used throughout the procedure to confirm fracture reduction and hardware placement. Distal radius fractures may be operatively approached through several different exposures, which will be highlighted here with emphasis on the pearls and pitfalls of each.

Volar Approach The uncomplicated volar shearing, as well as the extra-articular, volar-displaced Smith's, and many dorsally displaced fractures may be approached through the modified Henry approach to the distal radius (Fig. 14.4). P.257 An advantage of a volar approach is the surgeon's ability to judge rotational alignment as well as length by reducing the volar cortical fracture lines as this area is not usually comminuted even in impacted, dorsally displaced fractures. The modified Henry approach exploits the interval between the radial artery and the flexor carpi radialis (FCR). The incision is marked out directly over the FCR, which is almost always palpable, beginning approximately 5 cm proximal to the distal wrist crease.

FIGURE 14.3 Preoperative template for ORIF of a distal radius fracture.

FIGURE 14.4 A-C. Volar modified Henry approach to the distal radius. At the distal wrist crease, the incision is angled ulnarly to avoid crossing the crease at a 90 degrees. The skin and volar sheath of the FCR are incised, the FCR tendon is retracted, and the dorsal sheath of the FCR is incised. P.258 Then the muscle belly of the flexor pollicis longus is retracted to expose the pronator quadratus. The pronator is sharply elevated in an L fashion to expose the distal radius and the fracture site, with the longer limb generally from the radial aspect of the radius and the shorter limb just proximal to the radiocarpal joint. A needle placed into the radiocarpal joint can help define exactly where the shorter limb should lie. Whenever possible, the proximal pedicle of the anterior interosseous artery should be preserved to maintain muscle viability and limit the potential for a pronation contracture that develops due to ischemia of the pronator quadratus (Fig. 14.5).

FIGURE 14.5 An unstable fracture in a 54-year-old woman. A. Initial radiographs of the wrist demonstrate an intra-articular fracture of the distal radius. B. Planned incision. C. The approach is carried out directly onto the FCR tendon. D. Exposure of the pronator quadratus. E. Exposure of the fracture site. P.259

FIGURE 14.5 (Continued) F. A K-wire can be inserted into the radiocarpal joint. G. Reduction of the fracture using an osteotome to elevate the distal fragment. H. A locked plate is applied to the volar distal radius and held in position with K-wires. I. Mini-C-arm fluoroscopy is used to check the positioning of the plate. J. Fluoroscopy imaging demonstrates excellent positioning of the plate. P.260

FIGURE 14.5 (Continued) K. The initial screw is placed in the proximal oval hole. L. Final appearance of the plate and screws. M. The pronator quadratus is repaired, if possible, using 2-0 Vicryl suture. N. Postoperative radiographs. Relatively complex fractures associated with high-energy trauma or those involving a small, displaced volar lunate facet fragment are better exposed through an extended ulnar-based incision that creates an interval between the ulnar nerve and artery and the flexor tendons. Extending this incision distally to release the transverse carpal ligament will further facilitate exposure (Fig. 14.6). Orbay (9) developed an extensile approach to the volar distal radius. By extending the Henry approach more distally, the surgeon releases the fibrous septum overlying the FCR and step cuts the insertion of the brachioradialis tendon, which permits further displacement of the distal fragment and allows for exposure of the dorsal surface of the distal fragment (Fig. 14.7). Irrespective of the approach, the vast majority of fractures can be reduced intraoperatively using longitudinal traction and direct digital manipulation of the distal fracture fragment(s). The locked-screw application of implants contoured to the specific anatomy of the volar surface of the distal radius increases the stability of fixation. The distal screws, if placed in the subchondral position, further enhance the stability of fixation, especially in osteopenic bone.

Proper intraoperative fluoroscopy is essential to avoid inadvertent penetration of the articular surface during volar plate fixation of the distal radius (10,11). One way to accomplish this is to always place the distal ulnar screws first and check their placement on fluoroscopy (with the beam 20 degrees inclined from distal to proximal to visualize the articular reduction) before proceeding with placement of the radial-sided screws. This allows an unobstructed fluoroscopic view of the initial screw placement. P.261

FIGURE 14.6 A. Extensile volar ulnar approach for complex high energy articular fractures. B. Approach to the transverse carpal ligament and interval between the ulnar artery and nerve and flexor tendons seen in crosssection. C. Release of the pronator quadratus from the ulna.

FIGURE 14.7 A-E. The extensile FCR exposure developed by Orbay involves distal release of the FCR septum, which permits wide exposure of the anterior surface as well as the ability to gain access to the dorsal surface of the distal fragment. P.262

FIGURE 14.7 (Continued)

Whenever possible, the pronator quadratus should be reapproximated, which provides muscle coverage over the implant. The wound is irrigated and closed, and a bulky postoperative dressing is placed, which incorporates a light volar wrist splint with the fingers left free. Several specific fracture patterns have potential pitfalls that may lead to loss of reduction or problems with internal fixation via a volar approach: 1. When approaching the displaced volar fracture in the older patient, one must suspect an element of dorsal cortical comminution, even if it is not apparent on the lateral x-ray. In the presence of dorsal comminution, an implant applied as a buttress to push up the displaced volar distal fragment has the potential to translate the fragment dorsally. This may cause loss of the normal volar tilt of the distal articular surface (Fig. 14.8). 2. The volar shearing radiocarpal fracture subluxation (Barton's fracture) most often has two or more distal fracture fragments. In some, the volar ulnar component may be relatively small. Failure to support this fragment can result in postoperative volar subluxation of both the small fragment as well as the carpus (Fig. 14.9). Anatomically, the very distal articular rim of the radius dips anteriorly both at the radial styloid as well as at its most ulnar aspect. Therefore, one implant may be unable to support the entire distal articular rim adequately (12). 3. When stabilizing a three- or four-part articular fracture through an volar approach, the radial styloid (column) component may not be protected against shearing forces when a single volar implant is utilized. In these instances, an additional small contoured radial implant can be applied through the same exposure by stepcutting the brachioradialis insertion (Fig. 14.10). In addition, the volar lunate articular facet fragment may be found to be rotated with minimal subchondral bony support (13). One option is to loop a wire through the volar capsular attachments to the fragment and through a hole drilled transversely in the distal radius metaphysic (Fig. 14.11) (14).

DORSAL APPROACH Although the use of contoured locking plates has enabled many fracture patterns to be treated with volar plating, there remain several indications for dorsal plating of the distal radius. These include shear fractures of the radial styloid with associated articular impaction, some complex four-part intra-articular fractures in which the dorsal lunate facet fragment cannot be reduced from a volar approach, fractures with associated intercarpal ligament disruptions, and some dorsally displaced fractures that present >3 weeks postinjury. Several surgical approaches can be used to access the dorsal aspect of the distal radius. For fractures of the radial styloid, a dorsal radial incision can be used to create exposure between the first and second extensor compartments. Care must be taken to avoid injury to the branches of the radial sensory nerve. For a broader approach to the dorsal aspect of the distal radius, the incision should be placed more dorsally. The extensor retinaculum is opened between the third and fourth extensor compartments. The fourth extensor compartment is elevated subperiosteally toward the ulnar fragment. The second extensor compartment can also be elevated subperiosteally. The exposure to the dorsoradial and intermediate columns can also be made through two incisions in the extensor retinaculum. One is between the first and second compartments, and the other is between the fourth and fifth compartments. P.263

FIGURE 14.8 A. A complex articular fracture in an older age patient. B. Loss of volar tilt due to unstable fixation. For the most part, fracture reduction can be accomplished by longitudinal traction and direct manipulation of the fracture fragments. A central articular impaction, however, may be ineffectively reduced with traction alone. In this case, the impaction is directly elevated through the fracture site, and an arthrotomy of the radiocarpal joint is needed to directly visualize the articular reduction. Direct visualization of the articular surface is also advisable in cases of intercarpal ligament injury. For difficult reductions, the use of either an external fixator or finger traps for traction can be considered. This is especially useful for fractures seen late or those associated with soft-tissue swelling. Additionally, provisional fixation with smooth Kirschner (K) wires is important with unstable articular fractures. This helps control the reduction when using intraoperative image intensification. There are a number of options for internal fixation via the dorsal aspect of the distal radius. The concept of “fracture-specific fixation” guides fixation by using small, strategically placed implants to support the specific fracture fragments. These include anatomically shaped plates, pins, and wire forms.

P.264

FIGURE 14.9 Postoperative volar subluxation of the radiocarpal joint. A. Shearing radiocarpal fracture subluxation with small lunate facet fragment. B. Immediate postoperative radiographs. P.265

FIGURE 14.9 (Continued) C. Subluxation of the radiocarpal joint noted at 2 weeks caused by failure to support the lunate facet fragment. D. Clinical appearance.

FIGURE 14.10 Complex articular fractures involving both the radial and intermediate columns can be stabilized from the volar approach using a radial column plate and volar surface plate. P.266

FIGURE 14.11 Fixation of a displaced, rotated, volar, ulnar, lunate-facet fragment can be done using a small gauge wire looped through the volar capsule and radius in a figure-of-eight fashion. A. Preoperative x-ray and CT scan reveal a displaced, volar, lunate facet. B. The radial styloid and dorsal lunate facet could be reduced and held with K wires, but the volar lunate facet required open reduction and wire loop fixation. P.267

FIGURE 14.11 (Continued) C. Healed fracture at 1 year. D. Clinical wrist motion. A metaphyseal defect underlying an articular fragment and/or concerns for the stability of the internal fixation necessitates additional support. This can be done with either autogenous bone graft, bone substitute, or allograft. A bone substitute such as Norian (Synthes, West Chester, PA) works well. Following anatomic reduction and stable fixation, the extensor retinaculum is closed, leaving the extensor pollicis longus free outside of the retinacular closure. Then, as with fractures treated via a volar approach, the wound is irrigated and closed, and a bulky postoperative dressing is placed, which incorporates a light volar wrist splint with the fingers free.

FIXATION OF DISTAL RADIOULNAR JOINT INSTABILITY At the conclusion of any operation for a fracture of the distal radius, stability of the DRUJ must be confirmed. This is done by taking the forearm through a full range of pronation and supination while palpating the ulnar styloid for any gross movement. True instability of the DRUJ is rare following stable fixation of the distal radius, but if present is best treated by operative fixation. If an ulnar styloid fracture is present, this can be accomplished

by fixation of the ulnar styloid. If not, then operative repair of the triangular fibrocartilage complex may be warranted. An additional exposure is necessary to address fractures of the distal ulna. A longitudinal incision is created along the diaphysis of the ulna. Remember that the ulnar styloid lies relatively anterior to the ulnar diaphysis. P.268

POSTOPERATIVE MANAGEMENT Postoperatively, the wrist is supported in a bulky postoperative dressing with a volar plaster splint incorporated for the first 7 to 10 postoperative days. During this period, the patient is encouraged to mobilize the upper limb, regain digital mobility, and incorporate the hand and limb in activities of daily living. In those patients in whom DRUJ instability is present, the forearm is also immobilized for 14 to 21 days. During this initial recovery period, antiedema measures are encouraged, including elevation, digital mobilization, and elastic wrapping as needed. The avoidance of excessive digital swelling and early range of motion of the fingers are key to a successful initial recovery. After 7 to 10 days the postoperative dressing and splint are removed and the patient is encouraged to begin active wrist and forearm range of motion, generally under the guidance of an occupational or physical therapist. Resistive activities are begun once healing is assured, generally around 6 to 8 weeks. Patients often need exercises for strength and motion for at least 3 months postoperatively, with a functional end point often reached only after 12 to 18 months.

COMPLICATIONS Complications following operative treatment of distal radius fractures are well recognized. These include loss of fixation, infection, nerve compression, complex regional pain syndrome, and digital and/or wrist stiffness (15, 16 and 17). With the increasing popularity of volar plating of the distal radius, there is increasing recognition of complications specifically associated with this approach. There have been numerous reports of flexor tendon irritation and rupture since volar plating has become more widely used, presumably related to impingement of the volar plate on the flexor tendons (18, 19, 20, 21, 22 and 23). Similarly, screws that protrude out of the dorsal cortex of the distal radius may lead to irritation and rupture of extensor tendons (24,25). Additionally, the inadvertent retention of angled drill guides is a complication unique to locked plating (26,27). There is some debate over the proper course of action following this complication. Certainly the patient must be informed of the risk of flexor tendon rupture. Then, the patient and surgeon together can decide whether and when to return to the operating room for removal. Careful patient selection, preoperative planning, technical care in fixation, and careful postoperative management will help minimize these adverse outcomes.

REFERENCES 1. Koval KJ, Harrast JJ, Anglen JO, et al. Fractures of the distal part of the radius. The evolution of practice over time. Where's the evidence? J Bone Joint Surg Am 2008;90(9):1855-1861. 2. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am 2009;91:1868-1873. 3. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early

function: a preliminary report of 20 cases. J Bone Joint Surg Br 1996;78(4):588-592. 4. Fernandez DL. Fractures of the distal radius. Operative treatment. Instr Course Lect 1993;42:73-88. 5. Ruedi TP, Murphy WM, eds. AO principles of fracture management. New York: Thieme; 2000:362. 6. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006;88(9):1944-1951. 7. Synn AJ, Makhni EC, Makhni MC, et al. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop Relat Res 2009;467(6):1612-1620. 8. Arona S, Grover SB, Batra S, et al. Comparative evaluation of postreduction intra-articular distal radial fractures by radiographs and multidetector computed tomography. J Bone Joint Surg Am 2010;92(15):25232532. 9. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5(2):103112. 10. Tweet ML, Calfee RP, Stern PJ. Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius. J Hand Surg Am 2010;35(4):619-627. Epub 2010 Mar 3. 11. Soong M, Got C, Katarincic J, et al. Fluoroscopic evaluation of intra-articular screw placement during locked volar plating of the distal radius: a cadaveric study. J Hand Surg Am 2008;33(10):1720-1723. 12. Harness N, Jupiter J, Fernandez D, et al. Loss of fixation of the volar lunate facet after volar plating of distal radius fracture. J Bone Joint Surg Am 2004;86:1900-1908. 13. Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop 1986;202:103-111. 14. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand Surg Am 1999;24(3):525-533. 15. Cooney WP III, Dobyns JH, Linscheid RL. Complications of Colles' fractures. J Bone Joint Surg Am 1980;62(4): 613-619. 16. Frykman G. Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function: a clinical and experimental study. Acta Orthop Scand 1967;108:5- 153. 17. Jupiter JB, Fernandez D. Complications of distal radius fractures: instructional course lectures. J Bone Joint Surg 2001;83:1244-1265. P.269

18. Lifchez SD. Flexor pollicis longus tendon rupture after volar plating of a distal radius fracture. Plast Reconstr Surg 2010;125(1):21e-23e. 19. Adham MN, Porembski M, Adham C. Flexor tendon problems after volar plate fixation of distal radius fractures. Hand 2009;4(4):406-409. Epub 2009 Mar 13. 20. Yamazaki H, Hattori Y, Doi K. Delayed rupture of flexor tendons caused by protrusion of a screw head of a volar plate for distal radius fracture: a case report. Hand Surg 2008;13(1):27-29. 21. Cross AW, Schmidt CC. Flexor tendon injuries following locked volar plating of distal radius fractures. J Hand Surg Am 2008;33(2):164-167. 22. Duncan SF, Weiland AJ. Delayed rupture of the flexor pollicis longus tendon after routine volar placement of a T-plate on the distal radius. Am J Orthop 2007;36(12):669-670. 23. Valbuena SE, Cogswell LK, Baraziol R, et al. Rupture of flexor tendon following volar plate of distal radius fracture. Report of five cases. Chir Main 2010;29(2):109-113. Epub 2010 Feb 6. 24. Bianchi S, van Aaken J, Glauser T, et al. Screw impingement on the extensor tendons in distal radius fractures treated by volar plating: sonographic appearance. AJR Am J Roentgenol 2008;191(5):W199-W203. 25. Hattori Y, Doi K, Sakamoto S, et al. Delayed rupture of extensor digitorum communis tendon following volar plating of distal radius fracture. Hand Surg 2008;13(3):183-185. 26. Lucchina S, Fusetti C. Is early hardware removal compulsory after retention of angled drill guides in palmar locking plates? The role of pronator quadratus reconstruction. Chin J Traumatol 2010;13(2):123-125. 27. Bhattacharyya T, Wadgaonkar AD. Inadvertent retention of angled drill guides after volar locking plate fixation of distal radial fractures. A report of three cases. J Bone Joint Surg Am 2008;90(2):401-403.

15 Femoral Neck Fractures: Open Reduction Internal Fixation Dean G. Lorich Lionel E. Lazaro Sreevathsa Boraiah

INTRODUCTION Approximately 50% of all hip fractures involve the intracapsular femoral neck (1,2). The total number of hip fractures is projected to increase from approximately 1.5 million in the year 1990 to 6 million by 2050 (3, 4 and 5). The United States has the highest incidence of hip fracture rates worldwide, with an age-adjusted annual incidence of 725 per 100,000 population (4,6). On a per-person basis, hip fractures are the most expensive fracture to treat (7, 8 and 9), with annual estimate hospital cost per hip fracture patient of $25,000 and rising (7,8,10,11). Femoral neck fractures are periarticular injuries where anatomic reduction and normal hip function are often sacrificed to maximize the potential for fracture healing. Traditionally internal fixation has utilized with either a sliding hip screw and side plate or multiple cannulated parallel lag screws (12) (Fig. 15.1). Although there is evidence documenting the superiority of parallel lag screw placement compared with other implants (13, 14, 15 and 16), controversy remains as to the optimal treatment of choice (17). Implants that allow sliding permit dynamic compression at the fracture site during axial loading, but some shortening of the femoral neck invariably follows. Until recently, a healed femoral neck fracture without implant failure or the development of avascular necrosis (AVN) was considered a success (Fig 15.1). Healing, however, comes at the expense of a shortened femoral neck. This impacts the biomechanics of the hip joint, which is either accepted or overlooked. The negative impact of altered hip mechanics following fracture has been studied and reported. Femoral neck shortening was shown to be associated with significantly lower physical function on SF-36 subscores (18). It has also been shown to correlate with decreased quality of life (19). P.272 This leads us to believe that anatomic reduction and internal fixation, which is maintained through fracture healing, is critical for successful outcomes. With an increased emphasis on preservation of hip function, understanding the pathomechanics and preservation of hip anatomy is imperative to restore in order to maximize the chance of a successful outcome. Anatomic reduction with intraoperative compression using length-stable devices to maintain the reduction can lead to high union rates with minimal shortening and better functional outcome.

FIGURE 15.1 AP radiographic view demonstrating two sliding constructs that healed in a shortened fashion. There is a large body of literature that documents high complication and reoperation rates following internal fixation of intracapsular femoral neck fractures (20). This may be related to both mechanical and biological problems related to femoral neck fracture healing. The femoral neck is intracapsular, is bathed in synovial fluid, and lacks a periosteal cambium layer that is necessary for callus formation. From a structural standpoint, the bone screw interface is strongest immediately after surgery and weakens over time. Restoring anatomic fracture reduction often requires direct visualization prior to fixation. The most widely used classification for femoral neck fractures is the Garden classification. However, this classification scheme is based on the anteroposterior (AP) radiographs alone and does not consider the lateral or sagittal plane alignment. Recent studies have shown posterior roll off or angulation of the femoral head leads to increased reoperation rates (21, 22 and 23) (Fig. 15.2). P.273 The authors report a 56% reoperation rate if the posterior tilt is >20 degrees (21). If anatomic reduction is the goal, it is important to address malalignment in all planes. We believe that the best and most consistent approach to achieve an anatomic reduction of this difficult fracture is through open reduction, direct visualization, and fixation of the fractures.

FIGURE 15.2 A. Anterposterior radiographic view demonstrating a valgus impacted femoral neck fracture. Lateral radiographic view (B) and axial CT view (C) demonstrating posterior roll-off of the femoral head not appreciated on the AP radiographic view.

INDICATIONS AND CONTRAINDICATIONS The indications for open reduction and internal fixation (ORIF) of femoral neck fractures continue to expand. It is important to distinguish between low-energy fragility fractures in elderly patients and younger patients with highenergy femoral neck fractures since the approach to treatment and methods of fixation vary. For geriatric patients with mechanical ground level falls, a complete assessment of the patients' status is helpful in selecting surgical options. In this group of patients, our treatment algorithm is as follows: (a) ORIF is indicated for most patients 85 years with a Garden I or II fractures should also be considered for ORIF. Garden III and IV fractures in this age group are treated with arthroplasty. When assessing the physiological age of a patient, one should consider multiple factors including, but not limited to, chronological age, preinjury activity level, preinjury ambulatory status, and potential patient compliance. Regardless of the fracture pattern, in patients presenting with significant medical comorbidities, advanced physiologic age, degenerative changes of the femoral head, or pathological fractures, hip arthroplasty should be considered. There is a large body of literature that supports the use of hemiarthroplasty or total hip arthroplasty in these situations (24). These are only guidelines for treatment, and the surgical treatment must be individualized to every patient. For nondisplaced and Garden I femoral neck fractures, we usually perform in situ fixation using a percutaneous approach to relieve pain, permit mobilization, and decrease the small chance of further fracture displacement. There are several randomized controlled trials comparing closed reduction and screw fixation with arthroplasty for displaced femoral neck fractures in the elderly. These studies report fewer complications and better outcomes with arthroplasty. However, there are no studies that we are aware that compare open reduction and lengthstable internal fixation to arthroplasty for comparable fractures.

PREOPERATIVE PLANNING History and Physical Examination

A thorough history and physical examination is essential. In geriatric hip fracture patients, a complete medical assessment and risk stratification should be performed with the assistance of an internal medicine specialist. On physical exam, the affected leg is usually externally rotated and shortened. Movement of the limb is painful, and range of hip and knee motion is resisted by the patient secondary to pain. A thorough neurovascular examination and assessment of the soft tissue and the skin should be made. Cutaneous bruises indicate that the patient may be anticoagulated. Traction has not shown to be of any benefit. A knee immobilizer may be helpful to immobilize and relieve pain. In younger patients (36 mm is chosen; however, a regular HMWP cup can be used if a 32 or 28 mm head has been selected. Once the permanent components have been implanted, a final trial with the selected head and neck length can be performed before the final head and neck are implanted. Following reduction, hip stability, and leg lengths are checked one last time. To be slightly long in leg length by design is professionally acceptable. To be long by happenstance is not acceptable. Wound closure is very important. The posterior hip capsule should be closed to cover the femoral head. This helps decrease dead space and has been shown to reduce the rate of dislocations. The piriformis tendon along with the gemellus muscles and obturator internus is repaired to the back of the trochanter or the abductor tendon in a pants-over-vest repair. The sciatic nerve should be examined or palpated to make sure it is intact and uninjured. If a drain is used, it should be inserted beneath the fascia latae. The tensor fascia latae is closed with heavy interrupted figure-of-eight sutures. The subcutaneous layer is closed with number 2-0 absorbable suture and the skin approximated with skin staples.

Postoperative Care Patients are allowed to be weight bearing as tolerated using a walker or crutches immediately after surgery. Balance is a major problem in this age group, and the use of walking aids is necessary until muscle rehabilitation P.303 and balance have been reestablished. This is a very different group from the elective total hip population. Drains, if utilized, should be removed at 24 to 48 hours. At 6 weeks, most patients can progress to a single or quad cane. By 12 weeks, most patients can be permitted to ambulate without assistive devices if they were able to do so before their fracture. Patients are seen in the clinic at 2 weeks for wound inspection and suture removal. Clinical follow-up is done at 3, 6, and 12 months postoperatively. Chemical deep vein thrombosis (DVT) prophylaxis (CHEST or AAOS guidelines) is started on the first postoperative day and continued as an outpatient for 14 to 28 days following discharge.

FIGURE 16.37 Seating of the femoral component.

FIGURE 16.38 The head and neck trial used to ensure proper length, offset, and stability.

Complications Complications can be divided into disease-specific and general complications. Hip fracture patients are more prone to confusion and delirium in the postoperative period. Supplemental nasal oxygen has been shown to reduce the potential for patient confusion during the first 48 hours postoperatively. General complications such as pneumonia, cardiac failure, DVT, pulmonary embolism, atrial fibrillation, and urinary tract infections require prompt diagnosis and treatment in collaboration with medical specialists. Prevention of dislocation of the hip is a team responsibility and involves the surgeon, orthopedic nurses, physiotherapist, occupational therapist, and the family.

Postoperative Wound Infection Streptococcus and Staphylococcus account for almost 85% of postoperative wound infections. Gram-negative and mixed microbial infections account for the remaining 15%. Presentation is usually with fever, redness around the wound, drainage, or pain with motion of the affected joint. The diagnosis is confirmed with blood tests (high ESR, CRP, and WBC) and a positive joint aspiration. Immediate surgical débridement of the joint combined with 6 weeks of culture-specific intravenous antibiotics has a 60% to 65% chance of success. For infections that occur in the first few weeks, we usually perform a liner exchange as well. Subacute and chronic infections invariably require removal of the prosthesis and an antibiotic spacer with staged reconstruction.

Hip Dislocation Hip dislocation is an uncommon event following arthroplasty, and prevention is the key. A hip dislocation is more common in patients that are treated with THA compared with those receiving a hemiarthroplasty. The initial reports of patients having a total hip replacement for fracture reported dislocation rates as high as 10%; however, more recent reports documented dislocation rates of 2 cm can lead to hip pain and a limp. Nonunion following internal fixation using a sliding hip screw is rare. If symptomatic, they often require revision fixation with or without bone grafting or complex revisions to joint arthroplasty.

REFERENCES

1. Morris AH, Zuckerman JD. National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture. J Bone Joint Surg Am 2002;84(4):670-674. 2. Johnston AT, Barnsdale L, Smith R, et al. Change in long-term mortality associated with fractures of the hip: evidence from the Scottish hip fracture audit. J Bone Joint Surg Br 2010;92(7):989-993. 3. Kesmezacar H, Ayhan E, Unlu MC, et al. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. J Trauma 2010;68(1):153-158. 4. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996;10(Suppl 1):36-40. 5. Skuban TP, Vogel T, Baur-Melnyk A, et al. Function-orientated structural analysis of the proximal human femur. Cells Tissues Organs 2009;190(5):247-255. 6. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am 2008;90(4):700-707. 7. Park SR, Kang JS, Kim HS, et al. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw—a randomised prospective trial. Int Orthop 1998;22(3):157-160. 8. Crawford CH, Malkani AL, Cordray S, et al. The trochanteric nail versus the sliding hip screw for intertrochanteric hip fractures: a review of 93 cases. J Trauma 2006;60(2):325-328; discussion 8-9. 9. Aros B, Tosteson AN, Gottlieb DJ, et al. Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation? Clin Orthop Relat Res 2008;466(11):2827-2832. 10. Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomised trials. Int Orthop 1996;20(3):163-168. 11. Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;;77(7):1058-1064. 12. Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135degree sliding screw with a two-hole side plate. J Orthop Trauma 1999;13(1):5-8.

18 Intertrochanteric Hip Fractures: Intramedullary Hip Screws Michael R. Baumgaertner Thomas Fishler

INTRODUCTION The number of hip fractures in the United States is estimated to be approximately 400,000 per year and will increase 50% by the year 2025. These fractures typically occur in elderly osteoporotic females, with 90% of fractures occurring in patients older than 65 years of age (1). The cost burden exceeds 20 billion dollars annually, which does not include care beyond 1 year from injury. Approximately one in four hip fracture patients requires long-term placement in an assisted care environment, and nearly 50% of these patients do not regain preinjury levels of activity. The 1-year mortality following surgery for a hip fracture remains around 20%. There are numerous classifications for hip fractures. All attempt to distinguish between stable and unstable fracture patterns. Unstable fracture patterns are marked by significant disruption of the posteromedial cortex, subtrochanteric extension, or reverse obliquity in the main fracture line. The AO/OTA classification of these fractures incorporates each of these features, classifying intertrochanteric fractures along a spectrum from most (31A1.1) to least (31A3.3) stable (Fig. 18.1). Stable two-part and some three-part fractures, once reduced, will resist medial and compressive loads and can be treated with either a compression hip screw and side plate or an intramedullary nail. On the other hand, unstable three- and four-part intertrochanteric fractures invariably collapse into varus and shorten, and this is only partially prevented by a sliding hip screw. Even when healing is successfully achieved, limb shortening >2 cm and medialization of the shaft can lead to poor outcomes.

INDICATIONS AND CONTRAINDICATIONS There are two broad categories of implants for the treatment of intertrochanteric hip fractures: a sliding hip screw and side plate and a cephalomedullary nail. A sliding hip screw and side plate remains the implant of first choice for stable two-part fractures, and multiple studies have shown no advantage with the use of an intramedullary device in this subgroup (2, 3, 4 and 5). Cephalomedullary nailing is indicated in unstable intertrochanteric hip fractures, particularly those with subtrochanteric extension and reverse oblique fracture patterns (AO/OTA 31A3). An additional indication for nailing is an impending or pathologic fracture of the proximal femur. Contraindications to the use of a cephalomedullary nail include fractures of the femoral neck, deformities within the femoral shaft including preexisting implants, and hip ankylosis. A relative contraindication is the young trauma patient because of concerns regarding removing substantial bone from the trochanteric block in order to accommodate these large implants. P.318

FIGURE 18.1 The AO/OTA classification of intertrochanteric hip fractures. Cephalomedullary nails direct a screw(s) or a triflanged blade into the femoral neck and head through a variable length intramedullary nail. Implant insertion can be performed in a closed, percutaneous manner, minimizing surgical trauma at the fracture site, and reducing intraoperative blood loss. The device functions as an intramedullary buttress, maintaining length and alignment while restoring the mechanical support of the posteromedial cortex, preventing shaft medialization.

PREOPERATIVE PLANNING History and Physical Examination Elderly patients typically present after a mechanical ground level fall and are unable to stand or walk. It is important to obtain a thorough medical and social history, which includes associated medical history and the patient's ambulatory status. On physical examination, the affected extremity is usually shortened and P.319 externally rotated. There is exquisite tenderness to palpation around the hip and proximal thigh, and any

movement in the extremity is painful. It is important to assess and to document the neurovascular examination as well as to rule out any associated injuries. Consultation with an internal medicine specialist is recommended to optimize the patient for surgery. Dehydration and associated metabolic abnormalities are common and should be corrected preoperatively. Diabetic patients must have good perioperative glucose control. Patients on anticoagulation therapy require temporary normalization of their clotting parameters prior to surgery. Prophylaxis against venous thromboembolism should take into account the relative risks of pulmonary embolism and bleeding complications. The choice of pharmacologic agent remains contoversial, but mechanical prophylaxis is indicated for all patients. Antiplatelet agents are usually stopped preoperatively but restarted shortly after surgery (6).

Imaging Studies The diagnosis of an intertrochanteric hip fracture is generally confirmed with standard anteroposterior (AP) and cross-table lateral radiographs of the hip. Additional x-rays, including an AP pelvis, centered over the pubic symphysis and full-length radiographs of the entire femur, should be obtained because deformities in the shaft may preclude the use of an intramedullary device. Internal rotation and traction radiographs are invaluable for understanding the fracture anatomy as well as the success of the anticipated closed reduction. Occasionally, xrays of the unaffected hip and femur are useful for preoperative planning. Computed tomography is not usually necessary but is obtained in complex fractures on a case-by-case basis.

Timing of Surgery In all cases, medical optimization should be expeditious, as mortality is increased when surgery is delayed beyond 48 to 72 hours from admission (7). Surgery is ideally performed during daylight hours with a rested team, 7 days a week. On the other hand, optimization efforts can and should be performed through the nighttime hours; as a result, we most commonly perform the procedure on the day following hospital admission. Occasionally, this timetable is altered by the need to correct coagulopathy or perform more involved preoperative medical studies.

Surgical Tactic Careful examination of the preoperative radiographs as well as x-rays of the unaffected hip are important parts of the preoperative plan and help guide implant selection with respect to the neck-shaft angle, diameter, and screw length. The nail-screw angle of the device should match the neck-shaft angle of the desired reduction. The most common configuration is a 135-degree neck angle with a 95-mm lag screw. It is important to note that the nail is not designed to fill the canal. Although first-generation short-stem implants were associated with an unacceptably high rate of subsequent femoral fracture, a recent meta-analysis showed no increased relative risk for this complication when intramedullary devices were compared to side plates (8). We use a full-length intramedullary nail in pathologic fractures and in patients with subtrochanteric extension. For the majority of patients, we use a short nail that facilitates distal locking through a nail mounted jig. Other authors advocate the use a full-length implant to protect the entire femur for all cases.

Surgical Technique Surgery is performed under a general or spinal anesthetic. While general anesthesia allows for complete muscle relaxation, it carries a higher risk of perioperative morbidity and mortality, particularly in the elderly hip fracture patient with multiple medical comorbidities. A decision on the method of anesthesia should be made in collaboration with the surgeon, anesthesiologist, and consulting internal medicine specialist. The preoperative prophylactic antibiotic of choice is a first-generation cephalosporin. In cases of penicillin allergy, a suitable alternative, typically vancomycin or clindamycin, is given. We prefer to use an orthopedic table that allows for balanced traction to be applied to both lower extremities, but a fracture table may be used as well. A well-padded post is placed in the perineum. Both lower extremities are secured to the table, and traction is applied. The operative side is adducted and slightly flexed at the hip and the

unaffected leg abducted and extended to allow for lateral plane fluoroscopic imaging (Fig. 18.2B,C). “Scissoring” the extremities in such a way prevents the pelvis from rotating on the perineal post as traction is applied to the fractured limb, which can lead to a varus reduction (Fig. 18.3). Once the patient has been securely positioned on the table, the fracture is reduced. There are two goals, the first of which is to gain access to the starting point in the proximal femur, the second being anatomic reduction of the fracture. Most stable fracture patterns will reduce with longitudinal traction and internal rotation of the limb. However, unstable intertrochanteric fractures may require different maneuvers, such as slight external rotation. A particularly troublesome deformity is subsidence of the proximal fragment into the intramedullary P.320 canal of the distal fragment. The hallmark radiographic sign of a triangular double density, representing the overlap between the fragments, must be recognized, as this deformity is not reducible by manipulative means; here, a percutaneous intrafocal reduction aid as described by Carr is helpful (Fig. 18.4A-E) (9). Prior to prepping and draping the field, we confirm that we can see the following areas with fluoroscopy: the anterior cortex of the proximal femur, the fracture zone, the anterior neck, the entire circumference of the femoral head, the posterior neck, and the greater trochanter.

FIGURE 18.2 A. In the typical position, the patient is supine on the orthopedic table with the torso windswept and the lower extremities in balanced traction. B. The C-arm is positioned on the contralateral side of the patient. C. “Scissoring” of the lower extremities allows for unimpeded lateral fluoroscopic imaging. In considering the reduction, we determine an acceptable neck-shaft angle to be 130 to 145 degrees. Increased

valgus is permissible because it reduces the bending forces on the implant and may offset limb shortening that occurs with fragment impaction. Loss or gain of femoral anteversion >15 degrees, as seen on the lateral view, is unacceptable. Once a provisional reduction has been achieved, the surgical field is prepped and draped in a standard sterile fashion. It is important to prep below the level of the knee in the event that a long nail is used that requires a distal interlocking screw. We use a sterile shower-curtain-type drape but add an extra sterile layer proximally to protect against puncture hole contamination from the instruments. If the closed reduction is inadequate, a number of percutaneous maneuvers may be attempted, utilizing such tools as the ball spike pusher, collinear clamp, and cerclage wire to improve the reduction (Fig. 18.5A-C). The tip of the trochanter and the femoral shaft axis is marked in both planes with a sterile skin marker under fluoroscopy (Fig. 18.6). This provides a visual aid for the correct insertion of the guide pin and the nail. In addition, it helps reduce fluoroscopy time. Prior to instrumenting the proximal femur, the reduction should be verified with biplanar imaging. Using a freehand technique, a 3.2-mm guide pin is inserted percutaneously approximately 5 cm proximal to the greater trochanter, engaging the bone at a point in line with the intramedullary canal, typically just medial to the tip of the greater trochanter. This location will counteract the tendency toward varus and increased neck-shaft offset as well as minimize any damage to the gluteus medius insertion. On the lateral fluoroscopic view, the guide pin should be centered in line with the medullary canal, and on the AP, it should be aimed slightly medial (Fig. 18.7A-B). P.321

FIGURE 18.3 With the application of unopposed traction, the pelvis rotates around the perineal post. The hip abducts, hampering access to the starting point.

FIGURE 18.4 A,B. A double density of the medial cortex corresponds to an intussusception of the neck into the shaft, seen on the lateral x-ray. P.322

FIGURE 18.4 (Continued) C. Traction will not correct the apparent apex posterior deformity, but an intrafocal pin will. D. A levering action disengages the fragments and allows for a line-to-line anterior cortical reduction. E. On the AP view, the medial cortex is restored.

FIGURE 18.5 Percutaneous reduction aids include the (A) ball-spike pusher to correct flexion deformity of the proximal fragment. P.323

FIGURE 18.5 (Continued) B. Colinear clamp with Hohmann-style arm attachment, inserted percutaneously and used to correct varus in a reverse-oblique fracture. C. A small cerclage wire, passed atraumatically, can be a powerful reduction aid, provisional fixation, and adjunctive definitive fixation in fracture patterns with a long subtrochanteric spike. The skin is infiltrated with local anesthetic containing epinephrine, and a 2-cm incision is made along the guide pin, through fascia, and directly onto the greater trochanter (Fig. 18.8). Once the guide pin is properly placed, the proximal femur is opened with a large cannulated drill. We do not use the soft-tissue protector sleeve but rather minimize soft-tissue trauma by advancing the reamer in reverse until it reaches bone. We ream until the widest part of the drill has reached the lesser trochanter (Fig. 18.9A). It is unnecessary to ream to the isthmus unless the medullary canal is exceptionally narrow. In these cases, we employ flexible medullary reamers. It is important that the reamer cuts a channel for the implant rather than displacing the fracture fragments as it passes into the canal (particularly if the guide pin is in the fracture line). Placing firm medial-directed P.324 pressure on the trochanteric mass as well as pushing the reamer medially as it is advanced will ensure

appropriate canal preparation (Fig. 18.9B). An incorrect entry site is more problematic than generous reaming in this patient population.

FIGURE 18.6 Marking of the femoral shaft axis and the tip of the trochanter. The nail is assembled on the driving/targeting device and pushed into the intramedullary canal. Only hand force should be required, forcing the nail with a hammer risks iatrogenic fracture (Fig. 18.10). The nail can be inserted with or without a guide pin. Biplanar fluoroscopy should be checked at this point to ensure that the nail is not exiting the canal through the fracture and that the nail is seated to the correct depth. If the nail does not fully advance but does not appear “tight” on the AP image, the surgeon should check the lateral image to see if the tip of the nail is impinging on the anterior cortex, because many nail systems do not incorporate a sagittal bow. Also, the soft tissues should be checked to ensure that they are not restricting the entrance site. A combination of expanding the entry portal, soft-tissue release, isthmic (flexible) reaming, or implant downsizing usually solves the problem. The correct position for the lag screw is estimated on the intraoperative fluoroscopic views, and a 2-cm skin incision is made in the proximal lateral thigh. It is important to split the deep fascia lata so that the drill sleeve can be placed flush against the lateral cortex of the femur. Taking into account the anteversion of the femoral neck, the surgeon should advance the appropriate guide pin through the jig and nail into the femoral neck and head.

FIGURE 18.7 A. Appropriate guide pin location on the AP view. B. Appropriate guide pin location: centered on the lateral view. P.325

FIGURE 18.8 By keeping the bevel of the blade in contact with the guide pin, a perfectly placed, minimally invasive path is cut for atraumatic passage of the reamer and implant. At this point, we confirm and, when necessary, “fine tune” the reduction. Manipulation of the insertion handle connected to the nail can improve the “sag” or translation on the lateral view. On the AP view, the guide pin acts as an excellent reference because it is 135 degrees to the shaft. If it is parallel to the neck but too superior or inferior in the head, the neck-shaft angle is acceptable. The guide pin is removed, the nail is advanced or backed out slightly, and the pin is reinserted. However, if guide pin is not parallel with the femoral neck, the fracture is

usually in varus. The reduction can often be improved (after removing the guide pin) with increased traction as well as abduction of the extremity. It is very helpful to remember that once the nail is seated in the femur, the adduction necessary to access the entry site is no longer needed. Significant valgus can be achieved by simply abducting the extremity at this point. With the nail seated to the appropriate depth, a 3.2-mm guide P.326 pin is inserted centrally and deep into subchondral bone using both the AP and lateral fluoro images for guidance (Fig. 18.11A,B). The pin should be directed toward the apex of the femoral head, defined as the point where the subchondral bone is intersected by a line parallel to and in the center of the femoral neck. The aim is to minimize the tip-apex distance (TAD), defined as the sum of the distances measured on AP and lateral fluoroscopy between the tip of the screw and the apex of the femoral head. This necessitates both central and deep placement. The known length of the guide pin's threaded tip can serve as a reference when estimating TAD that effectively controls for magnification (Fig. 18.11C). A partially radiolucent aiming jig can make placement of the pin along the axis of the neck on the lateral view considerably easier.

FIGURE 18.9 A. Firm medial pressure is placed to prevent lateral fracture displacement and to assure that a channel for the implant is created. B. Insertion of the proximal reamer so that the widest part is at the level of the lesser trochanter.

FIGURE 18.10 The nail is fully seated in the canal. Once satisfied with the reduction and the position of the guide pin, an auxiliary stabilizing pin for all unstable fractures is placed (Fig. 18.12A,B). This auxiliary pin is directed through the jig such that it avoids the path of the lag screw and locks the jig to the head-neck fragment. The auxiliary pin serves as an antirotation device during screw insertion as well as an independent fracture stabilizer should the guide pin be inadvertently removed while the surgeon is reaming for the lag screw.

FIGURE 18.11 A. Appropriate guide pin placement on the AP x-ray. B. Appropriate guide pin placement on the lateral x-ray. P.327

FIGURE 18.11 (Continued) C. The technique to measure TAD. With the guide pin seated deep into the subchondral bone of the femoral head, we ream 3 to 5 mm short of the subchondral bone. Reamer progress is monitored with spot fluoroscopic images to identify inadvertent binding or advancement of the guide pin as well as to prevent joint penetration. An obturator should be used during removal of the reamer to prevent inadvertent removal of the guide pin. We seldom use a tap because of the bone quality typically seen in this patient population.

FIGURE 18.12 A. Certain implant systems provide a targeting attachment to place the auxiliary stabilizing pin. B. An auxiliary stabilizing pin is added to help control rotation. It is placed out of the path of the lag screw. P.328

FIGURE 18.13 A. The lag screw is seated to the appropriate depth. Image was taken prior to centering of sleeve insertion. B. The centering sleeve is advanced through the lateral cortex and into the nail using the sleeve pusher. The lag screw length is selected so that the distal aspect of the fully seated screw is recessed 5 to 8 mm into the

centering sleeve, exactly as one would do when using a sliding hip screw and side plate. For a 135-degree nail, a 95-mm screw is the most common size. The lag screw is then inserted over the guide pin with the centering sleeve. Once the lag screw has reached the appropriate depth (Fig. 18.13A) and the reduction is verified, the centering sleeve should be advanced though the lateral cortex and into the nail using the sleeve pusher (Fig. 18.13B). The head-neck fragment is typically torqued somewhat as the screw is seated into the dense subchondral bone. In right hips, screw tightening tends to extend the proximal fragment, which often helps correct the common mild extension deformities at the fracture. However, for left-side fractures, the clockwise seating of the screw flexes the hip and worsens such a deformity. We scrutinize the fracture on the lateral fluoroscopic image while slightly rotating the screw insertion handle back and forth (which controls the head-neck fragment) to identify the optimum reduction (Fig. 18.14). The reduced position is then maintained while an AP image is P.329 obtained to confirm the reduction. The sleeve is locked to the nail when it is tightened with the set screw. This locks the rotational reduction but allows unimpeded sliding of the screw within the sleeve.

FIGURE 18.14 A. Lag screw insertion in a left hip showing worsening of extension deformity. B. Rotation of the screw results in fracture reduction.

FIGURE 18.15 A-C. A demonstration of compression screw insertion. Note how the fracture reduces with the applied compression. For most cases, we insert a compressing screw to initiate sliding and increase the immediate stability of the fracture (Fig. 18.15). This also prevents the rare but catastrophic complication of proximal disengagement of the screw from the nail. For length-stable fractures, traction should be released from the extremity prior to considering a distal interlocking screw. We then assess rotational stability by securing the distal extremity and gently rotating the insertion jig. If the fracture fragments move as a unit, we consider distal interlocking optional (Fig. 18.16A,B). If there is any question of motion, a single screw is placed in the dynamic slot using the alignment jig. For length-unstable fractures, two distal interlocking screws are placed through the insertion jig, or, with full-length nails, by a freehand technique. The abductor fascia proximal to the trochanter at the nail insertion site is closed with a heavy absorbable suture. The subcutaneous tissue and skin are closed in layers. The proximal wound is at risk of contamination from a disoriented elderly patient's wandering fingers (Fig. 18.17). A dry sterile dressing is applied with care in consideration of the elderly patient's fragile skin.

P.330

FIGURE 18.16 A,B. AP and lateral postoperative radiographs.

FIGURE 18.17 The two small skin incisions with staple closure. P.331

POSTOPERATIVE MANAGEMENT Patients receive antibiotic prophylaxis for 24 hours, generally with a first-generation cephalosporin. Prophylaxis against deep venous thrombosis is carefully considered with a combination of sequential compression devices

and pharmacologic medication. Patients are mobilized from bed to chair and are gait trained with a physical therapist on the first or second postoperative day, weight bearing to tolerance. Patients are typically discharged to a short-term rehabilitation facility on postoperative day 3 or 4. Patients are seen in the outpatient clinic at 10 to 14 days for suture removal and at 6 and 12 weeks to confirm clinical and radiographic union. All patients who sustain a low-energy fracture of the hip should be evaluated and treated for osteoporosis.

COMPLICATIONS The soft-tissue envelope surrounding the proximal femur is redundant, well vascularized, and forgiving. For these reasons, as well as the low-energy mechanisms that most often cause these fractures, soft-tissue necrosis, wound dehiscence, and surgical site infection are rare following internal fixation. When it occurs, treatment ranges from oral or intravenous antibiotics to surgical débridement, depending on the extent of process. Screw cutout has historically been the primary mode of failure for both compression hip screws and cephalomedullary nails. It may be avoided entirely by appropriate reduction and implant placement. A varus neck-shaft angle universally leads to an increased TAD and an increased offset when an intramedullary device is used. The absolute importance of TAD in predicting screw cut-out with intramedullary devices has been recently confirmed (10). Stiffness of the hip following fixation is commonly encountered but rarely limits function. Excessive collapse of the sliding hip screw, however, does lead to limb length discrepancy and reduced femoral offset, both of which contribute to an asymmetric gait with a limp. It is here where intramedullary nails, which collapse less than a sliding hip screws, provide a superior maintenance of anatomy, particularly in unstable fracture patterns (11). Nonunion is rare in this highly vascularized, metaphyseal, and extracapsular anatomic region. When it occurs, it can be attributed, like screw cut-out, to malreduction or poor implant placement. Additional complications include femoral shaft fracture, fractures below the implant, and painful hardware. A number of techniques, such as conversion to a hip replacement, revision osteosynthesis with a long-stem implant, or open reduction and internal fixation, can be used to address these problems. Fortunately, these complications are uncommon with proper surgical technique and new generation devices (12).

REFERENCES 1. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007;22(3):465-475. 2. Parker MJ, Handoll HH. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2006;3:CD004961. 3. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2008;(3):CD000093. 4. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A metaanalysis of 24 studies involving 3,279 fractures. Int Orthop 2006;30(2):69-78. 5. Saudan M, Lübbeke A, Sadowski C, et al. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and

proximal femoral nail. J Orthop Trauma 2002;16(6):386-393. 6. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed). Chest 2008;133(6 Suppl):299S-339S. 7. Moran CG, Wenn RT, Sikand M, et al. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 2005;87:483-489. 8. Bhandari M, Schemitsch E, Jönsson A, et al. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma 2009;23(6):460-464. 9. Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma 2007;21(7):485-489. 10. Geller JA, Saifi C, Morrison TA, et al. Tip-apex distance of intramedullary devices as a predictor of cutout failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop 2010;34(5):719-722. 11. Hardy DC, Descamps PY, Krallis P, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg Am 1998;80(5):618-630. 12. Utrilla AL, Reig JS, Munoz FM, et al. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma 2005;19(4):229-233.

19 Intertrochanteric Hip Fractures: Arthroplasty George J. Haidukewych Benjamin Service

INTRODUCTION The number of patients treated for intertrochanteric hip fractures continues to increase and represents a significant financial and societal impact. The vast majority of intertrochanteric hip fractures treated with modern internal fixation devices heal. However, certain unfavorable fractures patterns, fractures in patients with severely osteopenic bone, or patients with poor hardware placement can lead to fixation failure with malunion or nonunion. Randomized prospective studies of displaced femoral neck fractures in elderly osteoporotic patients treated with internal fixation have shown high complication rates. For this reason, most surgeons favor arthroplasty, which has fewer complications and offers the advantage of early weight bearing. This has led some surgeons to consider the use of a prosthesis in the management of selected, osteoporotic, unstable, intertrochanteric hip fractures. In theory, this may allow earlier mobilization and minimize the chance of internal fixation failure and need for reoperation. The use of arthroplasty in this setting, however, poses its own unique challenges including the need for so-called calcar replacing prostheses, and it raises questions regarding the need for acetabular resurfacing and the management of the often-fractured greater trochanteric fragment. The purpose of this chapter is to review the indications, surgical techniques, and specific technical details needed to achieve a successful outcome. Also addressed are the potential complications of hip arthroplasty for fractures of the intertrochanteric region of the femur.

INDICATIONS The overwhelming majority of intertrochanteric hip fractures, whether stable or unstable, will heal uneventfully when the procedure is performed correctly, using modern internal fixation devices. Both intramedullary nails and a compression screw and side plate have proven safe and effective. Several European studies have found that hip arthroplasty can lead to successful outcomes; however, there is a higher perioperative mortality rate among these patients compared to those who undergo internal fixation. In North America, the indications for hip arthroplasty for peritrochanteric fractures include patients with neglected intertrochanteric fractures (>6 weeks) when attempts at open reduction and internal fixation (ORIF) are unlikely to succeed; pathologic fractures due to neoplasm (primarily metastatic disease); internal fixation failures or established nonunions where the patient's age or proximal-bone stock precludes revision internal fixation; and in patients with severe preexisting, symptomatic osteoarthritis of the hip with an unstable fracture pattern. Recent studies have documented that hip arthroplasty for salvage of failed internal fixation provides predictable pain relief and functional improvement.

PATIENT EVALUATION AND PREOPERATIVE PLANNING Because these patients are typically elderly and frail with multiple medical comorbidities, a thorough medical evaluation is recommended. Preoperative correction of dehydration, electrolyte imbalances, and anemia is important. In acute cases, surgery is performed within 48 hours of injury to avoid prolonged recumbency P.334 following medical consultation. When done as a reconstruction procedure, it is scheduled as an elective procedure similar to a total hip.

Plain anteroposterior (AP) and lateral radiographs of the hip, femur, and pelvis are important for preoperative planning. If the surgeon has any concern regarding the possibility of a pathologic fracture, computed tomography (CT) or magnetic resonance imaging (MRI) scanning can be helpful. If a pathologic fracture due to metastasis is diagnosed, full-length femur radiographs are critical to rule out distal femoral lesions that would impact treatment. Appropriate imaging of the proximal fragment is important to allow templating of the femoral component for length and offset as well as to determine whether a proximal calcar augmentation will be necessary to restore the anatomic neck-shaft relationship. Careful scrutiny of the hip joint is necessary to determine whether a total hip arthroplasty is needed rather than hemiarthroplasty. A final decision is often made intraoperatively after visual inspection of the quality of the remaining acetabular cartilage. If previous hardware from internal fixation is present, implant-specific extraction equipment and a broken screw removal set, with or without the use of fluoroscopy, are invaluable. Obtaining the original operative report can assist the surgeon in determining the implant manufacturer if it is not recognized from the radiographs. Templating cup size and femoral component length and diameter is an important part of the preoperative plan. It is often difficult to determine preoperatively whether hemiarthroplasty or total hip arthroplasty is appropriate, and whether a cemented or uncemented femoral component fixation is necessary. I prefer to have a variety of acetabular resurfacing and femoral-component fixation options available intraoperatively. Although having such a large inventory of implants available for a single case is cumbersome, it is wise to be prepared for unexpected situations that arise during these challenging reconstructions. To evaluate infection as a possible contributing factor in a patient with failed internal fixation, a complete blood count with differential, a sedimentation rate, and a C-reactive protein should be obtained preoperatively. I have not found aspiration to be predictable in the setting of fixation failure and rely on preoperative serologies and intraoperative frozen section histology for decision making.

SURGICAL TECHNIQUE The exact surgical technique will vary, of course, based on whether the reason for performing the arthroplasty is an acute fracture, a neglected fracture, a pathologic fracture, or a nonunion with failed hardware. However, many of the surgical principles are similar regardless of the preoperative diagnosis. General or regional anesthesia is utilized. The patient is placed in lateral decubitus position using a commercially available positioner on the operating room table. An intravenous antibiotic, typically a first-generation cephalosporin, is given. Antibiotics are continued for 48 hours postoperatively until the intraoperative culture results are available and then stopped or continued if the culture is positive. We carefully pad the down side, insert an axillary roll, protect the peroneal nerve area, and ankle to minimize the chance of neurological or skin pressure problems due to positioning. A stable vertical and horizontal position allows the surgeon to improve pelvic positioning, which facilitates proper acetabular-component implantation when necessary. Several commercially available hip positioners are available that provide accurate and stable pelvic positioning. Consideration should be given to the use of intraoperative blood salvage (cell saver), as these surgeries can be long with significant blood loss. The leg, hip, pelvis, and lower abdomen are prepped and draped in the usual fashion. If possible, the previous surgical incisions are used. If no previous incision is present, then a simple curvilinear incision centered over the greater trochanter is recommended. The fascia is incised in line with the skin incision, and the status of the greater trochanter is evaluated. If the greater trochanter is not fractured, either an anterolateral or posterolateral approach can be used effectively based on surgeon preference. In the acute fracture situation, it is always preferable, if possible, to leave the abductor-greater trochanter-vastus lateralis complex intact in a long sleeve during the reconstruction.

In nonunions or neglected fractures, the trochanter may be malunited and preclude access to the intramedullary canal. In this situation, the so-called trochanteric slide technique may be useful (Fig. 19.1). The technique of preserving the vastus-trochanter-abductor sleeve may minimize the chance of so-called trochanteric escape and should be used whenever possible. If hardware is present in the proximal femur, I have found it helpful to dislocate the hip prior to hardware removal. The torsional stresses on the femur during surgical dislocation can be substantial, especially in these typically stiff hips, and iatrogenic femur fracture can occur with attempted hip dislocation. Whether removing an intramedullary nail or sliding compression hip screw and side plate, having implant-specific extraction tools is extremely helpful. The principles of reconstruction are similar regardless of whether a nail or plate was used. If previous surgery has been performed, intraoperative cultures and frozen section pathology are obtained from the deep soft tissues and bone. If there is evidence of acute inflammation or other gross clinical evidence of infection, the hardware is removed, all nonviable tissues are débrided, and the proximal femoral-head fragment is resected with placement of an antibiotic-impregnated polymethacrylate spacer. Reconstruction is delayed 6 to 12 weeks or longer while the patient receives organism-specific intravenous antibiotics based on the intraoperative cultures. P.335

FIGURE 19.1 A. Trochanteric slide technique, initial exposure: the sleeve of abductors and vastus lateralis are in continuity. B. Trochanteric slide technique, deep exposure. Note continuity of the musculotendinous sleeve with mobilization of the greater trochanter. With the hip dislocated either anteriorly or posteriorly, the proximal fragment is excised, and the acetabulum is circumferentially exposed. The quality of the remaining acetabular cartilage is evaluated. If the cartilage is well preserved, then a hemiarthroplasty is most commonly utilized. Appropriate attention to head size with hemiarthroplasty is important as an undersized component can lead to medial loading, instability, and pain, while an oversized component can lead to peripheral loading, instability, and pain as well. If preexisting degenerative change is seen on radiographs or the acetabular cartilage is damaged from prior hardware cutout, a total hip replacement is strongly recommended. Of course, even in the setting of normal-appearing acetabular cartilage, an acetabular component may provide more predictable pain relief, and this decision should be made at the time of surgery. The acetabulum is carefully reamed because these hips do not have the thick, sclerotic subchondral bone commonly found in patients with osteoarthritic hips. The acetabulum is reamed circumferentially until a bleeding bed is obtained. I prefer uncemented acetabular fixation due to the versatility it allows with the liner, bearing surface, and head size options. I also typically augment the cup fixation with several screws.

Attention is then turned to the femur. It should be emphasized that the femoral side of the reconstruction is typically more challenging than the acetabular side in this setting. The general principles of femoral P.336 reconstruction are summarized diagrammatically in Figure 19.2. It is important to carefully evaluate the level of bony deficiency medially. Typically, bone loss from the fracture or a nonunion results in a bony deficit well below the standard resection level for a primary total-hip arthroplasty. Therefore, a calcar prosthesis is almost always necessary to restore leg length and hip stability. Femoral components with modular calcar augmentations are available and allow intraoperative flexibility in restoring the hip mechanics. Occasionally, a large posteromedial fragment may be reduced and stabilized with cerclage wires or cables, which helps in determining femoral component height. In the acute fracture situation, reduction by wire or cable can potentially result in bony healing, thereby restoring medial bone stock.

FIGURE 19.2 A. Illustration summarizing the general principles of femoral reconstruction for intertrochanteric fracture or salvage of failed internal fixation. Note the restoration of appropriate femoral-component height using a calcar-replacing stem. Referencing the tip of the greater trochanter as a guide to restoring the center of rotation. Secure fixation of the greater trochanter has been obtained as is typical: with a cable through and a

cable below the lesser trochanter. Note the stem length chosen to bypass all cortical stress risers by a minimum of two diaphyseal diameters. B. Preoperative nonunion and hardware cutout after ORIF of an intertrochanteric fracture. Note the acetabular erosion superiorly from the lag screw. C. Postoperative reconstruction with a total hip arthroplasty with particulate bone grafting of the superior acetabular cavitary defect. Sclerotic hardware tracks, fracture translation, callus, etc., can alter the morphology of the proximal femur increasing the technical difficulty. These alterations can deflect reamers and broaches, leading to intraoperative fracture or femoral perforation. I have found it useful to use a large diameter burr to provisionally shape the P.337 funnel of the proximal femur. Once these sclerotic areas have been opened, standard reamers and broaches can be used to prepare the canal more safely. If a compression screw and side plate are present, I recommend that the femoral stem bypasses the most distal screw hole in the shaft by at least two cortical (diaphyseal) diameters. Because most adult femoral shafts are approximately 30 mm in diameter, templating for 6 cm of bypass is a good general guideline for stem length. Either cemented or uncemented femoral-component fixation can be effective in this type of reconstruction and is based on the preoperative as well as the intraoperative assessment of bone quality. If an uncemented femoral component is chosen, I use an extensively coated design that can achieve distal diaphyseal fixation. This strategy allows the surgeon to bypass stress risers effectively yet not rely on proximal bony support for implant stability. Cemented fixation may be advantageous for elderly patients with capacious, osteopenic femoral canals. Regardless of whether cemented or uncemented fixation is used, intraoperative radiographs are recommended to assure appropriate alignment and length as well as to rule out iatrogenic fracture or extravasation of cement. Extravasated cement can be a cause of late periprosthetic fracture, and it if it occurs, it should be carefully removed. Small, medial, screw-hole extravasations can usually be ignored as long as they are bypassed sufficiently by the femoral component. A helpful guide to the proper height of the calcar reconstruction is the relationship between the center of the femoral head and the tip of the greater trochanter: It should be essentially coplanar. Although this may be difficult to assess in the presence of a trochanteric fracture, usually, the greater trochanteric fragments are still somewhat attached and can be used as a gross guide for evaluating the appropriate level of calcar buildup. A trial reduction is performed, and leg lengths and hip stability are assessed. Again, intraoperative radiographs should be obtained. The author typically obtains an intraoperative radiograph after the permanent acetabular component and the trial femoral component are in place, and then once again, after the definitive femoral components are implanted, and the greater trochanteric fragment fixation, if necessary, is complete. Intraoperative fluoroscopy can be very useful and is used routinely. Regardless of the method of femoral fixation, it is wise to use local bone graft obtained from the resected femoral-head fragment to fill any lateral cortical defects from prior hardware as well as the interface with the greater trochanter and the femoral shaft, if necessary. Countless methods of greater trochanteric fixation have been described; however, most surgeons now use multiple wires or a cable claw technique. Commercially available “claw plates” may be advantageous, but their lateral bulk can be problematic in thin patients. Regardless of the method chosen, the greater trochanteric fixation should be stable through a full range of motion of the hip. Liberal autogenous bone graft from reamings is applied around the interface of the greater trochanter and the femoral shaft. The fascia, subcutaneum, and the skin are in layers. Representative cases emphasizing these principles are shown in Figures 19.2 to 19.5.

FIGURE 19.3 A. Preoperative failed ORIF with proximal fragment translation and screw cutout. B. Postoperative reconstruction with a total hip arthroplasty with calcar augmentation to restore appropriate femoral-component height, thereby restoring leg length and hip stability. P.338

FIGURE 19.4 A. Preoperative failed ORIF of a reverse obliquity fracture. Note the difficulty in managing the greater trochanter in this situation. B. Postoperative reconstruction with calcar-replacing bipolar hemiarthroplasty through a trochanteric slide technique.

FIGURE 19.5 A. Preoperative failed ORIF with screw cutout. The acetabular joint space is well preserved. B. Postoperative radiograph demonstrating a cemented calcar-replacing bipolar hemiarthroplasty. P.339

REHABILITATION In general, weight bearing can progress as tolerated after surgery; however, the surgeon should individualize the rehabilitation regimen based on patient compliance, quality of intraoperative component fixation achieved, and, most importantly, the status of the greater trochanter. If trochanteric fixation is required, the selective use of an abduction orthosis, partial weight bearing for 6 weeks, and avoidance of abductor strengthening until trochanteric union has occurred is recommended. Sutures are typically removed at 2 weeks, and periodic radiographs are obtained to evaluate component fixation and trochanteric healing. Clinical and radiographic follow-up is performed at 6 weeks, 12 weeks, and 1, 2, and 5 years postoperatively, then every 2 years thereafter. For asymptomatic elderly patients with transportation difficulties, the follow-up periods are modified to 6 weeks, 3 months, 1 year, and then every 5 years thereafter.

RESULTS There are several reports of arthroplasty for intertrochanteric fracture in the literature. They generally document the efficacy of arthroplasty as an alternative treatment for the acute fracture; however, complications still remain concerning. Most reports using arthroplasty for intertrochanteric fractures are for salvage of failed internal fixation. Haidukewych and Berry reported on 60 patients undergoing hip

arthroplasty for salvage of failed ORIF. Overall, functional status improved in all patients, and the 7-year survivorship free of revision was 100%. Pain relief was predictable. Dislocation was not a problem; however, persistent trochanteric complaints and problems obtaining bony trochanteric union were common. Both bipolar and total hip arthroplasties performed well. Calcar-replacing designs and long stem prostheses were necessary in the majority of cases.

COMPLICATIONS Medical complications are common due to elderly, frail patients undergoing complex, prolonged surgery. Thromboembolic prophylaxis, perioperative antibiotics, and early mobilization are recommended. If a long-stem cemented implant is used, intraoperative embolization and cardiopulmonary complications can occur. It is important to lavage and dry the canal thoroughly prior to cementing longer stems in these frail patients, and little, if any, pressurization should be used. Infection and dislocation are surprisingly rare after such reconstructions in which modern techniques and implants are used. The principles of treatment of an infected arthroplasty are beyond the scope of this chapter. Dislocations are managed with closed reduction and bracing as long as the trochanteric fragment fixation remains secure. Problematic recurrent dislocations due to trochanteric (abductor) insufficiency in patients with well-positioned components can be effectively managed with constrained acetabular liners. Trochanteric complaints, including bursitis, hardware pain, and nonunion, are the most common complications after reconstruction. Patients should be counseled preoperatively that such chronic complaints are very common. Bony union will occur in many but not all trochanteric fragments. Stable trochanteric fibrous unions in good position will often be asymptomatic and not require treatment. Displaced trochanteric escape, if symptomatic, is typically treated with a repeat internal fixation attempt with some form of bone grafting. The best treatment is prevention, with extremely secure initial trochanteric fixation, the use of the trochanteric slide technique if mobilization of the trochanter is required, liberal use of autograft bone at the trochanter-femur interface, and careful postoperative rehabilitation and bracing. Problematic high Brooker grade heterotopic ossification is rare after these reconstructions, and the senior author does not use routine prophylaxis.

SUMMARY Hip arthroplasty is a valuable addition to the armamentarium of the surgeon treating intertrochanteric hip fractures. In general, it is reserved for neglected fractures, pathologic fractures due to neoplasm, salvage of internal fixation failure and nonunion, and (rarely) for fracture in patients with severe, symptomatic, preexisting degenerative change. Attention to specific technical details is important to avoid complications and provide a durable reconstruction. Trochanteric complications are common, but functional improvement and pain relief are predictable.

RECOMMENDED READING Chan KC, Gill GS. Cemented hemiarthroplasty for elderly patients with intertrochanteric fractures. Clin Orthop 2003;371: 206-215.

Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Orthopedics 2010;33:721. Choy WS, Ahn JH, Ko JH, et al. Cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients. Clin Orthop Surg 2010;2:221-226. P.340 D'Arrigo C, Perugia D, Carcangiu A, et al. Hip arthroplasty for failed treatment of proximal femoral fractures. Int Orthop 2010;34:939-942. Eschenroeder HC Jr, Krackow KA. Late onset femoral stress fracture associated with extruded cement following hip arthroplasty. Clin Orthop 1988;236:210-213. Geiger F, Zimmermann-Stenzel M, Heisel C, et al. Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality. Acta Orthop Trauma Surg 2007;127:959-966. Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop 1987;224:169-170. Grimsrud C, Monzon RJ, Richman J, et al. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplasty 2005;20:337-343. Haentjens P, Casteleyn PP, DeBoerk H, et al. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients: primary bipolar arthroplasty compared with ORIF. J Bone Joint Surg Am 1989;71(8):1214-1225. Haentjens P, Casteleyn PP, Opdecam P. Primary bipolar arthroplasty or total hip arthroplasty for the treatment of unstable intertrochanteric or subtrochanteric fractures in elderly patients. Acta Orthop Belg 1994;60:124-128. Haentjens P, Casteleyn PP, Opdecan P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Arch Orthop Trauma Surg 1994;113:222-227. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;85:899-905. Haidukewych GJ, Berry DJ. Revision internal fixation and bone grafting for intertrochanteric nonunion. Clin Orthop 2003;412:184-188. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity of fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650. Hammad A, Abdel-Aal A, Said HG, et al. Total hip arthroplasty following failure of dynamic hip screw fixation of fractures of the proximal femur. Acta Orthop Belg 2008;74:788-792.

Harwin SF, Stern RE, Kulich RG. Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly. Orthopedics 1990;13:1131-1136. Kim Y-H, Oh J-H, Koh Y-G. Salvage of neglected unstable intertrochanteric fractures with cementless porous-coated hemiarthroplasty. Clin Orthop 1992;277:182-187. Knight WM, DeLee JC. Nonunion of intertrochanteric fractures of the hip: a case study and review. Orthop Trans 1982;16:438. Kyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227-253. Laffosse JM, Molinier F, Tricoire JL, et al. Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients. Acta Orthop Belg 2007;73:729-736. Lifeso R, Younge D. The neglected hip fracture. J Orthop Trauma 1990;4:287-292. Mariani EM, Rand JA. Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation: results of second attempts to gain union. Clin Orthop 1987;218:81-89. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop 1991;269:32-37. Parvizi J, Ereth MH, Lewallen DG. Thirty day mortality following hip arthroplasty for acute fracture. J Bone Joint Surg Am 2004;86:1983-1986. Patterson BM, Salvati EA, Huo MH. Total hip arthroplasty for complications of intertrochanteric fracture: a technical note. J Bone Joint Surg Am 1990;72:776-777. Rodop O, Kiral A, Kaplan H, et al. Primary bipolar hemiarthroplasty for unstable intertrochanteric fractures. Int Orthop 2002;26:233-237. Sarathy MP, Madhavan P, Ravichandran KM. Nonunion of intertrochanteric fractures of the femur. J Bone Joint Surg Br 1994;77:90-92. Sharvill RJ, Ferran NA, Jones HG, et al. Long-stem revision prosthesis for salvage of failed fixation of extracapsular proximal femoral fractures. Acta Orthop Belg 2009;75:340-345. Sidhu AS, Singh AP, Singh AP, et al. Total hip replacement as primary treatment of unstable intertrochanteric fractures in elderly patients. Int Orthop 2010;34:789-792. Stoffelen D, Haentjens P, Reynders P, et al. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Acta Orthop Belg 1994;60:135-139.

Tabsh I, Waddell JP, Morton J. Total hip arthroplasty for complications of proximal femoral fractures. J Orthop Trauma 1997;11:166-169. Wu CC, Shih CH, Chen WJ, et al. Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture. Arch Orthop Trauma Surg 1998;117:193-196.

20 Subtrochanteric Femur Fractures: Plate Fixation Michael J. Beltran Cory A. Collinge

INTRODUCTION Subtrochanteric femur fractures are challenging injuries to manage, and no single method of treatment is applicable to all fracture patterns. Following a fracture, powerful hip muscle forces often lead to complex but predictable deformities (Fig. 20.1). Intertrochanteric extension, fracture comminution, and poor bone quality increase the difficulty in treatment and require careful preoperative planning. The goal of surgery is to restore length, alignment, and rotation using an implant that provides stable internal fixation and allows early mobilization and protected weight bearing. Subtrochanteric fractures are usually treated with an intramedullary nail or a fixed angle plate; however, the choice of implant depends on the fracture pattern, host factors, and the surgeon's experience and resources (1, 2, 3, 4, 5, 6, 7 and 8). Several classification schemes have been proposed to categorize subtrochanteric fractures. The comprehensive classification of the AO/OTA is predominately descriptive while the Russell-Taylor classification attempts to guide treatment with either a nail or plate. The purpose of this chapter is to discuss the rationale for plating of the proximal femur and highlight proven techniques that are necessary to achieve a quality reduction and place appropriate, stable internal fixation.

INDICATIONS AND CONTRAINDICATIONS Virtually all subtrochanteric femur fractures in adolescents and adults require surgery. Given the substantial and serious risks associated with nonoperative care, including deep vein thrombosis, pressure decubiti, urinary tract infections, and pneumonia, traction and casting should only be considered in patients with extremely serious medical comorbidities that preclude surgical intervention. There is widespread agreement that the benefits of correctly done surgery far exceed the risks. For any surgery in the proximal femur, the surgeon must be familiar with the anatomy around the hip to achieve consistently good outcomes. Furthermore, a working knowledge of fracture fixation principles, both mechanical and biologic, is necessary. Proximal femoral plating is contraindicated in any circumstance where the surgeon is unfamiliar with these techniques. For most subtrochanteric fractures, an intramedullary nail is the treatment of choice. There is a large body of literature documenting successful outcomes following nailing of these difficult injuries (1,2,4,8). Plating is reserved for a subset of fractures where nailing would be challenging and place the patient at an increased risk for complication or failure. Open reduction and plate fixation of a subtrochanteric femur fractures is indicated in the following situations: 1. The use of an intramedullary implant is precluded by distal implants (i.e., stemmed total knee prosthesis). 2. A preexisting implant that must be removed through an open approach. 3. Comminution of the lateral wall or fracture extension into the greater trochanter or piriformis fossa that makes the use of an intramedullary device difficult or impossible. 4. For internal fixation after corrective osteotomies for malunion or nonunion of the proximal femur. The advantage of plating, compared with nailing, is that it reduces the risk of injury to the hip abductors and short external rotators, minimizing the incidence of heterotopic ossification, especially in patients with head injuries.

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FIGURE 20.1 Muscle attachments around the proximal femur lead to predictable deformity pattern after displaced subtrochanteric fracture.

PREOPERATIVE PLANNING History and Physical Examination While subtrochanteric femur fractures are seen in all age groups, they most commonly occur in two age clusters. The first group is elderly osteoporotic patients with fractures that occur following low energy falls or bisphosphonate-related stress fractures. Recent studies have shown a correlation between prolonged bisphosphonate use and atypical fractures of the femur (9,10). In older patients, a history of malignancy should also be sought, as the subtrochanteric region of the femur is a common site for bony metastasis. The second group of patients is younger individuals whose fracture occurs after high-energy trauma (e.g., motorcycle or motor vehicle collisions and falls from a height). A thorough history and physical examination is mandatory prior to treatment. Advanced Trauma Life Support protocols are used in all seriously injured patients. Virtually all patients present with a painful swollen thigh and are unable to stand or walk. The leg is externally rotated and shortened. Motion in the leg is reduced and very painful. The physical examination should clearly document the neurovascular status. Abnormal or asymmetric

distal pulses warrant further studies (i.e., ankle-brachial indices) to rule out a vascular injury. ABIs 8 to 12 hours, skeletal traction is preferred. A Kirschner wire should be placed in the distal femur or proximal tibia and attached to a tensioned traction bow. This can often be done in the emergency department or intensive care unit under local anesthesia. In the unstable polytrauma patient, damage control orthopedics using external fixation may be preferable to skeletal traction if the patient is going to be in the operating room for life-saving procedures. An external fixator can be applied in the intensive care unit, but this is not ideal. Single-stage conversion of an external fixator to a nail should be done early (ideally within 14 days) to minimize the risk of infection (15). Scannell et al. (16) showed no apparent difference in morbidity or outcome between patients treated with skeletal traction or external fixation in the severely injured patient.

Surgical Tactic Prior to surgery, the surgeon should develop a surgical plan based on the findings of the physical exam and imaging studies. This plan must be shared with the operating room staff to make sure all the personnel work efficiently. The surgeon should decide patient positioning, whether a fracture table will be used and whether the patient will need damage control techniques (external fixator) or definitive treatment. If the patient is going to be treated P.396 definitively with an intramedullary nail, will the surgeon place the nail retrograde or antegrade? If antegrade nailing is chosen, will the surgeon use a piriformis or trochanteric entry? The surgeon will also need to decide if he/she will ream or not ream. Other key decisions that will need to be determined before the case are the location of the C-arm and if any ancillary reduction devices such as Shanz pins, a crutch, bolsters, etc. will be needed. All of these decisions need to be made before the case starts to be sure the appropriate equipment and resources available. Once the surgical tactic is completed, the surgeon is now ready to execute the plan and perform the operation.

Surgery For the most part, the anesthesiologist will determine whether a regional or general anesthetic will be most appropriate for the patient and the planned operation. Absolute contraindications for regional anesthetic are head injury, a large blood loss, and coagulopathy. The trauma surgeon and/or anesthesiologist will most likely determine whether an arterial and/or central line will be needed. In general, unstable patients with a large blood loss or patients with cardiopulmonary comorbidities will require arterial and central venous access. A foley catheter is usually indicated to help monitor volume status. Prophylactic antibiotics should be given based on the patients' drug allergies and soft-tissue status. An antibiotic with staphylococcus and streptococcus coverage such as a first-generation cephalosporin is recommended for closed fractures. An alternative antibiotic such as clindamycin should be given if the patients have a significant penicillin allergy. Routine antibiotic prophylaxis is typically given for 24 hours post-op. Patients with open fractures should receive antibiotics as soon as possible to cover gram-positive organisms (first-generation cephalosporin) for small skin wounds with little to no contamination. If the open wound is more extensive or contaminated, then additional antibiotics should be given to cover gram-negative organisms (gentamycin) and

possibly anaerobic organisms (penicillin) if there is significant soil contamination. The appropriate duration of postoperative antibiotics after an open femur fracture is not clearly defined. Continuing antibiotics for 1 to 3 days after the last washout is reasonable based on initial wound contamination.

Patient Positioning There are several ways to position a patient for femoral nailing, and each has its advantages and disadvantages. Classically patients are positioned either supine or lateral on a fracture table. Traction through the leg extension or using a skeletal traction pin is almost always necessary to restore length and alignment of the shortened femur. Alternatively, nailing on a flat-top radiolucent table can be done, but usually requires a scrubbed assistant, traction with weights off the end of the table, or a femoral distractor to maintain length during the procedure. Kuntscher (2) originally described femoral nailing with the patient in the lateral position on a fracture table (Fig. 22.2). The chief benefit of lateral positioning is that it provides easier access to the piriformis fossa P.397 and facilitates nailing of fractures in the proximal portion of the femur as well as in large or obese patients. Disadvantages of lateral nailing include limitations in patients with multiple injuries and the difficulty judging proper rotation of the extremity. Lateral decubitus nailing on a fracture table is used much less frequently today.

FIGURE 22.2 Lateral decubitus operative position. Access to the proximal femur is facilitated by increased hip flexion, which minimizes interference of the insertion instrumentation with the patient's torso. A drawback to this technique is that pulmonary function is slightly compromised, the setup is time consuming, and venous congestion can be caused from the peroneal post compressing the medial thigh and femoral vessels.

FIGURE 22.3 Supine positioning for antegrade femoral nailing on a fracture table. Both lower extremities are secured in traction boots. The injured femur may require a traction pin if the fracture is particularly short or there has been a delay to surgery with prior traction applied. Supine nailing on a fracture table (Fig. 22.3) is the most commonly utilized technique for femoral nailing in North America. Benefits include a relatively straightforward setup, familiarity by the operating room staff, improved ability to assess limb length and rotation when both legs are in extension, and it can often be performed without a scrubbed assistant. The major drawback with this method is difficulty gaining access to the piriformis fossa, particularly in large patients. Supine or floppy lateral positioning on a radiolucent table has recently become more popular due to its simple setup and accommodation of patients with multiple injuries. Multiple procedures can be performed on the same patient without a position change when this method is chosen. The major disadvantage with this technique is accurate restoration of length and alignment that requires a scrubbed assistant for reduction and traction, especially in delayed cases or in patients with large muscle mass. Because most femoral nailings are done supine on a fracture table and it is currently the most universal method of femoral nailing, the rest of the chapter focuses on this technique. Once the patient has been placed on the fracture table, it is helpful to “bend” the patient's torso away from the injured side (Fig. 22.4) to improve access to the starting point in the proximal femur. The upper extremity P.398 on the injured side is secured across the chest and held on bolsters, a Mayo stand, or pillows (see Fig. 22.4). With isolated femur fractures, the injured leg is placed into the boot of the fracture table. If a skeletal traction pin is required or is already in place, it is incorporated into the fracture table. A distal femoral traction pin must be strategically placed to avoid interfering with the nailing process. If there are no injuries to the knee joint, many surgeons prefer a proximal tibial pin. We routinely place the noninjured extremity in the contralateral traction boot with the hip and knee in extension so that modest counter traction can be applied through this limb as well (see Fig. 22.4). This stabilizes the pelvis and prevents rotation of the pelvis around the perineal post when traction is applied to the injured limb. Another benefit of nailing with both legs in extension is the excellent ability to assess length and rotation by using the uninjured femur as a guide. Although many surgeons prefer to flex, abduct, and externally rotate the uninjured leg in a well-leg support, we have found this to be less reliable for stabilizing the pelvis and assessing length and rotation.

FIGURE 22.4 The patient's torso should be gently angled away from the injured limb to allow freer access to the proximal end of the femur. The upper extremity should be brought over the chest and secured so that it will not interfere with the ball-tipped guide rod and reamer when placing them into the proximal end of the femur. The noninjured limb should have a small amount of counter traction so it will prevent the pelvis from rotating around the perineal post. When both limbs are in positioned in this manner, length and rotation can be determined fairly accurately. Once the patient is positioned and secured to the fracture table with both lower extremities in extension, gentle traction is applied to the noninjured injured extremity to keep it from sagging. The next step is to apply traction to the injured extremity to restore the length, alignment, and correct the rotation. For simple and minimally comminuted femur fractures, this is relatively easy to accomplish. However, in patients with comminuted unstable fractures, we use the uninjured side as a reference.

Imaging The C-arm is brought in perpendicular to the patient from the opposite side, and a posterior-anterior (PA) image of the hip on the injured side is taken. This image is saved to the second screen of the C-arm monitor. A PA image is then taken of the hip on the uninjured side. The uninjured extremity is rotated (usually slightly external) until the PA profile matches the hip from the injured side. Once the two hips match, a PA image of the knee on the uninjured extremity is taken and saved. The injured extremity is then rotated until the knee image on the injured side matches the knee image on the uninjured side. Once the two knee images match, the rotation of the femurs should be correct. The C-arm can now be centered over the fracture site, and traction can be applied or released as needed to restore the length of the injured femur. If the fracture is a simple pattern, rotation and length can be fine-tuned based on matching up the fracture lines like a puzzle. If there is significant comminution,

length can be determined by measuring the uninjured femur with a long ruler using the image intensifier (Fig. 22.5). The injured femur can be pulled out to the desired length as needed with the traction boot or traction pin. The most difficult situation is when both femurs are fractured, and there are no normal landmarks to judge length and rotation. In this infrequent scenario, the surgeon takes a lateral image P.399 of the least injured extremity's hip and rotates the C-arm until a lateral projection of the hip is obtained with about 10 to 15 degrees of femoral neck anteversion. The C-arm is then moved down to the knee, and the knee is rotated (usually slight external rotation is required) until a perfect lateral of the knee is obtained. At this point, the femur should have acceptable rotational alignment. Length should be restored as best as possible using the ligamentotaxis of the fractured fragments as guides to length. Once one side is fixed, then the other side can be matched using the technique described above so that both extremities have symmetric length and rotation. One important technical point to emphasize is that a direct lateral of the hip is difficult to obtain in large patients due to the need to image through the entire pelvis. However, rotating the C-arm 10 to 15 degrees off the true lateral allows adequate visualization in most patients. Once length and rotation have been restored, the two extremities are scissored by lowering the uninjured extremity toward the floor (Fig. 22.6).

FIGURE 22.5 When the fracture is comminuted and there are no intact edges on the proximal and distal fragments from which to judge length, a ruler can be used to measure the noninjured side to guide how much traction to apply to restore the length of the injured extremity.

FIGURE 22.6 Scissor the legs, dropping the uninjured lower extremity toward the floor to allow lateral fluoroscopic views of the injured lower extremity.

Entry Point Antegrade femoral nailing can be done via entry through the piriformis fossa (trochanteric fossa) or the tip of the greater trochanter (trochanteric entry). The choice between piriformis fossa or trochanteric entry is mainly based on surgeon preference and experience. The trochanteric portal may be easier to locate in larger patients. There has been concern that trochanteric entry nails may damage the gluteus medius and lead to hip dysfunction. However, randomized controlled trials show no difference in outcome between the two approaches (4,5). If a trochanteric entry portal is to be used, the surgeon must use a nail designed for trochanteric entry and insert the nail in the location recommended by the manufacturer. Small deviations from the recommended entry portal may cause malalignment in more proximal fractures. A 4 to 6-cm incision is made several centimeters proximal to the tip of the greater trochanter. A skin incision made well above the trochanter improves the trajectory for guide wire insertion, reaming, and nailing. Be sure that the insertion handle will be able to accommodate the soft tissue distance when using a more proximal skin incision. The incision is deepened through the subcutaneous tissue down to the gluteal myofascia, which is incised in line with the incision. Blunt finger dissection through the muscle allows identification of the tip of the greater trochanter. The piriformis fossa is located medial and slightly posterior to the base of the femoral neck. An AP image of the hip with a guide pin or awl placed in the fossa should appear as being slightly “inside the bone” (Fig. 22.7). If the tip of the guide pin or awl appears perched directly on the cortex of the femoral neck, it is too anterior. It is important to avoid anterior entry portals as this may cause iatrogenic comminution due to large hoop stresses created by an eccentric nail trajectory and pathway. The surgeon must also avoid starting the nail lateral to the piriformis fossa in the greater trochanter as this will result in varus malreduction with proximal femur fractures. The guide pin should be adjusted so that it is projected to be down the center of the medullary canal on both the AP and lateral fluoroscopic views. Once the guide pin is in the piriformis fossa and in line with the femoral canal on the PA and lateral views, it is advanced to the level of the lesser trochanter. The staring point in the proximal femur is opened with the cannulated drill or end-cutting reamer. Meticulous attention to detail in regard to obtaining a “perfect” starting point cannot be overemphasized. With a trochanteric entry site, the guide pin should be placed on the tip of the greater trochanter as seen on the AP view (17) and in the middle or slightly posterior in the greater trochanter on the lateral view. If the surgeon is using a nail that he/she is not familiar with, the manufacturer's technique guide should be reviewed to verify the recommended entry site on the greater trochanter. Anterior placement of a trochanteric entry nail can lead to malalignment of the proximal femur (18). It is important to use a femoral nail designed specifically for trochanteric entry with this approach. If a “straight” nail designed for piriformis entry is placed through a trochanteric entry

portal, a varus malreduction can occur.

Guide Wire Passage To facilitate passage of the guide wire, it is helpful to place at slight bend in the wire 1 or 2 cm from the tip (Fig. 22.8). This bend helps passing the guide wire into the distal segment when there is mild residual displacement. With greater degrees of fracture displacement, manual manipulation of the fracture with an intramedullary reduction tool can be helpful (Fig. 22.9). Most modern nail sets have a cannulated reduction tool that can be inserted over the guide wire and advanced just proximal to the fracture site. In patients with small medullary canals, reaming of the proximal fragment may facilitate insertion of this device. The proximal fragment can then be manipulated to allow passage of the guide wire into the distal fragment. It is important that the guide wire be centered in the middle of the medullary canal on the AP and lateral view using the C-arm prior to reaming. Occasionally, the proximal or distal fracture fragments can be “pushed or pulled” into better alignment with a crutch or a lifting pad attachment that is part of some fracture tables. If these maneuvers are also not successful, then direct manipulation of the proximal or more commonly the distal fracture can be done using a percutaneously inserted terminally threaded 2.5-mm pin or external fixation pin (Shanz pin) attached to a handle (Fig. 22.10). By manipulating the fragment(s), alignment can usually be improved allowing passage of the balltipped guide wire (Fig. 22.11). Schantz or external fixation pins should be placed eccentrically or in a unicortical fashion to allow easy passage of the ball-tipped guide wire. In many cases, one or more of these “tricks” will need to be employed simultaneously to allow successful guide wire passage. P.400

FIGURE 22.7 A. The guide pin should sit in the piriformis fossa on the AP view of the proximal femur. The pin should look like it is inside the bone a short distance instead of being perched on the anterior cortex. If the tip does not appear slightly into the bone on the AP view, then it is too anterior, being perched on the anterior cortex of the femoral neck. B. X-ray image example of what is presented in (A).

FIGURE 22.8 A slight bend placed near the end of the guide rod will facilitate passage of the guide rod across a mildly displaced fracture. P.401

FIGURE 22.9 Fracture reduction with small-diameter nail or reducing tool. A more powerful reducing force may be applied with the use of a small-diameter nail or reducing tool. When proximal diaphyseal fractures are encountered, this instrument can be used to control the flexed, externally rotated, and abducted proximal fragment during reduction. If closed or percutaneous reduction methods are unsuccessful after a reasonable period of time (20 to 30 minutes), an open reduction with direct passage of the ball-tipped guide wire should be done. An open reduction should not be considered a treatment failure. A seriously injured patient may be better off with a small open

incision and shorter operation than a prolonged procedure with multiple failed attempts at closed reduction that increase the risk of fat embolism, pudendal nerve palsy, and heterotopic ossification.

Reaming After C-arm confirmation of satisfactory placement of the ball-tipped guide wire in the femur (central and advanced to the epiphyseal scar; Fig. 22.12), the surgeon prepares to ream the intramedullary canal. To avoid inadvertent contamination, the work area above the insertion site and adjacent to the patient's abdomen and chest should be inspected. Not uncommonly, an overhead light or IV pole at the head of the table can create potential obstructions and need to be moved. At this time, we often add an additional sterile sheet near the head of the table. Ideally, sharp reamers with narrow drive shafts, small heads, and deep cutting flutes are utilized. Based on the estimated canal width determined preoperatively, an end-cutting reamer at least 1 mm smaller than the medullary canal diameter is introduced. The reamer is passed slowly down the intramedullary canal until the reamer head reaches 1 to 2 cm from the end of the guide wire. Whenever possible, a skin protector is utilized to avoid damage to the skin and soft tissues at the entry site (Fig. 22.13). Reamer size is increased in P.402 0.5 to 1.0 mm increments until the cortical chatter is encountered. Thereafter, it is advisable to increase size by 0.5 mm increments to avoid nail incarceration and thermal necrosis. The femur should be “overreamed” 1.0 to 1.5 mm greater than the planned nail diameter. When using a trochanteric entry portal, reaming the proximal fragment at least 2 mm larger than the desired nail diameter will make passage of the nail easier in the proximal femur and decrease the chance for iatrogenic comminution.

FIGURE 22.10 2.5-mm terminally threaded guide pins can be used as percutaneous reduction aids. One or two pins placed into a bone fragment can be used to steer or direct the fragment into alignment with the proximal fragment allowing the ball-tipped guide rod to be placed into the intramedullary canal. Larger Schanz pins can be equally effective.

Nail length is determined by specific measurement tools found in most nailing sets. This step can be done prior to reaming if the surgeon desires. The most important factors in determining nail length are reduction of the fracture and confirmation that the guide wire has not backed out during the reaming process. The surgeon P.403 should ensure that the fracture is reduced radiographically. Length can be fine-tuned and adjusted using the fracture table as needed. If the surgeon is using a nailing system without a length measurement tool, then the “two-wire” technique can be used. Keeping the original ball-tipped guide wire in place, a second guide wire of the same length can be placed adjacent to it down to the entry site. The length of the wire above the tip of the original guide wire is the correct length of the nail to be inserted.

FIGURE 22.11 The surgeon must be cognizant not to block passage of the guide rod with the pins. The pins should be placed unicortically or above or below the passage of the proposed path of the guide rod.

FIGURE 22.12 Fluoroscopic AP image showing the ball-tipped guide wire centered in the distal femur at the level of the epiphyseal scar.

Nail Insertion The nail should always be inserted over a ball-tipped guide wire. Most modern nail designs allow the guide wire to be removed through the nail eliminating the need to exchange the ball-tipped guide wire for a smooth nonbeaded wire through an exchange tube. The nail with its attached insertion handle nail is then manually pushed down the intramedullary canal until it stops. It is then advanced with light blows using a mallet or hammer. If back slapping is needed to overcome distraction at the fracture site, the nail should be inserted slightly deeper into the femur so that after the fracture is compressed, the nail will be at the proper level, just below the tip of the greater trochanter. When inserting a trochanteric or a piriformis entry nail, it may be helpful to rotate the nail 90 degrees toward the patient to facilitate nail passage through the proximal femur. Once the nail tip is past the lesser trochanter, the surgeon slowly rotates the nail back to its normal position while the nail is being tapped into place. The nail is advanced taking periodic spot views with the C-arm. During passage of the nail across the fracture, the surgeon should utilize any reduction “techniques” previously used to reduce the fracture. If at any time, the nail does not advance smoothly with each tap of the mallet, the C-arm images should be scrutinized to ensure that the nail is not stuck on a bone fragment or fracture edge (Fig. 22.14). It is important to remember that an intramedullary nail can only realign fractures in the middle third of the femur, but cannot predictably realign metadiaphyseal injuries due to nail size and medullary canal mismatch. P.404 If the fracture is malreduced after nailing, the implant should be removed and length, rotation, and frontal and sagittal plane alignment reassessed. Occasionally, with comminuted infraisthmal fractures, blocking screws may be necessary. Once the nail is placed into the correct position, the guide wire is removed. If the fracture is at its proper length, then the surgeon proceeds with cross-locking. If back slapping is needed to compress or shorten the fracture, the distal cross-locks need to be placed first.

FIGURE 22.13 A skin protection instrument will protect the skin edges from burning or abrasion during reaming. A lap-pad strap is tied to the protector to prevent it from falling on the floor.

FIGURE 22.14 The surgeon should not hesitate to image the nail if smooth passage of the nail is interrupted. In some cases, the nail may get hung up on a bone fragment or the edge of a fracture fragment.

Blocking Screws Not uncommonly, it is difficult to obtain or maintain coronal or sagittal plane alignment in fractures proximal or distal to the isthmus due to comminution, muscle forces, or a mismatch of the canal diameter and the nail. If closed reduction maneuvers fail to overcome malalignment, then blocking screws can be helpful. Blocking screws are designed to narrow the canal within metaphyseal bone and direct the nail in a preferential direction by “blocking” its passage down a less optimal path. In general, the blocking screw is placed on the side of the fracture “concavity” in the fracture fragment where the canal is wider than the nail (Fig. 22.15). The blocking screw is most effective if placed closer to the fracture site than farther away from it. The surgeon should be careful to look for nondisplaced fracture lines extending away from the primary fracture in the proposed area of the blocking screw to avoid iatrogenic comminution. Once the blocking screw is placed, the guide wire is reinserted into the new path and then reamed to assist with nail passage. Care must be taken when reaming near the blocking screw to prevent jamming or reamer head damage. The nail can now be reinserted and statically locked. In most cases, the blocking screw should be left in place after nail placement (Fig. 22.16).

Proximal Locking The most important aspect to successful proximal cross-locking is verifying that the insertion jig handle is still fully tightened onto the nail. If the handle is tight, most modern proximal cross-locking jigs work very well. The surgeon should verify with the C-arm that the proposed cross-locking screws will not enter P.405 the fracture site. A common pitfall with proximal locking is making the incisions for the drill sleeves too small. The drill sleeves need adequate room to slide smoothly down to the bone to avoid entrapment by the skin, muscle, and fascia, which could affect drilling and subsequent screw placement. Because most current nail systems use the drill sleeves to measure the screw length, it is critical that the sleeves are placed firmly against bone. After placing the proximal cross-locking screw(s), their position should be confirmed fluoroscopically.

FIGURE 22.15 If proper coronal or sagittal plane alignment is difficult to achieve by indirect methods, blocking screws placed on the concave side of the deformity in the proximal fragment can help align the fragments into a satisfactory position. Some nail designs allow proximal cross-locking screws to be placed into the femoral head (historically referred to as reconstruction nails). The surgeon should consider placing cross-locking screw into the femoral P.406 head if the fracture is at the level of the lesser trochanter or higher where standard transverse or oblique (greater trochanter to lesser trochanter) cross-locking screws will not be above the proximal fracture. The other reason to use cross-locking screws into the femoral head is to stabilize a femoral neck fracture ipsilateral to a femoral shaft fracture. Using a single device to stabilize an ipsilateral femoral neck and shaft fracture is controversial, and the modern trend is to fix both fractures with separate implants (i.e., cannulated screws for the neck fracture and a retrograde nail or plate for the shaft fracture.) Despite this controversy, some surgeons currently advocate routine placement of cephalomedullary screws into the femoral neck for all patients with a femoral shaft fractures. These surgeons advocate this approach because of the significant risk of missing a nondisplaced femoral neck fracture even with CT scanning to screen for these fractures (19).

FIGURE 22.16 Example of a blocking screw placed to prevent varus malalignment of a distal femoral fracture.

Distal Locking Whereas proximal locking is done with a jig, distal locking is most commonly accomplished using a freehand technique. Distal locking jigs have been developed, but for the most part have been abandoned as unreliable. Other attempts at simplifying distal locking have included radiolucent drill attachments, handheld radiolucent drill guides, navigation, and an intramedullary radiofrequency probes. While these devices can be helpful, they are expensive and not widely available. The vast majority of distal cross-locking is still done freehand. Freehand distal locking is predicated on obtaining “perfect circles” of the distal locking holes with the C-arm (Fig. 22.17). Having both of the patient's lower extremities in extension and scissored as described above facilitates freehand distal locking. Once the C-arm has been positioned to project perfect circles, the surgeon localizes the spot on the skin overlying the center of the intended cross-locking hole with a drill bit or tip of a knife blade. A 1.5-cm skin incision is made through the skin and iliotibial band and spread down to bone. A calibrated drill bit is placed on the lateral aspect of the femur and moved in small increments until the sharp tip of the drill bit is within the projected image of the center of the cross-locking hole. The position of the drill bit should be clearly visualized on several projections. Once the tip is confirmed to be in the center of the cross-locking hole, the drill is adjusted to be “in line” with the x-ray beam. Pressure should be kept on the drill bit so that it does not “walk” or slip off the rounded cortex. The lateral cortex is opened with the drill, and an x-ray image at this point must confirm that the drill is still pointing toward the center of the locking hole, and if not, what adjustments should be made to the angle of insertion. If at anytime, the surgeon loses his direction or encounters unexpected resistance, a spot image with the C-arm should be obtained. If the drill bit has deviated from its intended course, the steps listed above should be repeated until the drill bit has successfully traversed the nail. Once the drill bit penetrates the far cortex, the length of the screw can be determined from the calibrations on the drill bit. Of course, length can be measured with a standard depth gauge. If more than one cross-locking screw is planned, it may be helpful to leave the first drill bit in place to provide a visual guide for insertion of the second drill bit and screw. The C-arm should be used to confirm that the drill bit(s) are through the holes in the nail prior to placing the cross-locking screws. After the screws have been tightened into place, the C-arm is used to confirm that the

locking screws are through the nail, are of appropriate length, and flush with the lateral cortex. For length stable fractures in the middle one-third of the femur, one cross-locking screw is sufficient (20). However, for comminuted fractures and infraisthmal injuries, at least two distal cross-locking screws are necessary to avoid rotation or toggling of the distal fragment (Fig. 22.18). Virtually all femur fractures should be statically locked to prevent loss of reduction, which has been reported to occur in up to 10% of femur fractures (21). Brumback et al. (2) has shown that statically locked femur fractures do not have higher rates of nonunion. Final Details At the completion of the nailing, the surgeon should reassess the hip region to rule out a missed femoral neck fracture. The C-arm can be rotated 180 degrees around the femoral neck taking spot images. With the patient still under anesthesia, the patient is moved off the fracture table and limb length, and rotation is compared to the opposite side. Ligamentous evaluation of the knee should also be performed, as this may be painful once awake. If gross malalignment is detected, the problem should be corrected before leaving the operating room. If the deformity is small or the patient is too sick, a post-op CT scan should be obtained.

POSTOPERATIVE MANAGEMENT The early postoperative phase, or hospital phase, should focus on patient monitoring, deep vein thrombosis (DVT) prophylaxis, pain control, antibiotics, surgical site care, and early physical therapy. In patients with other injuries, variations from the routine management are often necessary. It is not uncommon to see a drop in the patient's hemoglobin and hematocrit after closed nailing and should be followed closely for several days although blood transfusions are uncommon. We strongly recommend mechanical and chemical prophylaxis for DVT prevention, which is initiated within 24 hours in the absence of any contraindications. Physical therapy focuses on early mobilization, and patients are encouraged to be full weight bearing if there is good cortical contact or otherwise partial weight bearing with crutches or a walker. Hip, knee, and ankle motion is stressed along with isometric strengthening exercises. The incision is kept covered with clean, P.407 dry dressings until oozing stops. Prolonged drainage usually may be due to an underlying seroma, hematoma, or anticoagulation therapy. This occasionally warrants surgical evacuation.

FIGURE 22.17 The C-arm should be positioned to obtain an optimal lateral view of the distal femur. The goal is to pass the beam exactly in line with the axis of the screw holes. When the C-arm is properly aligned, the holes appear as perfect circles. An elliptical appearance of the holes suggests malalignment of the beam. Malalignment of the beam in the coronal plane makes the holes appear as vertical ellipses. Malalignment in the sagittal plane makes holes appear as horizontal ellipses. After hospital discharge, patients are continued on DVT prophylaxis for 2 weeks and pain medications as needed. Follow-up 10 to 14 days postoperatively is recommended for suture/staple removal and wound evaluation. Physical therapy is continued to assist with early functional recovery. Radiographs are obtained at follow up and at 4 to 6-week intervals to assess fracture healing. Once fracture callus is evident on radiographs, weight bearing is advanced, and the patient weaned from external supports. P.408

FIGURE 22.18 Cross-locking a fracture in the distal third of the femur with a single screw permits the short distal fragment to toggle or rotate on the axis of the screw. Return to preinjury function can be prolonged after a femoral shaft fracture. Up to 20% of people fail to return to full-time preinjury employment after 3 years (22). With union rates ranging from 97% to 99% in most series, there is a significant discrepancy between fracture healing and functional recovery. Abnormal gait, hip abductor weakness, knee extensor weakness, knee pain, and hip pain are all common postoperative issues. Soft-tissue damage from the trauma can be a significant cause of disability as well. All these factors support the need for early, focused rehabilitation, and a long-term exercise programs (23).

COMPLICATIONS With careful technique, complications are uncommon. Patients commonly experience mild hip and knee pain as well as loss of motion. Hip abductor and knee extensor weaknesses typically occur and contribute to a limp that may persist for several months. Malunion is more common than nonunion.

Post-Op Wound Infection Postoperative wound infection occurs in fewer than 1% of patients. Early infections can be effectively treated with irrigation and débridement of the infected wound and hematoma. Deep cultures should be obtained to direct antibiotic choice. Antibiotics will usually be administered for several weeks due to the presence of hardware. If the infection is delayed more than several weeks and involves the intramedullary canal, the existing nail should be removed and the intramedullary canal reamed to remove infected tissue. The Reamer Irrigator Aspirator (Synthes, Paoli, PA) is a useful device to ream the canal and irrigate and aspirate the intramedullary contents at the same time. An intramedullary nail made of polymethylmethacrylate and antibiotic (tobramycin and/or vancomycin) is a simple way to deliver high-dose local antibiotics to the intramedullary canal. This antibiotic nail is not stable so the femur should be temporarily stabilized with an external fixator or KAFO for a few days to allow maximal antibiotic elution.

After a few days to a few weeks, the antibiotic nail can be exchanged for a standard interlocking nail. For intramedullary infections, antibiotics will usually be given for several weeks based on the organism, its sensitivities to various antibiotics, and host factors. Malunion/Delayed Union/Nonunion Typically, malunions result from improper alignment at the time of fixation. Surgeons treating these fractures must have a system in place to be able to assess the length, angulation, and rotational components intraoperatively. Angular malunion is seen most commonly with fractures that are near the proximal or distal shaft region and also with unstable, comminuted fracture patterns (i.e., AO/OTA types 32-B and 32-C) (21). P.409 Malrotation is the most common type of malunion and > 15 degrees of malrotation has been reported to occur in 28% of cases in one study. Functional limitations were greater in patients that were externally rotated (24). Another series reported an average of 16 degrees of malrotation (25). Typical pitfalls contributing to malunion include improper starting point, failure to obtain adequate reduction prior to reaming, and not critically assessing length and rotation prior to cross-locking. With newer generation nails, the trochanteric starting point may be inadvertently “lateralized,” even after appropriate guide pin placement. As the proximal femur is opened, the reamer will follow the path of least resistance and be pushed laterally by the tension of the soft tissues, reaming a path, which is eccentric and lateral to that which is intended. This results in a varus malalignment and can be challenging to correct, even if recognized intraoperatively. The overall nonunion rate with the use of reamed, statically locked nails is 2% to 3% as compared to 7.5% with nonreamed nails (21). Dynamization, the technique of removing the proximal or distal interlocking screws to allow fracture compression with during weight bearing, should be considered for length stable fractures that have not healed within 3 to 4 months. However, dynamization may be successful in only 50% of cases (26). The ideal fracture would have a gap 90 degrees P.422 should be obtained between 6 and 8 weeks postoperatively. Weight bearing can be initiated early in axially stable fractures but is usually delayed 6 to 10 weeks until callus forms in unstable fractures. Most fractures heal between 3 and 6 months. Low molecular weight heparin and mechanical prophylaxis with sequential compression hose are routinely used. Patients are seen in the clinic at 2 weeks postoperatively to remove sutures and assess knee motion. Follow-up visits are scheduled at 6, 10, 16, and 20 weeks or longer until union occurs. Weight bearing is increased based on clinical and radiographic healing. Once there is firm bridging callus, full weight bearing can be initiated without restrictions.

FIGURE 23.16 A. After depth gauging the hole, the screw is inserted. A captured screwdriver or a suture around the screw head should be used so that the screw is not lost in the quadriceps muscle during insertion. B. Screw for proximal interlocking inserted in the middle of the dynamic slot. C. A lateral fluoroscopic view should be obtained after proximal interlocking by placing the leg in a figure 4 position to assure that the proximal screw has been fully inserted.

COMPLICATIONS Soft Tissue/Infection Fortunately, infections following retrograde nailing are uncommon and rarely lead to a septic knee joint. Localized infection can be treated with an incision and drainage with maintenance of hardware if the infection is in the early postoperative period. Suppressive antibiotics can be continued until union. Most of these patients P.423 benefit from late removal of the nail with reaming of the intramedullary canal. Early knee motion is

encouraged to prevent arthrofibrosis.

FIGURE 23.17 A. Final A-P fluoroscopy view with C-arm demonstrating fracture alignment after retrograde intramedullary nailing. B. AP radiograph showing fracture reduction and proper placement of retrograde intramedullary nail.

Stiffness and Knee Motion Most patients regain their knee motion by 8 to 12 weeks. Continuous passive motion machines may be considered for obtunded patients or those with multiple injuries that require prolonged bed rest. Several studies comparing antegrade and retrograde nailing of femoral shaft fractures have not shown a difference in knee motion, strength of the quadriceps, or knee scores. Leaving the nail prominent at the intercondylar notch can lead to patellar impingement and should be revised as soon as it is recognized. Quadriceps adhesion to the suprapatellar pouch is common in supracondylar fractures. Active assisted knee motion should be encouraged and supervised in the early postoperative period. In patients with limited knee motion, we recommend an aggressive physical therapy program for limb rehabilitation. Full extension and flexion to 120 degrees should be expected with a well-placed, retrograde, femoral nail. If by 4 months, a patient has not achieved 90 degrees of knee flexion, manipulation under anesthesia should be considered.

Nonunion/Malunion Nonunion is more frequent when small diameter, noncanal filling nails are employed. Reamed canal-sized implants have been shown to achieve union rates >90%, which compare favorably to antegrade nailing. In patients with delays in union, dynamization can be performed if the fracture is axially stable. This is beneficial in fractures that have some callus but have a gap at the fracture site with a well-fitting nail. Almost always, the proximal screw is removed to allow the nail to move in a proximal direction with compression of the fracture site and not toward the knee joint. With bilateral fractures, nailing the less comminuted fracture first and then using the same length nail on the more complex contralateral side decreases the risk of leg length discrepancy. Fractures at the tip of the implant have been reported in osteoporotic bone with the use of short nails. For this reason, full-length nails are recommended for all fractures, including those in the supracondylar region. Most malunions that have been reported with the use of retrograde nails for fractures

occur in the proximal and distal ends of the femur.

Knee Pain/Symptomatic Hardware Pain caused by prominent distal screws is common and is usually caused by screws that are too long. The most distal locking screw is inserted into the trapezoidal distal femur, and screws that appear with their tips just outside the medial femoral cortex are usually too long. Sometimes the screw heads are prominent or click or snap under the iliotibial band in thin patients. Symptomatic distal screws can be removed as an outpatient procedure P.424 once union has occurred, or a painful screw may be removed once abundant callus is visible on radiographs. Long-term knee pain is uncommon with proper operative technique. Residual anterior knee pain is occasionally seen and is most common secondary to original injury or with residual weakness in the quadriceps muscle.

RECOMMENDED READING Daglar B, Gungor E, Delialioglu OM, et al. Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation. J Orthop Trauma 2009;23(9):640-644. Gregory P, DiCicco J, Karpik K, et al. Ipsilateral fractures of the femur and tibia: treatment with retrograde femoral nailing and unreamed tibial nailing. J Orthop Trauma 1996;10(5):309-316. Herscovici D, Whiteman KW. Retrograde nailing of the femur using an intercondylar notch approach. Clin Orthop Relat Res 1996;332:98-104. Moed BR, Watson JT. Retrograde intramedullary nailing, without reaming, of fractures of the femoral shaft in multiply injured patients. J Bone Joint Surg Am 1995;77:1520-1527. Ostrum RF. Treatment of floating knee injuries through a single percutaneous approach. Clin Orthop 2000;375:43-50. Ostrum RF, Agarwal A, Lakatos R, et al. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501. Ostrum RF, DiCicco J, Lakatos R, et al. Retrograde intramedullary nailing of femoral diaphyseal fractures. J Orthop Trauma 1998;12:464-468. Ostrum RF, Maurer JP. Distal third femur fractures treated with retrograde femoral nailing and blocking screws. J Orthop Trauma 2009;23(9):681-684. O'Toole RV, Riche K, Cannada LK, et al. Analysis of postoperative knee sepsis after retrograde nail insertion of open femoral shaft fractures. J Orthop Trauma 2010;24(11):677-682. Ricci WM, Bellabarba C, Evanoff B, et al. Retrograde versus antegrade nailing of femoral shaft fractures. J

Orthop Trauma 2001;15:161-169. Sears BR, Ostrum RF, Litsky AS. A mechanical study of gap motion in cadaveric femurs using short and long supracondylar nails. J Orthop Trauma 2004;18:354-360. Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral nailing: a prospective, randomised trial. J Bone Joint Surg Br 2000;82:652-654.

24 Distal Femur Fractures: Open Reduction and Internal Fixation Brett D. Crist Mark A. Lee

INTRODUCTION The treatment of distal femur fractures is challenging due to disruption of the joint surface, metaphyseal comminution, bone loss in open fractures, and limited space for fixation in fractures with small articular segments. Most distal femur fractures in adults are managed operatively due to poor outcomes with nonoperative management even in elderly patients. High-energy fractures typically occur in younger patients and are associated with open fractures, diaphyseal extension, and intra-articular comminution. Lower-energy fractures usually occur in elderly females secondary to ground-level falls and may be extra-articular or intra-articular. Periprosthetic femur fractures above a total knee or below a total hip arthroplasty create unique problems in treatment. For all of these reasons, fixed-angle devices (including locking plates) and indirect reduction techniques for the nonarticular fracture components have been developed to decrease the need for bone grafting, prolonged external fixation, or medial plating. For the most of these fractures, plate osteosynthesis is the implant of first choice.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY While the vast majority of distal femur fractures in adults are managed surgically, there are a few indications for nonoperative treatment. These include truly nondisplaced fractures that can be managed for a short period of time in a cast or hinged knee brace. Occasionally, an impacted stable supracondylar fracture in an elderly patient can be managed without surgery. Similarly, adolescents with open epiphysis and minimally displaced fractures are often well managed in a cast. Lastly, in extremely frail patients with multiple medical comorbidities who do not walk, nonoperative management should be considered. On the other hand, displaced distal femur fractures that occur in adults are primarily managed surgically to restore stability and allow early range of knee motion and rehabilitation. Even in elderly patients, nonoperative management of displaced fractures is associated with poor outcomes because of an increased risk of pneumonia, deep vein thrombosis, pressure ulcers, and knee stiffness (1).

PREOPERATIVE PLANNING History and Physical Examination As with all patients that sustain trauma, a complete history and physical should be performed. Critical factors include mechanism of injury and associated medical comorbidities that might increase the risk of intra- or postoperative complications. These include underlying cardiovascular disease, diabetes mellitus, osteoporosis, P.426 tobacco use, a preexisting surgical history (particularly arthroplasty), and preinjury ambulatory and functional status. A complete physical should include evaluation of the patient, their extremity, pelvis, and spine to avoid missed injuries. Typically the affected lower extremity is shortened and externally rotated. Careful skin inspection and neurovascular exam should be done to avoid missing an open fracture wound posteriorly or neurovascular compromise including compartment syndrome. Ecchymosis and swelling develop rapidly and should be noted. If there is diminished or absent pulses, gentle longitudinal traction should be applied to the lower extremity, and reexamination should be performed to see if the vascular status improves. This often distinguishes whether the

difference in the pulse is secondary to fracture displacement or due to an arterial injury that requires vascular consultation. Once the physical examination is complete, either a well-padded long-leg splint or knee immobilizer is applied to relieve pain and provide support to the injured limb. If surgery is delayed, frequent skin and neurovascular checks should be performed. When the fracture is significantly shortened or the patient is not comfortable in a splint or brace, proximal tibial skeletal traction should be considered.

FIGURE 24.1 A,B. Initial injury AP and lateral knee radiographs.

Imaging Studies Anteroposterior (AP) and lateral radiographs of the knee and femur are crucial and provide valuable information about the injury and treatment alternatives (Fig. 24.1A,B). Since the fracture is typically shortened and rotated, traction, radiographs can be obtained following appropriate sedation. Full-length femur films are required to avoid missing a more proximal fracture or hip injury. Additionally, bone quality can be assessed on plain films on the basis of the cortical diaphyseal thickness and intramedullary diameter. This information helps guide the choice of implants particularly in the elderly. Computed tomographic (CT) scans with 2D and increasingly 3D reconstructions are obtained for many fractures and virtually all injuries with intra-articular extension. P.427

FIGURE 24.2 The AO/OTA classification of distal femoral fractures. 33A fractures are extra-articular and can be treated with plates or medullary implants. 33B fractures are articular injuries that are best treated with open reduction and compression across the fracture; locked implants are not indicated for these fractures. 33C fractures require restoration of the articular surface as well as the relationship of the distal articular segment to the shaft of the femur. The AO/OTA classification is useful to guide treatment including the surgical approach and fracture implants (Fig. 24.2). The distal femur region is designated as 33 in the comprehensive classification of fractures. Type 33A fractures are extra-articular distal femur injuries and can be fixed with a variety of implants, frequently dictated by surgeon preference. 33B fractures are partial articular injuries and may involve either the medial or lateral femoral condyle. It is mandatory to rule out a coronal plane fracture (B3 component or Hoffa fracture) with even simple supracondylar/intercondylar patterns. This fracture can occur in up to 38% of fractures and if missed leads to poor outcomes (2). It is best seen on the sagittal reconstruction of the CT scan. Type 33C fractures involve both the articular surface and metadiaphysis and range from fairly simple splits to highly comminuted fracture patterns. We use both plain radiographs and CT scans for preoperative planning. The AP and lateral radiographs of the distal femur are helpful to determine plate length. Many of the high-energy distal femoral fractures with comminution and femoral shaft extension require a total plate length that is two to three times the length of the

zone of comminution. It is critical to have a plate of proper length, as short plates are a common cause of fixation failure. Digital imaging software can be used for preoperative planning and to ensure that adequate distal fixation can be achieved with the implant. Finally, we frequently obtain a comparison image of the contralateral femur (if not injured) to determine femoral length when either significant comminution or bone loss exists. This radiograph also determines the normal lateral distal femoral angle (LDFA). Once this is known, the frontal plain reduction angle for the injured side is determined and is used to determine our 95-degree reference path for our implant of choice. Almost all contemporary implants include a 95-degree reference screw or wire to assist in frontal plane reduction and restoration of the LDFA. P.428

FIGURE 24.3 Sagittal reconstruction CT scan showing coronal plane fracture of the lateral condyle (Hoffa). CT scans are very important in preoperative planning for two reasons. First, the CT may reveal unrecognized coronal plane fractures (Fig. 24.3; Hoffa fracture) that usually require independent interfragmentary screw fixation and may affect implant fixation, selection, and location. Second, detailed information is gained regarding the distal extent of the fracture to determine whether or not internal fixation is technically feasible. Current implant designs have increased our ability to gain fixation in increasingly distal fracture patterns, and primary distal femoral replacement arthroplasty is rarely performed today.

Timing of Surgery To allow for early mobilization, most supracondylar fractures should be surgically repaired as soon as the

patient's overall condition permits, usually within the first 48 hours. Open fractures require urgent irrigation and débridement as soon as operating room resources are available, and the patient is physiologically stable. In patients with open fractures, definitive fixation may be delayed for appropriate imaging, implant availability, and preoperative planning. Staged surgery should also be employed if the soft tissues or patient status or hospital resources preclude early definitive fixation. For most closed fractures in noncritically ill patients, we do not utilize temporary spanning external fixation for distal femur fractures, even for higher energy articular patterns. We favor simple splinting and early definitive internal fixation. This stands in marked contrast to high-energy proximal tibial fractures, where soft-tissue complications are more frequent with early internal fixation (3). Urgent but thoughtful intervention is required, and a detailed preoperative plan remains important especially with intra-articular fracture patterns as this can influence implant selection.

Temporary Spanning External Fixation The indications for temporary spanning external fixation have increased over the past 10 years to manage complex extremity fractures in the seriously injured patient. The benefits of temporary external fixation include decreased pain, improved mobilization of the patient, and easier access to the soft tissues when compared to splinting or traction. Furthermore, in complete articular fractures, preoperative planning is improved when radiographs and a CT scan are obtained after closed reduction and external fixation due to ligamentotaxis (Fig. 24.4A,B). The external fixator can also be used intraoperatively as a reduction device. P.429

FIGURE 24.4 A,B. AP and lateral radiographs of a distal femur fracture placed in temporary knee-spanning external fixator. The indications for temporary knee joint spanning external fixation include Polytrauma patients with multiple orthopedic injuries who are too unstable to undergo definitive fixation Open contaminated fractures that will require multiple débridements

Closed fractures with significant soft-tissue trauma that precludes early definitive fixation Complex articular fractures that would benefit from CT imaging after external fixation due to ligamentotaxis Femoral and tibial external fixation pins should be placed outside of the zone of injury and away from future definitive surgical approaches. Typically, 150- to 200-mm Schantz pins are used in the femur, and approximately 150-mm pins are used in the tibia. Femoral pins can be placed anteriorly, laterally, or anterolaterally. However, if the external fixator is going to be used intraoperatively, a configuration that uses anterior pin placement in the femur is recommended to avoid interfering with plate placement. Furthermore, anterior femoral pin placement avoids any potential contamination of the lateral surgical approach to the distal femur. In order to improve radiographic visualization of the distal femur after external fixation, the bar-to-bar clamps should be strategically placed distal or proximal to the articular surface. The knee should be flexed 10 to 20 degrees to decrease the hyperextension deformity of the distal fragment and relax the posterior neurovascular structures. Standard external fixator pin care should be used. In order to minimize the risk of infection, definitive internal fixation should be performed within 2 weeks whenever possible (4).

Preoperative Surgical Tactic Once the x-rays and CT scan have been obtained and carefully reviewed, a surgical plan can be developed. Using the tracing technique popularized by the AO or digital templating software, a formal plan should be formulated that includes identifying each fracture fragment that needs reduction and the steps necessary to accomplish it (5). The surgical tactic should describe in detail the procedure from beginning to end. For less experienced surgeons and residents in training, this should include the surgical approach, the equipment required, and the sequence of the procedure including operating room set up, patient positioning; fracture exposure, reduction, and fixation; wound closure and postoperative course. We recommend including specific fracture reduction steps with specific techniques and clamps utilized, provisional fixation, and sequence and location of internal fixation with the specific implants. This ensures that all of the necessary equipment will be available at the time of surgery. P.430

FIXATION DEVICES Implant selection is dictated primarily by the fracture location and pattern. Extra-articular AO/OTA 33A fractures can be managed with intramedullary nails, traditional fixed-angle implants, or periarticular locking plates. The choice between these implants is largely dictated by surgeon experience and preference as there is little Level I evidence supporting one implant over another. However, a recent study concluded that locking implants may function better in osteoporotic bone than other techniques due to improved fixation in the distal fragment as well as better control of angular stability under physiologic loading (6). Advances in intramedullary nail designs have also improved performance in osteoporotic bone because angular stability is improved by multiplaner fixation with locking options in the distal fragment (Fig. 24.5). Another implant uses a bone-sparing spiral blade in the distal fracture segment with subsequent submuscular plate passage of a plate that is attached to the blade. This type of implant provides the bone-sparing benefit of the first-generation angled blade plates with the submuscular plate techniques seen with modern periarticular locking plates (Fig. 24.6). Isolated partial articular or AO/OTA 33 type B fractures are uncommon injuries that require internal fixation when displaced conventional nonlocking contoured or traditional buttress techniques are highly effective except in the extremely osteoporotic patients. In this small subgroup, a locking plate is indicated (Fig 24.21A-F). In North America, the anatomically contoured periarticular locking plates have become the treatment of choice for most intra-articular distal femoral fractures (AO/OTA type C). These systems combine the ability to use both locking and nonlocking screws (hybrid technique) that have addressed many of the major limitations and

concerns about the first-generation locking plates such as the Less Invasive Surgical Stabilization (LISS; Synthes, West Chester, PA). The multiple fixed angle screw design provides secure fixation in the distal articular block that can be advantageous in osteoporotic bone or short articular segments. Additionally, multiple points of angular stability can provide fixation around independent articular lag screws. Newer generation multidirectional locking plates allow screws to be directed through an arc of up to 20 degrees in each direction and precisely direct screws around other distal fixation (Fig. 24.7A,B). This has been shown to provide reliable angular stability in bridging constructs (7). Most of the current generation of locking implants includes insertion handles and aiming arms that facilitate percutaneous screw placement along the femoral shaft.

FIGURE 24.5 AP radiograph of a femoral shaft fracture managed with a retrograde femoral nail with fixed-angle blade fixation distally.

FIGURE 24.6 AP knee radiograph showing comminuted intra-articular distal femur fracture managed with a modular blade plate. P.431

FIGURE 24.7 A,B. AP and lateral knee fluoroscopy views showing multidirectional locking screw fixation used to avoid lag screws placed across the articular fragments.

Surgical Technique The patient's condition and medical comorbidities often influence whether a general or spinal anesthetic is recommended. We prefer general anesthesia to ensure reliable and sustained muscle paralysis that is required for fracture reduction and fixation. Standard antibiotic prophylaxis is utilized. Appropriate blood products should be available, and an arterial line should be considered in unstable patients or if a prolonged procedure is expected. A Foley catheter is utilized in most patients.

Patient Positioning Internal fixation of distal femur fractures is done on a radiolucent table that allows for unobstructed imaging from the pelvis to the foot. The patient is placed supine on the operating table with a small bump placed beneath the ipsilateral hip to allow the leg to lie in neutral rotation (Fig. 24.8A).

FIGURE 24.8 A. The patient is positioned in the supine position with a bump under the ipsilateral hip to position the femur in neutral rotation. Surgical drapes should allow for access to the ipsilateral hemipelvis. Custom positioning pads (A) or radiolucent triangles and towel bumps (B) can be used to flex the knee to aid with fracture reduction in the sagittal plane. P.432

FIGURE 24.9 A. Supine patient position with both lower extremities draped into surgical field to allow for better visualization of the proximal femur and intraoperative assessment of limb length and alignment. B. The nonoperative extremity can be flexed above the C-arm to be able to visualize the proximal femur. The entire lower extremity should be prepped and draped from the iliac crest to the toes to allow for accurate intraoperative assessment of length, alignment, and rotation. In fractures with significant comminution or bone loss, we often include the contralateral extremity in the operative field for comparison and easier fluoroscopic access to the proximal femur for the lateral view (Fig. 24.9). Sterile bumps or towels, custom ramps, or radiolucent triangles can be used to help position the leg (Fig. 24.8B). In very distal fractures, a sterile tourniquet can be used, but for most fractures, it is not applicable. Fluoroscopy is a vital component for internal fixation of a distal femur fracture and is utilized in all cases. It is important that the C-arm has the ability to easily rotate around the operating table to provide high-quality lateral imaging. Typically, the C-arm is placed on the opposite side of the surgical approach.

SURGICAL APPROACHES Several surgical approaches can be used for internal fixation of the distal femur. The surgical approach selected depends on the fracture location and pattern, the degree of articular involvement, the soft-tissue injury, and planned implants.

Direct Lateral Approach The most common approach for extra-articular fractures (33A) and some intra-articular fractures (33C) is the direct lateral approach (Fig. 24.10). With modification to incorporate a lateral patellar arthrotomy, this approach is used for most intra-articular fractures that do not have medial articular comminution. The benefits of this approach include ease of plate application, the ability to reduce the metaphyseal component of the fracture, and its extensile nature. The inability to completely visualize the medial articular surface significantly limits its use in

most type C2 and C3 fracture patterns that involve the medial condyle. The transarticular approach and retrograde plate osteosynthesis (TARPO) are used to address complex articular fractures and allow for lateral submuscular plating (8). Through a midline total knee incision, a P.433 lateral parapatellar arthrotomy is performed. Subluxating the patella medially allows for excellent visualization of the articular surface for joint reconstruction (Fig. 24.11A). Following reconstruction of the distal articular block, the epimetaphysis is attached to the shaft with a plate passed submuscularly beneath the vastus lateralis along the lateral femoral cortex, and diaphyseal screw placement is done percutaneously (Fig. 24.11B).

FIGURE 24.10 Direct lateral approach to the distal femur that allows for an extensile approach to the entire femur. The extended TARPO approach is used for complex medial articular fractures with medial retraction of the quadriceps to address the joint surface and the metadiaphyseal fracture component as well (9). Through a lateral parapatellar arthrotomy, the vastus lateralis fascia is elevated from the muscle belly that allows for easier mobilization of the muscle anteromedially without injuring the perforating vessels. Extending the approach proximally provides visualization of the metaphysis for direct reduction and internal fixation.

FIGURE 24.11 TARPO surgical approach to the distal femur (A) articular visualization and (B) plate application using a percutaneous aiming arm. P.434

FIGURE 24.12 Medial subvastus approach to address medial articular comminution with the vastus medialis retracted anteriorly.

FIGURE 24.13 Medial femoral condyle coronal fracture reduced with a pointed reduction clamp perpendicular to the fracture line. Occasionally, a medial subvastus approach to the distal femur is required to address medial articular involvement in complex distal femur fractures or for isolated medial condyle fractures (Fig. 24.12). The incision is centered over the medial condyle and extends proximally anterior to the adductor tubercle. A medial arthrotomy is done to visualize the articular surface. If a lateral arthrotomy has already been performed through another approach, caution should be used to minimize the risk of devascularizing the patella. If proximal extension is necessary, the vastus medialis is elevated anteriorly. However, the femoral vessels limit proximal extension beyond the metadiaphyseal region.

SURGICAL TACTIC Articular Reduction Typically, the articular fracture fragments are more displaced than they appear on radiographs, especially the intercondylar split, and an adequate articular exposure is required to accurately reduce the fracture. Because anatomical reduction is the goal for articular fractures, we do not recommend percutaneous reduction and fixation techniques for distal femoral fractures with articular involvement. Any coronal plane fractures (Hoffa fragment) are addressed first. Carefully placed pointed reduction clamps applied from within the exposure are necessary to achieve the appropriate reduction vector (Fig. 24.13). Following anatomical reduction, the fracture is provisionally fixed with Kirschner wires (K-wires) placed perpendicular to the fracture. To control rotational forces, a minimum of two anterior to posterior interfragmentary compression screws are placed obliquely across the frontal plane fracture from the articular margin and away from the weight-bearing articular surface whenever possible. To avoid patellar impingement, these screws must be countersunk below the articular surface. If the coronal fragments are displaced, multiple 1.6- or 2.0-mm smooth or terminally threaded wires placed into the fragment allow for multiplanar manipulation and reduction. Once the coronal articular fragments have been reduced, the medial and lateral condyles are reduced. Each condylar segment is derotated and reduced using multiple wires as joysticks to hold the rotational aspect of the reduction (Fig. 24.14). Since comminution is less common along the central fracture line in the intercondylar notch, interfragmentary compression can usually be achieved with the use of colinear or periarticular specialty clamps. Due to the trapezoidal nature of the distal femur, the reduction may look anatomic at one point, but can be malreduced in the sagittal plane or gapped at another point. Once an anatomical articular reduction is verified, the condyles are reduced and compressed with screws placed anteriorly and/or posteriorly (Fig. 24.14), which allows for future plate placement. Occasionally,

we insert screws from medial to lateral when a medial parapatellar approach for articular reduction has been utilized. A minimum of two, but frequently several, 2.7-mm or larger screws are used to stabilize the intercondylar split.

Reduction of the Articular Surface to the Femoral Shaft and Minimal Invasive Reduction Techniques Once the articular surface is anatomically reduced and rigidly fixed, it is reduced and fixed to the femoral shaft. A variety of methods can be used, but the goals should be to restore the length, rotation, and sagittal and coronal plane alignment of the femur. Traditional open techniques require direct visualization and manipulation of the metadiaphyseal fracture fragments. These techniques are used for simple fracture patterns where primary fracture healing is the goal and lag screw fixation or compression plating can be utilized. Standard reduction forceps are used to manipulate the fragments and maintain fracture reduction (Fig. 24.15). Schantz pins or Kwires can also be used as joysticks to manipulate the fragments prior to compression with the reduction forceps. P.435

FIGURE 24.14 A. Medial and lateral condyle separated with coronal fracture lines provisionally K-wired. B.

Medial and lateral condyles derotated, reduced with a pointed reduction clamp, and held with K-wires. C. Accompanying AP fluoroscopic view of provisional K-wire fixation of figure (B). D. Intercondylar lag screw fixation in place (two screws noted with arrows). P.436

FIGURE 24.14 (Continued) E. Diagram showing potential intercondylar lag screw positions that will avoid impeding plate positioning. However, in comminuted fractures, direct reduction techniques can cause devascularization of the fracture fragments leading to delayed union and implant failure. With comminuted fractures, bridge-plating techniques are commonly used with the goal of restoration of length, alignment, and rotation rather than anatomic reduction of the individual fracture fragments. Indirect reduction techniques avoid direct exposure and manipulation of the metaphyseal fracture fragments. They minimize disruption of the blood supply to the fracture fragments, reducing the risk of nonunion and hardware failure. These indirect techniques can be used in a minimally invasive fashion. First and foremost, minimally invasive reduction of the articular surface is not recommended. However, the techniques for minimally invasive reduction of the reconstructed articular segment to the femoral shaft are reliable and reproducible for most fracture patterns. Indirect reduction techniques utilize ligamentotaxis and manipulation of the fracture fragments remote from the fracture site to regain the alignment of the femur. Following a distal femur fracture, muscle forces lead to predictable deformities that must be recognized and addressed in order to achieve a satisfactory reduction. The gastrocnemius muscles cause fracture extension, and the hamstrings and quadriceps cause fracture shortening. The first step in reducing the articular surface to the shaft is to regain leg length with the use of manual traction or a femoral distractor or external fixator. While shortening can usually be corrected with manual traction, the need for sustained traction while addressing other planes of deformity is better facilitated with the use of a femoral distractor or external fixator. Although a knee-spanning external fixator can be useful, it is not as P.437 effective at correcting the sagittal plane deformity as using an “all-femur” external fixator (Fig. 24.16A). First, image the distal femoral articular block and try to match rotational alignment with the preoperatively captured image of the uninjured femur to appreciate a perfect AP projection. A 5.0-mm Schantz pin is placed near the patella in the proximal edge of the distal fragment perpendicular to the bone (Fig. 24.16B). This pin is then used to correct fracture extension and shortening (Fig. 24.16C). Once the alignment is corrected, the pin is connected

to a second Schantz pin in the femoral shaft proximal to the fracture site with a single rod. Surgical bumps and/or radiolucent triangles can be used to help correct posterior translation. Manipulating the two pins can also correct residual rotational deformity. However, it is very difficult to reduce coronal plane malalignment with an anteriorly placed external fixator or distractor. If the alignment can be corrected in all planes, additional temporary K-wire fixation can be placed across the metaphyseal fracture line to maintain the reduction.

FIGURE 24.15 Lateral fluoroscopic view showing large reduction forcep reducing the shaft component of the distal femur fracture with lag screw in place.

FIGURE 24.16 A. An “all-femur” external fixator can be used as an intraoperative reduction aid placing a Schantz pin in the articular block and the femoral shaft. B,C. The metaphyseal fracture component can be reduced by using the pin in the articular block to correct the sagittal plane deformity and length. Coronal plane alignment is usually corrected by an anatomically precontoured implant. Once the overall length and sagittal plane alignment are restored, the plate is inserted via the articular surgical approach or occasionally through a separate lateral approach. The plate is centered on the femur using AP and lateral fluoroscopy (Fig. 24.17). The plate should be placed along the anterolateral surface of the distal femur in line with the axis of the femoral shaft. Placing the plate posterior to the axis of the femur can lead to a malreduction. A guide wire is placed through the 95-degree fixed-axis hole of the plate parallel to the knee joint on the AP view to create 5 degrees of valgus when the bone is drawn toward the plate (Fig. 24.17A). Next, temporary proximal fixation is done with provisional wires, plate reduction instruments, or clamps. If a percutaneous aiming arm is utilized with the plate, it is helpful to center the plate proximally by positioning the leg or the C-arm to visualize the aiming arm superimposed on the plate to determine screw trajectory (Fig. 24.17B). P.438

FIGURE 24.17 A. AP fluoroscopic view with the 95-degree axis wire with a periarticular clamp in place. B. Lateral fluoroscopic view with the percutaneous aiming arm superimposed on the plate to insure that the plate is centered. A proximal wire is in place to hold the plate position. C. Oblique lateral fluoroscopic view showing that the posterior cortex is reduced. D. AP fluoroscopic view showing the cortical screw being placed proximal to the fracture to use the plate to restore coronal plane alignment. P.439

FIGURE 24.17 (Continued) E. Once the cortical screw is placed, the coronal plane reduction is complete. F. It is important to verify that the sagittal plane reduction has not changed on the oblique lateral view that shows the posterior cortex reduced. The plate is either compressed to the bone or within proximity of the periosteum with either a plate reduction instrument or a cortical screw. Prior to placing the screw proximal to the fracture site, the plate must be perfectly positioned and compressed to the distal femur with a periarticular reduction forceps to avoid plate prominence or subsequent malpositioning of the distal screws (Fig. 24.21). We prefer to use a cortical screw to “draw” the bone toward the plate to obtain coronal plane reduction (Fig. 24.17D,E). Once the plate is secured to the bone, the lateral view should be checked to ensure that the sagittal plane alignment has not changed (Fig. 24.17F). It is important to emphasize that the plate can only correct coronal plane alignment; it does not correct length or sagittal plane alignment. The use of both cortical and locking screw fixation is termed “hybrid” fixation. If only locking screw fixation is desired in the diaphysis, the plate can still be used as a coronal plane reduction aid as described by utilizing plate reduction devices included in the plate instrument set. Overall fracture alignment is verified with fluoroscopy and intraoperative long-cassette radiographs. Oblique lateral fluoroscopic views help verify the sagittal metaphyseal reduction by avoiding the obstruction of the aiming arms typically used with precontoured locking plates (Fig. 24.17C). Fluoroscopy has a relatively small field of view; therefore, intraoperative long cassette radiographs should be obtained in fractures with comminution to ensure that overall alignment is restored (Fig. 24.18C). The posterior cortex can often be used as a reduction reference even when there is significant metaphyseal comminution (Fig. 24.18D). Although optimal plate length and the number of diaphyseal screws are controversial, there are several general guidelines that are useful. If comminution exists in the metadiaphyseal region, it is common to use a plate length

that spans three times the length of comminution. If bridge-plating techniques are utilized, the initial screw placed for coronal plane reduction with a precontoured plate is placed close to the fracture site. If this technique is used, it is important to verify that the reduction has not changed in the sagittal plane during screw placement and that the proximal end of the plate is also reduced to the bone prior to placing locking screws in the diaphysis. Once coronal plane alignment is restored, the periarticular locking screws are placed with fluoroscopic assistance. Since the medial condyle is sloped 25 degrees (Fig. 24.19), it is important to avoid placing screws that are too long or penetrate the medial cortex. P.440

FIGURE 24.18 In comminuted fractures, especially with bone loss (A,B), it is important to get intraoperative alignment views both AP (C) and lateral views (D) to verify reduction. Postoperative radiographs show that the overall length and alignment were restored (E,F). P.441

FIGURE 24.18 (Continued)

Periprosthetic Fractures Although periprosthetic fractures do not have an articular component, they present unique challenges. The overall technique for reduction and plate application is the same as with standard fractures, but hardware P.442 placement may need to be adjusted or nonstandard techniques utilized to gain adequate fixation around the femoral component. Locking screw technology has vastly improved the ability to manage these fractures with open reduction internal fixation instead of revision arthroplasty.

FIGURE 24.19 The distal femoral anatomy as it relates to plate applications. The lateral metaphysis is angulated 10 degrees from the sagittal plane; the medial metaphysis is angulated 25 degrees from the sagittal plane. To avoid a medial translational deformity of the articular surface, lateral plate applications should follow the sloped, lateral, metaphyseal surface. To ensure that screws are contained within the distal femur, the anterior location of the metaphysis must be appreciated. Anterior implants are shorter than those angulated or placed more posteriorly. The critical question that needs to be answered for any fracture around a prosthesis is whether the components are well fixed or loose. In distal femur fractures around a total knee arthroplasty, the type of femoral component should be determined (cruciate retaining vs. stabilizing) to determine if there is enough bone available for distal fixation. A traction view often provides additional information regarding bone stock. The level of the fracture and the amount of bone available for distal fixation may influence the method of treatment with either an intramedullary nail or plate osteosynthesis. Although fixed angle and multiplanar locking options exist in several of the current intramedullary nail systems, use of a retrograde intramedullary nail can be challenging when there is limited bone available distally. Therefore retrograde intramedullary nail fixation is more likely to be considered when the fracture is well above the femoral component, in patients that have an “open box” femoral component that can accommodate a nail. If there is limited distal bone, either unidirectional or multidirectional locking screws can be used to improve fixation when a distal femoral locking plate is chosen. Occasionally, in patients with significant comminution or unstable arthroplasty components, revision arthroplasty may be a better option especially in low-demand patients. In patients with ipsilateral knee and hip arthroplasties and a periprosthetic fracture, plate fixation must bypass both arthroplasty components to avoid creating a stress riser for future fractures. Combinations of unicortical, bicortical locking screws, specialty attachment plates, and cables may be required for adequate plate fixation in these complex cases. It is important to gain length stabilization by obtaining screw fixation proximal and

distal to the fracture and avoid cable fixation alone to avoid postoperative fracture displacement.

Open Fractures Open fractures are typically associated with higher energy injury patterns, fracture comminution, and bone loss. Gustilo and Anderson type I or II open fractures with a simple fracture pattern may undergo early definitive fixation after urgent irrigation, and débridement is adequately performed. In complex type III open fractures with significant contamination and fracture comminution, urgent thorough irrigation and débridement and temporary knee-spanning external fixation is our preferred approach. Once the patient's overall condition has improved, appropriate imaging studies have been obtained, a surgical tactic developed, and the soft tissue and fracture bed is clean, healthy, and stable, definitive internal fixation may be performed. When there is significant bone loss, we often use an antibiotic cement spacer as a void filler at the time of definitive fixation to create a sterile space for staged bone grafting. In these fractures, either a second medial plate or a medial cortical substitution plate as described by Mast et al. (5) may reduce the incidence of hardware failure (Fig. 24.20). Bone grafting is performed approximately 4 to 6 weeks later when the acute inflammatory phase has resolved. The choice of graft material remains controversial but it is helpful to use material that is osteogenic, osteoinductive, and osteoconductive. When bone grafting is performed, the biomembrane that forms around the antibiotic spacer should be left in place because of its favorable biological properties as described by Masquelet (10).

FIGURE 24.20 AP radiograph showing a medial cortical substitution plate used in an open fracture with bone loss. P.443 In fractures with large bony defects, it is not uncommon to have slow fracture consolidation leading to plate failure and nonunion at the junction between the femoral shaft and the bone graft. It is often difficult to verify complete healing with plain radiographs. These patients should be followed clinically and radiographically for several years.

Unicondylar Fractures

AO/OTA type 33B (unicondylar) fractures are approached with direct exposure, open reduction, and rigid fixation. The surgical approach is determined by the fracture pattern and location. For lateral condyle fractures, both in the sagittal and coronal (Hoffa) planes, a direct lateral approach provides adequate visualization unless there is intercondylar comminution seen on the CT scan. If there is comminution that extends into the intercondylar notch, a lateral parapatellar arthrotomy should be used to adequately visualize and reduce the fracture. With very posterior fractures, a posterolateral approach to the distal femur is indicated for reduction and fixation (11). Medial condylar fractures in the sagittal and coronal (Hoffa) planes are typically approached through the medial subvastus approach with arthrotomy as previously described. Articular reduction is accomplished with the use of joysticks, pointed reduction clamps, and provisional K-wire fixation. It is critical to ensure that both the intercondylar, articular, and cortical fracture exit points are anatomically reduced prior to fixation. It is common to have the articular surface reduced but have the other areas malreduced, especially in the sagittal plane. Intercondylar notch comminution needs to be reduced prior to reduction of the main condylar fragment to avoid malreduction of the entire condyle. Lag screw fixation can be performed with either standard or cannulated screws with the screw diameter dependent upon the size of the fragments and patient. For coronal plane fractures, it is important to start the screws as peripherally as possible and countersink the screw heads to avoid injury to the patella with knee motion. We have found “headless” screws in this area to be very useful. It is important that the screws do not penetrate the articular surface posteriorly. If there is comminution at the epicondylar exit point or if the fracture line is very vertical with a high risk of shear forces, an antiglide plate can be helpful (Fig. 24.21).

FIGURE 24.21 A. AP knee radiograph showing the comminuted lateral condyle fracture. B. Lateral radiograph, (C) axial CT scan image, (D) sagittal reconstruction CT image, (E) postoperative AP knee radiograph, and (F) postoperative lateral radiograph. P.444

FIGURE 24.21 (Continued) P.445

POSTOPERATIVE MANAGEMENT For extra-articular fractures, patients are kept toe-touch weight bearing (25 pounds) for 6 weeks and then progress to weight bear as tolerated. For intra-articular fractures, toe-touch weight bearing is continued for a total of 10 to 12 weeks, and weight bearing is progressed based on radiographic evidence of healing. Lower extremity range-of-motion exercises and gait training are begun on postoperative day 1. For most patients, a hinged knee brace or knee immobilizer is utilized for the first 6 weeks during ambulation. In closed fractures, antibiotics are administered for 24 hours. In open fractures, the duration of antibiotics is typically 48 to 72 hours. Deep vein thrombosis prophylaxis, including sequential compression devices and low molecular weight heparin, are routinely employed. Continued anticoagulation after hospital discharge is determined on a case-by-case basis. Sutures are removed 2 to 3 weeks postoperatively. Patients are seen in the clinic at 6 weeks for clinical examination and radiographs. Range-of-motion exercises are continued, and strengthening protocols are instituted. Weight bearing is advanced in patients with extra-articular fractures. For patients with intra-articular

distal femur fractures, radiographs at 10 to 12 weeks postoperatively help determine if weight bearing can be progressed. Thereafter, patients are seen at 2- to 3-month intervals until the fracture is clinically and radiographically healed. Physical therapy is continued until knee range of motion and quadriceps function has improved to allow the patients to transition to a home exercise program. Patients with bone loss are followed yearly until union is certain.

RESULTS Outcomes following internal fixation of distal femur fractures continue to improve. Indirect reduction techniques have significantly decreased the need for acute bone grafting and decreased the rate of hardware failure. Locking plates have decreased the technical challenge for plate application. Zlowodzki et al. (12) systematically reviewed the literature for operative treatment of distal femur fractures from 1989 to 2005 (majority case series) and showed that operative management significantly decreased the rate of poor outcomes. However, there were no significant differences in outcomes (nonunion, deep infection, fixation failure, and secondary surgery) between antegrade intramedullary nailing, retrograde femoral nailing, compression plating, submuscular locked plating (primarily LISS), and external fixation. Submuscular locked plating showed a significant decrease in deep infection but a higher rate of fixation failure and secondary surgeries when compared to compression plating.

COMPLICATIONS Intraoperative Major intraoperative complications are uncommon during fixation of distal femur fractures. The most common intraoperative complication is incomplete multiplanar fracture reduction. Length and coronal plane restoration are more readily achieved; however, sagittal plane (with apex posterior deformity) and rotational malreduction can be difficult to recognize. Maintenance of the sagittal plane reduction can be optimized with an “all femur” external fixation reduction frame or provisional wire fixation of the metaphyseal reduction. Rotational reduction requires use of comparison views of the uninjured limb, and intraoperative imaging can help identify radiographic landmarks.

Plate Application Errors Plate malposition leads to several errors that are avoidable. Placing the plate too posteriorly on the distal fragment can lead to medialization of the condyles in relation to the shaft as the plate is fixed to the femoral shaft. It will also lead to anterior translation and extension of the condyles when using fixed-angle devices in order to get the plate to fit along the femoral shaft. This error can be avoided by insuring that the plate sits along the anterolateral surface of the distal femur in line with the lateral axis of the femoral shaft. Placing the plate too anterior along the femoral shaft can lead to fixation failure especially when using unicortical locking screws in the diaphysis (13). This can be avoided with careful plate application using intraoperative lateral plane imaging or with the use of a more generous lateral approach to the femur proximally that allows for tactile evaluation of plate position. Intra-articular screw penetration can occur in both the knee joint and the patellofemoral joint (Fig. 24.22). This can be avoided by compressing the distal end of the plate to the anterolateral distal femur with a periarticular reduction forceps prior to screw insertion into the articular block. In addition, intraarticular screw placement is avoided by placing the plate anterior to Blumenstaat's line on the lateral view. If screws must be placed posterior to Blumenstaat's line, they should be unicondylar. Internally rotating the plate to fit along the anterolateral surface of the distal femur also minimizes the risk of plate prominence causing iliotibial band irritation. P.446

FIGURE 24.22 Axial CT scan shows that the lateral locking plate is externally rotated with locking screws placed into the patellofemoral joint.

Nonunion/Malunion The incidence of malunion and nonunion is not known with the current generation of locking implants. Early series of first-generation locking plates reported very low rates of nonunion but contemporary experience describes a higher rate of nonunion (12). There are also new concerns regarding the stiffness of these implants in osteoporotic bone, and whether a stiffness mismatch may lead to poor callus formation and delayed union (14). Our experience is that many nonunions are related to an inadequate biologic responses and suboptimal fracture reduction. For some nonunions, plate fixation is required to correct residual malalignment and provide compression at the nonunion site, which is important for the nonunion repair. Retrograde intramedullary nails may be used for selected metaphyseal nonunions when the alignment is acceptable.

Knee Stiffness The goal of surgery is to restore the range of motion of the knee for activities of daily living. However, loss of knee motion is common after distal femur fractures. Although loss of flexion is more common, loss of extension is more problematic because it is very difficult to regain. One of the chief benefits of internal fixation is that it allows for early range of knee motion that is started within the first few days after surgery. To avoid a flexion contracture, either a hinged knee brace that can lock in full extension or a knee immobilizer can be worn when the patient is not performing range-of-motion exercises. If therapeutic exercises fail, surgical management including arthroscopic lysis of adhesions in combination with knee manipulation should be considered for mild contractures. For more severe or late contractures, an open lysis of adhesions and quadricepsplasty may be necessary. An extensile direct lateral approach or incorporation of the previous incision should be used with an arthrotomy to release the intra-articular adhesions—typically in the suprapatellar pouch and the medial gutter. The most common area of extra-articular adhesions involves the quadriceps along the anterior metadiaphyseal region, especially if there was prior comminution or bone loss. This is best treated with a quadricepsplasty with careful elevation of the vastus musculature from the anterior femur leaving the periosteum intact. Once the quadriceps is elevated from the anterior femur, careful manipulation of the

knee should be performed to stretch the contracted quadriceps muscle, but avoid iatrogenic fracture or avulsion of the patellar tendon. If knee flexion has not been restored, V-Y quadriceps lengthening or release of the rectus origin should be considered. Deep drains should be used to minimize the risk of a postoperative hematoma. Perioperative regional anesthesia and a continuous passive motion machine should be considered to maintain knee motion. Aggressive physical therapy should be continued postoperatively up to 5 days per week to try to maintain the range of motion.

CONCLUSION Distal femur fractures present technical challenges secondary to articular comminution, deforming muscle forces, a short articular segment, osteoporosis in elderly patients, and bone loss in open fractures. While several implant options exist, precontoured periarticular locking plates have become the most commonly used method to address these fractures. Careful preoperative planning, anatomical reduction of the articular surface, and accurate restoration of length and alignment is required to successfully treat these fractures. As with all articular fractures, early range of motion and rehabilitation is important for joint function. P.447

REFERENCES 1. Crist BD, Della Rocca GJ, Murtha YM. Treatment of acute distal femur fractures. Orthopedics 2008;31(7):681-690. 2. Nork SE, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am 2005;87(3):564-569. 3. Egol KA, et al. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 2005;19(7):448-455; discussion 456. 4. Della Rocca GJ, Crist BD. External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft. J Am Acad Orthop Surg 2006;14(10 Spec No.):S131-S135. 5. Mast J, Jakob R, Ganz R. Planning and reduction technique in fracture surgery. 1st ed. Berlin, Heidelberg, New York: Springer-Verlag; 1989. 6. Higgins TF, et al. Biomechanical analysis of distal femur fracture fixation: fixed-angle screw-plate construct versus condylar blade plate. J Orthop Trauma 2007;21(1):43-46. 7. Haidukewych G, et al. Results of polyaxial locked-plate fixation of periarticular fractures of the knee. Surgical technique. J Bone Joint Surg Am 2008;90(Suppl 2 Pt 1):117-134. 8. Krettek C. et al. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28(Suppl 1):A31-A41.

9. Starr AJ, Jones AL, Reinert CM. The “swashbuckler”: a modified anterior approach for fractures of the distal femur. J Orthop Trauma 1999;13(2):138-140. 10. Masquelet AC. Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction. Langen-becks Arch Surg 2003;388(5):344-346. 11. Taitsman LA, et al. Osteochondral fracture of the distal lateral femoral condyle: a report of two cases. J Orthop Trauma 2006;20(5):358-362. 12. Zlowodzki M, et al. Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma 2006;20(5):366-371. 13. Button G, Wolinsky P, Hak D. Failure of less invasive stabilization system plates in the distal femur: a report of four cases. J Orthop Trauma 2004;18(8):565-570. 14. Lujan TJ, et al. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma 2010;24(3):156-162.

25 Patella Fractures: Open Reduction Internal Fixation Matthew R. Camuso

INTRODUCTION The patella is the largest sesamoid bone in the body and is a key component of the extensor mechanism, adding a distinct mechanical advantage for optimal knee function. Between the massive quadriceps muscle and the sturdy patellar tendon (ligament), the patella transmits three to seven times body weight through the patellofemoral joint during deep knee flexion. In the absence of a patella, the extensor mechanism loses nearly 60% of its strength during terminal extension. The surrounding retinacular tissues are also a key component of the extensor mechanism complex; when intact, they can transmit loads to the leg even in the presence of a displaced patella fracture (Fig. 25.1). The patella has two chondral facets, each articulating with the patellofemoral groove of the distal femur. The thickest portion of cartilage is in the central third; the patella thins out near its periphery both medially and laterally. Between two-thirds and three-fourths of the undersurface is covered with articular cartilage, with the distal most portion being nonarticular. Understanding the dimensions of the patella will help the surgeon avoid penetration of the articular surface with implants during surgery (Fig. 25.2). Fractures of the patella are commonly the result of an eccentric load to the knee. An extreme tensile moment results in failure of the patella in the form of a transverse fracture. The injury continues both medially and laterally, tearing the retinaculum, causing a complete disruption of the extensor mechanism (Fig. 25.3). In this setting, fracture fixation is relatively straightforward and is combined with repair of the retinaculum. Alternatively, the patella can fracture when a direct force is applied to its surface, such as when the knee strikes the dashboard in a vehicle crash (Fig. 25.4). Associated injuries are common, and these stellate multifragmentary impacted patella fractures can be very difficult to manage.

CLASSIFICATION Patella fractures are classified in many ways. The AO/OTA classification groups the fractures into three types.

Type A fractures are extra-articular and are associated with disruptions of the extensor mechanism. These require surgery to restore the continuity of the extensor mechanism. However, articular reconstruction is not necessary. Most commonly, these are fractures of the inferior pole of the patella (Fig. 25.5). Type B fractures are partial articular fractures. These vertically oriented fractures can often be confused with bipartite patellae. When significant articular displacement is present, operative treatment is recommended to reduce the risk of patellofemoral arthrosis. In these injuries, the extensor mechanism remains intact and therefore does not require repair (Fig. 25.6). Type C fractures are complete articular fractures, often resulting in displacement of the articular surface with disruption of the extensor mechanism. These fractures occur from a direct fall or blow to the patella, causing a more complex comminuted fracture pattern. Simple fractures are considered C1 fractures. Comminution of one segment of the patella is termed C2. When both poles are comminuted, the fracture is categorized as C3. These injuries require realignment of the articular surface and repair of the extensor mechanism, making them the most challenging to treat (Figs. 25.4 and 25.7). P.450

FIGURE 25.1 Anatomy of the patella and associated extensor mechanism.

FIGURE 25.2 Anatomy of the chondral surface of the patella.

INDICATIONS AND CONTRAINDICATIONS Regardless of the mechanism of injury, a disruption of the knee extensor mechanism leaves the lower limb severely disabled. Surgery is necessary to restore active leg extension and to repair the articular surface of the patella. A displaced fracture of the patella usually indicates that a significant disruption of the extensor mechanism has occurred. For this reason, surgical treatment should be considered for most displaced patella fractures. Nondisplaced fractures and those with an intact extensor mechanism can be managed nonoperatively in a knee

immobilizer, hinged knee brace, or cylinder cast for 4 to 6 weeks. The goals of surgery are twofold: to repair the extensor mechanism and to restore the articular surface. Restoration of extensor mechanism is necessary for normal gait and independent ambulation. Articular congruity is important to reduce the risk of patellofemoral arthrosis, a condition that is difficult to treat. For this reason, P.451 patella fractures with articular displacement of more than 1 to 2 mm in adults should be considered for repair. The multiply injured patient with a patella fracture, even when minimally displaced, may benefit from internal fixation to allow for early mobilization during rehabilitation.

FIGURE 25.3 Transverse patella fracture with associated retinacular tears.

FIGURE 25.4 Stellate patella fracture with articular impaction.

FIGURE 25.5 Type A: Extra-articular, inferior pole patella fracture with disruption of extensor mechanism.

FIGURE 25.6 Type B: Vertically oriented articular patella fracture with intact extensor mechanism. Relative contraindications for patella fracture surgery include medically frail patients whose surgical risk is high, severe osteoporosis, fractures in nonambulators, and soft-tissue injury or infection that would preclude safely operating on the extremity.

PRE-OP PLANNING History and Physical Examination A thorough history is an important part of the initial patient evaluation. A patient with a suspected fracture of the patella presents with pain over the anterior aspect of the knee. Understanding the mechanism of injury (direct force vs. indirect load) gives important information as to the severity of the injury as well as the fracture pattern. Medical history, prior activity level, and patient expectations are important factors that may affect decision making.

Physical examination includes an evaluation of the entire extremity. Gentle palpation and rotation of the hip, thigh, leg, and ankle are important to rule out associated fractures. A careful neurovascular examination with a methodical evaluation of the lower leg compartments should be documented. Knee swelling and ecchymosis are commonly present. Soft-tissue swelling can be significant due to the hemorrhage associated with the fracture and its subcutaneous location. The soft tissues should be thoroughly inspected for abrasions, blisters, or degloving injuries. All wounds around the knee must be appropriately investigated to rule out an open fracture or traumatic arthrotomy, which requires urgent treatment (Fig. 25.8).

FIGURE 25.7 Type C: Articular patella fracture with associated disruption of extensor mechanism. P.452

FIGURE 25.8 Patella fracture with injured soft-tissue envelope. In many patients, there is a palpable gap in the patella on examination; however, its absence does not rule out a patella fracture. The hallmark of a patella fracture with disruption of the extensor mechanism is the inability to actively extend the lower leg from a flexed position at the knee. Unfortunately, in most patients, this is difficult or impossible to perform because of pain with displaced fractures. The ability to perform a straight leg raise may suggest an intact extensor mechanism when it’s integrity is in question. Joint aspiration with instillation of local anesthetic can aid in the physical examination for fractures that are not significantly displaced.

IMAGING In a patient with a suspected patella fracture, radiographs of the knee, femur, and tibia should be obtained. Plain films are usually sufficient to confirm the diagnosis of patella fracture. The anteroposterior (AP) view can be difficult to interpret secondary to the overlying distal femur. The lateral projection provides the most information regarding the magnitude of articular involvement and fracture displacement (Fig. 25.9A,B). Oblique images and tangential views are rarely necessary but may add information about the extent of comminution. The axial or sunrise view may diagnose a vertical fracture of the patella, which can be difficult to see on traditional views (Fig. 25.10). Comparison views may be helpful when a bipartite patellae is suspected. Other studies such as CT or MRI scans are rarely indicated in isolated injuries to the patella, but may give a better understanding of the extent of comminution in selected cases. In minimally displaced fractures where nonsurgical management is being considered, a MRI scan may give useful information about the integrity of the retinaculum.

TIMING OF SURGERY

The timing of surgery varies depending on the patient’s medical condition or associated injuries. Open fractures require early administration of intravenous (IV) antibiotics, tetanus prophylaxis, débridement of nonviable tissue followed by thorough irrigation and fracture fixation. In closed fractures, fixation is delayed until all other life or limb-threatening conditions have been addressed. In nonmultiply injured patients, the status of the soft-tissue envelope determines surgical timing. If soft tissues are good, fracture surgery is performed on a semielective basis, usually within the first week following injury. Timely surgery allows for earlier mobilization of the limb and rehabilitation of the quadriceps mechanism. Unnecessary delays in surgery should be avoided to minimize the potential for knee stiffness. P.453 Prolonged delays can result in proximal migration of the patella and shortening of the extensor mechanism associated with spasm of the quadriceps, making reduction and fixation of the fracture more difficult. However, if the soft-tissue envelope is compromised, delay in surgery is warranted to minimize the risk of infection.

FIGURE 25.9 Anteroposterior (A) and lateral (B) views of knee.

SURGICAL TACTIC Patient positioning, the need for intraoperative fluoroscopy, reduction tools, and implants must be clearly communicated to the operating room staff. Large-pointed reduction clamps are necessary for compression of the major fracture fragments; medium and small clamps should be available for smaller fracture fragments. Smalldiameter Kirschner wires (K-wire), size 1.25 to 2.0 mm, are often necessary to hold very small fragments of comminution. In addition, small and minifragment screws (1.5 to 3.5 mm) and plates should be available. Doubleended 1.6-mm K-wires can be helpful for accurate longitudinal wire placement when employing a modified tension band technique with wires. Small fragment-cannulated screws (3.5 to 4.0) can also be used for a modified tension band technique with screws when the fracture pattern allows. Stainless steel wire (16 to 20 gauge) for cerclage or tension band placement, wire tightening devices, and wire cutters are routinely required for patella fracture surgery. Suture and wire passing devices, such as a Hewson suture passer or a 14-gauge angiocatheter, facilitate suture passage through the soft tissues of the extensor mechanism and patella itself.

Bank bone graft should be available to support disimpacted articular surfaces. Mersilene tape and/or fiberwire suture should be available if the surgeon believes that augmentation might be necessary.

SURGICAL TECHNIQUE Anesthesia, Positioning, Imaging Surgery can be performed using general, spinal, or regional anesthetic techniques. The patient is placed supine on a radiolucent operating room table with the affected limb elevated slightly on a bump (Fig. 25.11). This allows for unobstructed lateral fluoroscopy to be performed without interference from the contralateral limb while bringing the injured limb closer to the surgeon’s view. A tourniquet should be positioned at the proximal end of the thigh, so as not to interfere with draping or the surgical exposure. A towel bump is placed beneath the ipsilateral flank to minimize external rotation of the leg and keep the patella facing upward (Fig. 25.12). A cephalosporin antibiotic is given within 1 hour of the incision and prior to the inflation of the tourniquet. P.454 The entire limb from tourniquet to toes is prepped and draped free (Fig. 25.13). The leg is elevated and exsanguinated with an Esmarch bandage, and the tourniquet is inflated. Care should be taken to ensure that the quadriceps does not get bound up proximally in the tourniquet, preventing distal translation of the superior patellar pole. The fluoroscopic unit is brought in from the opposite side of the patient (Fig. 25.14). Sterile halfsheet drapes will be necessary to maintain sterility for lateral imaging (Fig. 25.15). Remaining in the lateral position, the image intensifier can be moved toward the head of the table, allowing the surgeon to work on the fracture and easily return the unit into position for repeated lateral fluoroscopic views as necessary (Fig. 25.16).

FIGURE 25.10 Sunrise view of patella

FIXATION Type A Fractures Type A fractures (Fig. 25.17A,B) require reattachment of the extensor mechanism to the adjacent patella. The vast majority of these fractures occur at the inferior pole of the patella and represent an avulsion of the inferior nonarticular pole of the patella. A much smaller number of cases involve avulsion of the quadriceps muscle from the superior pole. They are often associated with tears in the retinaculum, which may require repair. Repair strategies for type A fractures fall into two categories: 1. Securing the small avulsion fractures back to the patella with screw fixation. Screw fixation may be possible when the avulsed fragment is large and noncomminuted. However, this technique may require

P.455 supplemental fixation to reduce the tensile stress seen at the repair site during initial healing and rehabilitation.

FIGURE 25.11 Patient positioned with injured extremity elevated on a bump and contralateral limb secured beside the bump, keeping it out of the operative field.

FIGURE 25.12 View of operative site with appropriate positioning aides.

FIGURE 25.13 Tourniquet placed at proximal extreme end of thigh allows for full exposure of the operative zone without interference from draping.

FIGURE 25.14 Fluoroscopic setup in anteroposterior plane. 2. Suturing the patellar tendon back to the patella through drill holes. Suture fixation, while maintaining the piece of avulsed bone if possible, allows for bone-to-bone healing while securing fixation in the distal aspect of the disrupted extensor mechanism. A heavy, nonabsorbable suture is used to resist the significant tensile forces seen during knee extension. With the knee in 5 to 10 degrees of flexion, an anterior approach to patella is performed, extending from 2 to 3 cm above the superior pole of the patella down to just above the tibial tubercle (Fig. 25.18). This allows access to the entire length of the patellar tendon for suture fixation and easy access to the superior pole for knot tying. Full-thickness flaps are created down to the extensor fascia, preserving vascularity to skin layers. The paratenon is incised so that the medial and lateral borders of the patellar tendon are visible. Both medially and laterally, the retinaculum is visualized and inspected for injury. The proximal pole of the patella may be everted to inspect the articular surface. The corresponding trochlear groove of the distal femur is also inspected for articular injury. The inferior pole of the patella is evaluated to determine if it is amenable to screw fixation versus suture repair. In

most cases, the inferior pole fracture fragment is too small or fragmented for screw repair alone and requires suture fixation.

FIGURE 25.15 Lateral projection fluoroscopic positioning.

FIGURE 25.16 The fluoroscopic unit can remain in the lateral position and slide out of the way of the operating surgeon, facilitating imaging as necessary. P.456

FIGURE 25.17 AP and lateral radiographs of type A patella fracture. The joint should be thoroughly irrigated to remove intra-articular bony debris. The fractured end of the patella is assessed for placement of drill holes. Placement of the drill holes too close to the dorsal surface will increase patellofemoral joint forces and placement too close to the joint surface risks intra-articular penetration and edge loading. Therefore, the central position is chosen (Fig. 25.19). Three retrograde drill holes (2.0 to 2.5 mm) are made through the cancellous surface of the fractured patella, exiting the superior pole at the insertion of the P.457 quadriceps tendon. Care is taken to ensure there are adequate bone bridges between the drill holes. Through each of the drill holes, a shuttle suture is placed using a suture passer. Each suture is clamped to later deliver a limb of fiberwire repair suture from the patellar tendon. A total of three sutures are now positioned in the patella, extending from distal to proximal.

FIGURE 25.18 Image of the midline incision with respect to the underlying structures of the extensor mechanism.

FIGURE 25.19 Three slightly diverging drill holes are placed into the superior segment of the patella, retrograde from the inferior cancellous surface to the superior pole. The distal end of the repair begins with identifying the tibial tubercle. Just proximal to the tubercle, a pair of heavy, nonabsorbable sutures (no. 2 or no. 5 Fiberwire) are placed, creating a set of four strands that exit proximally through the patellar tendon. Starting from near the tibial tubercle, the suture is run up the axis of the ligament using a locking technique (such as a modified Krackow technique) for maximum security (Fig. 25.20). A tapered needle with a small radius of curvature is used to minimize the risk of inadvertently cutting the suture or injuring the tendon. One limb of suture is brought out through each edge of the tendon, medially and laterally, while the two central limbs are brought out together in the midsubstance of the tendon (Fig. 25.21). The suture is brought directly through the bony fragments of the inferior pole fracture, when possible, so that when

reapproximated, there is bone-to-bone apposition to maximize healing. Retaining these bony fragments reduces the risk of significantly shortening the extensor mechanism, minimizing the risk of patellar baja. Once brought through, the suture is tensioned to remove any slack that remains in the repair. Using the shuttle sutures, the Fiberwire sutures are now delivered through the drill holes of the patella. The medial and lateral limbs are brought through their corresponding drill holes, while the central limbs are together pulled through the central drill hole. Each of the two central limbs are then paired with their respective sutures both medially and laterally. Now the patellar tendon and inferior pole of the patella can be drawn together by pulling the suture strands (Fig. 25.21). With the knee in full extension, the sutures are then tied directly over the bone bridges in the proximal patella with multiple square knots (Fig. 25.22). The retinaculum is repaired with no. 0 or no. 1 absorbable suture, using a simple, interrupted suture technique. The retinacular repair is critical to decrease stress on the patellar repair. The tourniquet is deflated and hemostasis is achieved. Range of knee motion is tested, using gravity to allow the knee to bend while watching the repair for gapping or failure. The arc of motion is documented and used to help direct postoperative P.458 rehabilitation. A properly done repair should allow 90 to 100 degrees of knee flexion. Testing range of motion with the tourniquet inflated may adversely stress the repair construct due to the binding of the quadriceps proximally.

FIGURE 25.20 No. 5 Fiberwire suture placed with modified Krakow technique into the patellar tendon for maximum security.

FIGURE 25.21 Fiberwire sutures are brought up through the drill holes using the shuttle sutures, drawing the inferior pole of the patella and patellar tendon to the superior patellar segment. Each pair of sutures is then tied using square knots over the bone bridge of the superior patella.

FIGURE 25.22 Final image of the repair with augmentation included.

Wounds are closed sequentially in layers. The extensor fascia and paratenon are closed (when possible). The subcutaneous layers are reapproximated with inverted 2-0 Vicryl used sparingly, and skin is carefully closed. In cases where the soft tissues are even moderately contused, skin closure with 3-0 nylon suture using AllgöwerDonati vertical mattress technique will maximize epidermal perfusion. Wounds are dressed with a sterile nonadherent dressing and reinforced with sterile pads. A compression bandage is applied over a bulky layer of cast padding to provide support. A knee immobilizer is applied with the knee in extension to protect the wound and repair in the early postoperative stages. Postoperative radiographs are obtained (Fig. 25.23A,B).

Type B Fractures By definition, type B fractures do not involve injury to the extensor mechanism. The purpose of repairing these fractures is to anatomically reduce the articular surface to minimize the risk of patellofemoral arthrosis. These fractures are typically oriented vertically and must be differentiated from a bipartite patellae (Figs. 25.6 and 25.24 A,B). Through a midline surgical incision, the displaced patellar cortex can be visualized and exploited for evaluation of the articular surface. When present, a tear in the retinaculum can be used to palpate and/or visualize the retropatellar joint surface. It is important to first address articular impaction prior to reduction of the fracture, as this may give the best access to the joint. Typically, the dorsal surface of the patella is used to judge the reduction. It is important, however, to palpate the articular surface while doing so. When unrecognized impaction is present, the reduction of the dorsal patellar surface may not reflect anatomic reduction of the articular surface. Palpation of the joint surface through a rent in the retinaculum is most effective with the knee in full extension to relax the extensor mechanism. It may be necessary to work directly through the primary fracture line. Alternatively, the retinaculum may be incised to give access to the joint surface. Using a small osteotome or elevator, the articular segment is elevated to match the adjacent levels of articular cartilage. When the impacted segment is large, the defect is grafted and initially stabilized with K-wires and subsequently fixed with small or minifragment screws. With smaller fragments, the K-wires alone are sufficient for fixation. Elevated segments should be grafted with cancellous autograft or allograft to prevent collapse. When satisfied with the alignment of the articular surface, the major fracture fragments are reduced and compressed with pointed reduction forceps placed perpendicular to the fracture line. Temporary K-wires help P.459 control rotation of the segments from the torque applied during screw insertion. When the fracture pattern allows, a series of interfragmentary lag screws are placed perpendicular to the fracture line in the patella (Fig. 25.25A,B). Preferably, the screw is begun in the smaller segment and lagged into the larger segment to maximize screw purchase. When comminution or bone loss is present, lag screw fixation may be contraindicated. In this case, screws are placed as position screws, so as not to overreduce the fracture fragments, resulting in loss of articular reduction. A clear understanding of the “V” shape of the patella is necessary to avoid articular injury during screw placement.

FIGURE 25.23 A,B. Type A fracture: postoperative radiographs.

FIGURE 25.24 A,B. AP and lateral radiographs of a type B patella fracture.

P.460

FIGURE 25.25 A,B. Intraoperative fluoroscopic images of the vertically oriented patella fracture reduction and interfragmentary lag screw fixation. After definitive implants are placed, the preliminary fixation is removed, and the articular reduction is reassessed. Without disruption of the extensor mechanism, additional fixation is rarely indicated. After deflation of the tourniquet, the knee range of motion is evaluated and the fracture carefully visualized during flexion to ensure that no displacement occurs. A safe range of motion is then documented, and the postoperative therapy program tailored to these findings. Final radiographs should show safe implant position with an anatomically reduced articular surface (Fig. 25.26A-C).

Type C Fractures A disruption of the extensor mechanism combined with a fracture of the articular surface constitutes a type C fracture of the patella (Fig. 25.7). Compression fixation of the articular surface combined with a tension band construct for conversion of the tensile forces into compression forces at the joint surface is the most common method of treatment. A modified tension band technique using K-wires or cannulated screws with a figure-ofeight tension band wire can be used. When applied correctly, the tension band with cannulated screws has been shown to provide improved biomechanical stability over the more traditional K-wires technique. However, any method that combines stabilization of the articular surface with neutralization of the tensile forces of the extensor mechanism (using suture, wires, plates, etc.) can be effective. The concept of fixation with absolute stability of the articular surface protected by a construct that converts the tensile forces into compressive forces at the joint surface is the key factor. Setup, positioning, and approach are the same as for fractures previously described. With the fracture exposed, the extent of the fracture comminution and impaction is assessed. Each pole of the patella is everted for evaluation of the articular cartilage. Surgical extension of the retinacular tear may allow improved visualization of the joint surface; however, this should be performed carefully to minimize injury to fragment vascularity. The organized clot is removed, and the periosteum is elevated for 2 mm along the fracture edges. Areas of comminution are assessed for the possibility of repair. Small fragments and fractures at the extreme periphery are usually excised. Larger fragments should be repaired. In simple two-part patella fractures, where there is no impaction nor comminution, the patella can be reduced using a pair of large-pointed reduction clamps. Positioning the leg in full extension facilitates the mobility of each fragment. Without impaction, reduction of the dorsal surface of the patella should indirectly reduce the articular

surface as well. This can be confirmed with direct visualization, palpation, or fluoroscopically. Once reduced, the fracture is ready for stabilization.

Modified Tension Band Fixation with K-Wires Classic patella fracture fixation combines longitudinal K-wire placement with a figure-of-eight tension band applied to the dorsal patellar surface. This converts tensile forces into compression forces at the fracture site with knee flexion. The two poles of the patella are everted to visualize the fracture surfaces (Fig. 25.27A,B). Using a wire driver, two double-ended 1.6-mm K-wires are placed at the fracture site in the superior pole, perpendicular to the fracture line, close to the articular surface, and parallel to one another. The trajectory must be parallel to the articular surface so that the wires do not penetrate the medial nor lateral facets. The wires are advanced from the fracture site in a retrograde fashion exiting through the proximal pole of the patella. P.461 The wire is advanced until it is just beneath the fracture surface. The fracture is then reduced to the adjacent pole and held with one or two large-pointed reduction clamps. Anatomic reduction is judged using the dorsal and (more importantly) articular fracture edges. Once an anatomic reduction is confirmed, the K-wires are advanced across the fracture site into the distal pole and out of the bone. Slight knee flexion facilitates accurate wire placement without displacing the fracture and helps avoid binding of the soft tissues both proximally and distally during wire placement. Accurate placement is confirmed on an AP and lateral fluoroscopic image.

FIGURE 25.26 A,B,C. AP, lateral, and sunrise plain radiographs demonstrating anatomic reduction and safe implant placement. A 14-gauge angiocatheter is then placed deep to the K-wires directly adjacent to the superior and inferior poles of the patella to facilitate passage of an no. 18-gauge wire (Fig. 25.28A,B). The two separate wires are then brought over the top of the patella directly over the bone ensuring no soft-tissue entrapment. It is critical that the tension band wire lay directly on bone for optimal function. This should be confirmed with fluoroscopy. P.462 The wires are then crossed over the dorsum of the patella in a figure-of-eight manner, creating two adjacent wires that can twist with each other. Care should be taken to place the twist in a location that will minimize irritation to the soft tissues. Using a wire tightener or heavy clamps, simultaneous gentle distraction with twisting is performed until adequate tension is achieved. The pointed reduction clamps are removed, and the repair is tested by flexing the knee. The stable arc of motion is documented to help guide postoperative rehabilitation. The K-wires are cut and bent over the tension band wires and buried beneath the soft tissues. Care is taken to close the soft tissues over the wires to minimize irritation and to prevent inadvertent migration. Final

intraoperative radiographs are obtained.

FIGURE 25.27 The displaced patella fracture ends are everted to inspect the articular surfaces.

FIGURE 25.28 Placement of 18-gauge tension band wire through angiocatheters at superior and inferior patellar poles. P.463

FIGURE 25.29 K-wires from the inferior segment of the patella are advanced into the superior segment while holding the fracture reduced with Weber clamps and securing the reduction with an additional antegrade K-wire.

Modified Tension Band Technique Using Cannulated Screws Cannulated screw fixation has the advantage of providing compression at the fracture site while utilizing a tension band wire construct to improve resistance to distraction. Either 3.5 cortical or 4.0 partially threaded screws can be used. Fully threaded screws can be used in poor quality bone if screw purchase is a concern, though it will not compress the fracture site. Guidewires for the cannulated screws are placed parallel to the articular surface and perpendicular to the fracture plane. These may be placed before or after reduction of the fracture. When placed before reduction, two parallel drill holes are made in the smaller patellar segment, using a parallel drill guide. Guidewires are then passed with their blunt ends first through the bone, out the end of the patella, and out through the soft tissue. Both wires are then retracted into bone to allow for the fracture to be reduced. Each wire is then advanced from the shorter segment of the patella into the larger segment and placed up to, but not through, the far cortex (Fig. 25.29). Their position is confirmed on AP and lateral plane fluoroscopy (Fig. 25.30). Wire length is measured, making sure that the depth gauge is directly on bone for correct measurement. Inaccurate measurements can lead to placement of excessively long screws, which may lead to early breakage of the tension band wire.

FIGURE 25.30 A,B. Accurate wire positioning confirmed fluoroscopically will ensure safe placement of cannulated screws. P.464

FIGURE 25.31 A,B. Partially threaded screws are placed for lag effect, keeping them well within bone. After measuring length, the terminally threaded guide wire can be advanced into the far cortex, which minimizes wire migration during drilling. The cannulated drill is placed over the guidewire and slowly advanced through the length of the patella. The drill bit should be removed and cleaned several times since the hard bone of the patella fills the shallow flutes quickly, causing thermal necrosis and making advancement of the drill difficult. The length of screw should be 2 mm shorter than what is measured. This ensures that the screws remain within the patella and not beyond the cortex so that the tension band wire contacts the patella and does not impinge on the screw edge itself. Partially threaded 3.5- or 4.0-mm screws are placed over each guide wire to provide compression across the fracture site (Fig. 25.31A,B). It is important that the threads of the screws are completely in the far segment of bone to provide compression. If this is not possible, then a fully threaded 3.5-mm lag screw should be used. Reduction clamps are left in place during placement of the screws to prevent unrecognized distraction during screw placement. With the patellar segments compressed, the fracture can be “locked in” by adding an additional fully threaded screw in the midline. This may help prevent displacement of the fracture in patients with poor quality bone.

Next, the tension band wire is applied. Through each of the two cannulated screws, a single 15-cm strand of 1mm (18 to 20 gauge) stainless steel wire is passed and brought out onto the dorsum of the patella. Straight surgical wire may be easier to pass through the cannulations, but may not have the tensile strength of wire on a spool. Sternal wires should be avoided because it has a lower tensile strength than annealed wire. The wire should be handled carefully, minimizing kinks and bends that could result in premature failure during application of tensile loads. A small incision near the quadriceps insertion at the exit point of the screw facilitates retrieval of the wire. After passage, each end of the wire is then paired with its opposite strand from the other screw, making a contiguous figure-of-eight between the two wires over the dorsum of the patella (Fig. 25.32). Care is taken to be sure the edge of the wire contacts the edge of the patella and does not get “hung up” on the soft tissues, reducing the effect of the tension band that could loosen over time (Fig. 25.33). In this way, the tension during knee flexion is transmitted directly to the patella and not through the soft tissues. Once the wires are P.465 adequately positioned, two wires should come together on each side of the patella. The wires are then twisted together in a clockwise manner, simultaneously, while gently pulling outward on the wire. A wire tightener is effective for twisting the wire; without it, a pair of stout needle drivers will suffice. Stop twisting the wire when it meets the surface of the patella (Fig. 25.34A,B).

FIGURE 25.32 Tension band 18-gauge wire is placed through the cannulation of the screws and brought out over the dorsum of the patella in a figure-of-eight manner.

FIGURE 25.33 Long screws create edge loading and failure of the tension band (A); tension band wire that does not contact the patella may not resist the tensile forces in flexion, also resulting in failure (B).

FIGURE 25.34 A,B. Using a jet wire tightener or a stout pair of needle drivers, the tension band is symmetrically twisted until the wire twist meets the patella. After deflating the tourniquet, the knee is put through a range of motion to assess fracture stability. The wires may be retightened if any creep has occurred, taking care not to overtighten them. When satisfied with the fixation, the wires may be cut short and folded flatly onto the peripheral soft tissues to minimize prominence (Fig. 25.35A,B). Closure and postoperative rehab is conducted as previously described. In many instances, the patella fracture is not a simple two-part fracture. There may be articular impaction and/or comminuted fractures that are not amenable to simple tension band fixation. In fact, tension band constructs are only effective when an anatomical reduction has been achieved on the side opposite the tension band, which can withstand compressive forces. Therefore, when articular comminution exists, one must consider alternative methods of fracture fixation. In this situation, my surgical strategy is to reconstruct the comminuted patellar fragments into a simple two-part fracture, which can subsequently be repaired with traditional methods (outlined above). The larger fragments of comminution are reduced to each pole of the patella, with the goal of creating a simple, transverse two-part fracture. In a stepwise manner, each fragment is cleaned of hematoma and reduced and stabilized P.466 with clamps or K-wires. Areas of impaction are reduced, and bony voids are filled with small amounts of cancellous allograft. Care is taken to pack this in tightly, so that no graft becomes a loose body within the joint. The reduction should be judged with either direct inspection of an everted patella or by simple palpation with the knee in extension. When a satisfactory reduction has been achieved, the fragments can be stabilized with minifragment position screws (1.1 to 2.4 mm) that are countersunk. This is important to allow for anatomic reduction of the opposite pole of the patella. These screws will become intraosseous screws after final fracture reduction (Fig. 25.36A,B).

FIGURE 25.35 A,B. Final radiographs. Once reconstruction of the comminuted superior and inferior poles is complete, they are reduced to one another and held with large-pointed reduction clamps. At this point, multiple strategies exist to secure the final reduction, depending upon how much “traffic” is present in the patella itself. Some intraosseous screws may interfere with subsequent placement of cannulated screws for fixation of the two poles. With the knee in extension, a lateral fluoroscopic image will show existing hardware, allowing the surgeon to avoid these implants during placement of K-wires or guidewires for cannulated screws. This technique is an effective and efficient method for reconstruction of comminuted patella fractures. However, when the comminution of the patella requires numerous multiplanar screws within each patellar pole, it may be impossible to place additional longitudinal (cannulated) screws perpendicular to the primary fracture plane. In this case, and in cases where there is articular bone loss, dorsal plate fixation may be necessary. In cases where there is bone loss, these implants function as neutralization plates. However, they can function as tension bands in situations where the opposite surface has adequate bony contact, similar to the function of the tension band wire. I favor 2.0-mm plates that are contoured to fit the dorsal surface of the patella. Lengths are chosen to ensure adequate fixation in each pole, extending from the most proximal to the most distal ends of the patella. Between six- and eight-hole plates are most commonly utilized. Each end of the plate is secured using one or two minifragment screws angled into quality bone for improved purchase. In the proximal pole, the screws are angled caudad; in the distal pole, they are angled cephalad. In certain situations, these screws can extend back into the P.467 opposite pole and span the fracture site. Care is taken to be sure that they do not penetrate the articular surface. In general, this technique is reserved for the most complex patella fractures (Fig. 25.37A,B).

FIGURE 25.36 A,B. Impacted joint surfaces must be elevated, reduced, and stabilized. In some cases, this may require bone grafting or even the use of intraosseous screws for large articular fragments.

FIGURE 25.37 A,B. Final radiographs after reconstruction of complex type C patella fracture with impaction.

Augmentation Some unstable fractures require supplemental fixation or augmentation. This may be necessary due to fracture comminution, inadequate fixation, obesity, or concerns with patient compliance. Though rarely needed, one may consider this technique anytime that the intraoperative exam suggests that the fixation is unstable or gapping occurs at the fracture site during knee flexion. In this situation, augmentation of the repair may allow for more aggressive rehabilitation and avoid prolonged immobilization. Several techniques exist to reduce the tensile stresses upon the extensor mechanism. One such technique is described here. Using a 2.5-mm drill bit, a drill hole is made through the anterior one-third of the tibial tubercle. A 5-mm Mersilene tape is passed through the tubercle drill hole, and a second Mersilene tape is then placed through the quadriceps tendon, just superior to the proximal pole of the patella (Fig. 25.38). Care is taken to place the tape into good tissue to adequately capture the proximal segment of the injured extensor mechanism. Each limb of Mersilene tape is then brought along the medial and lateral aspects of the patella, and with the knee flexed P.468 30 degrees (Fig. 25.39), the limbs are tied together, creating a “check reign.” Patellar baja can be created with overzealous tightening of the backup fixation (Fig. 25.40).

FIGURE 25.38 Single limbs of 5-mm Mersilene tape is each placed through the quad tendon above the superior pole of the patella and through a hole drilled in the tibial tubercle.

FIGURE 25.39 The two limbs of Mersilene tape are tied together with the knee flexed at 30 degrees to prevent overtightening of the extensor mechanism. In highly comminuted patella fractures, reconstruction of the joint surface may be impossible or ill-advised. In this situation, the surgeon’s goal should be focused upon restoring the extensor mechanism. Simple cerclage of the bony fragments with supplemental Mersilene tape or wire loop from quadriceps to tibial tubercle will restore leg extension. Early range of motion is generally avoided until healing of the fragments and peripheral soft tissues has occurred. Partial patellectomy is reserved for small polar fractures with significant comminution. Complete patellectomy is uncommon acutely but may be indicated as a salvage procedure in chronic nonunions or infected cases.

POSTOPERATIVE CARE The knee is wrapped in a compressive dressing with a knee immobilizer or hinged knee brace locked in extension. The knee is maintained in extension until the surgical incisions are dry. Rehabilitation begins on the first day after surgery, and the progress is determined upon the stability of fracture fixation and the safe range of motion determined during surgery. Full weight bearing as tolerated protected with crutches or a walker is allowed in the immobilizer or knee brace. Straight leg raises in the brace are encouraged to minimize quadriceps weakness and atrophy without stressing the repair. In stable fractures, gentle knee range of motion is begun to minimize knee stiffness when the wounds have healed, usually within the first 10 days after surgery. The brace may be removed during range-of-motion exercises but should be worn at all other times. Active knee extension is avoided for the first 6 weeks to minimize P.469 the stress across the repair. With guidance from a therapist, active knee flexion and passive knee extension is encouraged. Active and active-assisted flexions are allowed, starting with 0 to 30 degrees and advanced as tolerated. The leg is extended passively, either with gravity assistance (prone positioning) or with assistance from the therapist. Knee flexion of at least 90 degrees in the first 6 weeks should be the goal. Passive flexion is avoided until there is clear evidence of fracture union.

FIGURE 25.40 Placement of the augment as shown can protect a tenuous repair/reconstruction of the extensor mechanism and may allow more aggressive rehabilitation. Drawing of the augmentation used with Mersilene tape through a drill hole in the tibial tubercle and over the patella. In fractures with suboptimal fixation or stability, range of motion is delayed. The limb is left in an immobilizer in extension for 4 to 6 weeks. Quad sets can be performed with the brace in place to reduce atrophy. Full weight bearing in the brace is allowed. After 4 to 6 weeks, range of motion is begun utilizing both active and passive modalities. In this setting, a therapist can be quite valuable to help maximize functional outcome. When the tenderness over the repair is minimal and the quadriceps function has returned, it is safe to begin ambulation with a knee brace, unlocked from 0 to 30 degrees to engage the extensor mechanism. As the gait improves, the motion in the brace is increased and eventually discontinued. Stationary cycling and half squats will improve quad strength and endurance as the knee range returns. Radiographs are evaluated at 6-week intervals until fracture union is evident. The patella heals with intramembranous ossification as opposed to callus; fracture lines can be expected to fill in by 3 to 6 months after repair.

COMPLICATIONS Complications rates exceeding 20% have been reported following patella fracture surgery. Most can be attributed to technical errors and/or patient compliance. Vigilance is recommended to identify these problems early to ensure optimal outcome. Knee stiffness is the most common complication following patella fracture surgery. Aggressive inferior pole patellectomy can lead to patellar baja, causing stiffness and early arthrosis. Higher energy fractures with associated soft-tissue trauma are more likely to develop arthrofibrosis. Retinacular scarring to the surrounding soft tissues may also limit motion. Physical therapy with manual patellar mobilization is used to minimize early adhesions. Early identification of the patient who is slow to regain motion is important so that a physiotherapist can promptly intervene. In cases where prolonged immobilization is necessary, physiotherapy is even more critical, and aggressive motion is begun as soon as it is safe. In patients with less than 90 degrees of motion 8 to 12 weeks after surgery, a manipulation under anesthesia should be considered. However, the surgeon must be confidant with the fixation stability before a manipulation is performed. Knee manipulation should be performed under anesthesia using fluoroscopic control. When

manipulation is done after 12 weeks, it may be necessary to combine it with an arthroscopic lysis of adhesions to reduce the risk of iatrogenic fracture. Most patients require at least 90 to 100 degrees of knee flexion to get up from a seated position using both lower limbs. Inappropriate surgical timing and poor handling of the soft tissues may lead to wound drainage, wound breakdown, or infection. Prevention is the key to avoiding this potentially devastating complication. Surgery should be delayed in patients with massive swelling, blisters, or abrasions. Gentle handling, meticulous dissection, and careful wound closure are important. Drain placement will minimize hematoma formation and may reduce the risk of infection. Since the patella is a subcutaneous bone, infection requires early aggressive treatment. Wound cellulitis may respond to simple antibiotics; however, deep infection must be treated with urgent return to the operating room, formal open irrigation and débridement of necrotic material, washout of the joint (if involved), sampling of the tissue for culture, and initiation of broad spectrum antibiotics. Antibiotic therapy is tailored to the results of final cultures and their sensitivities, and an infectious disease consultant can be very helpful. Typically, 6 weeks of IV antibiotics are recommended followed by suppression until contaminated hardware can be removed. Fixation is left in place, if stable, to maintain fracture alignment, but may require removal after the fracture is healed. Range of motion and therapy are stopped until the infection is under control. Fixation failure can occur as a result of poor surgical technique, severe fracture comminution, or a combination of the two. Careful attention to detail and an understanding of the postoperative range-ofmotion limits will prevent most of these failures. When recognized early, salvage may still be possible. Displaced fractures can be revised, and nondisplaced fractures can be immobilized. Unreliable patients may require application of a cylinder cast to improve compliance. Fibrous union or nonunion can develop, causing pain with stair climbing and kneeling. For symptomatic patients, this may be treated with revision fixation or partial patellectomy. Extensor lags are usually the result of poor quadriceps rehabilitation, and a focused therapy program will correct this. Symptomatic hardware is common after patella fracture surgery. Careful attention during implant placement is important to minimize this occurrence. Tension band wires should be folded back and into the soft tissues when possible. Closure of the extensor fascia and prepatellar bursa in separate layers from the dermis will provide a layer of cushion in most patients. Removal of hardware should be delayed until the surgeon is certain that the fracture is healed. I require that the fixation remains in place for at least 1 year prior to removal to be sure that the fracture is completely healed. If asymptomatic, the hardware is left in place. Patella fractures occasionally result in patellofemoral arthrosis as a result of joint incongruity or cartilage injury. Patients may be symptomatic with activities that require deep knee flexion, such as stair climbing or kneeling. In mild cases, physiotherapy to strengthen the quadriceps can help, and injection therapy with P.470 corticosteroids or hyaluronic acids may be of some benefit. Arthroscopic débridement may be necessary for large articular flaps or when severe fibrillation is present. A lateral release may be indicated when the lateral facet is primarily involved. Other options such as microfracture, mosaicplasty, chondrocyte implantation, and patellar realignment are controversial and have variable results. Patellofemoral arthroplasty may have some role, but their results after patella fractures are unknown. Patellectomy can improve patellofemoral symptoms but is associated with some extensor mechanism weakness.

OUTCOMES Patients with isolated patella fractures can expect to walk brace free within the first 3 months after injury.

However, regaining quadriceps strength for daily activities and sports may be prolonged. In the absence of complications, most patients approach their baseline level of function within 1 year after surgery. Functional results following internal fixation of patella fractures are generally good. The best results occur in patients with anatomic reduction and early range of motion of the knee. Several studies have shown that patients followed for more than 5 years have outcomes similar to an uninjured population cohort. Most are able to return to work, with more than two-thirds returning to the same job. Those patients requiring limited fixation due to poor bone quality or fracture comminution have suboptimal results. Articular incongruity with subsequent arthrosis, weakness, and stiffness is the primary reason for poor long-term results.

RECOMMENDED READING Benjamin J, Bried J, Dohm M, et al. Biomechanical evaluation of various forms of fixation of transverse patellar fractures. J Orthop Trauma 1987;1:219-222. Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws. J Orthop Trauma 1997;11(8):573-576. Burvant JG, Thomas KA, Alexander R, et al. Evaluation of methods of internal fixation of transverse patella fractures: a biomechanical study. J Orthop Trauma 1994;8(2):147-153. Carpenter JE, Kasman R, Matthews LS. Fractures of the patella. J Bone Joint Surg Am 1993;75:1550-1561. Gardner MJ, Griffith MH, Lawrence BD, et al. Complete exposure of the articular surface for fixation of patellar fractures. J Orthop Trauma 2005;19(2):118-123. Marder RA, Swanson TV, Sharkey NA, et al. Effects of partial patellectomy and reattachment of the patellar tendon on patellofemoral contact areas and pressures. J Bone Joint Surg Am 1993;75(1):35-45. Melvin JS, Mehta S. Patellar fractures in adults. JAAOS 2011;19:198-207. Perry CR, McCarthy JA, Kain CC, et al. Patellar fixation protected with a load-sharing cable: a mechanical and clinical study. J Orthop Trauma 1988;2(3):234-240. Smith ST, Cramer KE, Karges DE, et al. Early complications in the operative treatment of patella fractures. J Orthop Trauma 1997;11(3):183-187. Weber MJ, Janecki CJ, McLeod P, et al. Efficacy of various forms of fixation of transverse fractures of the patella. J Bone Joint Surg Am 1980;62(2):215-220.

26 Knee Dislocations James P. Stannard

INTRODUCTION Dislocation of the knee is a relatively rare injury and occurs more commonly following high-energy trauma than with athletic events. Knee dislocations are challenging to treat, requiring expertise in complex knee ligament reconstruction in patients with compromised soft tissues and multisystem trauma. Recovery is prolonged, and many patients require up to 2 years to reach maximum improvement following this injury, and most patients do not regain preinjury levels of activity. In the past, knee dislocations were classified by the position of the tibia relative to the femur. This classification while descriptive gave little information about pathoanatomy or treatment. The anatomic classification initially proposed by Schenck is the most useful and commonly employed classification (Table 26.1). This classifies the dislocation based on what structures are injured regardless of the position of the tibia. Surprisingly, one of the initial challenges in caring for these patients is making the correct diagnosis. Multiple studies have shown that two-thirds to three-quarters of patients who sustain a knee dislocation present to the trauma center with the knee reduced. This reduction may occur spontaneously following injury, or it may occur as emergency medical services personnel splint the extremity and transport the patient. The diagnosis is very straightforward and easy when the patient presents with the knee dislocated, but is more difficult to diagnose when the knee is reduced, particularly in a patient with other injuries.

INDICATIONS AND CONTRAINDICATIONS It is well established that nonoperative treatment of knee dislocations leads to poor results in active patients. Therefore, surgery is indicated for the vast majority of patients with this injury. Patient factors such as obesity, severe soft-tissue injuries, open knee dislocations, and multiple injuries often require staged management protocols. This usually consists of temporary spanning external fixator, imaging studies, and delayed surgical repair. Contraindications to surgery include patients who are physiologically unstable for surgery, nonambulatory patients or those with severe medical comorbidities that make them unsuitable for surgery. Some elderly patients with a sedentary lifestyle and low demands may be considered for nonoperative management as well. However, some of these patients benefit from temporary spanning external fixator to maintain the reduction for 3 to 4 weeks followed by a brace. Because of poor outcomes associated with nonoperative care, as well as with spanning external fixation as definitive treatment, most patients benefit from surgical repair. There is considerable variability in the type, location, and number of soft-tissue injuries associated with knee dislocations. Several authors have noted a higher incidence of vascular and neurologic injury in morbidly obese patients following low-energy knee dislocations.

PREOPERATIVE PLANNING History and Physical Examination The first step in preoperative planning is recognition of the injury. Knee dislocations most frequently occur as a result of high-energy trauma such as motor vehicle or motorcycle collisions, with concomitant injuries that may draw attention away from the knee. Ipsilateral extremity fractures are very common and make performing a knee P.472

examination in the trauma room very difficult. The key to making the diagnosis is to have a high index of suspicion. An effusion may or may not be present depending on the degree of damage to the joint capsule. However, any knee with an effusion should be examined thoroughly. Similarly, abrasions and contusions around the knee may indicate significant trauma to the joint. The condition of the soft-tissue envelope should be documented because it may influence the timing of surgical repair. Additionally, radiographs of the knee may demonstrate subtle clues such as avulsions of flecks of bone or asymmetry between compartments of the knee. Finally, an examination under anesthesia (EUA) is the “gold standard” test to diagnose a knee dislocation and to classify the torn structures.

TABLE 26.1 Anatomical Classification Class

Description

Knee dislocation I

Cruciate intact knee dislocation

Knee dislocation II

Both cruciates torn, collaterals intact

Knee dislocation III

Both cruciates torn, one collateral torn Subset KD III Medial or KD III Lateral

Knee dislocation IV

All four ligaments torn

Knee dislocation V

Periarticular fracture dislocation

Patients who present with the knee dislocated should have the joint reduced as quickly as possible. Normally, longitudinal traction on the lower leg produces a rapid and easy reduction. Occasionally, patients will present with an irreducible knee, most frequently as a result of the femoral condyle “button holing” through the capsule or muscle. This is frequently accompanied by puckering of the skin when a reduction is attempted. If the knee does not reduce easily, the patient should be taken to the operating room for a reduction under anesthesia expeditiously. In a patient with a suspected ligamentous injury to the knee, a careful and gentle knee exam should be performed. The anterior cruciate ligament (ACL) is best examined with the Lachman’s test with the knee in approximately 30 degrees of flexion. The posterior cruciate ligament (PCL) should be examined with a posterior drawer test. It is important to make certain the knee is not posteriorly subluxed prior to the examination, as that can yield a false diagnosis of a torn ACL rather than a torn PCL. Varus and valgus laxity testing should be done with the knee in full extension and 30 degrees of flexion. Instability in extension implies both the PCL and one of the lateral collateral ligaments is torn. The dial test performed at both 30 and 90 degrees of flexion can identify a posterolateral corner (PLC) tear with damage to the popliteus muscle unit. Finally, an anterior drawer that is increased with the knee in external rotation can differentiate a torn posteromedial corner (PMC) from a simple medial collateral ligament (MCL) tear. It is critical to perform a careful neurologic and vascular examination of the leg, in addition to the assessment knee stability. The vascular examination must include palpation of the distal pulses, which is the best marker of clinically significant vascular injury. Popliteal artery injuries occur in 5% to 15% of patients with knee dislocations and are limb-threatening injuries. There is strong support in the literature for a “selective arteriography” that uses a careful vascular examination as the trigger for obtaining vascular imaging studies. If the vascular examination is

normal, the patient should be admitted for observation with serial clinical examinations. If the vascular status is abnormal, vascular surgery consultation and additional studies are warranted. If there is any doubt regarding the vascular status of the patient, a magnetic resonance angiogram (MRA) or classic contrast angiography should be obtained. MRA is usually adequate and is preferred in stable patients who can undergo this procedure in the acute setting. Otherwise, arteriography is utilized. If the imaging study documents an intimal tear, the patient should be evaluated by a vascular surgeon. The contemporary treatment of a non-flow limiting intimal tears is observation and careful serial vascular examinations. Additional physical examination tests such as ankle brachial index may be performed in equivocal cases, but are not necessary in most patients. A detailed neurologic examination of the extremity should also be performed and documented. Peroneal nerve injuries due to traction at the fibular head occur in up to 20% of patients and are often a source of longterm disability. It is important to document neurological injuries prior to surgical reconstruction. It may be beneficial to perform a peroneal nerve neurolysis at the time of knee ligament reconstruction if there is a traction injury. While much less common, tibial nerve injuries do occur, and the status of that nerve should also be documented prior to surgical intervention.

Imaging Studies In all patients with trauma around the knee, an anteroposterior (AP) and lateral radiograph should be obtained. These should be studied carefully as they frequently yield subtle signs of a ligament knee injury such as bony flecks or avulsions, asymmetry of the medial or lateral compartments, subtle subluxation, or rim fractures. If the physical examination documents ligamentous instability, an MRI scan should be obtained when the patient is stable as a supplement to the physical examination. The MRI scan helps identify the pathoanatomy, P.473 the location, and pattern of injury, provides a good evaluation of the menisci, and can confirm the exact location of the neurovascular bundle relative to the knee joint.

Timing of Surgery The timing of surgical repair in patients with a knee dislocation is controversial. Open dislocations require urgent reduction, irrigation and débridement, and placement of a spanning external fixator. Similarly, patients with irreducible dislocations should be taken to the operating room as soon as an operating room becomes available. In patients with closed injuries without vascular embarrassment, the timing of definitive ligament repair is debatable. The condition of the soft-tissue envelope as well as other associated injuries is a key factor in determining the ideal timing for reconstruction. My preference is to treat associated fractures within 1 week of injury and reconstruct the ligaments in the 3rd or 4th week following injury. I place the vast majority of patients in a simple knee immobilizer prior to reconstructive surgery. The exceptions are open injuries and grossly unstable knees where a spanning external fixator is employed for 3 to 4 weeks prior to reconstruction.

Surgical Tactic Reconstruction of a dislocated knee is a complex procedure that requires careful preoperative planning in order to maximize results. It is important to understand which structures are torn prior to surgery so that appropriate equipment and allografts are available. An EUA is always performed at the beginning of the case to confirm the findings on physical examination and correlate it with the results of the MRI. The sequence of the reconstruction is important, particularly if a hinged external fixator will be used in conjunction with the reconstruction. My surgical tactic includes a diagnostic arthroscopy at the outset of the case to document ligament injury and assess the knee for meniscal and articular cartilage injury. After addressing those injuries, the notch is débrided of torn ligament remnants, and the PCL reconstruction is performed when disrupted. Following repair of the PCL, a reference wire for a hinged external fixator (if necessary) and the femoral pins must be placed prior to further

reconstruction. Next, the PMC and PLC are constructed. All tunnels are drilled and allografts placed prior to tightening any of the PMC or PLC reconstructions. Normally, the PCL is tensioned first, followed by the two corners. If a hinged external fixator is used, it is placed on the femoral pins after the skin is closed, and the three tibial pins are drilled and placed as the final step of the procedure. I prefer to delay reconstruction of the ACL for 6 weeks or longer in the majority of cases. This allows rehabilitation to be focused on the PCL initially, shortens an already long case, and allows the surgeon to “jump start” knee motion at the time of ACL reconstruction if the patient is having difficulty with motion. The surgical procedures described later in this chapter are my preferred techniques. I use an inlay doublebundle PCL reconstruction in virtually all cases. If the patient has an adequate sized femur, I combine it with a doublebundle ACL reconstruction 6 weeks later. There is no compelling clinical evidence that double-bundle reconstructions are superior to their single-bundle counterparts. However, both seek to reconstruct the precise anatomy and both provide additional rotational stability. This may be more important in a patient who has a PCL injury as well as medial and lateral corner damage than in a patient with an isolated cruciate ligament injury. However, in patients with complex multiligament knee injuries, there is limited bone stock available for tunnel placement, and they must be placed perfectly when performing combined ACL and PCL reconstructions using double-bundle techniques. I routinely use drill guides that improve tunnel placement as “free-hand techniques” are often unreliable. Another controversy is whether to repair the PMC and PLC primarily if adequate tissue is present. Recent studies have shown that reconstruction is superior to primary repair for tears of the PMC and PLC. As a result, I routinely reconstruct these areas. If the patient has reasonable tissue that might be amenable to repair, it is repaired and then reconstructed in a belt and suspenders technique. The time necessary to complete a complex multiligament knee injury is approximately 4 hours, and there is a long learning curve.

SURGERY Anesthesia General, spinal, or regional anesthesia can be utilized for reconstruction of a knee dislocation. These are lengthy and painful procedures, and an indwelling epidural catheter or a femoral nerve block helps alleviate postoperative pain and is strongly encouraged. Because these cases frequently take 3 to 4 hours to complete, a Foley catheter is advisable. The need for arterial lines, central venous pressure (CVP) lines, or a Swan-Ganz catheter is determined by the age, physiologic status of the patient, and associated injuries. Patients are given 1 to 2 g of a first-generation cephalosporin and are given an additional 1 g if the surgery takes longer than 4 hours.

Anatomic Posterior Cruciate Ligament Reconstruction The PCL is the cornerstone of the knee and should be reconstructed and tightened prior to any of the other ligaments in most cases. Historical results of PCL reconstructions have been very disappointing, with many P.474 patients having mild to moderate residual posterior laxity following reconstruction. There are two potential causes for the unsatisfactory results associated with PCL reconstructions. The first is that the PCL has two functional bundles: the anterolateral (AL) and the posteromedial (PM). They are named for their position on the femur and tibia, respectively, when the knee is in extension. The AL bundle is tight with the knee in 70 to 80 degrees of flexion, while the PM bundle is tight with the knee in approximately 15 degrees of flexion. Reconstructing both ligaments may improve stability throughout the entire range of motion of the knee. The second potential cause of postoperative instability following ACL reconstruction is the sharp angle the graft must turn around the back of the knee when a transtibial reconstruction technique is used. The angle has been called the “killer turn,” and may be responsible for graft stretching and/or failure. The anatomic PCL reconstruction I will detail below

addresses both of these issues and yields a consistently stable reconstruction. The patient is positioned supine on the operating table. After an EUA confirms the diagnosis, standard arthroscopy portals are created, and the knee is examined. Arthroscopic portions of the procedure are completed by dropping the leg off the side of the table or using a lateral post if necessary. Particular care should be taken to evaluate both menisci as well as both femoral condyles for articular cartilage injuries. Since many of these injuries result from impact between a flexed knee and the dashboard of a vehicle, the femoral condyles are at particular risk of articular cartilage damage. Once that assessment is complete and the articular cartilage and meniscus have been addressed, attention is turned to the PCL. The notch is débrided of the remnants of the torn ligament, while noting the femoral footprint of the native PCL. The femoral tunnels are drilled using a guide that drills from the outside in through the medial femoral condyle. Advantages of using the “outside in” guide include precise placement of the tunnel with no constraints based on the patient’s anatomy and eliminating a “killer turn” at the femoral tunnel. The AL guidewire is drilled first and should be placed high in the notch 8 to 10 mm back from the articular cartilage. After marking the skin with the guide, a stab incision is made over the medial femoral condyle, and a drill tip-guide pin is drilled through the condyle and into the notch. After confirming the position in the notch, the process is repeated for the PM tunnel. The PM tunnel should be placed immediately inferior to the AL tunnel, with a minimum 4- to 5-mm bone bridge between the two tunnels. The diameter of the two tunnels is determined by the graft, but is usually either 8 or 9 mm for the AL tunnel and 6 or 7 mm for the PM tunnel. Both tunnels are drilled to match the measured diameter of the limbs on the graft (Fig. 26.1). Both tunnels are tapped if necessary for the interference screws used to stabilize the graft. The arthroscope is now removed from the knee. A nonirradiated Achilles tendon allograft is selected for the anatomic PCL reconstruction. The tendon is split into a larger (about 60%) AL bundle and a smaller PM bundle. Locking stitches are placed into each of the limbs using a strong suture to allow the graft to be passed into the knee and the respective tunnels. The bone block is cut with an oscillating saw. The block should be trimmed to a size that is 15 to 20 mm long, 10 to 15 mm wide, and at least 10 mm thick (Fig. 26.2). It is very important to leave the bone block a minimum of 10 mm thick, as a thinner bone block can crack when the screw is tightened to secure it into the trough. Once the trimming has been completed, a 4.5-mm hole is drilled through the bone block in a slightly oblique PM to AL direction. The knee is now placed in a figure four position, and a PM approach is performed. The skin incision is identical to the incision used for the PMC reconstruction. Carefully dissect down to the PM border of the tibia. P.475 The inferior landmark of the incision is the insertion of the pes anserinus tendons, and the exposure should extend approximately 10 cm proximally. Once the PM border of the tibia is exposed, a Cobb elevator is used to elevate the popliteus muscle from the back of tibia. This keeps the popliteus between the surgeon and the neurovascular bundle, helping prevent vascular injury. The Cobb elevator is kept tightly against the posterior tibia, and the popliteus is elevated all the way across the tibia. A blunt Hohmann retractor is then hooked over the lateral aspect of the posterior tibia and used to keep the popliteus and neurovascular structures away from the posterior tibia. The foot can also be turned to rotate the posterior tibia toward the surgeon, improving the exposure of the posterior surface of the tibia.

FIGURE 26.1 The diameter of the two tunnels is determined by the graft (either 8 or 9 mm for the AL tunnel and 6 or 7 mm for the PM tunnel). Both tunnels are drilled to match the measured diameter of the limbs on the graft.

FIGURE 26.2 A nonirradiated Achilles tendon allograft is selected for the anatomic PCL reconstruction. The tendon is split into a larger (about 60%) AL bundle and a smaller PM bundle. Locking stitches are placed into each of the limbs using a strong suture to allow the graft to be passed into the knee and the respective tunnels.

FIGURE 26.3 A one-half-inch curved osteotome is used to create a trough in the back of the tibia.

FIGURE 26.4 A 4.5-mm cannulated screw and washer are used to stabilize the bone block into the trough. A one-half-inch curved osteotome is used to create a trough in the back of the tibia (Fig. 26.3). The trough should be 0.9. Values 20-year follow-up have indicated an inconsistent relationship between residual osseous depression of the joint surface and the development of osteoarthrosis. However, if joint deformity or depression produces knee instability, the likelihood of a poor outcome significantly increases (2,5,6). The goals of surgery and thus the surgical tactic should address the four primary areas specific to the fracture that ultimately determines prognosis. These include A. The amount of articular depression B. The extent of condylar displacement C. The degree of metadiaphyseal comminution D. Associated soft-tissue injuries MCL, ACL, etc. A preoperative plan should address these factors and helps ensure that proper implants, reduction tools, bone graft or bone graft substitutes, and fluoroscopic equipment are available for the surgical procedure. The surgical tactic begins by analyzing the location of the major metaphyseal fracture fragments as well as location of articular impaction. Specifically, the condylar fracture area identifies the “apex” exit point as the primary determining factor where fixation hardware should be placed. Buttress and antiglide plates must be centered over these apices’ to maintain the reduction and avoid late condylar displacement. This assessment determines the placement and location of the surgical incisions. This may require posteromedial, direct posterior, or posterolateral surgical approaches, in addition to the more common anterolateral and medial approaches. This gives the surgeon 360-degree access to the entire proximal tibia. The majority of plateau fractures involve the lateral condylar surface (lateral column), and an anterolateral parapatellar incision is used. The length of incision depends on the specific fracture pattern and varies from patient to patient. With medial condyle and combined column fracture patterns, the preoperative CT scan determines the need and location of a second incision (Schatzker IV, V, VI). Occasionally with a posterior column injury (“fracturedislocation of the medial condyle”) (4), the apex of the fracture line is oriented directly posteriorly, which requires a direct posterior approach for exposure and fixation (14,15). Equipment requirements for most patients should include small fragment plates and screws (3.5/2.7 mm) as well as proximal tibial precontoured plates. These are useful because they have a low profile and anatomically match the proximal tibial. However, in very large or obese patients and those with substantial comminution, 4.5/5.0-mm implants should be available (16). In depressed fractures that require articular reduction but have minimal condylar displacement, an anatomic precontoured nonlocking buttress plate is indicated, assuming that the bone quality is adequate. Bone on bone apposition of the condyle provides an inherent buttress and resists axial displacement. A locking plate is not required in length-stable fracture patterns. Precontoured locking plates offer potential advantages in certain fracture patterns including increased holding power in osteopenic bone, the ability to successfully bridge severely comminuted metadiaphyseal areas, and most importantly prevent unwanted cantilever loading. Most preshaped plating systems allow for the use of both locking and nonlocking screws. A step-by-step written problem list with a simple drawing outlining the reduction and fixation tactic is very helpful for residents and less experienced surgeons. This simple exercise summarizes the exposure, hardware requirements, and fixation strategy PRIOR to the actual event, and facilitates the case by doing the surgery on paper first. A full complement of fracture-specific reduction clamps is necessary as these are designed specifically to apply

linear compression to both condyles. A femoral distractor and/or external fixator components should be available to provide consistent ligamentotaxis throughout the case. P.494

SURGERY Positioning Unless there is a medical contraindication to general anesthesia, this is our anesthetic technique of choice. General anesthesia provides more consistent muscle relaxation and facilitates better patient control when the patient is positioned in a prone position. Additionally, it avoids masking an evolving compartment syndrome that has been reported when long-acting regional anesthesia is used. Following the induction of anesthesia, the patient is positioned either supine or prone, depending on the location of the fracture. I prefer a radiolucent operating table with the involved leg elevated on a bean bag positioner (Fig. 27.7A). Once the patient is draped, multiple sterile bolsters can be used to further flex the knee if necessary. Some surgeons prefer a table that can “break” so that the knee can be flexed (Fig. 27.7B). For some fractures, the patient is positioned in a “floating position,” with the patient primarily in a modified medial or lateral decubitus position to allow for an initial anterolateral or posteromedial approach. By rotating the leg, a second posterolateral or modified posterior incision can be accomplished (13) (Fig. 27.7C). The advantage of the bean bag for use with the “floating position” is that once the initial procedure has been completed, the bean bag can be deflated, and the leg rotated to accommodate a secondary approach.

Skin Prep and Drape A tourniquet is placed on the upper thigh with a steridrape at the tourniquet margin (Fig. 27.7C). The limb is prepped from toes to tourniquet. For more extensive approaches, the limb is prepped from toes to umbilicus, and a sterile tourniquet is placed on the upper thigh. The tourniquet is inflated for the primary exposure. Once completed, the tourniquet is deflated and hemostasis achieved. The majority of the fixation and the bulk of the case is then performed without tourniquet control.

Imaging The C-arm image intensifier should be brought in from the contralateral side. Preliminary images should be obtained prior to prepping and draping to ensure that high-quality AP, lateral, and oblique fluoroscopic images P.495 P.496 are easy to obtain without interference from the table. The entire extremity is then prepped and draped as noted above (Fig. 27.7A).

FIGURE 27.7 A. The patient is positioned supine on a radiolucent table with entire extremity elevated on a bean bag positioner that allows flexion of the knee. A tourniquet is placed on the upper thigh and draped off with a steridrape. B. Once prepped and draped the knee can be extended and elevated off the table surface as well as fully flexed with the use of sterile bumps.

FIGURE 27.7 (Continued) C. Demonstration of a patient in a “floating lateral” position. The patient is positioned on a bean bag in the lateral position to perform a posterolateral approach. The entire table can be rotated to the patient’s right to facilitate this posterior exposure. D. Following the posterior exposure, the beanbag can be deflated, and the patient rotated to his left to perform an anterolateral exposure.

FIGURE 27.7 (Continued) E. The ability to achieve 360-degree fluoroscopic visualization is mandatory by elevating the limb with two sterile bolsters. The C-arm is positioned on the opposite side of the extremity. The knee is elevated with a sterile bolster to obtain a lateral x-ray.

Reduction and Fixation of Specific Fracture Types In order to successfully treat complex high-energy Schatzker IV, V, and VI injuries (multicolumn), it is helpful to understand and gain experience treating lower-energy type I, II, and III (single column) fractures. The principals of treating low-energy (single column) injuries are then brought together to treat the higher-energy complex fractures by combining the individual exposures as well as fixation strategies specific to each fracture type (column).

Lateral Column Injuries Current concepts in treating low-energy lateral tibial plateau fractures are based on the ability to achieve a congruent articular surface through a limited surgical exposure and fixation of the condyle. For most lateral column injuries, Schatzker type I or II fractures, nonlocking plates are usually sufficient in normal healthy bone. With comminution or significant osteoporosis, a locking plate is indicated.

Schatzker I/Isolated Lateral Column Fractures Split condylar fractures (Schatzker I) without comminution can often be reduced and fixed with percutaneous cannulated lag screws alone (17) (Fig. 27.8A). It is helpful to obtain a preoperative MRI to rule out a lateral meniscus tear. If the meniscus is intact, it may be possible to perform a closed reduction and percutaneous fixation with 3.5- or 4.5-mm conventional or cannulated screws (17). Reduction is achieved with longitudinal traction and a varus force. Alternatively, a laterally based femoral distractor can assist with the reduction. If the preoperative MRI demonstrates a peripheral meniscal tear or incarceration of the meniscus within the fracture site, or if closed reduction fails to adequately reduce the fracture, an open reduction is indicated. When an acceptable reduction is obtained, the fracture is compressed with large pointed forceps placed percutaneously on the medial and lateral tibial condyles (Fig. 27.8B). Screw fixation is done through small stab incisions laterally (16). The orientation of these screws should be determined preoperatively based either on the MRI or CT scan. Evaluation of the “apex” of the lateral condylar fragment distally should be based on the preoperative CT or MRI scan (12). If the apex of the fracture fragment is comminuted precluding bone on bone stability following reduction, a precontoured buttress or antiglide plate (nonlocking or locking) is necessary to maintain the reduction rather than screw fixation alone.

Schatzker II/Lateral Column with Articular Impaction Fractures These injuries involve both a lateral condyle fracture combined with varying degrees of articular surface depression. Preoperative imaging studies are important to determine the degree and location of articular impaction P.497 as well as the orientation of the apex of the condylar fracture line (Fig. 27.9). In most cases, the depression is anterior or central and is best approached through the utility anterolateral incision. The length of the incision is determined by the individual fracture pattern. The articular surface is visualized through a transverse submeniscal arthrotomy with elevation of the meniscus using several small traction sutures or small angled retractors (Fig. 27.10A). A varus stress applied to the knee improves visualization.

FIGURE 27.8 A. A lateral column fracture without articular impaction also known as a Schatzker type I tibial plateau fracture. Reduction was accomplished with distraction, valgus stress, and a percutaneous reduction clamp through a small incision to elevate the fracture and meniscus. B. Guide wires are advanced percutaneously, followed by 3.5-mm cannulated screws. The lateral ligament complex is reattached with suture

anchors. Flexing the knee also improves visualization of the articular surface by distracting the joint by the weight of the leg. Alternatively, a laterally based femoral distractor can be used to enhance joint visualization through sustained distraction. Impacted articular fragments can be reduced by two different techniques. In the first method, the split in the condyle is wedged open like a book. The articular depression is directly visualized, and using an impactor, elevator, osteotome, or dental pick inserted from below, the osteoarticular fracture fragments are disimpacted and elevated (Fig. 27.10B,C). Once the osteochondral P.498 fragments have been repositioned and the joint is congruent, temporary Kirschner wires (K-wires) are used to provisionally stabilize the articular reduction. The defect created after elevating the joint surface is filled with bank bone graft or alloplastic calcium substitutes (18, 19 and 20). Following graft placement, the split condyle is reduced and held with a large reduction forceps, and intraoperative fluoroscopy is used to assess the reduction (Fig. 27.10C,D).

FIGURE 27.9 A lateral column injury with articular impaction (Schatzker type II). Comminution and impaction of

the lateral articular surface occur with a large wedge fracture of the lateral tibial condyle. The CT images demonstrate the depth and orientation of the articular impaction as well as comminution of lateral wall and apex (arrows). This information is important to help determine the length of incision and plate placement. Fixation is achieved with a precontoured lateral tibial plateau plate with multiple “raft screws” supporting the joint surface. The plate now functions as an intact lateral cortical support (lateral I-beam). The screws extending across the subchondral region provide support for the reconstructed surface and should engage the intact medial cortex (medial I-beam). This twin I beam rafter construct supports the elevated joint surface preventing late subsidence (14) (Fig. 27.10C,D) (9,10). In the elderly or in patients with osteoporosis, a locked plate is indicated to improve fixation and resist axial load. Following column reconstruction care should be taken to repair the meniscotibial ligament and any peripheral meniscal tears that may be present. P.499

FIGURE 27.10 A. An anterolateral incision is used. It begins 1 to 2 cm proximal to the joint line in the midline and is carried distally over Gerdy’s tubercle and gently angled toward the lateral border of the tibial crest. The incision can be extended proximally or distally when needed. The fascia lata is split in line with the skin incision,

and the anterior compartment muscles are reflected off the proximal tibia. The retractor in the proximal aspect of the wound spreads the fascia exposing the capsule and meniscal-tibial ligament. B. The fascia is retracted anteriorly and posteriorly to expose the major fracture line and capsular structures. The meniscal-tibial ligament is incised horizontally to visualize the joint. The sagittal plane lateral column fracture line has been defined. C. The major column fracture line has been “gapped open” with a lamina spreader to visualize and gain access to the impacted articular fragments. The depressed osteoarticular fracture fragments are elevated from below using a curved impactor under direct vision. The meniscal-tibial ligament has been incised below the level of the lateral meniscus. The tibial attachment of the ligament is preserved to facilitate repair of the lateral meniscus (green suture). An elevator is inserted into the joint to palpate the articular reduction. Following articular reduction, the lateral column fragment is reduced and held with a large reduction forceps and adjunctive K-wires. P.500

FIGURE 27.10 (continued) D. (a) Condylar reduction maintained with K-wire and large reduction clamp. (b) A curved impactor has been inserted through a subcondylar window to elevate the articular surface. (c,d) Bone graft substitute has been inserted into the void to provide additional stability to the elevated articular surface. A K-wire has been inserted to maintain the joint reduction. (e,f) A precontoured plate is applied and held with a reduction clamp. “Raft” screws are placed through the proximal portion of the plate, capturing the intact medial cortex providing additional support for the elevated articular surface. A second method of reduction reduces the condylar split fracture first particularly when it extends distally, and it is held with large pointed reduction forceps (Figs. 27.10D and 27.11). The impacted articular surface is then reduced indirectly. Multiple 2-mm drill holes are placed in the subcondylar flare distal to the impacted articular fragments, and a 1-cm cortical window is created by connecting the drill holes with a small osteotome. The cortex is impacted directly into the metaphysis using a small curved impactor. Under fluoroscopic control, the impactor is positioned to engage the depressed osteochondral fragments from below. It is important to disimpact and

elevate the fracture fragments en masse by placing graft material continuously beneath the fracture fragments. The pressure from the impactor is distributed over a larger surface area preventing fragmentation or splitting of the articular surface. The joint surface is slowly elevated and visualized with fluoroscopy or directly through the submeniscal exposure. Once the articular surface has been reduced, provisional K-wire fixation is used to maintain the reduction. Depending on the size of the incision, a periarticular lateral plateau plate can be placed directly on the tibia or passed in a submuscular fashion with the distal screws inserted through small percutaneous incisions (Figs. 27.10D, 27.11, 27.12 and 27.13 and 27.15). Following internal fixation, the meniscotibial ligament is repaired along with any meniscal pathology, and the fascia is closed. The anterior compartment fascia may be “pie crusted” by making multiple small incisions that mesh the fascia to allow closure and decrease pressure in the anterior compartment. A drain is inserted and the incision closed in layers avoiding skin tension (Figs. 27.13 and 27.14).

Schatzker III/Zero-Column Fracture This injury usually occurs in older patients with osteoporotic bone after a low-energy fall with a valgus stress. The articular surface of the lateral plateau is impacted without an associated lateral column fracture. Preoperative P.501 MRI or CT scans are helpful to precisely locate the area of impaction and its orientation. Additionally, the MRI is helpful in identifying a peripheral meniscal tear or incarceration of the meniscus within the depressed articular surface.

FIGURE 27.11 A. The impacted joint is visualized through the submeniscal arthrotomy. The fascia has been reflected anteriorly (clamp) and posteriorly (forceps) to expose the condylar fragment. B. The lateral column fracture is reduced and held with a large and small percutaneous reduction forceps. At the inferior apex of the major columnar fracture line (black arrow), a 1-cm bone window has been created. C. A small cortical window is removed, and a curved impactor is used to elevate the impacted articular surface from below. D. The metaphyseal defect is filled with an alloplastic bone graft substitute. The surface is continuously elevated until congruency is achieved under direct vision and fluoroscopy. With increased sophistication of arthroscopic techniques, this is one of the few tibial plateau fractures that are amenable to arthroscopically assisted reduction and fixation (21). The fracture can be treated through small incisions using either an image intensifier or arthroscopic visualization of the articular surface (Fig. 27.16). A limited lateral incision is made over the metaphyseal region of the lateral condyle, and a small metaphyseal cortical window is made below the depressed articular fragments. The window must be of sufficient size to allow elevation and grafting of the fragments while assessing the reduced surface from above or arthroscopically. Once reduction of the joint is confirmed, the reduction is stabilized by percutaneous cancellous or cannulated screws placed in a subchondral location (21,22).

Schatzker IV/Medial and Posterior Column Fractures Fractures of the medial column are usually caused by high-energy trauma and are often associated with neurovascular injuries and significant fracture displacement. They can occur with other injuries such as knee dislocations; therefore, a high index of suspicion is necessary to avoid overlooking a limb-threatening injury. P.502 P.503 P.504 P.505 In a few fractures with minimal comminution or displacement, closed reduction can be attempted with large reduction forceps. If an anatomic reduction can be achieved, fixation with multiple percutaneous screws is usually sufficient. With more complex medial condylar injuries, screw fixation alone is contraindicated when the intercondylar eminence is avulsed with the anterior cruciate ligament or if comminution medially precludes bone on bone reduction at the “apex” (Fig. 27.17A) (2,23). The energy required to produce a displaced medial condylar fracture is substantially higher than what is required to produce a lateral condyle fracture and usually requires a buttress plate to resist the deforming (varus) forces (Fig. 27.17B) (2,3).

FIGURE 27.12 A precontoured plate is advanced in a submuscular fashion along the lateral condyle and shaft. A. The plate is held in place with a large pointed forceps and/or temporary K-wires while screws are inserted. B, C, D. Following application of fixation hardware, the meniscaltibial ligament (sutures) is repaired to the capsule.

FIGURE 27.13 The submeniscal arthrotomy is closed by suturing the meniscal-tibial ligament.

FIGURE 27.13 (Continued)

FIGURE 27.14 A. The fascia lata is closed over suction drains. B. The anterior compartment fascia has been “pie crusted” to allow closure without tension. C,D. Skin closure.

FIGURE 27.15 Radiographs and CT scan 1 year following repair. The CT scan shows maintenance of articular congruity with complete incorporation of bone graft. Solitary “raft” screws placed in a subchondral location continue to support the articular surface. The screws are supported by the reconstructed lateral cortex and the intact medial cortex. Note the healed MCL avulsion fracture from medial femoral condyle.

FIGURE 27.16 A. A zero-column injury (Schatzker type III). This injury involves impaction and comminution of the lateral articular surface without a condylar split. The CT scan demonstrates a central impaction of the lateral articular surface and preservation of the intact lateral condylar rim. This particular pattern is often amenable to arthroscopic-assisted fixation. B. A subchondral window is produced using a cannulated drill with the guide wire localized using arthroscopy or fluoroscopy.

FIGURE 27.16 (Continued) C. The articular surface is elevated using a bone impactor followed by percutaneous raft screw fixation. D. Follow-up x-rays demonstrate a healed fracture. Not infrequently, the articular comminution extends across the midline into the lateral column, which is common with fracture dislocation patterns. If the lateral plateau (column) articular involvement requires reduction, a lateral approach may be required as well (Fig. 27.4C). Preoperative CT scans are critical in determining the location of the apex of the medial column fracture lines. The location may be variable with the “apex” directed posterior, posteromedial, directly medial, or anteromedial. The location and orientation of the “apex” determine the medial column surgical approach. Very few fractures are amenable to a standard medial parapatellar incision. In order to limit the surgical exposure, a thorough understanding of the CT scan is imperative to localize the incision to maximize reduction and fixation of the condylar fragment (23). Fixation is accomplished with a small fragment buttress plate located at the apex of the medial condylar fracture line (Fig. 27.18). In most isolated medial column fractures, the apex of the medial condyle is noncomminuted allowing direct bone on bone apposition. In these circumstances, a nonlocking buttress plate or antiglide plate is sufficient for stabilization, and locking plates are not usually necessary for the medial fixation (5,8,10). Precise positioning of the plate at the apex of the fracture line minimizes varus collapse with weight bearing. When there is an anteromedial fracture, the anterior pes anserine as well as the superficial portion of the medial collateral ligament must be reflected in continuity posteriorly (Fig. 27.19). This avoids soft-tissue entrapment by the plate (Figs. 27.18 and 27.20). Alternatively, if the apex of the fracture is located at the posteromedial corner, or slightly posterior to the corner, the inferior margin of the pes can be reflected anteriorly. The fascia of the gastrocnemius muscle is incised to allow a plate to be positioned directly on the posteromedial aspect of the tibia (Figs. 27.21 and 27.22A,B). When the fracture “apex” is located posteriorly or posterolaterally, a direct exposure of the posterior column is accomplished through a posterior approach. The patient is placed prone and exposure is achieved with an incision placed along the posteromedial border of the proximal tibia (Fig. 27.23A). The fracture is exposed by P.506 P.507

elevation and lateral retraction of the medial gastrocnemius, soleus, and popliteus muscles. This provides direct visualization of the majority of the posterior aspect of the proximal tibia and facilities reduction and application of a posterior plate (22) (Fig. 27.23B,D). Alternatively, the patient can be placed in a “floating position,” which allows the patients’ limb to be rotated into the prone position yet allows an anterolateral approach without repositioning (Fig. 27.7) (13,23). A transverse posterior L-shaped incision begins at the center of the popliteus P.508 P.509 and turns distally at the medial corner of the popliteal fossa (Fig. 27.23A). To avoid injury to the neurovascular bundle in the popliteal space, the dissection should progress from medial to lateral under the soleus and popliteus muscles in the proximal region. Through this approach, the medial column can be visualized along the medial edge of this incision (Fig. 27.23C). The interval between the pes anserine tendons and medial gastrocnemius can be developed. The pes can be released as noted above and the plate positioned anterior to the medial collateral ligament. If the pes and semimembranous have been released, they should be repaired with nonabsorbable sutures after fracture fixation (Fig. 27.23E).

FIGURE 27.17 A. Radiographs and CT scan showing a medial column fracture dislocation. This fracture is often

associated with intercondylar comminution and fragmentation. Arrows indicate apex comminution. B. A highenergy medial column fracture dislocation with apex comminution. There is involvement of the tibial spine and eminence and distal shaft extension. This degree of instability requires a medial buttress plate.

FIGURE 27.18 A medial column injury with the fracture apex directly medially, just anterior to midline (arrows). Following disimpaction, the reduction is accomplished with large reduction forceps and K-wires used as joysticks to manipulate the fracture. A contoured buttress plate is positioned directly over the apex with lag screws through the plate.

FIGURE 27.19 A. The medial column exposure is directed to the apex of the medial condyle fracture; in this case, the apex is at just anterior to the posteromedial border of the tibia. B. The pes fascia is identified (forceps)

and incised in line with the skin incision exposing the pes complex.

FIGURE 27.19 (Continued) C. In this case, the apex of the fracture is directly inferior to the pes insertion. The pes is tagged, incised (elevator and scalpel), and reflected inferiorly revealing the apex of medial column fracture. D. Apex comminution and impaction of medial condyle are identified following pes reflection.

FIGURE 27.20 A. The fracture is disimpacted with small cobb elevator. B. Reduction is achieved with a large reduction forceps and a smaller tenaculum. C. The plate is positioned directly at the apex of the condylar fracture, bridging the area of comminution. D. Following plate application, the pes (green tagged suture) is

repaired.

FIGURE 27.21 A. Through a posteromedial incision, the inferior edge of the pes is identified, and the interval between it and the medial gastrocnemius is developed. B. The apex of the fracture is localized and reduced. C,D. A contoured plate is placed along the posteromedial condylar flare in an extraperiosteal fashion. Following screw application, the pes is allowed to cover the plate, and the wound is closed. While most of the posterior aspect of the proximal tibia can be visualized through the posteromedial approach, access to the posterolateral corner of the knee is problematic. It is not easily accessed from the anterolateral approach either. The fracture fragments are often just posterior to the fibular head and covered by iliotibial band, lateral collateral ligament, as well as the popliteus muscle and tendon. Several authors have described a direct posterolateral approach to this area with or without a fibular osteotomy (14,15,24,25). Whenever possible, an approach avoiding a fibular osteotomy is preferable. When a posterolateral exposure is necessary, we use a longer, more laterally based incision, which still allows a submeniscal arthrotomy and anterolateral fixation if necessary. Surgery in the posterolateral corner of the knee always requires identification and protection of the peroneal nerve. Dissection between the biceps femoris tendon and lateral head of the gastrocnemius is developed, and the peroneal nerve is identified and protected. The popliteus muscle is retracted medially exposing the lateral aspect of the soleus muscle as it attaches onto the tibia and proximal fibula. The soleus is detached from proximal to distal exposing the posterolateral aspect of the plateau. Fixation is achieved with small implants to buttress this region; however, distal extension of the exposure is not possible because of the neurovascular bundle.

P.510

Shatzker V, VI/Multiple Column Injuries These complex plateau injuries are usually the result of high-energy forces that are often associated with compromise to the surrounding soft tissues. A staged approach is now widely accepted as the preferred method of treatment (8, 9 and 10,26). This consists of early application of bridging external fixation to restore length and knee stability (Fig. 27.3A,B). Distraction CT or MRI scans provide detailed information about the articular injury, the degree of comminution, and the orientation of the fracture lines. When the soft tissues have recovered, definitive internal fixation can be performed. For some high-energy fracture patterns, surgery should be delayed for 2 or 3 weeks to allow sufficient time for the soft tissues to recover (Fig. 27.16). Column-specific techniques regarding surgical exposure and fixation are combined to treat these difficult fractures. For some fractures, stabilization of both the medial and lateral column injuries, Schatzker V patterns can be achieved through a lateral approach using a solitary locking plate (27,28). The indications for this method of treatment are based on the preoperative evaluation of the CT scan following ligamentotaxis reduction after external fixation. If the medial column in a bicondylar fracture is adequately reduced and there is no “apex” comminution and bone on bone apposition exists, the fracture is often amenable to fixation with a laterally based locked plate. If however, the medial condyle cannot be reduced indirectly, or there is apex comminution, then a separate surgical approach with independent fixation is necessary. This is typically the case with coronal plane posteromedial fractures (Fig. 27.24). Fractures involving both columns are frequently comminuted, and there may be dissociation of the shaft from the metaphysis (Schatzker VI; Fig. 27.25A). Articular impaction can often be elevated using cortical windows placed in the subcondylar regions either medially or laterally. Large percutaneously applied P.511 reduction forceps may reduce or improve the position of the intercondylar fracture lines. Cannulated or 3.5 cortical screws can be used to secure the intercondylar reduction after which the condyles must be attached to the tibial shaft. Using one or two femoral distractors, limb length and alignment can be restored allowing placement of a submuscular-locked plate. Locking plates are used to “bridge” the zone of comminution at the metadiaphyseal junction (29). Virtually all proximal tibial locking plate systems have outriggers to place screws in the distal portion of the plate through small percutaneous incisions (27). Remember that if the condylar fracture fragments are not comminuted and the condyles are well reduced, the medial condyle can usually be controlled with a laterally based locking plate. However, if the apex of the medial condyle is comminuted, then this fragment requires independent support to prevent late varus deformity. A locking plate on the medial side of a bicondylar fracture using unicortical locking screws can be helpful. Typically hardware from a laterally based plate interferes with medial condylar fixation making medial fixation problematic. Unicortical locking screws placed into the medial condyle may prevent hardware “gridlock.” Care should be taken to limit dissection through the second incision and avoid development of large skin flaps (Fig. 27.25B-D).

FIGURE 27.22 A. A CT scan reveals a posterior column fracture, with the fracture apex just lateral to posteromedial corner. A comminuted coronal split divides the column injury (white arrow). The skin incision is oriented posteromedially to gain access to the posterior aspect of the plateau. The pes is identified (elevator), tagged, and reflected anteriorly. The gastrocnemius is reflected posteriorly exposing a highly comminuted column fracture.

FIGURE 27.22 (Continued) B. The coronal split in the medial column (red line) is reduced with a horizontal rim plate to maintain articular integrity. A posterior buttress plate is required to maintain the column reduction. Occasionally, fracture comminution or soft-tissue injury is so extensive that surgical incisions may be contraindicated, and a fine wire ring fixator is indicated. In a small subgroup of patients, the soft tissues do not recover sufficiently during the first month to tolerate open reduction and internal fixation. These patients are better treated with small tensioned wire or hybrid external fixation techniques.

Pitfalls and Tricks One of the most common errors in tibial plateau fracture surgery is not placing the plates directly at the apex of their respective condylar fracture fragments. This is primarily due to poor preoperative planning with incorrect P.512 P.513 placement of the surgical incisions. Thus, if the apex is not directly visualized, it is impossible to place the plate in the correct location leading to axial displacement and condylar collapse with the development of a varus malunion.

FIGURE 27.23 A. Patient positioned prone or floating lateral position. An “L” shaped incision is marked on the skin that will be utilized to gain access to the posterior column. B. Through a direct posterior approach, the medial head of gastrocnemius is retracted laterally, exposing the soleus and postmedial border of the tibia. C. The soleus muscle is incised along the medial border of the tibia and then retracted laterally with the popliteus, exposing the proximal posterior aspect of the tibia. Reflecting the pes anteriorly will also allow access to the medial column (suction attachment).

FIGURE 27.23 (Continued) D. CT and x-ray studies show posterior and medial column fractures with significant articular impaction. The joint is elevated through a posterior approach, and a buttress plate is applied directly to the posterior tibia. The medial column injury is buttressed with a small antiglide plate. Post-op CT scans document the articular and column reductions. E. The location of plates posteriorly and posterior medially prior to wound closure. Inverted “L” incision at followup. Numerous fracture-specific reduction clamps are available and are useful to help reduce these complex injuries. Large hemispherical reduction forceps can apply substantial compressive forces in a linear fashion improving intercondylar reduction. Reduction of the condyles can be facilitated using small external fixation pins (4 or 5 mm diameter) placed into the displaced condylar segment and used as joy sticks to help with the reduction. When used in conjunction with a large reduction forceps, displaced condyles can often be reduced avoiding large surgical incisions with further soft-tissue stripping (Fig. 27.26A,B). P.514

FIGURE 27.24 A high-energy medial and lateral column injury with significant lateral articular impaction. A distraction CT scan shows restoration of the medial column (black and white arrows). In this situation, a single laterally based locking plate is used following articular reduction and subchondral grafting. Final image (right lower) demonstrates no varus or articular collapse at 1-year follow-up. Adjunctive rim fixation is useful to maintain reduction in very proximal cortical “rim” fractures. Eccentric rim or peripheral margin fractures can displace the cortex at the level of the subchondral bone. If the cortex is not reconstituted, the elevated joint surface has no “rim” to support the elevation leading to a loss of height and subsequent subsidence. Precontoured buttress plates do not typically extend this far proximally. A horizontally oriented cortical substitution “rim” plate positioned on top of the cortical rim fracture can be helpful. The plate serves to reestablishing an intact rim and allows the subchondral elevation to be maintained (Figs. 27.27 and 27.28). Tibial tubercle fractures occasionally occur with high-energy tibial plateau fractures. Fixation may be a problem if the posterior cortex is also fractured preventing lag screw fixation from front to back. In some fractures, the tibial tubercle region may be the only available bone in which to anchor fixation hardware. Fixation of the tubercle fragment can be accomplished with an anterior hook plate or unicortical locking plate. Both maintain fixation to the tubercle via the hook or locking screws (Fig. 27.29). The plate extends distally allowing fixation to the intact posterior cortex at a site distal to the posterior comminution (15).

Postoperative Management Postoperatively, the limb is placed into a bulky Jones dressing from the toes to groin. A cephalosporin antibiotic

is administered for 24 to 48 hours after surgery for closed fractures. Antibiotic coverage for open fractures consists of a cephalosporin and aminoglycoside antibiotic given for 48 hours after the most recent surgical P.515 procedure. Prolonged use of antibiotics in open fractures is contraindicated unless culture-specific wounds with antibiotic sensitivities have been identified. The suction drain remains for at least 24 hours or until drainage is 10 mm; any moderate instability of the knee, and varus malreduction of the medial condylar segment. All of these factors lead to a dynamic deviation of the mechanical axis with weight bearing. Rapid progression of posttraumatic arthritis in followup is seen in patients who have undergone meniscal resection and those with residual tilt of the tibial plateau. Surprisingly, P.522 P.523 P.524 little association between residual articular step-off and progressive degenerative changes has been found in long-term studies assuming the dynamic mechanical axis has been maintained with minimal knee instability (3,5,6,9).

FIGURE 27.30 A. Injury films demonstrate a fracture dislocation of the left knee. Intraoperative traction fluoroscopic views reveal comminution and depression of the articular surface as well as metadiaphyseal extension. The spanning external fixator restores length and alignment. B. Distraction CT images reveal a three-column injury with a coronal split in the medial column producing an anteromedial and posteromedial column injuries. There is joint depression in the lateral column injury. C. (top) Posterior and medial column fixation was approached through a posteromedial approach. A posterior plate was applied to the posterior fragment and the medial column reduced and fixed through the same exposure. (bottom left) Medial approach. (bottom right) Lateral approach was limited to the proximal one half of the marked incision.

FIGURE 27.30 (Continued)

FIGURE 27.30 (Continued) D. (top) The lateral column was reduced and the articular impaction elevated through a small lateral incision. A lateral locking plate was used to provide fixation and subchondral joint support with an oblique “kickstand” locking screw. (bottom) At 18-month follow-up, there is good joint congruity and alignment. Articular incongruities appear to be well tolerated, and many other factors are more important in determining outcome rather than articular step-off alone, joint stability, retention of the meniscus, and coronal alignment. Thus, in high-energy fractures in which severe comminution may prevent an anatomic articular reconstruction, emphasis should be placed on optimizing the overall joint congruity and restoring the sagittal and coronal plane alignment.

REFERENCES 1. Muller M, Allgower M, Schnieder R, et al. Patella and tibia. In: Allgower M, ed. Manual of internal fixation. New York, NY: Springer Verlag; 1979:553-594. 2. Schatzker J, McBroom R. Tibial plateau fractures: the Toronto experience 1968-1975. Clin Orthop 1979;138:94-104. 3. Watson JT. High energy fractures of the tibial plateau. Orthop Clin North Am 1994;25:728-752.

4. Apley AG. Fractures of the tibial plateau. Orthop Clin North Am 1979;10:61-74. 5. Lansinger O, Bergman B, Courmner L, et al. Tibial condylar fractures: a 20 year followup. J Bone Joint Surg Am 1986;68:13-18. 6. Rasmussen P. Tibial condylar fractures, impairment of knee joint stability as an indicator for surgical treatment. J Bone Joint Surg Am 1973;55:1331-1350. 7. Kerkhoffs GM, Rademakers MV, Altena M, et al. Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal [art of the tibia]. Surgical technique. J Bone Joint Surg Am 2009;91(Suppl 2):101-115. P.525 8. Tejwani NC, Achan P. Staged management of high-energy proximal tibia fractures. Bull Hosp Jt Dis 2004;62(1-2): 62-66. 9. Barei DP, Nork SE, Mills WJ, et al. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am 2006;88:1713-1721. 10. Barei DP, Nork SE, Mills WJ, et al. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004;18(10):649-657. 11. Shepherd L, Abdollahi K, Lee J, et al. The prevalence of soft tissue injuries in nonoperative tibial plateau fractures. J Orthop Trauma 2002;16(9):628-631. 12. Yacoubian SV, Nevins RT, Sallis JG, et al. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 2002;16(9):632-637. 13. Luo CF, Sun H, Zhang B, et al. Three column fixation for complex tibial plateau fractures. J Orthop Trauma 2010;24:683-692. 14. Galla M, Lobenhoffer P. The direct, dorsal approach to the treatment of unstable tibial posteromedial fracture- dislocations. Unfallchirurg 2003;106(3):241-247. 15. Lobenhoffer P, Gerich T, Bertram T, et al. Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures. Unfallchirurg 1997;100:957-967. 16. Westmoreland GL, McLaurin TM, Hutton WC. Screw pullout strength: a biomechanical comparison of large-fragment and small-fragment fixation in the tibial plateau. J Orthop Trauma 2002;16(3):178-181. 17. Koval KT, Sanders R, Borrelli J, et al. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma 1992;6:340-351. 18. Russell TA, Leighton RK, Alpha-BSM Tibial Plateau Fracture Study Group. Comparison of autogenous

bone graft and endothermic calcium phosphate cement for defect augmentation in tibial plateau fractures. A multicenter, prospective, randomized study. J Bone Joint Surg Am 2008;90(10):2057-2061. 19. Simpson D, Keating JF. Outcome of tibial plateau fractures managed with calcium phosphate cement. Injury 2004;35(9):913-918. 20. Watson JT. The use of an injectable bone graft substitute in tibial metaphyseal fractures. Orthopedics 2004;27 (1 Suppl):s103-s107. 21. Hung SS, Chao EK, Chan YS, et al. Arthroscopically assisted osteosynthesis for tibial plateau fractures. J Trauma 2003;54(2):356-363. 22. Chan YS, Yuan LJ, Hung SS, et al. Arthroscopic-assisted reduction with bilateral buttress plate fixation of complex tibial plateau fractures. Arthroscopy 2003;19(9):974-984. 23. Barei DP, Mara TJ, Taitsman LA, et al. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma 2008;22:176-182. 24. Frosch KH, Balcarek P, Walde T, et al. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma 2010;24(8):515-520. 25. Solomon LB, Stevenson AW, Baird PV, et al. Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale. J Orthop Trauma 2010;24(8):505-514. 26. Egol KA, Tejwani NC, Capla EL, et al. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 2005;19(7):448-455. 27. Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004;18(8):528-535. 28. Phisitkul P, McKinley TO, Nepola JV, et al. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 2007;21(2):83-91. 29. Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma 2007;21(5):301-306.

28 Extra-Articular Proximal Tibial Fractures: Submuscular Locked Plating Mark A. Lee Brad Yoo

INTRODUCTION Extra-articular fractures of the proximal tibial metadiaphyseal region are uncommon injuries and are typically extensions of tibial plateau fractures. These fractures are technically challenging to treat due to the short proximal fragment and significant muscular deforming forces. In the AO/OTA classification, these fractures are classified as 31 and are geographically localized within a trapezoidal shaped area, whose dimensions equal the epiphyseal width at its widest point and narrow distally (Fig. 28.1). These fractures are usually the result of highenergy trauma such as motorcycle or pedestrian motor vehicle accidents in younger patients and fragility fractures in the elderly. With high-energy trauma, associated soft-tissue injuries are common, and with displaced and comminuted fracture patterns, the popliteal artery or trifurcation is at risk. The management of extra-articular fractures of the proximal tibia depends upon a combination of patient-and surgeon-dependent factors. Some issues to consider are the extent of the soft-tissue injury, the fracture pattern, significant medical comorbidities or concomitant injuries, as well as the surgeon's level of expertise and the hospital's ability to care for critically injured patients. A patient with a minimally displaced isolated transverse fracture should be considered separately from the multiply injured patient with an open comminuted proximal tibial injury (Fig. 28.2A,B).

INDICATIONS AND CONTRAINDICATIONS There are three absolute indications for surgery, which include an open fracture, a concomitant compartment syndrome, and fractures associated with a vascular injury. Furthermore, there are several relative indications for surgery and include residual angulation >5 degrees in the coronal plane and 7 degrees in the sagittal plane (1), patients with an ipsilateral femoral patellar or ankle fracture, and multiply injured patients. Other indications for surgery include patients that would not tolerate prolonged immobilization of the knee or ankle if treated nonoperatively. Contraindications to internal fixation of an extra-articular proximal tibia fracture include a compromised soft-tissue envelope acutely in closed fractures or contaminated wounds in open fractures. In these cases, temporary bridging external fixation followed by delayed internal fixation has been shown to decrease the rate of deep infection (2). Additional contraindications include active infection in the extremity and a subgroup of patients with severe medical comorbidities that preclude a surgical procedure. P.528

FIGURE 28.1 OTA classification of proximal tibial fractures

FIGURE 28.2 Proximal extra-articular fractures demonstrate extreme variability from high energy, highly displaced (A) to lower energy, minimally displaced patterns (B). P.529

History and Physical Examination In the cooperative patient, a detailed history may provide important information regarding the mechanism of injury, and important medical comorbidities such as diabetes, cancer, or autoimmune diseases should be noted. The patient's medication list should be examined for items such as anticoagulants or immunosuppressive agents. A history of prior fracture or previous orthopedic interventions is also important in preoperative planning. The evaluation of the injured patient begins with the advanced trauma life support protocols, which proceeds systematically with airway management, cardiopulmonary resuscitation, and spine precautions. Once lifethreatening issues have been addressed, a secondary survey of the musculoskeletal system is completed. Although this evaluation includes an assessment of the spine, pelvis, and all four extremities, only the evaluation of the lower extremity will be discussed. The patient is fully exposed, and a visual inspection of the limb for open wounds, limb deformity, and degree of soft-tissue damage is performed. Pulses are palpated, with particular attention to asymmetry between sides. The posterior cortex of the proximal tibia is in close proximity with the popliteal artery and tibioperoneal trunk, and displaced fractures in this region may cause a laceration, thrombosis, or traction injury to these structures (Fig. 28.3). If pulses are absent or asymmetric, gross realignment of the limb with gentle traction frequently improves perfusion. Measurement of an ankle-brachial index (ABI) provides a rapid, objective assessment of vascular impairment. An ABI lower than 0.9 alerts the surgeon to a potential vascular injury (3). If further investigation of the arterial supply is warranted, angiography or computed tomography (CT) angiography should be performed. A

detailed neurological examination should also be performed and documented. High-energy proximal tibial fractures are associated with an increased risk of compartment syndrome. Hallmark signs include pain out of proportion to the injury, pain with passive stretch of the muscles within the compartment, and a tense swollen leg. In some instances, an assessment of the patient's pain is not possible due to sedation, intoxication, or a head injury. In these circumstances, direct measurement of intracompartmental pressures should be performed. A difference of 30 mm Hg between the measured compartment pressure and the diastolic pressure (delta p) has been shown to correlate closely with the need for fasciotomy (4). Since muscle damage occurs as early as 2 hours, prompt diagnosis and surgical intervention may prevent long-term functional disability. Displaced fractures in the proximal tibia are associated with an increased rate of compartment syndromes, since most of the lower legs muscle mass is located proximally (5). Because of the subcutaneous location of the tibia, open fractures are common and require timely operative débridement and irrigation (6). Sterile dressings and a long leg splint or knee immobilizer should be applied until an operating room becomes available. Both tetanus toxoid and a first-generation cephalosporin are indicated, with the addition of penicillin in grossly contaminated wounds to prevent a clostridial infection. When the soft tissues have absorbed a high amount of kinetic injury following fracture, microvascular damage and leg swelling rapidly occur. This often results in serious or hemorrhagic fracture blisters (7). Surgical intervention should proceed only after the soft tissues have recovered, heralded by the appearance of fine skin wrinkles as well as improved mobility of the skin over the deeper dermal layers. Surgical intervention prior to soft-tissue recovery has been associated with higher rates of wound complications and deep sepsis (8).

FIGURE 28.3 An angiogram demonstrating partial occlusion of the popliteal artery at the level of the knee with reconstitution of the tibioperoneal trunk distally. P.530

Imaging Studies Orthogonal anteroposterior (AP) and lateral radiographs are the basis for fracture characterization. High-quality x-rays should be obtained of the tibia-fibula as well as separate films centered over both the knee and ankle joints. The clarity of the image is greatly enhanced when the overlying splint material is removed. Traction radiographs can help elucidate fragment morphology, and the quality of reduction performed through indirect means; however, this maneuver is painful in the conscious patient. CT scans may detect the presence of an intra-articular fracture but give detailed information about fragment morphology. While the presence of concomitant injury to intra-articular soft-tissue structures (ACL, PCL) has been described in high-energy proximal tibia fracture variants, these are usually addressed on a delayed basis after fracture reduction and fixation. Exceptions are injuries to the cruciate or collateral ligaments with large bony avulsions. Magnetic resonance imaging scan may be helpful in some patients with rim avulsion fractures or fracture dislocations of the knee.

Surgical Timing In patients with displaced proximal tibial fractures and an acceptable soft-tissue envelope, definitive internal fixation within 24 to 48 hours is safe and effective. In patients with higher energy injuries with significant softtissue swelling and blistering are admitted for further evaluation and treatment. Immediate internal fixation in this group of patients is ill advised because of the risk of wound problems and deep sepsis. In these patients, if the fracture is not comminuted and length stable, a long leg splint or knee immobilizer can be used as temporary stabilization while waiting for soft-tissue recovery. When fine skin wrinkles return, soft-tissue swelling resolves, and the skin is mobile on the deeper structures, surgery can be performed. In many patients, this takes several weeks. On the other hand, in patients with fracture blisters or severe open wounds or the fracture is comminuted and unstable, application of a bridging external fixation is indicated. A spanning external fixator is used to maintain length and permit circumferential soft-tissue care.

Surgical Tactic The size of the proximal segment and the amount and location of fracture comminution influence the type of implant and the method of insertion. There are two internal fixation devices that can be utilized for definitive treatment of an extra-articular tibial fracture and include plate osteosynthesis or an intramedullary nail. There are advantages and disadvantages with each of these implants, and the use of one device over another varies among surgeons as there is little level I or II evidence supporting a specific technique. Intramedullary nailing of proximal tibial fractures is a technically difficult procedure (10). Standard tibial nailing often leads to a malreduction in valgus with an anterior apex. Semiextended or suprapatellar approaches have been used to improve fracture alignment but the impact of these techniques on the periarticular soft tissues and articular cartilage is not clear. The use of blocking screws has also been shown to minimize deformities with nailing proximal fractures. When using an intramedullary nail, modern implants that provide multiple proximal axial fixation options are important. In the past decade, anatomically designed periarticular plates have been developed specifically for the proximal tibia. These plates combine the use of conventional and locking screws with the ability for submuscular placement. The enlarged upper end of the plate allows multiple screws to be placed in the short proximal segment. The plate remains extra-articular minimizing a potential source of postoperative knee pain (Figs.28.4 and 28.5). Plate length should be determined before surgery as part of the preoperative plan. For fractures with significant comminution, long plates may be required, and these may not be part of the normal inventory. It is

important to use preoperative conventional or digital templating to ensure that the plate will achieve three to four bicortical points of fixation distal to the fracture.

SURGICAL TECHNIQUE Operating Room Setup Preoperative planning and proper operating room setup improve the surgical procedure. The patient is positioned supine on a fully radiolucent table. The fluoroscopy machine is placed on the side opposite of the injury. A bump is placed under the ipsilateral hip to internally rotate the knee to a neutral position, and a tourniquet P.531 is place on the thigh. The leg is prepped from tourniquet to toes (Fig. 28.6). Except for very simple fracture patterns, fluoroscopic images of the contralateral tibia are obtained and saved as these radiographs are important for verifying length and rotation on the injured side. In comminuted fracture patterns with metadiaphyseal extension or in cases with bone loss, we routinely drape both extremities into the surgical field to allow for intraoperative determination of limb length.

FIGURE 28.4 Some implants are contoured lower on the metaphyseal flare and are best suited for fractures with larger proximal segments.

FIGURE 28.5 Fracture implants designed to fit closer to the joint line are better for small proximal fracture segments, especially when there are articular fracture extensions.

FIGURE 28.6 The patient is placed supine with the leg draped free. The C-arm is placed on the opposite side of the table.

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Common Intraoperative Challenges Restoration of length and rotational reduction are challenging in comminuted fracture patterns. One simple technique is to position a cautery cord along the anatomic axis of noninjured tibia and to apply clamps at easily reproducible proximal and distal radiographic landmarks. The clamped cord segment is maintained on the sterile field until provisional reduction of the injured tibia is completed (Figs. 28.3B and 28.7A,B). The clamp and cord construct are then placed along the anatomic axis of the injured tibia and aligned against the previously utilized radiographic landmarks to determine correct restoration of length. The lateral radiograph is more accurate for determining length intraoperatively and eliminates differences related to the amount of knee flexion seen on the AP image. Lateral imaging is critical to accurately judge fracture reduction but is frequently obstructed by the uninjured leg with single leg draping. The use of an elevated platform below the injured extremity allows for unimpeded lateral imaging and allows the extremity to remain stable during provisional reduction attempts (Fig. 28.8A-C).

Anesthesia For acute fractures, general anesthesia is preferred to provide maximal muscle relaxation for fracture reduction and evaluate the postoperative neurovascular status. In the absence of other severe injuries, arterial lines and central venous pressure monitoring are not required. A cephalosporin antibiotic is administrated within 30 to 45 minutes of the skin incision and continued for 24 hours in closed fractures and longer in open injuries.

SURGICAL APPROACHES An anterolateral approach is utilized for plating of proximal tibia fractures. Gerdy's tubercle provides a reproducible and easily palpable landmark for the surgical incision; even in obese or large patients. A curvilinear incision of variable length is made just caudal to Gerdy's tubercle from a point just lateral to the patellar tendon curving proximally and posteriorly toward the tip of the fibular head (Fig. 28.9). Care should be taken to avoid developing superficial flaps as the subcutaneous tissue is typically thin in this region. The fascia is divided in line with the skin incision, and a full thickness flap is developed. The dissection should remain anterior to the fibular neck to avoid injury to the common peroneal nerve. The proximal fascial flap over Gerdy's tubercle can be delicate, and care must be taken to maintain its integrity to ensure that it is adequate to cover the head of the plate. Placement of several heavy sutures in each flap allows retraction during plate insertion and ultimately can be used for side-to-side fascial closure (Fig. 28.10). When an open reduction P.533 P.534 and internal fixation is planned, the anterior compartment muscles are then carefully elevated off the tibial condyle. With indirect reductions and submuscular plating, the insertion of the anterior tibialis muscle is lifted off the flare of the tibia. A submuscular path along the lateral surface of the tibia is created using a long blunt-tipped soft-tissue elevator.

FIGURE 28.7 A bovie cord is clamped along the anatomic axis of the tibia at reproducible points (A) and (B) to recreate the length based on the noninjured leg tibia.

FIGURE 28.8 Elevating the extremity on a radiolucent platform (A) allows for unimpeded AP (B) and lateral (C) imaging.

FIGURE 28.9 The skin incision is oblique and just below Gerdy's tubercle.

FIGURE 28.10 Placing heavy suture in fascial flaps keeps them from getting trapped under plate during passage and simplifies closure over head of plate.

FIGURE 28.11 Grade IIIB open proximal tibial fracture

Fracture Reduction The use of direct and indirect reduction techniques is determined by both the fracture level and the condition of the soft tissues. In high-energy injuries, the soft-tissue envelope can be severely compromised with deep contusion, degloving, and open wounds (Fig. 28.11) (9). Compared with extensile approaches required for articular reconstruction in tibial plateau fractures, the approach for submuscular plate placement for extraarticular fractures is less extensile. With very proximal fractures, direct reduction can be achieved using classic open techniques from within the surgical exposure (Fig. 28.10). Noncomminuted fracture patterns can often be reduced with large-pointed reduction clamps (Fig. 28.12A,B) and, when strategically placed, allow unimpeded access for lateral plating. Another reduction technique involves placing screws anteriorly in the proximal and distal fragments and then P.535 applying a pelvic reduction clamp to manipulate, reduce, and compress the fracture. In some patients, the fracture can be reduced closed and stabilized provisionally with multiple percutaneous 1.6 or 2.0 mm wires prior to definitive fixation (Fig. 28.13).

FIGURE 28.12 A,B. A standard pointed bone reduction clamp and be applied anteriorly to reduce the fracture.

FIGURE 28.13 Percutaneous smooth wires can be used to maintain the reduction during plate insertion. Comminuted fracture patterns are more safely treated with indirect reduction techniques (11). While kneespanning external fixation can provide some degree of reduction and restoration of length, sagittal plane displacement is rarely restored with longitudinal traction alone (Fig. 28.14). The leg is positioned in extension to decrease the deforming forces of the extensor mechanism. Under fluoroscopic control, a 5.0-mm external fixation pin is inserted perpendicular to the medial surface of the tibia (Fig. 28.15A,B). This “joystick” provides excellent sagittal plane control of the proximal fragment and easily corrects the apex anterior fracture P.536 deformity. An additional external fixation half pin is placed perpendicular to the first half pin from anterior to posterior in the proximal fragment to provide frontal plane reduction when necessary (Fig. 28.16A-C). These pins can then be connected to a pin placed distally in the shaft using pin to bar clamps in the standard external fixator set to maintain the reduction during fixation (Fig. 28.17).

FIGURE 28.14 Anterior knee spanning external fixation frames can sometimes maintain reduction during plate insertion.

FIGURE 28.15 A frontal plane half pin (A) can easily correct apex anterior deformity (B).

Fixation Simple fracture patterns are uncommon and are seen more commonly in younger patients. With anatomic reduction and stable internal fixation, uneventful healing usually occurs. Following direct or indirect reduction, the

plate is inserted on lateral side of the tibia, and its position is confirmed fluoroscopically. Temporary K-wire fixation is used to maintain plate position. A large linear or round periarticular clamp is used to compress the plate against the lateral surface of the proximal segment (Fig. 28.18). Alternatively, nonlocking or conical head screws can be placed into the plate to pull the plate against the bone. These can later be exchanged for locking screws if necessary. Once several points of proximal fixation are placed, noncomminuted fractures should be compressed with an articulated tension device or a “push-pull screw” (Fig. 28.19A,B). In the shaft, three or four bicortical screws are necessary. In patients with good bone quality, conventional cortical screws are appropriate. In osteoporotic bone, locking screws may be helpful. Short plates are typically used with simple fracture patterns in patients with good bone quality. However, in patients with poor bone quality, substantially longer plates are necessary to reduce the risk of frontal plane pullout on the shaft screws. In patients with higher energy injuries with soft-tissue compromise and comminuted fracture patterns, minimally invasive submuscular bridge plating is recommended. Most current plate designs include an outrigger for guided shaft screw insertion. The sequence of screw placements in a plate depends on the fracture pattern. For comminuted fracture patterns, an indirect reduction technique is typically utilized to maintain an optimal biologic environment for healing. Plate length should be two to three times the length of the zone of comminution. Following indirect reduction, the plate is passed submuscularly beneath the anterior compartment. Fluoroscopic imaging is utilized in the AP and lateral planes to ensure proper plate position and maintenance of reduction. Correct positioning is important to avoid lateral prominence at Gerdy's tubercle. Most contoured anatomic plates fit the proximal lateral tibial surface well. Once the plate is properly positioned, provisional K-wires are placed through the plate proximal and distally to maintain its position. A periarticular clamp or nonlocking screws are utilized to compress the proximal part of the plate firmly against the bone. Often, the fracture may angulate into a slight valgus deformity or translate away from the plate. This deformity is corrected with placement of a long nonlocking cortical screw or a specialized pull reduction tool (whirley-bird) to reduce the shaft segment back to the plate. A distal cortical screw is placed at the end of the plate to ensure provisional fracture stability. At this point, AP and lateral radiographs are obtained using fluoroscopy or with a portable plain radiograph to verify the reduction. If the reduction is adequate, additional locking screws are placed into the proximal fragment and conventional or locking screws distally. For long-bridging fixation constructs, three to four well-spaced bicortical screws are necessary (Fig. 28.20A-F). P.537

FIGURE 28.16 A medial half pin (A) can control varus and valgus position (B) and (C) of the proximal fracture fragment.

FIGURE 28.17 Half pins used for reduction can be connected to a temporary fixation frame.

FIGURE 28.18 A large periarticular or linear clamp is used to compress the head of the plate to the bone. P.538

FIGURE 28.19 A,B. External tensioning devices can be used to compress simple fracture patterns. Another method of indirect reduction is using a push/pull technique. The plate is inserted submuscularly and fixed to the proximal fragment as described previously. One or two nonlocking screws are placed in the head of the plate to hold its position but allow for manipulation in the frontal plane. Length is restored using manual longitudinal traction. Distally, the plate is aligned with the shaft of the tibia through a 4- to 8-cm open incision that exposes the most distal part of the plate. K-wires or a reduction clamp can be used to maintain the sagittal plane

position. An articulated tensioning device or “push-pull screw” inserted distal to the plate is used to restore correct length. Radiographic verification of alignment is then performed. A 5.0-mm medial Schanz pin allows for some frontal plane manipulation and deformity correction. Once the reduction has been achieved, locking screws can be placed proximally and distally to maintain the alignment.

POSTOPERATIVE MANAGEMENT The incisions are closed in layers, and a posterior splint is used to maintain the foot in neutral dorsiflexion for a few days. Weight bearing is based on bone quality and fracture configuration. In patients with good bone quality and very stable fixation, partial weight bearing is allowed during the first 6 weeks following surgery and is then progressed. In patients with long bridging constructs and limited bony contact must remain non-weight bearing for 6 to 12 weeks. Weight bearing is progressed based on clinical examination and signs of radiographic healing. Early active and passive range of knee motion is started on the first or second postoperative under the direction of a physical therapist. While there is little evidence that continuous passive motion machines have long-lasting benefit, selected patients with head injuries or multiple trauma may benefit from its use. Patients are seen in the clinic at 2 weeks and their sutures removed. Clinical and radiographic follow-up is done at 4, 8, and 12 weeks. Patients with complex fracture patterns are followed until there is complete fracture healing, which can take up to a year. P.539

FIGURE 28.20 A high-energy proximal tibia fracture (A,B) is initially spanned (C). Indirect reduction is performed with longitudinal traction (D) and then medial half pin to correct residual varus (E). Final construct is long plate with multiple bicortical shaft screws (F). P.540

FIGURE 28.20 (Continued)

COMPLICATIONS As with every surgical procedure, complications may occur following operative intervention. Common complications include infection, delayed union or nonunion, and hardware prominence. Superficial and deep sepsis may be difficult to differentiate clinically. The question is whether the hardware and fracture site are involved. Acute superficial infections may be treated with local wound care and antibiotics for 2 weeks. Close clinical monitoring is imperative to ensure that the pharmacologic intervention is effective. Deep infections require operative irrigation and débridement, with deep microbial cultures and appropriate intravenous antibiotics. If the hardware is stable, it should be retained. If the hardware is loose, it should be removed. Screws without torsional resistance when tightened should be removed. Vancomycin- and tobramycin-impregnated methylmethacrylate beads can be effective to obliterate dead space and provide high local antibiotic concentration when bone has been resected. Long-term systemic antibiotics are tailored based on intraoperative cultures. The erythrocyte sedimentation rate, C-reactive protein, and white blood cell counts are used to follow the response to treatment. Once the antibiotic course is complete and the serologic parameters have returned to normal revision, internal fixation may be indicated. Knee arthrofibrosis is another common complication following treatment proximal tibia fractures. This complication can be usually avoided by early supervised range of knee motion. If physical therapy fails to improve knee motion, a manipulation under anesthesia with or without arthroscopy should be performed. A small number of patients with persistent stiffness may benefit from a quadricepsplasty. Loss of fracture reduction is uncommon with good surgical techniques. If it occurs in the early postoperative period, the original fracture construct may have been inadequate. A history of noncompliance with the weight-bearing precautions may also be a contributing factor. Infection should always be considered as a causative factor and treated accordingly. A CT evaluation may aid in preoperative planning and help determine the feasibility of revision fixation. Other modalities such as intramedullary fixation, fine-wire

fixation, or even cast treatment should be considered. P.541 Fracture malunion occurs along a wide spectrum. Minor degree of malalignment may be clinically acceptable to the patient and require no further care. Symptomatic malunions often require operative correction. Corrective osteotomies along the original fracture line will correct simple malunions. More complex deformities are often associated with limb shortening and soft-tissue contractures. In these cases, a circular fine wire distraction frame may be required for correction. Fracture nonunion can occur due to infection, insufficient fracture stability, or a biologically deficient fracture environment. A fracture construct that is too flexible and allows too much fracture motion usually results in a hypertrophic nonunion. Treatment involves improving the stability of the fracture by revision internal fixation. When the construct is too stiff, an atrophic nonunion with resorption at the fracture site may occur. These are best treated by compression of the nonunion, stable internal fixation, and autogenous bone grafts.

OUTCOMES A recent metaanalysis of outcomes following surgical treatment of extra-articular proximal tibia fractures has an estimated complication rate between 8% and 23% (12). These authors recommended cautious interpretation of these heterogeneous results. The majority of studies included were retrospective case series with relatively small number of patients. The estimated rate of malunion has been reported to be as high as 10% (11, 12, 13 and 14). Similarly, the rate of nonunion has been cited to be 0.3% to 8% (12). Three publications on the use of locked plates for proximal tibia fractures reported two nonunions in a total of 154 patients (11,13,14). Both of these nonunions occurred in high-energy open fractures, but their precise fracture pattern is unknown (articular vs. nonarticular pattern). Injury to the superficial peroneal nerve has been documented with lateral plating of proximal tibial fractures with long plates. The superficial peroneal nerve exits the crural fascia approximately 12.5 cm proximal to the ankle joint. Screws inserted percutaneously in the distal leg may injure the superficial peroneal nerve at this location. For the less invasive stabilization system plate (Synthes, Paoli, PA), screws inserted in the distal portion of 13-hole plates are particularly prone to nerve injury. For patients of short stature, the nine-hole plate has also been associated with this complication (15). To avoid iatrogenic nerve injury, it is recommended that distal screws are inserted with a formal open incision, directly visualizing the recipient screw hole as the screw in inserted. Hardware prominence is a frequent cause of reoperation. This is particularly relevant for locking plates, where construct stability is not reliant upon an intimate plate bone interface. The added thickness of the proximal section of locking proximal tibial plates has the potential for iliotibial band irritation. Plate-induced irritation is particularly bothersome with knee flexion (11,13,16, 17 and 18). Implant removal rates between 5% and 8% have been reported (13,16,19). By way of comparison, intramedullary devices used for treatment of proximal tibia fractures had a 30% reduction in the rate of hardware removal compared with lateral locked implants (19). Numerous reports have documented the difficulty of locked plate removal, especially with titanium implants (18). Although the implants are inserted percutaneously, it is often impossible to remove the plate in a similar fashion because of cold welding or stripping of the screws, which significantly increased operative time for removal (18,20,21). If the screws cannot be removed, then a highspeed carbide-tipped burr may be used to cut the plate around the stripped screws, which in turn may be removed with pliers. Metal debris generated during this process adheres intimately with the soft tissues and should be carefully removed at the conclusion of the procedure.

Unfortunately, outcomes data following locked plating of extra-articular fractures of the proximal tibia is embedded within studies that include both intra-articular and extra-articular fractures. Taken together, postoperative range of knee motion averaged 122 degrees (11,13,14). In one study, the average Lysholm knee score was 90 (range, 53 to 100). Poor outcomes were associated with ligamentous instability (11). The average lower extremity measure score was 88 (range, 55 to 100), indicating that patients were community ambulator's or better. Low scores were attributed to worker's compensation claims (14).

REFERENCES 1. Sarmiento A. A functional below-the-knee brace for tibial fractures. A report on its use in one hundred thirty-five cases. J Bone Joint Surg Am 1970;52(2):295-311. 2. Barei DP, et al. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004;18(10):649-657. 3. Mills WJ, Barei DP, Mcnair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004;56(6):1261-1265. 4. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br 1996;78(1):99-104. 5. Halpern AA, Nagel DA. Anterior compartment pressures in patients with tibial fractures. J Trauma 1980;20(9):786-790. 6. Burgess AR, et al. Pedestrian tibial injuries. J Trauma 1987;27(6):596-601. 7. Strauss EJ, et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma 2006;20(9):618-622. 8. Sirkin M, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13(2):78-84. P.542 9. Egol KA, et al. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 2005;19(7):448-455; discussion 456. 10. Nork SE, et al. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma 2006;20(8):523-528. 11. Stannard JP, et al. The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: shortterm results. J Orthop Trauma 2004;18(8):552-558. 12. Bhandari M, et al. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma 2003;17(8):591-595.

13. Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004;18(8):528-535. 14. Ricci WM, Rudzki JR, Borrelli J. Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system. J Orthop Trauma 2004;18(8):521-527. 15. Deangelis JP, Deangelis NA, Anderson R. Anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the less invasive stabilization system. J Orthop Trauma 2004;18(8):536-539. 16. Boldin C, et al. Three-year results of proximal tibia fractures treated with the LISS. Clin Orthop Relat Res 2006;445: 222-229. 17. Phisitkul P, et al. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 2007;21(2):83-91. 18. Suzuki T, et al. Technical problems and complications in the removal of the less invasive stabilization system. J Orthop Trauma 2010;24(6):369-373. 19. Lindvall E, et al. Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases. J Orthop Trauma 2009;23(7):485-492. 20. Georgiadis GM, et al. Removal of the less invasive stabilization system. J Orthop Trauma 2004;18(8):562-564. 21. Pattison G, Reynolds J, Hardy J. Salvaging a stripped drive connection when removing screws. Injury 1999;30(1):74-75.

29 Tibial Shaft Fractures: Intramedullary Nailing Daniel S. Horwitz Erik Noble Kubiak

INTRODUCTION Tibial shaft fractures encompass a spectrum of injuries ranging from low-energy closed fractures to limbthreatening open fractures. Intramedullary nailing is the treatment of choice for most displaced fractures in the middle three-fifths of the tibia. Contemporary tibial nailing is performed with minimal medullary reaming using cannulated locking nails for both closed and open fractures. Recent prospective studies have shown that reaming is not associated with a statistically significant increase in infection rates for most open fractures (1, 2 and 3). Solid nails have largely been abandoned due to their inability to reduce the infection rate and difficulty with insertion and removal. The favorable mechanical and biologic characteristics of intramedullary nails as well as advances in nail design have expanded the indications for nailing to include more proximal and distal tibial fractures. However, nailing of proximal tibial fractures with conventional entry portals often leads to angular deformities. To minimize malalignment following nailing, both a change in the approach (infrapatellar vs. suprapatellar) and the position of the leg (flexed or extended) is required. Another recent technical advance in nailing is the introduction of angular stable locking bolts or screws. This may improve stability following nailing in very proximal or distal fractures, particularly in osteoporotic bone. There are several widely used classifications for tibial fractures. The Gustillo and Andersen, as well as the Tscherne classifications, are used to describe soft-tissue injury patterns associated with both closed and open tibial fractures. The AO/OTA fracture classification of tibia fractures is a morphologic or geometric tool to describe the location and pattern of bony injury (Fig. 29.1).

INDICATIONS AND CONTRAINDICATIONS Numerous studies have shown satisfactory rates of healing and earlier weight bearing compared to other fixation techniques when using an intramedullary nail. However, the advantages with this method of treatment must be carefully weighed against the risks unique to tibial nailing such as chronic knee pain and infection. Contraindications to nailing include patients who have isolated low-energy fractures with minimal shortening, displacement, or angulation that can be treated in a cast. Sarmiento and others have shown that shortening up to 12 mm and angulation up to 5 degrees in the frontal plane and 7 degrees in the sagittal plane are associated with good outcomes following functional bracing (4,5). Nonoperative treatment of high-energy fractures with substantial shortening, displacement, and angulation, particularly when there is associated soft-tissue injury, makes cast or brace treatment inadvisable. Nailing is also contraindicated in young adolescents with open epiphysis and in adults with very small medullary canals (2 to 3 cm.

FIGURE 32.66 Oblique fractures without fixation can shorten but tend to displace (yellow). A lateral malleolus with comminution may shorten with less displacement. If the plafond is comminuted and mild shortening can be accepted, then oblique lateral malleolus fractures will need to have a section removed to allow shortening without fibular malalignment.

FIGURE 32.67 Acute shortening is accepted in patients who are not candidates for lengthening. An elevated shoe is prescribed. A proximal corticotomy with lengthening is used to regain length in patients who are physiologically capable of bone transport. P.668

FIGURE 32.68 A. Type A distal tibia fracture with intact joint but segmental loss of the distal tibia. B. Débridement results in a substantial segmental bone defect. The shaft is cut square with at least 75% of the bone cross section exposed. Distally, the metaphysis is cut square. Posterior lateral bone spikes are left in place to improve docking site union. The green fragments represent the removal of intact bone to facilitate the docking of the reconstruction. The foot is controlled with a foot extension until the soft tissues have healed, and the patient can place partial weight on the extremity. C. The transport is completed to docking. A revision bone graft may be needed to heal the docking site. The foot plate is removed to allow ankle and hind foot motion as the leg becomes more stable.

Technical Sequence for C3 Pilon Fractures 1. The stable proximal base is applied to the tibia with two AP half-pins on universal mounting cubes. The base must be orthogonal. 2. A horizontal reference wire is placed in the calcaneus. The hind foot is aligned on the foot plate to center the dome of the talus with the axis of the tibia on AP and lateral fluoroscopic images. 3. The fracture is distracted. If the fracture can be brought out to length, the fibula is fixed with a plate or pin. When shortening of the comminuted metaphysis will be used to facilitate healing, the fibula is not fixed. 4. Distraction may produce anatomic alignment of the joint surface. Percutaneous screws and pins are placed to stabilize the joint. Percutaneous screws are also used to align large proximal metaphyseal and shaft fragments. 5. If distraction does not produce an acceptable reduction, the fracture is approached through the anteriormedial or anterior-lateral interval (Fig. 32.9). The joint fragments are reduced and fixed with small screws, wires, and small or minifragment plates. Bone graft is used to support the reconstructed articular surface. 6. The carbon fiber fracture ring is placed over the metaphysis, and at least three opposed divergent olive wires are placed. An opposed olive wire is added to the foot fixation. 7. Olive wires are not placed in the metaphysis in two fracture patterns: (a) The comminution is so severe that there are literally no fragments large enough for fixation or (b) the technique of bridging distraction with limited internal fixation will be accepted as the definitive fixation technique. In this circumstance, a second opposed olive wire in the calcaneus and a medial to lateral talar neck wire are added to the foot plate. 8. An additional medial half-pin is added to the proximal tibial stable base. 9. A bulky compressive dressing is placed around the ankle. On rare occasions, a severe open pilon fracture with comminution and osteoarticular bone loss occurs. Salvage arthrodesis is a possible alternative to a below-knee amputation (Figs. 32.69, 32.70, 32.71). If the fracture has 3 cm, a delayed shortening (2 to 4 mm a day) is indicated, or an intercalary bone transport is applied maintaining the leg to length. A proximal lengthening is combined with shortening in patients physiologically and mentally capable of a bone transport. For larger defects involving loss of the plafond, an intercalary bone transport is P.669 used to reconstruct the defect. The proximal fixation block is a five-eighth full-ring block (Fig. 32.72). Rods connect to the foot fixation block with opposed olive wires in the talus. The midtibia transport ring has two AP half-pins and a medial pin. The transport is lengthened 0.5 mm a day. Docking site revision is recommended for transports more than 3 or 4 cm in length. Hind foot motion will be lost or severely restricted with this technique. The patients have some forefoot circular motion and use a soft rubber rocker bottom shoe.

FIGURE 32.69 A C3.1 pilon fracture or trimalleolar fracture with open dislocation, fragment ejection, and gross contamination was not reconstructible. The joint fragments were discarded, and a horizontal osteotomy of the metaphysis and dome of the talus was created for arthrodesis of the joint.

POSTOPERATIVE CARE Depending on the frame configuration, active-assisted range of motion of the ankle and hindfoot or/and forefoot and toe therapy is started. The patients are encouraged to place partial weight on the leg using a sandal and increase weight as tolerated. Patients should be placing 50% weight by the sixth week, and some will be full weight before frame removal. If the patient had bridging distraction with wire fixation through the plafond/metaphysis, the foot plate and calcaneal wires are removed in clinic 4 to 6 weeks after surgery. If the patient had bridging distraction without wire fixation, the frame has to be maintained for at least 4 to 6 months. Maintenance of the pin/wire interface with the skin is essential to reduce inflammation and subsequent pin/wire infections. Once the surgical wounds are healed, the leg is washed in the shower with soap, removing all blood and secretions where the pin/wire enters the skin. Skin that is tenting over wires is released with local anesthesia. Gauze sponges are applied over wires that develop inflammation. Oral antibiotics are prescribed if inflammation worsens. Frame removal is indicated when callus has bridged the multiple fragments, and the patient can place 50% or more weight on the extremity. If the patient is not bearing weight at 3 to 4 months, the fracture is not united. Average frame time is 4 to 6 months for pilon fractures (Fig. 32.73). Outpatient frame removal with sedation or a light general anesthesia is recommended. The ankle is casted for 2 weeks, and the patient is encouraged to bear full weight in the cast. The cast is removed in the office, and a hinged ankle orthosis is placed, which the patient uses until mature callus is observed at the fracture site. Physical therapy continues for an additional 6 months if funds are available. The functional result at 1 year postinjury will be the extent of recovery. The patients rarely recover function comparable to their preinjury function (2).

COMPLICATIONS Rarely, a patient will have purulent drainage and require wire removal and intravenous antibiotics. Deep infection when using circular fixators for pilon fractures is uncommon, but does occur. This requires irrigation and débridement and culture-specific antibiotics. In some patients, there is a dead bone fragment that requires removal. Deep vein thrombosis (DVT) occurs infrequently. Rapid swelling in the frame indicates the possibility of a venous obstruction, and swelling of the lower leg and thigh is often a deep clot. Anticoagulation is required when a DVT has been diagnosed. P.670

FIGURE 32.70 The limb can be salvaged with acute shortening and compression arthrodesis. Proximal lengthening is offered to appropriate patients to equalize length. The foot frame for smaller extremities is a single ring using a post to place two talar body wires. For larger ankles, a double foot plate separated by 3cm hexagonal sockets provides improved frame stiffness. Five to 7 cm of the fibula is excised to improve compression of the arthrodesis and prevent lateral impingement. P.671

FIGURE 32.71 Intercalary proximal to distal transport for arthrodesis. The proximal fixation block is a fiveeighth full ring. The midtibia transport ring has two AP half-pins and a medial half-pin. The foot fixation has two opposed olive wires in the calcaneus and two opposed olive wires in the talus.

FIGURE 32.72 The five-eighth full-ring block has a horizontal reference wire and a smooth wire placed from

the fibula head to the anterior-medial tibia on the proximal five-eighth ring. The full ring has a medial olive wire and an AP half-pin. P.672

FIGURE 32.73 Frame removal time on 98 cases of distal tibia Type A and C fractures treated by the author. Most fractures heal between 3 and 6 months. More complex fractures may need additional reconstructive procedures and require many more months in the fixator. A local bone graft is indicated if there is no callus formation after 3 to 4 months. Autograft is indicated because an osteoinductive response is necessary to promote healing. The patients rarely recover function comparable to their preinjury function (2). Nonunion is an infrequent complication that can be treated by several methods (7).

REFERENCES 1. Watson JT, Moed BR, Karges DE, et al. Pilon fracture treatment protocol based on severity of soft tissue injury. Clin Orthop 2000;375:78-90. 2. Pollak AN, McCarthy ML, Shay BR, et al. Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg [Am] 2003;85A:1893-1900. 3. Vora AM, Haddad SL, Kadakia A, et al. Extracapsular placement of distal tibia transfixation wires. J Bone Joint Surg [Am] 2004;86A:988-993. 4. De Coster TA, Stevens MS, Robinson B. Safe extracapsular placement of proximal and distal tibial external fixation pins. Annual meeting of Ortho. Trauma Assoc Poster #68:247-248, 1997. 5. Watson JT. Tibial pilon fractures. Tech Ortho 1996;11:150-159. 6. Hutson JJ, Dayicioglu D, Oltjen JC, et al. Treatment of Gustillo GIIIB tibia fractures with application of antibiotic spacer, flap and sequential Ilizarov distraction osteogenesis. Ann Plast Surg 2010;64(5):541-552. 7. Hutsson JJ. Salvage pilon fracture nonunion and infection with circular tensioned wire fixation. Foot Ankle Clin N Am 2008;13:29-68.

RECOMMENDED READING

Hutson JJ. Applications of Ilizarov fixators to fractures of the tibia: a practical guide. Tech Orthop 2002;17:1111. An extensively illustrated monograph which will give the reader a basic understanding of Ilizarov technique to treat tibia fractures. Recommended as a starting point for surgeons who would like to incorporate Ilizarov technique into their trauma practice. Murat B, Durmus AO, Mahmut U, et al. Tibial pilon fracture repair using Ilizarov external fixation, capsuloligamentotaxis and early rehabilitation of the ankle. J Foot Ankle Surg 2008;47(4):302-306. Papadokostakis G, Kontakis G, Giannoudis P, et al. External fixation devices in the treatment of fractures of the tibial plafond. J Bone Joint Surg [Br] 2008;90B:1-6. Seybold D, Gebman J, Ozokysy L, et al. Custom made Ilizarov ring fixator for fracture care in morbidly obese patients. Langenbecks Arch Surg 2009;394:393-398.

33 Ankle Fractures Rena L. Stewart Jason A. Lowe

INTRODUCTION Ankle fractures are among the most common musculoskeletal injuries. These injuries span a spectrum from simple closed fractures to complex open injuries. As a result, the orthopedic management is varied and can range from nonoperative casting to staged surgery with a primary focus on damage control procedures followed by definitive fixation. Treatment of ankle fractures is also dictated by patient-related factors. The presence of diabetes and a growing population of geriatric patients, with osteoporotic, increase the complexity of ankle fracture management. These fractures typically result from a low-energy rotational force to the tibia about a planted foot but can also present as a more complex, high-energy injury. The AO/Danis-Weber and Lauge-Hansen (Fig. 33.1) systems are the most commonly used classifications to describe ankle fractures. The AO/Danis-Weber classification is an anatomic system based upon the location of the fracture with regard to the tibiotalar joint (Weber A—below the joint; Weber B—at the joint; Weber C—above the joint). Lauge-Hansen described four ankle injury patterns based upon the mechanism of injury (Fig. 33.1). These patterns are determined by the foot’s position (supination or pronation) at the time of fracture and the direction of applied force (external rotation, adduction, and abduction). Injury to the supinated foot begins anterior-lateral and moves around the osteoligamentous structures (posterior then medial) as the force vector continues. If the foot is externally rotated from a supinated position, supinationexternal rotation (SER), the anterior, inferior tibiofibular ligament (stage I) is the first structure to fail. With continued external rotation, a classic fibula fracture (stage II) occurs. Fibula fractures resulting from an SER injury will have a spiral pattern that moves from anterior-interior to posterior-superior. The long posterior-superior spike of the distal fragment is a hallmark of SER injuries. Continued external rotation results in disruption of the posterior-inferior tibiofibular ligament or fracture of the posterior malleolus (stage III). The most severe SER, stage IV, injury pattern occurs as the rotational force tears through the deltoid ligament or fractures the medial malleolus (typically a transverse fracture). Adduction of the supinated foot will lead to disruption of the lateral collateral ligaments or a tension (transverse) fracture of the distal fibula. As more force is directed medial to the supinated foot, the medial malleolus will fracture. An important distinction of this injury pattern is that the medial column fracture is typically associated with articular impaction of the tibial plafond. In contrast to supination fractures, injuries to the pronated foot begin at the medial malleolus/deltoid ligament to the anterior-inferior tibiafibula ligament before exiting laterally. Pronation-external rotation injuries are classically observed with a high (suprasyndesmotic) fibula fracture, while pronation-abduction fractures are associated with comminution of the fibula. Questions over the reproducibility and reliability of the Launge-Hansen schema have been raised; however, it remains a useful classification when correlating the mechanism or injury and radiographs following ankle injuries (1).

INDICATIONS AND CONTRAINDICATIONS Making a decision to treat ankle fractures operatively or nonoperatively depends largely upon the fracture personality: open versus closed, stable versus unstable, displaced versus nondisplaced, and the presence or absence of articular impaction. Many of these injuries, such as isolated closed lateral or medial malleolar

fractures, can be successfully treated nonoperatively (2,3). Fibula fractures with displacement of 2 mm or less, without ankle instability, can be managed conservatively in a walking cast or boot. Similarly, medial malleolar fractures with P.674 up to 5 mm of displacement, with no mortise instability, or articular impaction can be successfully treated with cast immobilization and regular radiographic follow-up (Fig. 33.2) (2). Nonoperative treatment is also recommended for patients whose medical condition precludes operative intervention. Operative management is recommended for open fractures and unstable fractures patterns, which include bimalleolar, bimalleolar equivalent (fibula fracture with deltoid ligament disruption), and trimalleolar fractures (3,4).

FIGURE 33.1 The Danis-Weber (AO/ASIF) classification system is based on the level of the fibula fracture. The Lauge-Hansen system is based on experimentally verified injury mechanisms. Type A Danis-Weber injuries are usually Lauge-Hansen supination-adduction injuries. Type B can be either supination-external rotation or pronation-abduction injuries. Type C injuries are usually pronation-external rotation injuries. Determination of ankle stability is crucial during the initial evaluation and assessment of the fracture. If

unrecognized, ankle instability may alter the joint contact pressure and can result in abnormal loading of the articular cartilage. Such changes can lead to posttraumatic osteoarthritis of the ankle joint (5, 6, 7 and 8). Since physical exam findings including medial tenderness, with or without swelling and ecchymosis, do not consistently correlate with disruption of the deep deltoid ligament, radiographic landmarks identified on high-quality anteriorposterior (AP), mortise, and lateral radiographs are employed when determining ankle stability (discussed below). P.675

FIGURE 33.2 A mortise radiograph of the left ankle with a nondisplaced medial malleolar ankle fracture, where nonoperative treatment would be indicated.

PREOPERATIVE EVALUATION AND PLANNING Good preoperative planning is essential for successful outcomes in all ankle fractures and begins with a thorough history and physical exam. Medical comorbidities such as diabetes, obesity, and osteoporosis negatively affect the patient’s functional outcome. Recognizing these illnesses in the preoperative period allows modification of the operative plan (fixation scheme), rehabilitation protocol, and optimization of the medical disease in the perioperative period. A complete neurovascular physical exam of ankle fracture patients, particularly the medically ill and polytraumatized patient, is required. We routinely do not evaluate ankle range of motion in patients with known unstable fracture; however, we routinely assess for the presence of palpable pulses and intact motor function of

the ankle and toes. Additionally, peripheral nerves are evaluated for light touch sensation. In diabetic patients, protective sensation is assessed with a 5.07 Semmes Weinstein monofilament. The location and condition of preinjury chronic wounds or acute soft-tissue injury, including ecchymosis, fracture blisters, lacerations, and abrasions, are documented. An ankle fracture is assessed for stability using anatomic landmarks identified on radiographs. A clear symmetric joint line along the medial, lateral, and superior joint should be observed. Disruption of the syndesmosis is a marker of instability and can be observed on the AP or mortise radiograph by assessing the tibia-fibula overlap. The distance between the medial fibular cortex and the fibular incisura should be 1 mm on a mortise view and 6 mm on a true AP radiograph. Disruption of the syndesmosis will increase the clear space between the fibula and incisura as well as decrease the tibia-fibula overlap either of which is a sign of instability. Another radiographic indication of instability is disruption of the deep deltoid ligament, which can be assessed on the ankle mortise view. Disruption of the deltoid is appreciated when there is asymmetry of the joint, talar tilt, or translation. The space between the medial malleolus and talar dome (medial clear space) should measure 4 mm indicates disruption of the deltoid ligament or a bimalleolar equivalent fracture. Ankle instability, however, may not be readily visualized on injury radiographs. SER injuries in particular do not immediately reveal the full extent of the injury. In “apparent isolated” SER II fibular fractures, 38% to 65% of fractures may also have disruption of the deltoid ligament (SER IV) (4,9). While a true SER II injury is stable and can be treated nonoperatively, an SER IV injury represents an unstable fracture pattern and internal P.676 fixation is recommended. The dynamic instability present in these injuries can be better appreciated following an external rotation stress radiograph (manual stress or gravity stress) (9, 10 and 11). During the stress test, it is important that the foot be in either neutral or slight dorsiflexion so as to not falsely reduce the radiographic medial clear space (12). Alternatively, a magnetic resonance imaging (MRI) can also show an occult deltoid ligament injury (1,13). The cost difference between a MRI and stress radiograph is substantial, and the authors do not recommend routine use of an MRI to determine injury to the medial deltoid complex.

FIGURE 33.3 Radiographic projection of fibula on tibia in standard AP radiograph. When measured 1 cm proximal to the ankle joint, the distance between the medial border of the fibula and the incisura should be 6 mm or more than 42% of the fibular width; however, individual variation and beam angle may affect individual measurements. There should be more than 1 mm of overlap of the tibia and fibula on any view. Contralateral films should be obtained when comminution of the fibula is present. These images aid in restoring the correct fibular length and rotation thereby avoiding a malreduction. A CT scan is recommended if articular impaction is present, or further delineation of the posterior malleolar fragment is needed (14). Open wounds should be irrigated at the bedside but will need emergent, formal I & D in the operating room. Initially, the fractures should be reduced and splinted. The majority of rotational ankle fractures are adequately reduced with longitudinal traction and rotation opposite the deforming force. A well-padded, posterior and “U” splint with the ankle in neutral dorsiflexion reduces pain and provides fracture immobilization. An adequate splint combined with judicious elevation and cryotherapy helps reduce swelling. The immediate application of a circumferential cast should be avoided. Even if nonoperative therapy is indicated, ongoing swelling can result in dangerous constriction and may exacerbate the soft-tissue injury. While most ankle fractures requiring surgery can be treated within the first 24 hours, they do not constitute a surgical emergency. It is our practice that the isolated, closed, reduced, and splinted ankle fractures are sent home with an office appointment and subsequent surgery within 5 to 7 days. In contrast, patients with significant medical comorbidities, polytraumatized patients, or those with an emergent surgical indication (open/irreducible fracture) are admitted and have definitive operative treatment as soon as their medical condition and soft-tissue envelope allow. It is important to ensure that the soft tissues will safely permit surgical intervention. Implementation of a staged, “damage control” protocol is indicated when the soft-tissue envelope precludes early operative intervention (Fig. 33.4) or when a reduction cannot be maintained in a splint. We recommend application of a spanning external fixator in patients with fracture blisters at the incision sites, open contaminated or degloving injuries that require

multiple débridements and soft-tissue coverage, or soft-tissue swelling that is preclusive of subsequent wound closure. The external fixator stabilizes the fracture while allowing for management of soft-tissue wounds and facilitates patient mobility. Definitive fracture fixation surgery is delayed until there is P.677 resolution of soft-tissue trauma. This is commonly judged by epithelization of fracture blisters and the presence of wrinkles on the dorsum of the foot when in neutral dorsiflexion (wrinkle sign).

FIGURE 33.4 Clinical photographs of two ankles. (A) Trimalleolar fracture with blisters over the lateral malleolus. (B) Bimalleolar fracture dislocation with abrasions over the medial malleolus. We believe that many ankle fractures are regarded as “simple” fractures, and a lack of preparation can lead to unnecessary errors or poor outcomes. A clear understanding of the patient’s condition and fracture morphology is necessary for selection of correct patient positioning and operative approach.

SURGERY Patient Positioning Patients are most commonly positioned supine, and a general or regional anesthetic technique is utilized. A towel roll placed beneath the ipsilateral hip allows the leg to lie in neutral rotation (Fig. 33.5). A pneumatic tourniquet is applied to the upper thigh. The leg is shaved and prepped, and a sterile sheet is placed beneath the leg to prevent inadvertent contamination of surgical gowns during draping. The leg is sterilely draped free, and the toes are sealed with a plastic adhesive drape. Prone positioning may be indicated for selected trimalleolar ankle fractures with a large, displaced posterior malleolar fracture or posterior articular impaction. With chest rolls positioned from the shoulders to the anterior superior iliac spines, care is taken to place the arms in a tension-free (90/90) position. Next, the anterior knees are padded with a foam/gel pad and the legs placed in a tension-free position with the knees slightly bent. From this position, the posterior malleolus and fibula may be fixed through a posterior-lateral approach (Fig. 33.6). Reduction and instrumentation of the medial malleolus in the prone position may be more easily performed with the knee flexed. In closed fractures, a first-generation cephalosporin is used unless there is an allergic contraindication, in which case an alternative antibiotic is chosen. In type II or III open fractures, an aminoglycoside is added to the preoperative antibiotic regimen.

FIGURE 33.5 Clinical photograph of right leg on a radiolucent ramp with the leg resting in neutral rotation (patella facing the ceiling) after placement of a hip bump. P.678

FIGURE 33.6 Clinical photograph of a left trimalleolar ankle fracture positioned prone. Tibia is padded with blankets that both flex the knee and elevate the ankle for lateral imaging.

Technique Bony landmarks (medial/lateral malleoli and joint line) are localized and identified with a surgical marking pen. The location of the fracture can also be marked based on palpation or, if needed, fluoroscopic imaging. Surgery can be performed with or without a tourniquet. Meticulous homeostasis during the surgical approach should be obtained and typically obviates the need for a tourniquet. In bimalleolar ankle fractures, it is the author’s preference to fix the fibula first.

MEDIAL MALLEOLAR FIXATION Our preferred medial approach is a straight incision just anterior to the midsagittal axis of the tibia (Fig. 33.7). This incision allows inspection of distal medial tibia and the talar dome, while facilitating instrumentation of the fracture. Some may favor a curved “J” incision for better access to the ankle joint. Care must be exercised when placing the distal extent of this incision so as to not preclude access to the medial malleolus for instrumentation. As with all approaches to the medial ankle, the saphenous vein and nerve should be preserved and protected

from inadvertent injury. Adequate exposure is required to ensure an anatomic reduction. Because of the fracture orientation, anterior or posterior malreductions may not always be appreciated when inspecting the medial cortical surface. We therefore recommend exposure of the anterior articular aspect of the medial malleolus (the shoulder or axilla), which aids in assessing the reduction. In addition, visualization of the anterior malleolus will facilitate inspection of the joint surfaces. As small osteochondral abrasions or defects are not uncommon, distal retraction of the fragment allows irrigation, débridement, and inspection of the joint (Fig. 33.8). Minimal dissection of the periosteum (2 mm) is performed along the fracture edges to assess fragment interdigitation and cortical reduction. Reduction of the medial malleolus is performed with a bone tenaculum or small (1.6 mm) Kuntscher-wires (Kwires). A small, pointed bone tenaculum can be placed on the medial malleolar fragment from anterior to posterior and used to guide the reduction. Alternatively a 1.6-mm K-wire can be placed into the lateral cortex and used as a joy-stick to guide reduction of the distal fragment. With either technique, a second pointed bone tenaculum or Weber clamp is used to hold and compress the fragment. A drill hole (2.5 mm) is placed in the intact distal medial metaphysis allowing insertion of one tine of the clamp while the other is placed around the medial malleolar fragment (Fig. 33.9). A second K-wire may be inserted across the fracture to prevent fragment rotation, at which point the first tenaculum/joy-stick can be removed.

FIGURE 33.7 Clinical photograph of a left ankle outlining the contour of the medial malleolus and planned incision. P.679

FIGURE 33.8 Retraction of the medial malleolar fragment distally allows inspection and irrigation of the ankle joint. Large, one-piece, medial fragments are typically secured with two 4.0 mm, partially threaded, cancellous screws. With the tenaculum centered on the fragment, a scalpel is used to split the superficial deltoid ligament in-line with its fibers. With the foot slightly everted, a 2.5-mm drill bit is placed against the anterior colliculus and directed inline with long axis of the tibia. A second drill bit is placed in the intercollicular groove and directed parallel to the first drill bit. While placing the second screw in the posterior colliculus has been common practice, it increases the risk of injury to the posterior tibial tendon and can result in postoperative pain (15). If the size of the fragment precludes placement of two 4.0-mm screws, then alternative methods of fixation should be considered. These include a single lag screw with a K-wire, small diameter screws, or tension band wiring. Long 2.0, 2.4, and 2.7mm screws should be available and are well suited for small medial malleolar fragments. Alternatively, tension band fixation can be performed by inserting 1.6-mm K-wires in a direction similar to the standard screw fixation. Eighteen-gauge wire or a large nonabsorbable suture is passed around the K-wires and crossed in a figure-ofeight fashion around a screw placed in the tibial metaphysis. The ends of the K-wires are then bent and impacted. Vertical medial malleolar fractures, as commonly seen with supination-adduction injuries, deserve special attention. These fractures may be accompanied by marginal impaction of the anterior-medial plafond (16). Reduction and fixation of the impacted distal tibia joint surface is mandatory. Small osteotomes and bone tamps can facilitate anatomic restoration of the joint surface. The resulting cancellous bone void is filled with bone graft, and the medial malleolus fracture is reduced (Fig. 33.10). While vertical, shear, medial malleolar fractures can be stabilized with lag screws placed perpendicular to the fracture line, we recommend buttress plate fixation using a 1/3 tubular plate. Cortical screws can be inserted, using a lag technique through the plate for added stability (17).

FIGURE 33.9 A pointed reduction tenaculum is used to provide provisional reduction of the medial malleolus. One tine is placed in a drill hole placed in the medial tibial metaphysis, and the other tine is placed around the distal aspect of the medial malleolus. Partially threaded, cancellous, lag screws are inserted anterior and posterior to the tenaculum. P.680

FIGURE 33.10 (A) Radiograph of a vertical medial malleolar ankle fracture with subtle articular impaction of the joint surface (white arrow). (B) Intraoperative radiograph with reduction of the depressed articular segment and medial malleolus. A joy-stick wire is seen (black wire) in the fracture fragment. (C) A minifragment plate applied as a buttress plate, and the fracture is lagged to the tibia with the distal most screw. P.681

FIBULAR FIXATION The fibular incision is selected based upon both the fibular fracture personality and location of the soft tissue injury. Minor adjustments in location of the incision may be needed due to associated soft-tissue abrasions or fracture blisters. The fibula is classically approached through a straight lateral incision (Fig. 33.11). If a fracture of the anterior-lateral tibia is present, the distal extent of the incision is curved anterior. This variation will allow access to the anterolateral ankle (avulsion of the anterior, inferior, tibiofibular ligament) and fixation of the Chaput-Tillaux fragment. Through this approach, the anterior-lateral plafond can be inspected. Any osteochondral debris should be removed and articular impaction corrected. Alternatively, a longitudinal incision just posterior to the fibula can be used to position a posterior antiglide plate. Here an undercontoured 1/3 tubular

plate may be placed with a 3.5-mm cortical screw at the apex of the fracture. Additionally, the plate frequently allows lag-screw fixation through the plate. Regardless of the fibular incision, care is taken to preserve the superficial peroneal nerve. This nerve may cross the surgical field at either the subcutaneous or fascial level, and failure to protect it may result in a painful neuroma. Periosteum at the fracture edge should be elevated to facilitate anatomic reduction, but further periosteal stripping is kept to a minimum. Fracture reduction can be achieved by using one or more of the following techniques: traction and rotation can be applied to the hind foot to assist with fracture reduction; a tenaculum may be placed on the distal fragment and used to manually reduce the fragment; the bone reduction clamp may be used to directly reduce and stabilize the fracture by placing the tines at a right angle to the fracture. Fracture reduction is usually fairly easy in the acute setting, but becomes more difficult if the fibula has been left in a foreshortened position for several days. Simple, oblique, fibula fractures are usually reduced and fixed with an interfragmentary lag screw and 1/3 tubular neutralization plate. Occasionally, long oblique fractures can be adequately fixed with interfragmentary lag screws alone (18,19). The benefits of lag screw-only fixation include a smaller incision and less hardware irritation. While this technique can be used in bi/trimalleolar fracture patterns, it should not be utilized in the presence of fibular comminution or osteoporosis (18,19). While we typically use a 3.5-mm cortical screws inserted in “lag” fashion, smaller diameter screws (2.0, 2.4, and 2.7 mm) are an alternative in smaller patients or small fragments. In these circumstances, a smaller diameter screw helps reduce the risk of iatrogenic comminution. Comminution that precludes lag screw fixation is commonly seen in pronation-abduction injuries. In these fractures, reduction and stabilization of the medial malleolus will reduce the ankle mortise and can be fixed before the fibula however, the authors typically fix the fibula first. During fibular exposure, care is taken to remain extraperiosteal through the zone of comminution (Fig. 33.12) (20). Maintaining the periosteal sleeve preserves the blood supply and contains the comminuted fragments while the coronal and sagittal alignments are corrected. If no bony “keys” are available to determine distal fibular rotation, the distal fragment may be reduced to the talus and provisionally held with K-wires passed into the talar body. Fixation is achieved using a “bridge plate,” spanning the zone of comminution (Fig. 33.13). While 1/3 tubular plates are useful in simple fibular fractures, we recommend stronger reconstruction or precontoured fibular plates for these comminuted fractures. Precontoured plates allow multiple screw hole options, which are also very helpful in small distal fragments (Fig. 33.13). These precontoured plates also allow locking screw fixation in the small distal fragment. It is the author’s recommendation that locking screws be reserved for small distal fragments or patients with poor bone quality, for example, osteoporosis, diabetes, or metabolic bones disease.

POSTERIOR MALLEOLUS FIXATION Ankle fractures involving the posterior malleolus have a higher incidence of posttraumatic osteoarthritis than bimalleolar fractures. The exact reasons for increased arthrosis following a posterior malleolar fracture are unknown, but dynamic fracture models have shown that posterior, malleolar fractures are associated with a shift in contact stress (anterior and medial) as opposed to an overall increase in the peak contact stress (7,21). Associated chondral injury and residual joint instability may also be contributing factors to the increased incidence of arthrosis following posterior malleolar fractures.

FIGURE 33.11 A clinical photograph of a direct lateral incision over the fibula. A pointed reduction clamp is seen holding reduced a short oblique fibula fracture. P.682

FIGURE 33.12 Demonstrates technique of extraperiosteal plating of a comminuted fibula fracture. A. A clinical photograph of the fibular plate fixed to the small distal segment. No periosteal dissection is performed through

the zone of injury. B. An intraoperative radiograph illustrating a push-pull screw and lamina (white arrow) spreader is used to restore length and alignment of the fibula. C. A cortical screw (black arrow) is used to secure the fibula proximally and finalize the coronal plane alignment.

FIGURE 33.13 Intraoperative mortise of a comminuted fibula fracture fixed with a precontoured plate applied as a bridging construct and multiple points of fixation in the small, distal segment. P.683

FIGURE 33.14 Upper left image. Sagittal CT scan image demonstrates an incarcerated and rotated posterior lateral articular fragment (white arrow). Bottom left. Sagittal CT image illustrates medial extension of the posterior malleolus fracture as well as comminution of the medial malleolus that often accompanies this fracture pattern. Right. A postoperative radiograph demonstrating reduction and stabilization of the comminuted medial and posterior malleolus with minifragment plates. Posterior malleolar fractures occur in three common patterns. Large posterior-lateral oblique fractures are the most common, followed by fractures with medial extension and small posterior lip fractures (22). Classic recommendations for posterior malleolar fixation have been based upon articular involvement of >25% of the joint surface. While plain radiographs can reliably estimate size of the posterolateral fragment, they do not reliably predict the presence of impacted articular fragments or posteromedial fracture extension (14). Fiftydegree external rotation radiographs have been suggested as an adjuvant method of evaluating the posterior fracture; however, this method has not been clinically verified in cases where the posterior malleolous fracture personality is not clear, we recommend CT scans with two-dimensional reconstruction to evaluate for fracture comminution, articular impaction, and medial extension as part of the preoperative workup (Fig. 33.14). Small posterior-lip malleolar fractures frequently represent avulsion of the posterior, inferior tibiofibular ligament.

These fragments often reduce with fibular fixation and therefore are addressed after fibular fixation. The larger, more common, posterior-lateral oblique and medial-extension fractures typically require fixation. For noncomminuted, nonimpacted, minimally displaced fractures, fixation can be accomplished with a wellplaced pointed tenaculum followed by percutaneous, anterior-to-posterior screws. One tine of the clamp is placed on the posterior malleolar fragment, and one tine is placed through a small, separate incision on the anterior tibia. Gentle dorsiflexion of the ankle or rotation of the clamp may facilitate final reduction, at which point P.684 an anterior-to-posterior, cannulated or noncannulated 3.5-mm screws will secure the fragment. These fractures are similarly addressed after fibular fixation. For fractures with a large displaced posterolateral fragment, those with posterior-medial extension and/or the presence of articular impaction, a direct surgical reduction is required. When a formal surgical approach is selected for the posterior malleolus, it is the authors preference to stabilize the posterior malleolus prior to fibular fixation so that the reduction can be radiographically visualized without interference from fibular implants.

FIGURE 33.15 A clinical photograph of a patient positioned prone. The Achilles tendon is identified by the diagonal lines, the fibula drawn laterally in black, and the posterior lateral incision (purple line). Open reduction through a posterolateral approach is used to repair large displaced posterior-lateral oblique fractures or fractures with impacted osteochondral fragments. With the patient in the prone position, a standard posterolateral incision is made (Fig. 33.15). The peroneals are retracted laterally and the flexor hallucis longus medially, which allows visualization of the posterior tibia metaphysis (Fig. 33.16). The posterior malleolar fragment can be gently booked open to reduce incarcerated osteoarticular segments. Any cancellous defects are bone grafted and fracture reduced. Fracture fixation is often achieved with two or three posterior-to-anterior screws over washers. With large fragments, internal fixation may be achieved with a 1/3 tubular plate applied in a buttress fashion. When articular impaction is present, we prefer to use a T-plate (3.5, 2.4, or 2.0 mm) and direct the distal screws just above the articular fragment in a rafting fashion (Fig. 33.17). Fractures with posterior-medial extension are often associated with articular comminution as well as a separate posterior-medial fragment (Fig. 33.14). Subtle radiographic findings of this fracture pattern include a double density of the medial tibia just above the medial malleolus; however, this finding is not always present. Fixation of this fracture pattern frequently requires a combined posteromedial as well as a posterolateral approach (22,23).

SYNDESMOTIC ASSESSMENT AND FIXATION

Disruption of the ankle syndesmosis is traditionally observed with Weber Type C (pronation external rotation) injuries. Injury to this ligamentous complex can occur with any rotational ankle fracture pattern and, if unrecognized, will result in ankle instability. Transsyndesmotic fixation, however, is not always required. Sequential rigid fixation of the distal fibula, medial malleolus, and when present posterior malleolus will often restore ankle stability, provided the respective ligaments (AITFL, Deep Deltoid, and PITFL) are intact (24,25).

FIGURE 33.16 A. A clinical photograph demonstrating the surgical interval of the posterior lateral approach: peroneal muscles (large white arrow) and the flexor hallucis longus (small white arrow). B. The muscular interval is retracted revealing a 2.7-mm plate buttressing the posterior malleolus. P.685

FIGURE 33.17 Lateral radiograph of a trimalleolar fracture. The posterior malleolar fragment is fixed with the distal screws directed just cephalad to the articular fragment. Injury to the syndesmotic ligament complex (anterior tibiofibular, posterior tibiofibular, and the interosseous ligament) cannot always be predicted based upon the fracture pattern (25). MRI imaging has been utilized as a mechanism to assess ligament integrity; however, the added cost is substantial. We therefore recommend careful intraoperative evaluation of the syndesmosis following fracture stabilization with a lateral stress test (25,26). Following fracture fixation, a clamp or small bone hook is placed around the fibula, just proximal to the syndesmosis, and a laterally directed force is applied while a fluoroscopic mortise x-ray is taken. Displacement of the tibiofibular clear space >1 mm is suggestive of syndesmotic disruption. Alternatively an external rotation stress test can be used to assess the integrity of the syndesmosis, but a laterally directed force has been shown to be more predictive of ligament disruption (25,26). Several controversies regarding syndesmotic fixation exist: screw diameter, screw number, number of cortices engaged, timing of weight bearing, and timing of screw removal. To add further complexity, new fixation techniques continue to emerge such as tight-rope fixation as well as locking syndesmotic screws. Regardless of fixation type, the distal tibiofibular reduction must be anatomic. In one study, up to 52% of syndesmotic reductions were shown by CT to be malreduced (27). We therefore recommend open reduction of the tibia-fibula joint. This is accomplished through the fibular incision. With the foot held at 10-degree dorsiflexion, a periarticular reduction clamp is applied from the fibula to the medial tibia, parallel to the joint. The reduction is visually and fluoroscopically inspected for any malrotation that may occur during clamp application. A

temporary K-wire may be placed to help maintain the reduction if needed, but is not standard practice. Following reduction, syndesmotic fixation is accomplished by elevating the heel on a small bump. This position affords a surgeon room to direct the drill in-line with the tibia-fibula axis (approximately 30 degrees) (Fig. 33.18). The authors prefer to insert a single, tricortical 3.5-mm screw for syndesmotic fixation in noncomplicated patients. For these patients, syndesmotic screws are typically removed 3 to 4 months postoperatively to facilitate early rehabilitation progress and improve functional outcomes (28,29). Syndesmosis disruption with a high fibula (Weber Type C) fracture, Maisonneuve fractures, is often closed reduced and fixed with two syndesmotic screws (30), and the fibula fracture is not internally fixed. This technique has been shown to result in a high incidence of tibiofibular malreduction. We recommend open reduction and internal fixation of proximal fibula fractures prior to syndesmosis fixation in Maisonneuve injuries (31). P.686

FIGURE 33.18 Exposure of the anterolateral ankle joint may be performed by dissecting anterior to the fibula and retracting soft tissues with a small right-angle retractor. Large-fragment 4.5-mm screws, engaging four cortices, and multiple syndesmotic screws are reserved for patients with osteopenia and diabetics with peripheral neuropathy. The combined increased screw diameter, screw purchase in the far cortex, and multiple points of fixation provide added stability for patients with poor bone biology or high risk noncompliance. Utilization of two angularly stable tricortical syndesmotic screws through a locking 1/3 tubular plate has recently gained support. Proponents of this technique suggest angularly stable screws prevent malreduction of the tibiafibula articulation compared to traditional cortical screws, which may malrotate the fibula if inserted off-axis (29). When combined with open reduction of the tibiofibular joint, angularly stable screws are shown to decrease the incidence rotational malreduction (52% to 16%); however, the clinical significance of this technique is still being investigated (32). Less rigid fixation with a fiber-wire tightrope is also an available option for syndesmotic fixation. Biomechanical studies have demonstrated greater physiologic motion of the tibofibular joint with a tightrope compared to screw fixation (33). Limited outcome data suggest a potential earlier return to function and work with a tightrope versus screw fixation (34). However, concerns over the ability of a fiber wire to maintain syndesmotic reduction have been raised in cadaver models (35), and granulomatous reactions have been reported (36).

POSTOPERATIVE MANAGEMENT A nonadherent dressing and sterile gauze are applied to the incisions and held in position with sterile cast padding. With the ankle held in neutral dorsiflexion, additional cast padding is applied followed by a short-leg, posterior, and “U” splint. The splint is maintained until the patient can comfortably dorsiflex the injured ankle and thus prevent equinus contracture. The leg is elevated postoperatively to minimize swelling. Patients with adequate pain control and sufficient home care may be discharged following surgery, but many patients require overnight observation for pain management. Patients are seen in follow-up appointments between 10 and 14 days after surgery. The splint and sutures are removed. Reliable patients are instructed in active ankle and subtalar range-of-motion and placed in a removable short-leg “Cam Walker.” Patients with simple fibular fractures are restricted from weight bearing for 6 weeks postoperatively. Repeat xrays are obtained at 6 weeks, and the patient’s weight bearing is at this time in the boot. Physical therapy is typically initiated at this time to assist with range of motion, proprioception, and strengthening. When a comminuted fibula is present, weight bearing is restricted until callus is observed at which point the patient is placed on a partial progressive weight-bearing program. Dependent swelling may persist for many months following ankle fractures and often require the use of compression stockings or elastic wraps once the incision is healed. Patients are cautioned against returning to sports until they have regained adequate strength and agility with a cross-training physical therapy program. Patient’s return to driving is deferred for 9 weeks as braking time has been shown to be decreased until that time (37).

SPECIAL CONSIDERATION Diabetics/Osteoporosis Successful, uncomplicated fracture union is more difficult patients with poor bone quality or complex medical conditions. In particular, the geriatric patient with osteoporosis and the diabetic patient deserve special P.687 mention. Diabetic patients whose fractured extremity is complicated by peripheral neuropathy, vasculopathy, or Charcot arthropathy are at a higher risk of wound-healing complications, infection, loss of fixation, and nonunions than the general population (38,39). In the diabetic patient, a poor soft-tissue envelope with significant swelling and fracture blisters that preclude early operative intervention are more commonly observed than in the general population. As such, damage control protocols are employed with application of an ankle spanning external fixator.

FIGURE 33.19 A Mortise radiograph illustrates three ways to improve stability in this osteoporotic and insulindependent diabetic patient: bicortical medial malleolar screws, three tetracortical syndesmotic screws, and locking screws at the proximal and distal extent of the fibular plate. When the soft-tissue envelope allows definitive fracture fixation, standard fixation techniques may be inadequate, and consideration is given to augmenting implant fixation. Like geriatric patients with osteoporosis, low bone mineral density is commonly observed in the diabetic. Poor bone quality can lead to early loss of fixation, hardware failure, and fracture collapse. The brittle bone encountered in both these patient populations is also prone to iatrogenic comminution during fracture reduction or fixation. Meticulous care must be exercised during fracture reduction and fixation so as to avoid propagation of existing fracture lines. Secure fixation of the medial malleolus is augmented with bicortical screw fixation (Fig. 33.19) (40). When a vertical medial malleolus fracture is stabilized, we recommend that lag screws are applied through a plate or a washer to prevent screws from sinking through the metaphyseal cortex. Fibular fixation can be augmented with precontoured, locked plating constructs in patients with osteoporotic bone. The ankle mortise can be further stabilized by placing multiple (three or four) syndesmotic screws that engage four cortices (Fig. 33.19). We recommend 3.5-mm plates and 3.5-mm cortical or 4.0-mm cancellous syndesmotic screws (41). Supplemental stabilization with an external fixator or calcaneal-talar-tibial Steinmann pins is occasionally employed for the neuropathic diabetic with poor bone stock.

COMPLICATIONS

Many ankle fractures are “simple, standard” injuries that can be easily treated with the anticipation of an excellent outcome. Complications, however, are inevitable with surgical treatment of any fractures. Surgeon failure to appreciate the complexity of either the fracture pattern or the patient’s biology may result in higher complication rates. In particular, preoperative appreciation of the posterior malleolar fracture size, presence of articular impaction, intra-articular fragments, osteoporotic bone, or complicated diabetes are necessary to select the appropriate surgical approach and implants. Patient-related factors that increase perioperative complication P.688 rates that are beyond the surgeon’s control include open fractures, complicated diabetes, peripheral vascular disease, and patient age >75 (42).

STIFFNESS Loss of motion, especially dorsiflexion, can be problematic following ankle fractures. This complication is best avoided with early patient-directed range-of-motion (active/active assist). If independent range-of-motion exercises and stretching do not rapidly restore normal functional range of motion, an early referral to physical therapy is recommended. Recalcitrant cases of stiffness may benefit from gastrocnemius recession, tendo Achilles lengthening, and/or capsular release to improve restricted ankle dorsiflexion.

LOSS OF FIXATION Screw purchase is often compromised in patients with osteoporosis and may result in loss of fixation. Biomechanical studies have shown that three tetra-cortical syndesmotic screws improve fibula fracture stability better than intramedullary K-wires (43). Utilization of locked-screw constructs can also improve fracture stability in the setting of osteoporosis. Addition of a second plate (90/90 plating) can be considered; however, further surgical dissection is required and that biologic insult must be balanced with fracture stabilization. Alternatively, screw fixation may be augmented with an injectable composite graft placed into the screw holes (44).

INFECTION AND WOUND COMPLICATIONS Postoperative infection usually presents with erythema as well as wound drainage or breakdown. Diabetics and smokers have a higher risk of this complication (38,42,45). Operative débridement and culture-specific antibiotics are usually required. Because of the risk of ankle joint involvement, careful clinical examination of the joint is recommended. If indicated, ankle aspiration through a noncellulitic area is also suggested. If wound soft-tissue swelling and débridement preclude skin closure, application of a negative pressure wound dressing can be applied. Once the infection is under control, the soft tissue can be closed in a tension-free manner. Utilizing a “pie-crust” technique can facilitate a tension-free closure (Fig. 33.16). Alternatively, soft-tissue coverage may require a rotational muscle flap or a free tissue transfer.

POSTTRAUMATIC ARTHRITIS The incidence of posttraumatic arthritis following ankle fractures is low, with reported incidence of 2 packs per day) is considered a relative contraindication to surgery. Similarly, patients with non-insulin-dependent diabetes mellitus and intact protective sensation are counseled regarding the importance of diligent blood glucose control but are still considered candidates for surgery.

PREOPERATIVE PLANNING Clinical Evaluation A patient with a calcaneal fracture typically experiences severe pain in the hind foot, which is related to bleeding into the limited soft-tissue envelope surrounding the heel. The severity of fracture displacement and the extent of soft-tissue disruption are proportional to the amount of force and energy involved in producing the injury—lower energy injuries produce more mild swelling and ecchymosis, while higher energy injuries result in severe softtissue disruption and may result in an open fracture.

Open Fractures An open fracture of the calcaneus may present as a puncture wound medially from a prominent spike of bone from the medial wall of the calcaneus or as a more substantial wound with significant soft-tissue disruption, typically laterally or posteriorly. Open fractures are distinct injuries requiring different treatment and are generally associated with higher complication rates relative to closed fractures.

Compartment Syndrome of the Foot and Skin Necrosis Within a few hours following the injury, soft-tissue swelling in the hind foot is typically so severe that skin creases in the area are no longer visible. In rare cases, severe swelling may produce a compartment syndrome of the foot, which, if untreated, can result in clawtoe deformities, contracture, weakness, and loss of function. Thus, it is important to ensure that pain associated with the fracture is not due to a compartment syndrome, particularly in the calcaneal compartment, which is contiguous with the deep posterior compartment of the leg. With tonguetype fractures, significant displacement of the tongue fragment may place excessive pressure on the posterior skin, causing necrosis if left untreated.

Associated Injuries A high index of suspicion must be maintained for other associated injuries, including lumbar spine fractures or other fractures of the lower extremities, particularly with falls from a height. Up to 50% of patients with calcaneus fractures may have other associated injuries—intuitively, these injuries are more common in higherenergy trauma. Appropriate diagnostic evaluation should thus be completed where necessary.

Resolution of Soft-Tissue Swelling Surgery is ideally performed within the first 3 weeks of injury prior to early consolidation of the fracture. Once fracture consolidation ensues, the fragments become increasingly difficult to separate to obtain an adequate reduction, and the articular cartilage may delaminate from the underlying subchondral bone. Surgery must be delayed, however, until the associated soft-tissue swelling has adequately dissipated, which may require up to 3

weeks. We utilize a Jones dressing and supportive splint initially, combined with limb elevation. Once the initial edema has begun to dissipate, the patient is converted to an elastic compression stocking and fracture boot. Sufficient resolution of soft-tissue edema is indicated by a positive wrinkle test, in which the lateral calcaneal skin is visually assessed and palpated with the foot positioned in dorsiflexion and eversion. The test is positive if skin wrinkling is seen, and no pitting edema remains, indicating that surgical intervention may be safely undertaken (5). P.719

RADIOLOGIC EVALUATION Plain Radiography With a suspected calcaneal fracture, plain radiographic evaluation should include a lateral view of the hind foot, an anteroposterior view of the foot, an axial view of the heel, and a mortise view of the ankle. A calcaneal fracture is most easily identified on the lateral view of the hind foot. With an intra-articular fracture, there is a loss of height in the posterior facet—the articular surface is impacted within the body of the calcaneus and usually rotated anteriorly up to 90 degrees relative to the remaining subtalar joint; a decreased tuber angle of Böhler and an increased crucial angle of Gissane are seen in fracture patterns where the entire posterior facet is separated from the sustentaculum and depressed (Fig. 35.2B); if only the lateral portion of the posterior facet is involved, the split in the articular surface is manifest as a “double density,” in which case the tuber angle of Böhler and crucial angle of Gissane may appear normal (Fig. 35.2C). The lateral view also allows delineation as to whether the fracture is a joint depression or tongue-type fracture (2). The anteroposterior view of the foot is helpful to identify if there is fracture extension into the calcaneocuboid joint, anterolateral fragments, and widening of the lateral calcaneal wall. The Harris axial view of the heel shows a loss of calcaneal height, increased width, and (typically) varus angulation of the tuberosity fragment, as well as visualization of the articular surface. A mortise view of the ankle often demonstrates involvement of the posterior facet.

Computed Tomography If the plain radiographs reveal intra-articular extension of the calcaneal fracture, CT scanning is indicated. Images are obtained in 2 to 3-mm intervals in the axial, sagittal, and 30-degree semicoronal planes. The axial or transverse cuts reveal extension of fracture lines into the anterior process and calcaneocuboid joint as well as the sustentaculum tali and anteroinferior margin of the posterior facet (Fig. 35.1A). The sagittal views demonstrate displacement of the tuberosity fragment, extent of involvement of the anterior process including superior displacement of the anterolateral fragment, anterior rotation of the superolateral posterior facet fragment, and delineation of the fracture as a joint depression or tongue-type pattern (Fig 35.1B) (2). The 30degree semicoronal images show displacement of articular fragments in the posterior facet, the sustentaculum tali, the extent of widening and shortening of the calcaneal body, expansion of the lateral calcaneal wall, varus angulation of the tuberosity, and location of the peroneal tendons (Fig. 35.1C).

SURGICAL TECHNIQUE Although a variety of surgical approaches have been described, we prefer the extensile lateral approach for displaced intra-articular fractures, as it consistently allows reduction of the calcaneal body, restoration of calcaneal height and width, even with severe comminution, as well as reduction of the intra-articular surface where possible (6).

OPEN REDUCTION INTERNAL FIXATION: EXTENSILE LATERAL APPROACH

FOR JOINT DEPRESSION-TYPE FRACTURES Patient Positioning/Draping/C-Arm The patient is given preoperative prophylactic antibiotics and positioned on an operating table with a radiolucent far end is utilized, preferably one with a “diving board” type attachment (i.e., without table legs distally) to facilitate surgeon position and intraoperative fluoroscopy. The patient is placed in the lateral decubitus position on a beanbag. The lower extremities are positioned in a scissor configuration, whereby the operative limb is flexed at the knee and angles toward the distal, posterior corner of the operating table, while the nonoperative limb is extended at the knee and lies away from the eventual surgical field. Protective padding is placed beneath the contralateral limb to protect the peroneal nerve, and an operating “platform” is created with blankets or foam padding to elevate the operative limb (Fig. 35.3). A pneumatic thigh tourniquet is used in all cases. The procedure should be completed within 120 to 130 minutes of tourniquet time, in order to minimize potential wound complications. A standard C-arm should be utilized rather than a “mini” C-arm, because the arc of “C” is too small to fit around the operating table for a true lateral view. The C-arm approaches the surgical field from opposite the surgeon and perpendicular to the table.

Approach Soft-tissue complications following the surgical management of calcaneal fractures remain a major source of morbidity with these injuries. Thus, careful attention to detail with respect to placement of the incision and gentle handling of the soft tissues are of paramount importance. The vertical limb of the incision begins P.720 2 cm proximal to the tip of the lateral malleolus, immediately lateral to the Achilles tendon and thus posterior to the sural nerve and the lateral calcaneal artery (9), and extends toward the plantar foot. The horizontal limb continues at the junction of the skin of the lateral foot and heel pad, with a gentle curve connecting the two limbs of the incision (Fig. 35.4A). Dissection is specifically taken “straight to bone” at the level of the calcaneal tuberosity proximally and continues to the midpoint of the horizontal limb.

FIGURE 35.3 Intraoperative positioning for extensile lateral approach. Note scissor configuration of operative and nonoperative limbs and operating platform.

FIGURE 35.4 Extensile lateral approach. A. Proposed incision. B. Full-thickness subperiosteal flap using “no touch” technique. A full-thickness subperiosteal flap is then raised starting at the apex, specifically avoiding the use of retractors until a sizeable subperiosteal flap is developed, in order to prevent separation of the skin from the underlying subcutaneous tissue (Fig. 35.4B). The calcaneofibular ligament is sharply released from the lateral calcaneal wall, and the adjacent peroneal tendons are released from the peroneal tubercle through their cartilaginous “pulley” (Fig. 35.4C). A periosteal elevator is used to gently mobilize the tendons in the distal portion of the P.721 incision, thereby exposing the anterolateral calcaneus. The peroneal tendons, sural nerve, and lateral calcaneal artery are thus contained entirely within the flap, which minimizes devascularization of the lateral skin.

FIGURE 35.4 (Continued) C. Mobilization of peroneal tendons. D. K-wire retractors. Deep dissection continues to the sinus tarsi and anterior process anteriorly and to the superior-most portion of the calcaneal tuberosity posteriorly for “window” visualization of the posterior facet. Using a “no touch” technique, three 1.6-mm Kirschner wires are placed for retraction of the subperiosteal flap: one into the fibula as the peroneal tendons are slightly subluxed anterior to the lateral malleolus; a second wire is placed in the talar neck; a third wire is placed in the cuboid as the peroneal tendons are levered away from the anterolateral calcaneus with a periosteal elevator (Fig. 35.4D).

Mobilization of the Fragments The expanded lateral wall fragment is mobilized and removed and preserved in saline on the back table. The adjacent impacted superolateral articular fragment of the posterior facet is gently elevated with a small periosteal elevator at the plantar margin of the fragment within the body of the calcaneus. The articular surface of the fragment is assessed for chondral damage, and the fragment is débrided of residual hematoma and preserved in saline on the back table. Removal of the articular fragment thereby affords exposure of the sustentacular fragment, the tuberosity fragment, and the obliquely oriented primary fracture line medially (Fig. 35.5A). A periosteal elevator is placed into the primary fracture line, and levered plantarward, which disimpacts the tuberosity fragment from the sustentacular fragment, and helps restore calcaneal height and length along the medial calcaneal wall (10,11) (Fig. 35.5B). A 4.5-mm external fixation pin is placed in the posterior-inferior corner of the calcaneal tuberosity, and the tuberosity is further manipulated by longitudinal traction, medial translation, and valgus angulation (12).

Reduction of the Articular Surface and Anterior Process Attention is next directed to the articular fragment(s) of the posterior facet: with only one fragment (Sanders type II fracture), 1.6-mm K-wires are placed parallel to the articular surface of the superolateral fragment to facilitate reduction; with two separate fragments (Sanders type III fracture), the central articular fragment is first reduced to the sustentacular fragment and provisionally held with 1.6-mm K-wires, which are exchanged for 1.5-mm bioresorbable (poly-l-lactide acid) pins. The protruding ends of the pins are removed flush with the bony surface with a handheld electrocautery unit (Fig. 35.6). The superolateral (lateral-most articular) fragment is then reduced and provisionally stabilized to the central and sustentacular fragments. A minimum of two K-wires should be placed across each fragment to prevent malrotation of the fragments. The articular fragment(s) must be precisely reduced such that (superior-inferior) height, (anterior-posterior) rotation, and coronal plane (varusvalgus) alignment are correct. Impingement from the tuberosity fragment against the articular fragment(s) may preclude reduction. Thus, the surgeon may need to further disimpact the tuberosity with varus force or remove excess bone from the tuberosity to facilitate the path for the articular fragment(s). P.722

FIGURE 35.5 Intraoperative views (A) following excision of lateral wall fragment and superolateral fragment. AL, anterolateral; SM, superomedial; PM, posterior main. B. Mobilization with blunt periosteal elevator through primary fracture line (white arrows). The anterior process fragments are typically displaced superiorly from the intact interosseous ligament. The fragments are pulled inferiorly with a dental pick and are provisionally secured with 1.6-mm K-wires. There is often variability in anterior process fracture lines, particularly with higher energy patterns, such that there may be three separate fragments. In this instance, as the anterolateral fragment is reduced, the surgeon must ensure that the central fragment does not remain residually displaced superiorly. A lamina spreader may be used to facilitate repositioning of the central fragment. A transverse fracture line may be present through the crucial angle of Gissane, in which case the sustentacular fragment may rotate anteriorly beneath the anterior main fragment. In this case, prior to the articular reduction, the sustentacular fragment must be derotated, reduced, and provisionally stabilized to the anterior main fragment to prevent malrotation of the entire posterior facet articular surface (Fig. 35.7). Once the posterior facet articular fragments are reduced, the articular reduction is verified through “window” visualization: the anterior and posterior corners of the superolateral fragment should align with the anterior and posterior corners of the sustentacular fragment. Full visualization of the articular surface posteriorly may be facilitated with a small retractor placed at the posterior margin of the joint surface. Failure to visualize the posterior facet from both sides of the “window” may lead to malreduction of the fragment(s) in the sagittal plane (Fig. 35.8A,B).

FIGURE 35.6 Stabilization of central articular fragment with bioresorbable pins (white arrows). The protruding portion of the pins is removed flush with bone using handheld electrocautery unit. P.723

FIGURE 35.7 Articular intussusception. Sustentacular fragment (SM) is derotated, elevated (white arrow), and reduced to anterior main fragment (AM). Note intra-articular (split) tongue fragment (SL) reflected on soft-tissue hinge to facilitate reduction of primary fracture line. At this point, the posterior edge of the anterolateral fragment should “key” into the anterior-inferior edge of the superolateral fragment, which restores the crucial angle of Gissane; the lateral wall and the body of the calcaneus should align with simple valgus manipulation of the external fixation pin; and the previously excised lateral wall fragment should anatomically reduce, thereby confirming at the least that the lateral column is fully restored.

FIGURE 35.8 Sagittal plane malalignment of superolateral fragment from inadequate “window visualization.” A. Postoperative coronal CT image through more anterior portion of posterior facet—articular reduction appears anatomic. B. Coronal image through more posterior portion demonstrating rotational malalignment. P.724

FIGURE 35.9 Intraoperative (A) lateral, (B) Broden’s, and (C) axial fluoroscopic images demonstrating provisional reduction; note anatomic alignment of posterior facet articular surface (B) and restoration of calcaneal height (C). Also note residual varus angulation of tuberosity (C), which corrects with simple manipulation during definitive fixation (Fig. 35.11). The reduction is confirmed by intraoperative fluoroscopy, including lateral, Brodén’s, and axial views. The lateral view should be a true lateral view of the talus at the ankle joint in order to accurately assess the calcaneus (Fig. 35.9A). Next, the limb is externally rotated 45 degrees and foot dorsiflexed to obtain a mortise view of the ankle. The beam is canted 10 degrees toward the foot of the bed to obtain a Brodén’s view, thereby revealing the posterior facet. The entire facet is visualized under live fluoroscopy through dorsiflexion and P.725 plantarflexion of the foot (Fig. 35.9B). Lastly, the limb is externally rotated 90 degrees and the foot maximally dorsiflexed through the midfoot. The beam is further angled 30 degrees toward the foot of the bed such that the head of the fluoroscope is centered over the plantar midfoot, demonstrating a clear axial view of the calcaneus (Fig. 35.9C).

Combined (Open/Closed) Techniques for Split Tongue Fractures Although extra-articular tongue-type (Sanders type IIC) fractures are amenable to percutaneous reduction techniques, intra-articular (split) tongue-type patterns (Sanders type IIA or B and III) require a formal open reduction through an extensile lateral approach. In these patterns, the pull of the Achilles tendon often precludes reduction of the lateral articular tongue fragment in proper sagittal plane rotation. We utilize the Essex-Lopresti reduction technique on the tongue fragment in an open fashion, using a 4.5-mm external fixation pin placed percutaneously into the tongue fragment (13). By levering the pin plantarly, the deforming force of the Achilles tendon is neutralized, which allows anatomic reduction of the articular surface in the sagittal plane (Fig. 35.10). The remainder of the procedure is completed (as described previously).

Definitive Fixation A low-profile laterally based calcaneal plate is selected. Bending or contouring of the plate along the longitudinal axis of the plate is strictly discouraged as it may result in varus malalignment of the tuberosity. As the screws are tightened, it brings the plate to the bone, which narrows the width of the calcaneus. The posterior facet is first secured with cortical lag screws (2.7 to 3.5 mm), typically one screw outside the plate and one screw through the plate, and placed just beneath the articular surface angling distally and slightly plantarly toward the sustentaculum to accommodate the slight lateral-to-medial downslope of the articular surface. The plate is secured with 3.5-mm cortical or 4.0-mm cancellous screws, starting with the anterior process. The distal-most screw holes in the plate are angled slightly posteriorly to accommodate the oblique orientation of the calcaneocuboid joint. The calcaneal tuberosity is next secured to the plate while maintaining a simultaneous lateral-to-medial force on the plate (with the surgeon’s thumb) and a valgus-directed force on the undersurface of the tuberosity (with the surgeon’s long and ring fingers; Fig. 35.11). The main components of the calcaneus (anterior process, posterior tuberosity, and articular surface) are further stabilized to the plate such that two screws traverse each component (Fig. 35.12A-C). In the event of poor patient bone quality, supplemental locking screws may be placed beneath the posterior facet articular block to better support and maintain calcaneal height (Fig. 35.12D). Final fluoroscopic images are obtained, confirming the final reduction and implant placement.

FIGURE 35.10 Essex-Lopresti technique for intra-articular split tongue pattern; note Schanz pin within tongue fragment to neutralize pull of Achilles tendon.

FIGURE 35.11 Fixation of calcaneal tuberosity: simultaneous lateral-to-medial force on plate (applied by surgeon’s thumb) and valgus-directed force on undersurface of tuberosity (applied by surgeon’s long and ring fingers). P.726

FIGURE 35.12 Intraoperative (A) lateral, (B) Broden’s, and (C) axial fluoroscopic images demonstrating final reduction and definitive fixation with nonlocking neutralization plate. D. Intraoperative lateral view showing use of locking neutralization plate (different patient)—note locking screws (white arrows) placed beneath posterior facet articular block as rafter support spanning bony defect. P.727

Open Reduction Internal Fixation/Primary Arthrodesis for Sanders Type IV Fractures Open reduction internal fixation (ORIF) with primary subtalar arthrodesis is indicated only for highly comminuted intra-articular (severe Sanders type III and all type IV) fractures (10), in which the articular surface is determined at the time of surgery to be nonreconstructable (6). Standard ORIF techniques are utilized through an extensile lateral approach to fully restore calcaneal height, length, and overall morphology. A primary subtalar arthrodesis is included in the event of a poor intra-articular reduction, severe cartilage delamination, or absence of a substantial portion of the joint surface (14).

Assessing the Peroneal Tendons

With removal of the K-wires, the peroneal tendons should reduce into the peroneal groove along the posterior edge of the lateral malleolus. A Freer elevator is advanced within the peroneal tendon sheath on the undersurface of the flap to the level of the lateral malleolus and levered forward while observing the overlying skin to assess stability of the superior peroneal retinaculum and peroneal tendon sheath (Fig. 35.13A). If the tendon sheath is detached from the lateral malleolus, the elevator will easily slide anterior to the fibula, in which case a tendon sheath repair is required. Following wound closure, a small (