Operative Techniques: Orthopaedic Trauma Surgery [2 ed.] 9780323508889, 2019945313

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Operative Techniques: Orthopaedic Trauma Surgery

Second Edition

Emil H. Schemitsch, MD, FRCS(C) Richard Ivey Professor and Chair/Chief Department of Surgery University of Western Ontario London, Ontario, Canada

Michael D. McKee, MD, FRCS(C) Professor and Chairman Department of Orthopaedic Surgery University of Arizona College of Medicine – Phoenix Physician Executive Director Orthopaedic and Spine Institute Banner University Medical Center Phoenix, Arizona, United States

1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103-2899 OPERATIVE TECHNIQUES: ORTHOPAEDIC TRAUMA SURGERY, SECOND EDITION Copyright © 2020 by Elsevier, Inc. All rights reserved.

978-0-323-50888-9

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous edition copyrighted 2010. Library of Congress Control Number: 2019945313

Content Strategist: Kristine Jones Content Development Specialist: Laura Schmidt Publishing Services Manager: Deepthi Unni Project Manager: Srividhya Vidhyashankar Design Direction: Amy Buxton Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my wife Maureen and our four wonderful children Laura, Geoffrey, Christine and Thomas. Emil H. Schemitsch I dedicate this book to the guidance of my parents David and Nancy. The love and support of my wife Niloofar. My children Sacha, Tyler, Robbin, Everett, and Darya who enrich my life every day. And the promise of the new generation Mickey, Felix, and Declan. Michael David McKee

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Preface Fracture surgery occupies a special place in the hearts and minds of orthopaedic surgeons. This book is designed to be a user-friendly and clinically relevant text on common fracture surgery procedures. Every orthopaedic surgeon may be required to have knowledge or involvement in some aspect of fracture care despite their subspecialty practice. The text is designed for those who wish to review the surgical treatment of the conditions that commonly confront them while on call. As fracture surgery becomes more and more sophisticated, it is obvious that the technical component of operative intervention is critical to clinical success or failure. Therefore, there continues to be an important need to understand the technical aspects of fracture surgery. Many pearls of wisdom are detailed by the authors in order to deal with the multiple potential pitfalls seen in patients with complex fracture patterns. A large number of chapters have been written by a member of the Canadian Orthopaedic Trauma Society (COTS) who is an expert in that particular area. COTS is a group of orthopaedic trauma surgeons with outstanding surgical skills who are

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recognized leaders in their field. In addition, through prospective and randomized trials, they are at the forefront of developing the evidence that exists for management of the patient with a fracture. Each chapter provides comprehensive technical descriptions supported by the best evidence in that area. We believe that the production qualities of this text are the highest possible. The illustrations in particular are outstanding and clearly define the complex technical aspects of fracture surgery. We would like to thank all the members of COTS who were contributors to this volume for their outstanding efforts in making it a success. We feel this text should prove to be the “resource of choice” for modern fracture care over the next several years. It will serve those who are novices in the field who wish to concentrate on principles, those experienced surgeons who wish to “fine–tune” their approach, and everyone in between. Emil H. Schemitsch, MD, FRCS(C) Michael D. McKee, MD, FRCS(C)

Foreword This textbook represents the thoughts of a unique group of orthopaedic surgeons. It is a synopsis of current thinking in surgery from a diverse but united group of physicians known as COTS. The Canadian Orthopaedic Trauma Society (COTS) is active as a sub-section of the Canadian Orthopaedic Association. COTS has been an avid leader in multi-center research studies for about two decades. This group has grown to over 50 members with the responsibilities of biannual research meetings and multiple study designs. They are a multiple award-winning group that has changed the way many simple and some complex problems are solved. The success of this group as a major force in conducting prospective multicenter randomized trials has been well recognized by many including the Canadian Orthopaedic Association who awarded the group the Award of Merit for their performance. The COTS group has won many awards from the world trauma organizations as a testament to their excellence in the field of clinical randomized trials and their impact on changing the way we treat fractures in our day-to-day practice. The ability of this group to produce world-leading research is a testament to the Canadian norm of friendly accommodation. Canadian demeanor is often a joke in other countries; Canada is seen as the overly polite country. It certainly has been in this spirit of accommodation that the varied COTS undertakings were shuttled along to completion with input from dozens of people in almost every phase of project development and completion. Ross Leighton, the current and only president of the organization since COTS was founded, has been instrumental in maintaining the collegiality that drives purposeful projects. The current group of authors, led by editors Emil H. Schemitsch and Michael D. McKee, has once again been able to produce a literary gem that can be used by residents and

staff as a resource for expert opinion on the best ways to “skin the cat.” Certainly there is more than one way to tackle the problems than presented here; but the textbook shows a tried and true method in the hands of each author. The method of approaching each area with pearls and pitfalls will be of great benefit to everyone involved in patient care. This book should find its way into every program’s library and the bookcase of most surgeons performing trauma cases. I have to reiterate Dr. Leighton’s words in saying that the COTS group is a great group of orthopaedic surgeons and I am lucky to have been around to participate with the cohort of surgeons and thinkers that make up this organization. Some of the world’s best speakers, teachers, and researchers make up COTS. Many surgeons from other countries wish they were members of COTS and in practice many of them have become members in spirit, having adopted the basic principles and mechanisms of COTS. I know that COTS will continue to thrive for years to come. Their influence will grow and they will be a positive force in orthopaedic surgery. This text from that group should be a prime resource for current orthopaedic trauma care. The COTS group would like to dedicate this book to the families who continue to support us despite the long hours and many missed family events, due to the erratic nature of our specialty. Their support is essential to our continued success. We also acknowledge the tireless dedication of the research coordinators and staff who make COTS a rich and viable association. Edward J. Harvey, MDCM, MSc, FRCSC Professor of Surgery McGill University Montreal QC Canada, COTS Member

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Contributors Mansour Abolghasemian, MD Orthopedic Surgery Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences Tehran, Iran, Islamic Republic Of Henry Ahn, MD, PhD, FRCSC Department of Surgery University of Toronto Toronto, Ontario, Canada Amro Alhoukail, MD, FRCSC Trauma and Reconstruction Fellow Orthopedic Surgery Dalhousie University Halifax, Nova Scotia, Canada Saad M. AlQahtani, MD, FRCSC Division of Orthopedics Sunnybrook Health Sciences Centre Department of Orthopedic Surgery University of Dammam Dammam, Saudi Arabia Kelly Apostle, MD, FRCSC Clinical Assistant Professor Department of Orthopaedics University of British Columbia New Westminster, British Columbia, Canada Diren Arsoy, MD, MSc Assistant Professor Department of Orthopaedics and Rehabilitation School of Medicine Yale University New Haven, Connecticut, United States George Athwal, MD, FRCSC Professor of Surgery Roth | McFarlane Hand and Upper Limb Center St. Joseph’s Health Care, University of Western Ontario London, Ontario, Canada David Backstein, MD, MEd, FRCSC Division Chief Granovsky Gluskin Division of Orthopaedics Univerity of Toronto Toronto, Ontario, Canada

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Rohit Bansal, MBBS, MS(ortho), D.Ortho Clinical Fellow (Orthopaedic Trauma) Department of Orthopaedic Surgery Foothills Medical Centre University of Calgary Calgary, Alberta, Canada Carl J. Basamania, MD Division of Orthopaedic Surgery Tygerberg Academic Hospital Division of Orthopaedic Surgery Department of Surgical Sciences Stellenbosch University Tygerberg, South Africa The Polyclinic and Swedish Orthopaedic Institute Seattle, Washington, United States Greg Berry, MDCM, FRCSC Assistant Professor Faculty of Medicine McGill University Staff Orthopaedic Surgeon Montreal General Hospital McGill University Health Centre Montreal, Québec, Canada Mohit Bhandari, MD, PhD, FRCSC Professor McMaster University of Health Research Methods, Evidence, and Impact McMaster University Department of Surgery, Division of Orthopaedics Hamilton, Ontario, Canada Ryan T. Bicknell, MD, MSc, FRCS(C) Associate Professor Departments of Surgery/Mechanical & Materials Engineering Queen’s University Kingston, Ontario, Canada Michael Blankstein, MSc, MD, FRCSC Orthopaedic Surgeon Orthopaedics and Rehabilitation University of Vermont Medical Center Burlington, Vermont, United States

PROCEDURE 1

Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation Michael D. McKee and Alireza Naderipour INDICATIONS • Acute injury • Grades IV, V, and VI in most patients unless surgery is contraindicated owing to medical or psychological factors • Grade III in selected patients, including heavy laborers (lifting, carrying) and overhead athletes/workers • Chronic injury • Grade II in patients with symptomatic anterior-posterior instability • Grades III, IV, and V in patients with symptomatic instability 

PHYSICAL EXAMINATION • Evaluate shoulder posture. • Determine the position of the distal clavicle relative to the acromion. • The deformity is more visible in standing or sitting position without support for the injured arm. • In grade IV dislocations, the clavicle is posterior to the acromion and stuck in the trapezius. • The distal end of the clavicle is level or superior to the acromion in other grades. • The distal clavicle is sitting subcutaneously, through the trapezius, in grade V injuries. • In contrast to higher grades, the acromioclavicular (AC) joint is reducible in grade III by applying an upward force on the ipsilateral elbow. • Assess horizontal stability by grasping and moving the clavicle. • Examine sternoclavicular (SC) joint for possible bipolar dislocation (synchronous AC and SC dislocation). • Assess active and passive shoulder motions. • AC joint pain is accentuated by abduction and cross-body adduction. • Manage glenohumeral stiffness prior to reconstruction of chronic separation. • Isolated AC injury does not typically produce decreased shoulder range of motion. • Evaluate deltoid and rotator cuff strength. • Consider the rare occurrence of concomitant rotator cuff pathology. • Perform neurovascular examination. 

IMAGING STUDIES • Plain radiographs • True anteroposterior view of the shoulder • Evaluate the glenohumeral joint. • Look for bony signs of rotator cuff pathology. • Axillary view will demonstrate posterior displacement of the clavicle in grade IV injuries. • Outlet/scapular Y view • Evaluate acromial anatomy. • The presence of a spur may warrant acromioplasty. • Bilateral anteroposterior acromioclavicular views (Zanca view) • Evaluate the acromioclavicular joint position. • Look for possible arthritic changes. • Compare coracoclavicular distance on both sides. • Normal coracoclavicular distance is 11 to 13 mm.

PITFALLS

• Acute injury • Skin abrasion: wait until healed • Noncompliant patient • Patient with substance abuse • Chronic injury • Noncompliant patient CONTROVERSIES

There is no consensus on • Optimum timing of surgery • Anatomic vs. nonanatomic reconstruction • Best type of graft • Acute repair of grade III injuries • Operative treatment of acute injuries is the only treatment that will restore normal anatomy, but it is associated with greater risk of complications. • Although often recommended, insufficient evidence exists to recommend surgery for heavy laborers or overhead athletes. • Successful nonsurgical treatment of type III injuries in professional athletes has been reported. • Inclusion of distal clavicle excision in management of chronic cases • Preserving distal clavicle may add to the stability of reduction. • Reduction of an already arthritic distal clavicle may produce or aggravate pain. • Resection of distal 1 cm of clavicle results in a 32% increase in posterior translation. • Resection of as little as 2.3 mm in women and 2.6 mm in men could release the clavicular insertion of the acromioclavicular (AC) ligaments in some patients. • Some studies suggest improved outcomes with preservation of the distal clavicle during AC reconstruction. TREATMENT OPTIONS

• Nonoperative treatment • Indicated for grade I and II and most grade III injuries • Good short-term results • 10% to 20% of patients will have residual symptoms and may need subsequent surgery. • Nonoperative treatment of high-grade injuries (IV, V) may be acceptable, but has a higher rate of poor outcome. • A short course (1–3 weeks) of sling support or immobilization may be used for comfort, Continued

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2

PROCEDURE 1  Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

TREATMENT OPTIONS—cont’d

but strict or prolonged immobilization should be avoided. • Physical therapy • Early passive and active assisted range of motion (ROM) exercises • When painless ROM is achieved, proceed to isometric periscapular and rotator cuff strengthening, followed by isotonic exercises. • Avoid contact sports and heavy lifting for 3 months. • Operative treatment • Components of optimal surgical technique • Anatomic reduction of acromioclavicular joint • Coracoclavicular ligament repair/ reconstruction • Acromioclavicular ligament repair/ reconstruction • Protection/augmentation of repair/ reconstruction • Deltoid/trapezoid fascia repair • Distal clavicle resection, if arthritic • Acute injury • Coracoclavicular ligament repair and augmentation • Multiple techniques have been described to stabilize the AC joint with autograft/ allograft tendon or ligament augmentation devices around the coracoid. • Transarticular acromioclavicular pin fixation • Needs limited dissection • Risk of pin migration/breakage significant, largely abandoned • Acromioclavicular hook plate • Mechanically very effective • May result in acromial wear or fracture • Newer hook designs that match acromial anatomy preferred • Avoid over-reduction • Most, but not all, patients require eventual hook plate removal. • Weaver-Dunn acromioclavicular ligament transfer • 40% failure rate, not used in isolation • Provides 25% of intact coracoclavicular ligament strength • Strength can be drastically increased by adding synthetic loop augmentation • Coracoclavicular screw fixation • Has a high failure rate, not used in isolation • Acromioclavicluar ligament repair • Imbrication of the torn AC ligaments • Chronic injury • Coracoclavicular ligament reconstruction with • Tendon graft • Synthetic loops • Weaver-Dunn procedure • Conjoined tendon transfer • Acromioclavicluar ligament reconstruction with • Suturing of the remaining coracocalvicular (CC) graft around the AC joint • Intramedullary free tendon graft • Reverse coracoacromial ligament



• Stress views • Originally described to differentiate between type II and type III injuries • Stress views are costly and uncomfortable for the patient and rarely provide new information to help diagnose an unstable injury. • Advanced imaging should be considered only if evaluation suggests rotator cuff or intraarticular glenohumeral pathology. • Magnetic resonance imaging may be indicated to evaluate the rotator cuff in chronic injury. 

SURGICAL ANATOMY • Clavicle • The distal clavicle forms the medial articulation of the acromioclavicular joint. • Acromion •  The acromion forms the lateral aspect of the acromioclavicular joint and typically slopes posteriorly and laterally. Newer designs of hook plates ­ ­recognize this. • The anterior acromion is also the site of coracoacromial ligament insertion, which is used in the Weaver-Dunn procedure. • Acromioclavicular joint • The orientation of the joint varies from vertical to 50 degrees oblique from inferomedial to superolateral. • The intraarticular meniscus • Made of fibrocartilage • True function unknown • Undergoes significant degeneration over time • Acromioclavicular ligaments • The posterior acromioclavicular ligament is an important restraint to posterior translation of the acromioclavicular joint. • The superior acromioclavicular ligament contributes to a lesser extent to restraint of posterior translation of the acromioclavicular joint. • The inferior acromioclavicular ligament contributes to restraint of anterior translation of the acromioclavicular joint. • Isolated disruption of the acromioclavicular ligament occurs in grade II injuries. • Coracoclavicular ligaments • The conoid ligament is a more medial structure that attaches on the conoid tubercle on the underside of the distal clavicle. The conoid tubercle is located at the juncture of the lateral and medial thirds of the clavicle. • The trapezoid ligament is more lateral and attaches on the trapezoid line of the inferior clavicle. •  Disruption of the acromioclavicular and coracoclavicular ligaments occurs in grades III, IV, V, and VI injuries. • Muscular anatomy • Trapezius, pectoralis major, and anterior deltoid muscles attach to the distal clavicle and acromion. • Their combined action provides dynamic stability to the acromioclavicular joint. • Neurologic anatomy • Brachial plexus, suprascapular, and musculocutaneous nerves are in the vicinity and could be injured in reconstruction surgeries. • AC joint is innervated by lateral pectoral, axillary, and suprascapular nerves. • Vascular anatomy • Branches of the thoracoacromial artery run in the vicinity of the distal clavicle and can bleed during the dissection and exposure of the base of the coracoid. 

POSITIONING • The patient is placed in the beach chair position, with the surgical field draped out, bony landmarks outlined, and the skin incision marked. • Neck alignment should be in a neutral position with the head on an adjustable articulating headrest or gel pad “donut.”

PROCEDURE 1  Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

• If desired, an articulating arm holder is used to support and position the arm during the procedure. Alternatively, the arm may be secured at the patient’s side. • A side pad is placed against the lateral chest to keep the patient from falling off the side of the table. 

• Articulating sterile arm holder • Gel headrest • Side pad

PORTALS/EXPOSURES

PITFALLS

• A superior surgical approach is used. • An incision is made along Langer’s lines over the distal end of the clavicle. • Begin just posterior to the clavicle and extend toward the coracoid process. 

PROCEDURE: HOOK PLATE FIXATION Step 1: Skin Incision and Surgical Dissection • Surgical incision is made along Langer’s lines. • Continue dissection through the subcutaneous tissue. • The skin and subcutaneous tissue are elevated to extend exposure medially and laterally to expose the distal 3 to 4 cm of the clavicle and the acromion.

Step 2: Acromioclavicular Joint Exposure and Mobilization • The deltotrapezial fascia is split over the distal clavicle and acromion. • Typically the acromioclavicular joint capsule and ligaments are disrupted by the injury. Be alert for this disruption and work through any defects created by the injury. • The meniscus is debrided. • Look for arthritic changes. Distal clavicle resection should be considered in chronic cases with frank arthritic changes. • Mobilize the distal clavicle and ensure that it can be reduced. 

Step 3: Hook Plate Insertion • Anterior deltoid is elevated off the distal clavicle, subperiosteally and retracted anteriorly. • Cauterize vessels imbedded in subdeltoid fatty tissue. • Open the subacromial space with a Cobb or periosteal elevator and insert the hook portion of the hook plate. This typically will be posterior in the subacromial space. • Use the hook plate trials to determine the correct height of the hook plate to be inserted; be careful not to over-reduce the joint. The clavicle should not require excessive force to reduce (Fig. 1.1). • Insert the chosen hook plate and then place the screws in the plate, which will bring the plate down to the clavicle. • Be careful that insertion of the screws in the shaft portion of the clavicle does not “lever” the clavicle down further. • If there is any question as to reduction, use radiographic imaging to ascertain this. Considerable variation exists in AC joint pathology: a preoperative radiograph of the opposite side can be useful to gauge proper reduction. 

Step 4: Optional Coraco-Acromial (CA) Ligament Transfer • If desired, especially in the chronic situation where an acute healing response will not occur, a CA ligament transfer can be performed in addition. • This Weaver-Dunn transfer can be performed by releasing the CA ligament from the acromion and inserting it through drill holes in the distal clavicle. • Alternatively, a small fragment of acromion can be resected with the CA ligament and then secured with a lag screw to a corresponding slot cut into the distal anterior acromion. This provides biologic healing and ligamentous stability following eventual hook plate removal. 

Step 5: Optional Coracoclavicular Augmentation • Acute repair • The coracoclavicular sutures (nonabsorbable no. 5 suture or 5-mm suture tape) are passed under the coracoid. • The clavicle is held reduced to the acromion with direct downward push on the distal clavicle and upward pressure on the arm through the elbow. • Tie the sutures over the plate.

EQUIPMENT

• Keep the neck aligned in neutral rotation and flexion/extension position to protect the cervical spine and prevent brachial plexus injury. PEARLS

• Drape high on the neck and inferior enough on the chest to have an adequate surgical field. • If a difficult reduction is anticipated, drape the operative arm free. • Position the shoulder in a way that imaging can be used if needed. PEARLS

• An incision parallel to Langer’s lines will heal with a very cosmetic scar. PITFALLS

• An incision that is too lateral limits exposure of the clavicle. • An incision that is too medial limits access to the acromion. • A longitudinal incision in line with the clavicle, across Langer’s lines, may heal with a thick, noncosmetic scar. INSTRUMENTATION/IMPLANTATION

• Place a self-retaining retractor to hold the skin and subcutaneous tissue apart. PEARLS

• Release enough capsule and soft tissue to facilitate anatomic reduction of the distal clavicle. • Have a preoperative radiograph of the opposite side. PITFALLS

• Avoid over-reduction of the AC joint: this leads to a painful, stiff shoulder with a high rate of subsequent mechanical failure (plate pull-off, acromial fracture) (Fig. 1.2) • Excessive distal clavicle resection potentially destabilizes the acromioclavicular joint by releasing the acromioclavicular ligaments. INSTRUMENTATION/IMPLANTATION

• Hook plate implants, including trials and definitive implants • Newer hook plate designs provide a better fit to the undersurface of the acromion and may minimize complication and removal rates (Fig. 1.3). • Power saw, osteotome or chisel for distal clavicle resection

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PROCEDURE 1  Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

B A

C

D FIG. 1.1  Proper alignment and positioning of the hook plate results in rapid healing in an anatomic position.

19 mm

B

A

C

D

FIG. 1.2  Over reduction of the clavicle is to be avoided as it increases pain and can lead to acromial erosion of the hook.

PROCEDURE 1  Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

A

B FIG. 1.3  The angle of the hook should match the usually sloped angle of the acromion.

• Chronic reconstruction • Tendon ends are prepared with passing sutures. • Tendon ends are passed under the coracoid. • The tendon ends are pulled up through clavicle drill holes or over the clavicle itself and tied into place. Avoid making the superior aspect of the graft too bulky: it will interfere with the hook plate placement. • Stability is then enhanced by the addition of the hook plate over top of the tendon graft. Once graft healing has occurred, typically 6 to 8 months postoperatively, the hook plate may be removed. 

Step 6: Deltotrapezial and Acromioclavicular Repair •  The acromioclavicular ligaments and capsule are repaired over the acromioclavicular joint, incorporating the lateral extension of the tendon graft for a chronic reconstruction. • The deltotrapezial fascia is sutured over the clavicle with nonabsorbable suture. 

CONTROVERSIES

• Distal clavicle resection is controversial. • Distal clavicle resection • May facilitate reduction • May prevent late acromioclavicular arthritis • At least partial resection is required for Weaver-Dunn procedure for ligament reattachment. • Preserving the distal clavicle • May facilitate acromioclavicular ligament repair • May improve acromioclavicular joint stability • Isolated coracoclavicular ligament reconstruction does not require distal clavicle resection.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

INSTRUMENTATION/IMPLANTATION

• A sling is used to support the arm for 6 weeks. • Physiotherapy protocol • 0–2 weeks: No shoulder motion is permitted. • 2–6 weeks: The sling is discontinued and supine passive and active assisted external rotation and scapular plane elevation is begun. • 6–12 weeks: Passive and active-assisted range of motion in all planes. Isometric deltoid and rotator cuff exercises below chest level are started. • >12 weeks: Progressive resisted exercises are begun. • 16 weeks: Return to sports is allowed if range of motion is full and strength is adequate. • Most patients attain a shoulder rating of 90+ after hook plate fixation of acute AC joint disruptions. The major complication rate is low, as long as over-reduction is avoided. • Most, but not all, patients require hook plate removal: it is recommended that the plate be left in place for at least 6 months prior to removal to allow adequate healing to occur to prevent re-displacement of the joint.

• Power drill or burr to make holes in the clavicle for suture and tendon passing CONTROVERSIES

• Coracoclavicular fixation can be achieved with heavy sutures, acromioclavicular hook plate, coracoclavicular screw, transarticular acromioclavicular screw, or pins. • When patient compliance is a concern, early motion is desired, or in a revision setting, the tendon graft is best supplemented with a hook plate. • Supplementing the graft with hook plate has been shown to result in less displacement in biomechanical testing. PEARLS

• Early motion is advantageous.

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PROCEDURE 1  Acromioclavicular Joint Injuries: Open Reduction and Internal Fixation

6 PITFALLS

• Overly aggressive early rehabilitation can lead to attenuation or failure of the repair or reconstruction.

EVIDENCE Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS. Management of acromioclavicular joint injuries. J Bone Joint Surg [Am]. 2014;96:73–84. A comprehensive review of modern treatment methods for acromioclavicular joint injuries. Galpin RD, Hawkins RJ, Grainger RW. A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations. Clin Orthop. 1985;193:150–155. This older retrospective review revealed that there was little improvement with surgical treatment of acute acromioclavicular joint injuries and recommended nonoperative treatment in general. Gstettner C, Tauber M, Hitzl W, Resch H. Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment. J Shoulder Elbow Surg. 2008;17:220–225. A retrospective study (mean follow-up 34 months) of 24 patients treated surgically with a hook plate and 17 patients treated conservatively. The mean Constant score was 80.7 in the conservative group and 90.4 in the hook plate group. The mean coracoclavicular distance was 15.9 mm in the conservatively treated group and 12.1 mm in the surgically treated group. In this study, better results were achieved by surgical treatment with the hook plate than by conservative treatment. Salem KH, Schmelz A. Treatment of Tossy III acromioclavicular joint injuries using hook plates and ligament suture. J Orthop Trauma. 2009;23:565–569. A study of 25 patients revealed the hook plate was a reliable fixation tool for complete AC joint dislocations, ensuring immediate stability and allowing early mobilization with good functional and cosmetic results (mean Constant score 97 points). Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomized prospective controlled trial. J Bone Joint Surg. 1989;71B(5):848–850. This study of 60 patients failed to reveal any improvement with surgery, in general. The authors postulate that patients with severe displacement (>2 cm) may benefit from surgery. von Heideken J, Windhamre HB, Une-larsson V, Ekelund A. Acute surgical treatment of acromioclavicular dislocation type V with a hook plate: superiority to late reconstruction. J Shoulder Elbow Surg. 2013;22:9–17. Patients treated with acute surgery (22) had a more satisfactory outcome than those with late surgery (15) after failed conservative treatment. Pauly S, Kraus N, Greiner S, Scheibel M. Prevalence and pattern of glenohumeral injuries among acute high-grade acromioclavicular joint instabilities. J Shoulder Elbow Surg. 2013;22:760–766. A review of 125 patients with high grade AC joint injuries who underwent shoulder arthroscopy revealed a high rate of intra-articular glenohumeral pathology (30%). Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromio-clavicular joint dislocation. J Orthop Trauma. 2015;29(11):479– 487. A clinical trial of 83 patients randomized to hook plate fixation versus nonoperative treatment. Although hook plate fixation resulted in superior radiographic alignment, it was not clinically superior to nonoperative treatment of acute complete dislocations of the acromioclavicular joint. Both groups improved from a significant level of initial disability to a good or excellent result (mean DASH score, 5–6; mean Constant score, 91–95 in both groups) at 2 years.

PROCEDURE 65

Sacroiliac Joint Injuries: Iliosacral Screws Milton Lee (Chip) Routt, Jr.

INDICATIONS PITFALLS

• Accurate assessment of SI joint instability is based on physical examination, plain pelvic radiographs, computed tomography (CT) scans, and dynamic imaging during stress examination. • Complete and incomplete SI joint instability is commonly noted on pelvic imaging. • SI joint instability may not be obvious if the pelvic imaging was performed after a circumferential pelvic wrap was applied; the pelvic wrap often produces an accurate SI joint reduction.

INDICATIONS CONTROVERSIES

• Controversy still exists in reliably diagnosing and safely treating incomplete posterior pelvic injuries. • The role of posterior pelvic instability in chronic symptomatic symphysis pubis instability remains controversial.

INDICATIONS • Unstable sacroiliac (SI) joint traumatic disruptions • Unstable SI fracture-dislocations • Symptomatic sacroiliac joint arthritis • Symptomatic chronic posterior pelvic instability 

EXAMINATION/IMAGING • The physical examination identifies open wounds, closed degloving injuries, ecchymoses, prior scars, urethral meatal blood, rectal blood, vaginal-labial injuries, and neurovascular injuries. • Manual compression toward the midline applied over each iliac crest during the physical examination reveals instability. • For the injured patient, anteroposterior (AP) pelvic radiograph prior to circumferential pelvic wrapping • Same patient, AP pelvic radiograph after wrap application • The pelvic CT reveals injury sites, displacements, deformities, body habitus, hematoma location and extent, and associated injuries. 

SURGICAL ANATOMY TREATMENT OPTIONS

• Closed reduction and percutaneous fixation (CRPF) is used whenever possible. • CRPF relies routinely on intraoperative fluoroscopy to both assess the reduction and direct the iliosacral screw insertion. • Usually incomplete SI joint injuries will indirectly reduce when the anterior pelvic injury is reduced, or when the precisely oriented lag screw compresses the residual SI joint distraction. • Open reduction internal fixation (ORIF) of the SI joint is selected when closed reduction techniques fail or are not possible. • Open reduction of the SI joint is performed using either an anterior exposure with the patient positioned supine, or via posterior surgical exposure in the prone position.

• The SI joint is an unusual articulation composed of iliac and sacral articular pads surrounded by strong ligaments. • The fifth lumbar nerve root is located on the sacral ala just medial to the anterior SI joint. • For reliable and safe iliosacral screw insertions, the upper sacral osteology (including sacral dysmorphism) must be identified and quantified on the preoperative imaging. • Hip flexion during the anterior surgical exposure for ORIF relaxes the iliopsoas muscle, eases retraction, and improves exposure of the anterior joint surface. • Aggressive medial retraction and/or clamp application along the lateral sacral ala during the anterior ORIF risks injury of the fifth lumbar nerve root. • Wound complications are more common when the posterior exposure is selected for ORIF. • Iliosacral screws can be safely inserted with the patient properly positioned either supine or prone. 

POSITIONING PEARLS

• The folded blanket is adjusted in thickness to elevate the pelvis from the OR table sufficiently to allow iliosacral screw insertion. • The surgeon must ensure that the eyes are free of pressure, the genitals are positioned appropriately, and that all bony prominences are well padded when the patient is positioned prone. • Prior to draping, use the C-arm to ensure that the patient is well positioned so that all appropriate images can be easily obtained.

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• When the supine position is selected, a folded operating room (OR) blanket is used to elevate the patient and pelvis from the OR table so the iliosacral screws can be inserted easily. • Skeletal traction is used as a reduction aid when necessary. • Positioning the patient supine allows surgical access to both the anterior pelvic ring and the anterior SI joint. • Prone positioning is more difficult in patients with anterior external fixation devices. •  The prone position denies the anesthesiologist easy access to the airway, and the surgeon must ensure that there is no pressure on the eyes during the surgery. • The upper extremities are positioned so they do not obstruct either pelvic imaging or iliosacral screw insertion. 

PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

PORTALS/EXPOSURES • The anterior SI joint is accessed using the lateral surgical interval of the ilioinguinal exposure. Hip flexion relaxes the iliopsoas muscle for easier retraction and improved visualization. • Because of the SI joint’s unusual osteology, the posterior surgical exposure only reveals the caudal articular facet, whereas the anterior articular reduction is assessed by palpation. • The iliosacral screw’s starting point and directional aim are planned preoperatively using the pelvic CT scan and then determined intraoperatively using inlet, outlet, and true lateral sacral fluoroscopic imaging.  PORTALS/EXPOSURES PEARLS

• A comprehensive preoperative plan includes the details of patient positioning, reduction maneuvers, clamp application, and iliosacral screw insertion. • The pelvic CT scan identifies and quantifies the parameters for the planned osseus fixation pathways. • To optimize screw accuracy, the three-dimensional (3D) surface rendered pelvic CT models are correlated with the intraoperative fluoroscopy views. PITFALLS

• SI joint malreduction decreases the area available for the iliosacral screw within the osseus fixation pathway. • Reduction clamps or the screws used to attach them to the bone should be positioned so that they do not obstruct the iliosacral screw insertion. PORTALS/EXPOSURES EQUIPMENT

• A poor quality C-arm unit will not produce sufficient images for safe screw insertion. • A radiology technician who does not pay attention to the intraoperative imaging details will add unnecessary radiation exposure, time, and cost to the operation. For numerous reasons, an attentive and skilled radiology technician is a critical part of the procedure.

CONTROVERSIES

• When prone posterior ORIF is selected, the reduction clamp is applied to the anterior sacral ala through the greater sciatic notch based on digital palpation of the anterior SI joint alone. This “blind” clamp application remains quite controversial and is not advocated. • The prone posterior surgical exposure remains controversial because it has been associated with higher wound complication rates.

PROCEDURE Step 1 • In patients with an incomplete SI joint injury, accurate reduction of the anterior pelvic ring injury (symphysis pubis, pubic ramus, combination injury) often will indirectly reduce the SI joint. In these patients, iliosacral screws are inserted to stabilize the SI joint injury and support the overall fixation construct. Some evidence indicates that iliosacral screw fixation of incomplete SI joint injury decreases the rate of failure of anterior fixation. If compression is needed to complete the SI joint indirect reduction, an initial iliosacral lag screw is inserted. • In patients with complete SI joint injuries, the anterior pelvic reduction may aid in the SI joint reduction. In these patients with residual SI joint uniform distraction after anterior pelvic reduction, an iliosacral lag screw is used to complete the reduction. Additional screws provide improved support for the SI joint. Multiple iliosacral screws inserted at multiple posterior pelvic levels have lower failure rates. • Open reduction is selected for those injuries when closed reduction fails. The clamp is applied so that it does not injure the fifth lumbar nerve root and does not obstruct the iliosacral screw fixation. 

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PITFALLS

• If the folded blanket is too thick, the pelvis will be overly elevated from the OR table causing un unstable patient position. • Once the patient is positioned and before draping, the necessary intraoperative fluoroscopy images should be obtained. Any positioning changes should be made prior to draping. • The surgical draping should be inclusive of all necessary exposures and implants. • Urethral meatal necrosis can result when the urinary catheter is poorly positioned. Similarly, the patient’s scrotum should not be crushed between his thighs during surgery. • Femoral vein and/or artery catheters and suprapubic catheters should be prepared and draped into the sterile field when necessary rather than removed. POSITIONING EQUIPMENT

• The C-arm is located on the opposite side from the surgeon. • The C-arm unit tilts and positioning are adjusted after the patient is positioned and prior to draping. The x-ray technician should mark the floor and C-arm machine so the necessary intraoperative images remain consistent throughout the operation. CONTROVERSIES

• Some surgeons prefer prone patient positioning for the ease of access to the posterior pelvic ring during iliosacral screw insertion. • Supine positioning allows the surgeon to access the anterior pelvic ring without compromising surgical access to the SI joint. • Insufficient imaging may result from poor patient positioning, morbid obesity, osteoporosis, residual bladder or bowel contrast agents, excessive flatus, among others. PEARLS

• Accurate reduction of the anterior pelvic injury will often result in an excellent indirect reduction of the SI joint. • In ORIF, the clamp must be properly located in order to provide uniform compression across the SI joint during the iliosacral screw fixation. PITFALLS

• The reduction clamp should not obstruct the optimal iliosacral screw pathway. • Poor positioning of the reduction clamp usually results in a poor reduction. INSTRUMENTATION/IMPLANTATION

• The optimal location for the iliosacral screw is best planned preoperatively using the CT scan. • For patients with a symmetric upper sacrum and a unilateral SI joint injury, the uninjured side is used for preoperative iliosacral screw planning.

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PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

CONTROVERSIES

• Controversy persists on the value of accurate anterior pelvic reduction prior to posterior.

Step 2 • The caudal anterior pathway of the sacral alar ellipsoid is selected because it is the most reliable initial iliosacral screw site. • Using inlet and outlet posterior pelvic imaging, a narrow diameter smooth Kirschner wire (K-wire) is used to identify the optimal skin insertion site and ideal directional aim. The wire is then inserted approximately 1 cm through the lateral iliac cortical bone. • The skin incision is then made and the cannulated drill is applied over the K-wire and oscillated into the lateral iliac bone. • The caudal-anterior location allows the drill to be advanced safely until the drill tip is located 2 to 3 mL lateral to the visible S1 nerve root tunnel, best seen on the outlet image. • The true lateral image is then obtained by superimposing the greater sciatic notches and iliac cortical densities. • The true lateral image is used to confirm the accurate location of the drill tip within the safe osseous fixation pathway. The drill tip should be located caudal to the sacral ala-iliac cortical density, posterior to the anterior cortical limit of the vertebral body, cranial to the S1 tunnel, and well anterior to the spinal canal. 

PEARLS PEARLS

• Using the cannulated drill to prepare the pathway first instead of completely inserting the guide pin allows a more precise pathway preparation. Thinner diameter guide pins often become misdirected, resulting in a poorly located screw. • The posterior iliac tangential image demonstrates the washer as it contacts the bone surface. The washer is used to decrease the chance of unwanted screw intrusion through the lateral iliac cortical bone surface.

• The intraoperative pelvic inlet image is optimized by superimposing the upper and second sacral vertebral bodies. • The mid-sagittal image on the injury pelvic CT scan demonstrates the ideal inlet tilt for each patient. • The intraoperative outlet tilt is best achieved when the cranial edge of the symphysis pubis is superimposed on the second sacral vertebral body. That tilt reveals the S1 nerve root tunnel anterior foramen. • For morbidly obese patients, the injury CT scan lateral scout image alerts the surgeon to potential intraoperative lateral fluoroscopic imaging difficulties. If the sacrum is not distinct on the CT scout lateral image, then the intraoperative lateral will be similarly obstructed by the soft tissues.

PITFALLS

PITFALLS

• If the cannulated drill exits the anterior vertebral body, the guide pin can inadvertently advance and injure the local neurovascular structures. • If the washer intrudes through the lateral iliac cortical bone, the iliosacral screw stability is compromised.

• Accepting a poorly located skin starting site will result in either an unacceptable lateral iliac bone insertion site or improper directional aim. • In morbidly obese patients, standard cannulated screw system guide pins, measuring devices, and screw drivers may be of insufficient length. Special longer instrumentation is available and should be utilized.

INSTRUMENTATION/IMPLANTATION

• Oblique iliosacral screws are more perpendicular to the SI joint surfaces than trans-sacral screws. • The oblique iliosacral lag screw compresses residual SI joint distraction. • Oblique iliosacral screws usually spare the majority of the SI joint articular surfaces, whereas transsacral screws penetrate the articular surfaces.

CONTROVERSIES

• Trans-sacral screws are controversial because they penetrate the uninjured SI joint and are riskier than oblique screws because they traverse the alar areas on both sides. • Trans-sacral screws result in better biomechanical construct strength, although it is unclear if this results in superior clinical outcomes.

CONTROVERSIES

• Controversy remains regarding the optimal iliosacral screw number, orientation, and length. • Some surgeons use only the lateral sacral image for iliosacral screw insertion. This is controversial because it limits the surgeon to just one style of iliosacral screw use.

Step 3 • Depending on the planned pathway, the drill is either advanced into the vertebral body or across the contralateral ala and SI joint, exiting the lateral iliac cortical bone. • If an oblique iliosacral screw is planned, the drill should not penetrate the anterior vertebral body cortical bone. • The guide pin for the cannulated screw system is then inserted into the drilled pathway, and the depth is assessed using a measuring device or guide pin of the same length. • The iliosacral screw and washer are inserted over the guide pin. • The C-arm is used at frequent intervals during screw insertion to ensure that the guide pin is not being inadvertently advanced. • At terminal tightening, the C-arm beam is oriented tangentially relative to the screw insertion site at the posterior lateral iliac cortical bone. The screw is tightened to approximate the washer against the lateral iliac cortical bone surface without intrusion. 

PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

Step 4 • Adding additional iliosacral screws improves stability and is performed whenever possible. • If the initial oblique screw is inserted in the caudal-anterior portion of the upper sacral safe osseus fixation pathway, the subsequent screw should be located slightly posterior and cranial to the initial screw in order to be properly contained. • If the initial screw has provided sufficient compression, the subsequent screw can be a fully threaded screw to maintain the reduction. 

Step 5 • The overall fixation construct is strengthened when both the unstable SI joint and the anterior pelvic injured are stabilized and reduced. • For more extensive injuries (e.g., “jumper’s fractures”), lumbopelvic fixation is added to augment the posterior pelvic stability. • Posterior trans-iliac screw and plating fixation techniques also have been described to supplement the iliosacral screw fixation. 

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PEARLS

• Safe and reliable iliosacral screw insertion occurs when the screw pathway is well planned, the osteology and its intraoperative imaging are completely understood, and the intraoperative imaging is high quality and consistent. PITFALLS

• Locating the initial screw in the middle area of the osseus fixation pathway improves the safety for that screw, but that location then adds risk to subsequent screw placement. CONTROVERSIES

• Using multiple screws (and/or trans-sacral screws) at multiple levels to further stabilize the SI joint injury remains controversial. No study has identified how much fixation is required to predictably provide durable stability until complete healing.

PEARLS

• The lumbopelvic supplemental fixation procedure is performed with the patient positioned prone after the SI joint injury has been reduced and stabilized. • Iliosacral screws are inserted before the lumbopelvic iliac bolts are placed. The LPF iliac bolts can be positioned to accommodate the iliosacral screws.

PITFALLS

• Failure to recognize, reduce, and stabilize the associated unstable anterior pelvic ring traumatic injury can result in posterior fixation failure. • Applying LPF or other implants prior to iliosacral insertion can obstruct the iliosacral screw’s optimal pathway.

INSTRUMENTATION/IMPLANTATION

• Malleable reconstruction plates and medullary ramus screws are used commonly to provide anterior pelvic fixation. • Safe iliosacral screws have a limited bone pathway, especially when trans-sacral screws are used. • LPF iliac bolts can be adjusted in position to avoid the iliosacral screws.

CONTROVERSIES

• Controversy remains concerning the number of iliosacral screws necessary to provide sufficient fixation

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Rehabilitation is guided by a licensed physical therapist whenever possible. • The patients use crutches or other assistive devices to unload the injured SI joint during gait. Protected weight bearing on the injured side is continued for 4 to 8 weeks after operation, depending on the injury and fixation details.

PITFALLS

• The fixation construct should be enhanced (i.e., more screws, more levels, trans-sacral screws) at surgery if patient noncompliance is anticipated prior to surgery.

CONTROVERSIES

• Noncompliant patients who exhibit early unprotected weight bearing have an increased risk of fixation failure.

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PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

EVIDENCE Lucas JF, Routt Jr ML, Eastman JG. A useful preoperative planning technique for transiliactranssacral screws. J Orthop Trauma. 2017;31(1):e25–e31. This article is a well-illustrated technique guide describing “state-of-the-art” planning for the insertion of trans-iliac and trans-sacral screws. Simonian PT, Routt Jr ML, Harrington RM, Mayo KA, Tencer AF. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instability and fixation. Clin Orthop Relat Res. 1994;309:245–256. A biomechanical study using seven cadaveric pelvii showed that plate fixation of the symphysis pubis alone reduced symphysis pubis motion, but not sacroiliac motion. Use of sacroiliac fixation alone without a symphysis pubis plate did not affect symphysis pubis motion. Both single iliosacral screws and plates produced equivalent decreases in sacroiliac joint motion. Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O’Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma. 1999;13(2):107–113. This paper describes the early results of 38 patients treated with iliosacral screw fixation for injuries of the SI joint. Nearly 44% of patients had some loss of reduction on final follow-up radiographs (malunion). It was recommended that iliosacral screw fixation be protected by anterior ring fixation. Carlson DA, Scheid DK, Maar DC, Baele JR, Kaehr DM. Safe placement of S1 and S2 iliosacral screws: the “vestibule” concept. J Orthop Trauma. 2000;14(4):264–269. This study attempted to determine the optimal starting points for placement of S1 and S2 iliosacral screws using normal subject study evaluating helical CT scans of 30 normal pelvic rings. Finding was that the transversely placed (horizontal) iliosacral screw was the least safe of the screws tested. The safest lateral ilium starting point for our entire population was at the posterior sacral body sagittally and at the inferior S1 foramen coronally. S2 iliosacral screws had less cross-sectional area for placement than S1 screws. Placement of the S2 screw slightly to the S1 foraminal side of the S2 vertebral body increased the safety of placement. Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma. 2004;18(3): 138–143. Anterior symphyseal plating for the vertically unstable hemipelvis significantly increases the stability of the fixation construct and restores the normal response of the hemipelvis to axial loading. A significant benefit to supplementary iliosacral screws, in addition to a properly placed S1 iliosacral screw, was not shown.

CONTRIBUTORS

Marissa Bonyun, MD Fellow Resident Department of Orthopedic Surgery University of Toronto Toronto, Ontario, Canada

Chad P. Coles, MD, FRCSC Associate Professor Division of Orthopaedic Surgery Dalhousie University Halifax, Nova Scotia, Canada

Steven Borland, MBChB, FRCS(Tr+Orth) Consultant Trauma and Orthopaedic Surgeon Department of Orthopaedic Surgery Royal Victoria Infirmary Newcastle Upon Tyne, United Kingdom

David W. Cruickshank, BSc, MD, FRCSC Assistant Professor Department of Surgery Queen’s University Kingston, Ontario, Canada

Karine Bourduas, MD, FRCSC Clinical Assistant Professor University of Montreal Montreal, Québec, Canada

Niloofar Dehghan, MD, MSc, FRCSC Orthopaedic Surgeon The CORE Institute Banner University Medical Center Phoenix, Arizona, United States Assistant Professor Department of Orthopaedic Surgery University of Arizona College of Medicine - Phoenix Phoenix, Arizona, United States

Henry M. Broekhuyse, MD Clinical Professor Department of Orthopaedic Surgery University of British Columbia Vancouver, British Columbia, Canada Richard E. Buckley, MD, FRCS Professor of Orthopedic Trauma Department of Surgery Foothills Medical Center, University of Calgary Calgary, Alberta, Canada Cory V. Carlston, MD Surgeon Department of Orthopaedics Adventist Medical Center Portland, Oregon, United States Damian Clark Oak Leigh House Bridge Road Leighwood, Bristol, United Kingdom Joseph B. Cohen, MD Assistant Professor of Orthopedic Trauma Department of Orthopedic Surgery and Rehabilitation Loyola University Medical Center Maywood, Illinois, United States Peter A. Cole, MD Chief Orthopaedic Surgery Regions Hospital St. Paul, Minnesota, United States Professor Orthopaedic Surgery University of Minnesota Minneapolis, Minnesota, United States

Johanna Charlotte Emilie Donders, MD Department of Orthopedic Trauma Service Hospital for Special Surgery New York, New York, United States Paul Duffy, BA (Hons), MD, FRCSC Division Chief Orthopedic Trauma Surgery Foothills Medical Centre Calgary, Alberta, Canada Uma E. Erard, DO, FAAOS Orthopaedic Foot and Ankle Surgeon San Antonio Military Medical Center San Antonio, Texas, United States Tym Frank, MD, MSc, FRCSC Fellow Department of Surgery Roth McFarlane Hand and Upper Limb Centre St. Joseph’s Health Care University of Western Ontario London, Ontario, Canada Andrew Furey, MD, MSc, FRCSC, MSM Associate Professor Department of Surgery Memorial University St. Johns, Newfoundland and Labrador, Canada Peter V. Giannoudis, MBBS, MD, FACS, FRCS Professor of Trauma and Orthopaedic Surgery School of Medicine University of Leeds Leeds, United Kingdom

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CONTRIBUTORS

Thomas J. Goetz, BSc(Eng), MD, FRCS(C) Clinical Professor Orthopaedics University of British Columbia Vancouver, British Columbia, Canada

Patrick Henry, MD Assistant Professor Surgery University of Toronto Toronto, Ontario, Canada

Wade Gofton, BScH, MD, MEd, FRCSC Associate Professor Department of Surgery University of Ottawa Ottawa, Ontario, Canada

James L. Howard, MD, MSc, FRCSC Program Director, Associate Professor Division of Orthopaedic Surgery Western University London, Ontario, Canada

John T. Gorczyca, MD C. McCollister Evarts Professor of Orthopaedics Chief, Division of Orthopaedic Trauma Department of Orthopaedic Surgery University of Rochester Medical Center Rochester, New York, United States

Adrian Huang, MB BCh BAO, FRCSC Clinical Instructor University of British Columbia Department of Orthopaedics Vancouver, British Columbia, Canada

Ruby Grewal, MD, MSc, FRCSC Associate Professor University of Western Ontario Roth | McFarlane Hand and Upper Limb Centre St Joseph’s Health Center London, Ontario, Canada Pierre Guy, MD, MBA Head Division of Orthopedic Trauma University of British Columbia Vancouver, British Columbia, Canada Director Centre for Hip Health and Mobility University of British Columbia Vancouver, British Columbia, Canada Jeremy A. Hall, MD, FRCSC, Med Assistant Professor Department of Surgery Division of Orthopaedics St. Michael’s Hospital University of Toronto Toronto, Ontario, Canada Chris Hamilton, MD, MSc, FRCSC Upper Limb Fellow Orthopaedic Surgery Dalhousie University Halifax, Nova Scotia, Canada Jonah Hébert-Davies, MD, FRCSC Assistant Professor Harborview Medical Center Seattle, Washington, United States David L. Helfet, MD Director Orthopaedic Trauma Service Hospital for Special Surgery/ New York Hospital New York, New York, United States

Stephen Hunt, P. Eng, MD, FRCSC Orthopedic Surgeon Department of Orthopedics South Health Campus Hospital Calgary, Alberta, Canada Clinical Lecturer University of Calgary Calgary, Alberta, Canada Ajmal Ikram, MMed(Orth), FC(Orth)SA Division of Orthopaedic Surgery Tygerberg Academic Hospital Division of Orthopaedic Surgery Department of Surgical Sciences Stellenbosch University Tygerberg, South Africa The Polyclinic and Swedish Orthopaedic Institute Seattle, Washington, United States Robert C. Jacobs, MD Orthopaedic Trauma Fellow Orthopaedic Surgery and Sports Medicine University of Washington Seattle, Washington, United States Richard Jenkinson, MD, MSc, FRCSC Head of Orthopaedic Trauma Surgery Sunnybrook Health Sciences Center Toronto, Ontario, Canada Assistant Professor Surgery University of Toronto Toronto, Ontario, Canada Assistant Professor Institute of Health Policy, Management and Evaluation University of Toronto Toronto, Ontario, Canada

CONTRIBUTORS

Aaron J. Johnson, MD Fellow Orthopaedics University of Maryland School of Medicine Baltimore, Maryland, United States

G. Yves Laflamme, MD, FRCSC Professor Department of Surgery University of Montréal Montréal, Québec, Canada

Clifford B. Jones, MD, FACS National Chief of Orthopaedic Trauma and Bone Health Center for Orthopedic Research and Education (CORE Institute®) Phoenix, Arizona, United States Professor Orthopaedic Surgery University of Arizona College of Medicine – Phoenix Center Chiefs for Orthopedic Trauma University Medical Center Banner University Medicine Orthopedics & Spine Institute Phoenix, Arizona, United States

Sebastien Lalonde, MDCM, FRCS(C) Assistant Professor, Hand and Microvascular Surgery Department of Orthopaedic Surgery University of Missouri Columbia, Missouri, United States

Graham King, MD, MSc, FRCSC Professor Department of Surgery Roth | McFarlane Hand and Upper Limb Center London, Ontario, Canada Paul R. King, MMed (Orth), FC(Orth)SA, Division of Orthopaedic Surgery Tygerberg Academic Hospital Division of Orthopaedic Surgery Department of Surgical Sciences Stellenbosch University Tygerberg, South Africa The Polyclinic and Swedish Orthopaedic Institute Seattle, Washington, United States Conor Kleweno, MD Associate Professor Harborview Medical Center Seattle, Washington, United States Hans J. Kreder, MD, MPH Professor Orthopaedic Surgery and Health Policy Evaluation and Management University of Toronto Toronto, Ontario, Canada Division of Orthopedics Sunnybrook Health Sciences Center Toronto, Ontario, Canada Adrian Z. Kurz, MD, FRCSC Resident Orthopedic Surgery McMaster University Hamilton, Ontario, Canada Paul R.T. Kuzyk, MD, MASc, FRCSC Assistant Professor Department of Surgery University of Toronto Toronto, Ontario, Canada

Robert P. Lamberts, MSc, PHD, FECSS Division of Orthopaedic Surgery Tygerberg Academic Hospital Division of Orthopaedic Surgery Department of Surgical Sciences Stellenbosch University Tygerberg, South Africa The Polyclinic and Swedish Orthopaedic Institute Seattle, Washington, United States Jean Lamontagne, MD, FRCSC Division Head Orthopaedic Surgery Québec, Québec, Canada Abdel-Rahman Lawendy, MD, PhD, FRCSC Associate Professor Department of Surgery Orthopedic Trauma Fellowship Director Chair Masters of Surgery Scientist Lawson Health Research Institute London, Ontario, Canada Vu Le, MD, FRCSC Orthopaedic Trauma Fellow Department of Orthopaedics University of British Columbia Royal Columbian Hospital New Westminster, British Columbia, Canada Kelly A. Lefaivre, MD, MSc, FRCSC Associate Professor Orthopaedic Surgery University of British Columbia Vancouver, British Columbia, Canada Ross Leighton, MD, FRCSC, FACS Orthopaedic Surgeon Surgery Nova Scotia Health Authority – Halifax Infirmary Halifax, Nova Scotia, Canada Professor Surgery Dalhousie University Halifax, Nova Scotia, Canada

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CONTRIBUTORS

Martin Lesieur, MD, B.Sc, FRCSC Orthopaedic Surgeon Orthopaedics Laval University Québec, Québec, Canada Allan S.L. Liew, MD, FRCSC Associate Professor of Surgery University of Ottawa Director of Orthopaedic Trauma The Ottawa Hospital Ottawa, Ontario, Canada Tyler R.S. MacGregor, BSc, MD, FRCSC Clinical Instructor Department of Orthopaedic Surgery Orthopaedic Surgeon Royal Inland Hospital (Kamloops B.C.) Kamloops, British Columbia, Canada Mark D. Macleod, MD, FRCSC Associate Professor Department of Surgery Western University London, Ontario, Canada Theodore T. Manson, MD Associate Professor Department of Orthopaedic Surgery R Adams Cowley Shock Trauma Center, University of Maryland Baltimore, Maryland, United States

Mark Miller, MD, FRCSC Clinical Fellow Department of Orthopaedics Division of Orthopaedic Trauma University of British Columbia Vancouver, British Columbia, Canada Saam Morshed, MD, PhD Associate Professor in Residence Orthopaedic Trauma Institute University of California San Francisco Department of Orthopaedic Surgery San Francisco, California, United States Alireza Naderipour, MD, FRCSC Clinical Fellow Orthopedic Surgery St. Michael’s Hospital Toronto, Ontario, Canada Aaron Nauth, MD, MSc Assistant Professor Division of Orthopaedic Surgery St. Michael’s Hospital, University of Toronto Toronto, Ontario, Canada Vasileios S. Nikolaou, MD, MSc, PhD Assistant Professor of Orthopaedics 2nd Department of Orthopaedics National and Kapodistrian University of Athens Athens, Greece

Jill M. Martin, MD Assistant Professor Department of Orthopaedic Surgery Medical College of Wisconsin Milwaukee, Wisconsin, United States

Markku T. Nousiainen, BA(Hons),MS, MEd, MD, FRCSC Program Director Division of Orthopaedic Surgery University of Toronto Toronto, Ontario, Canada

Christopher Ryan Martin MD, FRCSC Cumming School of Medicine University of Calgary Calgary, Alberta, Canada

Tyler Omeis, BSc, MD Surgical Resident Plastic Surgery University of British Columbia Vancouver, British Columbia, Canada

Michael D. McKee, MD, FRCS(C) Professor and Chairman Department of Orthopaedic Surgery University of Arizona College of Medicine – Phoenix Physician Executive Director Orthopaedic and Spine Institute Banner University Medical Center Phoenix, Arizona, United States Matthew Menon, MD, FRCSC, MHSc Associate Professor Department of Surgery University of Alberta Edmonton, Alberta, Canada

Peter J. O’Brien, MD, FRCSC Associate Professor Department of Orthopedics The University of British Columbia Vancouver, British Columbia, Canada Steven Papp, BSc, MSc, MDCM / FRCSC Associate Professor Orthopedic Surgery University of Ottawa Ottawa, Ontario, Canada

CONTRIBUTORS

Ryan A. Paul, BHSc, MD, FRCSC Clinical Fellow Roth | McFarlane Hand and Upper Limb Centre St. Joseph’s Health Care London, Ontario, Canada Bertrand Perey, MD, FRCSC Clinical Professor Department of Orthopaedics Surgery University of British Columbia Vancouver, British Columbia, Canada Brad Petrisor, MD, FRCSC Professor Surgery, Division of Orthopaedic Surgery McMaster University Hamilton, Ontario, Canada Orthopaedic Trauma and Foot and Ankle Reconstruction Surgeon Surgery Hamilton Health Sciences Hamilton, Ontario, Canada David Pichora, MD, FRCSC Professor Paul B. Helliwell Chair in Orthopedic research Professor of surgery and Mechanical and Materials Engineering Division of Orthopedic Surgery, Queen’s University Kingston, Ontario, Canada James Nelson Powell, MD Clinical Professor of Surgery Orthopedic Surgery Cumming School of Medicine University of Calgary Calgary, Alberta, Canada Darryl N. Ramoutar, MA, MBBChir, FRCS (T&O) Consultant Orthopaedic Trauma Surgeon University Hospitals Coventry and Warwickshire Warwick, United Kingdom Lee M. Reichel, MD Associate Professor Orthopedic Surgery Department of Surgery and Perioperative Care Dell Medical School Austin, Texas, United States Rudolf Reindl, MD, FRCSC Associate Professor Orthopedic Surgery McGill University Health Centre Montréal, Québec, Canada

David Ring, MD, PhD Associate Dean for Comprehensive Care Professor of Surgery and Psychiatry Department of Surgery and Perioperative Care Dell Medical School – The University of Texas at Austin Austin, Texas, United States Bill Ristevski, MD, MSc, FRCS(C) Associate Professor Department of Surgery, Division of Orthopaedic Surgery McMaster University Hamilton, Ontario, Canada Aaron M. Roberts Department of Orthopaedic Surgery University of Rochester Medical Center Rochester, New York, New York Dominique M. Rouleau, MD, MSc, FRCSC Associate Professor Université de Montréal Surgery Department Montréal, Québec, Canada Marie-Ève Rouleau, MPS University of Québec at Montreal Montreal, Québec, Canada Milton Lee (Chip) Routt, Jr., MD Professor and the Andrew R. Burgess M.D. Endowed Chair Orthopaedic Surgery University of Texas Health, McGovern Medical School Houston, Texas, United States H. Claude Sagi, MD, FACS Professor Director Division of Trauma Program Director Orthopedic Trauma Fellowship Department of Orthopedic Surgery and Sports Medicine Cincinnati, Ohio, United States David W. Sanders, MD, FRCSC Professor Orthopedic Surgery Western University London, Ontario, Canada Emilie Sandman, MD Associate Clinical Professor Université de Montréal, Surgery Department Montréal, Québec, Canada

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CONTRIBUTORS

Bruce J. Sangeorzan, MD, FAAOS, FAOA Professor Department of Orthopedics and Sports Medicine University of Washington Director CLiMB, VA Center for Limb Loss and Mobility Deputy Editor Journal of Bone and Joint Surgery Past President of American Orthopedic Foot and Ankle Society, AOFAS Rosemont, Illinois, United States Emil H. Schemitsch, MD, FRCS(C) Richard Ivey Professor and Chair/Chief Department of Surgery University of Western Ontario London, Ontario, Canada Andrew H. Schmidt, MD Chief Orthopaedic Surgery Hennepin County Medical Center Minneapolis, Minnesota, United States Professor Orthopedic Surgery University of Minnesota Minneapolis, Minnesota, United States Prism S. Schneider, MD, PhD, FRCSC Clinical Assistant Professor Department of Surgery Division of Orthopaedic Trauma University of Calgary Calgary, Alberta, Canada

Trevor Stone, MD, FRCSC Clinical Associate Professor Department of Orthopedics University of British Columbia Vancouver, British Columbia, Canada Max Talbot, MD, FRCSC Assistant Professor McGill University Staff Surgeon Montreal General Hospital McGill University Health Centre Major and Medical Director Canadian Forces Trauma Centre (East) National Defence Government of Canada Montreal, Québec, Canada Michel A. Taylor, MD, MSc, FRCSC Clinical Fellow Department of Orthopedic Surgery Victoria Hospital London Health Sciences Centre London, Ontario, Canada J. Andrew I. Trenholm, MD, MSc Associate Professor of Surgery Department of Surgery Dalhousie University Halifax, Nova Scotia, Canada

Karen N. Slater, MD Chief Resident Department of Surgery Division of Plastic Surgery University of British Columbia Vancouver, British Columbia, Canada

Ted Tufescu, BSc, MD, FRCSC Assistant Professor Department of Surgery University of Manitoba Program Director, Orthopaedic Surgery Residency Department of Surgery University of Manitoba Fellowship Director, Orthopaedic Trauma Department of Surgery University of Manitoba Winnipeg, Manitoba, Canada

Graham Sleat, MD Locum Consultant in Orthopaedic Trauma Surgery Trauma Department, John Radcliffe Hospital Oxford University Hospitals NHS Foundation Trust Oxford, United Kingdom

Kayee Tung, RN, CCRP Surgeon Orthopaedics Royal Children’s Hospital Melbourne, Victoria, Australia

Gerard Slobogean, MD Associate Professor Orthopaedics University of Maryland School of Medicine Baltimore, Maryland, United States

Darius Viskontas, MD, FRCSC Clinical Associate Professor Department of Orthopaedics University of British Columbia Royal Columbian Hospital New Westminster, British Columbia, Canada

David Stephen, MD, FRCS(C) Associate Professor Division of Orthopaedics, University of Toronto Sunnybrook Health Sciences Centre Toronto, Ontario, Canada

CONTRIBUTORS

David Weatherby, MD Fellow Division of Orthopaedic Surgery Dalhousie University Halifax, Nova Scotia, Canada

Jesse Wolfstadt, MD, MSc, FRCSC Assistant Professor Granovsky-Gluskin Division of Orthopaedics Sinai Health System University of Toronto

Ian Whatley, MD Resident Physician Division of Orthopaedic Surgery St. Michael’s Hospital, University of Toronto Toronto, Ontario, Canada

Jeff Yach, MD, FRCS(C) Assistant Professor Surgery Queen’s University Kingston, Ontario, Canada

Daniel B. Whelan, MD, MSc, FRCSC Associate Professor Department of Surgery Division of Orthopaedics University of Toronto Toronto, Ontario, Canada

Michelle L. Zec, MD, PhD Orthopaedic Surgeon Hand and Upper Extremity Surgery Department of Surgery Cumming School of Medicine University of Calgary

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PROCEDURE 2

Sternoclavicular Joint Open Reduction and Internal Fixation Marissa Bonyun and Aaron Nauth INDICATIONS • Acute posterior injuries of the sternoclavicular (SC) joint having symptoms consistent with mediastinal compromise (∼30%) representing a life-threatening emergency (e.g., dysphagia, dyspnea, limb tingling, feeling of choking or venous congestion in the neck or ipsilateral arm) • Failed closed reduction of posterior SC dislocations • Chronic recurrence of posterior SC dislocations • Recurrent subluxation and/or dislocation of anterior SC dislocations

Examination/Imaging • A careful examination should be performed to asses for neurovascular injuries in addition to examination of the chest to identify any associated injuries (e.g., rib fractures, pneumothorax). • Initial imaging should consist of plain radiographs of the chest and clavicle (Fig. 2. 1). • Computed tomography scan (with intravenous contrast to assess the vasculature) is the gold standard for assessing injuries to the SC joint (Fig. 2.1). 

SURGICAL ANATOMY • Important structures include the medial aspect of the clavicle, the sternum, the SC ligaments, the subclavian vessels, the great vessels of the neck, the brachial plexus, the trachea, the esophagus, the vagus nerve, and the superior aspect of the pleura (Fig. 2.2). • The medial physis of the clavicle closes between the ages of 22 and 25, and injuries to the SC joint in patients below this age often represent physeal injuries as opposed to true dislocations. • The closest structure at risk is the brachiocephalic vein (which can be as close as 1 mm from the SC joint in anatomic studies; the mean distance from the SC joint is 6 mm) (see Fig. 2.1). 

POSITIONING • For closed reductions, the patient is positioned supine with a 3 to 4 inch thick pad placed between the scapulae. • For acute (70 years) patient (Boyle et al., 2013). • ORIF may be preferred over hemiarthroplasty in a subset of patients with valgus-impacted four-part fractures (not considered true four-part fractures): • The humeral head is impacted upon the humeral shaft and, while the tuberosities are fractured, they are still in close approximation to the head and shaft. • The head is not dislocated or displaced laterally and some contact with the glenoid is maintained. • If lateral displacement is present, then the medial periosteal vessels that perfuse the articular segment may be disrupted; therefore, hemiarthroplasty would be preferred. • Nonoperative management for displaced proximal humerus fractures has recently gained popularity. • Nonoperative management can lead to satisfactory outcomes; in some reports, patient outcomes are similar to hemiarthroplasty. • Failed nonoperative treatment may be addressed more predictably with RSA than hemiarthroplasty, especially if there is tuberosity displacement/cuff dysfunction.

95

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

EXAMINATION AND IMAGING History and Physical Examination • History should include mechanism of injury, as proximal humeral fractures can occur with high-energy mechanisms in younger patients and lower-energy mechanisms in elderly patients with poor bone quality. • It is important to establish any history of seizure or head injury. • It is also important to establish the patient’s level of function prior to injury in addition to occupation, hand dominance, and ability to participate in an active rehabilitation program. • Prior history of shoulder surgery, poor active function, or a known rotator cuff tear should be determined, as these may be relative contraindications to hemiarthroplasty. • Symptoms include: • Pain and swelling • Decreased motion or weakness • Paresthesias associated with neurologic or vascular injury • Physical examination • Inspection • There may be ecchymosis or swelling of chest, shoulder, and arm. • With anterior fracture-dislocations, there may be a fullness visible anteriorly. • Identify any abrasions, previous skin incisions, skin quality, and presence of fracture blisters. • Identify rotator cuff atrophy. This may require further investigation as it is a relative contraindication to hemiarthroplasty. • Neurovascular examination • A detailed neurovascular examination is performed to document the motor and sensory function of the medial, radial, ulnar, musculocutaneous, and axillary nerves. • There is a high incidence of concomitant nerve injury, with the axillary nerve being the most commonly injured. • If a true nerve palsy is identified and any ongoing pathologic nerve compression is ruled out (e.g., humeral head dislocation), then follow-up should be arranged with electromyelography (EMG) at 4 to 6 weeks. • Arterial injury may be masked by extensive collateral circulation preserving distal pulses. • Evaluation under emergent arteriography with possible vascular surgery consultation is warranted in cases of presumed arterial injury (i.e., diminished or absent pulses, poor capillary refill, pulsatile lesion proximally). 

Imaging Studies • Radiographs • Complete trauma series • True anteroposterior (AP) view of the scapula (Fig. 9.1) • Transscapular lateral or scapular Y view. • Axillary view, with the arm abducted 20° to 30° and the x-ray tube placed in the axilla with the plate placed above the shoulder. • Additional views • Apical oblique • Velpeau if true axillary view cannot be obtained. • West Point axillary. • Imaging the contralateral shoulder may be helpful to determine the appropriate height for eventual prosthesis placement. • Computed tomography (CT) • Indicated if radiographs are not satisfactory for determining fracture lines, fracture displacement, or the quality of the articular surface. • CT can assist with preoperative planning.

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FIG. 9.1  An anteroposterior shoulder radiograph of a 4-part proximal humerus fracture in a 68-year-old active woman. TREATMENT OPTIONS



• CT can aid in determining humeral head or tuberosity quality or fracture position. • CT can assist with rotator cuff assessment; degree of fat infiltration within the cuff can be assessed on sagittal oblique views (high-grade fat infiltration, indicative of cuff dysfunction, is a contraindication to hemiarthroplasty). • 3D reconstructions can improve visual assessment of fracture pattern, displacement, and comminution. 

SURGICAL ANATOMY Proximal Humerus • Osteology • Greater and lesser tuberosities • Anatomic reduction of the tuberosities during hemiarthroplasty results in the best prognosis. • Anatomic head • Average humeral head diameter is 46 ± 5 mm. • Average humeral head thickness is 19 ± 2 mm. • Lateral humeral offset, or the distance from the base of the coracoid process to the most lateral part of the greater tuberosity, is 56 ± 6 mm. • Shaft • Average retroversion is 22° ± 15° (based on transepicondylar assessment; if using the forearm/ulnar axis, this is often 10° greater). • Average neck-shaft angle is 130°. • Vascular supply • The arcuate artery, a continuation of the lateral ascending branch of the anterior humeral circumflex artery, enters the humerus at the area of the intertubercular groove. Its branches supply both the greater and lesser tuberosities (Fig. 9.2). • Damage to this vessel may lead to avascular necrosis. • A large, intact, medial (metaphyseal) spike on the head fragment may indicate that vascularity to the head is better preserved. • A smaller contribution to the blood supply of the humeral head comes from the posterior humeral circumflex arteries. 

• Hemiarthroplasty • Nonoperative management • Closed reduction with or without immobilization • Open reduction and internal plate/screw fixation • Reverse total shoulder arthroplasty • Intramedullary rod fixation

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures Vessels from rotator cuff

Anterior circumflex humeral artery

Arcuate artery

Posterior circumflex humeral artery

Axillary artery

FIG. 9.2  The vascular supply of the humeral head is largely provided by the arcuate artery. POSITIONING PEARLS

• A sterile padded Mayo stand can help with arm abduction; it lessens the tension on the deltoid, making it easier to place sutures around the greater tuberosity posteriorly. • Obtain proper fluoroscopic anteroposterior views of the shoulder prior to prepping and draping.

POSITIONING PITFALLS

• Free positioning must be possible, especially in extension, to deliver the humeral shaft forward into the wound to prepare the canal, place the stem of the implant, and appropriately cement.

POSITIONING • Beach chair position with the head secured in neutral position with a headrest and the waist at 30° to 45°. • Position the affected arm off the edge of the table nearest the primary surgeon so that the intramedullary canal can be accessed for the prosthetic stem. • Prep and drape the entire affected arm free such that the arm has full movement throughout the procedure. • An arm-positioning device is optional. Our preference is to place the arm on a padded Mayo stand. • Position a large C-arm on the opposite side of the table for assessing implant alignment and tuberosity reduction intraoperatively. • Position the monitor at the foot of the table on the opposite side of the table for easy viewing. 

EXPOSURES POSITIONING EQUIPMENT

• Radiolucent operating room table • Arm-positioning device may be helpful in some circumstances. • Sterile padded Mayo stand

• Use a standard deltopectoral approach with a 10- to 15-cm skin incision directed from the coracoid tip to the deltoid insertion on the humerus (Fig. 9.3). • This provides excellent humeral exposure and preserves the deltoid origin. • The incision may be extended proximally to the clavicle or more distally along the humerus as needed.

EXPOSURES PEARLS

• It is commonly more helpful to retract the cephalic vein laterally with the deltoid as there are more tributary branches to the muscle belly. • If more exposure is needed: • The leading edge of the coracoacromial ligament may be resected to improve exposure of the rotator cuff muscles. If the ultimate structure of the coracoacromial ligament is compromised, shoulder instability may become problematic. • The incision can be extended distally to improve deltoid mobilization. • Muscle paralysis may assist with deltoid relaxation. • Shoulder abduction assists with deltoid mobilization.

Palpable tip of coracoid

Initial incision

FIG. 9.3  The skin incision is directed from the coracoid tip toward the insertion of the deltoid muscle on the humerus.

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

• Superficial • Place self-retaining retractors to place tension on the skin to reduce cutaneous exsanguination while hemostasis is achieved. • Identify the interval between the deltoid and pectoral origins proximally on the clavicle with blunt retraction. • This allows easy identification of the cephalic vein in the deltopectoral interval (Fig. 9.4). • Typically, the vein is dissected off of the pectoralis major and retracted laterally with the deltoid, as there are several perforators that attach to the deltoid. • Depending on surgeon preference, however, the vein may be retracted either medially or laterally. • Deep • Identify the coracoid process and the conjoint tendon. The clavipectoral fascia is incised longitudinally, lateral to the conjoint tendon/muscle (Fig. 9.5). • Excessive retraction on the conjoint tendon should be minimized, as the musculocutaneous nerve can be injured. • Part of the conjoint tendon can be released from the coracoid to improve exposure if required. • Develop the subacromial, subcoracoid, and subdeltoid spaces bluntly with Mayo scissors. • Place a deltoid retractor to aid in adequately visualizing the fracture. • Fracture exposure is discussed in Step 1. 

Acromioclavicular joint

99

EXPOSURES PITFALLS

• Care should be taken with medial retraction of the conjoint tendon as the musculocutaneous nerve is in close proximity and enters the back of the tendon between 3 and 7 (mean 4.7) cm from the coracoid tip. • Avoid dissection of the deltoid off the clavicle. • The axillary nerve may be injured anterior to the subscapularis, inferior to the glenohumeral joint, or exiting the quadrilateral space.

EXPOSURES EQUIPMENT

• Gelpi self-retaining retractors • Large blunt retractors • Deltoid retractor

Deltoid lateral fibers (retracted)

Coracoid Coracoid

Deltoid medial fibers (retracted)

Cephalic vein

Cephalic vein

Deltoid

Pectoralis

Pectoralis

Long head of biceps FIG. 9.4  The cephalic vein demarcates the superficial interval between the deltoid and the pectoralis major muscle.

FIG. 9.5  The deep exposure shows the deltoid retracted laterally and the pectoralis major retracted medially.

PROCEDURE Step 1: Mobilize the Tuberosities and Size the Humeral Head • Identify the long head of the biceps tendon or the bicipital groove if the tendon is displaced. • The tendon courses toward the rotator interval and is used as the landmark when reestablishing the relationship between the greater and lesser tuberosities. • The authors prefer to perform a tenodesis at this stage, attaching the biceps tendon to the superior border of the pectoralis major tendon with heavy nonabsorbable sutures. • Perform a tenotomy of the long head of the biceps tendon close to the rotator interval. The stump is typically excised to aid with visualization.

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

• Mobilize the greater and lesser tuberosities. • Remove the fracture hematoma gently. • Carefully preserve large bony fragments with soft-tissue attachments. • Identify and characterize fracture fragments, with the greater tuberosity fragment being lateral to the biceps groove and the lesser tuberosity being medial (Fig. 9.6). • The typical “intertuberosity” fracture line of a four-part fracture is actually lateral to the bicipital groove; thus, it goes through the greater tuberosity. • As such, the lesser tuberosity fragment contains the biceps groove and many times the anterior insertion of the supraspinatus. • Develop the rotator interval (Fig. 9.7). • If the intertuberosity fracture is lateral to the bicipital groove, the proximal softtissue release should be in line with the supraspinatus fibers and should not cut across those tendon fibers in order to connect with the rotator interval.

Greater tuberosity

Humeral head Lesser tuberosity Shaft Long head of biceps

FIG. 9.6  The fracture is exposed, with the biceps tendon being used to identify the interval between the greater and lesser tuberosities.

Corcacoacromial ligament Open rotator interval

FIG. 9.7  Split the rotator interval in line with the biceps tendon in order to separate the soft tissues between the greater and lesser tuberosities. Take care not to incise the entire coracoacromial ligament, as this can lead to shoulder instability.

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures



• Tag the rotator cuff insertions with traction sutures placed at the tendon-to-bone interface (Fig. 9.8). • Retract the greater tuberosity posterior and the lesser tuberosity anterior to gain access to the fractured humeral head. • Retrieve the humeral head and fracture fragments. • Release any remaining capsular attachment on the head, taking care to avoid injury to the axillary nerve. • In three-part fractures with the lesser tuberosity attached to the humeral head, the lesser tuberosity has to be osteotomized in order to retrieve the humeral head. • Sometimes there is a large remnant of humeral head still attached to the greater tuberosity, which needs to be removed. • Care is taken to resect all parts of the humeral head for reconstruction and accurate sizing of the prosthetic implant on the back table. • Inspect the glenoid for any fracture or preexisting arthritic wear. • If there is a glenoid fracture (typically of the anterior rim), osteosynthesis should be performed at this stage. • Conversion to a total shoulder arthroplasty (with placement of a glenoid component) may be indicated if there is significant preexisting glenoid wear. • Measure the size of the humeral head. • The retrieved humeral head is measured with a caliper to determine the appropriate prosthetic size. It can also be directly compared to a trial head. • A radiograph of the contralateral humeral head can be used in cases of severe head comminution. • If the head is between sizes, it is better to undersize rather than oversize. • The humeral head can be used as a source of bone graft and should be saved for later in the procedure. • Tuberosity suturing • Once the humeral head has been extracted, space is available in the joint to provisionally pass sutures around the tuberosities. • Four to five heavy #5, nonabsorbable sutures are passed circumferentially around the greater and lesser tuberosities. (Fig. 9.9)

101

STEP 1 PEARLS

• Identify the long head of the biceps tendon. This aids in the determination of the greater and lesser tuberosity fragments. • In cases of comminution, a radiograph of the contralateral humeral head can be used to determine the appropriate humeral head size. • Be sure to save as much cancellous bone as possible taken from the humeral head so that it can be morcellized for bone grafting of the prosthesis and tuberosities prior to closure. • If there has been an anterior dislocation: • The head typically resides in the subcoracoid recess and can potentially compromise the neurovascular structures. Careful blunt dissection should be undertaken. • If there has been a posterior dislocation: • The shaft and tuberosity fragments are gently distracted laterally, allowing access to the posterior joint capsule. The humeral head can then be removed whole or piecemeal. • Alternatively, and very rarely, a separate posterior approach may be used to aid in retrieving the humeral head. This is usually only required in cases presenting subacutely or chronically. • Placement of the extracted humeral head back on to the humeral shaft/calcar can assist with length determination and version assessment. • Suturing of the tuberosities is best done after head extraction (maximum space within the joint) and prior to hemiarthroplasty cementation.

STEP 1 PITFALLS

Humeral head

Greater tuberosity

Humerus shaft

Canal opened for trial prosthesis Lesser tuberosity

FIG. 9.8  Stay sutures are used to reflect the tuberosities on their muscular origins in order to increase fracture exposure and assist with removal of the fractured head.

• Avoid using forceps or clamps in osteoporotic bone, as this will typically increase fracture comminution. Instead, use sutures for manipulation and reduction. • Avoid placing sutures through the bony fragments, as the tuberosities are often osteopenic and comminuted and tensioning of the sutures can result in them cutting through the bone fragments. • Avoid resection of the coracoacromial ligament during tuberosity mobilization, as this can lead to superior instability of the shoulder.

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

Subscapularis

Greater tuberosity

Lesser tuberosity

Humeral shaft

FIG. 9.9  Demonstration of the placement of cerclage sutures for closure of the tuberosities over the implant.



• These sutures are passed at similar levels around the lesser tuberosity and posterior aspect of the greater tuberosity. • After hemiarthroplasty, when tied, these sutures compress the tuberosities to each other and to the implant (Fig. 9.10A–B) • Two to three additional sutures each are placed at the tendon-to-bone interface of the greater and lesser tuberosities for fixation to the implant and to the humeral shaft. 

A

B

FIG. 9.10  A, The tuberosities are incorrectly reduced when the sutures are placed through the fin of the implant. B, The cerclage sutures should be passed around the shaft and secured over the implant metaphysis.

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

Step 2: Humeral Shaft Preparation • Externally rotate, adduct, and extend the arm to deliver the humeral shaft up into the wound. • Inspect the proximal humeral shaft. • This is to ensure that there is not an undisplaced humeral shaft fracture that will compromise prosthetic fixation. • If a fracture is detected that extends distally into the shaft, it is important to reinforce the fracture prior to prosthesis placement. • This can be achieved with a cable plate, cerclage wires, or biologic strut graft. • Prepare the humeral canal. • Remove the hematoma and loose endosteal bone fragments from the shaft. • Depending on the specific instrumentation for the prosthesis chosen, sequentially ream or rasp the canal. • Care must be taken at this stage to be gentle with reaming or rasping, as most patients will have osteoporotic bone. • Use axial reamers without power. • Alternatively, use rasps of increasing size as recommended in the technical manual of the implant being used. Although the authors prefer cemented hemiarthroplasty for fracture indications, a press-fit implant may be used. If the rasp fits snugly in the canal, the optimal size has been found. If not, increase the rasp size and progress until you reach the appropriate height. Be careful not to exert too much force, as the shaft is at risk of fracturing. • Stem size is determined. 

Step 3: Determination of Prosthetic Retroversion and Height with Trial Prosthesis Determine the Retroversion • Traditionally, the humeral head should be retroverted approximately 30° relative to the distal humeral epicondylar axis, although this value varies significantly in normal human anatomy. • Determine retroversion using one of three methods: • Most systems have a retroversion guide rod system on the prosthetic inserter, with the neutral forearm assumed to be perpendicular to the epicondylar axis. • The elbow is placed in 90° of flexion and neutral rotation. • With the trial prosthesis reduced, the guide rods template an arc between 20° and 40° of retroversion. • With the forearm bisecting the guide rods, the prosthesis should therefore be placed in the ideal 30° of retroversion. • Externally rotate the humerus to 30° away from the sagittal plane with the humeral head facing directly medially. • Position the lateral fin of the prosthesis about 8 mm posterior to the deepest part of the biceps groove. • This should put the prosthesis in approximately 30° of retroversion. • The authors prefer to determine anatomic patient-specific retroversion. • Traditionally, retroversion for fracture hemiarthroplasty has been set at population averages. • Alternatively, patient-specific retroversion may be determined by an assessment of metaversion, which has been shown to be a reliable predictor of version. • Metaversion is the version of the humeral metaphysis, which tends to correlate with the version of the humeral head (Fig. 9.11) (Athwal et al., 2010). • Humeral component version may also be adjusted based on the nature of the joint pathology: the component may be placed in a more anteverted position when dealing with a posterior fracture-dislocation and in a more retroverted position for an anterior fracture-dislocation. 

103

STEP 2 PEARLS

• For press-fit implants, if rotational stability cannot be obtained, it is best to downsize to a cemented implant.

STEP 2 PITFALLS

• Owing to the nature of the fracture, placing the humeral head trial prosthesis directly on the proximal humeral shaft will usually lead to overall humeral height loss and an inability to appropriately reapproximate the greater and lesser tuberosities.

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Humeral canal reamers or rasps • The use of a “platform” humeral stem (one that can be converted to a reverse arthroplasty) is preferred in the event that tuberosity/cuff failure postoperatively requires revision.

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

104

STEP 3 PEARLS

• Prosthesis with pronounced calcar design • If a prosthesis with a pronounced calcar design is used, this type of prosthesis will center itself if the maximal stem size is used. This technique acknowledges the patient’s individual retroversion using the metaversion.

STEP 3 PITFALLS

• Placement of a hemiarthroplasty that is too high, overstuffing the joint • Results in difficulty with tuberosity reduction and premature impingement. • Placement of a hemiarthroplasty that is too low • This de-tensions the deltoid. • Results in excessive overlap of tuberosities on the humeral shaft.

STEP 3 INSTRUMENTATION/ IMPLANTATION

• Sterile ruler • Humeral head retroversion guide • Proximal humeral prosthesis system with trial implants

A

FIG. 9.11  An intraoperative image of a right shoulder prior to hemiarthroplasty. The proximal humeral metaphysis and calcar are visible. The white arrow depicts the metaphyseal version (metaversion), which approximates native humeral head retroversion.

Determine the Height of the Prosthesis • Placing the prosthesis at the correct height is critical to restore normal shoulder biomechanics. If the prosthesis is placed too low, deltoid function is compromised and there is less room for reattachment of the tuberosities. • The correct height can be determined by six methods: • The native humeral head can be re-reduced to the humeral shaft to estimate length (Fig. 9.12A). • The medial neck calcar should be at the same level as the medial aspect of the humeral stem if there is no metaphyseal comminution (Fig. 9.12B).

B

FIG. 9.12  A, Demonstration of the estimation of prosthesis height by replacing the native humeral head and measuring the distance of the greater tuberosity from the fractured metaphysis. B, The trial prosthesis should be placed at the same distance from the fractured metaphysis.

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105



• Preoperative templating compared to the contralateral limb • The top of the prosthesis should be 5.6 cm proximal to the superior border of the pectoralis major tendon (Torrens et al., 2008). • The center of the humeral head should be at the level of the glenoid face. • There should be adequate space for tuberosity reattachment, which can be templated by using the traction sutures to reapproximate the tuberosities around the trial stem. • This is also useful to determine appropriate soft-tissue tension on the tuberosities. • When reduced, the greater tuberosity should be 5 to 10 mm below the head. 

Step 4: Trial Reduction • Assess the position of the humeral head, shaft, and tuberosities prior to cementing. • Place two to four 2-mm drill holes in the proximal humerus medial and lateral to the bicipital groove (Fig. 9.13). • Place #2 nonabsorbable suture through the holes for fixation of the tuberosities to the shaft. • Place towel clips to hold the tuberosities below the head of the prosthesis when assessing the implant fluoroscopically. • Reduce the shoulder and test flexion, extension, abduction, adduction, and stability. • The greater tuberosity should be 5 to 10 mm below the top of the humeral head. • Assess glenohumeral stability. • The reduced prosthesis should be stable through a range of 40° to 50° of external and internal rotation. • The humeral head should not subluxate more than 25% to 30% of the glenoid height inferiorly. • Remove the trial implant. 

STEP 4 PEARLS

• It is important to ensure that the nonabsorbable sutures for tuberosity attachment are passed through the predrilled holes in the proximal shaft prior to cementing. • Modular systems that have a variably eccentric humeral head can relieve tension on the rotator cuff if a patient’s anatomy is such that it leads to an eccentrically placed stem. Offset can be useful since the center of the shaft is usually lateral and anterior to the center of the humeral head. • Radiographic imaging with the humeral trial in place is beneficial for implant height estimation and tuberosity reduction.

STEP 4 PITFALLS

• Failure to control tuberosities or ensure that the joint will reduce before cementing can result in failure of repair. • Malposition of the prosthesis may involve abnormal version or incorrect height.

STEP 4 INSTRUMENTATION/ IMPLANTATION

• #2 and #5 nonabsorbable sutures

FIG. 9.13  Prior to cementing, a drill is used to make a cortical bone tunnel for passage of sutures that will be used to secure the tuberosities to the shaft.

Step 5: Bone Grafting and Cementing of Final Implant • Irrigate and dry the canal thoroughly. • Retrieve cancellous autograft bone from the humeral head. • Place graft in the spaces between the tuberosities, prosthesis, and shaft. • This will increase the primary stability of the tuberosities, particularly in osteopenic bone.

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

STEP 5 PEARLS

• The authors recommend cement fixation of the humeral component, as it provides immediate stability and ensures maintenance of prosthetic height. • The authors recommend provisionally passing all sutures prior to cementing the hemiarthroplasty.

STEP 5 PITFALLS

• Poor outcomes are associated with the combination of a prosthesis that is too proud and too retroverted, with a greater tuberosity that is placed too low. • If the prosthesis is too proud, it can lead to impingement against the acromion or the superior glenoid. • If the prosthesis is too inferior, the deltoid muscle may be dysfunctional due to abnormal decreased tension, leading to an inability to laterally elevate the arm. Additionally, the greater tuberosity can become relatively proud and can also lead to impingement.

STEP 5 INSTRUMENTATION/ IMPLANTATION

• Cement instrumentation (vacuum mixing equipment, antibiotic cement)

• Cement the humeral component (Fig. 9.14). • In most cases, there is not enough bone stock distally for a press-fit component; therefore, cementing is necessary. • Use of a cement restrictor is recommended. • Insert the prosthesis, respecting the previously determined height and retroversion. • Remove extra cement from the upper inner metaphysis such that the region is available to place bone graft underneath the tuberosities prior to reduction. • Place the final head implant. • Impact the head onto the stem once the cement has set. • Pass the four to five #5 circumferential greater and lesser tuberosity sutures around the medial neck of the implant prior to reduction. • Reduce the hemiarthroplasty. 

Prosthesis

Humerus shaft

STEP 5 CONTROVERSIES

• The use of postoperative drains in this setting is controversial. While they have little proven benefit, they may be of some use where excessive bleeding or oozing is encountered or anticipated.

FIG. 9.14  The final prosthesis is cemented in place at the predetermined height and version. Cancellous bone is placed in the window of the fracture prosthesis. Note that no cement is interposed between surfaces meant for tuberosity healing once reduced.

Step 6: Tuberosity Repair and Closure This step is crucial to a successful functional outcome after surgery. • Reduce tuberosities after packing cancellous bone graft around the implant (while many techniques are described for suture or wire fixation of the tuberosities, the authors’ preferred technique is described here). • Use the individual sutures placed around the greater tuberosity to reduce it to the implant (these sutures are passed through holes in the implant; Fig. 9.15A–B). • Confirm appropriate greater tuberosity reduction on fluoroscopy (Fig. 9.16A–B). • Use the individual sutures placed around the lesser tuberosity to reduce it to the implant (these sutures are passed through holes in the implant). • Once the provisional reduction has been obtained with the greater and lesser tuberosities to the implant, the four to five #5 circumferential sutures are tied (Fig. 9.17). • These are important sutures that compress the tuberosities together and to the implant. • Final sutures that secure the tuberosities to the shaft through transosseous tunnels are tied. • Confirmation of reduction • After fixation of the tuberosities, the reduction has to be confirmed visually, by palpation, and by fluoroscopy.

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107

FIG. 9.15  A, Pack cancellous autograft around the stem and close the tuberosities with the cerclage sutures. B, A cross-sectional view showing the cerclage sutures pass around the entire shaft and tuberosities.

A

B

FIG. 9.16  Over- or underreduction of the greater tuberosity is common. Fluoroscopy is used to assist in assessing the position of the tuberosities. A, With provisional reduction and a snap holding the cerclage sutures, the greater tuberosity is found to be too low. B, With manipulation, the greater tuberosity is placed in a more anatomic location.



• There should be no gap and no step-off between the tuberosities underneath the humeral head prosthesis. The tuberosities must be under the humeral head. • The inferior spike of the greater tuberosity should fit snugly into the fracture gap; if needed, it can be rounded off with a rongeur. • Irrigation • Irrigate the incision.

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

STEP 6 PEARLS

• Fixation of the tuberosities should be supplemented with cancellous bone graft taken from the excised humeral head or allograft/biologic graft substitutes. FIG. 9.17  Final construct showing the suture configuration. STEP 6 PITFALLS

• Early failure of tuberosity fixation with migration is one of the most common reasons for poor functional outcome. • To avoid this, rigid suture fixation is required. • Nonanatomic repair of the tuberosities • To avoid this, the authors recommend intraoperative fluoroscopy to assist with greater tuberosity reduction.

• Closure • If required, use a drain to limit hematoma formation. • Reapproximate the deltopectoral interval. • Use 2-0 absorbable suture for subcutaneous closure. • Close the skin with absorbable monofilament suture for subcuticular closure or staples. • Place the patient in a sling for comfort. An abduction orthosis may be beneficial if tuberosity fixation is poor or tenuous. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Postoperative Care • Postoperative radiographs should be taken to confirm correct positioning of the tuberosities and implant. • Rehabilitation is started on postoperative day one and encourages active range of motion (ROM) of the hand, wrist, and elbow throughout. • The authors prefer a conservative shoulder rehabilitation protocol to allow some tuberosity healing before passive and active motion. • Gravity-assisted pendulum exercises are started at approximately 4 weeks postoperatively. • Active-assisted progressing to active ROM is started at 6 weeks. • Sling/immobilizer is discontinued at 6 weeks. • Strength-training exercises typically start at 12 weeks postoperatively. • Progressive resistance exercises using TheraBands and/or light weights are introduced along with a ROM stretching program. • Maximum return of function may take from 12 to 24 months. 

Expected Outcomes • Pain relief is reliably achieved (73%–97%), despite functional restoration being more variable (average, 38–68/100 Constant score) (Robinson et al., 2003). • The goal of rehabilitation following a hemiarthroplasty has been quoted as 130° of forward elevation and 30° of external rotation. A more conservative goal is return to light activities of daily living (e.g., self-care and feeding; Fig. 9.18A–B) (Moeckel et al., 1992). • Expected outcomes are reported to be a function of the stability of tuberosity repair, maintenance of tuberosity reduction in the immediate postoperative period, and long-term physiotherapy (Tanner et al., 1983).

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

109

A

B FIG. 9.18  Postoperative function demonstrating 100° of active forward elevation (A) and 30° of active external rotation (B).

• Poor outcomes are expected with: • Tuberosity malposition, nonunion, or resorption (Boileau et al., 2002) • Superior migration of the humeral prosthesis • Persistent pain • Stiffness • Poor implant position • Age over 75 years in women • The most common complaint of an unsatisfactory outcome is related to weakness and an inability to raise the arm above the horizontal level 

COMPLICATIONS • The most common complications postoperatively include tuberosity displacement, prosthesis problems, stiffness, and infection. • Tuberosity displacement • Tuberosity displacement occurs more commonly in older patients with osteoporotic bone, and the greater tuberosity is at greater risk for displacement compared to the lesser tuberosity (Warner et al., 2013). • If migration or total displacement of the greater tuberosity occurs early, consideration may be given to revision surgical repair, although the outcomes are unpredictable.

POSTOP PEARLS

• If use of a sling immobilizer is needed in the immediate postoperative period, it is recommended to keep the patient in a neutral position as opposed to internal rotation. This will limit the strain on the greater tuberosity repair. • If the patient has sudden loss of ROM in the recovery period, tuberosity repair failure should be considered. • Prognosis is generally poor if patients note a gradual loss of rotator cuff function and tuberosity resorption.

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PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures

POSTOP PITFALLS

• Early active ROM, although recommended for many orthopedic surgeries, may be detrimental for tuberosity healing in the early postoperative period.

• Prosthetic loosening • Due to the typical patient population, the bone quality of the proximal humerus is usually osteopenic; hence, prosthetic loosening is a recognized complication. • All patients presenting with loose arthroplasty components should be worked up for the presence of infection. • Postoperative stiffness • Postoperative stiffness is a common complication; most patients will lose some degree of motion. • Postoperative stiffness is most commonly due to a delayed rehabilitation protocol to maximize tuberosity healing. • Infection is an uncommon complication.

EVIDENCE Alentorn-Geli E, Guirro P, Santana F, et al. Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty. Arch Orthop Trauma Surg. 2014;134:1545–1550. The purpose of this study was to compare the functional and quality of life–related outcomes, and complications in the treatment of proximal humeral fractures between hemiarthroplasty (HA, 12) and reverse shoulder arthroplasty (RSA, 20). The RSA group demonstrated a higher improvement in total Constant score and a lower complication rate compared to the HA group. The RSA may be a better option than HA given the trend toward better total Constant score and a significantly lower number of complications requiring revision surgery. Athwal GS, MacDermid JC, Goel DP. Metaversion can reliably predict humeral head version: a computed tomography-based validation study. J Shoulder Elbow Surg. 2010;19(8):1145–1149. This study tested the hypothesis that the metaphyseal version (metaversion) is a landmark that can assist with correct head version and used CT to evaluate its reliability as a predictor of anatomic version. The mean difference between the metaversion and the humeral head version was 2.5°. Proximal humeral metaphyseal version (metaversion) is an accurate predictor of ipsilateral humeral head version. 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 Elb Surg. 2002;11:401–412. Sixty-six consecutive patients were followed up postoperatively for a mean of 27 months. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Tuberosity migration could be observed after initial tuberosity malpositioning as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (excessive height and/or retroversion), poor position of the greater tuberosity, and women over 75 years old. Boyle MJ, Youn SM, Frampton CMA, et al. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elb Surg. 2013;22:32–37. This study compared the functional outcomes of reverse shoulder arthroplasty (RSA, 55) with hemiarthroplasty (HA, 313) in patients with acute proximal humeral fractures. The RSA group had a significantly better 5-year Oxford Shoulder Score than the hemiarthroplasty group. There was no significant difference between the RSA and HA groups in revision rate per 100 componentyears. Moeckel BH, Dines DM, Warren RF, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg [Am]. 1992;74:884–889. A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in 22 shoulders in 22 patients. The patients were followed for an average of 36 months: 20 had a good or excellent result. The active forward elevation averaged 119°; external rotation, 40°; and internal rotation, to the 12th thoracic vertebra. The overall scores correlated inversely with the age of the patients and the interval from the injury to the operation. Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg [Am]. 2003;85:1215–1223. This 13-year study of 163 patients treated with hemiarthroplasty for a proximal humeral fracture revealed a rate of prosthetic survival of 96.9% at 1 year and 93.9% at 10 years. The overall median modified Constant score was 64 points at 1 year, with a typically good score for pain relief and poorer scores for function, ROM, and power. A good functional outcome can be anticipated for a younger individual who has no preoperative neurologic deficit, no postoperative complications, and a satisfactory radiographic appearance. The results are poorer in elderly patients if they have a neurologic deficit, a complication requiring a reoperation, or prosthetic malposition with retracted tuberosities. Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343:230–238.

PROCEDURE 9  Hemiarthroplasty for Proximal Humerus Fractures Torrens C, Corrales M, Melendes E, Solano A, Rodriguez-Baeza A, Caceles E. The pectoralis major tendon as a reference for restoring humeral length and retroversion with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2008;17:947–950. The purpose of this cadaveric study was to determine the value of the upper edge of the pectoralis major insertion (PMI) as a landmark to establish the proper height and version of hemiarthroplasty implanted for proximal humeral fractures. The mean distance from the PMI to the top to the humeral head was 5.6 cm. The upper edge of the pectoralis major insertion constitutes a reproducible reference point to restore proper humeral height and retroversion in hemiarthroplasty for proximal humeral fracture. Wiesel BB, Nagda S, Williams GR. Technical pitfalls of shoulder hemiarthroplasty for fracture management. Orthop Clin North Am. 2013;44:317–329. The two most important technical factors influencing functional outcome in hemiarthroplasty patients are the restoration of the patient’s correct humeral head height and version and healing of the greater and lesser tuberosities in an anatomic position. Hemiarthroplasty for proximal humerus fracture provides predictable pain relief, but functional recovery is much less predictable.

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PROCEDURE 10

Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures Ryan T. Bicknell and David W. Cruickshank INDICATIONS PITFALLS

• D  eltoid dysfunction/paralysis • Brachial plexopathy, particularly if involving the axillary nerve • Acromion or scapular spine fracture • Severe glenoid fracture preventing baseplate implantation • Open or contaminated fracture, or preexisting function

INDICATIONS • T  hree- and four-part comminuted proximal humerus fractures in elderly patients • Severe tuberosity comminution that may compromise repair or healing and ultimately rotator cuff function • Preexisting chronic rotator cuff tear/deficiency or glenohumeral arthritis • Elderly and lower-demand patients 

INDICATIONS CONTROVERSIES • L  ong-term longevity unknown, suggest age more than 70 years • No objective way to predict tuberosity healing 

EXAMINATION/IMAGING TREATMENT OPTIONS

• N  onoperative treatment in a collar and cuff sling • Open reduction and internal fixation with plate or intramedullary nail • Proximal humerus hemiarthroplasty • Reverse total shoulder arthroplasty (RSA)

• T  he skin should be examined for open wounds, previous scars, or surgical incisions. • A thorough neurovascular examination is performed and documented, including the sensory and motor function of the axillary nerve. • Standard shoulder radiographs should include an anteroposterior (AP), a scapular Y lateral, and axillary view, if possible (this is often difficult in a patient with a fracture) (Fig. 10.1). • Bilateral scaled AP views of the entire humerus can aid in humeral component positioning (particularly implant height) in highly comminuted fractures, where the proximal humerus anatomy is severely distorted. • In most shoulder fractures, a computed tomography (CT) scan with 3D reconstructions should be obtained to fully understand the fracture morphology and to identify any other associated pathology that may be missed on radiographs alone (Fig. 10.2).

A

B FIG. 10.1 

112

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

113

• 3  D reconstructions with humeral head subtraction also facilitates assessment of glenoid morphology and aids in accurate glenoid component positioning. 

A

B FIG. 10.2 

SURGICAL ANATOMY • T  he long head of the biceps becomes intraarticular in the shoulder and attaches to the superior labrum and glenoid. A tenotomy of the intraarticular portion should be performed and a tenodesis can be performed to anchor the tendon to the humerus. • The greater and lesser tuberosities form the insertions of the rotator cuff muscles. • Outcomes with reverse shoulder arthroplasty may be improved when the tuberosities are repaired versus excised, specifically internal and external rotation. 

POSITIONING

POSITIONING PEARLS

• P  osition the patient supine in the beach chair position at approximately 45° under general anesthesia (Fig. 10.3: The patient is positioned in a beach chair position). • Use of a shoulder-specific bed where the portion of the bed directly under the shoulder can be removed will facilitate the use of intraoperative fluoroscopy. • Prepare and drape the entire arm and shoulder, leaving the arm free for manipulation during the procedure (Fig. 10.4: The arm is draped free for later manipulation). • Use of a pneumatic or robotic positioning device can assist in arm positioning throughout the procedure, especially if surgical assistants are unavailable. 

• P lace a small bolster or rolled towel under the medial scapular border to antevert and lock the scapula in position, and aid in glenoid visualization and preparation (Fig. 10.5: A rolled towel is placed along the medial scapular border to aid in glenoid exposure). • Ensure that the shoulder joint can be extended without impinging on the bed, to aid in humeral preparation and humeral stem placement.

POSITIONING PITFALLS

• S terile field should include enough exposure to extend the standard deltopectoral approach distally, if required, particularly for a fracture that extends into the humeral shaft. • Carefully position the cervical spine in a neutral position to avoid any excessive traction on the brachial plexus.

POSITIONING EQUIPMENT

FIG. 10.3 

• O  perating bed with beach chair attachment. A shoulder-specific bed is preferred, which enables free access to the shoulder and has bolsters to hold the patient in position. • A robotic or pneumatic arm positioning device is optional but can aid in maintaining arm position during the duration of the procedure.

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PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

POSITIONING CONTROVERSIES

• A radiolucent table facilitates the use of intraoperative fluoroscopy; however, the benefits of this are outweighed by those of using a shoulder-specific bed (as mentioned previously) and this still allows use of fluoroscopy.

FIG. 10.4 

A

B FIG. 10.5 

PORTALS/EXPOSURES • S  tandard deltopectoral approach is utilized. • This gives the option of an extensile exposure that can be utilized if complications arise or if more distal fracture management is required • Incision starts 1 cm lateral to the coracoid and continues down the medial border of the deltoid toward the deltoid insertion on the humerus, approximately 15 cm (Fig. 10.6: The incision for a standard deltopectoral approach, starting 1 cm lateral to the coracoid). • The full thickness flaps on top of the deltopectoral fascia are raised and the deltopectoral interval and cephalic vein are identified. • The vein is isolated and retracted laterally with the deltoid. • Release the upper 1.5 cm of pectoralis major from its insertion on the humerus and retract it medially. • The conjoined tendon is identified and is retracted medially. • Avoid excessive retraction of the conjoined tendon as the musculocutaneous nerve pierces through it 5 to 8 cm distal to the coracoid process.

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

• A  subdeltoid release is performed with care taken to protect the axillary nerve laying on the deep surface of the deltoid. • Identify the biceps tendon in the bicipital groove, and open the biceps sheath up into the bicipital groove and perform a tenotomy of the intraarticular portion (Fig. 10.7: The biceps tendon is easily identified within the bicipital groove and between the LT and GT fragments). • Perform a tenodesis of the biceps tendon to the remnants of the upper border of the pectoralis major insertion using a heavy nonabsorbable suture. • Place a blunt self-retractor underneath the deltoid laterally and conjoint tendon medially. • In comminuted proximal humerus fractures, the lesser tuberosity (LT), the greater tuberosity (GT), head, and shaft are all separate fragments, which can make glenoid exposure easier. • Identify the upper border of subscapularis and release the rotator interval to the level of the coracoid base. • Place two heavy nonabsorbable sutures through both the subscapularis tendon/ LT fragment and the infraspinatus tendon/GT fragment for both retraction and later repair. (Fig. 10.8: Two #5 sutures are placed through the LT and GT fragments for retraction). • If intact, release the supraspinatus tendon from its insertion on the GT, making sure to leave the infraspinatus and teres minor intact. • Next, remove the humeral head from inside the joint (the fracture location usually avoids the need for an osteotomy) and save it for later bone grafting. • Place a posterior glenoid neck retractor or similar device on the posterior–inferior corner of the glenoid and retract the humerus to gain exposure of the glenoid (Fig. 10.9: A retractor is placed on the posterior inferior corner of the glenoid for exposure). • The labrum must be excised in its entirety and the inferior capsule should be released to prevent the humeral component from levering in adduction. • Extensive release of the glenohumeral capsule and ligaments is usually not necessary because an acute fracture is different from an arthritic shoulder in which structures are very stiff and contracted, particularly the anterior capsule and subscapularis. 

FIG. 10.6 

115

PORTALS/EXPOSURES PEARLS

• M  ake an incision along the medial edge of the deltoid to allow extensile exposure distally, if needed. • Tenodesis the biceps tendon to the upper border of the pectoralis major insertion. • Release the rotator interval and resect the supraspinatus tendon. • Place heavy retraction sutures in the lesser tuberosity (LT) and the greater tuberosity (GT) fragments to aid in exposure and for later repair. • Muscular blockade/paralysis by the anesthetist can aid in gaining access to the glenoid in cases of difficult exposure or heavily muscled individuals. PORTALS/EXPOSURES PITFALLS

• Incomplete muscular paralysis • Inadequate bolstering and positioning of the scapula PORTALS/EXPOSURES EQUIPMENT

• A blunt self-retractor • An assortment of glenoid retractors PORTALS/EXPOSURES CONTROVERSIES

• A superolateral approach is often used for reverse shoulder arthroplasty; however, in the management of proximal humerus fractures, this is not our preference because it limits distal extension of the exposure.

FIG. 10.7 

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PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

FIG. 10.9 

FIG. 10.8 

PROCEDURE STEP 1: Glenoid Preparation and Baseplate Implantation • G  lenoid preparation is the same as in a primary reverse total shoulder arthroplasty and varies somewhat based on the implant system. • Using a guide, drill the guide pin in the glenoid, inferior to the mid portion of the glenoid to allow inferior overhang of the glenosphere and with 5° to 10° of inferior tilt, to decrease the risk of scapular impingement and notching (Fig. 10.10: The guide pin is placed using the instrument guide and is inferior to the center point of the glenoid and with 5° to 10° of inferior tilt).

FIG. 10.10 

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

• R  eam the glenoid to subchondral bone. • Drill, implant the baseplate, and fix it with screws as per the manufacturer’s recommendations (Fig. 10.11: The baseplate is secured to the glenoid). • Once the baseplate is well fixed, secure the glenosphere onto the baseplate. • Ensure that the glenosphere overhangs the inferior rim of the glenoid and is centered anterior-to-posterior. The glenosphere size chosen will depend on the size of the patient. 

117

STEP 1 PEARLS

• E xposure of the glenoid is usually easier than in the setting of an arthritic shoulder. • Ensure inferior glenoid rim coverage with glenosphere sizing and 5° to 10° of inferior tilt to reduce the risk of scapular notching. • Screw fixation options vary by manufacturer, but ensure as many well-fixed screws for fixation as possible. A superior screw into the base of coracoid, an inferior screw into the lateral scapular pillar, and a posterior screw into the scapular spine are our preferences.

STEP 1 PITFALLS

• G  lenosphere position is critical to reduce the risk of scapular notching. • Ensure the baseplate is well fixed and stable before proceeding.

STEP 1 INSTRUMENTATION/ IMPLANTATION

• P osterior glenoid neck retractor; Fukuda retractor or Sonnabend retractor can aid in gaining exposure of the glenoid.

STEP 1 CONTROVERSIES

FIG. 10.11 

• G  lenosphere size is controversial. We generally recommend a larger size in males and a smaller size in females. The use of a too large glenosphere can affect the ability to anatomically reduce the tuberosities.

STEP 2: Humeral Canal Preparation and Stem Trial • P  lace the arm into external rotation and extension to bring the proximal humerus into view. • Ream and broach the humeral canal as per the manufacture’s recommendations (Fig. 10.12: The humerus is reamed and broached in preparation for a cemented stem). • Avoid excessive reaming and broaching of the humeral canal because this can weaken often already osteoporotic bone and lead to humeral shaft fracture. In a fracture setting the humeral stem will generally be cemented. Only in rare occasions (a tight stem fit at the proper height with a simple, proximal fracture line) will fixation depend on press-fit methods. • Implant height can be determined in several ways: soft tissue tension and stability of the prosthesis is more important with reverse arthroplasty than with anatomic height restoration as in hemiarthroplasty. Temporary reconstruction of the greater tuberosity (if there is minimal comminution) can help determine anatomy. Finally, an intraoperative radiograph with the trial component in place may be helpful. • Mark the predicted level of the humeral fracture line on the trial stem (this indicates the predicted implant height) (Fig. 10.13: The level of the humerus fracture line is marked on the trial stem and inserted in the humerus to this height). • Insert a trial humeral stem with a liner to the level marked out on the stem, which should line up with the top of the humeral shaft, and place in 10° to 20° of retroversion. • Reduce the reverse prosthesis articulation. • Place a finger on the medial neck of the humeral trial stem and keep it against the glenosphere as the other hand pulls the arm down and tensions the deltoid. • This allows confirmation of the correct final height of the implant and soft-tissue tension. • Remove implants, finish humeral canal preparation, and place cement restrictor.

STEP 2 PEARLS

• E nsure accurate humeral implant height and rotation. However, avoid increased height or retroversion because this can limit reduction of the joint and tuberosity reduction and fixation.

STEP 2 PITFALLS

• A void excessive reaming and broaching of the humeral canal because this can weaken often already osteoporotic bone and lead to humeral shaft fracture. • Improper height of the implant during trialing can lead to instability (too low) or to an irreducible joint (too high) in the final implants. However, of the two errors, an implant that is too low is easier to deal with by increasing the final liner thickness.

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PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

STEP 2 INSTRUMENTATION/ IMPLANTATION

• In the setting of fracture, plan on using a cemented humeral stem for fixation. • Using a fracture-specific stem may provide more options for tuberosity fixation. However, depending on the manufacturer, this may not be an option. If a fracture-specific stem is not available, it has been our preference to use an uncemented stem, inserted with cement distally. This has the benefit of cement fixation but also a bone ingrowth coating proximal to aid in tuberosity healing.

• A  ll sutures needed for the future repair of the tuberosities are passed at this point, before the final stem is implanted. • Pass two heavy, nonabsorbable sutures through transosseous tunnels in the humerus. • Pass two heavy, nonabsorbable sutures through each of the subscapularis tendon/ LT and the infraspinatus tendon/GT, replacing the traction sutures (Fig. 10.14A and B: Two sutures are passed through transosseous tunnels in the humeral shaft and two sutures each are placed around the LT and GT fragments, in their respective tendons). • Finally, a double stranded #5 nonabsorbable suture is also passed around the stem and around each tuberosity through the subscapularis and infraspinatus insertions, which will eventually be tied with a NICE knot (Fig. 10.15: A double stranded #5 suture is then passed around each tuberosity and the stem). 

FIG. 10.12 

FIG. 10.13 

B

A FIG. 10.14 

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

FIG. 10.15 

STEP 3: Implantation of Final Humeral Components • T  he final height of the implant above the top of the humeral shaft is marked out on the final stem, as determined by the trial (Fig. 10.16: The height of the humeral stem is marked onto the final implant). • Cement final humeral stem into the humerus maintaining the version and implant height as previously determined by trial components (Fig. 10.17: The final stem is cemented into the canal to the correct height and version). • Remove cement from proximal aspect of humerus to allow bone graft insertion. • Select a trial liner and place it onto the humeral component and reduce the joint.

FIG. 10.16 

FIG. 10.17 

119

120

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

STEP 3 PEARLS

• It is critical to cement the final stem at the same height and version as determined by trial reduction and trialing. • Final adjustments for tension can be made by adjusting liner thickness.

• E  nsure the joint has the correct tension and is stable throughout range of motion with no open-booking of the liner-glenosphere articulation. • Adjust liner thickness as required to create a stable joint with the correct amount of soft-tissue tension. • Open and insert the final liner and reduce the joint (Fig. 10.18: The final liner is inserted into the cemented stem). 

STEP 3 PITFALLS

• F ailure to cement the stem at the correct height can lead to either an unstable joint or an irreducible joint.

FIG. 10.18 

STEP 4 PEARLS

• R epair rather than excision of tuberosities improves outcomes. Release the supraspinatus (if still intact) to allow tuberosity repair around the proximal humeral stem. • Tie all sutures at appropriate tension to reduce the tuberosities anatomically to each other and the humeral shaft. Over-or under-tensioning can easily result in malreduction of the tuberosites.

STEP 4 PITFALLS

• T uberosity malreduction can lead to poorer healing, malunion, or nonunion.

STEP 4 CONTROVERSIES

• U se of implant designs with varying neckshaft angles or offsets has unclear effects on outcomes of RSA. • Repair of tuberosities may limit overall forward elevation. However, the benefits of tuberosity repair (i.e., improved rotation and stability and another layer of soft tissue coverage) may outweigh this concern.

STEP 4: Repair of the Tuberosities • R  epair of the tuberosities has an impact on postoperative function and outcome, especially internal and external rotation, potentially improved stability, and providing another layer of soft tissue coverage. • Repair of the tuberosities proceeds in a combined horizontal and vertical tensionband type technique, similar to what is done for a hemiarthroplasty. • Before implantation of the final stem, two sutures each were passed around the greater and lesser tuberosities and around the stem/humerus and a double-stranded #5 nonabsorbable suture was passed around the stem and around each tuberosity. • Morsellized bone graft from the humeral head is packed into the proximal humerus and around the proximal metaphyseal portion of the stem. • Using the two sutures on each of the GT and LT, tie the tuberosities together in an anatomic position. These are the horizontal tension-band sutures. • The transosseous sutures through the humeral shaft are then passed, one each through the infraspinatus and subscapularis insertion, and tied. These are the vertical tension-band sutures (Fig. 10.19: The transosseous sutures are passed through the infraspinatus and subscapularis tendons and tied forming a vertical tension band). • Finally, the double-stranded #5 nonabsorbable suture is tied around both the greater and lesser tuberosity and the stem using a NICE knot to provide final cerclage fixation (Fig. 10.20: The #5 suture is tied last around the stem and both the lesser and greater tuberosities with a NICE knot, providing cerclage fixation). 

PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

FIG. 10.19 

121

FIG. 10.20 

STEP 5: CLOSURE • • • •

 horoughly irrigate the joint. T Place a drain deep to the deltoid. Close the deltopectoral interval with an absorbable suture. Close the subcutaneous tissue and skin. 

STEP 5 PEARLS

• Ensure meticulous hemostasis before closure to minimize hematoma formation.

STEP 5 CONTROVERSIES

• D  rains may reduce the incidence of postoperative hematoma, but their value has not been determined in prospective or comparative studies.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • P  atient is placed into a sling with an abduction pillow to maintain an appropriate orientation between the joint surfaces and neutral rotation for protection of the tuberosity repair. • Begin gentle pendulum exercises at 2 weeks postoperative. • Begin passive forward flexion to 90°, internal rotation to the abdomen, and external rotation to neutral at 4 weeks postoperative. • Begin unrestricted active-assisted and active range-of-motion exercises at 8 weeks postoperative. • Begin deltoid and rotator cuff strengthening at 12 weeks postoperative. • Postoperative radiographs should be performed at 2 weeks, 6 weeks, and 12 weeks following the operation to ensure joint reduction and to monitor tuberosity healing (Fig. 10.21).

POSTOPERATIVE PEARLS

• Place into a sling with an abduction pillow.

POSTOPERATIVE PITFALLS

• E arly active range-of-motion exercises may displace tuberosities. • Start gentle passive range-of-motion exercises early to avoid significant stiffness. • Avoid extremes of rotation in the early postoperative period.

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PROCEDURE 10  Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures

A

B FIG. 10.21 

EVIDENCE Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95:2051–2055. A prospective trial of consecutive patients having 26 hemiarthroplasties and 27 reverse shoulder arthroplasties for three- and four-part proximal humerus fractures or fractures with a head split, with an average 30-month follow-up. The authors showed that reverse shoulder arthroplasty had better clinical outcomes with similar complication rates with a higher revision rate in patients having hemiarthroplasty. Mata-Fink A, Meinke M, Jones C, et al. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013;22:1737–1748. A systematic review of 15 studies of three- and four-part fractures treated with reverse shoulder arthroplasty in patients more than >60 years of age and with more than 1 year follow-up. They found that in studies comparing reverse shoulder arthroplasty with hemiarthroplasty, reverse shoulder arthroplasty had improved forward flexion and functional outcome scores but lower external rotation. They also concluded that the complication rate was not appreciably higher in the reverse shoulder arthroplasty group. Sebastia-Forcada E, Cebrian-Gomez R, Lizaur-Utrilla A, Gil-Guillen V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014;23:1419–1426. A blinded, randomized controlled trial of 62 patients over 70 years of age comparing hemiarthroplasty with reverse shoulder arthroplasty for three- and four-part fractures or fractures with a head split, with a mean follow up of 28.5 months. The authors found that reverse shoulder arthroplasty had superior results with clinical and functional outcomes with a higher revision rate in hemiarthroplasty. They also found that revision of hemiarthroplasty to a reverse shoulder arthroplasty did not improve outcomes.. Wang J, Zhu Y, Zhang F, et al. Meta-analysis suggests that reverse shoulder arthroplasty in proximal humerus fractures is a better option than hemiarthroplasty in the elderly. Int Orthop. 2016;40:531–539. A meta-analysis of eight studies including 160 reverse shoulder arthroplasties and 421 hemiarthroplasties. They concluded that reverse shoulder arthroplasty is a better alternative for treatment of complex fractures of the proximal humerus than hemiarthroplasty, with a lower rate of total complications, higher American Shoulder and Elbow Surgeons (ASES) score, more healed tuberosities and improved active forward elevation.

PROCEDURE 11

Humeral Shaft Fractures: Open Reduction and Internal Fixation Chad P. Coles and Karine Bourduas

INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION (ORIF) • Failure of nonoperative treatment • Malreduction (>3 cm shortening, 30-degree angulation or rotation) • Delayed union or nonunion • Polytrauma • Open fracture • Ipsilateral upper extremity fracture • Floating elbow or shoulder • Associated intraarticular fracture • Vascular injury • Pathologic fracture • Bilateral humeral fractures • Neurologic indications • Brachial plexus injury • Parkinson’s disease • Head injury • Relative indications • Segmental fracture • Transverse fracture • Obesity 

INDICATIONS FOR HUMERAL INTRAMEDULLARY (IM) NAILING • Pathologic fractures • Segmental fractures • Some complex fractures 

EXAMINATION/IMAGING • Examination • Initial assessment and resuscitation of the trauma patient by Advanced Trauma Life Support® or similar protocol. • Take history, including prior injuries or surgery involving the injured extremity, and perform a physical examination. • Perform a vascular examination, including brachial, radial, and ulnar pulses and capillary refill. • Perform a neurologic examination and document motor and sensory function of the axillary, musculocutaneous, median, ulnar, and, in particular, radial nerves. • Examine hand, wrist, elbow, and shoulder to exclude associated injury. • Imaging • Plain radiographs, including anteroposterior (AP) (Fig. 11.1A) and lateral (Fig. 11.1B) views of the humerus, are the mainstay of diagnosis and decision making. These should include the elbow and shoulder joints, as well as any other suspected ipsilateral injuries detected on physical examination. • A full-length radiograph may be helpful in planning for complex injury patterns.

PITFALLS

• Occult proximal or distal fracture extension • Compromised soft-tissue envelope (e.g., burns, abrasions) • Periprosthetic fractures involving prior elbow or shoulder arthroplasty • Osteoporotic bone CONTROVERSIES

• Owing to a high rate of spontaneous recovery, a primary radial nerve palsy in association with a closed humeral shaft fracture can be treated expectantly and in isolation is not an indication for surgery. Even a secondary nerve palsy, after reduction or splinting, is not considered an absolute indication for surgery. • Randomized trials have consistently shown that, for humeral shaft fractures, open reduction and internal fixation (ORIF) with a compression plate has superior results compared to intramedullary (IM) nailing. The main reason for the difference is the higher incidence of postoperative pain and functional limitations, as well as increased rates of reoperation and fracture nonunion, with humeral nails. ORIF remains the “gold standard” in the treatment of diaphyseal fractures of the humerus. TREATMENT OPTIONS

• Fractures of the midshaft or more proximal humerus are best addressed through an anterolateral approach. This allows excellent proximal access, including fixation of proximal humerus fractures, but has limited distal access as one approaches the antecubital fossa. • Fractures distal to the midshaft of the humerus are ideally addressed through a posterior approach. This allows excellent distal exposure, from the elbow joint distally to the surgical neck of the humerus, with proximal dissection limited by the crossing of the axillary nerve. • Alternatively, a lateral approach may be used for distal fractures, with the advantage of supine positioning. • Less frequently, a medial approach may be appropriate when there is an associated vascular injury that requires surgery or when the soft tissue envelope precludes the other approaches (e.g., burn patient). A medial approach is also advocated by some for the morbidly obese patient. 123

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PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

PEARLS

• Anterolateral approach • The cephalic vein serves as an anatomic landmark to the deltopectoral interval proximally. • Adequate visualization and mobilization of the radial nerve will result in a lower risk of nerve injury than blind retraction and potential stretching. • Proper identification of the radial nerve, and observation that the nerve is not entrapped in the fracture site or beneath the distal corner of the plate, will avoid the need to reexplore the nerve in the event of postoperative nerve palsy. • Posterior approach • The lateral brachial cutaneous nerve assists in locating the radial nerve. • Adequate visualization and mobilization of the radial nerve is mandatory to ensure the nerve is not in the fracture site or under the plate. Careful, but thorough, mobilization will result in a lower incidence of nerve injury than blind retraction and potential stretching. • Careful documentation in the dictated operative notes of the location of where the radial nerve crosses the plate in relation to the holes of the plate will assist in localization of the nerve in the event that revision surgery is required in the future. • Lateral approach • Identify the radial nerve distally, at the elbow, between the brachioradialis and brachialis. • Medial approach • Identify and mobilize the neurovascular bundle medially; the ulnar nerve may be reflected from the medial triceps to allow anterior retraction. PITFALLS

• It is important to remember that interphalangeal joint extension is NOT a function of the radial nerve: metacarpalphalangeal, thumb, and wrist extension are radial nerve functions that must checked, preferably without any splint or bandage obscuring the examination. PEARLS

• Anterolateral approach • Ensure the patient is positioned far enough laterally on the operating table to allow imaging of the humerus through a radiolucent arm board. • Freely drape the arm with exposure to the elbow and shoulder to allow extensile exposure, if needed. • Posterior approach • Prone positioning requires a secure airway, neutral position of the neck, and adequate eye protection. • For lateral positioning, consider the use of a chest (axillary) roll to avoid brachial plexus compression (see Fig. 11.6), and pad pressure points appropriately. • Ensure that patient positioning allows adequate imaging before sterile draping. • Freely drape the arm with exposure to the elbow and shoulder to allow extensile exposure, if needed.

A

B FIG. 11.1 

• More advanced imaging with computed tomography or magnetic resonance imaging is rarely, if ever, required. 

SURGICAL ANATOMY • Anterolateral approach (Fig. 11.2A) • The cephalic vein is a useful landmark to the interval between the deltoid (axillary innervation) and pectoralis major (pectoral innervation) proximally. • The musculocutaneous nerve runs along the undersurface of the biceps, on the surface of brachialis, and should be identified and retracted medially with the biceps muscle (musculocutaneous innervation). • The radial nerve pierces the intermuscular septum, entering the anterior arm approximately 12 cm proximal to the lateral epicondyle, and should be identified in the interval between the brachioradialis and brachialis. •  The brachialis has dual innervation from the radial and musculocutaneous nerves. • Posterior approach (Fig. 11.2B) • The lateral brachial cutaneous nerve is a useful landmark in identifying the radial nerve. • The radial nerve crosses the posterior humerus obliquely in the spiral groove, from approximately 20 cm proximal to the medial epicondyle to 12 cm proximal to the lateral epicondyle, and then pierces the intermuscular septum, entering the anterior arm. •  Reflecting the entire triceps muscle (radial innervation) off the lateral intermuscular septum and retracting it medially exposes the posterior surface of the humerus from the lateral condyle distally to the axillary nerve proximally. • Lateral approach (Fig. 11.2C) •  The humeral shaft can be exposed laterally between the biceps and triceps muscles. • The radial nerve should be identified distally in the interval between the brachioradialis and brachialis. • Medial approach (Fig. 11.2D) • The medial approach is within an intraneural plane, with the ulnar nerve posterior to the intermuscular septum, and the median nerve and brachial artery located anteriorly. • The ulnar nerve is tethered to the triceps and needs to be mobilized. 

PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation Anterior

Posterior

Cephalic vein Deltoid Axillary nerve

Humeral shaft Pectoralis major

Humerus Radial nerve Triceps brachii

Musculocutaneous nerve

Radial nerve Brachialis

Lateral brachial cutaneous nerve

Biceps brachii

Intermuscular septum Intermuscular septum Lateral epicondyle

A

B

Brachioradialis

Medial

Lateral

Triceps brachii Biceps brachii Humeral shaft

Brachial artery

Radial nerve

Triceps brachii

Brachialis (detached and reflected)

Intermuscular septum

Brachioradialis

C

Ulnar nerve Median nerve

Capitellum

D FIG. 11.2 

POSITIONING For Open Reduction and Internal Fixation • Anterolateral, lateral, and medial approaches • Position the patient supine, near the edge of the operating table, with the arm on a radiolucent arm board (Fig. 11.3). • A fluoroscopic imager can be brought in from the head of the table to provide anteroposterior (AP) and lateral images intraoperatively. • Posterior approach • Position the patient prone (Fig. 11.4A) or, preferably, in the lateral position, with the arm draped over a radiolucent bolster (Fig. 11.4B).

125

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PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

EQUIPMENT

• Anterolateral, lateral, or medial approach • A radiolucent board, extending from beneath the mattress and padded with blankets, provides an excellent working platform while allowing intraoperative imaging.

• A fluoroscopic imager positioned at the head of the table can provide AP and lateral images intraoperatively (Fig. 11.5). • For lateral positioning, consider use of a chest (axillary) roll to avoid brachial plexus compression (Fig. 11. 6). 

FIG. 11.3 

A

B FIG. 11.4 

PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

A

127

B FIG. 11.5 

FIG. 11.6 

PORTALS/EXPOSURES

PITFALLS

• Anterolateral approach • Make an appropriately sized incision along a line drawn from just distal to the coracoid process, extending along the lateral edge of the biceps, toward the lateral aspect of the biceps tendon at the elbow (Fig. 11.7). • Proximally, identify the cephalic vein and deltopectoral interval, exposing the proximal aspect of the humeral shaft (Fig. 11.8). • The anterior portion of the deltoid insertion may need to be released subperiosteally and reflected posteriorly. • The tendon of the long head of the biceps must be protected. The biceps is reflected medially, and the musculocutaneous nerve, running in the interval between the biceps and brachialis, must be identified and protected as it is retracted medially with the biceps.

• Anterolateral, lateral, or medial approach • With the patient’s head near the edge of the surgical table, inadequate stabilization of the head may result in dangerous, and easily unrecognized, change in position under the surgical drapes! Ensure the head is securely stabilized. • Anterolateral approach • Distal exposure is difficult as one approaches the antecubital fossa. This limits the use of this exposure for more distal fracture patterns. • Failure to identify the radial nerve may result in iatrogenic injury.

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PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

FIG. 11.7 

FIG. 11.8 

Deltoid Cephalic vein Pectoralis major

Humerus Biceps brachii Brachialis (split and retracted)

A

B FIG. 11.9 

PEARLS

• Use pointed reduction forceps to avoid the soft-tissue stripping, or crushing, associated with larger fracture clamps. • Temporary Kirschner wires may assist in maintaining reduction. • Small fragment (3.5-mm) lag screws may be placed in spiral, or more complex, fractures prior to neutralization with a plate. PITFALLS

• Medial approach • Careful identification of, and dissection posterior to, the neurovascular bundle is the key to the exposure. PITFALLS

• Excessive soft-tissue stripping may lead to delayed union or nonunion.

• Identify, distally, the radial nerve as it enters the anterior arm between the brachioradialis and brachialis to avoid iatrogenic injury. Then split the brachialis longitudinally, from proximal to distal, in line with the humerus, exposing the midportion of the humeral shaft (Fig. 11.9). • Lateral approach • Make a midlateral incision, extending it to the lateral epicondyle. • Identify the radial nerve in the interval between the brachialis and brachioradialis. The brachioradialis is detached along the lateral humerus and reflected anteriorly with the radial nerve. This allows distal exposure to the level of the capitellum for fixation of distal fractures with a laterally applied implant. • Proximal dissection is between the biceps and triceps, along the intermuscular septum, exposing the lateral humerus. • Medial approach • A longitudinal medial incision is used from the medial epicondyle extending proximally. • Carefully dissect anterior to the intermuscular septum, in the interval between the ulnar nerve posteriorly and the median nerve and brachial artery anteriorly. • Tether the ulnar nerve to the triceps and then mobilize it.

PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

129

Lateral brachial cutaneous nerve

FIG. 11.10 

FIG. 11.11  PITFALLS

• Posterior approach • In the prone position, dislodgement of the endotracheal tube and loss of airway is always a possibility. If this occurs the patient must emergently be returned to the supine position for airway management! Keep a stretcher readily available (and clearly marked “patient in the prone position”) in the event that an urgent repositioning is required. • Proximal extension is limited by the crossing of the axillary nerve, precluding the use of this exposure in fractures extending to the proximal humerus.

Radial nerve

EQUIPMENT

• Posterior approach • For prone positioning, a padded radiolucent board is used. • In the lateral position, either a beanbag or hip arthroplasty positioning frame is used to maintain position. A padded, radiolucent bolster is used to support the operative arm. FIG. 11.12 

• Posterior approach • We prefer the modified posterior approach as described by Gerwin et al. (1996). • A midline posterior skin incision is used (Fig. 11.10). A full-thickness lateral skin flap is raised off the posterior triceps (Fig. 11.11). • The lateral brachial cutaneous nerve (see Fig. 11.11) is identified, protected, and followed proximally to identify the radial nerve (Fig. 11.12). • The triceps muscle is elevated off the lateral intermuscular septum and reflected medially, and the radial nerve is carefully mobilized and protected with a Penrose drain or vessel loop (Fig. 11.13).

CONTROVERSIES

• Although some prefer the prone position for the posterior approach, lateral positioning is likely safer from an airway and positioning perspective. It is also preferred by anesthesiologists in the potentially unstable multiple-trauma patient. • Posterior approach • A triceps-splitting approach is preferred by some surgeons, but proximal exposure is more difficult with the crossing of the radial nerve, and the extensive splitting potentially traumatizes the triceps muscle.

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PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

Penrose drain

Radial nerve Lateral brachial cutaneous nerve

Triceps brachii

A

B FIG. 11.13 



• If necessary, proximal dissection may be carried between the triceps and deltoid. The proximal limit of this exposure is the crossing axillary nerve at the level of the surgical neck of the humerus. 

PROCEDURE: OPEN REDUCTION AND INTERNAL FIXATION Step 1 • Minimize soft-tissue stripping at the fracture site with extra-periosteal exposure and the least amount of muscle elevation possible. • After irrigation and cleaning of the fracture site, reduce the fracture and stabilize it with pointed reduction clamps or temporary Kirschner wires, depending on fracture configuration (Fig. 11.14). • Transverse fracture patterns may require clamping of fracture segments directly to the plate. 

PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

131

CONTROVERSIES

• Select an appropriate-length plate. Longer implants distribute stress over a larger area and provide stronger fixation. • The number of cortices of screw purchase is not as important as the distribution of screws along the length of the plate, with points of fixation close to the fracture, and at the far end of the plate. As a minimum, six cortices of fixation should be achieved on each side of the fracture. 

• The use of narrow plates with holes in a straight line has been associated with longitudinal splitting of the humerus owing to the stress riser of the linear perforations. Broad plates, with offset holes, minimize this risk but are not well suited to the small dimensions of many humeri. The use of longer narrow plates, without filling every hole, or with screws inserted at differing angles, should help avoid this devastating complication. • Locked plates may be of benefit in osteoporotic bone, for very distal or proximal fractures with limited points of fixation, or in revision/ nonunion cases. They are rarely required for typical humeral shaft fractures and, given the significant cost difference, use should be carefully considered and justified. Improperly applied locked implants may lead to nonunion if proper reduction and appropriate stability are not achieved at the fracture site. • An alternative method to conventional open plating is minimally invasive plate osteosynthesis (MIPO), intended to improve biological fixation by minimizing soft-tissue dissection at the fracture site. In the humerus, this approach should be reserved for experienced surgeons who are familiar with the MIPO technique.

Step 3

PEARLS

FIG. 11.14 

Step 2

• Contour the plate to fit the bone. This is critical to maintaining an anatomic reduction. For compression plating of a transverse fracture, slight over-contouring of the plate will prevent gapping of the far cortex when compression is applied (Fig. 11.15). • Temporarily clamp the plate in place and confirm position and fracture reduction using fluoroscopy. • Secure the plate using cortical screws and proper compression technique, as appropriate (Fig. 11.16).

• Longer plates provide more stable fixation with a lower mechanical failure rate. • Not every screw hole needs to be filled, but rather a good spread of screws is desired. • A minimum of six cortices of fixation on each side is recommended. PITFALLS

• Shorter plates may not provide adequate stability, and may not extend beyond areas of subtle fracture lines and comminution, leading to loss of fixation. INSTRUMENTATION/IMPLANTATION FIG. 11.15 

• Obtain final images to confirm reduction and the position of the implants (Fig. 11.17). • Confirm the location of the radial nerve, and document its position relative to the plate as discussed (see Surgical Anatomy). 

• Conventional large fragment plates and screws are typically employed. Either a broad 4.5-mm plate with staggered holes or, more commonly, a 4.5-mm narrow plate with linear holes is used, based on the size of the bone. • Occasionally, in the setting of significant osteoporosis or short fixation segments, the use of locking plates may be appropriate. These are not a substitute for appropriate fracture reduction and fixation technique. PEARLS

• For transverse fractures, slight over-contouring of the compression plate will prevent gapping of the far cortex when compression is applied. PITFALLS

• A poorly contoured plate may lead to malreduction and delayed union or malunion.

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PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

INSTRUMENTATION/IMPLANTATION

• A large plate-bending press and torque irons are essential. PEARLS

• Initial fixation should be sufficiently secure to permit use of the upper extremity for crutch mobilization in patients with polytrauma. Studies show a properly plated humerus is stable enough to allow early upper extremity crutch or walker use.

PITFALLS

• Inadequate intraoperative documentation of the position and safety of the radial nerve may result in uncertainty and unnecessary reexploration in the event of postoperative radial nerve palsy.

FIG. 11.16 

FIG. 11.17 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Apply light dressings. No splint is required. • Encourage early, active and active-assisted range-of-motion exercises. • Use of the extremity for crutch mobilization of the polytrauma patient has been shown to be safe, given sufficient initial fixation.

PROCEDURE 11  Humeral Shaft Fractures: Open Reduction and Internal Fixation

• With adequate mobilization and exposure of the radial nerve, postoperative nerve palsy is rare. As long as the nerve is seen intraoperatively to be in continuity and not trapped in the fracture site or beneath the plate, then a postoperative radial nerve palsy can be treated expectantly, with high rates of recovery. • The expectation with ORIF is a high rate of fracture union (98%), with good functional recovery (>95% good to excellent results).

EVIDENCE Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience. J Bone Joint Surg [Br]. 1985;67:293–296. Level IV case series showing good functional results with ORIF in 34 cases of humeral shaft fracture, with only one nonunion, one failure of fixation, and one infection. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis. Acta Orthop. 2006;77:279–284. Level II meta-analysis of three RCTs indicating lower reoperation rate and less shoulder pain with ORIF than IM nail. (Grade B recommendation.) Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14:162–166. Level II RCT of 84 patients randomized to ORIF or IM nail, with similar rates of healing. Increased incidence of shoulder pain with IM nail. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg [Am]. 1996;78:1690–1695. Level IV case series of the modified posterior approach, and anatomic study describing the anatomy of the radial nerve in relation to posterior approaches to the humerus. Gupta R, Raheja A, Sharma V. Limited contact dynamic compression in diaphyseal fractures of the humerus: good outcome in 51 patients. Acta Orthop Scand. 2000;71:471–474. Level IV case series of ORIF of the humerus for various indications, yielding good results, but inadequate evidence to influence treatment recommendation. McCormack RG, Brien D, Buckley RE, et al. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg [Br]. 2000;82:336–339. Level I RCT comparing 44 patients randomized to either ORIF or IM nail, showing fewer complications and reoperations with ORIF. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996;10:81–86. Level IV case series describing the lateral approach to the humerus. Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY. Results of non-operative and operative treatment of humeral shaft fractures: a series of 104 cases. Chir Main. 1998;17:195–206. Level III retrospective comparative study of 104 humerus fractures managed with and without surgical stabilization. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg [Am]. 2000;82:478–486. Level IV, very large case series of nonoperatively managed humeral shaft fractures showing good results can be obtained (33% loss to follow-up). Scheerlinck T, Handelberg F. Functional outcome after intramedullary nailing of humeral shaft fractures: comparison between retrograde Marchetti-Vicenzi and unreamed AO antegrade nailing. J Trauma. 2002;52:60–71. Level III retrospective comparative study of 22 retrograde and 30 antegrade intramedullary nails, showing better shoulder function with retrograde nailing. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg [Br]. 2005;87:1647–1652. Level III systematic review article describing radial nerve palsies following humerus fractures ­favoring expectant treatment for 6 months prior to surgical exploration. (Grade B recommendation.) Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000;49:278–280. Level IV case series showing early weightbearing for crutch mobilization through the humerus following ORIF to be safe practice.

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PROCEDURE 12

Intramedullary Nailing of Humeral Shaft Fractures Vasileios S. Nikolaou and Peter V. Giannoudis

PITFALLS

• Narrow, obstructed, or too short medullary canal • Occult proximal or distal fracture extension • Articular involvement • Osteoporotic bone • Active infection • Radial nerve palsy/possible nerve entrapment in fracture site • Iatrogenic fracture at entry point

CONTROVERSIES

• While intramedullary (IM) nailing is recommended worldwide as the procedure of choice for stabilization of acute tibial and femoral shaft fractures, controversy exists regarding the treatment of choice for humeral shaft fractures. • In many countries, the treatment of choice for acute, uncomplicated diaphyseal humeral fractures remains nonoperative. • Recent randomized trials and meta-analyses have shown that open reduction and internal fixation (ORIF) with plate fixation has superior results compared with IM nailing for most humeral shaft fractures.

134

INDICATIONS • Failure of nonoperative treatment • Malreduction (>3 cm shortening, 30-degree angulation or rotation) • Nonunion • Closed midshaft and distal diaphyseal fractures (antegrade nailing) or midshaft and proximal diaphyseal fractures (retrograde nailing) • Segmental fractures • Floating elbow injures • Pathologic fractures • Fractures associated with thermal burns • Fractures in polytrauma patients • Fractures in obese patients • Nailing is generally contraindicated in: • Open humerus fractures • Fractures with associated radial nerve palsy • Open epiphysis • Narrow medulary canal • Humeral shaft preinjury deformities • Medullary canal obstruction or too short canal • Active infection 

EXAMINATION/IMAGING • Examination • History and physical examination, including prior injuries or surgery involving the injured extremity and anticipated start point (shoulder or elbow) • Vascular examination, including brachial, radial, and ulnar pulses and capillary refill • Assessment and documentation of neurologic condition of the extremity (particularly axillary and radial nerve) • Examination of hand, wrist, elbow, and shoulder to exclude associated injury • Imaging • Anteroposterior and lateral plain radiographs, including anteroposterior and lateral views of the humerus (Fig. 12.1). Radiographs should include the elbow and shoulder joints. • Computed tomography scan if very proximal or distal or intraarticular fracture line extension is suspected. • Parameters, like the size of the medullary canal and the length of the canal up to the proximal aspects of the olecranon fossa, should be examined. Intramedullary (IM) nailing should be avoided if available implants do not match patient’s anatomy (i.e., if the smallest available nail is 9 mm in diameter and the canal is 8 mm or less). 

PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

A

135

B

FIG. 12.1  A, Anteroposterior radiograph of right humeral shaft fracture. B, Lateral view of fracture.

POSITIONING • For antegrade IM nailing • Position the patient supine or in the beach chair position (Fig. 12.2) with a radiolucent arm board. • Place a small towel roll between the scapulae. • A fluoroscopic imager can be brought in from the head of the table or the contralateral side. • Prior to draping, the surgeon should be able to see good quality fluoroscopic imaging of the proximal humerus (anteroposterior and axillary views). • For retrograde IM nailing • Position the patient supine, lateral decubitus, or prone. • A fluoroscopic imager is positioned on the same side of surgeon and can be brought in from the head or the foot of the table. • Prior to draping, the surgeon should be able to see good quality fluoroscopic imaging (anteroposterior and lateral views). 

PITFALLS

• Supine or in beach chair position • Stabilize or tape the head. With the patient supine and patient’s head near the edge of the surgical table, inadequate stabilization of the head may result in dangerous, and easily unrecognized, change in position under the surgical drapes. • The upper extremity must be freely movable. • Ensure the patient is positioned far enough laterally on the operating table to allow imaging of the humerus through a radiolucent arm board. • Good visualization of the full length of the humerus, using fluoroscopy is mandatory. Do not start surgery if patient positioning and radiographic imaging are not optimal! EQUIPMENT

FIG. 12.2  Intraoperative picture illustrating the beach chair position of the patient.

• A radiolucent fracture table • An image intensifier • Instrumentation that includes: • For antegrade IM nailing: • A curved awl, a ball-tipped guidewire, and a T-handle chuck • Flexible reamers and nail instruments. • For retrograde IM nailing: • Drill bits and routers to open medullary canal, flexible reamers, and nail instruments

136

PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

PITFALLS

• Transdeltoid approach for antegrade nailing • Avoid damaging the rotator cuff during the reaming procedure or nail insertion. • Failure to meticulously repair the rotator cuff at the end of the procedure can impair shoulder joint functional recovery. • During the approach a small portion of the articular cartilage of the humeral head can be exposed. The entry point should be just lateral to the edge of the articular cartilage. • During proximal interlocking of the nail, the axillary nerve, the circumflex artery, and the long head of biceps are at risk and should be protected: use a “mini-open” approach if there is any question of nerve proximity. • Retrograde nailing approach • Avoid damaging the triceps tendon during reaming or nail insertion. Protect edges with right angle retractors. • Protect the elbow joint capsule. • Insertion of a locking screw from lateral to medial, apart from being technically more difficult, bears the danger of injury to the radial and/or the lateral cutaneous nerves.

PORTALS/EXPOSURES • Transdeltoid approach for antegrade nailing • Make a small skin incision over the superior and anterior aspect of the greater tuberosity. Extend the incision from the lateral edge of acromion 3 to 5 cm distally, toward the deltoid insertion (Fig. 12.3). • Incise the deltoid muscle in line with its fibers. Clear away the subacromial bursa and incise the supraspinatus tendon in line with its fibers. • The entry point, using the awl, is just medial to the greater tuberosity and posterior to the bicipital groove. • Retrograde nailing approach • Identify, using fluoroscopy and palpation, the olecranon fossa. Make an incision over the proximal half of the olecranon fossa and in line with the longitudinal axis of the olecranon (Fig. 12.4). • Split the triceps tendon in line with its fibers. • The entry point to the medullary canal is approximately 2 cm proximal to the olecranon fossa. 

FIG. 12.3  Intraoperative picture illustrating the small skin incision over the superior and anterior aspect of the greater tuberosity. The entry point, using the awl, is just medial to the greater tuberosity and posterior to the bicipital groove.

FIG. 12.4  Intraoperative picture of the incision for the retrograde nailing. The incision is made over the proximal half of the olecranon fossa and in line with the longitudinal axis of the olecranon.

PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

PROCEDURE (ANTEGRADE IM NAILING) Step 1 • Reduce the fracture by longitudinal traction and neutral rotation. • Ensure there is no gap at the fracture site: this may indicate entrapment of the radial nerve. In this situation, minimize the chance for iatrogenic radial nerve injury by performing a limited open approach to aid in reduction. 

Step 2 • Palpate the surface anatomy of the humeral head from anterior to posterior and locate the midline. • Make a longitudinal lateral incision over the superior and anterior aspect of the greater tuberosity. Extend the incision from the lateral edge of acromion to 3 to 5 cm distally. • Incise the deltoid muscle in line with its fibers. Clear the subacromial bursa and incise the rotator cuff in line with its fibers. • The entry point, using the awl, is just medial to the greater tuberosity and posterior to the bicipital groove. Correct entry point should be confirmed by fluoroscopy. 

Step 3 • Maintain fracture reduction by applying traction and neutral rotation. Pass the guidewire across the fracture site (Fig. 12.5). • Use fluoroscopy during reaming and nail insertion. • Select a nail 1.0 to 1.5 mm smaller than the largest reamer that was used. 

FIG. 12.5  Fluoroscopic image of proximal humerus showing advancement of the guidewire after intramedullary canal opening.

137

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PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

Step 4 • The nail should be introduced by hand under fluoroscopy (Fig. 12.6). Avoid using a mallet except for terminal seating of the nail. • The proximal end of the nail has to be countersunk below the cortical/articular surface in order to avoid rotator cuff damage and/or subacromial impingement. • Proximal interlocking is performed using the handle/aiming guide. To introduce the screws, make percutaneous incisions and spread soft tissues down to bone. Avoid the region of the axillary nerve and brachial plexus (Figs. 12.7 and 12.8). • Distal interlocking is usually performed with the “free hand” technique. Anteroposterior interlocking is safest. Using fluoroscopy, achieve perfect circles of the nail holes, then perform a limited open approach using blunt dissection of soft tissues up to the bone. A drill cannula or sleeve is used to prevent soft-tissue damage. The brachial artery and the median nerve are located medial to the skin incision and should be protected (Fig. 12.9). 

FIG. 12.6  Intraoperative image showing advancement of the nail in the intramedullary canal; and fluoroscopic image showing advancement of nailing distally bypassing the fracture.

FIG. 12.7  The nail should be introduced by hand under fluoroscopy. Avoid using a mallet except for terminal seating of the nail in order to avoid iatrogenic fractures.

PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

FIG. 12.8  Fluoroscopic image showing the proximal interlocking using the aiming guide. The proximal end of the nail should be countersunk below the cortical/articular surface in order to avoid rotator cuff damage and/or subacromial impingement.

FIG. 12.9  Fluoroscopic image showing the distal interlocking. Anteroposterior interlocking is safest.

Step 5 • Obtain final anteroposterior and lateral radiographs before closure. • Rotator cuff and deltoid muscle should be anatomically repaired. • Close skin in the routine fashion. • Obtain postoperative radiographs (Fig. 12.10). 

A

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B

FIG. 12.10  Postoperative (A) anteroposterior radiograph and (B) lateral radiograph of right humerus.

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PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

CONTROVERSIES

• Antegrade nailing is considered to offer easier access to the medullary canal and more convenient fluoroscopy handling. However, it increases postoperative shoulder problems, including rotator cuff tendinopathy and shoulder stiffness. • Many authors advise that retrograde nailing is preferred in humeral shaft nailing procedures. However, retrograde nailing is a more technically demanding procedure, more time consuming, and more inconvenient for the anesthesiology team. • Recent trials have failed to demonstrate significant differences between the two methods, regarding complications and postoperative results. Operating surgeons should ensure that they use a method and implant that is reliable and reproducible in their hands.

PITFALLS

• Beware the narrow canal (avoid IM nailing if the canal is less than 9 mm). • Better to err on the side of a shorter than a longer nail. The distal humeral canal tapers to an end in diaphyseal bone. Impacting a nail that is too long, in an effort to countersink it, will cause it to impact distally and distract the fracture site. This is poorly tolerated by the humerus and leads to a high rate of delayed union and nonunion. • Inadequate preoperative documentation of the functional status of the radial nerve may result in uncertainty and unnecessary nerve exploration in the event of postoperative radial nerve palsy. • During retrograde nailing the olecranon does not facilitate nail direction in line with the humeral canal. A great risk for supracondylar fracture exists around the entry portal (anterior cortex).

PEARLS

• Maintain anatomic reduction (no gapping at fracture site) during reaming (reduced risk to radial nerve). • If an anatomic reduction cannot be obtained prior to and during reaming, exposure of the radial nerve at the level of the fracture is recommended to ensure that the nerve is not within the fracture site during reaming and nail insertion. • Incidence of injuries to the long head of the biceps and the axillary nerve could be reduced with the avoidance of the anteroposterior proximal locking screw. • In retrograde nailing, make a broad entry portal to avoid anterior cortex penetration during nail insertion. • Antegrade nailing has a higher incidence of postoperative shoulder problems. • Retrograde nailing has a higher incidence of postoperative elbow problems.

PROCEDURE (RETROGRADE IM NAILING) Step 1 • Reduce the fracture by gentle longitudinal traction. Usually the proximal fragment is abducted and internally rotated. Lateral pressure of the proximal fragment is helpful. • Avoid fracture gapping to minimize the chances for potential iatrogenic radial nerve injury as with antegrade nailing. 

Step 2 • Using fluoroscopy and palpation, identify the olecranon fossa. • Make an incision over the proximal half of the olecranon fossa. • Incise the triceps in line with its fibers. • The entry point to the medullary canal is approximately 2 cm proximal to the olecranon fossa. Confirm the correct entry point by fluoroscopy. • Start the entry portal using a 4.5-mm drill bit. Enlarge the entrance with a router. 

Step 3 • Maintain fracture reduction by applying traction and neutral rotation. Pass the guidewire across the fracture site. • Use fluoroscopy during reaming and nail insertion. • Select a nail 1.0 to 1.5 mm smaller than the largest reamer that was used. 

Step 4 • The nail should be introduced by hand under fluoroscopy. Avoid using a mallet except for terminal impaction. • The proximal tip of the nail should be impacted into the humeral head, stopping short of the subchondral bone. • Distal interlocking is made using the special handle/aiming guide. Make percutaneous incisions and spread the soft tissues to the bone. Lateral to medial screws put the radial nerve in risk. Anterior to posterior screws put the brachial artery and musculocutanous nerve at risk. • Proximal interlocking is usually made with the “free hand” technique. Using fluoroscopy, achieve perfect circles of the nail holes. Make a stab skin incision and use blunt dissection of soft tissues up to the bone. The axillary nerve is at risk using the anterior to posterior screws. 

Step 5 • Obtain final anteroposterior and lateral radiographs before closure. • Repair the distal aspect of the triceps tendon. • Close skin in the routine fashion. • Obtain postoperative radiographs (Fig. 12.11). 

PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures

A

B

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C

FIG. 12.11  A, Anteroposterior radiograph of a midshaft fracture of the humerus that was chosen to be treated by retrograde nailing. B and C, Immediate postoperative anteroposterior and lateral images. The proximal tip of the nail should be impacted into the humeral head and stop short of the subchondral bone.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Apply light dressings. A splint is not necessary. A sling aids in comfort. • Early, active, and active-assisted range-of-motion exercises are encouraged. • Patients may weight bear on the arm if necessary owing to concomitant injuries. • Patients are seen at 2-week, 6-week, and 3-month intervals until fracture healing has occurred. • The expectation with IM nailing is a high rate of fracture union with good functional recovery (>95% good to excellent results). • Implant removal is usually not necessary and is mainly performed for soft-tissue irritation (including rotator cuff tendinopathy and/or impingement).

EVIDENCE Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev. 2011;(6). Level I meta-analysis of five randomized and quasi-randomized controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults, showing that intramedullary nailing is associated with an increased risk of shoulder impingement, restriction of shoulder movement, and need for removal of metalwork. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg. 2013;22(3):387– 395. Level II meta-analysis of 10 prospective comparative trials, comparing plating and nailing in patients with humeral shaft fractures. Both plating and nailing achieved similar treatment effect on humeral shaft fractures, but plating may reduce the occurrence of shoulder problems. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis. Acta Orthop. 2006;77:279–284.

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PROCEDURE 12  Intramedullary Nailing of Humeral Shaft Fractures Level II meta-analysis of three RCTs indicating lower reoperation rate and less shoulder pain with ORIF than IM nail. (Grade B recommendation.) Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14:162–166. Level II RCT of 84 patients randomized to ORIF or IM nail, with similar rates of healing. Increased incidence of shoulder pain with IM nail. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg [Br]. 2000;82:336–339. Level I RCT comparing 44 patients randomized to either ORIF or IM nail, showing fewer complications and reoperations with ORIF. Scheerlinck T, Handelberg F. Functional outcome after intramedullary nailing of humeral shaft fractures: comparison between retrograde Marchetti-Vicenzi and unreamed AO antegrade nailing. J Trauma. 2002;52:60–71. Level III retrospective comparative study of 22 retrograde and 30 antegrade intramedullary nails, showing better shoulder function with retrograde nailing. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg [Br]. 2005;87:1647–1652. Level III systematic review article describing radial nerve palsies following humerus fractures favoring expectant treatment for 6 months prior to surgical exploration. (Grade B recommendation.) Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma. 2008;65(1):94–102. Level I prospective randomized comparative study of 92 humeral shaft fractures, managed with ­antegrade or retrograde nailing. Results showed similar treatment results, including healing rate and eventual functional recovery.

PROCEDURE 13

Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus Paul R. T. Kuzyk and Emil H. Schemitsch INDICATIONS

CONTROVERSIES

• Displaced intraarticular distal humerus fractures 

EXAMINATION/IMAGING • Clinical examination should include inspection of the skin for any lacerations indicating an open fracture; evaluation of median, ulnar, and radial nerve function; and examination of the wrist and shoulder for any associated injuries. • Anteroposterior (Fig. 13.1A) and lateral (Fig. 13.1B) radiographs are required for preoperative planning. A traction radiograph of the elbow provides an excellent view of comminuted fractures; however, this is difficult to obtain as it is painful for the patient. It may be obtained intraoperatively using fluoroscopy once anesthesia has been administered. • High-quality computed tomography scans with coronal and sagittal reformats may also be useful for planning reduction and internal fixation in comminuted fractures. 

• Some elderly patients with comminuted fractures may benefit from primary total elbow arthroplasty. • Lower-demand, medically unwell older patients may benefit from nonoperative management.

TREATMENT OPTIONS

• Open reduction and internal fixation comprise the “gold standard” treatment for these intraarticular fractures. • Total elbow arthroplasty may be considered for elderly patients with comminuted intraarticular fractures and poor bone stock. • Closed management consisting of 2 weeks of rigid splinting followed by unrestricted range of motion in a hinge brace may be effective for very elderly, low-demand patients who have medical contraindications to surgery.

EQUIPMENT

• Axillary roll • Sterile stockinette for the hand • Sterile tourniquet

A

B FIG. 13.1  (A) Anteroposterior and (B) lateral radiographs of a distal humerus fracture.

SURGICAL ANATOMY • Muscular anatomy: medial head, lateral head, and long head of the triceps; triceps tendon, intermuscular septum, flexor carpi ulnaris, anconeus, and extensor carpi ulnaris • Neurologic anatomy: radial nerve, ulnar nerve, and posterior antebrachial cutaneous nerve • Bony anatomy: medial and lateral epicondyles, trochlea, capitellum, olecranon fossa, and olecranon  143

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PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

POSITIONING • The patient may be placed in the lateral decubitus position with the operative side facing upward (Fig. 13.2A) or, alternatively, the patient may be placed in the prone position (Fig. 13.2B). • The operative arm is placed over a padded bolster so that the elbow may hang freely at an angle of approximately 90 degrees. 

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B

Fig. 13.2  Positioning the patient (A) lateral and (B) prone. Modified from AO Surgery Reference Online (www.aofoundation.org).

PORTALS/EXPOSURES • A posterior approach with identification and protection of the ulnar nerve is typically performed. • The triceps can be mobilized in several ways to expose the distal humerus. • Triceps-splitting approach • A midline skin incision is made extending along the subcutaneous border of the ulna, over the olecranon and proximally in the midline of the humerus (Fig. 13.3A). Generous subcutaneous dissection is performed, both medially and laterally, to expose both epicondyles. • The ulnar nerve is identified over the posterior aspect of the medial epicondyle (see Fig. 13.3A). The nerve is released both proximally and distally and retracted with a vessel loop.

PEARLS

• The olecranon osteotomy approach provides the best exposure of the articular surface of the distal humerus. Approximately 52% of the articular surface may be seen through the olecranon osteotomy approach. The tricepssplitting approach provides exposure of 37% of the articular surface, and the tricepssparing approach provides exposure of 26% of the articular surface. • Choice of approach to the distal humerus is determined by the type of distal humerus fracture. Simple articular fractures (AO type C1 and C2) may be addressed through the tricepssparing approach. More complex articular fractures (AO type C3) require a triceps-splitting or olecranon osteotomy approach. • If a coronal shear fracture is also present, then an olecranon osteotomy allows the best visualization.

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B

Fig. 13.3  The triceps splitting approach to the distal humerus. Modified from McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646– 651.

PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

Cubital tunnel

A

Triceps muscle

Triceps muscle

Olecranon

Olecranon

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B

Fig. 13.4  The triceps sparing approach (A) medial and (B) lateral windows. Modified from AO Surgery Reference Online (www.aofoundation.org).

• The triceps tendon and muscle are split in the midline (dotted line in Fig. 13.3A). The radial nerve must be identified and protected if the triceps muscle split is extended proximal to the distal third of the humerus. • Any traumatic defects in the triceps tendon should be incorporated into the triceps split. These traumatic defects are often encountered with open fractures as the bone tears through the triceps muscle/tendon before piercing the skin. • The triceps tendon should be sharply dissected off the olecranon, preserving a continuous layer medially and laterally that can be easily repaired through drill holes in bone at the end of the procedure (Fig. 13.3B). • The medial and lateral edges are retracted to expose the distal end of the humerus. • A towel clip can be used to retract the olecranon posteriorly, allowing for better visualization of the fracture. 

PROCEDURE Step 1 • Once the distal humerus has been appropriately exposed, the elbow should be flexed greater than 140 degrees to provide greater access to the distal humerus. • Identify and then clean the fracture fragments of hematoma or intervening soft tissues. • Begin reduction with restoration of the articular surface (Fig. 13.5A). • Restoration of the normal anatomic alignment of the trochlea is most important. • Congruency of the ulnohumeral articulation is required for normal range of motion and stability of the elbow. Care should be taken not to over compress the trochlea and thereby cause incongruency of the ulnohumeral joint. • The reduction of the articular surface should be held provisionally with pointed reduction forceps and Kirschner wires (K-wires) (Fig. 13.5B). A 4.0-mm cancellous screw or two may then be used to rigidly stabilize the articular surface. Take care to ensure that these screws do not enter the olecranon fossa or protrude through the articular surface and into the joint. Additionally, it is preferable that as many distal screws as possible pass through a plate: if “real estate” distally is limited the number of screws outside of the plate should be minimized. 

Step 2 • After reduction of the articular surface, the nonarticular supracondylar component of the fracture is reduced and the articular surface is provisionally fixed to the humeral shaft using K-wires (Fig. 13.6A). • Stable fixation of the fracture using two plates (one on each column) is mandatory (Fig. 13.6B). Precontoured 3.5-mm periarticular distal humerus plates are preferred if available: 3.5-mm reconstruction plates contoured intraoperatively may also be used.

CONTROVERSIES

• The most common complication associated with an olecranon osteotomy is prominent hardware that requires a second procedure for removal. Nonunion of the osteotomy has also been reported; however, this is an uncommon complication. Some surgeons suggest plate fixation of the osteotomy as this reduces the chance of nonunion. • Triceps-sparing approach • A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (see Fig. 13.3A). • The ulnar nerve is followed proximally along its course over the intermuscular septum. • The medial (ulnar) window is created by dissecting out the ulnar nerve and mobilizing the medial head of the triceps laterally to expose the humerus (Fig. 13.4A). • The ulnar window provides some exposure of the medial humerus that may be adequate for simple fracture patterns. • Greater exposure of the lateral side of the humerus is obtained by creating a lateral window. • The lateral window is created by mobilizing the lateral head of the triceps off the lateral intermuscular septum toward the ulnar side (Fig. 13.4B). • Distally, the anconeus muscle is detached from the radius to allow for greater exposure. If this approach does not provide sufficient exposure then it may be converted to an olecranon osteotomy. • Olecranon osteotomy approach • A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted. • A hole maybe predrilled through the olecranon to allow for anatomic reattachment of the olecranon at the end of the operation. This hole is made with a 3.2-mm drill bit for fixation with a 6.5-mm cancellous screw. Continued

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PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

CONTROVERSIES—cont’d

• A precontoured proximal ulnar plate may also be used to repair the osteotomy. • Alternatively, two 1.5-mm K-wires may be used to predrill holes through the olecranon and anterior cortex of the ulna, then removed prior to performing the osteotomy. This is useful if the osteotomy is to be fixed using a tension band technique. • The osteotomy should be made through the nonarticular portion of the olecranon, which is located between the olecranon articular facet and the coronoid articular facet (the bare area). • Subperiosteal dissection along the medial and lateral sides of the olecranon allows the surgeon to view the ulnohumeral joint and locate the bare area. An apex distal chevron osteotomy is then marked on the olecranon. • An oscillating saw is used to cut two-thirds of the way through the olecranon. An osteotome should be used to complete the osteotomy through to the articular surface. • The triceps is released off the posterior aspect of the humerus and retracted with the distal portion of the olecranon to expose the distal humerus.

PEARLS

• Obtain anatomic reduction of the trochlear groove: this is the critical articulation of the elbow.

PITFALLS

A

B

FIG. 13.5  Articular surface should be (A) reduced and then (B) provisionally held with K-wires. Modified from Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg [Am]. 1985;67:226– 239.

• Biomechanical studies suggest that plates may be placed either parallel (i.e., one plate medial and one plate lateral) or perpendicular (i.e., one plate medial and one plate posterolateral or one plate lateral and one plate posteromedial) to provide stable fixation. More distal fractures, or those with significant comminution, may benefit from the enhanced stability that is seen with parallel plating on biomechanical studies. • In some situations it may be advantageous to initially fix a clear and noncomminuted extraarticular column fracture then build on that construct to establish overall fracture reduction. 

• Do not use lag screws if there is significant comminution of the articular surface. Overreduction of the trochlear groove will lead to incongruity of the ulnohumeral articulation.

INSTRUMENTATION/IMPLENTATION

• Small fragment set with reduction forceps and K-wires • Anatomic precontoured locking plates for the distal humerus and olecranon

PEARLS

• Two strong plates are required for any bicondylar distal humerus fracture to provide adequate stability for early postoperative range of motion. • Precontoured plates are very useful in helping to ensure adequacy of reduction and ease of plate application. • Use long screws that pass through plates and allow for fixation between the medial and lateral columns. Plan lag screw fixation to avoid interfering with screws that pass through plates. Headless compression screws can be used to stabilize small articular fragments.

A

B

FIG. 13.6  After the articular surface is (A) reduced and the fracture provisionally fixed with K-wires, (B) two contoured plates are used to provide stable definitive fixation. Modified from Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg [Am]. 1985;67:226–239.

PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

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B

FIG. 13.7  (A) Anteroposterior and (B) lateral radiographs showing definitive fixation of the distal humerus fracture with two plates placed parallel.

A

B

FIG. 13.8  (A) Anteroposterior and (B) lateral radiographs showing definitive fixation of the distal humerus fracture with two plates placed perpendicular.

Step 3 • Prior to closure, the elbow should be taken through a range of motion (flexion, extension, pronation, and supination) to ensure the elbow is stable and that there are no blocks to motion. The reduction and the position of the hardware should be checked using fluoroscopy. • If a triceps-splitting approach was used, take care to ensure the triceps tendon is appropriately repaired. • After repair of the distal humerus fracture, place drill holes in the olecranon to allow for repair of the triceps tendon (Fig. 13.9A). • Use heavy nonabsorbable sutures to repair the triceps tendon (Fig. 13.9B). Place interrupted sutures through the drill holes in the olecranon.

INSTRUMENTATION/IMPLANTATION

• Small fragment set • 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates • K-wires and reduction forceps

PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

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A

B

FIG. 13.9  (A) The triceps splitting approach and (B) repair of the triceps through drill holes in the ulna. Modified from McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–651.

A

B

C

Fig. 13.10  Methods of fixation for the olecranon osteotomy: (A) one cancellous screw with tension band; (B) two K-wires and tension band; (C) plate fixation. Modified from AO Surgery Reference Online (www.aofoundation.org).

CONTROVERSIES

• Arrangement of the plates to provide greatest biomechanical stability is a matter of ongoing debate. Parallel plate (medial and lateral side of the humerus) (Fig. 13.7) and perpendicular plate (medial and posterolateral humerus (Fig. 13.8) or lateral and posteromedial humerus) configurations seem to provide satisfactory stability in most cases. If maximum stability is required with severe comminution, osteopenia, or bone loss, parallel plating may be ideal.

• If an olecranon osteotomy was used, this must be rigidly fixed. There are three reported methods for fixation of an olecranon osteotomy: • One 6.5-mm cancellous screw and a tension band wire (Fig. 13.10A) • Two 1.5-mm K-wires with a tension band wire (Fig. 13.10B) • A 3.5-mm plate contoured to fit the olecranon (Fig 13.10C). A precontoured olecranon plate is helpful in this case. • Subcutaneous transposition of the ulnar nerve may be considered if the nerve is under tension or directly overlying the plate. In general, however, there are no differences in outcomes between simple decompression and anterior transposition of the ulnar nerve, resulting in simple decompression being the preferred choice of the authors. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Early gentle range of motion should begin on the first postoperative day to prevent elbow stiffness. • If a triceps-splitting approach or olecranon osteotomy approach was used, then active elbow extension should be restricted for 6 weeks. • If the posterior skin/soft-tissue condition is poor, especially in elderly female ­patients, then a period (10–14 days) of immobilization in extension may prevent breakdown or dehiscence.

PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus

• Patients may be fitted for an extension brace to wear at night to prevent flexion contracture. •  In selected cases (i.e., associated head injury) nonsteroidal antiinflammatory medication may be given to prevent heterotopic ossification.

EVIDENCE Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20:164–171. In this case series of 67 patients with intraarticular distal humerus fractures treated with olecranon osteotomies, no nonunions were encountered, 3% required revision of osteotomy fixation owing to malreduction, and 8% required removal of osteotomy fixation owing to prominent hardware. The authors concluded that olecranon osteotomy can be useful in the visualization of complex articular injuries, allowing accurate articular reduction. (Grade C recommendation; Level IV evidence.) Dakouré PW, Ndiaye A, Ndoye JM, et al. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007;29:671–674. This cadaveric study examined the amount of articular surface exposed by three different posterior approaches to the elbow. The median exposed articular surface for the triceps-sparing ­approach, the triceps-splitting approach, and the olecranon osteotomy was 26%, 37%, and 52%, respectively. Desloges W, Faber KJ, King GJ, Athwal GS. Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elbow Surg. 2015;24(8):1187–1196. This study found that satisfactory outcomes were observed after the nonoperative management of selected distal humeral fractures in lower-demand, medically unwell, or older patients. Doornberg JN, van Duijn PJ, Linzel D, et al. Surgical treatment of intra-articular fractures of the distal part of the humerus: functional outcome after twelve to thirty years. J Bone Joint Surg [Am]. 2007;89:1524–1532. In this case series, 39 patients were evaluated at a mean follow-up of 19 years (range, 12–30 years). The authors found that long-term results of open reduction and internal fixation of intraarticular distal humerus fractures were similar to those reported in the short term (70% good to excellent results), suggesting that the results are durable. They found that functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis. Approximately 40% of patients required a repeat operative intervention. (Level IV evidence.) Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21:58–62. In this case series of 17 patients with intraarticular distal humerus fractures that were treated with an olecranon osteotomy fixed with a 3.5-mm reconstruction plate, there were two reoperations related to the osteotomy. The authors concluded that plate fixation of an olecranon osteotomy provides a construct with predictable healing and few complications. (Grade C recommendation; Level IV evidence.) Lee SK, Kim KJ, Park KH, Choy WS. A comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial. Eur J Orthop Surg Traumatol. 2014;24(7):1123–1131. This study found no significant differences between the orthogonal and parallel plating methods in terms of clinical outcomes or complication rates. The authors suggested the orthogonal plating method may be preferred in cases of coronal shear fractures and the parallel plating method may be the preferred technique for fractures that occur at the most distal end of the humerus. McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–651. This retrospective comparative study evaluated functional outcome of 26 open distal humerus fractures (13 treated using a triceps-splitting approach and 13 treated using an olecranon osteotomy). The authors concluded that immediate open reduction with internal fixation of open intraarticular fractures of the distal humerus is a safe and effective technique with a low rate of complications and good limb-specific outcome. Patients whose fractures were fixed by a triceps-splitting approach, incorporating any traumatic defects in the triceps into the approach, had improved limb-specific and pain scores compared with those who had an olecranon osteotomy. (Grade B recommendation; Level III evidence.) McKee MD, Veillette CJ, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18:3–12. This study found that total elbow arthroplasty (TEA) for the treatment of comminuted intraarticular distal humerus fractures in elderly patients (mean age 78 years) resulted in more predictable and improved 2-year functional outcomes compared with open reduction and internal fixation. Also, there was a trend toward a lower reoperation rate in the TEA group. (Grade A recommendation; Level I evidence.)

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PITFALLS

• Good visualization of the olecranon fossa is required prior to closure to ensure there are no screws within the fossa which may block extension. • Two plates should not be placed alone on the posterior surface of the distal humerus as this increases the risk of fixation failure. • A single plate is inadequate fixation for the distal humerus.

PITFALLS

• Early postoperative range of motion is required to prevent posttraumatic elbow stiffness. • Ulnar nerve symptoms are common after surgery, so patients should be warned of this preoperatively and carefully examined preoperatively and postoperatively.

150

PROCEDURE 13  Open Reduction and Internal Fixation of Intraarticular Fractures of the Distal Humerus McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg [Am]. 2000;82:1701–1707. This study provided evidence that open reduction with internal fixation of intraarticular distal humerus fractures is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Although clinical outcomes were generally good (mean Mayo elbow score …), there was a significant decrease in the elbow range of motion and muscle strength of these patients as compared with the contralateral elbow at the time of final follow-up (mean 37-month follow-up), indicating that intraarticular distal humerus fractures are severe injuries with long-term sequelae. (Grade C recommendation; Level IV evidence.) Taylor PA, Owen JR, Benfield CP, Wayne JS, Boardman 3rd ND. Parallel plating of simulated distal humerus fractures demonstrates increased stiffness relative to orthogonal plating with a distal humerus locking plate system. J Orthop Trauma. 2016;30(4):e118–e122. This biomechanical study demonstrated that parallel plating of a distal humeral fracture model had significantly superior strength, especially when an unstable fracture pattern was simulated, compared with traditional orthogonal or “90-90” plating.

PROCEDURE 14

Arthroplasty in Supracondylar Humeral Fractures Thomas J. Goetz TREATMENT OPTIONS IN DISTAL HUMERUS FRACTURE • Nonoperative • Open reduction and internal fixation. (Should be considered primary treatment objective.) • Primary total elbow arthroplasty (TEA) • Distal humeral hemiarthroplasty 

THE ROLE OF ARTHROPLASTY Evidence • Poor bone quality and osteoporosis, which are often found in elderly patients, can lead to inadequate fixation and mechanical failure following open reduction and internal fixation (ORIF). In addition, articular comminution and cartilage fragmentation may preclude anatomic reduction. • TEA provides good to excellent results in carefully selected patients with comminuted intraarticular distal humeral fractures. • Distal humeral fractures in patients with underlying rheumatoid arthritis or preexisting arthrosis involving the elbow can be well managed with primary TEA. • Hemiarthroplasty is a viable option when encountering an unreconstructable distal humerus in a middle-aged individual with low to moderate functional demands and who is considered too active for treatment with TEA. • Early TEA or hemiarthroplasty has been shown to have better results than delayed arthroplasty. 

Indications • Several factors play an important role in decision-making for primary TEA versus ORIF. These include: • Physiologic age and functional demands of the patient • Intraarticular comminution and cartilage fragmentation • Preexisting joint arthrosis or underlying rheumatoid arthritis • Bone quality and degree of osteoporosis • Surgeon experience and familiarity with elbow arthroplasty 

PEARLS

• Solution for unreconstructable distal humerus fracture secondary to articular comminution, cartilage loss fragmentation, or osteoporotic bone • Excellent option for distal humeral fractures in patients with preexisting symptomatic arthritis • Assessment of patient functional demands is essential. • TEA outcomes have been shown to be superior when compared with ORIF in elderly patients age more than 65 years of age with comminuted distal humerus fractures. • Primary TEA or hemiarthroplasty results are better when done acutely rather than as a salvage reconstruction.

PITFALLS

• Preoperative assessment and decisionmaking about options for hemi- or total elbow arthroplasty are critical to gain understanding of the functional demands of patient. • Surgical approach decision critical for reconstructive options • Compound fracture (other than Gustilo I), poor soft-tissue coverage, or skin lesions are contraindications. • Presence of active infection is a contraindication. • Lack of familiarity with the techniques of hemiarthroplasty and total arthroplasty of the elbow

Contraindications Total Elbow Arthroplasty • Active infection • Contaminated wound Gustilo II or greater • High anticipated functional level • Surgeon inexperience with elbow arthroplasty 

Hemiarthroplasty • Reconstrucable articular segment • Patient with high functional demands • Open wound: Gustilo grade II or higher • Active infection • If TEA is indicated it should be preferred to hemiarthroplasty because rehabilitation is easier and outcomes more consistent and literature more extensive. • Surgeon inexperience, lack of available implant choices 

CONTROVERSIES

• Type I Gustilio open fractures seen within 12 hours of injury can be treated by early incision and drainage and primary TEA. Alternatively, a two-stage procedure with early incision and drainage and insertion of an antibiotic spacer followed by TEA can be done. • Patients referred from other centers with grade I Gustilo open fractures can be treated by early incision and drainage, intravenous antibiotic therapy, and splinting with subsequent referral to a center with expertise in TEA. 151

152

PROCEDURE 14  Arthroplasty in Supracondylar Humeral Fractures

EXAMINATION • Careful history of injury with trauma protocol if high level injury and multiple injuries suspected • Assess patient factors, specific health issues, history of inflammatory arthritis involving the elbow, previous elbow trauma, or surgery about the elbow. • Examine joint above and below. • Visualize skin circumferentially; do not miss open fracture, abrasion, poor quality skin. • Careful neurologic examination, including sensory and motor examination of ulnar, median, and radial nerves. Document ulnar nerve sensation and first dorsal interosseous strength. • Evaluate the vascular status of the arm by palpation of the distal pulses and assessment of capillary refill. • Assess the forearm compartments. 

IMAGING • Plain radiographs are the initial study of choice. • Fig. 14.1 shows the preoperative anteroposterior (Fig. 14.1A) and lateral (Fig. 14.1B) radiographs of a 68-year-old woman with a comminuted intraarticular distal humerus fracture. • If comminution appears severe and arthroplasty is contemplated it is important to obtain a high-quality computed tomography scan with accurate axial, sagittal, and coronal reconstructions. A 3D reconstruction can be very helpful in making a decision to perform ORIF, hemiarthroplasty, or TEA.

A

B FIG. 14.1 

PROCEDURE 14  Arthroplasty in Supracondylar Humeral Fractures



153

• If TEA is planned, then obtain forearm views of the ulna and of the humerus to allow templating for prosthesis. • If hemiarthroplasty is contemplated then imaging of the normal elbow allows templating of articular surface to determine implant size. 

SURGICAL ANATOMY

PEARLS

• Axis of rotation of the elbow passes through the anterior/inferior aspect of the medial epicondyle at the origin of the anterior bundle of the medial collateral ligament on the medial side and the center of rotation of the capitellum or the lateral epicondyle on the lateral side. • The axis is parallel to a line 15° internally rotated from the flat posterior surface of the distal humerus. 

• Use of a positioning device to hold the elbow greatly facilitates dissection and allows visual access to the anterior elbow joint. • Surgical exposure varies according to treatment plan.

POSITIONING

• Surgical exposure must be decided in advance and it differs for TEA versus hemiarthroplasty or ORIF.

• For ORIF or arthroplasty place the patient in the supine position with affected shoulder elevated by a roll or beanbag. Affected fore-quarter should be elevated so that the elbow and forearm will lie against the thorax and not fall off with gravity. • The forearm is held with a sterile arm-holding device (e.g., Tenet spider). This allows adjustment of arm position and stabilization of the elbow. It allows excellent visualization of the anterior aspect of the capitellum and trochlea during ORIF or hemiarthroplasty (Fig. 14.2). • Alternatively, the patient may be positioned in the lateral position with the affected arm hanging over a booster. This position may be preferable if an arm-holding device is not available. • A sterile tourniquet should be used in cases with extensive proximal comminution of fracture or short arm; however, a standard tourniquet is often adequate for a distal fracture. • After exsanguinating the extremity, inflate the tourniquet. Set the pressure at 250 mm Hg.

PITFALLS

EQUIPMENT

• Beanbag or roll • Arm holder • Tourniquet • Penrose drain for ulnar nerve • Equipment to perform ORIF or hemi- or total arthroplasty

PEARLS

FIG. 14.2 

Controversies in Approach • Hemiarthroplasty can be done through an olecranon osteotomy. This allows the decision to treat with ORIF versus hemiarthroplasty to be made after exposure of the articular surface. • TEA approach should avoid olecranon osteotomy because of concerns about healing of olecranon osteotomy and stability of the ulnar implant. Postoperative rehabilitation is simplified with a triceps-on approach. Triceps split or reflecting approaches improve access but complicate rehabilitation and risk triceps failure. Decision to perform TEA must be made prior to starting the procedure. 

• A Hohmann retractor can be used on either side of the humeral shaft to “lift up” the shaft for exposure, rather than levering excessively on the soft tissue. This is especially important on the lateral side where the radial nerve courses proximally. • In most cases, the radial head will be left intact. However, in the setting of a distal humeral fracture in a joint afflicted with preexisting inflammatory arthritis, the radial head should be resected. • For the triceps-on technique in TEA the exposure of the proximal ulna for implant preparation and cementing can be challenging. Using the medial 25% triceps split technique for the medial window greatly facilitates access to the ulnar canal. It can also simplify ulnar nerve management as the medial soft tissues are dissected from the ulna and medial epicondyle as a single soft tissue sleeve, thus moving the ulnar nerve out of the field.

PROCEDURE 14  Arthroplasty in Supracondylar Humeral Fractures

154 PITFALLS

• Olecranon osteotomy should be avoided in the TEA treatment of distal humerus fracture. The osteotomy will jeopardize the positioning and stability of the ulnar component and osteotomy healing. • Component malrotation is likely a key factor in early loosening. Gaining good access to the proximal ulna and attention to component positioning during cementing is important.

CONTROVERSIES

• Several techniques exist to deal with the triceps tendon. These include a “triceps-on” or triceps-sparing approach, a midline triceps split, or a medial-to-lateral triceps reflection. • Initially, or with complex cases, a midline split is utilized because this is technically simpler. As experience and skill with TEA grows, a “triceps-on” approach is utilized. Excision of the distal fragments creates a “working space” that allows canal instrumentation and component insertion without detaching the triceps from the olecranon (Fig. 14.5).

EXPOSURE FOR TEA For Triceps-on Technique • A straight posterior midline skin incision biased either medial or lateral to the tip of the olecranon • Dissection is carried down to the triceps fascia proximally and subcutaneous border of the ulna distally. • Full-thickness medial and lateral fasciocutaneous flaps are elevated. • The ulnar nerve is identified and mobilized. Transposition is not routinely required. • Medial access to the fracture is best made through a medial triceps split (Fig. 14.3). A portion of the medial triceps tendon (4 weeks) was associated with poor results. Ectopic ossification occurred in only one patient. These observations demonstrate that the injury should be treated with early reduction of the ulnohumeral joint and treatment of the radial head fracture according to its type. Cohen MA. Lateral collateral ligament instability of the elbow. Hand Clin. 2008;24:69–77. Lateral elbow support is provided by a combination of bony anatomy and the ligaments and tendons that originate at the lateral epicondyle. In the acute setting of elbow fracture-dislocation, restoration of lateral soft-tissue support typically can be accomplished by a direct repair, whereas in chronic settings, a reconstruction is most commonly necessary using a free tendon graft. Forthman C, Henket M, Ring DC. Elbow dislocations with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg [Am]. 2007;32: 1200–1209. A study of 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. Operative treatment consisted of open reduction and internal fixation or prosthetic replacement of all fractures and reattachment of the LCL to the lateral epicondyle. The MCL was not repaired. Twenty-five of 34 patients (74%) had good or excellent results. Giannicola G, Calella P, Piccioli A, Scacchi M, Gumina S. Terrible triad of the elbow: is it still a troublesome injury? Injury. 2015:68–76. Suppl 8. Twenty-six patients with terrible triad injuries were reviewed with elbow stiffness in five cases, mild posterolateral instability in three cases, and chronic subluxation in one case. Radiographic evaluation showed secondary arthritis in nine cases, symptomatic heterotopic ossification (HO) in three cases, and late hardware displacement in two cases. Of 26 patients, six underwent reoperation with satisfactory results. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique. J Bone Joint Surg [Am]. 2005;87:22–32. Thirty-six terrible triad injuries were treated with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion and enhance functional outcome. A mean Mayo Elbow Performance Score of 88 points, which corresponded to 15 excellent results, 13 good results, 7 fair results, and 1 poor result. Concentric stability was restored to 34 elbows. Eight patients had complications requiring a reoperation.

PROCEDURE 15  Terrible Triad Injuries of the Elbow: Open Reduction Internal Fixation Pichora JE, Fraser GS, Ferreira LF, Brownhill JR, Johnson JA, King GJ. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg [Am]. 2007;32: 1210–1217. The purpose of this study was to determine whether suture repair of the MCL can restore the normal kinematics and stability of the elbow and to determine the optimal initial MCL repair tension. Six cadaveric elbows were tested with simulated active and passive elbow range of motion with native ligaments and three different repair tensions. The 60-N repair was statistically different than the other groups, suggesting an overtightening that tended to pull the ulna into a varus position, especially in the midrange of flexion. These data suggest that MCL repair using transosseous sutures provide adequate joint stability to permit early motion. Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Upper Extrem Surg. 2002;6: 21–29. The surgical technique and rationale of terrible triad injuries are discussed. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86-A(6):1122–1130. Thirty-six elbows at a mean of thirty-four months follow-up, 15 patients were rated as excellent, 13 as good, 7 as fair, and 1 as poor using the Mayo Elbow Performance Index Score. Flexionextension arc averaged 112 degrees and rotation 136 degrees. Eight patients had a complication requiring reoperation. Also, a delay in treatment or revision surgery resulted in 20% greater loss of motion when compared with acutely treated injuries. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg [Am]. 1989;71(9):1348–1354. Thirty-five patients who had a fracture of the coronoid process revealed three fracture types. The outcome was well correlated with the type of fracture with 92 percent with Type I fracture, 73 percent with type II fracture and 20 percent with type III fracture had a satisfactory result. Reduction and fixation followed by early motion when possible may be the preferred treatment for patients with type III fractures. Ring D. Fractures of the coronoid process of the ulna. J Hand Surg [Am]. 2006;31:1679–1689. An excellent review article about fractures of the coronoid process. Optimal coronoid fracture fixation is determined by fracture morphology, which can usually be predicted based on the overall pattern of injury. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg [Am]. 2002;84:1811–1815. Fifty-six patients in whom an intraarticular fracture of the radial head had been treated with open reduction and internal fixation were evaluated: the result was unsatisfactory for 4 of the 15 patients with a comminuted Mason Type-2 fracture of the radial head. Of the 14 patients with a Mason Type-3 comminuted fracture with more than three articular fragments 13 had an unsatisfactory result. In contrast, all 15 patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair.

179

PROCEDURE 16

Traumatic Elbow Dislocation Jonah Hebert-Davies and Conor Kleweno INDICATIONS • Grossly unstable elbow • Failed nonoperative management • Missed/chronic elbow dislocation 

INDICATION PITFALLS

• The elbow should be tested after closed reduction by ranging it through a normal arc of flexionextension. • If stability is not maintained through an arc of flexion-extension of 30° to 130°, surgical management is recommended (instability in extension is most common). • Close follow-up is essential to ensure concentricity of the elbow. Early subluxation or dislocation can occur due to lack of proper immobilization or due to an injury requiring surgical repair. • Early subluxation will result in joint incongruence and lead to accelerated posttraumatic arthritis.

INDICATIONS CONTROVERSIES

• Simple dislocations (without associated fractures) are common, representing approximately 74% of all elbow dislocations. The most frequent pattern is posterolateral dislocation (Josefsson et al., 1987). • Most (95%) simple elbow dislocations can be successfully treated nonoperatively by immobilization in a long arm splint for 7 to 10 days followed by a functional brace with extension block. Extension limits should be progressively removed over a 4-week period. • Complex dislocations (with associated fractures) often require surgical management. However, recent literature supports nonoperative management in select cases (Chan et al., 2014).

EXAMINATION AND IMAGING • The elbow is inspected for soft-tissue injury and open wounds. • A comprehensive neurologic exam is performed before and after any reduction attempts. • A vascular examination and forearm compartment evaluation is also documented. • Standard two-view orthogonal radiographs are obtained. • Standard radiographs • Acute simple elbow dislocation (Fig. 16.1A–B) • Acute complex elbow dislocation (Fig. 16.1C) • Chronic elbow dislocation (Fig. 16.1D–E) • Computed tomography (CT) scan is typically not needed, although it can be helpful to evaluate for suspected associated fractures. • Magnetic resonance imaging (MRI) is generally not required in acute elbow dislocations. • The “drop sign” is an increase in the ulnohumeral joint space seen on a lateral elbow radiograph. It should raise the suspicion of persistent instability (Fig. 16.1F–G). 

TREATMENT OPTIONS

• Closed reduction and examination under anesthesia/sedation • Ligament/soft-tissue repair or reconstruction in select cases (see Indications)

180

PROCEDURE 16  Traumatic Elbow Dislocation

A

B

C

D

E

F FIG. 16.1 A–F 

181

PROCEDURE 16  Traumatic Elbow Dislocation

182

G FIG. 16.1, CONT’D G

SURGICAL ANATOMY • Bony • The articular surface of the elbow provides 55% to 75% of stability to varus stress. • The radial head provides up to 30% valgus stability. • The coronoid process is an important constraint to posterior displacement of the elbow. • Ligamentous • The lateral collateral ligament (LCL) complex is composed of three distinct structures: • The lateral ulnar collateral ligament • The radial collateral ligament • The annular ligament • The lateral ligament complex originates from the isometric point 2 mm proximal to the center of the capitellum and inserts broadly onto the annular ligament and the crista supinatoris (Fig. 16.2A).

Lateral view

Medial view

Humerus Lateral ulnal collateral ligament Radial collateral ligament Annular ligament

Medial collateral ligament

Anterior bundle Transverse ligament

Annular ligament of radius Radius

Ulna

A

Posterior bundle

B FIG. 16.2 A–B 

Humerus

PROCEDURE 16  Traumatic Elbow Dislocation

• The medial collateral ligament (MCL) complex is also formed by three distinct structures. • The anterior band, which originates on the anterior inferior margin of the medial epicondyle and inserts on the sublime tubercle (Fig. 16.2B) • The posterior band • The transverse band • The anterior band of the MCL is the primary stabilizer to valgus in elbow flexion. • Muscular • Dynamic stability is conferred by compression through a congruous joint. • Major stabilizers are biceps and triceps. • Secondary stabilizers include the flexor pronator mass, anconeus, and common extensors. 

POSITIONING • Lateral decubitus (Fig. 16.3A) • Supine with hand table (Fig. 16.3B)  POSITIONING PEARLS

• Externally rotating the shoulder will allow medial-sided access while supine (Fig. 16.3C). • Using a large towel bump under the wrist will help create valgus. POSITIONING PITFALLS

• Stiff shoulder motion or an acute shoulder injury makes supine positioning difficult. • Placing the tourniquet too distal can limit surgical approaches. POSITIONING EQUIPMENT

• Sterile tourniquet • Hand table/bolster • Overhead arm board POSITIONING CONTROVERSIES

• Positioning supine is often easier for procedures limited to the lateral side. • If the probability for dual exposure is high, lateral positioning with the affected arm over a bolster should be chosen.

A

B

C FIG. 16.3 A–C 

183

184

PROCEDURE 16  Traumatic Elbow Dislocation

PORTALS/EXPOSURES PEARLS

• When using a posterior skin incision, elevation of full-thickness flaps will decrease risk of necrosis. • Separate lateral and medial incisions allow greater exposure if the soft tissues allow it.

PORTALS/EXPOSURES PITFALLS

• The posterior interosseous nerve (PIN) is particularly at risk in lateral approaches. Keeping the forearm pronated is important. Supination can decrease the distance between the PIN and the radiocapitellar joint depending on the approach, from 5.6 to 3.2 cm (Kaplan) or from 3.8 to 2.2 cm (Kocher). • If using a posterior skin approach, anterior dissection should be minimized to decrease postoperative hematoma.

PORTALS/EXPOSURES • Lateral exposure (Fig. 16.4A) • Kocher: Between the extensor carpi ulnaris (ECU) and anconeus • Kaplan: Between the extensor digitorum communis (EDC) and ECU • Extensor split: Through the common extensor tendon • Medial exposure (Fig. 16.4B) • Flexor-pronator split: Through posterior one-third of the common flexors • Flexor carpi ulnaris (FCU) split: Between both heads of the FCU • Hotchkiss: Over the top after flexor-pronator release • Posterior skin exposure 

Common extensors

PORTALS/EXPOSURES EQUIPMENT

• Long narrow retractors • Self-retaining retractors

Anconeus

PORTALS/EXPOSURES CONTROVERSIES

• Deciding between two incisions versus one posterior skin incision is sometimes difficult. • Factors favoring a single incision are the need for additional surgeries in the future, smaller patient with less need for large fasciocutaneous flaps, and at-risk anterior elbow soft tissue. • Factors favoring lateral and medial incisions include poor posterior soft tissue and low likelihood for medial repair.

A

Extensor carpi

Flexor-pronator mass (reflected)

Ulnar nerve

Flexor carpi ulnaris

STEP 1 PEARLS

• In most cases, LCL and common extensor origin repair is enough to restore stability. • If there is subluxation following repair, the joint should be examined to ensure that no loose body or interposed tissue is preventing concentric reduction.

B FIG. 16.4 A–B 

PROCEDURE Step 1: Repair of LCL

STEP 1 PITFALLS

• Overtensioning of the lateral side should be avoided, as it can result in stiffness. • Failure to repair annular ligament leads to increased instability.

• A lateral skin incision approximately 8 to 10 cm long is made centered over the epicondyle. • The fat stripe overlying the ECU/anconeus is identified. • In many cases, the traumatic avulsion of the extensor origin/LCL from the distal lateral condyle will provide a large portion of the exposure (Fig. 16.5A).

PROCEDURE 16  Traumatic Elbow Dislocation

• The joint is visualized to evaluate for cartilage injury. • Loose bodies and interposed tissue (annular ligament and capsule) are removed from the joint. • The LCL complex is repaired in a layered fashion using double-loaded suture anchors placed into the isometric point (Fig. 16.5B). • The annular ligament is repaired to itself using a figure-of-eight stitch. • The LCL origin is repaired with two mattress sutures from the suture anchor. • The common extensor origin is then repaired in a running fashion. 

A

STEP 1 INSTRUMENTATION/ IMPLANTATION

• Small-caliber suture anchors (2.4/3.5 mm) • #2 Nonabsorbable braided suture STEP 1 CONTROVERSIES

• Fixation of the lateral ligament complex/ common extensor origin can be achieved using suture anchors or transosseous tunnels.

B FIG. 16.5 A–B 

STEP 2 PEARLS

Step 2: Repair of MCL • If there is gross instability following lateral side repair, one can consider addressing the MCL. • Medial approach: Skin incision slightly posterior to the medial epicondyle • The ulnar nerve is identified and protected. • The avulsed flexor/pronator mass is identified and mobilized to provide adequate exposure. • Alternatively, the flexor/pronator mass is split through its posterior third. • The MCL and flexor/pronator muscles are repaired using two suture anchors—one at the isometric point and one in the medial epicondyle. 

185

• Repair the MCL in 30° of flexion to avoid overtensioning. • The isometric point is found just anterior and distal to the medial epicondyle.

STEP 2 PITFALLS

• Repairing the MCL to the medial epicondyle can result in overtensioning with decreased flexion or extension.

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Suture anchors

STEP 2 CONTROVERSIES

• Ulnar nerve identification and protection is important but transposition is generally not necessary, although it can be performed if required at the conclusion of the surgery.

186

PROCEDURE 16  Traumatic Elbow Dislocation

STEP 3 PEARLS

• Bone tunnels should be created in a converging fashion to form a “V” or “U.” This will make passing the graft through tunnels much simpler. • Bone tunnels should be placed 1 to 1.5 cm away from each other to avoid tunnel blowout. • If there is residual laxity in the graft following docking, it can be sutured to itself to increase tension.

Step 3: Reconstruction of LCL/MCL • Use appropriate approaches, as previously described. • Create bone tunnels with at least 1.5 cm bony bridge in the ulna using a high-speed burr. • For the LCL, create tunnels at either end of the crista supinatoris (Fig. 16.6A) • For the MCL, create tunnels at the level of the sublime tubercle. • Determine the appropriate length of the graft. • Use the Krackow whipstitch with nonabsorbable #2 suture. • The isometric point is determined dynamically using a suture placed through the ulnar tunnel and moving the elbow through an arc of motion. • The docking technique is used to secure the graft. 

STEP 3 PITFALLS

• Incorrectly sizing the graft prior to docking will result in a graft that is either overtensioned or too lax.

STEP 3 INSTRUMENTATION/ IMPLANTATION

• Allograft (semitendinosus) or autograft (palmaris longus or hamstring) • High-speed burr

STEP 3 CONTROVERSIES

• It is generally agreed upon that ligaments should be reconstructed > 4 to 6 weeks after injury. • In select cases (bony avulsion, concentric reduction delayed by medical clearance), repair can still occur up to 6 to 8 weeks postinjury.

FIG. 16.6 

Step 4: External Fixator • If residual instability is present following lateral and medial ligament repair/reconstruction, a hinged (preferred) or static external fixator is applied (Fig. 16.7A). • The pins are inserted and the frame is constructed. • The joint is then reduced concentrically and the frame is tightened (Fig. 16.7B).  STEP 4 PEARLS

• For static frames, connector rods between spanning carbon rods will increase stability. • Insertion of humeral pins should be done in open fashion to isolate and protect the radial nerve. Separate adjacent stab wounds can be used for the individual pins. • If a hinged frame is to be used, selecting the correct center of rotation (COR) is important: a COR that is too posterior will promote recurrent posterior instability. STEP 4 PITFALLS

• Injury to the radial nerve can occur if a percutaneous approach for humeral pins is used (see earlier discussion). STEP 4 INSTRUMENTATION/IMPLANTATION

• External fixator pins: 5 mm for the humerus and 4 mm for the ulna

PROCEDURE 16  Traumatic Elbow Dislocation

STEP 4 CONTROVERSIES

• Some surgeons have used articulated external fixators for complex or recurrent elbow instability. While these devices allow for range of motion (ROM) during healing, in practice they can be difficult to install without extensive experience. Incorrect placement of the axis of rotation (especially posteriorly) will result in both an unstable and stiff elbow. If the operating surgeon has no experience with, or access to, a hinged or articulated frame, a static external fixator is easier to install and can ensure a stable elbow. Secondary stiffness can be addressed in a second stage.

A

B FIG. 16.7 A–B 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Rehabilitation • Posterior splint 60° to 90° of flexion (depending on incisions) • Remove splint at 7 to 10 days and initiate ROM if wounds are healing appropriately. • Extension block is reduced progressively over a 4-week period. • Pronation/supination is initiated at 90° of flexion. 

Outcomes • A majority of patients treated with nonoperative management will have a decreased flexion arc (average, 5°–15°) when compared with the normal side. Patients most commonly complain of difficulty with demanding physical activity and neurologic issues. • In a randomized trial, Josefsson et al. (1987) showed that surgical management of simple elbow dislocation is not superior to nonoperative treatment in general. • Conversely, Schnetzke et al. (2017) demonstrated that elbows with recurrent or gross instability had better outcomes with surgical management. Surgery in this setting reduced complications from 37% to 9%.

187

188

PROCEDURE 16  Traumatic Elbow Dislocation

POSTOP PEARLS

• Avoid rehabilitation in the shoulder abducted position that places varus stress on the elbow. • Beginning ROM exercise supine with the shoulder adducted and flexed overhead helps reduce loads on repaired structures (Lee et al., 2013). POSTOP PITFALLS

• Heterotopic ossification (HO) may occur, even with nonoperative treatment. Significant limitations of ROM and neurovascular compression are indications for surgical intervention. This should be undertaken once motion has plateaued, the soft-tissue envelope has stabilized, and associated injuries have healed: this can be as early as 6 months postinjury. Postoperative HO prophylaxis (radiation, indomethacin) is a useful adjunct. POSTOP INSTRUMENTATION/IMPLANTATION

• Progressive static splint or turnbuckle orthotics can be used for patients with limited ROM recovery.

POSTOP CONTROVERSIES

• In general, early (1–2 weeks postinjury) motion is to be encouraged. Longer periods of immobilization have been shown to result in more stiffness and worse functional outcome. Often, some residual instability (such as seen with the “drop sign”) will improve with early motion and the beneficial effect of dynamic muscular action. If instability persists despite this, operative repair, not prolonged immobilization, is indicated.

EVIDENCE Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Can we treat select terrible triad injuries nonoperatively? Clin Orthop Relat Res. 2014;472(7):2092–2099. Case series of 12 patients that identifies fracture characteristics that allow for successful nonoperative treatment for complex elbow fracture-dislocations. Important treatment goals include early supervised ROM (within 10 days of injury) and passive stretching by 6 to 8 weeks. Only one patient went on to surgical treatment. None of the other patients had residual instability at last follow-up and all had good ROM. Josefsson O, Gentz C-F, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. J Bone Joint Surg Am. 1987;69-A(4):605–608. Randomized study of 30 elbows with simple dislocation treated with either surgical or nonopera­ tive treatment found no difference in ROM or stability at an average of 27 months follow-up. Lee AT, Schrumpf MA, Choi D, et al. The influence of gravity on the unstable elbow. J Shoulder Elbow Surg. 2013;22(1):81–87. Cadaveric study evaluating the effect of elbow position on joint distraction during ROM. The authors found 104% more displacement across the ulnohumeral joint in the upright LCL-sectioned elbows compared with the supine LCL-sectioned ones. Schnetzke M, Aytac S, Keil H, et al. Unstable simple elbow dislocations: medium-term results after nonsurgical and surgical treatment. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2271–2279. Retrospective study of 118 patients treated with both surgical and nonsurgical treatment. Patients were divided into slight, moderate, and gross instability. Those with moderate instability had worse outcomes with nonsurgical treatment and a fivefold increased rate of complications.

PROCEDURE 17

Radial Head and Neck Fractures: Open Reduction and Internal Fixation John T. Gorczyca and Aaron M. Roberts

INDICATIONS

CONTROVERSIES

• Significantly displaced radial neck fracture (Fig. 17.1A), partial articular (Fig. 17.1B) or complete articular radial head fracture (Fig. 17.1C) • Mechanical block to forearm pronation/supination or elbow flexion/extension • Fracture fragment incarcerated in the joint • Associated elbow instability • Radial head fracture with elbow dislocation (Fig. 17.1D) • Terrible triad injury (elbow dislocation with radial head fracture and coronoid fracture) • Radial head fracture with medial collateral ligament injury (valgus instability) • Radial head fracture with Essex-Lopresti injury (forearm interosseous membrane disruption and distal radioulnar joint dislocation) (Fig. 17.2)

• The displacement and articular surface disruption at which partial articular fractures benefit from open reduction and internal fixation versus nonoperative management is unclear. • Although there are some general guidelines, the amount of articular comminution at which stable open reduction with internal fixation is not achievable and radial head arthroplasty becomes a better surgical option is unclear (Fig. 17.3).

A

B

C

D FIG. 17.1 

189

190

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

PITFALLS

• The fracture must be amenable to anatomic reduction and stable fixation if it is to be treated successfully with internal fixation. This will depend on: • Number and size of articular fragments • Associated joint stability (radial head fixation failure has been shown to be higher when there is associated elbow joint instability) • Quality of bone • Patient compliance with postoperative physiotherapy regimen • If the patient is low-demand or elderly, other treatment options may be more appropriate, such as nonoperative management, radial head excision, or replacement. • Always suspect associated periarticular fracture or elbow instability. There is higher prevalence of this with increasing radial head fracture severity and displacement. • When planning internal fixation, always be prepared to perform a radial head arthroplasty as an alternate plan if stable fixation is not possible. TREATMENT OPTIONS

• Nonoperative treatment • Fracture fragment excision • Radial head excision • Open reduction and internal fixation • Radial head arthroplasty

A

B FIG. 17.2 

FIG. 17.3 

Examination/Imaging • History • Location of pain, date of injury, mechanism of injury, treatment history, age, occupation, activity level • Clinical evaluation • Inspect for swelling, ecchymosis, deformity, open wound • Palpate, particularly medial and lateral humeral epicondyles and forearm interosseous membrane to assess for ligamentous injury • Document neurovascular status (especially posterior interosseous nerve) • Evaluate the shoulder and wrist for associated injury (e.g., associated distal radioulnar joint injury, scaphoid fracture)

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

191

B

A

C

D

E FIG. 17.4 

• Perform active and passive range of motion to assess for mechanical block; aspiration of hematoma with or without injection of local anesthetic may be helpful if pain is limiting motion • Stress examination: limited use acutely except for partial articular fractures • Imaging • Anteroposterior (Fig. 17.4A) and lateral (Fig. 17.4B) radiographs of the elbow • Computed tomography scanning (Fig. 17.4C) with reconstructions (Fig. 17.4D) or three-dimensional reformatting (Fig. 17.4E) allows better definition of the anatomy, the degree of comminution, and the size of the fracture fragments. • Magnetic resonance imaging will depict concomitant soft-tissue injuries, but has not been shown to change patient treatment 

PEARLS

• Consider physical and fluoroscopic examination under anesthesia to better assess for elbow instability and mechanical block to motion.

192

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

SURGICAL ANATOMY • Radial head/neck • Radial head is an important stabilizer for valgus, axial, and posterolateral rotational forces. • Variable anatomy of the radial neck, and “anatomic” plates may require bending to provide proper contour. • “Safe zone” for plate placement: 110-degree arc where the radial head does not articulate with the lesser sigmoid notch of the ulna at any point through a full range of rotation; this is represented by the area between two longitudinal lines from Lister’s tubercle and from the radial styloid to the radial head (Fig. 17.5). • Muscles and nerves • Anconeus muscle, extensor carpi ulnaris (ECU), extensor digitorum communis (EDC), extensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL) (Fig. 17.6) • Posterior antebrachial cutaneous nerve (PABCN), which lies superficial and anterior to common extensor origin; lateral antebrachial cutaneous nerve (LABCN) (Fig. 17.7) • Supinator muscle (Fig. 17.8) • Posterior interosseous nerve (PIN), which courses through the supinator muscle (Fig. 17.9; see also Fig. 17.8) • Ligaments • Medial collateral ligament (MCL) • Lateral ligamentous complex (Fig. 17.10) • Includes lateral ulnar collateral ligament (LUCL), injury (traumatic or iatrogenic) to which may cause posterolateral rotatory instability (PLRI) 

Radial styloid Neutral “Safe zone” Lister’s tubercle

Supination

Pronation FIG. 17.5 

Extensor carpi radialis brevis

Triceps

Brachioradialis Extensor carpi radialis brevis

Lateral epicondyle Extensor carpi radialis longus

Brachioradialis Anconeus Extensor carpi radialis longus

Extensor digitorum communis

Triceps

Extensor digitorum communis

Extensor carpi ulnaris Extensor digiti minimi

Extensor pollicus longus Adductor pollicus longus

Extensor pollicus brevis

A

Anconeus Extensor carpi ulnaris

B FIG. 17.6 

Radial nerve (deep branch) entering supinator muscle

Brachialis Supinator muscle

Lateral antebrachial cutaneous nerve

Exodus of nerve from supinator muscle

Brachioradialis Extensor carpi radialis longus

A (6.6 cm) Lateral epicondyle

Recurrent interosseous artery

B (2.1 cm) Posterior antebrachial cutaneous nerve FIG. 17.7 

Dorsal interosseous artery

FIG. 17.8 

Overlying Muscles Retracted

Supinator Muscle Split Over Nerve

Superficial radial nerve

Extensor carpi radialis brevis

Brachioradialis Supinator muscle Extensor carpi radialis brevis

Extensor carpi radialis longus

Superficial radial nerve Brachioradialis Supinator muscle Extensor carpi radialis longus

Radial nerve

Radial nerve Posterior interosseous nerve

Posterior interosseous nerve

Extensor digitorum communis

A

Extensor digitorum communis Extensor carpi ulnaris

FIG. 17.9 

B

Extensor carpi ulnaris

194

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

Radial collateral ligament

Anterior capsule

Annular ligament

Posterolateral capsule

Lateral ulnar collateral ligament FIG. 17.10 

POSITIONING • The patient is positioned supine (Fig. 17.11) • Either with an arm table (authors’ preference) • Or with the affected arm across the chest on a bolster with the ipsilateral scapula supported by a bump • A tourniquet can be placed high on the arm. • The arm is prepared and draped free. 

PEARLS

• Posterior skin incision • Reduced risk to cutaneous nerves • Increased risk of hematoma/seroma • Raise medial full-thickness flap for access to medial elbow; access radius and ulna through separate fascial incisions • Exposure may proceed through traumatic defect in lateral structures • Kocher approach • Preferred for repair of lateral ulnar collateral ligament (LUCL) • Kaplan approach • Improved exposure of anterior radial head; most partial articular fractures are located in the anterolateral quadrant • Less risk of injury to LUCL

FIG. 17.11 

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

EXPOSURES

PITFALLS

• Incision • Lateral (authors prefer a lateral incision in line between the lateral humeral condyle and a point over the ulnar shaft 6 cm distal to the tip of the olecranon) • Posterior with elevation of full thickness flaps. If exposure to the ulnar shaft or olecranon is necessary to reduce and stabilize associated injuries, the proximal radius and proximal ulna can be approached through a common posterior skin incision, but the authors recommend using two separate fascial incisions to minimize the occurrence of synostosis. • Kocher approach (anconeus-ECU interval) (Fig. 17.12A–D) • Interval is easiest to identify distally between the ECU and anconeus. • Mobilize the ECU anteriorly. • Make a capsular incision along the anterior border of the LUCL to expose the radial head and neck. • Kaplan approach (EDC-ECRB interval) (Fig. 17.13A and see 17.15B) • Incise the capsule and annular ligament anterior to the LUCL; this approach is more anterior and provides better visualization to the anterior aspect of the joint. 

• Prevention of posterior interosseous nerve (PIN) injury: pronate the forearm (to displace nerve anteriorly and away from operative field), use careful and gentle retraction, limit distal exposure to the radial tuberosity whenever possible. • Dissect along anterior border of LUCL, if intact, to preserve its integrity and prevent iatrogenic posterolateral rotatory instability.

INSTRUMENTATION/IMPLANTATION

• Small periosteal elevators • Kirschner wires (K-wires) (small sizes) • Sharp points (dental picks) • Small curettes

Brachioradialis Triceps

Extensor carpi radialis longus

Extensor carpi radialis brevis

Anconeus (radial nerve)

Lateral epicondyle of humerus

A

Posterior antebrachial cutaneous nerve

Head of radius

B

Extensor digitorum communis Extensor carpi ulnaris (posterior interosseous nerve)

Brachioradialis Triceps

Extensor carpi radialis longus

Extensor carpi radialis brevis Extensor carpi ulnaris

Anconeus

Anconeus

C

195

Extensor carpi ulnaris

D FIG. 17.12 

Extensor digitorum communis

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

196

Extensor carpi radialis brevis

Brachioradialis

Brachioradialis Extensor carpi radialis longus

Triceps Extensor carpi radialis brevis

Extensor carpi radialis longus

Triceps

Anconeus

Anconeus

Extensor carpi ulnaris Extensor digitorum communis

A

B

Extensor digitorum communis Extensor carpi ulnaris

FIG. 17.13  PEARLS

• Care must be taken to identify the fracture fragments while preserving the soft tissue/ articular cartilage attachments to the pieces (if present). This is especially important when dealing with impacted fragments in osteopenic bone. PITFALLS

• Avoid manipulation that could damage cartilage. • Avoid stripping soft-tissue attachments that provide viability to fracture fragments. • Avoid comminuting fragile fracture fragments.

A

PROCEDURE Step 1 • Identify fracture fragments: • Large fragments with little/no comminution or impaction, as seen in Case 1 (Fig. 17.14) and Case 2 (Fig. 17.15) • Fragments with comminution and/or impaction on preoperative radiographs, as seen in Case 3 (Fig. 17.16) • Remove interposed soft tissue and fracture hematoma. • Small instruments can be utilized to manipulate fracture fragments. • Kirschner wire (K-wires) can be used as joysticks to reduce fracture fragments. 

B

C FIG. 17.14 

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

A

B

C

D

FIG. 17.15 

FIG. 17.16 

Step 2 • Reduce the fracture fragments and provisionally stabilize them. • Large fragments can be reduced with small instruments or K-wires, as shown for Case 1 (Fig. 17.17) and Case 2 (Fig. 17.18) • In complete articular fractures with articular comminution, after provisional reduction of the articular surface, lag screw fixation to create an articular block can be performed to simplify reduction and stabilization to the radial shaft, as shown for Case 3 (Fig. 17.19). 

PEARLS

• Elevate impacted fracture fragments and use bone graft or bone graft substitutes if mechanical support is necessary; local bone graft can be obtained from the olecranon or the lateral humeral epicondyle. • Always be prepared to proceed with either excision or radial head arthroplasty, if indicated, and the fracture is not amenable to stable internal fixation. PITFALLS

• Avoid placing temporary fixation in areas where definitive fixation will best maintain fracture reduction. INSTRUMENTATION/IMPLANTATION

• Small periosteal elevators • Sharp points (dental picks) • K-wires (small sizes) • Pointed reduction forceps

FIG. 17.17 

197

FIG. 17.18 

198

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

INSTRUMENTATION/IMPLANTATION

• 1.5- to 2.5-mm headless or countersunk standard screws • Low profile periarticular plate and screw sets • Bioabsorable pins • Suture anchors • Radial head implants (metallic, modular) PEARLS

• Ensure that plates are placed in the safe zone, and always check for smooth pronation/ supination range of motion after fracture fixation. • Countersink screw heads under the articular surface. • Address any corresponding relevant soft-tissue injury at the time of fixation (LUCL injury most common). • Appreciate the concavity of the radial head articular surface to avoid encroachment on the joint surface with internal fixation.

A

B FIG. 17.19 

Step 3 • Fracture reduction is maintained with stable internal fixation. • Partial articular fractures are reduced against the intact part of the radial head and can be stabilized with screws alone, as shown for Case 1 (Fig. 17.20). • In complete articular fractures with noncomminuted neck fractures, antegrade obliquely oriented countersunk cannulated screws can be used for fixation to the neck/shaft, as shown for Case 2 (Fig.17.21). • With poor-quality, comminuted, impacted fragments or with a complete articular fracture with a comminuted neck fracture or metaphyseal defect, plate fixation is usually required, as shown for Case 3 (Fig.17.22). • Repeat radiographs are obtained to check reduction, alignment, and implant position. •  Figs. 17.23 and 17.24 show results for Cases 1 and 2, respectively. •  Fig. 17.25 shows results for Case 3. 

PITFALLS

• Violating the safe zone • Prominent hardware through opposite cortex/ chondral surface • Precontoured plates may still need to be contoured owing to variable patient anatomy.

A FIG. 17.20 

B FIG. 17.21 

A

B FIG. 17.22 

A

B FIG. 17.23 

A

B FIG. 17.24 

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation

200

A

B FIG. 17.25 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES PEARLS

• If associated injuries, such as an elbow dislocation, are present, test and document safe range of motion (ROM) intraoperatively to plan rehabilitation. • Utilize a hinged ROM brace to restrict extremes of motion, if necessary.

PITFALLS

• Avoid prolonged immobilization: this will increase the risk of dysfunctional stiffness CONTROVERSIES

• Use of postoperative nonsteroidal antiinflammatory drugs to prevent heterotopic ossification in complex elbow dislocations; radiation should not be used owing to an increased rate of nonunion.

• The arm is immobilized in a well-padded posterior splint for 7 to 10 days. • The patient may then begin active range-of-motion (ROM) exercises within the range determined to be safe intraoperatively. • With injury to the collateral ligaments, the LUCL is protected in pronation and the MCL is protected in supination. • In lateral ligamentous injury, shoulder abduction and varus stress is avoided. • The postregimen may depend on the stability of fixation of associated injuries (i.e., LUCL, coronoid). • No strengthening exercises until there is clinical and radiographic evidence of fracture union • Complications • PIN palsy • Hardware impingement • Infection • Elbow stiffness • Heterotopic ossification/radioulnar synostosis • Malunion/nonunion • Osteonecrosis of radial head fragments • Degenerative arthritis

EVIDENCE Lapner M, King GJ. Radial head fractures. J Bone Joint Surg Am. 2013;95:1136–1143. Review article of the epidemiology, anatomy, biomechanics, classification, clinical assessment, imaging, management, complications, and postoperative care of radial head fractures. Yoon A, Athwal GS, Faber KJ, King GJ. Radial head fractures. J Hand Surg Am. 2012;37:2626–2634. Review article of the clinical assessment, imaging, classification, treatment, rehabilitation, and complications of radial head fractures. Ruchelsman DE, Christoforou D, Jupiter JB. Fractures of the radial head and neck. J Bone Joint Surg Am. 2013;95:469–478. Review article covering the anatomy, biomechanics, classification, decision-making principles, and treatment of radial head fractures. Burkhart KJ, Wegmann K, Muller LP, Gohlke FE. Fractures of the radial head. Hand Clin. 2015;31: 533–546. Review article covering the anatomic principles, epidemiology, classification, clinical evaluation, imaging, treatment, surgical management, and postoperative rehabilitation of radial head fractures.

PROCEDURE 17  Radial Head and Neck Fractures: Open Reduction and Internal Fixation Kaas L, Struijs PA, Ring D, van Dijk CN, Eygendaal D. Treatment of Mason type II radial head fractures without associated fractures or elbow dislocation: a systematic review. J Hand Surg Am. 2012;37:1416–1421. Systematic review comparing the results of operative and nonoperative treatment of Mason type II radial head fractures without concomitant elbow fracture or dislocation. There was insufficient evidence to draw firm conclusions on the optimal treatment of isolated, displaced, partial articular Mason type II radial head fractures. Caputo AE, Mazzocca AD, Santoro VM. The nonarticulating portion of the radial head: anatomic and clinical correlations for internal fixation. J Hand Surg Am. 1998;23:1082–1090. Anatomic study analyzing 24 cadaveric elbows to localize the “safe zone,” the area of the radial head that does not articulate with the sigmoid notch of the ulna. The safe zone consistently encompassed a 90-degree angle localized by palpation of the radial styloid and Lister’s tubercle. Giannicola G, Manauzzi E, Sacchetti FM, et al. Anatomical variations of the proximal radius and their effects on osteosynthesis. J Hand Surg Am. 2012;37:1015–1023. Anatomic study analyzing 44 cadaveric radii. The proximal radius at the level of the safe zone exhibited substantial morphologic variation. These anatomic differences may markedly affect the congruence of plates during fixation of radial head and neck fractures. Desloges W, Louati H, Papp SR, Pollock JW. Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval. J Bone Joint Surg Am. 2014;96:387–393. Anatomic study using fresh-frozen cadaveric upper extremities to compare the osseous and articular surface areas visible through an EDC splitting approach and the Kocher interval. The EDC splitting approach provided greater exposure of the anterior half of the radial head. Smith AM, Morrey BF, Steinmann SP. Low profile fixation of radial head and neck fractures: surgical technique and clinical experience. J Orthop Trauma. 2007;21:718–724. Technical article describing a technique for and the authors’ experience with low profile fixation of radial head and neck fractures. Obliquely oriented, countersunk-threaded wires or screws are inserted from the proximal radius into the radial neck. Nauth A, Giles E, Potter BK, et al. Hetertopic ossification in orthopaedic trauma. J Orthop Trauma. 2012;26:684–688. Review article covering heterotopic ossification in orthopedic trauma. For elbow fracture-dislocations, the authors conclude that the use of radiation is contraindicated owing to an increased risk of nonunion and no strong evidence supports routine prophylaxis. The authors recommend selective use of NSAIDs for prophylaxis in high-risk patients.

201

PROCEDURE 18

Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid Lee M. Reichel and David Ring INDICATIONS PITFALLS

• Subluxation can be dynamic. Concentric reduction on radiographs and computed tomography does not preclude subluxation that may occur with shoulder abduction (varus stress). • Dynamic subluxation, although difficult to diagnose and follow, may lead to arthrosis. • Arthrosis caused by insufficiency of the anteromedial facet of the coronoid is difficult to salvage so reduction and fixation of these fractures should be strongly considered in most cases.

INDICATIONS • Anteromedial facet fracture of the coronoid combined with one of the following: • Subluxation of the ulnohumeral joint • Fracture of the olecranon

Examination/Imaging • Elbow flexion and extension with the arm at the side, with the shoulder abducted, and with slight pressure on the arm with the shoulder abducted • Radiographs (Fig. 18.1)

INDICATIONS CONTROVERSIES

• Nonoperative treatment can be effective but requires the following: • No subluxation on radiographs or computed tomography • No crepitation with elbow flexion and extension with the arm at the side • A reliable patient that can avoid shoulder abduction for 4 weeks • Fractures that do not involve the sublime tubercle may be more amenable to nonoperative management.

A

B

C FIG. 18.1 

202

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

203

• Two- and three-dimensional computed tomography (CT). Anteromedial facet fractures are typically comminuted. CT scanning is indicated in analyzing size and location, which helps direct the best medial approach (Fig. 18.2). • Adequate elbow stability has been defined as maintenance of congruency when the elbow is extended with the forearm in neutral rotation to a minimum of 30 degrees within the first 10 to 14 days from injury (CHAN). 

TREATMENT OPTIONS

FIG. 18.2 

SURGICAL ANATOMY

• Buttress plate fixation of a larger anteromedial facet coronoid fracture • Suture fixation of a smaller anteromedial facet coronoid fracture • Combined buttress and suture fixation when needed to provide stability • Other elements of treatment: reattachment of the lateral collateral ligament origin to the lateral epicondyle; open reduction and internal fixation of a fracture of the olecranon and other associated fractures when present

POSITIONING PEARLS

• Medially, the surgeon should identify the medial epicondyle, flexor pronator mass, ulnar nerve, medial collateral ligament, and anteromedial coronoid. Pay specific attention to identification of the sublime tubercle and its medial collateral ligament attachment (Fig. 18.3). • Laterally, the surgeon identifies the supracondylar ridge, extensor tendon origin, and lateral humeral condyle. • Based mostly on expert opinion: a single posterior skin incision is less conspicuous and limits the potential for injury to subcutaneous sensory nerves. Other elbow experts prefer separate medial and lateral skin incisions to limit the potential for postoperative hematoma. 

FIG. 18.3 

POSITIONING • Position the patient supine with the affected arm on an arm table. • Use large or mini C-arm fluoroscopy. 

• Ensure adequate fluoroscopic visualization can be obtained prior to preparing and draping. • Use of sterile tourniquet allows extension of proximal exposures, if needed.

POSITIONING PITFALLS

• Use of nonsterile tourniquet may limit proximal exposures.

204

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

POSITIONING EQUIPMENT

• Not applicable POSITIONING CONTROVERSIES

• Lateral positioning can be considered when an associated proximal ulnar fracture is present. It facilitates manipulation and fixation of the olecranon fragment and aids in access to the coronoid.

PORTALS/EXPOSURES • A posterior skin incision provides both medial and lateral access (Fig. 18.4). • A medial exposure is used to stabilize the coronoid fracture and decompress the ulnar nerve. • A lateral approach is used to reattach the origin of the lateral collateral ligament complex to the lateral epicondyle. 

PORTALS/EXPOSURES PEARLS

• Medially, identify and preserve medial collateral ligament (MCL) and attachments to medial coronoid bony fragments. Frequently, the sublime tubercle may be one of the fracture fragments. • Laterally, there is typically an avulsion of the lateral collateral ligamentous complex from the lateral epicondyle of the humerus.

PORTALS/EXPOSURES PITFALLS

• Medially, the ulnar nerve must be visualized during exposure. Transposition is not usually necessary, but identification and protection are. Use of drill guides and an oscillating drill aids in protecting the ulnar nerve during bony stabilization. • Laterally, lateral collateral ligament avulsion may not be visualized until the fascia over the lateral epicondyle is incised. • Posterior exposure when the olecranon is fractured allows visualization of the ulnohumeral and radiocapitellar joints and allows for assessment of lateral collateral ligament competence. STEP 1 PEARLS

• Preserve soft tissue and ligamentous attachments to bony fragments (especially the medial collateral ligamentous attachments). • When the exposure proceeds through the two heads of the flexor carpi ulnaris, greater mobilization of the ulnar nerve is required.

STEP 1 PITFALLS

• Avoid cutting through the medial collateral ligament. • The medial collateral ligament may be attached to fracture fragments and care must be taken not to strip the ligament off the fragments during exposure. Preservation of soft tissue increases the difficulty in reduction and stabilization of small bone fragments, but it is important. • Use drill guides and the oscillating drills to protect the ulnar nerve during fracture stabilization.

FIG. 18.4 

PROCEDURE Step 1: Repair of Medial-Sided Injury: Anteromedial Coronoid Fracture • Make a posterior skin incision or direct medial skin incision (Fig. 18.4). • The ulnar nerve is identified proximally, medial to the triceps. Perform an in-situ ulnar nerve decompression with or without anterior subcutaneous transposition of the nerve (Fig. 18.3). Oscillating drills should be used in this area. Avoid excessive traction on the nerve. If an anterior subcutaneous transposition is performed, consider temporarily suturing the subcutaneous tissue to the fascia to keep the nerve anterior instead of using a tape around the nerve or another type of retractor. • The medial epicondyle and flexor pronator mass are visualized (Fig. 18.5). • The majority of anteromedial coronoid fractures are accessed through the natural split in the flexor carpi ulnaris created by the ulnar nerve. • Small fractures (identified on CT imaging prior to surgery) can be approached with the Hotchkiss “over-the-top” exposure splitting the flexor pronator mass. Dissection is carried along the anterior portion of the medial supracondylar ridge superficial to the elbow capsule. The flexor pronator mass is split in continuation with the anterior medial supracondylar ridge and deep dissection proceeds just anterior to the medial collateral ligament. Elevate the flexor pronator mass and brachialis off the anterior humerus and the elbow capsule. • Expose large basal fractures associated with a fracture of the olecranon by elevating the entire flexor-pronator mass (dorsal to volar) as described by Taylor and Scham. 

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

205

STEP 1 INSTRUMENTATION/ IMPLANTATION

• Plate and screw buttress type fixation is typically used for anterormedial coronoid fractures. This stabilizes large fragments and also allows buttress of comminuted fragments (Fig. 18.6). • Prior to plate and screw buttress stabilization, it is helpful to provisionally stabilize fracture fragments with Kirschner wires (K-wires). • Suture fixation of the capsule for small fragments, through or around larger fragments and through drill holes to the dorsal ulnar surface. Sutures are tied over a bone bridge on the dorsal ulna.

FIG. 18.5 

STEP 2: REPAIR OF LATERAL-SIDED INJURY: LATERAL COLLATERAL LIGAMENT INJURY • A posterior or direct lateral skin incision is made (see Fig. 18.4). • Full-thickness fasciocutaneous flaps are elevated (see Fig. 18.4). • The fascia over the lateral supracondylar ridge is incised (Fig. 18.7). • The origin of the lateral collateral ligamentous complex is reattached to the lateral epicondyle with No. 2 nonabsorbable sutures through bone tunnels or using suture anchors. 

STEP 3: REPAIR OF BASILAR CORONOID FRACTURE WITH OLECRANON FRACTURE • A universal posterior incision or combined direct medial and lateral incisions can be utilized (see Fig. 18.4). • Identify the ulnar nerve and perform an in-situ decompression. • Elevate the periosteal tissues 1 to 2 mm off the olecranon fracture. • Continue exposure along the medial side of the proximal ulna in a posterior to anterior direction. • Use a lamina spreader to gap open the olecranon fracture to visualize the coronoid fracture and the ulnohumeral joint. • Remove loose osteochondral fragments. • A combination of dorsal plating and medial plating can be performed to reduce and stabilize the fracture. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The evidence about anteromedial coronoid fractures is limited to a few small retrospective cases series. • Park et al. reviewed 19 patients who underwent operative treatment of anteromedial coronoid fractures, evaluated an average of 31 months after surgery. Range of motion averaged 6-degree flexion contracture to 134 degrees flexion. The Mayo Elbow Performance score averaged 89 points with categorical ratings of 4 excellent, 6 good, and 1 fair. No one developed significant heterotopic ossification. No redislocations occurred. Two patients had ulnar neuropathy, one of which had preoperative symptoms. • Chan et al. recently described 10 patients with anteromedial coronoid fractures treated nonoperatively. An average of 50 months after injury, the average range of motion was from a 2-degree flexion contracture to 137 degrees of flexion.

STEP 2 PEARLS

• Lateral collateral ligament injury may not be readily apparent until exposure proceeds deep to the fascia. • Less soft-tissue injury is typically present in lateral-sided injuries with a varus posteromedial mechanism that is noted in a posteriorlateral rotary type injury. STEP 1 CONTROVERSIES

• It has been suggested coronoid repair converts injury into a simple dislocation and lateral collateral repair is unnecessary. Although this may be true, lateral collateral ligament repair in this setting is straightforward with low morbidity. It provides the benefit of added overall stability to the elbow and protects the coronoid repair. It should be strongly considered.

STEP 2 PITFALLS

• Repair of the lateral collateral ligament may protect the medial coronoid repair, which is often tenuous when the fracture fragments are small or comminution is present. • Cutting the lateral collateral ligamentous complex during exposure STEP 2 INSTRUMENTATION/ IMPLANTATION

• Large (No. 2) suture applied through bone tunnels or adequate-sized suture anchors STEP 2 CONTROVERSIES

• Some authors have advocated lateral collateral ligament repair only in cases where coronoid fracture stabilization is inadequate. In our opinion, lateral collateral ligament repair is straightforward with low morbidity. It provides the added benefit of protecting the medial coronoid and adding stability to the elbow.

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

206

A

C

B

D FIG. 18.6 

STEP 3 PEARLS

• Whereas large coronoid fracture fragments can be stabilized with a dorsal plate alone, reduction and fixation can be difficult. Initial medial fixation allows reliable visualization of the reduction and specific plate fixation of the medial side provides stronger overall fixation (Fig. 18.8). • Dorsal proximal ulnar plating in isolation to stabilize both olecranon and coronoid fracture should be reserved for three-part fractures (olecranon, coronoid, ulnar shaft) and not utilized when comminution is present. • The integrity of the lateral collateral ligamentous complex should always be assessed, visually when possible, with physical examination (varus stress examination) and fluoroscopically. It can be assessed through direct visualization of the radiocapitellar articulation through the olecranon fracture.

The Mayo Elbow Performance score averaged 94. No patient developed elbow instability. • Rhyou et al. described 18 patients who underwent an algorithmic approach to treatment of anteromedial coronoid fractures and associated soft-tissue injuries. This included fixation of anteromedial coronoid fracture fragments only and no ligamentous repair, repair of lateral collateral ligament only, repair of the anteromedial coronoid fracture and lateral collateral ligament, and no operative intervention. Treatments were based first on size of the coronoid fracture: large fractures (>6 mm) were fixed and fractures smaller than 5 mm were not fixed. After fracture fixation, varus stress test under fluroscopy was performed. If a congruent medial ulnohumeral joint and firm-end feeling was present, then no repair of the lateral collateral ligament was performed, otherwise lateral collateral ligament repair was performed. For fractures not undergoing internal fixation, varus stress test under fluoroscopy was performed. When a firm-end feeling and congruent medial ulnohumeral joint was present, no lateral collateral ligament repair was performed, otherwise the lateral collateral liga-

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

207

STEP 3 PITFALLS

• Underestimating the quality of fixation with dorsal ulnar plating alone to capture comminuted medial coronoid fracture fragments or when working with osteoporotic bone

A

STEP 3 INSTRUMENTATION/ IMPLANTATION

• Precontoured dorsal plates with multidirectional locking screws can be helpful in capturing fragments (especially in osteoporotic bone). • Use drill guides and the oscillating drill whenever working near the ulnar or median nerves.

B

POSTOPERATIVE PEARLS FIG. 18.7 

• If fixation is secure, elbow motion and active, self-assisted stretching can begin within a few days. Shoulder abduction is avoided for a month. • If the fixation is tenuous, the initiation of exercises can be delayed for up to a month.

POSTOPERATIVE PITFALLS

• Elbow range-of-motion exercises should be performed, avoiding shoulder abduction (for 4 weeks), which stresses the repair sites. • When stable elbow injuries are treated nonoperatively, strict avoidance of shoulder abduction and weekly x-rays are obtained for 4 weeks.

FIG. 18.8 

ment was repaired. Follow-up averaged 37 months. Mayo Elbow Performance score averaged 98. • Doornberg and Ring reviewed 18 patients with anteromedial facet fractures of the coronoid. Six of 18 patients were found to have malalignment of the anteromedial facet arthrosis and subluxation an average of 2 years after surgery. Of these six patients, four had nonoperative care and two had loss of coronoid fixation.

208

PROCEDURE 18  Open Reduction and Internal Fixation of Fractures of the Anteromedial Facet of the Coronoid

EVIDENCE Sukegawa K, Suzuki T, Ogawa Y, et al. Anatomical cadaver study of the Hotchkiss over-the-top ­approach for exposing the anteromedial facet of the ulnar coronoid process: critical measurements and implications for protecting the median nerve. J Hand Surg Am. 2016;41(8):819–923. Twenty fresh-frozen cadavers were dissected using the Hotchkiss over-the-top approach. Distances to the median nerve were evaluated. The length of the flexor-pronator detachment from the medial epicondyle necessary to expose the anteromedial facet of the coronoid is nearly the same distance to the median nerve. The median nerve also lies close (5 mm) to the brachialis muscle insertion. Chan K, Faber KJ, King GJW, et al. Selected anteromedial coronoid fractures can be treated ­nonoperatively. J Shoulder Elbow Surg. 2016;25:1251–1257. Ten carefully selected patients with anteromedial coronoid fractures underwent nonoperative ­treatment and did well. At average follow-up of 50 months, average range of motion was 5 to 137 degrees extension to flexion, average Mayo Elbow Performance Score was 94, and average Disabilities of Arm, Shoulder and Hand score was 7. Small, minimally displaced fractures, with no elbow subluxation can be managed nonoperatively. Park S, Lee JS, Jung JY, et al. How should anteromedial coronoid facet fracture be managed? A surgical strategy based on O’Driscoll classification and ligament injury. J Shoulder Elbow Surg. 2015;24:74–82. Eleven patients with isolated coronoid anteromedial facet fractures were retrospectively reviewed. All patients had an associated lateral collateral ligament injury and 6 of 11 patients had medial ­collateral ligament injuries. Following treatment, average range of motion was 128 degrees. ­Average Mayo Elbow Performance Score was 89 points. Mellema JJ, Janssen SJ, Guitton TG, et al. Quantitative 3-dimensional computed tomography ­measurements of coronoid fractures. J Hand Surg Am. 2015;40(3):526–533. Computed tomography scans of 82 patients with coronoid fractures were evaluated with Q3DCT modeling. Anteromedial facet fractures were more fragmented than tip fractures. The average volume of anteromedial facet fractures is small, which limits direct screw fixation. Ring D, Horst TA. Coronoid fractures. J Orthop Trauma. 2015;29:437–440. Review of coronoid fracture anatomy, classification, treatment principles, and postoperative management. Anteromedial facet fractures with elbow subluxation are best treated with buttress plating of the fracture and lateral collateral ligament reattachment. Rhyou H, Kim KC, Lee J, et al. Strategic approach to O’Driscoll type 2 anteromedial coronoid facet fracture. J Shoulder Elbow Surg. 2014:924–932. Eighteen patients with anteromedial coronoid facet fractures were treated with bony fixation of anterior medial coronoid only, lateral collateral ligament repair only, or a combination of these techniques with no significant differences in outcomes. Average follow-up was 37 months with average Mayo Elbow Performance Score of 98, and Disabilities of Arm, Shoulder and Hand score of 5.6. Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process surgical technique. J Bone Joint Surg Am. 2007;89(suppl 2; Part 2):267–283. Detailed surgical technique presented for repair of anteromedial facet coronoid fractures and associated elbow instability. Intraoperative examination, exposures, and fixation techniques are presented. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006;31(10):1679–1689. Eighteen patients with anteromedial facet of coronoid fractures were treated (15 operative, 3 nonoperative). Evaluation at 26 months demonstrated malalignment of the anteromedial facet of the coronoid with varus subluxation of the elbow in four patients where the anteromedial facet was not addressed and in two patients with loss of fixation. These patients developed radiographic arthrosis with fair and poor results according to the Broberg and Morrey rating system. The remaining 12 patients had good or excellent elbow function. Sanchez-Sotelo J, O’Driscoll SW, Morrey BF. Medial oblique compression fracture of the coronoid process of the ulna. J Shoulder Elbow Surg. 2005;14:60–64. Early publication detailing two cases of two anteromedial facet fractures prior to the classification and identification of this injury pattern. Taylor TK, Scham SM. A posteromedial approach to the proximal end of the ulna for the internal fixation of olecranon fractures. J Trauma. 1969;9(7):594–602. Early publication detailing a posteromedial approach to proximal ulna. The original intent of this article was to detail an approach to screw fixation of olecranon fractures.

PROCEDURE 19

Radial Head Arthroplasty Steven Papp INTRODUCTION • Isolated radial head fractures can occur but are usually minimally displaced. • Most comminuted radial head fractures have been shown to occur in conjunction with other associated injuries around the elbow or wrist (Davidson et al., 1993; Itamura et al., 2005). • The radial head becomes an important elbow stabilizer if there are other injuries, such as ligament tears or coronoid fractures. Therefore, nonoperative treatment or a simple radial head resection for a comminuted radial head fracture is an uncommon treatment choice in this scenario. • Open reduction and internal fixation or radial head arthroplasty remain the treatment choices for displaced and/or comminuted fractures. • Displaced, comminuted (Mason type 3) radial head fractures are better treated by arthroplasty than internal fixation, even in the hands of experienced surgeons (Ring et al., 2002). • The decision regarding fixation versus arthroplasty is often made intraoperatively. • Any surgeon planning to perform fixation of a displaced radial head fracture should be prepared to perform a radial head arthroplasty if unexpected comminution or technical difficulty is encountered. 

INDICATIONS • The indications for radial head arthroplasty include a comminuted, irreconstructible radial head fracture with: • Associated elbow dislocation with medial or lateral collateral injury (Doornberg et al., 2007) (Fig. 19.1) • Associated fracture of the coronoid (terrible triad injury) (Pugh et al., 2004) (Fig. 19.2A–B) • Interosseous membrane injury (Essex-Lopresti lesion) (Sowa et al., 1992) (Fig. 19.3) 

PITFALLS

• The decision to fix or replace the radial head is often made intraoperatively; therefore, the surgeon should be prepared to perform either procedure as necessary.

CONTROVERSIES

• Isolated comminuted radial head fracture with minimal elbow instability • Young age • Open fracture with contamination • Fixation versus arthroplasty in “technically” reconstructible fracture

FIG. 19.1 

209

PROCEDURE 19  Radial Head Arthroplasty

210

A

B FIG. 19.2 

FIG. 19.3 

PROCEDURE 19  Radial Head Arthroplasty

EXAMINATION/IMAGING

211

TREATMENT OPTIONS

• Locations where the patient is tender—medial epicondyle, lateral epicondyle, radial head, interosseous membrane, distal radioulnar joint—are noted. • Bruising and swelling can often point to associated injuries. • The range of motion (ROM) is documented in supination, neutral, and pronation. ROM/stability testing may be most accurate after administration of a general anesthetic. • Preoperative neurovascular status is documented thoroughly, with special attention paid to the posterior interosseous nerve. • Radiographic imaging includes high-quality anteroposterior (AP)/lateral radiographs of the elbow (Fig. 19.4A–B). • If there is an associated dislocation or subluxation, postreduction radiographs are usually helpful in evaluating the fracture. • Preoperative fluoroscopy (after general anesthetic), including AP/lateral and moving (live) fluoroscopic examination, can be helpful. • Computed tomography can be helpful (but is not mandatory) preoperatively to understand and plan the surgery; three-dimensional reconstruction views may be very informative (Fig. 19.5A–B). 

A

B FIG. 19.4 

• Nonoperative treatment may be indicated for some patients. • Radial head fixation is preferred in simple fracture patterns. • Radial head resection is an option if the elbow remains stable after resection (uncommon in our experience).

212

PROCEDURE 19  Radial Head Arthroplasty

A

B FIG. 19.5 

SURGICAL ANATOMY • Bony structures: radial head and neck, capitellum, trochlea, coronoid (Fig. 19.6) • The normal angle of the radial neck to the shaft is approximately 15° with a lateral flare (Fig. 19.7). • The average radial head is elliptical at 22 × 24 mm, and the average height is 12 mm. • Ligamentous structures: lateral ulnar collateral, radial collateral, and annular ligaments (Fig. 19.8) • The lateral ulnar collateral ligament is most important for posterolateral instability. • Neurovascular structures • The posterior interosseous nerve (PIN) is in close proximity to the radial neck (Diliberti et al., 2000) (Fig. 19.9A–B). • Pronation and supination have an effect on nerve position. Pronation increases the “safe” working distance to the PIN when working from a lateral approach. 

PEARLS

• Choosing a supine versus lateral patient position is based on the preferred skin incision. A lateral position is used if a posterior approach is anticipated; a supine approach is used for an isolated lateral approach. • Using a popliteal post allows the arm to hang freely. This can also be accomplished by taping of pillows and then sterile rolls under the arm, which allows easier intraoperative fluoroscopic examination. • Since most dislocations are posterior, in the lateral decubitus position, gravity helps to reduce the elbow (Fig. 19.11).

PITFALLS

• Pad the axillary area carefully.

Lateral supracondylar ridge

Medial supracondylar ridge Coronoid fossa

Radial fossa

Medial epicondyle

Lateral epicondyle

Trochlea

Capitulum

2.2

A

Radial head Neck

FIG. 19.6 

3.8

B FIG. 19.9 

15˚

FIG. 19.7 

Lateral (radial) collateral ligament Annular ligament

A

Accessory lateral collateral ligament

Articular capsule

Lateral ulnar collateral ligament FIG. 19.8 

B FIG. 19.10 

214

PROCEDURE 19  Radial Head Arthroplasty

FIG. 19.11 

EQUIPMENT

• Using a padded sterile Mayo stand allows the arm to rest on the table when needed.

CONTROVERSIES

• Some surgeons prefer supine positioning, with the arm draped across the chest. This may be a safer position, in particular in a polytrauma patient with chest/pelvic/abdominal injuries.

PEARLS

• Many radial head fractures have an associated lateral ligament injury; most commonly, the ligament is torn off the lateral humeral epicondyle (Fig. 19.14). Work through this defect in this scenario: identify and prepare the injured lateral ligament for closure during exposure and plan a solid lateral collateral ligament repair at the end of the surgery.

POSITIONING • Either lateral or supine positioning (Fig. 19.10A–B). • Typically, supine patient positioning is used for a lateral approach. • A lateral patient position is used for a posterior approach. • Bony prominences must be appropriately padded. • The endotracheal tube must be protected. • The entire arm to the shoulder must be prepped and a sterile tourniquet used; a regular tourniquet can limit proximal exposure. 

PORTALS/EXPOSURES • A lateral skin incision is made (Fig. 19.12A). • Alternatively, the skin incision is made posteriorly and a lateral fasciocutaneous flap is raised (Fig. 19.12B). • Once a fasciocutaneous flap is raised and the lateral side exposed, the Kaplan (between ECRB and EDC) or Kocher interval is identified (between the ECU and anconeus) (Fig. 19.13A–B). • The extensor carpi ulnaris and underlying radial collateral ligament are raised anteriorly. • In the distal portion of the incision, the annular ligament needs to be incised to expose the radial head and neck. • The lateral ulnar collateral ligament (LUCL) lies under the anconeus muscle posteriorly and is protected using this interval. • The operating surgeon should be alert for, and work through, any traumatic tear/ defect that is present to minimize unnecessary dissection. 

PROCEDURE 19  Radial Head Arthroplasty

A

215

B FIG. 19.12 

PITFALLS RCL

Ligament incision

• Avoid displacing a stable, minimally displaced radial neck fracture with careful retractor positioning.

PITFALLS

AL

A

LUCL

• Avoid damaging an intact lateral collateral ligament by staying anterior to this structure. • Careful distal exposure along the radial neck with the forearm pronated minimizes the chance of nerve injury. • Careful retractor placement on the radial neck is needed to avoid posterior interosseous nerve injury.

CONTROVERSIES

• A straight posterior skin incision allows full-thickness skin flaps to be mobilized for medial and lateral fascial intervals. The straight posterior skin incision prevents injury to lateral-side cutaneous nerves and is cosmetically hidden, but the skin incision is significantly longer. Alternatively, a shorter, more direct lateral skin incision is preferred by some authors, with an additional medial skin incision as needed.

B

Anconeus

ECU FIG. 19.13 

216

PROCEDURE 19  Radial Head Arthroplasty

FIG. 19.14 

PROCEDURE INSTRUMENTATION/IMPLANTATION

• Use a Hohmann retractor on the radial neck posteriorly and a Langenbach retractor on the anterior capsule for adequate exposure. Avoid using a Hohmann anteriorly where inadvertent injury to the PIN might occur.

PEARLS

• The stem used should be loose enough to allow some rotation. • If maltracking of the prosthesis occurs, downsizing the stem will allow some toggle and may improve the alignment of the prosthesis. • When assessing elbow stability with the trial prosthesis, temporarily reapproximating the lateral ligament with a Kocher clamp will prevent an impression of recurrent instability (especially in supination) and a tendency to overstuff the radial head. • We tend to choose a slightly smaller arthroplasty (up to 2 mm smaller) than the native head without compromising stability.

Step 1:  Preparation • With adequate exposure, the radial head is assessed and fixation options are considered. • If multiple (three or more) fragments are present or significant comminution prevents stable reconstruction, then arthroplasty is undertaken. • The remaining radial head is removed using a micro-oscillating saw or rongeur at the head-neck junction (articular surface junction). It is important to ensure that no residual portion of the head articulates with the lesser sigmoid notch: this can cause pain and restricted motion. • Radial head removal allows access to the anterior aspect of the elbow joint. • The elbow is irrigated and loose osteochondral fragments are removed. • The radial head fragments are reassembled (1) to size the replacement radial head and (2) to ensure complete removal of the native head. • The capitellum, lesser and greater sigmoid notch, coronoid, and trochlea can all be assessed. Osteochondral fragments can be repaired if large enough, or debrided if too small/thin to permit fixation. 

Step 2:  Radial Head Sizing • A metal, modular radial head should be used. Although a variety of radial head prostheses are available, including cemented, bipolar, anatomic, and press-fit designs, we prefer a smooth-stemmed component that allows some rotation of the stem in the radial canal. • Elbow stability is examined clinically and with fluoroscopic guidance to confirm that there is instability and that radial head replacement is indicated. Associated bony/ ligamentous injuries usually preclude simple radial head excision. • The radial neck cut is confirmed to be perpendicular to the long axis of the radial neck and just proximal to the lesser sigmoid notch. • Retractors are positioned to visualize the medullary canal and preparation is begun, starting with the smallest canal rasp and working up until the fit is snug with the rasp (Fig. 19.15). • A trial stem is placed for a nontight fit. • A neck rasp can be used to smooth off the neck, ensuring a 90° cut. • A trial head, based on the resected head portion diameter and height (most commonly 22- or 24-mm diameter), is placed. • The appropriate neck cut and trial head should restore the normal head height. • Several keys allow the head height to be placed appropriately. • The radial head should articulate with the proximal radioulnar joint. 

PROCEDURE 19  Radial Head Arthroplasty

217

PITFALLS

FIG. 19.15 

• Overstuffing should be avoided to avoid a detrimental effect on motion and capitellar wear. If the surgeon is trying to decide between two sizes of replacement radial head, it is typically prudent to choose the smaller. • The ulnotrochlear joint is checked fluoroscopically to confirm that the medial and lateral joints are close to symmetric and not overstuffed, as in Fig. 19.16. Also, the medial translation of the ulna on the trochlea is noted. • The relationship of the proximal lip of the radial head to the lateral portion of the coronoid is assessed; they reside near the same level (Doornberg et al., 2006) (Fig. 19.17). • The elbow is taken through ROM. The radial head usually has less space available in full flexion. Overstuffing can lead to loss of flexion. • Elbow stability with the trial radial head in place is assessed and improvement noted. If assessing in supination, instability will remain unless the lateral ligamentous structures are temporarily reapproximated.

INSTRUMENTATION/IMPLANTATION

• We use a metal, modular, monopolar radial head arthroplasty (Fig. 19.18). • Modularity allows the surgeon to independently adjust stem width, head height, and head width to match native anatomy accurately without overstuffing or undersizing.

CONTROVERSIES

• Bipolar radial head arthroplasty allows some rotation at the polyethylene-metal junction and may lessen capitellar wear. However, polyethylene wear and osteolysis remain a concern (Fig. 19.19). Press-fit designs may improve fixation but if they loosen can result in a “sandpaper” effect that causes excessive radial osteolysis.

PEARLS

FIG. 19.16 

• If the radial head is assembled on the back table, take care not to damage the capitellum during relocation of the head with traction, retractors, and careful manipulation. • Be aware of a fracture that extends down to the radial neck. This is unusual but may require a different arthroplasty with sufficient stem length to span the fracture, such as a cemented bipolar arthroplasty. Alternatively, fracture fixation of the neck may allow sufficient stability so that a standard prosthesis can be inserted.

PITFALLS

• A secure lateral collateral ligament repair is mandatory; inadequate repair will lead to recurrent instability.

218

PROCEDURE 19  Radial Head Arthroplasty

A

B FIG. 19.17 

FIG. 19.18 

FIG. 19.19 

PROCEDURE 19  Radial Head Arthroplasty

Step 3:  Placement and Closure

INSTRUMENTATION/IMPLANTATION

• Retractors are repositioned and the trial prosthesis is removed. • The permanent component (neck and head) is usually connected on the back table using the appropriate impactors; however, sometimes in situ assembly can be used. • The replacement radial head is impacted securely into place and a repeat examination is performed. • The LUCL repair is performed to the lateral epicondyle (Fig. 19.20A–B). • If deficient, this may be augmented with a strip of triceps fascia or #5 Mersilene. • Repair is performed using drill holes or suture anchors in this circumstance to allow anatomic repair of the ligament to the isometric point on the lateral epicondyle. • Midsubstance tears of the LUCL can be managed with direct suture repair. • The skin is closed in layers and a temporary splint is applied. • The splint is applied in 90° of flexion in pronation; this promotes intrinsic elbow instability. • If the medial side opens widely in pronation, then the splint is applied in neutral rotation. • Postoperative radiographs are obtained (Fig. 19.21A–B). 

A

219

B FIG. 19.20 

• Suture anchor repair is straightforward. We usually use 2.3-mm suture anchors with #0 Ethibond sutures.

PEARLS

• Having an experienced physiotherapist and specific instructions is important. The surgical goal is to establish sufficient stability to allow early ROM exercises and enhance functional return.

PROCEDURE 19  Radial Head Arthroplasty

220

A

B FIG. 19.21 

COMPLICATIONS

• Early • Wound breakdown • Infection • Recurrent instability • Stiffness/capsular contracture/HO • Late • Loosening • Radiocapitellar arthritis • Elbow posttraumatic arthritis

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative management • Antibiotics are given preoperatively, and two doses are given postoperatively. • If there are any risk factors for the development of heterotopic ossification (HO; i.e., head injury, revision surgery, prior HO) then oral indomethacin 25 mg three times per day is given for 3 weeks (unless contraindicated). • An early ROM program is started. • Full active flexion and extension are started within 7 days of surgery. • If any concern exists for instability (usually in extension), then the postoperative regimen may be modified to avoid the unstable position (30° extension block) with a hinged brace. • Overhead exercises and limiting varus force–inducing positions are helpful initially. • If the LUCL repair is tenuous, then full supination is not allowed until 4 to 6 weeks postoperatively. • Expected outcomes (Grewal et al., 2006; Popovic et al., 2007) • Disability is mild to moderate, on average (disability of the arm, shoulder, and hand [DASH] score: 24). • The amount of disability is dependent on many factors, including successful technical surgery and good postoperative rehabilitation. • Equally important are associated fractures of the elbow, patient age and medical comorbidities, associated injuries, workers’ compensation status, and other factors. • On average, ROM is 25–140° of flexion/extension (normal: 0–140°). • On average, ROM is 71–55° of pronation/suppination (normal: 80–80°). • On average, 6 months is required to reach final goals, with little improvement afterward.

PROCEDURE 19  Radial Head Arthroplasty

EVIDENCE Davidson PA, Moseley B, Tullos HS. Radial head fracture: a potentially complex injury. Clin Orthop Relat Res. 1993;297:224–230. (Level V evidence) This prospective study of 50 patients found that the morphology of the radial head fracture can be used to determine the overall severity of the injury. Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during approaches to the proximal part of the radius. J Bone Joint Surg [Am]. 2000;83:809–819. This cadaveric anatomic study defined the course of the posterior interosseous nerve and its relationship to common surgical approaches to the elbow. Doornberg JN, Linzel DS, Zurakowski D, Ring D. Reference points for radial head prosthesis size. J Hand Surg [Am]. 2006;31:53–57. (Level IV evidence) This study defines easily recognizable intraoperative and radiographic reference points for inserting a radial head prosthesis of the proper size and dimensions. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg [Am]. 2007;89:1075–1080. (Level IV evidence) Twenty-four patients treated with a loosely fit metal spacer following radial head resection had generally good results despite a high rate of radiographic loosening. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJW. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. J Bone Joint Surg [Am]. 2006;88:2192–2200. (Level IV evidence) One of the largest series of metallic radial head replacements demonstrated consistent midterm results (55 patients with a mean of 8.2 years follow-up) with a mean Mayo Elbow Score of 91 and a low complication rate. Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch T, Shean C. Radial head fractures: MRI evaluation of associated injuries. J Shoulder Elbow Surg. 2005;14:421–424. (Level III evidence) This study looked at the results of an MRI in 24 patients following radial head fracture and found a high rate of associated injuries. The authors concluded that a high level of suspicion should be used when one is treating displaced or comminuted radial head fractures, because concurrent osteochondral injuries and/or ligamentous injuries may be present. Popovic N, Lemair R, Georis P, Gillet P. Midterm results with a bipolar radial head prosthesis: radiographic evidence of loosening at the bone-cement interface. J Bone Joint Surg [Am]. 2007;89:2469– 2476. (Level IV evidence) This study examined 51 patients with an implanted bipolar radial head prosthesis at a mean 8 years postsurgery. The authors concluded that although satisfactory midterm functional results were achieved in 39 of the 51 patients, the high prevalence of adverse radiographic changes should alert clinicians to this possible drawback of the use of bipolar radial head prostheses. Pugh DM, Wild LM, Schemitsch EH, King GJW, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg [Am]. 2004;86:1122–1130. (Level IV evidence) This was the first study to describe a standard surgical technique to treat the “terrible triad” of the elbow. Consistent results with a mean Mayo Elbow Score of 87 was achieved in 43 patients. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg [Am]. 2002;84:1811–1815. (Level IV evidence) This definitive study demonstrated that results with open reduction and internal fixation were poor when three or more fragments of the radial head were present, especially when there was associated elbow instability. Sowa DT, Hotchkiss RN, Weiland AJ. Symptomatic proximal translation of the radius following radial head resection. Clin Orthop Relat Res. 1992;275:79–84. (Level IV evidence) A cautionary study of eight patients who had proximal radial migration following radial head resection. Reconstructive surgery was not effective, in general.

221

PROCEDURE 20

Open Reduction and Internal Fixation of Olecranon Fractures Bill Ristevski

PITFALLS

• Surgical exposure is technically simple owing to the subcutaneous nature of the olecranon; this advantage, however, increases the likelihood of symptomatic hardware and the requirement for subsequent implant removal. • Poor implant selection, weak fixation, and low bone density can lead to loss of reduction/ proximal olecranon escape. • Olecranon fractures may be associated with other bony or soft-tissue injuries about the elbow and forearm that require greater surveillance and clinical acumen to avoid a missed or late diagnosis.

• Fractures of the olecranon are common and injury patterns vary from transverse fractures to complex fractures associated with injury to other structures of the elbow and forearm. • Reliable diagnosis of the fracture can be made with history, physical examination, and plain radiographs. Computed tomography (CT) can aid in the preoperative planning of complex injuries. • Goals of surgery include anatomic restoration of the olecranon (especially the joint surface), restoration of the extensor mechanism and sufficient stability to allow early range of motion (ROM). • Increasing evidence indicates that operative fixation of displaced olecranon fractures in the elderly has a high complication rate, and that the functional outcome with nonoperative treatment is surprisingly good. Therefore, nonoperative treatment of significantly displaced olecranon fractures may be an option in elderly, frail, low-demand individuals (especially those with a medical comorbidity, such as diabetes). 

TREATMENT OPTIONS

INDICATIONS

• If nonoperative treatment is chosen: • Weekly follow-up radiographs for 2 to 3 weeks to diagnose and potentially treat secondary displacement • A brief period of immobilization (7–10 days), followed by progressive active and active-assisted ROM exercises. Passive/ forced flexion or resisted extension may be contributory to displacement: these exercises are initially avoided until sufficient healing has occurred. • Strengthening after healing is confirmed clinically and radiographically (typically 6–8 weeks after injury/surgery).

• Undisplaced fractures, which typically have an intact soft-tissue sleeve, are unlikely to displace, and have excellent results with nonoperative treatment. • Open fractures are typically treated operatively. • The most common indication for surgery is fracture displacement owing to the pull of the triceps on the proximal olecranon fragment. As most olecranon fractures involve the joint, these injuries naturally displace the joint surface and also disrupt the extensor mechanism of the elbow.

222

Examination/Imaging • A detailed physical examination and close inspection of plain radiographs are necessary to diagnose concomitant injuries. This includes assessment of: • Bone, joint, and ligament status: the coronoid process, radial head, elbow collateral ligaments, and proximal and distal radioulnar joints • Neurologic status: median, ulnar, and radial nerve sensorimotor function • Vascular status: radial and ulnar artery perfusion • Skin condition: open fracture, swelling, contusion, abrasion • Imaging includes plain radiographs (anteroposterior, true lateral, and oblique views). •  Fig. 20.1A shows a preoperative lateral radiograph of a transverse fracture of the olecranon: a fracture pattern that is typically amenable to tension band fixation (Fig. 20.1B). • CT scanning may be beneficial for complex fracture patterns involving joint depression, severe comminution, radial head fracture, intraarticular fragment, or associated distal humerus fracture. 

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

A

B FIG. 20.1 

SURGICAL ANATOMY • Bones, muscles, and tendons of the elbow joint (Fig. 20.2) • Neurovascular anatomy of the elbow (Fig. 20.3) • Median, ulnar, and radial nerves • Radial and ulnar arteries 

Triceps Biceps

Brachialis Biceps

Triceps

Brachioradialis

Brachialis Ulna Brachioradialis Extensor carpi radialis longus

Extensor carpi radialis longus

Anconeus

Humerus

Extensor carpi ulnaris

Pronator teres

Flexor carpi radialis

Flexor carpi radialis Palmaris longus Flexor carpi ulnaris

Extensor digitorum

A

B FIG. 20.2 

Extensor carpi radialis brevis

223

224

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

Radial nerve Humerus Ulnar nerve

Humerus

Radial nerve

Ulnar nerve Radial artery

Radius

Median nerve

Median nerve Ulna

Ulnar artery Radial artery

Ulnar artery Radius

Ulna

A

B FIG. 20.3 

CLASSIFICATION AND CHOICE OF FIXATION TECHNIQUE • The Schatzker classification (Fig. 20.4) is simple, comprehensive, and aids in the selection of implants and fixation technique. • Optimal fixation construct depends on the fracture type. • Type A: the classic pattern amenable to tension band fixation (Weber and Vasey, 1963); plate and screws constructs have been shown to be effective as well. • Type B: the joint surface impaction must be recognized, reduced, and stabilized with bone graft and/or an implant; fracture fixation as per type A. • Type C: compression across the fracture is generated by a lag screw(s), which is protected (“neutralized”) with either plate and screw or tension band fixation. • Type D: reduction with fixation of the intermediate fragments with transcortical or intraosseous screws is followed by either tension band fixation (if a stable fracture configuration permitting compression is achieved) or plate and screw fixation. Fracture patterns that do not permit compression should be stabilized

A

Transverse

B

Transverse-impacted

C

Oblique

D

Comminuted

E

Oblique-distal

F

Fracture-dislocation

FIG. 20.4 

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

with a plate and screw construct. A prerequisite for a tension band to work properly is a bone construct whose configuration is such that it allows for compression between fragments. • Type E: not mechanically amenable to tension band wiring; a plate and screws with lag technique across the fracture is recommended for fixation. • Type F: complex fracture with significant instability requiring that all osseous and soft-tissue components of the injury be addressed. 

POSITIONING • Typically, the patient is placed supine. The affected upper extremity can be placed across the patient’s chest on a bolster, folded sheets, or a firm pillow. • One can consider lateral decubitus positioning (Fig. 20.5A) if operating without assistance because this will allow the elbow to be positioned in extension on a Mayo stand without an assistant to hold it (Fig. 20.5B). 

A

PEARLS

• A tourniquet is used at the discretion of the surgeon.

PEARLS

• If fracture pattern and fixation choice permit, consider harvesting graft from the metaphyseal bone adjacent to the fracture if only a small amount of graft is required. This graft can be helpful for supporting depressed joint fragments that have been anatomically reduced.

B FIG. 20.5 

PORTALS/EXPOSURES • The posterior approach to the olecranon is used: the incision can be curved around the tip of olecranon and not over it to avoid a bothersome scar. • It is not usually necessary to expose or isolate the ulnar nerve. • Minimal dissection of the soft tissues (including the periosteum and the origin of the flexor muscles) at the fracture site will preserve the biologic healing environment. However, sufficient exposure must be completed to evaluate the fracture reduction, especially at the joint surface, as dictated by the fracture pattern. 

PROCEDURE: TENSION BAND TECHNIQUE Step 1 • Expose the fracture, clearing periosteum and other soft tissues 2 mm from the margin of the fracture, as well as removing interfragmentary clot or debris (Fig. 20.6). • As required, the flexor muscle origins (flexor digitorum superficialis, flexor pollicis longus, and pronator teres) can be raised from the ulnar side to access the joint surface, allowing evaluation of fracture reduction. • Any joint impaction is elevated and back-grafted with autograft or allograft. 

225

PEARLS

• Reduction can be visually and/or fluoroscopically evaluated at this point.

226

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

FIG. 20.6 

Step 2 • Drill two holes distal to the fracture with a 2.5-mm drill bit. • The first is a transverse hole 10 to 15 mm from the fracture margin for the tension bandwire (Fig. 20.7). Take care to keep an adequate posterior bone bridge to prevent tension bandwire cutout. • The second is a unicortical oblique hole angled back toward the fracture that will accept the tine of a pointed reduction clamp. • Reduce the fracture with the aid of elbow extension and a pointed reduction clamp. One tine of the clamp is anchored in the unicortical drilled hole distal to the fracture and the other on the proximal olecranon fragment. 

FIG. 20.7 

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

Step 3 • Two 1.6-mm Kirschner wires (K-wires) are drilled from the posterior surface of the olecranon through the triceps insertion, angled toward the volar ulnar surface. Once through the latter surface, they are backed out 8 to 10 mm to allow for bending and impaction later (see Step 4). Larger (2-mm) K-wires may be used in a larger patient. • Construct the tension band using two lengths of 18-gauge stainless steel wire. • Pass one strand transversely through the triceps tendon proximal to the two Kwires at the surface of the posterior ulna. This can be accomplished by first passing a large-bore angiocatheter along the described course (Fig. 20.8A). Remove the needle, leaving the catheter to receive the wire, which is then brought through the tendon as the catheter is withdrawn (Fig. 20.8B). • Pass the second strand through the transverse hole distal to the fracture (Fig. 20.8C). • Cross the distal wire over the ulnar crest, and create two twisted ties on either side of the olecranon, which progressively develops balanced compression across the fracture site (Fig. 20.9A). • Cut the twisted wires short and bury them next to the cortical surface on either side of the olecranon (Fig. 20.9B). 

A

B

C FIG. 20.8 

227

228

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

A

B FIG. 20.9 

Step 4 • Cut the K-wires and bend or curve them 180 degrees (Fig. 20.10A) and then impact them into the posterior ulnar cortex with a tamp placed through a vertical incision in the triceps tendon (Fig. 20.10B). • Reapproximate the triceps tendon fibers with resorbable sutures to prevent backing out of the wires. • Gentle flexion/extension and pronation/supination will help ascertain fracture and implant stability, and serves as a test ensuring the K-wires do not protrude into the proximal radioulnar joint (PRUJ). 

A

B FIG. 20.10 

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

229

Step 5 • Confirm accuracy of reduction and implant position visually and with intraoperative radiographs or fluoroscopy. • Pay particular attention to the length of K-wire extending across the volar ulnar surface into the anterior compartment on the lateral view. •  By placing the forearm into maximal supination in an anteroposterior view (Fig. 20.11), the PRUJ can be imaged to confirm no incursion of hardware, which would lead to limited pronation/supination and potentially increase the risk of synostosis. 

FIG. 20.11 

Step 6 • Evaluate the “safe zone” for ROM (void of implant or fracture fragment stress) in order to guide postoperative rehabilitation. • Irrigate the wound and close it in layers. • Apply a sterile dressing and a plaster splint holding the elbow at 90 degrees. 

ALTERNATIVE MODES OF FIXATION Oblique Fracture • Fixation of an oblique fracture of the olecranon (Fig. 20.12A) is achieved by compression across the fracture using an interfragmentary lag screw protected (“neutralized”) with tension band wiring or a neutralization plate and screws (Fig. 20.12B). • A small fragment plate is used for fixation. Although in the past one-third tubular, 2.7- or 3.5-mm reconstruction plates have been popular, precontoured plates for the proximal ulna have many advantages in this setting. They decrease the requirement for intraoperative contouring, have expanded options for screw placement (enhancing fracture stability), may decrease operative time, and may be used as templates for the reconstruction of complex fracture patterns. 

Comminuted Fracture with Joint Depression • For a comminuted fracture of the olecranon with residual joint depression (Fig. 20.13A): if a simple transverse fracture pattern can be recreated, the tension band technique can be applied. • If the fracture remains too unstable for this compressive technique, plate and screw fixation must be used to provide greater stability.

PEARLS

• Alternatively, a single length of wire can be used to construct the tension band, but this is more demanding. • Adequate tension is achieved once there is slight bending of the K-wires toward one another and no motion occurs at the fracture site with gentle ROM. • The twisted ties of the tension band can be strategically positioned against cortical bone to potentially help hold down small areas of cortical comminution.

PEARLS

• When using plate fixation, a triceps detensioning suture (suture from the triceps tendon to the plate) can be used to help stop proximal olecranon escape of comminuted fractures. • Precontoured plates for the proximal ulna simplify intraoperative plate placement and have expanded screw options, especially for the proximal fragment. • A small longitudinal incision in the distal triceps tendon allows the proximal part of the plate to be opposed directly to the bone, decreasing soft tissue irritation. The triceps can then be repaired.

A

B FIG. 20.12 

A

B

C FIG. 20.13 

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

• With comminuted fractures, temporary K-wire fixation may be extremely helpful, especially with associated coronoid fractures that require reducing anterior and distal fragments prior to posterior and proximal fragments. • Typically, to get plate apposition to the bone, the terminal portion of the triceps tendon is partially dissected from the olecranon to allow seating of the plate, avoiding plate prominence. However, with very comminuted proximal olecranon fractures, removing this sleeve of tissue can result in denuding these fragments. Maintaining this soft-tissue attachment and accepting slight plate prominence may be the preferred technique in this setting. • Joint depression is reduced (Fig. 20.13B) and small fracture fragments can be secured using 2.0-mm, 2.4-mm, or 2.7-mm lag screws, either through the cortex or in an intraosseous position (Fig. 20.13C). 

Grossly Comminuted Fracture • Especially in the osteoporotic patient, a combination of any of the above techniques can be employed in the repair of a grossly comminuted fracture of the olecranon (Fig. 20.14A). • Precontoured locked plating (Fig. 20.14B) has the capability of supporting depressed fragments that have been elevated and reduced with fixed angled screws and can increase the resistance to pull-out of captured fragments. • For unreconstructable olecranon fractures, resection of the posterior 50% of the olecranon can be performed, with suturing of the triceps tendon to the remaining fracture surface (Gartsman et al., 1981). • The tendon should be reattached as close to the remaining articular surface as possible to function as a sling for the distal and posterior humeral articular surface (trochlea). 

A

B FIG. 20.14 

231

COMPLICATIONS

• Complications of open reduction and internal fixation (ORIF) of olecranon fractures include prominent hardware (with or without olecranon bursitis), wound dehiscence/infection, reduced ROM, malunion, nonunion (rare), and decreased extension strength. • Symptomatic hardware, which is a common complaint, is caused by the subcutaneous position of the implants, often necessitating their removal once fracture healing has occurred. • In cases of infection, local wound care with antibiotics, as required, generally leads to satisfactory healing, with reoperation necessary in cases of deep infection, septic arthritis, and/or osteomyelitis. • Stiffness can be minimized through early and diligent physiotherapy, which is made possible by stable fixation of the fracture. As with many elbow injuries, lack of terminal extension (15–20 degrees) is common at final follow-up.

232

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative care includes a brief period of immobilization for patient comfort and wound healing. Typically, this lasts 7 to 10 days; however, some surgeons prefer more rapid mobilization, as early as the first postoperative day. • Immobilization may be prolonged if elbow flexion or repetitive flexion-extension puts undue stress on marginally viable posterior soft tissues (as may be seen in elderly or frail patients). • For the first 6 to 8 weeks, physiotherapy is limited to active and active-assisted ROM flexion, extension, and pronation/supination. Passive or forced flexion and resisted extension can both lead to fracture site distraction and are avoided. • The “safe” arc of motion will be based on the ROM determined at the end of surgery prior to wound closure. • Longer periods of immobilization or limited ROM may be necessary for the fracture that remains unstable following ORIF. This should represent only a small minority of cases. Immobilization exceeding 3 weeks is to be avoided, as it can result in permanent dysfunctional stiffness. • Once radiographic healing has been confirmed at 6 to 8 weeks, strengthening exercises can begin. Once the patient has achieved full (or near-full) ROM and adequate strength, a progressive return to work, sport, and/or leisure activities can begin. • Outcomes following ORIF of olecranon fractures are generally favorable. • Patients can expect high rates of union, good to excellent ROM, good strength, and satisfactory overall outcome (De Giacomo et al., 2016; Flinterman et al., 2014; Akman et al., 2002; Bailey et al., 2001; Garstman et al., 1981; Murphy et al., 1987). • Increasing instability and fracture complexity have been correlated with worse prognosis (Rommens et al., 2004).

EVIDENCE De Giacomo AF, Paul Tornetta III P, Sinicrope BJ, et al. Outcomes after plating of olecranon fractures: a multicenter evaluation. Injury. 2016;47:1466–1471. This retrospective review analyzed 182 consecutive patients who underwent open reduction internal fixation of displaced olecranon fractures with plate fixation. Disability of the Arm, Shoulder, and Hand (DASH) scores, elbow range of motion, hardware complications, and hardware removal were analyzed. Patients had a 15% removal of hardware rate, and a DASH score of 10.1 at final follow-up. Loss of full extension was the most common finding. Flinterman HJA, Doornberg JN, Guitton TG, Ring D, Goslings JG, Kloen P. Long-term outcome of displaced, transverse, noncomminuted olecranon fractures. Clin Ortho Relat Res. 2014;472:1955– 1961. This study analyzed 41 patients a minimum of 10 years from having open reduction and internal fixation of simple pattern displaced olecranon fractures with the majority (90%) fixated via tension-band wiring. The sole factor associated with higher DASH scores seems to be age at time of surgery, with younger patients having better results. Residual patient-related disability did not seem to correlate with arthrosis or loss of extension; however, a greater arc of motion was associated with a lesser grade of arthrosis. Akman S, Ertuere RE, Tezer M, et al. Longterm results of olecranon fractures treated with tension-band technique. Acta Orthop Traumatol Turc. 2002;36:401–407. This study evaluating 41 patients a mean of 46.7 months from having open reduction and internal fixation of their olecranon fractures with tension band wiring found the majority of patients (75.6%) had results considered very good or good. Complications included K-wire migration in two patients and hardware irritation in four patients. The authors felt that the minimal joint stiffness that is commonly seen following this injury and treatment did not present a functional disability to the patients. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. J Orthop Trauma. 2001;15:542–548. In this retrospective study, plate fixation was used in 25 patients with displaced olecranon fractures (simple and comminuted). Patient satisfaction was high, scoring (9.7/10) and pain scores were low (1/10) with an average DASH score of 10. Of the patients, 20% did require a second operation for hardware that was irritating.

PROCEDURE 20  Open Reduction and Internal Fixation of Olecranon Fractures Gartsman GM, Sculco TP, Otis JC. Operative treatment of olecranon fractures: excision or open ­reduction with internal fixation. J Bone Joint Surg [Am]. 1981;63:718–721. A review of 53 patients with olecranon fractures treated by primary excision and 54 patients treated with open reduction and internal fixation (various methods of fixation). In the fixation group, 13 patients (23%) required a repeat operation to remove the hardware and an additional 23% of patients from the ORIF group had local complications such as skin slough, infection, delayed union, device breakage, comminution of the proximal fragment requiring treatment switch to excision, and so forth. The excision group had two patients with minor complications (4%). The authors felt the study supported olecranonectomy rather than internal fixation. Murphy DF, Greene WB, Dameron TB. Displaced olecranon fractures in adults: clinical evaluation. Clin Orthop Relat Res. 1987;(224):215–223. This study reviewed adult patients treated for displaced olecranon fractures from 1976 through 1983. For comminuted fractures, most were treated with excision of the proximal fragments and triceps repair. Multiple fixation strategies were used, including intramedullary screw, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) tension band, screw and wire combination, figure-ofeight wire, and Rush rod with figure-of-eight wiring. Better clinical results were obtained using screw and wire fixation; poorer results were associated with intraarticular involvement greater than 60% and postoperative fracture displacement. Fixation was associated with a high rate of repeat operations for hardware removal. Rommens P, Schneider RU, Reuter M. Functional results after operative treatment of olecranon fractures. Acta Chir Belg. 2004;104:191–197. This study evaluating 58 patients found a high rate of hardware irritation requiring removal, a correlation between fracture pattern and development of arthrosis, and a correlation of suboptimal osteosynthesis and development of arthrosis. However, these radiographic findings did not affect elbow functioning. Worse fracture patterns (increasing comminution) and, particularly, elbow instability led to more elbow dysfunction. Weber BG, Vasey H. Osteosynthese bei Olecranonfraktur. Unfallmed Berufskrankheiten. 1963;2:90–96. This original German article outlines the fixation technique of “traction-absorbing wiring” to deal with olecranon fractures. This technique is also known as the Weber-Vasey technique, but in more recent times has commonly been referred to as “tension-band wiring.”

233

PROCEDURE 21

Open Reduction and Internal Fixation of Forearm Fractures Ted Tufescu INDICATIONS • Forearm fractures of both bones in an adult • Isolated radial shaft fractures • Unstable ulnar shaft fractures (all fractures of the proximal-third of the ulnar shaft and those of the distal two-thirds of the shaft with more than 10° of angulation or less than 50% apposition) • Open radius or ulnar shaft fractures 

INDICATIONS PITFALLS

• Distal radioulnar joint (DRUJ) instability is associated with the location of the radial shaft fracture: 55% of isolated radial shaft fractures located within 7.5 cm from the midarticular surface of the radius were associated with DRUJ instability, whereas only 6% of fractures located beyond 7.5 cm from the midarticular surface of the radius were associated with DRUJ instability. • Proximal-third ulnar shaft fractures are often associated with posterior/lateral radial head dislocation or radial head fracture. Proper clinical and radiologic examination of the radiocapitallar joint is necessary with these injuries.

INDICATIONS CONTROVERSIES

• No published study prospectively compares operative and nonoperative management of isolated ulna shaft fractures; the operative indications for isolated ulnar shaft fractures may evolve as new evidence arises.

EXAMINATION/IMAGING • Examination of the skin for open lacerations • Palpation of the radial and ulnar arteries • Examination of motor and sensory function of the median, ulnar, and radial nerves • Anteroposterior (AP) and lateral radiographs of the forearm. Fig. 21.1 shows orthogonal radiographs of combined radial and ulnar shaft fractures. • Dedicated wrist and elbow radiographs of the affected arm 

TREATMENT OPTIONS

• Open reduction with dynamic compression plate fixation is the treatment of choice. • Bridge plate fixation is reserved for severely comminuted fractures. • Closed management in a short arm cast is currently recommended for stable, isolated fractures of the ulnar shaft. • Closed reduction with long-arm cast immobilization is reserved for pediatric fractures. • Closed reduction with intramedullary fixation is reserved for pediatric fractures. • Closed reduction with external fixation is not recommended unless used as a temporizing measure in hemodynamically unstable multiple trauma patients or in those with severely contaminated open fractures.

234

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

A

B FIG. 21.1 

SURGICAL ANATOMY • Volar anatomy of the radius • Superficial layer: brachioradialis muscle, flexor carpi radialis muscle, superficial branch of the radial nerve, and radial artery • Fig. 21.2 shows the superficial layer of the volar forearm; note the interval between the brachioradialis (radial side) and the pronator teres/flexor carpi radialis (ulnar side). • Fig. 21.3 shows a view of the volar forearm with the brachioradialis and flexor carpi radialis cut away. Note the position of the radial artery and the superficial branch of the radial nerve. • Deep layer: pronator quadratus, flexor pollicis longus, flexor digitorum superficialis, pronator teres, and supinator • Fig. 21.4 shows the deep layer of the volar forearm. Note the insertion of the pronator quadratus on the distal third, the flexor pollicis longus and flexor digitorum superficialis on the middle third, and the pronator teres and supinator on the proximal third of the radius. • Dorsal anatomy of the forearm (Fig. 21.5) • Flexor carpi ulnaris • Extensor carpi ulnaris • Anconeus 

235

236

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures Brachioradialis

FCR

Radial Artery

Pronator Teres

Tufescu

FIG. 21.2  Brachioradialis

Radial Nerve

Pronator Quadratus FPL Radial Artery FDS

FCR

Supinator

Pronator Teres

Tufescu

FIG. 21.3  Supinator Brachioradialis

Pronator Quadratus

FPL FDS Pronator Teres

Tufescu

FIG. 21.4  Extensor carpi ulnaris (posterior interosseous nerve)

Flexor carpi ulnaris (ulnar nerve) FIG. 21.5 

POSITIONING

POSITIONING EQUIPMENT

• A tourniquet is applied to the operated arm and inflated to 250 mm Hg. • A mini C-arm should be draped and brought in from the same side as the arm board.

• The patient is placed supine on the operating table with the affected arm placed on an arm board. • The forearm may be supinated to allow for a volar approach to the radius. • The forearm may be pronated to allow for an approach to the ulna. • Alternatively, once the radius is stabilized, the elbow may be flexed to allow for an approach to the ulna. • For isolated fractures involving the proximal ulnar shaft, the affected arm may be draped over the patient’s body. 

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

PORTALS/EXPOSURES • Volar (Henry’s) approach to the radius: • Position the forearm in supination (Fig. 21.6A). • The skin incision should lie within a line from the radial side of the biceps tendon proximally to the radial styloid distally. • Superficial dissection • The interval between the brachoradialis (radial side) and the pronator teres/ flexor carpi radialis (ulnar side) is developed. The radial artery is retracted with the flexor carpi radialis and the superficial branch of the radial nerve is retracted with the brachioradialis (Fig. 21.6B–D). • The superficial intermuscular interval lies between the brachioradialis and pronator teres muscles for the proximal third of the radius. The interval is between the brachioradialis and flexor carpi radialis muscle for the distal two-thirds of the radius. • The radial artery and its two venae comitantes lie directly under the brachioradialis in the middle of the forearm. Care must be taken to identify the radial artery in the superficial interval and mobilize the artery in the ulnar direction. • The superficial radial nerve runs under the brachioradialis muscle and is retracted in a radial direction with the brachioradialis muscle. • Deep dissection •  Fig. 21.7 shows the deep muscle attachments to the radius: the supinator and pronator teres (proximal third), the flexor digitorum superficialis, flexor pollicis longus (middle third), and the pronator quadratus (distal third) (see Fig. 21.7). The deep muscle attachments to the radius are reflected subperiosteally off the radius (Fig. 21.8).

Superficial branch of radial nerve

Brachioradialis Supinator

Flexor digitorum superficialis

A

C

B

Radial artery

D FIG. 21.6 

Pronator teres

Flexo carpi radialis

237

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

238

Superficial branch of radial nerve Flexor digitorum superficialis

A

Radial artery

Brachioradialis Supinator

Radius Biceps tendon

Flexor carpi radialis Pronator teres

B

C FIG. 21.7 

Superficial branch of radial nerve

Brachioradialis Supinator

Biceps tendon

Periosteal incision

Radial artery

A

Radius

Flexor carpi radialis Pronator teres

B FIG. 21.8 

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures



• In the proximal third of the forearm, the supinator muscle must be stripped off and retracted from its insertion on the radius. The attachment of the supinator muscle to the radius should be incised with the forearm in full supination. This retracts the posterior interosseous nerve away from the operative field. Dissection should continue subperiosteally around the radius to prevent injury to the posterior interosseous nerve. • In the middle third of the forearm, the pronator teres and flexor digitorum superficialis muscles attach to the radius. The forearm should be pronated to expose the insertion of the pronator onto the radius. The pronator teres muscle can be released off the radial side of the radius. The flexor digitorum superficialis muscle can then be released off the radius with subperiosteal dissection. • In the distal third of the radius, the pronator quadratus and the flexor pollicis longus muscles arise from the volar aspect of the bone. The forearm should be supinated and these muscles may be stripped subperiosteally from the radial edge of the radius.

Approach to the Ulna • The skin incision is made along the subcutaneous border of the ulna, in a line running from the middle of the olecranon proximally to the ulnar styloid distally (Fig. 21.9A). • The intermuscular interval is between the anconeus and flexor carpi ulnaris muscles along the proximal third of the ulna (Fig. 21.9B, C). The interval is between the extensor carpi ulnaris and flexor carpi ulnaris muscles along the distal two-thirds of the ulna. 

Extensor carpi ulnaris Anconeus

Periosteum Ulna

Flexor carpi ulnaris

B

A

C FIG. 21.9 

239

240

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

PEARLS

• The simplest fracture to reduce should be addressed first (i.e., in the case of a segmental radius fracture and transverse ulna fracture, the ulna fracture should be reduced prior to reducing the radius fracture).

PROCEDURE Step 1: Preparation for Fixation • The fracture sites of the radius and ulna should be exposed prior to reduction and fixation of either fracture. • Reduction forceps may be used to obtain reduction and provisionally fix the fracture prior to application of the compression plate (Fig. 21.10). 

PITFALLS

• Discarding any fragments free of soft tissue makes the judgment of anatomic reduction difficult. Keep all fragments until reduction is complete.

INSTRUMENTATION/IMPLANTATION

• Small fragment pointed reduction clamps • Small Hohmann retractors

A

B FIG. 21.10  PEARLS

• An AP radiograph of the contralateral intact forearm may be helpful to measure the radial bow. The amount and location of the maximum radial bow may be obtained from this radiograph and used to help produce an anatomic reduction of the fractured radius. • In cases of severe comminution, 2.4- or 2.7-mm lag screws available on a mini fragment set allow more points of fixation in small fragments and, when countersunk, will not interfere with plate application (Fig. 21.13). • Additional compression in simple fracture patterns may be achieved with the use of a push-pull screw placed outside the plate, and a small verbrouge clamp. • In cases of bone loss, length may be restored with the use of a push-pull screw placed outside the plate, and a small lamina spreader. DRUJ alignment should be restored based on imaging of the contralateral wrist.

Step 2: Fixation • After reduction has been obtained, a lag screw should be placed if the fracture pattern allows. • If a lag screw cannot be placed, a 3.5-mm dynamic compression plate may be applied to the bone and compression obtained through the plate. • If the fracture is comminuted, then the dynamic compression plate should be applied as a bridging plate across the fracture. • Both bones should be fixed using a 3.5-mm dynamic compression plate with eight cortices obtained above and below the fracture site. •  Fig. 21.11 shows the radius (Fig. 21.11A) and ulna (Fig. 21.11B) after fixation with 3.5-mm dynamic compression plates. Note that the compression plates are placed on the volar surface of both bones. • The ulnar shaft is straight, and minimal contour of the dynamic compression plate is required. • The radius is a curved bone, and re-creation of the radial bow is necessary to allow for normal forearm supination and pronation. The dynamic compression plate will therefore require appropriate contouring to fit the radius. Fig. 21.12 shows AP

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

241

(Fig. 21.12A) and lateral (Fig. 21.12B) radiographs of the forearm fracture in Fig. 21.1 after fixation with 3.5-mm dynamic compression plates. Note that the bow of the radius has been restored. • If the fracture is open with segmental bone loss, the bone should be plated out to length. This may produce a bone defect that can be bone grafted 6 to 8 weeks after initial fracture fixation. 

A

B FIG. 21.11 

PITFALLS

• Failure to obtain anatomic reduction of the first bone stabilized will result in an inability to obtain anatomic reduction of the second bone to be fixed. • Choosing a pelvic reconstruction plate or a one-third tubular plate for fixation of either bone may lead to construct failure.

INSTRUMENTATION/IMPLANTATION

• 3.5-mm dynamic compression plates

CONTROVERSIES

• The length of the plate used and the number of cortices obtained above and below the fracture site are a matter of some controversy. Biomechanical evidence suggests that the strength of the intact bone is approximated with ten cortices above and below the fracture site (ElMaraghy et al., 2001). It is often difficult to obtain ten cortices on either side of the fracture. We therefore recommend eight cortices above and below the fracture site as this provides excellent stability and allows for early range of motion.

A

B FIG. 21.12 

242

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures

A

B

C

D

FIG. 21.13 

Step 3: Fluoroscopic Verification and Closure

CONTROVERSIES

• If adequate intraoperative images are obtained, imaging immediately postoperative or at the two-week mark may not be necessary. When surveyed, 51% of Canadian surgeons do not take x-rays immediately after fixation, and 69% do not take x-rays at the two week mark in clinic (Tufescu, 2016).

• The position of the plates and screws should be checked with fluoroscopic imaging prior to closure of the incisions. The forearm should be fully pronated and supinated to ensure that normal range of motion has been achieved. • An AP and a lateral fluoroscopic image of the wrist and elbow should also be obtained. Care should be taken to fully examine the DRUJ and radiocapitellar joint to ensure that these joints are reduced and stable. • The wound should be irrigated with normal saline prior to closure. The fascia should not be closed to prevent postoperative compartment syndrome. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES •  Early mobilization at 10 to 14 days postoperative is recommended to improve strength and endurance.

EVIDENCE Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. Outcomes following plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg [Am]. 2007;89:2619–2624. This case series investigated patient-based functional outcomes and objective forearm and wrist strength after plate fixation for diaphyseal both-bone forearm fractures in adults. Thirty patients were followed for a mean duration of 5.4 years. Plate fixation of diaphyseal both-bone forearm fractures was found to restore normal anatomy and range of motion. A moderate reduction in the strength of the forearm, the wrist, and grip was found when comparing the injured arm with the contralateral limb (Grade C recommendation; Level IV evidence).

PROCEDURE 21  Open Reduction and Internal Fixation of Forearm Fractures ElMaraghy AW, ElMaraghy MW, Nousiainen M, Richards RR, Schemitsch EH. Influence of the number of cortices on the stiffness of plate fixation of diaphyseal fractures. J Orthop Trauma. 2001;15:186–191. This biomechanical study was performed to determine the number of cortices obtained with screw purchase on either side of the fracture required to provide appropriate fixation for a transverse fracture of the radial diaphysis. Torsional stability approximating that of the intact bone was only obtained when ten cortices of fixation where obtained on either side of the fracture (i.e., five screws with bicortical contact on either side of the facture). We thus suggest that at least four screws with bicortical contact should be obtained on either side of the fracture to obtained adequate stability (Grade C recommendation). Handoll HH, Pearce P. Interventions for treating isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev. 2012;13(6). This 2012 review of the literature offers some consensus on nonoperative management methods for isolated ulna fractures. It concludes however, that insufficient evidence from randomized control trials exists to determine which method of treatment is the most appropriate for isolated fractures of the ulnar shaft in adults. The authors recommend well-designed and reported randomized trials, and note that one such trial comparing surgery versus conservative treatment is underway. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg [Am]. 2003;85: 2343–2348. This randomized controlled trial compared limited-contact dynamic compression plates (conventional screws) with the point-contact fixator (locked screws). No significant difference was found between the two groups with regard to operative time, time to union, callus formation, pain, or functional outcome. The authors concluded that the two implants were equally effective for the treatment of diaphyseal forearm fractures (Grade A recommendation; Level I evidence). We recommend the use of dynamic compression plates over locked plates for the treatment of standard diaphyseal forearm fractures because the dynamic compression plates allow for compression, may be contoured to the radial bow, and are generally less expensive. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg [Am]. 2001;26:228–235. In this case-control study of 40 patients with radial shaft fractures, fractures were classified according to distance from the distal radius articular surface: type I fractures were located within 7.5 cm proximal to the midarticular surface, and type II fractures were located greater than 7.5 cm proximal to the midarticular surface. Twelve of the 22 type I fracture (54.5%) had an unstable DRUJ, whereas only 1 of the 18 type II fractures (5.6%) had an unstable DRUJ. Patients with distal radial shaft fractures should be thoroughly investigated for an unstable DRUJ (Grade B recommendation; Level III evidence). Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg [Am]. 2004;86:2440–2445. In this case series, 32 patients with segmental bone defects (1–6 cm in size) resulting from diaphyseal forearm fracture (22 were open fractures) were treated with cancellous bone autograft and rigid plate fixation. All fractures went on to heal within 6 months of treatment. The authors concluded that, in the presence of a compliant soft-tissue envelope that consists largely of healthy muscle, autogenous cancellous bone grafting and stable internal plate fixation result in a high rate of union and improved upper limb function (Grade C recommendation; Level IV evidence). Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg [Am]. 1992;74:1068–1078. This case series of 55 patients with a mean follow-up of 6 years examined the effect of fracture malunion on functional outcome for both-bone forearm fractures. Malunion was quantified by measuring the amount and location of the maximum radial bow in relation to the contralateral, normal forearm. Restoration of the normal radial bow was found to correlate with functional outcome. A good functional result (>80% of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow (P < 0.05 and P < 0.005, respectively). The recovery of grip strength also correlated with restoration of the location of the radial bow toward normal (P < 0.005). We recommend that attention be given to restoration of the radial bow when reducing both-bone forearm fractures (Grade C recommendation; Level IV evidence). Tufescu TV. Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons. Can J Surg. 2016;59(1):26–28. This survey of mainly Canadian orthopaedic surgeons provides a glimpse at the current standard of care for follow-up or “check” radiographs after fixation of forearm fractures, and other fractures treated with a load-sharing construct. Only 51% of surgeons feel it necessary to acquire radiographs immediately after fixation, provided intraoperative fluoroscopy was used, and 69% feel it necessary to acquire radiographs at 2 weeks at follow-up in clinic. Of those surgeons who did acquire radiographs, 58% would consider changing their practice immediately postoperative, and 24% would consider a change in practice at 2 weeks.

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PROCEDURE 22

Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures Emilie Sandman and Dominique M. Rouleau INDICATIONS PITFALLS

• Understanding the pattern of injury is important to optimize the patient’s treatment and outcome. • Always be sure to have good elbow radiographs prior to surgery since an isolated ulna fracture might, in fact, be a Monteggiatype injury. • Always evaluate the radial head to rule out associated fractures and be prepared intraoperatively for possible internal fixation or radial head arthroplasty if comminuted. • Monteggia fractures are often associated with osteoporosis, which may impair the strength of internal fixation. • Evaluate for associated ulnohumeral instability, which may be present with coronoid fractures or lateral collateral ligament (LCL) injuries.

INDICATIONS CONTROVERSIES

• The Monteggia equivalent concept described in the pediatric population has different trauma mechanisms, outcomes, and treatment.

TREATMENT OPTIONS

• Nonoperative treatment is usually restricted to the pediatric population in whom an adequate closed reduction has been obtained. • The gold standard for Monteggia fractures in the adult population is open reduction and internal fixation (ORIF) of the ulna with plate and screws, with closed reduction of the radial head dislocation or, when necessary, ORIF of the radial head or coronoid fractures and softtissue stabilization.

244

MONTEGGIA FRACTURES Indications • Proximal ulna fracture associated with a radial head dislocation or fracture • Acute, unstable, or open fractures • Comminuted fracture of the proximal ulna 

Examination and Imaging •  Complete history and physical examination. Clinical examination should include evaluation of deformity; inspection of the soft tissues to rule out an open fracture or a compartment syndrome; range of motion (ROM) of the elbow; neurologic evaluation of the median, ulnar, and radial nerves; complete vascular examination of the upper extremity (especially in high-energy trauma); examination of the joint above, the shoulder, and the joint below, the wrist. • Anteroposterior (AP) and lateral radiographs of the elbow are required to evaluate the alignment of the ulnohumeral and radiocapitellar joints, as well as to characterize the fracture pattern, which is important for preoperative planning. • Bado Classification (Fig. 22.1) • Type I: Fracture of the proximal ulna associated with an anterior dislocation of the radial head • Type II: Fracture of the proximal ulna associated with a posterior or posterolateral dislocation of the radial head • Type III: Fracture of the proximal ulna associated with a lateral or anterolateral dislocation of the radial head • Type IV: Fracture-dislocation of the proximal ulna and the radius combined in any direction • Jupiter’s subclassification of posterior Monteggia lesions (Bado Type II) •  Type IIA: Fracture of the ulna involving the distal olecranon and coronoid process • Type IIB: Fracture of the ulna distal to the coronoid at the metaphysealdiaphyseal junction • Type IIC: Diaphyseal ulna fracture • Type IID: Complex ulna fracture extending from the olecranon to the diaphysis • Radial head alignment with the capitellum is evaluated with the radiocapitellar ratio (RCR) on a lateral view. This method uses the measurement of the smallest distance between the axis of the radial head and the center of the capitellum divided by the diameter of the capitellum. Thus, in a 25-mm capitellum, an RCR within 3 mm anterior (13%) to 1 mm posterior (−5%) is considered well aligned. Moreover, this method has been shown to be reliable even when a perfect lateral view is difficult to obtain in the circumstances of the trauma. • Contralateral elbow AP and lateral radiographs are strongly recommended to determine the proximal ulna dorsal angulation (PUDA), since it has been determined that a malreduction of even 5° may lead to radial head malalignment. • Computed tomography (CT) scanning may be helpful to better understand the fracture pattern and for surgical planning, comminuted fractures, intraarticular fractures, and for fractures of the radial head or coronoid. 

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

A

B

C

D FIG. 22.1 

Surgical Anatomy • Bones and surrounding soft tissues of the elbow (Fig. 22.2) • The elbow is the summation of three articulations: the proximal radio-ulnar joint (PRUJ), radio-capitellar (RC), and ulno-trochlear. • The radial head articulates with the lesser sigmoid notch. • Hyaline cartilage covers the greater sigmoid notch except for the “bare area,” which separates the olecranon and the coronoid. • The radial head is elliptical and is covered with hyaline cartilage except for the safe zone on its anterolateral aspect. • The LCL inserts on the lateral epicondyle and includes the annular ligament, the lateral ulnar collateral ligament (LUCL), and the radial ligament.

245

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PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

Radial collateral ligament

A

Ulna

Annular ligament

Lateral ulnar collateral ligament

Radius Ulna

B FIG. 22.2  POSITIONING PEARLS

• A beanbag or anterior and posterior posts may be used to stabilize the patient in the lateral decubitus position. • Place the elbow bolster slightly lower than shoulder level to prevent the arm from sliding back and to use gravity to help reduce the fractures. • Drape a Mayo stand, which can help position the elbow in extension if operating without a second assistant. • To access the lateral aspect of the elbow, place the table under the elbow with the shoulder in external rotation.

• Neurologic and vascular anatomy of the elbow joint • Radial and ulnar arteries • Radial (including the posterior interosseous nerve [PIN]), median, and ulnar nerves 

Positioning • The patient is placed in the lateral decubitus position with a well-padded elbow bolster placed under the arm (Fig. 22.3). • Alternatively, the patient can be placed in the supine position with the upper limb supported by an arm table. The arm is placed over the chest and supported by an assistant or a rolled drape to allow adequate elbow flexion and exposure of the ulna. • This position allows for an easier approach to the radial head if ORIF is needed and may be easier in a polytrauma patient. 

POSITIONING PITFALLS

• Arm bolster placed in the antecubital fossa. POSITIONING EQUIPMENT

• A sterile pneumatic tourniquet is used and applied after draping. • Fluoroscopy is necessary throughout the intervention and placed on the side of the operated arm. POSITIONING CONTROVERSIES

• Alternatively, the patient can be in the supine position on the operating room table with the arm supported over the chest, but this may be difficult without an assistant.

FIG. 22.3 

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

Portals/Exposures

PORTALS/EXPOSURES PEARLS

• A posterior longitudinal skin incision starting proximally, centered on the distal humerus, curving laterally around the tip of the olecranon and centered on the proximal ulna distally, according to the level of the fracture. • Deep dissection in the interval of the extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU) distally and between the FCR and the anconeus proximally. 

• A posterior longitudinal approach gives access to the ulnar fracture as well as most radial head and coronoid fractures (Fig. 22.4). • If needed, a separate deep lateral and medial approach may be done with adequate skin flaps. • For radial head exposure, the Kaplan approach (extensor carpi ulnaris–extensor carpi radialis brevis [EDC-ECRB] interval) or the Kocher approach (anconeus-ECU interval) can be done with the forearm in pronation to protect the PIN (Fig. 22.5).

PORTALS/EXPOSURES PITFALLS

• Superficially, the posterior antebrachial cutaneous nerve (PABCN)—and deep, the PIN—are at risk with the lateral elbow approach.

Ulna Radius

FIG. 22.4 

Brachioradialis Extensor carpi radialis longus/brevis

Triceps Kaplan approach

Anconeus

Kocher approach

247

Extensor digitorum communis FIG. 22.5 

Extensor carpi ulnaris

248

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

Procedure Step 1 • Expose the ulnar fracture after meticulous dissection and clear it from periosteum, clot, debris, or other soft tissues to evaluate the fracture and allow anatomic reduction. • Associated coronoid fractures should be addressed first through the proximal ulnar fracture site. Associated radial head fractures may be approached through a separate incision to avoid synostosis that might occur if approached through the proximal ulna fracture. If the injury has caused sufficient soft-tissue disruption that an associated radial head is adequately exposed, fixation can be performed through this defect. • If there is insufficient exposure of the radial head, a separate standard lateral approach may be used. • If there is inadequate exposure of the coronoid fracture, a separate medial approach may be done. • If needed, careful dissection and elevation of the flexors’ origin may be done to provide access to the ulnohumeral joint and aid in anatomic fracture reduction. 

STEP 1 PEARLS

• Protect the cutaneous nerves as well as the ulnar (medially) and radial (laterally) nerves throughout the surgery. • Protect the soft tissues and preserve the periosteum and muscle attachments as much as possible to enhance the fracture biology.

STEP 1 PITFALLS

• Failure to protect the neurovascular structures • Addressing radial head fractures through the proximal ulna fracture may increase the risk of synostosis if extensive surgical dissection is performed.

STEP 1 INSTRUMENTATION/IMPLANTATION

• Be prepared, making available all instrumentation and implants needed during the surgery. • Precontoured 3.5-mm proximal ulnar plates • Radial head plates and headless screws • Radial head arthroplasty implants • Appropriate mini-fragment or specialty plates and screws for coronoid fractures • Suture anchors

STEP 1 CONTROVERSIES

• Some authors believe that fixing a radial head injury through the proximal ulna fracture might increase the risk of synostosis. A separate incision, using a Kaplan or Kocher approach, may decrease this possible complication. • The Kaplan approach (EDC-ECRB interval) is anterior to the LCL and is centered on the radial head. However, this approach is closer to the PIN; thus, dissection should be done carefully while maintaining the forearm in pronation. • The Kaplan approach (anconeus-ECU interval) is more posterior and farther away from the PIN; however, it is closer to the LCL; thus, care should be taken to preserve it during dissection.

Step 2: Open Reduction • For simple ulna fractures, drill a unicortical hole, distal to the fracture site, with a 2.5-mm drill bit. The pointed reduction clamp is placed in this hole and on the proximal fracture fragment for fracture reduction. • The proximal ulna fracture is reduced by bringing the elbow into extension.

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

• For comminuted ulna fractures: • Use the dorsal cortex as a guide to the appropriate length of the ulna. • Bone graft may be used to restore dorsal ulnar and trochlear length. • If unsalvageable, up to 50% of the olecranon tip may be excised without causing any instability to the elbow. However, as much as possible, the proximal bone fragment where the triceps inserts should be safeguarded. • Spontaneous reduction of the radial head usually occurs after anatomic reduction of the proximal ulna. 

STEP 2 PEARLS

• Use a perfect lateral fluoroscopic view to evaluate the anatomic reduction of the proximal ulna and the radial head alignment with the capitellum. • For comminuted fractures, be sure to remove any intraarticular fracture fragments.

STEP 2 PITFALLS

• Narrowing of the trochlea by overcompressing and failure to bring the ulna out of length • Failure of radial head reduction should raise suspicion of inadequate proximal ulna reduction, which is the cause in the majority of cases. Less likely is interposition of soft tissues, such as the capsule, annular ligament, cartilage or nervous structures, or bony fragments. • Inadequate anatomic ulnar reduction may cause chronic radial head malalignment and instability as well as future elbow arthritis associated with loss of ROM and pain.

Step 3: Internal Fixation • Fracture reduction is stabilized with rigid internal fixation. • First, any associated articular fracture or joint depression must be identified, reduced, and fixed with 2.0-mm or 2.4-mm lag screws. • A precontoured, dorsally placed 3.5-mm limited-contact dynamic compression plate (LC-DCP) is bent to respect and reproduce the PUDA. • A longitudinal incision is made in the triceps tendon to allow the plate to slide on the bone proximally. • If comminuted, intermediate olecranon fragments should be identified, reduced, and stabilized with a “home run screw.” • The reduction and internal fixation are confirmed with C-arm fluoroscopy imaging. • Evaluate the PRUJ, the ulnohumeral, and especially the RC articulations for anatomic restoration and confirm that there is no hardware incursion. 

STEP 3 PEARLS

• Reinforcement of the triceps insertion may be done with a Krackow-type suture fixation through the proximal fragment and the plate. • In communitive fractures, reduction and fixation should be done from distal to proximal.

STEP 3 PITFALLS

• Be aware of associated osteopenic bone that may compromise fixation—thus, the importance of contouring the proximal plate to allow multiple orthogonal screw fixations in the proximal fragment. • Failure to obtain stable fixation of all fragments generates a risk of loss of reduction. • Inadequately placed hardware may cause loss of motion, early arthrosis, or neurovascular injuries. • Radial head malalignment is usually due to ulnar fracture malreduction.

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PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

STEP 4 PEARLS

• Congruity of the articular surfaces • Stable elbow STEP 4 PITFALLS

• Protruding hardware • Crepitus or grinding during elbow ROM • Failure to identify elbow instability of persistent radial head malalignment

Step 4 • Before closure, the elbow should be brought into full ROM to evaluate good internal fixation, anatomic reduction of the articular surfaces, impingement, and stability. • Ulnohumeral instability may be present with associated LCL injuries, often seen in posterior Monteggia fractures. • Perform an isometric repair of the LCL through a separate lateral approach, placing a suture anchor or a bone tunnel in the center of the capitellum. The braided sutures are placed in a locking fashion in the LCL, which is most commonly avulsed from the humeral side. 

Postoperative Care and Expected Outcomes POSTOP PEARLS

• In presence of a type II Monteggia fracture, with posterior radial head dislocation, placing the forearm in pronation should increase stability. With a type I Monteggia fracture, with an anterior radial head dislocation, the forearm should be maintained in supination to optimize stability. POSTOP PITFALLS

• Possible complications • Infection • Stiffness • Nonunion • Proximal radioulnar synostosis • Nerve injuries • Malunion and radial head instability • Protruding hardware • Heterotopic ossification POSTOP CONTROVERSIES

• With a surgical procedure to the elbow, nonsteroidal antiinflammatory drugs (NSAIDs) postoperatively should be considered to decrease the risk of heterotopic ossification (HO), especially if the patient presents with other risk factors for HO, such as concomitant head injury or revision surgery. However, the surgeon must weigh the pros and cons, since NSAID use has been reported to be associated with delayed union and nonunion of fractures.

INDICATIONS PITFALLS

• The DRUJ dislocation can be missed on suboptimal radiographs. • Always consider that an isolated radius shaft fracture is a Galeazzi injury until proven otherwise. INDICATIONS CONTROVERSIES

• Immobilization position after ORIF is controversial. • Some authors recommend a cast above the elbow in supination even for stable DRUJ.

• Rehabilitation • Postoperative rehabilitation depends on soft-tissue condition, stability of the internal fixation, and safe ROM, evaluated intraoperatively. • Initial immobilization with a splint should be in the position of maximal stability (evaluated intraoperatively) until the wound is healed, for approximately the first 7 to 10 days. For unstable fractures, immobilization can be maintained up to 3 weeks. • Then, full active ROM may begin, using gravity-assisted exercises, until 6 to 8 weeks. • Strengthening exercises, weight-bearing, and passive ROM should be postponed until healing of the fracture, usually at 6 to 8 weeks. • Outcomes • Good to excellent outcomes should be expected in simple Monteggia fractures. • Worse prognosis is seen with Monteggia fractures associated with radial head or coronoid injuries. 

GALEAZZI FRACTURE OF THE FOREARM IN ADULT Introduction The Galeazzi fracture is defined as a fracture of the radius diaphysis associated with a distal radioulnar joint (DRUJ) subluxation or dislocation. This injury involves a partial or complete rupture of the DRUJ ligaments and some elements of the interosseous membrane. Conservative treatment has yielded poor results in 92% of adult cases, which is why its eponym is “fracture of necessity.” Anatomic ORIF of the radius with a compression plate is the gold standard, followed by closed reduction of the DRUJ and DRUJ stability assessment. Open reduction of the DRUJ is reserved for irreducible DRUJ or a DRUJ unstable even in supination. There are three types of Galeazzi fractures based on the location of the radius fracture: type 1, distal 10 cm; type 2, 10–15 cm proximal to the radius styloid; and type 3, more than 15 cm from the styloid. Fractures 10 cm distal of the radius are more likely to have an unstable DRUJ after radius fixation and have worse clinical outcomes. Fractures can also be classified according to the direction of DRUJ dislocation: the radius can dislocate in the dorsal or volar direction in relation to the ulna. Galeazzi fractures with the radius dislocated on the volar side are more “classic” and will be reduced in the supination position. When the radius is dislocated on the dorsal aspect of the DRUJ, the pronation position is more stable. 

Indications • All Galeazzi fractures in adults should be treated by ORIF with a compression plate. • Indication for DRUJ pinning includes a reducible but unstable DRUJ. • Open reduction, ligament repair, and pinning are indicated for irreducible DRUJ dislocations or subluxations. • ORIF of large ulnar styloid fragments associated with unstable DRUJ after radius reduction and fixation 

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

251

Examination and Imaging • Preoperative radiographs of a Galeazzi fracture with volar displacement of the radius (Fig. 22.6A–B) • Preoperative radiographs of a Galeazzi fracture with dorsal displacement of the radius (Fig. 22.7A–B) 

A

B FIG. 22.6A–B 

TREATMENT OPTIONS

• Open anatomic reduction and internal fixation of the radius should be done at all times with a small fragment compression plate in adults. • If possible, the DRUJ should be reduced at the same time as the fracture. The mobility of the distal fragment usually leads to easier DRUJ reduction. If impossible, it can also be addressed after radius fixation. • An irreducible DRUJ needs to be addressed in an open manner. The approach is dictated by the localization of the ulna head, which is usually dorsal.

A

B FIG. 22.7A–B 

Surgical Anatomy • The radius is usually approached using the anterior approach of Henry (Fig. 22.8). • Henry describes two groups of muscles: the mobile wad and the flexor pronator mass. The first group originates from the lateral elbow and is innervated by the radial nerve. The ulnar and median nerves innervate the second group of muscles. • The plane is between the brachioradialis and the pronator teres/flexor carpi radialis (FCR).

252

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

Flexor pol. longus Flexor digitorum sup.

Pronator teres

Sup. br. Radial N.

Brachioradialis Supinator

Radial artery

Flexor carpi radialis

FIG. 22.8 

• In this approach, the radial artery is under the brachioradialis and needs to be identified and protected. The median nerve is just medial to the dissection and should also be managed carefully. Proximally, the posterior interosseous nerve is at risk. The forearm needs to be maintained in supination at all times and the retractor on the lateral aspect of the proximal radius needs to be blunt, like an army-navy retractor. When drilling from volar to dorsal in the one-third of the proximal radius, some PIN branches are also at risk dorsally. A sharp drill bit should be used to improve control and prevent plunging. • The DRUJ is usually opened dorsally, using a dorsal approach through the fifth extensor compartment (extensor digiti quinti, or EDQ). There is typically a great deal of soft-tissue disruption in this setting and the surgeon can work through any traumatic defect. Care must be taken not to injure the ECU. The sensory branch of the ulnar nerve is usually subcutaneous and directly on the ulnar styloid at this level. • Alternatively, the ulnar styloid can be approached directly between the ECU and FCU. Careful dissection with loupes is recommended because of the presence of the ulnar nerve sensory branch. Kirschner wire (K-wire) and a tension band can be used for fixation. This approach is adequate for fixation of an ulnar styloid with an already reduced DRUJ, as it will be difficult to reduce the joint itself from an ulnar approach. • In the rare case of the ulnar head dislocated volarly to the radius, the volar approach is recommended. The volar DRUJ surgical approach is radial to the FCU tendon. The ulnar artery and nerve are at risk, as well as the contents of the carpal tunnel. 

Positioning • A supine position is the ideal for this surgery. • A radiolucent arm table should be chosen. • A tourniquet needs to be installed prior to arm preparation.  POSITIONING PEARLS

• The patient’s shoulder should be as close as possible to the lateral side of the operating table on the fracture side.

POSITIONING PITFALLS

• Draping of the forearm should leave the elbow free for unrestricted rotation and to help with landmark identification for skin incision and for DRUJ stability testing in prosupination.

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

Portals/Exposures

PORTALS/EXPOSURES PEARLS

• The Henry volar approach for radius fixation (see Fig. 22.8) • The dorsal approach to the DRUJ (Fig. 22.9A–B) • The volar approach to the DRUJ (Fig. 22.10A–B) 

• Minimally invasive surgery is not appropriate in the forearm considering the close proximity of numerous neurovascular structures. • Loupes are useful for surgical dissection around nerves. PORTALS/EXPOSURES PITFALLS

• Blunt dissection can cause muscular and neurologic damage in the forearm. Careful intermuscular dissection is safer and more efficient.

A

B FIG. 22.9A–B 

A

253

B FIG. 22.10A–B 

Procedure Step 1: Skin Incision Planification • Skin incision for the volar approach of the forearm (see Fig. 22.8) • Dorsal skin incision for the DRUJ in the case of an irreducible DRUJ (see Fig. 22.9A–B) • Volar skin incision for DRUJ in the case of an irreducible DRUJ and volar ulnar head position (see Fig. 22.10A–B) 

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PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

STEP 1 PEARLS

Volar Approach to the Radius • An imaginary line can be drawn from the center of the elbow flexion crease, proximally to the radial third of the wrist flexor crease distally, just radial to the FCR. • A fluoroscopic view should be done to identify the exact position of the fracture. • The skin incision is done 5 cm proximal to 5 cm distal to the fracture level on the imaginary line. The skin incision can always be extended afterwards.

STEP 1 PITFALLS

• The superficial radial sensory branch is found as it exits from under the brachioradialis at the midforearm and is then located adjacent to the brachioradialis tendon distally.

STEP 1 CONTROVERSIES

• Some authors prefer a curved skin incision in the forearm. The present authors have never experienced problems with straight incisions.

STEP 2 PEARLS

• A careful dissection done between the muscle bellies will minimize bleeding and will help in the identification of structures.

STEP 2 PITFALLS

• Proximal dissection of the radius is risky for the PIN. The supinator needs to be elevated from the ulnar aspect of the radius with the forearm in supination. • Never use a Hohmann retractor on the radial side of the proximal radius.

STEP 3 PEARLS

• During ORIF of the radius, it is often easier to perform a closed reduction of the DRUJ at the same time. The anatomic alignment of the DRUJ makes the reduction of the radius easier. • Difficulty reducing a simple radius fracture may be the surgeon’s first clue that there is something interposed in the DRUJ.

STEP 3 PITFALLS

• Persistent instability of the DRUJ may be due to radial fracture malreduction: check fracture reduction clinically and radiographically in this situation. • Closing fascia and missing small vessel leakage after radius fixation may contribute to postoperative compartment syndrome.

STEP 3 INSTRUMENTATION/ IMPLANTATION

• 3.5-mm compression plate or precontoured radius plate

Step 2: Henry Volar Approach Superficial dissection is done between the FCR and the brachioradialis. The radial artery is between these two tendons distally and is under the brachioradialis more proximally. It must be identified and protected throughout surgery. The sensory branch of the radial nerve, which follows the distal half of the brachioradialis tendon, is also protected. • The deep and superficial flexor tendons are retracted ulnarly with the median nerve (see Fig. 22.8). • The interval between the pronator teres and the brachioradialis is dissected. Perforating arteries are ligated or cauterized. • The deep dissection is done by release of the following muscles, as needed, starting from the radial aspect of the radius: pronator quadratus, flexor pollicis longus, pronator teres. • If the fracture extends proximally farther than the pronator teres, the supinator needs to be released from the radius on the ulnar side in order to protect the PIN while maintaining the forearm in supination. 

Step 3: Fixation of the Radius After completion of the surgical exposure, the radius needs to be reduced anatomically and fixed. The forearm fracture chapter provides a detailed description of the anatomic specificity of the radius. The radius presents an important radial bow to allow forearm rotation. All fragments should be reduced using interfragmentary compression if possible. Then, the two major fragments need to be reduced together with a 3.5-mm compression plate. The plate should be contoured in order to respect the anatomy and provide compression on the opposite side of the cortex. Precontoured forearm plates are also available commercially. We recommend six cortices of fixation on both sides of the fracture. The cortical screws are usually sufficient for fixation. In osteoporotic bone, or when the fracture is distal and needs metaphyseal screws, locking screws are useful. Before skin closure, we recommend deflating the tourniquet and evaluating possible small-vessel bleeding that may cause a hematoma postoperatively. The fascia should normally not be closed to prevent iatrogenic compartment syndrome. Skin closure is usually performed with interrupted horizontal mattress nonresorbable sutures. • Example of ORIF for Galeazzi fracture with the radius dislocated in the volar direction (Fig. 22.11A–B) • Example of ORIF for Galeazzi fracture with the radius dislocated in the dorsal direction (Fig. 22.12A–B) 

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

A

B FIG. 22.11A–B 

A

B FIG. 22.12 

Step 4: Evaluation of the DRUJ Needs to be Done after Fixation of the Radius Usually, palpation of the DRUJ is straightforward. Full prosupination should be tested. Radiologic evaluation with fluoroscopy is also mandatory. Perfect lateral and AP views can show dislocation or subluxation of the DRUJ. In the presence of volar displacement of the radius, the ulna will be dislocated dorsally to the radius. The “unstable” position would then be the maximal pronation position. In a dorsal displacement of the radius, it would be the opposite. Four situations are possible after radial fracture fixation and DRUJ examination: • Reduced DRUJ, stable in all forearm rotation positions. We recommend a postoperative above-the-elbow cast for 14 days, followed by forearm immobilization until complete healing of the radius fracture. Regular physical examination and proper

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PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

STEP 4 PEARLS

• When conventional imaging is unclear, the DRUJ should be evaluated by a CT scan in the postoperative period.

STEP 4 PITFALLS

• Any fracture of the radius diaphysis should be a red flag for the presence of DRUJ instability. • Ensuring accurate radial fracture reduction will aid in DRUJ reduction.

STEP 4 INSTRUMENTATION/ IMPLANTATION

• Ulna to radius pins should be at least 0.062 inch (1.6 mm) in size to prevent breakage (see Fig. 22.14)

radiographs should be done to reassess the DRUJ during follow-up. Some authors now use a more aggressive approach, with early mobilization (2 weeks) and careful monitoring. • Reduced DRUJ in supination, instability in pronation. There are two options, immobilization in a long-arm cast in supination for 4 weeks, then a below-elbow cast for another 2 weeks. Alternatively, it may be appropriate to pin the DRUJ. We recommend pinning the DRUJ with two pins in the reduced position. The pins should be at least 0.062 inch (1.6 mm) in size (larger in physically bigger or noncompliant patients). They are inserted from the ulna to the radius, just proximal to the DRUJ. Pins should protrude past the radius slightly so that they can be removed if they break in the interosseous area and are bent outside the skin on the ulnar side. Pins are kept 4 to 6 weeks. An above-the-elbow cast immobilization is also used with the pins to reduce the risk of pin breakage. • The DRUJ is reducible but unstable in all forearm positions. In this scenario, DRUJ pinning, as described earlier, is recommended. If this is associated with a large ulnar styloid fragment, this may be fixed (as described later). • The DRUJ is irreducible in a closed manner. Open reduction, extraction of any obstructing tissue (EDQ, ECU, cartilage, bony fragment) and ligament repair should be done on the side of the ulnar head position, followed by DRUJ pinning. • Dorsal Approach to the DRUJ: The incision can be longitudinal directly on the DRUJ. This is safe for the sensory branch of the ulnar nerve, but variations exist and dissection should be done carefully. The DRUJ is then opened using a dorsal approach through the floor of the fifth extensor compartment (EDQ). Often, there is significant tissue damage from the injury, and this interval is used in the approach. If not, a longitudinal incision can be done to open the dorsal joint capsule. To access the triangular fibrocartilagenous complex (TFCC) insertion on the ulnar styloid, the incision can be extended in an “L” shape with a transverse incision under the TFCC. Care must be taken not to injure the ECU. The sensory branch of the ulnar nerve is usually subcutaneous and directly at the level of the ulnar styloid at this level. The capsule, TFCC, or EDQ/ECU tendon can be trapped in the joint, explaining its incapacity to be reduced. After reduction, we usually repair the capsule with strong nonabsorbable 4.0 sutures. When there is a clear avulsion of the TFCC ligaments, it can be repaired with transosseous sutures or small (3-mm) metallic suture anchors. Typically, the avulsion is from the ulna styloid. In the presence of an unstable DRUJ and fracture of the ulnar styloid, fixation of the styloid may benefit stability. Usually, when the fracture also involves the fovea, it is called a large styloid fracture. We believe that a large fragment should be fixed with a tension band technique. Usually, this type of fixation is precarious therefore, pinning of the DRUJ also needs to be done. Finally, regardless of the local repair performed, DRUJ pins are also inserted as described and the arm is immobilized in an above-elbow cast. • Ulnar Approach to the DRUJ: If the ulnar head is displaced in a volar position and the radius is irreducibly dislocated dorsally, the volar approach is recommended. The volar DRUJ surgical approach is done radial to the FCU tendon. The ulnar artery and nerve are at risk as well as the content of the carpal tunnel. After retraction of the FCU and neurovascular bundle on the ulnar side, the content of the carpal tunnel is retracted radially. The DRUJ is found in the floor of the tunnel with this approach. The dislocated ulnar head should be easily palpable. Using a blunt instrument, the ulna can usually be anatomically reduced. The DRUJ capsule can then be repaired with 4.0 nonabsorbable sutures. • Fixation of the styloid (Fig. 22.13) • Fixation of the DRUJ (Fig. 22.14) 

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

257

FIG. 22.14 

FIG. 22.13 

Step 5: Open Reduction and Internal Fixation of the Ulna Styloid • In the presence of a larger associated ulna styloid fracture, most authors recommend an ORIF of the styloid. As it is usually associated with a dorsal position of the ulna in relation to the radius, the dorsal approach to the DRUJ can be used as described. The ulnar styloid is dorsal in pronation and is easily accessible by the dorsal DRUJ approach. As an alternative, a subcutaneous flap could be done and the interval between the ECU and the FCU can be identified. Transosseous sutures or suture anchors can be used to stabilize the styloid. • Alternatively, the ulnar styloid can be approached directly, between the ECU and FCU. Careful dissection with a loupe is recommended because the ulnar nerve sensory branch will be there. K-wire and tension band fixation is then performed. A small C-arm is helpful in this setting. • Fixation of a ulnar styloid (see Fig. 22.13) 

Postoperative Care and Expected Outcomes • After a Galeazzi fracture, the immobilization period and the type of immobilization varies and is subject to debate in the literature. • For the first 2 weeks, we recommend immobilization in an above-the-elbow splint, in the position of reduction, even for the reduced and stable DRUJ. We believe that the 2-week immobilization should not cause elbow stiffness, whereas a secondary DRUJ dislocation is a negative prognostic factor for outcome. A Galeazzi with dorsal dislocation of the radius (ulna volar) is more stable in pronation and a volar dislocation of the radius (ulna dorsal) is more stable in supination. • In the case of a stable DRUJ in all positions after radius fixation, a short-arm cast could be installed at 2 weeks following the above-the-elbow cast until radius healing. • In the presence of an unstable DRUJ that has been pinned, 4 weeks of above-theelbow immobilization is recommended as a protection against DRUJ pin breakage. POSTOP PEARLS

• Close follow-up is essential to ensure that the immobilization is maintained during the desired time.

POSTOP PITFALLS

• DRUJ pins should be commensurate with the size and compliance of the patient: larger sizes and higher levels of anticipated noncompliance dictate larger-caliber pins to prevent breakage.

STEP 5 PEARLS

• Careful dissection should be done to protect the sensory branch of the ulnar nerve. STEP 5 PITFALLS

• A precarious fixation of the TFCC or of an ulnar styloid fracture without DRUJ pinning could lead to secondary instability. STEP 5 INSTRUMENTATION/ IMPLANTATION

• Mini K-wires can be used for tension band fixation of the ulnar styloid with 2.0 sutures or mini metallic flexible wires. STEP 5 CONTROVERSIES

• Some authors advocate that 3 weeks in supination is sufficient after TFCC repair without ulna to radius pins for a reduced and stable DRUJ.

258

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures

POSTOP CONTROVERSIES

• Some authors recommend no immobilization if the DRUJ is stable in all positions after radius fixation. However, secondary instability has been seen with this rapid mobilization. We believe that 2 weeks in an above-the-elbow cast is a valuable safeguard even in stable cases. • The length of immobilization is also debatable. Some authors recommend 4 weeks of above-the-elbow cast after DRUJ reduction; others recommend 6 weeks. • Another controversial question is the forearm position in an above-the-elbow cast. Most authors recommend mid-supination in all cases, others recommend full supination. There are also some authors who recommend a position that respects the direction of the DRUJ dislocation on initial radiograph. A radius displaced on the volar aspect, associated with dorsal dislocation of the ulna, is more stable in supination. The opposite dislocation direction is more stable in pronation. We routinely immobilize patients in mid-supination. In some rare cases, DRUJ stability testing after radius fixation could demonstrate a smaller translation in pronation. Usually, it is linked to dorsal dislocation of the radius and volar dislocation of the ulna. In these instances, we immobilize with the forearm in 25° of pronation. • The last element of controversy is the need to pin. Some authors believe that immobilization in the reduced position in an above-the-elbow cast is sufficient for cases of moderate instability. We usually recommend pinning in selected cases (as described) after radius fixation to prevent secondary instability.

EVIDENCE Monteggia Fractures An KN, Morrey BF, Chao EY. The effect of partial removal of proximal ulna on elbow constraint. Clin Orthop Relat Res. 1986:270–279. Biomechanical cadaveric study evaluating the proportion of greater sigmoid fossa resection possible before causing instability. The ulnohumeral joint is proportionally stable to its surface area and the proximal ulna is an important stabilizer to the joint. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86. The original classic article describing the Monteggia lesion and the Bado classification of this type of injury. Eathiraju S, Mudgal CS, Jupiter JB. Monteggia fracture-dislocations. Hand Clin. 2007;23:165–177. Level IV review article describing Monteggia fracture-dislocations. The classification, associated fractures, mechanism of injury, preoperative, perioperative, and postoperative management, as well as possible complications, are described. Egol KA, Tejwani NC, Bazzi J, Susarla A, Koval KJ. Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res. 2005;438:233–238. Level IV retrospective study of 25 patients with a Monteggia variant lesion, describing the clinical and functional outcomes after surgery. Complications are common in this complex injury, such as heterotopic ossification, arthritis, nonunion, instability, and revision surgery. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J Orthop Trauma. 1991;5:395–402. Level IV retrospective study of 13 patients treated for a posterior Monteggia fracture-dislocation. A specific pattern of injury was observed in this population consisting of a proximal ulna fracture, fracture near the coronoid, posterior radiocapitellum dislocation, and, often, radial head fracture. Malreduction of the proximal ulna with persistent posterior radial head subluxation caused decreased supination. Korner J, Hoffmann A, Rudig L, et al. Monteggia injuries in adults: critical analysis of injury pattern, management, and results. Unfallchirurg. 2004;107:1026–1040. Level IV retrospective study of 68 patients with Monteggia injuries, evaluating the functional results after surgery. Of 68 patients, 14 had “very good” and 21 of 68 patients achieved “good” outcomes after intervention. The other patients were classified as having satisfactory or poor outcomes. McCann F, Canet F, Sandman E, Petit Y, Rouleau DM. Does radiographic beam angle affect the radiocapitellar ratio measurement of subluxation in the elbow? Clin Orthop Relat Res. 2013;471:2556– 2562. Cadaveric study evaluating the effect of the beam angle on the RC ratio measurement to evaluate radial head dislocation. The RCR is a valid method up to 20° of beam angulation variation to identify radial head displacement. Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone Joint Surg Am. 1998;80:566–580. Level IV review article describing the fracture-dislocation patterns in the elbow and the importance of identifying the dislocation pattern to optimize treatment and prognosis. Ring D. Monteggia fractures. Orthop Clin North Am. 2013;44:59–66. A review article from a recognized expert on Monteggia fractures in adults and children. Description of the treatment principles and specific techniques with pitfalls and pearls for each type of injury.

PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures Rouleau DM, Faber KJ, Athwal GS. The proximal ulna dorsal angulation: a radiographic study. J Shoulder Elbow Surg. 2010;19:26–30. A radiographic study characterizing the proximal ulna dorsal angulation (PUDA) in 50 patients. Most patients (96%) had a PUDA, mean of 5.7°, at 47 mm from the tip of the olecranon. Rouleau DM, Sandman E, Canet F, et al. Radial head translation measurement in healthy individuals: the radiocapitellar ratio. J Shoulder Elbow Surg. 2012;21:574–579. Anatomic and imaging study describing and validating a new method to assess radial head alignment in the elbow: the RCR, in 40 healthy patients. The study describes that in a normal elbow, the radial head has an RCR of −5% (1 mm posterior) to 13% (3 mm anterior) in a 25-mm capitellum. Rouleau DM, Sandman E, van Riet R, Galatz LM. Management of fractures of the proximal ulna. J Am Acad Orthop Surg. 2013;21:149–160. Level IV review article on the management of proximal ulna fractures. Description of the elbow’s anatomy, biomechanics, and mechanism of injury, with treatment algorithms for optimal fracture management. Sandman E, Canet F, Petit Y, Laflamme GY, Athwal GS, Rouleau DM. Effect of elbow position on radiographic measurements of radio-capitellar alignment. World J Orthop. 2016;7:117–122. Case series of 51 healthy patients to evaluate the effect of elbow position on the RCR measurement. The mean RCR in different elbow positions are described. Overall, 95% of the values were found to be in the normal range. Sandman E, Canet F, Petit Y, Laflamme GY, Athwal GS, Rouleau DM. Radial head subluxation after malalignment of the proximal ulna: a biomechanical study. J Orthop Trauma. 2014;28:464–469. Biomechanical cadaveric study demonstrating the strong relationship between malalignment of the proximal ulna and radial head displacement, emphasizing the importance of anatomic reconstruction for each patient. Wong JC, Getz CL, Abboud JA. Adult Monteggia and olecranon fracture dislocations of the elbow. Hand Clin. 2015;31:565–580. Level IV review article on Monteggia fracture-dislocations in the adult population. Understanding the type of injury and obtaining an anatomic reconstruction of the ulna and the radius are important in order to achieve good functional outcomes.

Galeazzi Fractures Atesok KI, Jupiter JB, Weiss AP. Galeazzi fracture. J Am Acad Orthop Surg. 2011;19(10):623–633. The authors conclude that, in 2011, no study has shown superior results between closed reduction and pinning alone versus open TFCC repair and pinning for reduceable DRUJ injuries in Galeazzi fractures. Fayaz HC, Jupiter JB. Galeazzi fractures: our modified classification and treatment regimen. Handchir Mikrochir Plast Chir. 2014;46(1):31–33. https://doi.org/10.1055/s-0034-1367035. Level IV review paper illustrating controversies on immobilization protocol following fixation. Hughston JC. Fracture of the distal radial shaft: mistakes in management. J Bone Joint Surg [Am]. 1957;39-A(2):249–264; passim. Level IV study. Landmark study in which 92% (35/38) of patients with a Galeazzi fracture treated with closed reduction had a poor outcome. Kim S, Ward JP, Rettig ME. Galeazzi fracture with volar dislocation of the distal radioulnar joint. Am J Orthop (Belle Mead NJ). 2012;41(11):E152–E154. Review. A case report of a Galeazzi fracture with dorsal dislocation of the radius and volar displacement of the ulnar head. They report a more stable DRUJ in pronation. Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Beris AE, Soucacos PN. Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern. J Hand Surg [Am]. 2011;36(5):847–852. https://doi.org/10.1016/j.jhsa.2010.12.020. PubMed PMID: 21435802. Level IV retrospective study on 95 cases of Galeazzi fractures, with 42 of 95 having DRUJ instability (treated with pinning) after radius fracture fixation. Most cases of DRUJ instability were associated with distal-third radial shaft fractures. Macintyre NR, Ilyas AM, Jupiter JB. Treatment of forearm fractures. Acta Chir Orthop Traumatol Cech. 2009;76(1):7–14. Review. Level IV review paper on forearm fractures; one of the best reviews on surgical approaches and treatment. Park MJ, Pappas N, Steinberg DR, Bozentka DJ. Immobilization in supination versus neutral following surgical treatment of Galeazzi fracture-dislocations in adults: case series. J Hand Surg [Am]. 2012;37(3):528–531. https://doi.org/10.1016/j.jhsa.2011.12.021. Level IV retrospective study on 10 cases of Galeazzi fracture with stable DRUJ following fixation. There was no difference between cases immobilized in neutral forearm rotation compared with patients immobilized in supination. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg [Am]. 2001;26(2):228–235. Of 40 patients treated with ORIF, 95% had excellent results, with 25% of them requiring DRUJ pinning for instability. Three cases of irreducible DRUJ injury needed open reduction. They also showed that DRUJ instability was more common in distal radius fracture. Ristic S, Strauch RJ, Rosenwasser MP. The assessment and treatment of nerve dysfunction after trauma around the elbow. Clin Orthop Relat Res. 2000;(370):138–153. Review.

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PROCEDURE 22  Open Reduction and Internal Fixation of Monteggia and Galeazzi Fractures Level IV review paper on nerve injury in the elbow. Forearm fractures have a 1% to 10% incidence of nerve injury either from the trauma or the operative intervention. Management of posterior nerve injury varies. Some authors recommend nerve exploration, with or without graft, at 6 weeks; others recommend it at 3 months. Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343:230–238.

PROCEDURE 23

Distal Radius Fractures Prism S. Schneider EXTERNAL FIXATION • Two forms of external fixation of the distal radius may be used: bridging and nonbridging external fixation. • Bridging external fixation extends from the second metacarpal to the radius and relies on ligamentotaxis to both obtain and maintain reduction of the fracture fragments. Longitudinal tension is transmitted mainly through the radioscaphocapitate and long radiolunate ligaments to restore and maintain distal radius anatomy. • Bridging external fixation can be used as temporizing fixation or to augment or neutralize other techniques of definitive fixation. • Nonbridging external fixation spans either side of the distal radius fracture, with pins within the radius itself, leaving the radiocarpal joint free to move. 

INDICATIONS • Bridging external fixation: temporizing • Initial management of severe open fractures with extensive soft-tissue injury, often requiring serial irrigation and debridement procedures • Temporizing measure in polytraumatized patient with a complex distal radius fracture • Temporary stability prior to transfer to a tertiary referral facility for definitive management of a complex distal radius fracture • Provisional fracture reduction to facilitate computed tomography (CT) evaluation of the fracture characteristics prior to definitive internal fixation • Bridging external fixation: definitive • This technique can be used for most fractures of the distal radius that have failed an attempt at closed reduction. • Can be used as a neutralization technique to support percutaneous Kirschner wire (K-wire) placement or internal fixation. • Nonbridging external fixation • This technique can be used for unstable extraarticular or minimally displaced articular distal radius fractures that have failed an attempt at closed reduction. • Can be used for intraarticular fractures where space exists for the distal pins after reduction of the intraarticular component. • Intact volar cortex of 1 cm is generally required for pin fixation. • Nonbridging external fixation can be combined with a distal radial osteotomy for the treatment of distal radius malunion.

Contraindications • Nonbridging external fixation should not be used in the pediatric patient with an open physis. • External fixation should not be used as an isolated definitive treatment method for volar displaced fracture patterns (Smith’s), volar or dorsal shear patterns (Barton’s), or in distal radius fractures with a combined unstable distal radioulnar joint, disrupted volar carpal ligaments, or radiocarpal dislocation. 

PITFALLS

• If anatomic reduction cannot be obtained using external fixation (with or without augmentation), then the surgeon must be equipped to convert to an open surgical procedure. This occurs in up to 10% of distal radius fractures. • It is unacceptable to leave the operating room without obtaining appropriate radial height, inclination, and volar tilt, as well as an anatomically reduced articular surface, regardless of reduction and fixation techniques used. • Articular gap or step injuries of the scaphoid or lunate fossae generally require direct reduction through open or limited open approaches, because these injury patterns are difficult to treat with external fixation alone.

CONTROVERSIES

• Some authors prefer to avoid external fixation in patients with osteoporosis, given the concern for delayed radial shortening and the risk for pin site failure. Others advocate the use of external fixation, considering that all stabilization techniques are compromised in this population and external fixation may provide supplemental support. • Most surgeons believe external fixation should be reserved for independent patients and should be used cautiously in patients who are unable to protect themselves, as those with severe head injuries or mental illness.

261

262

PROCEDURE 23  Distal Radius Fractures

EXAMINATION/IMAGING Physical Examination • Treatment with external fixation should be individualized according to each patient’s functional status, occupational requirements, hand dominance, pertinent medical history, and functional expectations. • The examination should initially focus on identifying additional systemic injuries. After diagnosing, prioritizing, and treating systemic injuries, the limb needs to be assessed locally and for additional ipsilateral upper extremity injuries. • It is essential to examine the forearm, elbow, and the carpus. Galeazzi, Monteggia, and Essex-Lopresti lesions are often missed in the forearm, whereas carpal ligament injuries or carpal fractures are often missed in the hand. Fig. 23.1 demonstrates a displaced distal radius fracture with an associated scaphoid waist fracture. • The entire arm must be inspected for open wounds. Traumatic wrist wounds are generally low grade and occur on the volar or ulnar side of the wrist. • A careful neurologic examination must be performed and documented before and after reduction to rule out neurologic insult. The most common neurologic injury involves compression of the median nerve. Any median nerve sensory or motor impairment must be examined serially and may require urgent decompression if a severe or progressive neurologic deficit is found. • Although acute tendon ruptures are rare, the patient should be informed of the possibility of late extensor pollicis longus (EPL) rupture. 

Imaging Studies • Anteroposterior (AP), lateral, and oblique radiographs should be obtained at the time of initial assessment. The patient should be splinted for comfort prior to transport to the diagnostic imaging department. • Repeat postreduction radiographs usually provide more information about the fracture pattern. Therefore postreduction radiographs are valuable to obtain, even if the definitive treatment will be operative. • Radiographic parameters for acceptable reduction must be assessed preoperatively and frequently intraoperatively. • Acceptable radiographic values for fracture reduction and normal anatomic values may vary depending on patient activity level and general health; therefore these parameters should be well known to the treating surgeon.

FIG. 23.1 

PROCEDURE 23  Distal Radius Fractures

263

TABLE   Summary of Normal Anatomic Radiographic Parameters and Acceptable Radiographic Parameters for the 23.1  Distal Radius

Parameter

Description

Normal Anatomic

Acceptable

Radial Height

The distance between two parallel lines drawn perpendicular to the long axis of the radial shaft (yellow line); one from the tip of the radial styloid and the other from the ulnar corner of the lunate fossa (blue line).

12 mm

Not more than 2 mm shortening compared with ulnar head or contralateral side

Ulnar Variance

The distance between two parallel lines drawn perpendicular to the long axis of the radius (yellow line) at the distal articular surface of the ulna and the ulnar corner of the sigmoid notch of the radius (green line)

−0.6 mm 60% of the population are ulnar neutral

Not more than 2 mm shortening compared with ulnar head or contralateral side

Radial Inclination

The angle between a line drawn perpendicular to the long axis of the radius at the ulnar corner of the lunate fossa and the other between that point in the lunate fossa and the tip of the radial styloid

24 degrees

Minimum of 10 degrees

Volar Tilt

On the lateral view of the wrist, an angle formed between the longitudinal axis of the radial shaft and a line between apex of the volar and dorsal rim

11 degrees

Neutral tilt

Intraarticular Displacement

Translational discontinuity or separation in the articular surface

None

Not more than 2 mm of intraarticular step-off or gap

Carpal Alignment

On the lateral view, a line drawn along the long axis of the capitate and one along the long axis of the radius should intersect within the carpus.

Intersection within the carpus

Lack of intersection within the carpus

• Normal anatomic vs. acceptable radiographic parameters are shown in Table 23.1 and Fig. 23.2. • There should be a low threshold to include radiographs of the ipsilateral elbow and forearm. • Contralateral wrist radiographs can be obtained to assess the patient’s normal anatomy. This may be useful in assessing anatomic variants of radial height or ulnar variance. • Traction radiographs can be valuable for identifying specific fracture fragments and are easily obtained in the operating room utilizing an image intensifier. • Fig. 23.3 shows traction views of a 47-year-old woman with an injury to her dominant wrist; these radiographs were taken in the operating room prior to deciding on a definitive treatment plan. The dorsal comminution was better characterized, so this patient was treated with a bridging external fixator in combination with a mini-open dorsal incision and supplementary K-wires. • A CT scan is occasionally indicated preoperatively for defining a complex distal radius fracture pattern (Fig. 23.4A). A CT scan provides the most information after a reduction maneuver is performed and a temporary external fixator may be used for maintaining the closed reduction during CT scan imaging (Fig. 23.4B). It should be reserved for complex intraarticular fractures when fragment size, position, and orientation are poorly understood without ligamentotaxis. 

SURGICAL ANATOMY • To safely place half-pins for external fixation, the bony anatomy of the distal radius must be well understood. • The articular surface is triangle-shaped with its base at the lunate facet and its apex the radial styloid. It slopes in an ulnar and volar direction. • Lister’s tubercle sits dorsally and acts as a fulcrum for the EPL tendon, which passes on its ulnar side. This acts as a landmark to identify and protect the EPL for nonbridging external fixator pin placement or mini-open procedures (Fig. 23.6A). • Knowledge of the six dorsal extensor compartments (Fig. 23.6B) is necessary for fixator pin placement on either side of the third (EPL) compartment (Fig. 23.6A). • Compartment I: abductor pollicis longus and extensor pollicis brevis

TREATMENT OPTIONS

• Most distal radius fractures are amenable to treatment with a closed reduction, under adequate procedural sedation, and cast immobilization. No current evidence supports the value of repeated closed reduction attempts. Multiple closed reduction maneuvers may increase the risk for compartment syndrome and can worsen dorsal comminution. Therefore, an indication for surgical treatment for a distal radius fracture includes failed closed reduction. Additional indications for surgical treatment of distal radius fractures include open fractures, polytrauma, ipsilateral upper extremity injuries, and associated neurologic injury requiring surgery. • Many surgical treatment options exist for managing distal radius fractures. Most can be used in isolation or in conjunction with external fixation. • Closed reduction with percutaneous pin fixation ± external fixation • Closed reduction with intrafocal pin fixation ± external fixation (Kapandji) • Mini-open reduction with percutaneous or intrafocal pin fixation ± external fixation • As above, with bone graft or substitute • Arthroscopic assisted reduction with any of the above • Open reduction and internal fixation with dorsal or volar plating, or with fragment-specific fixation. This may also be combined with any or all of the above techniques (Fig. 23.5).

264

PROCEDURE 23  Distal Radius Fractures

Radial Height

Ulnar Variance

Radial

Palmar

Inclination

Tilt

FIG. 23.2 

FIG. 23.3 

• Compartment II: extensor carpi radialis longus and brevis • Compartment III: extensor pollicis longus • Compartment IV: extensor digitorum communis and extensor indicis • Compartment V: extensor digiti minimi • Compartment VI: extensor carpi ulnaris

PROCEDURE 23  Distal Radius Fractures

265

A

B FIG. 23.4 

PEARLS

• The superficial branch of the radial nerve and its branches are at risk during proximal and distal fixator pin placement as well as during percutaneous K-wire placement from the radial styloid. Painful neuromata can cause significant morbidity postoperatively; therefore, small open incisions with blunt dissection is strongly recommended for the placement of pins or K-wires. • The dorsal–radial anatomy of the radius in the middle third must be well known for proximal fixator pin placement. • From radial to ulnar, the bone is covered by the flat tendons and musculotendinous junctions of the brachioradialis, extensor carpi radialis longus and brevis, and the crossing abductor pollicis longus muscles.

• Image intensification is necessary for this procedure. If a C-arm is used, it is best to bring it in from the distal aspect of the hand and have the surgeon and assistant on either side of the hand table (Fig. 23.8A). A wide scope of image is helpful; to achieve this, the image intensifier should be as close as possible to the wrist. • A hand table secured to the operative table (as opposed to a hand table with a ground support) is advantageous to allow the C-arm to move underneath the hand table freely (Fig. 23.8B). • A mini C-arm that allows the surgeon to have control is generally more versatile. • Moving the patient’s arm from AP to lateral is easier than attempting to move the C-arm through its arc.

PROCEDURE 23  Distal Radius Fractures

266

A

B

C FIG. 23.5 

PITFALLS

• With any concerns about image acquisition, then radiographic images should be taken preoperatively to confirm ease of acquisition during the procedure. It may be helpful to drape the elbow into the operative field to aid with positioning between AP, lateral, and oblique views. • Preoperative or intraoperative traction images can be helpful to confirm the fracture pattern is well understood. This is the best time to convert from planned percutaneous fixation to an open procedure (see Fig. 23.3).



• The superficial branch of the radial nerve exits from under the brachioradialis and crosses the abductor pollicis longus and extensor pollicis brevis after exiting from below the brachioradialis (Fig. 23.7). • For bridging fixator pins, the anatomy of the second metacarpal must be understood. 

POSITIONING • The patient is positioned supine with the affected arm on a radiolucent hand table. The table height is adjusted such that the surgeon and assistant can sit comfortably.

PROCEDURE 23  Distal Radius Fractures Extensor pollicis longus Lister’s tubercle

Pin 2

PEARLS

Pin 1 Extensor digitorum (communis)

Extensor carpi radialis brevis

267

Extensor digiti minimi Extensor carpi ulnaris

Extensor carpi radialis longus

Ulna

Radius Extensor pollicis brevis

• Pilot holes should be drilled with local irrigation, then insert pins by hand. Insertion of pins using power carries a risk of a ring sequestrum from heat necrosis, which may predispose to loosening and pin site infection. • Pins should be advanced until they are bicortical and any self-tapping flute is completely past the far cortex (usually two full treads). • Parallel drill guides are recommended to ensure parallel placement of half-pins in order to avoid torsion on the pins, which can lead to iatrogenic metacarpal fractures.

Abductor pollicis longus PITFALLS

A III

IV V

II

VI

• If the skin incision is made in the wrong place, it should be abandoned and closed or extended. Minimizing skin tension around pin tracts is essential in preventing pin tract complications and decreasing postoperative pain. • Pin placement should not be attempted when a soft-tissue tether is present. Tight fascial bands will serve to redirect drills or pins inappropriately; therefore, blunt dissection is recommended to create a clear, tension-free tract.

I INSTRUMENTATION

B FIG. 23.6 

• A tourniquet is applied to the proximal aspect of the arm and set at 250 mm Hg, but it is usually not necessary to inflate the tourniquet for percutaneous procedures. • The elbow, wrist, hand, and forearm are prepared and draped in a sterile fashion. 

PORTALS/EXPOSURES • Fixator half-pins are safely placed using mini-open approaches. • Care is taken to isolate and protect surrounding nerves, vessels, and/or tendons. • Blunt dissection is used to ensure a safe pathway to the bone. It is recommended to err on the side of a slightly larger incision to ensure atraumatic soft-tissue management. • Conditions should be optimal prior to drilling. Drill guides and soft-tissue sleeves should be utilized at all times. 

PROCEDURE Step 1: Closed Reduction to Correct Significant Deformity • With an assistant providing countertraction at the elbow, the key reduction maneuver is prolonged traction. • Volar and ulnar deviation of the wrist combined with digital manipulation of the fracture fragments is helpful. A rolled sterile towel can be used as a fulcrum to maintain position. • Image intensification is used to assess and confirm reduction. • An incarcerated fragment can often be freed by recreating the initial deformity under traction. 

• The authors recommend use of 1.5-mm bicortical pilot holes followed by 3-mm selftapping partially threaded half-pins proximally and distally. • The use of multi-pin clamps can provide additional stability between half-pins and allow for quadrangular external fixation frame. CONTROVERSIES

• Fixator pins can be safely established in the middle of the radius and in the second metacarpal by using one incision or two separate mini-open incisions (Fig. 23.9). The same principles of meticulous soft-tissue handling must be followed, but both are acceptable techniques. • Self-drilling half-pins are available by most manufacturers; however, drilling pilot holes, followed by placement of the pins by hand is recommended for definitive treatment of distal radius fractures with external fixation in order to prevent pin site complications.

PROCEDURE 23  Distal Radius Fractures

268

Lateral bands Central slip Dorsal digital expansion First dorsal interosseous Extensor indicis

Abductor pollicis longus

Extensor digiti minimi Expansion of abductor pollicis brevis Extensor digitorum comunis Extensor pollicis longus

Abductor digiti minimi

Abductor pollicis longus

Dorsal cutaneous branch of ulnar nerve

Extensor carpi radialis longus and brevis

Extensor retinaculum

Superficial radial nerve

Extensor carpi ulnaris

Extensor pollicis brevis Extensor digitorum comunis

Abductor pollicis longus

FIG. 23.7 

A

B FIG. 23.8 

PROCEDURE 23  Distal Radius Fractures

A

269

B

C FIG. 23.9  PEARLS

• Following closed reduction and traction x-rays, the surgeon must be confident that an acceptable reduction can be obtained and maintained with either percutaneous wires, intrafocal wires, or by elevating the joint surface through a mini-open procedure. Otherwise, this is the best opportunity to convert to an open reduction with internal fixation procedure (Fig. 23.10). • If an anatomic reduction is obtained, it is reasonable to proceed with K-wire fixation at this time. Generally two wires directed from the radial styloid in distal-to-proximal, radial-to-ulnar, and volar-to-dorsal directions are combined with one cross wire securing the lunate facet. This wire is directed from dorsal to volar, distal to proximal, and ulnar to radial. Stable K-wire fixation can be used as definitive fracture care or can be augmented with an external fixator. CONTROVERSIES

FIG. 23.10 

Step 2: Placement of Proximal Fixator Pins • The proximal pins should be placed approximately 5 cm proximal to the zone of injury. This is usually 10 cm proximal to the radial styloid in the middle third of the radius; however, each injury should be addressed individually (Fig. 23.11). • A mini-open approach is used. In the setting of a nonbridging frame, it is beneficial to have dorsal-to-volar pins, whereas in the setting of a bridging frame, it is optimal

• Some authors advocate anatomic reduction prior to application of an external fixator, whereas others feel that the external fixator pin can be used as a reduction tool. It can be cumbersome to operate around an external fixator frame, but either technique is acceptable. It is acceptable to gain radial height, inclination, and tilt with a closed reduction, then place an external fixator to maintain the reduction, and finally address the articular surface through a mini-open procedure. Ultimately, there is no clear stepwise approach, and the surgeon can proceed with his or her preferred sequence. Techniques must, however, be effective and reproducible in order to accomplish the goals of obtaining and maintaining reduction.

270

PROCEDURE 23  Distal Radius Fractures

PEARLS

• Proximal fixator pins can be placed through two separate mini-incisions (see Fig. 23.9A and C) depending on surgeon preference. The same meticulous soft-tissue protection principles are employed. • There is a temptation to utilize a small skin incision for proximal fixator pin placement. However, a generous skin incision to place these pins is recommended in order to reduce the risk of damage to sensory nerves causing painful neuroma. Nerve injury, although rare, will leave a patient with significant morbidity. • Following the application of traction, the incisions may need to be extended to ensure tension-free approximation of skin surrounding the pin sites. PITFALLS

• Care must be taken to avoid drilling across the interosseous membrane, because there is a small incidence of heterotopic ossification and the potential to create a synostosis. • Irrigation and intermittent drilling should be used to minimize thermal necrosis, because pin site infection or pin loosening can result in loss of reduction prior to sufficient fracture healing. INSTRUMENTATION/IMPLANTATION

• A variety of systems are available. Most systems have either self-tapping or selftapping and self-drilling 3-mm half-pins. Drilling a 1.5-mm pilot hole through both cortices and inserting the fixator pins by hand is recommended. Fully two threads should cross the far cortex. Self-drilling pins leave sharp ends proud in the soft tissues and are not recommended. CONTROVERSIES

• Proximal or distal fixator pins may be placed first. It is often easier to place the proximal pins first, followed by the distal pins, to avoid having to work around prior pin site placement. • If using two separate mini-incisions, a second incision is made for the more proximal pin. • Angled retractors are used to identify the periosteum, and then the fixator pins are sequentially placed. • The most distal of the proximal pins is drilled through both cortices utilizing a drill guide anchored on bone. The fixator pin is then placed by hand to gain bicortical fixation. These steps are then repeated for the most proximal pin. • A double drill guide or multi-pin clamp is ideal to space the pins appropriately. Slight convergence of the pins allows them to be clamped under tension, providing a stiffer construct. • Pin placement and depth should be confirmed with image intensification.

to have pins at 45° to the long axis of the arm. Having the distal and proximal pins in the same orientation allows for easier construction of a quadrangular frame. • The approach can be planned in the palpable interval between the extensor carpi radialis longus and extensor carpi radialis brevis for dorsal-to-volar pins or in the interval between the brachioradialis and extensor carpi radialis longus for the 45° oblique pins (see Fig. 23.6B). • Image intensification is used to plan the starting point of the most distal proximal pin. • The skin is marked and a 4-cm incision is extended proximally from this point. Blunt dissection is used to identify the intramuscular plane. Large subcutaneous veins are often encountered and should be protected. • Direct identification of the superficial branch of the radial nerve and antebrachialcutaneous nerve is not necessary; however, their course must be well understood in order to preserve and protect them. One or both of these nerves is often encountered and should be protected. Injury to these structures carries significant morbidity. • Ultimately, the surgeon needs to visualize each layer and see the periosteum prior to pin insertion. A soft-tissue sleeve should be employed for drilling and pin insertion. 

Step 3: Placement of Distal Fixator Pins • For nonbridging external fixation, the pins are planned from dorsal to volar on either side of the EPL tendon. A limited open technique is utilized to protect the extensor tendons (see Fig. 23.9A and B). • Separate longitudinal incisions on the radial and ulnar sides of Lister’s tubercle are planned using image intensification to mark the ideal location. A lateral view assists in identifying the ideal entry point exactly halfway between the fracture line and the joint surface (Fig. 23.12). • The first pin is placed on the ulnar side of the EPL. Through a short longitudinal skin incision, the extensor retinaculum is identified and entered between the third and fourth extensor compartments. Blunt dissection is used to create a path to bone. It is important to use the appropriate soft-tissue sleeve for drilling and for pin placement. 

Step 4: Assembly of Fixator Frame • The incisions around the pin sites are closed in layers with the fracture reduced. A tension-free closure is important to prevent pin site complications. Interrupted 3–0 nylon mattress sutures are recommended for skin approximation. • The proximal and distal pins are joined using short bars or multi-pin clamps that accommodate two pins, depending on the fixator system used (Fig. 23.13). • Carbon-fiber bars are recommended to connect the proximal pins to the distal pins, because these will not obscure intraoperative or postoperative radiographs while the fracture is followed to union. • Placing the multi-pin clamps close to the skin increases the stability of the external fixator construct, but a minimum of 2 cm should be left between the bars and the skin. The external fixator frame should be positioned such that it does not interfere with finger range of motion or wrist range of motion for nonbridging frames. • The first rod is connected and image intensification is used to confirm anatomic reduction. At this time, any final modifications to the reduction using percutaneous K-wires or mini-open techniques can be used. • Once reduction is confirmed, the carbon-fiber rod is secured and a second rod is connected to create a quadrangular frame (Fig. 23.14). • Final fluoroscopic images are obtained. The distal radioulnar joint is assessed at this time. • All connectors are tightened firmly using counter-torque wrenches so as not to stress the fixator pins.  

PROCEDURE 23  Distal Radius Fractures

FIG. 23.11 

A

B FIG. 23.12 

FIG. 23.13 

271

PROCEDURE 23  Distal Radius Fractures

272

A

B FIG. 23.14 

A

B FIG. 23.15 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Postoperative Care PEARLS

• Hand and wrist stiffness in the postoperative period is a concern. When placing pins into the second metacarpal, do not tether the extensor mechanism. It is recommended to flex the index finger completely during pin insertion, followed by examination after pin placement to ensure free finger range of motion • In the situation of a dorsally displaced fracture pattern, the distal nonbridging fixator pins are often directed obliquely from proximal to distal. Gentle pressure on the pins is used to reduce the dorsal angulation and translation. Forceful pressure can cause pin cutout; therefore, if the reduction is not obtained easily, an alternate technique must be employed. The nonbridging fixator pins are intended as joysticks with which to lever the fracture gently into the reduced position. Further, these pins act as a powerful reduction tool, and over-reduction is a risk.

• The pin sites are dressed using loosely places petroleum jelly–soaked sterile gauze and a bulky dressing to wick moisture away from the pin sites for the initial 10 to 14 days (Fig. 23.15). Dressings can be loosely secured with an elastic wrap. If the outer dressings become saturated with serosanguinous drainage, the outer dressing may be changed prior to discharge (Fig. 23.16). • Patients generally tolerate this procedure as an outpatient day surgery procedure and are discharged home the same day. A single dose of preoperative prophylactic antibiotics is administered. • Patients are encouraged to place all movable joints through a full range of motion immediately postoperatively. Patients are encouraged to use their arm gently for activities of daily living but to avoid lifting more than 5 lb or submerging the extremity in water. • Patients are followed at 10 to 14 days postoperatively and again at 6 weeks postoperatively. • At the initial follow-up, surgical incisions are inspected and sutures are removed, if appropriate. All connectors are inspected for any early loosening and retightened, as necessary. Orthogonal radiographs are obtained and evaluated. Patients are encouraged to mobilize actively and passively any moveable joints. If the pin sites are clean and dry, dressings may be removed and minimal pin site care is

PROCEDURE 23  Distal Radius Fractures

273

PITFALLS

FIG. 23.16 

recommended. If pin sites begin to drain, daily pin site care with a sterile cotton swab and sterile saline is recommended. At this time, patients can shower but should not submerge the arm. • At the 6-week follow-up, orthogonal radiographs are obtained and evaluated. If there is evidence of sufficient fracture union, the fixator pins are removed in the clinic, with local anesthetic, if required. Early rehabilitation is initiated for finger, hand, and wrist range of motion followed by strengthening. Formal physical therapy with a focus on return to activity may be required. • Patients are routinely followed at 3-, 6-, and 12-month postoperative time frames, and further with any ongoing concerns. 

Expected Outcomes • Several randomized clinical trials and meta-analyses have compared open reduction and internal fixation (ORIF) with locking plates versus external fixation with or without supplemental K-wires for unstable distal radius fractures. Most have reported some early functional gains at 6-week to 3-month follow-up for patients treated with locking plate fixation; however, most report very similar functional and clinical outcomes between the same groups at longer term follow-up. • Some studies have found improved radiographic outcome measures with locked plating; however, these improved radiographic parameters have not correlated with clinically significant improvements in functional outcomes. • External fixation carries the risk of pin site infections and peripheral nerve injury; however, ORIF with plate fixation has increased risk for deep infection and may require secondary surgery for implant removal. • If an acceptable closed or percutaneous open reduction can be achieved and maintained using external fixation combined with supplemental K-wire fixation, external fixation is a valuable treatment option for unstable distal radius fractures, in a cooperative patient.

EVIDENCE Gu W-L, Wang J, Li DQ, et al. Bridging external fixation versus non-bridging external fixation for unstable distal radius fractures: a systematic review and meta-analysis. J Orthop Sci. 2016;21(1):24–31. http://doi.org/10.1016/j.jos.2015.10.021. Systematic review and meta-analysis of six cohort studies, with a total of 905 patients with unstable distal radius fractures treated with either bridging or nonbridging external fixation that supports the preferred use of bridging external fixation, given an increased risk for pin tract infection, extensor pollicis longus rupture, and nerve injury with nonbridging external fixation.

• When planning mini-incisions for nonbridging external fixator pins, it is important to make the incisions distal to the planned site of insertion. Once a reduction maneuver is performed, the pins will be gently levered distally and will align with the distally placed skin incision without creating skin tension. • Distraction of the volar cortex with nonbridging pins is not recommended. The goal is to use the pins as reduction tools, to perform a gentle reduction maneuver to lever about the volar cortex. Ultimately, the pins are stronger than the bone, so excessive force may cause iatrogenic fracture or malreduction. • The pin is placed midway between the fracture and the radiocarpal joint and directed parallel to the joint surface. The pin should be inserted by hand under fluoroscopic guidance. On a true lateral view of the wrist, the pin should be parallel to the floor of the operating room and thus an AP view is not necessary. The pin must have stable purchase in the volar cortex. • This process is repeated on the radial side of Lister’s tubercle between the second and third extensor compartments. The first pin trajectory is utilized as a guide for parallel placement of the second pin. The two fixator pins should appear in parallel on the transstyloid lateral view (see Fig. 23.12). • If either pin does not achieve stable volar purchase, a second attempt may be warranted; however, repeated attempts are unlikely to succeed as bone stock diminishes. The surgeon must be prepared to convert to a bridging external frame construct. • For bridging external fixation, the distal pins are planned on the dorsal radial aspect of the second metacarpal at a 45° angle to the long axis of the forearm (halfway between radial to ulnar and dorsal to volar) and perpendicular to the long access of the metacarpal diaphysis. • These pins are placed through separate longitudinal mini-incisions, with the most proximal pin planned on the bare area just distal and dorsal to the first interosseous muscle. With any uncertainty, image intensification is used to plan placement of this pin. The second pin is placed through a more distal second incision. • The multi-pin clamp can be used to plan the distal pin at the correct distance and in parallel to the first pin. Be certain that these two pins are in the proximal 60% of the metacarpal to avoid entering the metacarpophalangeal joint capsule distally. • Pin placement should be confirmed by image intensification.

274

PROCEDURE 23  Distal Radius Fractures

PEARLS

• The external fixator is a powerful reduction tool. Be cautious of over-reduction in the sagittal plane when using the nonbridging external fixator. • When using a bridging frame, there is a tendency to excessively pronate the distal fragment. This will limit the patient’s supination. To avoid this complication, look specifically for excessive pronation on final intraoperative x-rays. • Avoid excessive distraction at the fracture site, as this can lead to delayed union and finger stiffness. PITFALLS

• With bridging external fixation, owing to viscoelasticity of the wrist ligaments, the amount of traction applied in the operating room often diminishes over the ensuing weeks, therefore supplementation with K-wires should be considered (see Fig. 23.5). • Owing to the strong volar ligaments, it is not always possible to recreate anatomic volar tilt of the distal radius, but only to bring a dorsally angulated fracture to a neutral position. In this situation, it is usually necessary to utilize percutaneous pin fixation in combination with bridging external fixation. • The thumb should be placed in full extension to confirm that the external fixator apparatus does not impinge on the first metacarpal. • If an acceptable reduction cannot be obtained, it is advisable to convert to an open procedure rather than accepting a suboptimal reduction (see Fig. 23.10). INSTRUMENTATION/IMPLANTATION

• It is important to know your equipment well and be aware of exactly what connector, clamp, rod, and pin options are available. If working with new equipment, scrubbing in early to trial the possible construct combinations is recommended. • During routine follow-up, it is recommended to examine the fixator connections for loosening. • Most patients will tolerate removal of K-wires and the external fixator in the clinic setting at 5 to 6 weeks postoperatively. COMPLICATIONS

• Postoperative pin site infection, the most common complication, can generally be managed by daily pin site care with a cotton swab and sterile saline, in combination with oral antibiotics. If a pin is loose early in the course of treatment, it must be removed and may need to be replaced. Generally this can be accomplished without loosening the entire frame by preserving a solid construct to the other intact pin. • Signs and symptoms of complex regional pain syndrome (CRPS) need to be identified early and treated with a multidisciplinary approach including chronic pain specialists, physical and occupational therapists, and occasionally a psychologist or psychiatrist with special interest in CRPS. CRPS can generally be avoided by taking care to identify and protect even the smallest branches of the peripheral nerves. Daily, oral vitamin C (500 mg/day for 50 days) may decrease the prevalence of CRPS when prescribed from the time of the fracture.

Hayes A, Duffy JP, McQueen MM. Bridging and non-bridging external fixation in the treatment of unstable fractures of the distal radius: a retrospective study of 588 patients. Acta Orthop. 2008;79:540–547. Retrospective review of 546 patients treated with either nonbridging (59%) or bridging (41%) external fixation supported a decreased risk for dorsal malunion and radial shortening with nonbridging external fixation, despite increased risk for minor pin tract infection. Karantana A, Downing ND, Forward DP, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg. 2013;95(19):1737–1744. http://doi.org/10.2106/JBJS.L.00232. A single-center randomized clinical trial comparing volar locking plate (n = 66) with closed reduction and percutaneous wire fixation with or without supplemental bridging external fixation (n = 64) with 95% 1-year follow-up. This study demonstrated significantly improved functional outcomes (Patient Evaluation Measure, QuickDASH, range of motion) and radiographic reduction in the volar locking plate group at 6 weeks, but no significant differences seen in function between groups at 12 weeks or 1-year. Kreder HJ, Agel J, McKee MD, Schemitsch EH, Stephen D, Hanel DP. A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires. J Orthop Trauma. 2006;20(2):115–121. http://doi.org/10.1097/01.bot.0000199121.84100.fb. A multi-center randomized clinical trial comparing closed reduction and casting (n = 59) with closed reduction and bridging external fixation with or without supplemental wire fixation (n = 54) for distal radius fractures with metaphyseal displacement, but a congruous joint over 2-year follow-up. This study demonstrated a trend toward better functional, clinical, and radiographic outcomes with external fixation and optional K-wire fixation, but statistical significance was not reached for any outcome variable. Mellstrand Navarro C, Ahrengart L, Törnqvist H, Ponzer S. Volar locking plate or external fixation with optional addition of K-wires for dorsally displaced distal radius fractures: a randomized controlled study. J Orthop Trauma. 2016;30(4):217–224. http://doi.org/10.1097/BOT.0000000000000519. A single center randomized clinical trial comparing open reduction and internal fixation with volar locking plate (n = 70) with closed reduction, bridging external fixation, and supplemental wire fixation (n = 70) for low-energy distal radius fracture in patients aged 50 to 74 years. This study reports no statistically significant differences in patient reported outcomes at 3-month or 1-year follow-up between groups, despite improved volar tilt and radial length with volar locking plate fixation. Payandeh JB, McKee MD. External fixation of distal radius fractures. Orthop Clin North Am. 2007;30:187–192. This article discusses the indications and surgical technique for external fixation of distal radius fractures with and without supplemental percutaneous pin fixation, along with postoperative care. Weil WM, Trumble TE. Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization. Hand Clin. 2005;21:317–328. https://doi.org/10.1016/j.hcl.2005.01.006. This article provides a review of literature and a description of surgical technique for percutaneous intrafocal (Kapandji) pinning for distal radius fractures. Williksen JH, Husby T, Hellund JC, Kvernmo HD, Rosales C, Frihagen F. External fixation and adjuvant pins versus volar locking plate fixation in unstable distal radius fractures: a randomized, controlled study with a 5-year follow-up. J Hand Surg. 2015;40(7):1333–1340. http://doi.org/10.1016/j.jhsa.2015.03.008. A randomized clinical trial of 111 patients with unstable distal radius fractures randomized to open reduction and volar locking plate compared with closed reduction, external fixation, and percutaneous pin fixation with 82% 5-year follow-up. Treatment with volar locking plates had statistically significant better supination, better radial deviation, and less radial shortening at 5-year follow-up, but no significant difference was found for QuickDASH between groups. Of patients, 21% required plate removal in this series. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multi-center dose-response study. J Bone Joint Surg [Am]. 2007;89:1424–1431. https://doi.org/10.2106/JBJS.F.01147. A multi-center, double-blind randomized clinical trial of 416 patients with wrist fractures who were randomized to 200, 500, or 1500 mg of vitamin C daily for 50 days. There was a significant reduction in the incidence of complex regional pain syndrome with the daily use of vitamin C. A daily dose of 500 mg for 50 days is recommended for patients after wrist fractures.

PROCEDURE 24

Distal Radius Fracture: Open Reduction and Internal Fixation Ryan A. Paul and Ruby Grewal INDICATIONS • Displaced intraarticular fractures with >2 mm displacement (radiocarpal or distal radioulnar joints) • Dorsal angulation >0° (>10° in elderly or low demand patients) • Volar angulation >20° • Ulnar positive variance (or radial shortening) >3 mm • Radial inclination 20°). • Intraarticular extension, articular congruency (i.e., step and/or gap) • DRUJ alignment • Radiocarpal alignment • Ulnar styloid fractures (large base of styloid fractures may be associated with DRUJ instability) • Computed tomography (CT) scans are helpful for identification of the location and size of articular fragments, judgment of reduction, and assessment of DRUJ stability. • Anatomic tilt views: useful for assessing joint congruence and/or hardware prominence

Missed associated injuries • DRUJ dislocation/subluxation • Scaphoid fracture • SL ligament injury (associated with radial styloid, or “Chauffer” fractures) • Acute carpal tunnel syndrome • Unstable fractures should be followed closely (weekly for 3 weeks to identify early loss of reduction).

INDICATIONS CONTROVERSIES

• Alignment parameters should be used as a guideline only. Patient factors must also be taken into consideration when deciding whether a fracture requires operative fixation, as elderly or low-demand patients may tolerate a greater amount of deformity than younger or higher-demand patients. • Open fracture management: there is some evidence to suggest that time to debridement does not affect outcome in low-grade open distal radius fractures. Traditional urgent irrigation and debridement (i.e., within 6 hours) may not be necessary. Careful logistical planning with optimal implants/environment/ surgical team/techniques is probably more important.

275

276

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

A

B FIG. 24.1AB 

• PA dorsal tilt view: this allows a coronal assessment of the radial articular surface, accounting for volar tilt. •  Fig. 24.3 shows a diagram of the technique (Fig. 24.3A) and comparison of standard (Fig. 24.3B) and dorsal tilt views (Fig. 24.3C). • 20° to 30° oblique lateral view: this allows a sagittal assessment of the radial articular surface into view, accounting for radial inclination. •  Fig. 24.4 shows a diagram of the technique (Fig. 24.4A) and comparison of standard (Fig. 24.4B) and oblique lateral views (Fig. 24.4C).

Radial inclination = 23° Radial height = 12 mm Radial variance

A

Palmar tilt 11–12°

B FIG. 24.2 

x-ray

11°

A

B

C

FIG. 24.3A–C  A, from Boyer MI, Korcek KJ, Gelberman RH, Gilula LA, Ditsios K, Evanoff BA. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg Am. 2004;29(1):116–122.

278

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

x-ray

23°

A

B

C

FIG. 24.4A–C  From Boyer MI, Korcek KJ, Gelberman RH, Gilula LA, Ditsios K, Evanoff BA. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg Am. 2004;29(1):116–122.

TREATMENT OPTIONS

• Closed reduction with cast/splint immobilization • Closed reduction with percutaneous pin fixation • Open reduction and internal fixation (ORIF) • Volar locking plate • Buttress plating (volar or dorsal) • Fragment-specific plating • External fixation • Bridging plate fixation (“internal” external fixator) • Combinations of the above options

• Dorsal horizon view: Primarily useful in assessing screw length in order to avoid dorsal screw protrusion as standard anteroposterior (AP) and lateral images are inadequate because of the convex configuration of the distal radius and presence of the Lister tubercle. • Intraoperatively, the wrist is hyperflexed with the fluoroscopic beam aimed tangentially along the longitudinal axis of the radius. • Greater degrees of angulation bring the carpus into profile and may result in false interpretation. •  Fig. 24.5 shows a diagram of the technique (Fig. 24.5A), an example of overlapping carpus (Fig. 24.5B), and an example of improved positioning (Fig. 24.5C). 

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

279

A

B

C

FIG. 24.5AB  From Brunner A, Siebert C, Stieger C, Kastius A, et al. The dorsal tangential x-ray view to determine dorsal screw penetration during volar plating of distal radius fractures. Journal of Hand Surgery. 2015;40(1):27–33.

SURGICAL ANATOMY Osseous Anatomy • The distal radius is involved in three articulations (radioscaphoid, radiolunate, radioulnar), each with its own articular facet (scaphoid facet, lunate facet, sigmoid notch). • Conceptually, the relevant anatomy can be divided into three stabilizing columns: lateral, intermediate, and ulnar. • The lateral column is made up of the radial styloid and scaphoid facet. • The brachioradialis tendon inserts broadly over the lateral aspect of the radial styloid and is often a deforming force. • The intermediate column is made up of the lunate facet and sigmoid notch. • The sigmoid notch is nearly perpendicular to the lunate facet. • The intermediate column is an attachment site for several important stabilizing structures, including the volar and dorsal radioulnar ligaments, short radiolunate ligament, and dorsal radiocarpal ligaments. These structures contribute to the common pattern of volar and dorsal fracture fragments of the intermediate column. • The ulnar column consists of the distal ulna, ulnar styloid, and its associated ligamentous attachments. • The distal ulna articulates with the sigmoid notch and the triangular fibrocartilage complex (TFCC) and is the origin of the robust ulnocarpal ligaments. • The ulnar styloid base serves as an attachment site of the radioulnar ligaments, which are critical to DRUJ stability.

280

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

• Biomechanically, the volar cortex of the distal radius is subject mainly to compression forces during activities of daily living. The dorsal cortex experiences variable tensile and compressive forces. • This results in a relatively thicker and more robust volar cortex. • The thinner dorsal cortex is more susceptible to fragmentation and comminution. • The Lister tubercle is a dorsal central prominence around which the extensor pollicis longus (EPL) tendon runs obliquely. • This is a landmark for the dorsal approach. 

VOLAR SURGICAL ANATOMY • Volar surgical interval is in line with the flexor carpi radialis longus tendon between the radial neurovascular bundle and the median nerve (Fig. 24.6). • The flexor pollicus longus (FPL) lies just deep to the flexor carpi radialis (FCR) sheath and is the first structure encountered in the deep interval. • Retraction of the FPL ulnarly facilitates exposure of the distal radius (based on its origin from the anterior/ulnar aspect of the radial shaft and interosseous membrane in the forearm). • The pronator quadratus (PQ) overlies the distal radius. It has two heads. The superficial head attaches broadly over the radial aspect of the distal radius and is involved in initiation of pronation. The deep head is more oblique and attaches distally on the radius. The deep head acts as a stabilizer of the DRUJ and is less likely to be disrupted. • The palmar cutaneous branch of the median nerve crosses radially into the palm at the distal aspect of the exposure. • The branch originates between 4 to 5 cm from the wrist crease and generally runs ulnar to the FCR. It can occasionally take an anomalous course through the tendon sheath (Fig. 24.7). • The median nerve lies just deep to the palmaris longus, along its radial border. • The radial septum separates the volar and dorsal forearm compartments. • At the level of the distal radius, the septum extends contributing to the brachioradialis insertion, first extensor compartment, and radial carpal ligaments. • Release of the radial septum allows more extensive exposure radially and dorsally. • The brachioradialis attaches broadly to the radial styloid, just volar to the first extensor compartment tendons. • This is an important deforming force in styloid fracture fragments and release aids in visualization/reduction of the distal fragment, especially in cases with delayed presentation.

Flexor pollicis longus tendon Radial artery Pronator quadratus

A

Median nerve Flexor carpi radialis tendon

Palmar extrinsic ligaments Pronator quadratus tissue cuff

B

Pronator quadratus reflected

FIG. 24.6  From Conti Mica MA, Bindra R, Moran SL. Anatomic considerations when performing the modified Henry approach for exposure of distal radius fractures. J Orthop. 2016;14(1):104–107.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

FIG. 24.7 

• The distal watershed line marks the junction between the distal tendinous insertion of the PQ and the volar joint capsule/extrinsic ligaments. • This serves as a landmark for the extent of distal release as well as plate placement. • Fig. 24.7 shows the distance of the median nerve and radial artery to the FCR at three locations in the volar approach. The branching and course of the palmar cutaneous branch is also shown. 

DORSAL SURGICAL ANATOMY • The dorsal surgical interval is through the third extensor compartment (containing the EPL) (Fig. 24.8). • The second extensor compartment is radial to the interval and contains the extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL). • The fourth extensor compartment is ulnar to the interval and contains the extensor digitorum communis (EDC), extensor indicus proprius (EIP), and terminal posterior interosseous nerve (PIN). • The terminal branches of the radial sensory nerve may cross the incision with distal/ radial extension. • The dorsal articular margin serves as the origin of the dorsal radiocarpal ligaments. • The distal ulnar border of the radius is an attachment point for the dorsal radioulnar ligament, an important stabilizer of the DRUJ in pronation. 

Second dorsal extensor compartment (retracted)

Fourth dorsal extensor compartment (retracted)

Third dorsal extensor compartment (opened) Distal radius FIG. 24.8 

281

282

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

POSITIONING PEARLS

• Conventional C-arm positioned at 45° to the arm, opposite to the primary surgeon allows examination under direct fluoroscopy throughout the procedure as needed.

POSITIONING PITFALLS

• Draping below the elbow can limit the ability to rotate the forearm and to assess DRUJ stability.

POSITIONING EQUIPMENT

• Radiolucent arm table • Nonsterile tourniquet • Positioning bumps or towels • Retraction devices • Mini or conventional C-arm fluoroscopy

POSITIONING • The patient is generally positioned supine, with the affected arm extended on a radiolucent arm table. • A nonsterile tourniquet is applied to the upper arm. • The arm is prepared and draped above the elbow to allow unrestricted forearm rotation. • A positioning bump or rolled-up green towel can be used to support the wrist and assist with restoration of volar angulation of the distal radius. Occasionally, additional retraction devices (i.e., lead hand) may be used. • The primary surgeon generally sits in the axilla; however, some prefer the opposite side for dorsal procedures. • Mini or conventional C-arm use is necessary. It must be draped and positioned appropriately to allow the surgeon access to the extremity while in use. • Fig. 24.9 shows an example of intraoperative positioning. A weight system with sterile rope is seen projecting from the end of the table, which may aid in the reduction of some complex fractures. 

FIG. 24.9 

PORTALS/EXPOSURES Volar Exposure • FCR approach to the distal radius (modified Henry approach) • Incision in line with the FCR tendon starting distally at the wrist crease. Length of incision is dependent on fracture specifics and extent of proximal exposure required. • The FCR tendon is located; the volar flexor sheath is incised longitudinally. • The FCR tendon is retracted ulnarly, protecting the median nerve and palmar cutaneous branch (see Fig. 24.7). • The FCR subsheath is then sharply incised to expose the deep interval and underlying FPL. The palmar cutaneous branch must be protected as dissection proceeds through this layer. • Deeper handheld or self-retaining retractors can then be used to retract the radial neurovascular bundle radially. The FPL and remaining flexor tendons/median nerve are retracted ulnarly. • This exposes the pronator quadratus, which is sharply released from its radial border. Distally, its tendinous insertion is reflected ulnarly with the remaining muscle belly. Meticulous subperiosteal elevation facilitates later repair, although the utility of this is debated.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

•  Fig. 24.10A shows the FCR approach with the release and elevation of the pronator quadratus. Fig. 24.10B shows complete pronator quadratus repair after volar plate application. • Extended FCR approach • The FCR approach can be extended to provide access to the radial and dorsal surfaces of the distal radius. • After completion of the traditional approach, dissection is carried out radially to release the radial septum and brachioradialis tendon. • Progressive dorsal subperiosteal dissection can then be performed. • Care must be taken to avoid injury to the first dorsal extensor compartment, which lies in close proximity to the brachioradialis tendon. • Pronating the proximal radial shaft then provides full access to the articular segment. •  Fig. 24.11A shows the extended FCR approach with labeling of the radial septum [1], brachioradialis (in forceps) [2], first extensor compartment [3], and radiocarpal ligament [4]. Fig. 24.11B shows exposure of the dorsolateral radius after release of these structures. • Volar ulnar approach • The volar ulnar approach is useful for concomitant medial and ulnar nerve release when presenting with acute nerve compression. • It also provides an extensile approach to the carpus, the ulnar aspect of the distal radius, the DRUJ, and forearm compartment release as necessary.

A

B FIG. 24.10AB 

4

A

3

2

1

B FIG. 24.11AB 

283

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

284

• Limitations include more difficult radial exposure (especially of the radial styloid). • Begins proximally, just radial to the FCU tendon in the forearm • Extends obliquely across the wrist crease to overlie the carpal tunnel (in line with the fourth metacarpal) • Can be extended obliquely across the thenar crease distally as needed. • The ulnar neurovascular bundle is identified and released. • The carpal tunnel is then decompressed by releasing the flexor retinaculum along its ulnar border (marked by the hook of the hamate in the palm). • The contents of the carpal tunnel are then retracted radially, and the ulnar neurovascular bundle/FCU are retracted radially. • This exposes the underlying carpus, distal radius, pronator quadratus, and DRUJ. • The PQ can then be released to access the fracture site. •  Fig. 24.12 shows the incision of the volar ulnar approach. Fig. 24.13A shows retraction of the contents of the carpal tunnel after release and exposure of the PQ. Fig. 24.13B shows the completed volar ulnar approach with access to the distal radius. 

FIG. 24.12 

A

B

FIG. 24.13AB  From Conti Mica MA, Bindra R, Moran SL. Anatomic considerations when performing the modified Henry approach for expsure of distal radius fractures. J Orthop. 2016;14(1):104–107.

Dorsal Exposure • Dorsal approach • Longitudinal incision made just ulnar to the Lister tubercle. • Incision can be extended ∼2 cm distal to the wrist crease and proximally as necessary. • Interval is through the third extensor compartment. • The EPL tendon is identified distally in its compartment after it curves around the Lister tubercle. The extensor retinaculum and third extensor compartment will be released by following the tendon proximally.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation



• Once the EPL is released, it can be reflected radially. It is generally left transposed at the end of the case. • A subperiosteal exposure of the distal radius can then be employed; the second and fourth compartments are reflected and retracted as necessary. • Distally, a dorsal capsulotomy can be performed (transversely or longitudinally based on surgeon preference) at the radiocarpal joint and provides excellent visualization of the articular reduction. Any defect created by the fracture is incorporated into the approach. Care must be taken to protect the scapholunate ligament during the exposure. The capsulotomy must be repaired at the end of the case, as it includes the origin of the dorsal radiocarpal ligaments. • A 1-mm cuff of tissue is left to repair for transverse capsulotomies.

285

PORTALS/EXPOSURES PITFALLS

For Volar Exposure Section • Distal extension of the modified Henry approach or dissection ulnar to the FCR tendon puts the palmar cutaneous branch of the median nerve at risk.  For Dorsal Exposure Section • Excessive stripping of the dorsal ulnar fragment may release the radioulnar ligaments and destabilize the DRUJ. • During distal extension of the dorsal exposure, branches of the superficial radial nerve must be protected.

PORTALS/EXPOSURES PEARLS

For Volar Exposure Section • For fractures of the radial styloid, those with significant loss of radial inclination, or those that present late, release of the brachioradialis/radial septum will reduce the deforming force and facilitate reduction. • Always protect the first extensor compartment tendons. • Repair of the pronator quadratus provides soft-tissue coverage over the plate and may decrease the incidence of attritional tendon rupture and/or adhesions. However, the benefit of this is debatable. • A cuff of tissue should be left radially during exposure. A meticulous subperi­osteal dissection will facilitate successful repair. For Dorsal Exposure Section • A step cut in the extensor retinaculum during dorsal exposure facilitates easier closure at the end of the case. • The extensor retinaculum (or one limb of the step cut) may be used to protect the extensor tendons from underlying hardware as needed.

PROCEDURE Step 1: Initial Reduction • Initial reduction is obtained using multiplanar ligamentotaxis (as described by Agee). • Longitudinal traction is applied initially to restore length and assess improvement in alignment. • After this, the hand and carpus are translated volarly and ulnarly in order to restore volar angulation and radial inclination, respectively. • Additionally, placing the forearm in neutral rotation (rather than full pronation/supination used for exposure) will help improve rotational malreduction. • Figs. 24.15 and 24.16 show clinical and radiographic outcome while performing traction followed by volar/ulnar translation.

STEP 1 PEARLS

• Volar translation is preferred over wrist flexion for reduction, as this may improve restoration of radiocarpal alignment. • A small fragment serrated reduction clamp (lobster claw) applied to the proximal radial shaft can be used to apply traction and help with reduction. It also functions as a proximal soft-tissue retractor. • Initial reduction requires an assistant to perform the maneuvers or to temporarily stabilize the fracture once reduction is obtained. • If necessary, an external fixator may be used to apply/maintain traction while obtaining reduction and performing fixation. • Fig. 24.17 demonstrates an example of an initial reduction maneuver. Note the use of a reduction clamp to assist with manipulation. The forearm is placed in neutral rotation and over a bump (to accentuate radial inclination). This positioning provides excellent visualization for the surgeon to perform open reduction and allows an assistant access to advance a Kirschner wire (K-wire) for provisional stability as shown.

PORTALS/EXPOSURES CONTROVERSIES

• Volar versus dorsal approach • Depends on fracture pattern • Volar approach is less likely to cause hardware irritation. • Dorsal approach allows arthrotomy for direct assessment of articular reduction. • A small dorsal exposure can be a useful adjunct to a volar approach. • A combination approach with volar and dorsal fixation is rarely necessary but can be used for complex fractures.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

286

Fourth dorsal extensor compartment

Second dorsal extensor compartment

Distal radius

Third dorsal extensor compartment FIG. 24.14 

A

B FIG. 24.15 

A

B FIG. 24.16 

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

FIG. 24.17 

tep 2: Articular Reduction S • Radial styloid fragments • Release brachioradialis if necessary. • Direct manipulation, dental pick reduction tools, and K-wires used as joysticks or to perform a Kapandji maneuver may be helpful. • Small pointed reduction clamps may be used, anchored to the ulnar cortex of the radius or through one of the holes of an applied plate. This can be applied to close articular gaps and restore radial inclination. • Fragment-specific plating options are available. • Intermediate column fragments • Dorsal fragments may be reduced indirectly as described initially. • K-wires may be used as joysticks or through the fracture site (Kapandji technique) • Small dorsal incisions may be used to pass an elevator into the fracture site as a reduction aid (Fig. 24.18). • Formal dorsal approaches and direct reduction may be required. • Dorsal buttress plating and fragment-specific plating options are available. • Central die-punch fragments • May be reduced by working through the fracture site, opening the cortex as a “trap-door.” • Articular pieces should be elevated and supported with internal fixation (i.e., raft screws, wires) or bone graft/substitutes. 

STEP 2 PEARLS

• Gentle use of reduction clamps. Poor bone quality and comminution may result in fragmentation if used aggressively. • Confirm articular reduction radiographically if uncertain. • Small dorsal exposure and arthrotomy if there is any doubt about articular congruity • Arthroscopic-assisted reduction • May be an option for selected, simple fracture patterns. Complex articular reductions are difficult to visualize well. The utility of this technique remains controversial.

287

288

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

A

B FIG. 24.18 

Step 3: Provisional Fixation • K-wires are useful for obtaining provisional articular reduction to the diaphysis, bypassing metaphyseal comminution. • Generally, extraarticular fractures and radial styloid fragments can be held well with one or two bicortical wires placed through the styloid, directed in a proximal-ulnar direction. • Dorsal-ulnar fragments may require separate K-wires. • For complex fractures, articular reduction may need to be held with transversely oriented subchondral K-wires and/or reduction clamps. • Kapandji interfocal pinning is useful for dorsal fracture fragments and residual dorsal angulation. 

Step 4: Volar Plate Application STEP 4 PEARLS

• During the lift-off maneuver, the plate can be held off the bone by an assistant, an elevator, or a locking screw applied to the plate. • Initial plate fixation to the shaft should be done though the oblong hole so that plate position can be adjusted proximally or distally as required. • Locked unicortical screws of at least 75% length have equal construct stiffness compared to bicortical fixation. This allows the placement of locking screws 2 to 4 mm shorter than measured without compromising stability (unless attempting to capture small dorsal fracture fragments). This reduces the risk of dorsal penetration and extensor tendon irritation/rupture. • Understanding the specifics of the plating system used is critical (i.e., orientation, size options, direction of screws for specific fragments). • In many systems, the distal aspect of the plate is appropriately positioned at the watershed line.

• Once initial reduction is obtained and provisionally held, definitive fixation is performed. • Critical to the success of volar fixed-angle plating is appropriate plate placement. • The plate should be positioned such that the distal locking screws are immediately subchondral (within 3 mm of the articular surface). •  Fig. 24.19 demonstrates two different fractures treated with volar plating with adequate fixation and outcome. The screws in Fig. 24.19A are suboptimal compared to those in Fig. 24.19B. This did not affect the clinical outcome in this case, but it is an important consideration in older, osteoporotic patients or those with significant fracture comminution. • If the provisional reduction was unable to achieve complete anatomic restoration, additional volar tilt/radial inclination can be obtained with plate application. • The “lift-off” maneuver restores volar tilt. The proximal aspect of the plate is held off the volar cortex of the radius during distal locking screw fixation (Fig. 24.20). • Once distal fixation (with fixed-angle locking screws) is complete, the proximal plate is reduced to the shaft with a reduction clamp, resulting in increased volar tilt. • This maneuver can be modified to include ulnar angulation of the proximal plate initially; this will result in increased radial inclination when reduced to the shaft. 

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

289

STEP 4 PITFALLS

• Proximal plate malposition may allow partial articular collapse and loss of volar angulation. • Failing to buttress the volar-ulnar corner may result in loss of reduction with volar subluxation of the fragment and carpus. • Distal plate malposition may result in intraarticular penetration or tendon irritation (especially FPL). • These complications are more common when the plate is positioned distal to the watershed line. • Due to the concave nature of the sigmoid notch, perforation of the distal ulnar screw is possible and the DRUJ should always be examined for crepitus after fixation.

A

B FIG. 24.19AB 

A

B FIG. 24.20 

Step 5: Dorsal Plate Application • Dorsal plate fixation is useful for isolated dorsal partial articular fractures (i.e., dorsal Barton fractures) as well as for significantly comminuted total articular fractures requiring direct exposure/reduction. • After preliminary reduction/fixation, definitive fixation with a single dorsal plate, or individual radial and intermediate column plates can be performed. • Dorsal rim plates should be applied in a buttress fashion with or without distal locking fixation. • Radial styloid plates should be applied to the true lateral aspect of the styloid and are at 70° to 90° to dorsal plates for maximum biomechanical stability. • Oblique proximal holes may be used to further elevate the articular surface after articular fixation is placed by sliding the plate distally. • Fig. 24.21 shows an example of a combined radial styloid and dorsal intermediate column fracture treated with dorsal plating. 

STEP 5 PEARLS

• For comminuted fractures, plan to have bone graft options available (structural, cancellous autograft, bone graft substitute). • A flap of extensor retinaculum can be used to protect extensor tendons from dorsal hardware.

290

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

A

B

C

D FIG. 24.21 

STEP 6 PEARLS

• Fragment-specific fixation requires detailed knowledge of the plating system as well as indications and surgical technique.

Step 6: Fragment-Specific Fixation • Fragment-specific fixation is useful for impacted fractures of the articular surface that are not of sufficient size to accommodate screw fixation. • Most systems involve a combination of distal fixation with smooth wires/wireforms and proximal plate fixation. • Plates exist for the radial styloid, volar-ulnar corner, and for dorsal and volar rim fractures. • Wireforms allow adjustment/elevation of the articular surface after fixation. • Pin plates provide stable fixation of the distal pins to the metaphysis. • Radial styloid plates are best applied to the true lateral aspect of the styloid to act as a buttress.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

• Fig. 24.22 shows an example of fragment-specific fixation in a patient with a depressed fracture of the scaphoid facet and ipsilateral scaphoid wrist fracture. Both were treated via the dorsal approach. The subchondral pins are used to elevate and support the articular fragment. 

A

C

B

D FIG. 24.22 

Step 7: Spanning Plate Fixation • Distal radius spanning plate fixation is a salvage option reserved for nonreconstructable fractures in patients with poor bone quality who have failed less invasive measures (i.e., casting, external fixation, etc.). • A spanning plate with three screws at either end confers significantly more biomechanical stability than an external fixator.

291

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

292

STEP 7 PEARLS

• Some resistance may be encountered while passing the plate distally. This can often be overcome with gentle manipulation. Occasionally, a shuttling suture passer is used. Rarely, an accessory incision is necessary to facilitate passage under direct visualization.

STEP 7 PITFALLS

• Unstable volar fragments are not addressed with this technique and require accessory fixation or a formal volar approach for buttress plating.

• The plate is placed through the second extensor compartment with fixation from the dorsal radial shaft to the second metacarpal. • The distal incision is made directly over the second metacarpal, and the insertion of the ECRL is identified and followed back to the second extensor compartment. • The proximal incision is made just proximal to the outcropping muscles (APL, EPB) in the forearm in line with the second extensor compartment. The ECRB and ECRL are identified and the radial shaft is exposed beneath them. • The plate is then passed from the proximal to distal incision. • Fixation is then performed distally to the metacarpal. • The plate can then be slid distally in order to restore length through the fracture site prior to proximal fixation. • Articular reduction may be further adjusted using limited incisions, K-wires, periarticular plates, and/or bone graft. • Plates are generally removed after 3 months, once the patient displays sufficient radiographic and clinical signs of union. • Figs. 24.23 to 24.25 show a case of spanning plate application. 

STEP 7 INSTRUMENTATION/ IMPLANTATION

• A 22-hole 2.4-mm titanium mandibular reconstruction plate can be used. • Specifically designed 2.4-mm stainless steel plates are also available. These have the advantage of being lower profile and tapered to facilitate passage within the extensor compartment. • These plates should be protected with a cast or splint to prevent breakage, especially in physically larger/less compliant patients. • Both options accept locking screw fixation.

A

C

B FIG. 24.23 

A

B FIG. 24.24 

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

293

FIG. 24.25 

Step 8: Closure and Imaging • The wound should be irrigated thoroughly. • Minimal subcutaneous absorbable sutures followed by interrupted vertical mattress skin closure. • Final imaging should be performed. • Standard AP and lateral views checking reduction/alignment parameters. • Distal fixation should be checked for intra-articular penetration using the 20° to 30° oblique lateral view. • Dorsal cortex perforation should be checked using the dorsal horizon view. • DRUJ stability, wrist range of motion (ROM), and forearm rotation are then assessed clinically. • DRUJ stability should be checked in three positions: full pronation, neutral rotation, and full supination. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Postoperative Care • Patients should be placed in a well-padded below-elbow splint with the metacarpals and thumb free. • Wound check and suture removal occurs at approximately 2 weeks. • Shoulder, elbow, and hand ROM can begin immediately postoperatively. • Most practitioners immobilize for 4 to 6 weeks followed by wrist progressive ROM exercise and weight bearing as tolerated. However, in compliant patients with stable fixation, earlier motion may be instituted (7–10 days). 

Expected Outcomes • Although a number of studies demonstrate improved early function with ORIF, no study to date has conclusively shown a significant difference in outcome with various types of treatment for distal radius fractures at later follow-up. • Diaz-Garcia et al. (2011) performed a systematic review of patients aged > 60 years with distal radius fractures and found equivalent clinical outcomes between volar locked plating, nonbridging external fixation, bridging external fixation, percutaneous K-wire fixation, and cast immobilization. • Cast immobilization was associated with worse radiographic outcomes; however, functional outcomes were no different from surgically treated groups.

STEP 8 PEARLS

• For persistent DRUJ instability: • Ensure anatomic reduction of distal radius. This is the issue in most cases of persistent DRUJ instability. • Assess the ulnar styloid—consider fixation if ulnar styloid base fracture is present. • Maintain DRUJ in a reduced position with an above-elbow splint in a position of stability for 3 to 6 weeks. • If the ulna is dorsally unstable, immobilize in supination. • If the ulna is volarly unstable, immobilize in pronation. • K-wire stabilization may be unnecessary for gross instability that is not satisfactorily reduced with rotation alone. • Confirm adequate DRUJ reduction postoperatively with CT scan.

POSTOPERATIVE CONTROVERSIES

• Duration of immobilization for stable fixed angle constructs may be reduced to allow early, active ROM in selected patients.

294

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation

• Larouche et al. (2016) performed a prospective cohort study in 129 high functioning patients aged > 55 years undergoing either cast immobilization or ORIF of distal radius fractures. They found no difference in radiographic outcomes, Disabilities of the Arm, Shoulder, and Hand (DASH), SF-36, and Patient-Reported Wrist Evaluation (PRWE) scores at 1 year. • Inferior patient-reported outcomes were associated with ulnar positive variance > 2 mm and persistent articular steps/gaps > 2 mm. • Grewal et al. (2007) performed a prospective cohort study of 216 patients with extra-articular distal radius fractures. Patients were evaluated at regular intervals to 1 year postinjury with PRWE and DASH scores. Overall fractures were considered to be malunited if there was dorsal angulation > 10°, radial inclination < 15°, or ulnar positive variance ≥ 3 mm. They found that malalignment (based on these parameters) was associated with higher reports of pain and disability in patients < 65 years old (one in every two malunions at risk of poor outcome). In addition, there was an increased relative risk of poor outcome with radiographic malalignment in all age groups. However, this effect was mitigated with advancing age, as only one in every eight malunions was associated with a poor outcome in patients aged ≥ 65 years. • Overall, this study suggests that radiographic malalignment does increase the risk of poor outcome but that this effect is most significant in younger patients and less apparent in patients ≥ 65 years old. • In general, when satisfactory reduction is obtained and maintained, regardless of technique, patients obtain a functional wrist ROM and acceptable clinical outcomes.

EVIDENCE Boyer MI, Korcek KJ, Gelberman RH, Gilula LA, Ditsios K, Evanoff BA. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg Am. 2004;29(1):116–122. This study of 24 cadavers examined the efficacy of anatomic tilt x-rays in detecting screw penetration of the distal radius articular surface. Standard and anatomic tilt x-rays were reviewed by three blinded observers who found that anatomic tilt x-rays improved overall accuracy, sensitivity, and specificity of articular penetration. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011;36(5):824–835. This systematic review analyzed patients aged > 60 years with distal radius fractures and found worse radiographic alignment with cast treatment but functionally equivalent outcomes between volar locked plating, nonbridging external fixation, bridging external fixation, percutaneous K-wire fixation, and cast immobilization. Grewal R, MacDermid JC, Pope J, Chesworth BM. Baseline predictors of pain and disability one year following extra-articular distal radius fractures. Hand. 2007;2(3):104–111. This prospective cohort study analyzed 216 patients with extra-articular distal radius fractures and found that malalignment was associated with higher reports of pain and disability in patients < 65 years old (one in every two malunions at risk of poor outcome) and > 65 years old (one in every eight malunions was associated with a poor outcome). Overall, this study suggests that radiographic malalignment does increase the risk of poor outcome and that this effect is most significant in patients < 65 years old. Joseph SJ, Harvey JN. The dorsal horizon view: detecting screw protrusion at the distal radius. J Hand Surg Am. 2011;36(10):1691–1693. This retrospective case series of 15 distal radius fractures describes the use of the dorsal horizon view intraoperatively. In 4 of the 15 cases, screw selection was changed based on this view—all for penetration beyond the dorsal cortex. In three of the four cases, dorsal screw penetration was not apparent on standard imaging. Larouche J, Pike J, Slobogean GP, et al. Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years. J Orthop Trauma. 2016;30(8):445–449. This prospective cohort study examined outcomes in 129 high functioning patients aged > 55 years undergoing either cast immobilization or open reduction and internal fixation for distal radius fractures. They found no difference in radiographic outcomes or wrist scores at 1 year. Inferior patient-reported outcomes were associated with ulnar positive variance (> 2 mm) and persistent articular steps or gaps (> 2 mm). Orbay JL, Badia A, Indriago IR, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. 2001;5(4):204–211. A detailed description of the extended flexor carpi radialis approach and its surgical technique. These techniques may be useful in select cases for radial-sided release and/or access to the dorsal aspect of the radius from a volar approach. Pourgiezis N, Bain GI, Roth JH, Woolfrey MR. Volar ulnar approach to the distal radius and carpus. Can J Plast Surg. 1999;7(6):273–278.

PROCEDURE 24  Distal Radius Fracture: Open Reduction and Internal Fixation In a retrospective review of 44 patients, the authors discuss the indications for the volar ulnar approach and provide a detailed description of the surgical technique. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radius fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg [Am]. 2005;87:945–954. A detailed description of the surgical technique of distraction bridge plating in fractures with extensive metadiaphyseal comminution in 22 patients. Plates were removed at an average of 124 days, with mean wrist flexion and extension of 57° and 65°, respectively, and 14 excellent, 6 good, and 2 fair results. Schumer ED, Leslie BM. Fragment-specific fixation of distal radius fractures using the Trimed device. Tech Hand Up Extrem Surg. 2005;9(2):74–83. A review of the indications and technique of one system of fragment-specific fixation. These concepts may be used in isolation or as an adjunct to conventional fixation in select cases regardless of the specific system used. Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am. 2012;37(3):446– 453. This biomechanical study assessed the effect of screw length on construct stiffness of volar locked plating in an established osteoporotic Sawbones model and found that locked unicortical distal screws of at least 75% of the bicortical length produced similar results to bicortical fixation in terms of construct stiffness.

295

PROCEDURE 25

Scaphoid Fracture Fixation Bertrand Perey and Karen N. Slater

INDICATIONS PITFALLS

• Fracture morphology is poorly demonstrated on plain radiographs. • Nondisplaced scaphoid waist and distal pole fractures can be managed successfully with 6 to 8 weeks of cast immobilization or until union is demonstrated. • Immobilization of the thumb is not required (Buijze, 2012). • Comminution without displacement and sclerosis or cystic change at the fracture line do not affect union rates; however, they result in longer times to union (Grewal et al., 2013). • Nonoperatively treated displaced fractures and proximal pole fractures demonstrate higher rates of nonunion (Grewal et al., 2013).

INDICATIONS • Displaced scaphoid fractures (> 1 mm gap, fracture comminution, increased intrascaphoid angle > 45°; Fig. 25.1) • Proximal pole fractures • Patient considerations • Operative treatment of nondisplaced waist fractures allows faster return to work and activities, although it does not improve union rate, time to union, or functional outcome and confers an increased risk of complications (Shen, 2015). 

INDICATIONS CONTROVERSIES

• Traditionally, a “missed” fracture with a delay to treatment of more than 4 weeks was an indication for operative management; however, Grewal et al. showed that subacute nondisplaced scaphoid fractures in nondiabetics may be treated successfully with cast immobilization (Langhoff and Andersen, 1988; Wong and von Schroeder, 2011; Grewal et al., 2015). • Operatively managed nondisplaced scaphoid waist fractures have a higher risk of complication and may have increased rates of scaphotrapezial arthritis (retrograde fixation) or radioscaphoid arthritis (anterograde fixation) at long-term follow-up (Vinnars et al., 2008, Clementson, 2015). • Nondisplaced proximal pole fractures can be treated successfully with prolonged (14 weeks or more) cast immobilization (Grewal et al., 2016). • Pulsed electromagnetic therapy does not affect time to union, rate of union, or functional outcome (Hannemann et al., 2014, 2015).

296

FIG. 25.1  Radiograph demonstrating displaced scaphoid fracture with comminution.

EXAMINATION AND IMAGING • Physical examination should include assessment for tenderness of the anatomic snuffbox and scaphoid tubercle, anatomic snuffbox pain with wrist ulnar deviation, and pain with axial loading of the thumb metacarpal (scaphoid compression test). Anatomic snuffbox tenderness is the most sensitive test. Specificity is increased when these tests are used together (Mallee et al., 2014; Tait et al., 2016). • Radiographs at initial presentation should include a posteroanterior view in ulnar deviation (scaphoid view). Lunocapitate angle and humpback deformity (intrascaphoid angle; Fig. 25.3) can be evaluated on lateral radiographs (Figs. 25.2, 25.4, and 25.5). • Additional investigations are warranted for suspected scaphoid fractures with negative initial radiographs. • Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate similar overall diagnostic accuracy for acute scaphoid fractures; however, MRI is slightly more sensitive than CT and is better at demonstrating other pathology (Mallee et al., 2015) (Fig. 25.6) • Bone scintigraphy is more sensitive but less specific than CT and MRI, is more invasive, and requires a delay of 48 to 72 hours postinjury (Mallee et al., 2015). 

PROCEDURE 25  Scaphoid Fracture Fixation

A

297

B

FIG. 25.2A,B  “Scaphoid view” radiograph (left) demonstrating nondisplaced scaphoid waist fracture, fracture not visible on PA radiograph (right).

EXAMINATION AND IMAGING CONTROVERSIES 30°

FIG. 25.3  Normal intrascaphoid angle.

A

B

FIG. 25.4A,B  Radiographs demonstrating increased intrascaphoid angle causing increased scapholunate angle (“humpback deformity”; red) and capitolunate angle (black) of injured wrist (DISI deformity). Normal intrascaphoid angle < 35°; normal capitolunate angle < 5°; normal scapholunate angle < 45°.

• In centers without acute access to other imaging modalities, patients should be immobilized in a short-arm cast and referred for definitive imaging. • Repeat radiographs do not reliably demonstrate scaphoid fractures and should not be used to rule out fracture (Duckworth et al., 2011). • Immediate advanced imaging may be more cost-effective than delayed radiographs or delayed advanced imaging (Bergh et al., 2014; Yin et al., 2015). • The value of immobilization within 4 weeks of injury prior to confirmation of fracture is unknown.

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FIG. 25.5 CT scan demonstrating increased intrascaphoid angle (“humpback deformity”).

FIG. 25.6  MRI demonstrating scaphoid waist fracture with compromised vascularity of proximal pole.

CLASSIFICATION • While multiple scaphoid fracture classification systems exist, the Herbert classification is most commonly used (Ten Berg et al., 2016) (Fig. 25.7). 

A1: Tubercle fracture

A2: Nondisplaced waist “crack”

B1: Oblique fracture

B2: Displaced waist fracture

B3: Proximal pole fracture

B4: Fracture dissociation of carpus

FIG. 25.7  Herbert classification of scaphoid fractures.

PROCEDURE 25  Scaphoid Fracture Fixation

SURGICAL ANATOMY

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TREATMENT OPTIONS

• Volar approach (Fig. 25.8) • Scaphoid tubercle • Flexor carpi radialis (FCR) tendon • Scaphotrapeziotrapezoid (STT) joint • Radial artery • Superficial palmar branch of radial artery • Dorsal approach (Fig. 25.9) • Anatomic snuffbox • Extensor pollicus longus (EPL), extensor carpi radialis longus and brevis (ECRL and ECRB), and extensor digitorum communis (EDC) tendons • Dorsal sensory branches of radial nerve • Radial artery 

• Cast immobilization • Percutaneous versus open approach • Volar versus dorsal approach • Combined volar and dorsal approach

FIG. 25.8  Volar surface anatomy: scaphoid tubercle (purple), FCR (black), radial artery and palmar branch (red). FIG. 25.9  Surface anatomy for dorsal approach, including the Lister tubercle, EPL, ECRB, ECRL, and EDC tendons, and transverse skin incision.

POSITIONING • Patient is positioned supine with the operative extremity on a radiolucent arm board. • An upper arm or forearm tourniquet is used. • Fluoroscopy is used for all techniques. 

PORTALS/EXPOSURES • Both volar and dorsal approaches are commonly used and demonstrate good results. •  Percutaneous techniques are preferred for nondisplaced or minimally displaced fractures. • Volar and dorsal percutaneous approaches demonstrate no significant difference in rate of union, postoperative complications, or overall functional outcome (Kang et al., 2016). • The volar approach is preferred for distal fractures or fractures that require access to the volar waist for correction of a humpback deformity, extensive volar comminution, or bone grafting. • The dorsal approach is preferred for proximal fractures, as it allows for more accurate placement of fixation centrally in the proximal pole, reducing the risk of nonunion (Trumble et al., 2000) • A combined volar and dorsal approach for isolated scaphoid fractures is rarely indicated but may be required for scaphoid nonunions, transcaphoid perilunate dislocations, or other complex wrist injuries. 

PORTALS/EXPOSURES PEARLS

• Precise screw placement is essential for minimizing morbidity and maximizing biomechanical advantage of screw fixation. • Central placement in the scaphoid axis confers greater stiffness and load to failure (McCallister et al., 2003) (Fig. 25.10). • Longer screws offer superior biomechanical stability (Dodds et al., 2006) • In oblique fractures, placement perpendicular to the fracture line produces similar compression to a centrally placed screw despite its shorter length (Swanstrom et al., 2016) (Fig. 25.11).

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PROCEDURE 25  Scaphoid Fracture Fixation

FIG. 25.10  Radiographs demonstrating central screw placement.

FIG. 25.11  Intraoperative radiograph demonstrating screw fixation perpendicular to proximal pole fracture.

EQUIPMENT EQUIPMENT CONTROVERSIES

• The large trailing end of the HCS may cause fragmentation of small proximal pole fractures. • Kirschner wire (K-wire) fixation or smallerdiameter standard screws may be indicated for very proximal fractures.

• Headless compression screws (HCSs) should be used for the majority of fractures. • Second-generation HCSs demonstrate higher compression forces compared to first-generation HCSs, though not all second-generation screws achieve equal compression (Assari et al., 2012; Fowler and Ilyas, 2010) • Use of a small-diameter HCS may allow for exchange to a larger-diameter screw if revision is required.

PROCEDURE 25  Scaphoid Fracture Fixation

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• Placement of the screw slightly dorsal to the central axis may prevent creation of a flexion deformity in cases of volar comminution. • K-wires can be used to augment screw fixation. 

PROCEDURE: OPEN VOLAR APPROACH Step 1: Incision • A 3-cm incision is centered over the FCR tendon. • At the level of the distal wrist crease, the incision travels obliquely at a 45° angle toward the base of the thenar mass (Fig. 25.12). 

FIG. 25.12  Incision for open volar approach.

Step 2: Superficial Dissection • The FCR tendon sheath is incised, the FCR tendon is retracted ulnarly, and floor of the FCR is then incised. • The incision is deepened through the volar capsule in line with the previous incision. 

Step 3: Deep Dissection • The volar capsulotomy can be extended proximally and distally to obtain additional exposure as required. • Adequate exposure of the waist does not require routine division of the volar radiocarpal ligaments. 

Step 4: Reduction • Reduction can be achieved through direct manipulation of the fracture fragments, typically with the use of K-wires as joysticks, and confirmed fluoroscopically.  STEP 4 PEARLS

• Provisional fixation can be obtained by temporarily pinning the proximal and distal poles to their adjacent carpal bones or distal radius. STEP 4 PITFALLS

• Provisional fixation across the fracture may interfere with placement of definitive fixation.

STEP 4 CONTROVERSIES

• If there is a significant volar defect once anatomic reduction had been achieved, supplemental bone graft may be beneficial (Fig. 25.13).

STEP 1 PEARLS

• Avoid an incision that crosses the wrist crease longitudinally to reduce the risk of hypertrophic scarring.

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PROCEDURE 25  Scaphoid Fracture Fixation

FIG. 25.13  Placement of bone graft with volar approach.

STEP 5 PEARLS

• True central placement in the distal pole is best obtained with a transtrapezial approach. • If a transtrapezial approach is not being used, ulnar deviation and extension of the wrist may allow improved access to the central distal pole following partial trapezial excision. • This can be augmented by dorsally translocating the trapezium using an elevator in the scaphotrapezial joint. • A pronated oblique fluoroscopy view with ulnar deviation and 45° of wrist flexion best visualizes the central scaphoid axis and required screw length (Verstreken and Meermans, 2015). • Subtracting 4 mm from the estimated screw length will allow for adequate fracture compression and subchondral screw placement without intraarticular penetration.

Step 5: Fixation • Access to the distal pole and central screw placement requires either partial excision of the volar ridge of the trapezium or a transtrapezial approach (Meermans and Verstreken, 2011; Verstreken and Meermans, 2015) (Fig. 25.14). • Guidewire placement within the central axis is confirmed fluoroscopically; appropriate screw length can then be estimated. • Follow individual manufacturer’s guidelines for obtaining screw length and for screw insertion. 

STEP 5 PITFALLS

• Central screw placement cannot be obtained with insertion through the scaphoid tubercle. • Overestimating screw length may result in intraarticular screw penetration or prominence.

FIG. 25.14  Partial excision of trapezium to facilitate central screw placement.

Step 6: Closure STEP 6 PEARLS

• If divided previously, the radiocarpal ligaments must be repaired. • The tourniquet is deflated prior to closure to ensure adequate hemostasis.

• A layered closure is preferred, with repair and reapproximation of the following: • Radiocarpal ligaments • Volar capsule/floor of the FCR sheath • Skin • Superficial FCR sheath repair is not required. 

PROCEDURE 25  Scaphoid Fracture Fixation

PROCEDURE: OPEN DORSAL APPROACH

STEP 1 PEARLS

Step 1: Incision

• A transverse skin incision provides superior cosmesis over a longitudinal incision.

• A 2- to 3-cm transverse or longitudinal incision is centered on the Lister tubercle (Fig. 25.15) 

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STEP 1 PITFALLS

• The dorsal sensory branches of the radial nerve are at risk with all dorsal approaches.

FIG. 25.15  Transverse skin incision just distal to and centered on the Lister tubercle.

Step 2: Superficial Dissection • Identify and incise the retinaculum over the EPL, performing a limited release extending no more than 1 cm proximal to the Lister tubercle, and retract the EPL radially (Fig. 25.16) • Identify and incise the retinaculum over the EDC tendons, performing a similar limited release, and retract the EDC ulnarly. 

STEP 2 PEARLS

• A limited release of the retinaculum over the ERCL and ECRB may provide improved radial visualization.

FIG. 25.16  EPL retinaculum released, allowing radial retraction.

Step 3: Deep Dissection

STEP 3 PITFALLS

• A transverse capsulotomy parallel to the distal radius allows optimal access to the proximal pole. • The scapholunate (SL) ligament is visualized as a reference point (Fig. 25.17). • Proximal pole fractures and more proximal waist fractures are easily visualized at this point in dissection (Fig. 25.18). 

• The dorsal capsule should not be dissected from the dorsal ridge of the scaphoid to avoid devascularization of the proximal pole. • Fractures distal to the ridge are poorly visualized through a dorsal approach.

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PROCEDURE 25  Scaphoid Fracture Fixation

FIG. 25.17  SL ligament visible just proximal to tenotomy tips.

STEP 4 PITFALLS

• Access and direct assessment of the volar scaphoid cannot be obtained through a dorsal approach without significant vascular compromise to the scaphoid.

FIG. 25.18  Scaphoid waist fracture visible at tips of tenotomies.

Step 4: Reduction • As in the volar approach, reduction can be achieved through direct manipulation of the fracture fragments with the use of K-wires as joysticks and confirmed fluoroscopically (Fig. 25.19) 

FIG. 25.19  Fracture reduction with K-wire joysticks (proximal scaphoid at top, radial wrist at left).

Step 4 Controversies • Vascularized bone grafts may improve union rates for very proximal fractures, though their main indication is for established nonunions with avascular proximal poles.  STEP 5 PEARLS

• Subtracting 4 mm from the estimated screw length will allow for adequate fracture compression and subchondral screw placement. • Before screw insertion, the guidewire should again be driven in an antegrade direction through the trapezium and volar soft tissues to allow access to both ends of the guidewire in case of breakage. STEP 5 PITFALLS

• Very proximal fractures may be fragmented with insertion of an HCS, which have large trailing heads.

Step 5: Fixation • Central access to the proximal pole requires at least 60° of wrist flexion. • The insertion point for the guidewire is 3 mm radial to the insertion of scapholunate ligament. • The guidewire is advanced along the central axis of the scaphoid. • Provisional assessment of guidewire placement has to be performed with the wrist in flexion, as wrist extension will bend or break the wire. • The wire is advanced through the trapezium and volar soft tissues until it no longer protrudes from the proximal scaphoid, allowing fluoroscopic assessment of the guidewire with the wrist extended. • Once proper positioning of the guidewire is confirmed, the wire is driven in a retrograde direction under fluoroscopic guidance until the tip lies within the scaphoid. • Follow individual manufacturer’s guidelines for measurement of screw length and screw insertion (Fig. 25.20) 

PROCEDURE 25  Scaphoid Fracture Fixation

FIG. 25.20  Screw fixation achieved with dorsal approach.

Step 6: Closure • The dorsal capsulotomy may be repaired or left open. • Skin is closed with a layered repair. 

PROCEDURE: PERCUTANEOUS VOLAR APPROACH Step 1: Approach • A small bolster is placed under the wrist, allowing approximately 30° of wrist extension. • The wrist is placed in maximal ulnar deviation so as to bring the longitudinal axis of the thumb metacarpal in line with the radius. • Fluoroscopy is positioned in the AP direction. 

Step 2: Insertion of Guidewire • The tip of the guidewire is inserted percutaneously at a 30° to 45° angle to the forearm to make contact with the mid-portion of the trapezium (Fig. 25.21).

FIG. 25.21  Percutaneous insertion of guidewire.

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STEP 2 PEARLS

• If the axis of the guidewire is too volar in the scaphoid, start your guidewire more distally in the trapezium.

• The guidewire is advanced under live fluoroscopy into the central axis of the scaphoid (Fig. 25.22). • Once the guidewire has traversed the scaphoid waist, confirm central positioning on lateral fluoroscopy. 

FIG. 25.22  Guidewire being advanced into the scaphoid. STEP 3 PEARLS

• Subtracting 4 mm from the estimated screw length will allow for adequate fracture compression and subchondral screw placement. • Advancing the guidewire into the distal radius prior to screw insertion may help prevent inadvertent removal of the guidewire.

Step 3: Fixation • Once proper positioning of the guidewire is confirmed, the desired length of the screw must be measured (Fig. 25.23). • To facilitate accurate measurement, a portion of the trapezium will need to be overreamed to gain direct access to the distal scaphoid. • Insert the screw according to the manufacturer’s guidelines (Fig. 25.24). 

FIG. 25.23  Wire length being measured with tip of depth gauge on scaphoid cortex.

FIG. 25.24  Intraoperative radiograph demonstrating transtrapezial screw insertion.

PROCEDURE 25  Scaphoid Fracture Fixation

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PROCEDURE: PERCUTANEOUS DORSAL APPROACH Step 1: Approach • The wrist usually needs to be manipulated into flexion, ulnar deviation, and pronation while holding the elbow flexed in order to obtain a signet ring appearance on fluoroscopy.  STEP 2 PITFALLS

• If the wrist is extended before the proximal end of the wire is withdrawn entirely into the scaphoid, the wire may bend and subsequently break upon reaming or screw insertion.

Step 2: Insertion of the Guidewire • The guidewire is inserted percutaneous overlying the center of the signet ring (Fig. 25.25). • Alignment along the central axis is confirmed on lateral fluoroscopy. • The guidewire is advanced down the central axis of the scaphoid and its position is confirmed. • The guidewire must be driven anterograde through the volar structures and withdrawn until the proximal tip is positioned within the proximal pole of the scaphoid (Figs. 25.26 to 25.28). • The wrist can then be extended to allow proper fluoroscopic assessment on the AP view. 

FIG. 25.25  Percutaneous insertion of guidewire using dorsal approach, with corresponding signet ring sign on radiographs.

FIG. 25.27 Guidewire advanced until proximal aspect contained within scaphoid.

FIG. 25.28  AP view demonstrating central placement of guidewire. FIG. 25.26  Guidewire is driven volarly through soft tissues.

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PROCEDURE 25  Scaphoid Fracture Fixation

STEP 3 PEARLS

• Subtracting 4 mm from the estimated screw length will allow for adequate fracture compression and subchondral screw placement. • Advancing the guidewire anterograde through the volar structures and securing it volarly prior to screw insertion may help prevent inadvertent removal of the guidewire.

Step 3: Fixation • With the wrist flexed, the guidewire is advanced and withdrawn in a retrograde fashion until the distal tip is positioned within the distal scaphoid. • The length of the guidewire is then measured directly and an appropriate screw is selected. • Insert the screw according to the manufacturer’s guidelines (Fig. 25.29). 

FIG. 25.29  Insertion of screw with guidewire secured volarly to avoid inadvertent removal.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE CONTROVERSIES

• Time and type of postoperative immobilization remains very controversial. • Higher-risk patients (patients with diabetes, smokers, comminuted fractures, proximal fractures) may benefit from immobilization until union is achieved. • In general, the surgical goal is to obtain sufficient stability to allow the patient early motion, enhancing return to work/sport/ activities. This is especially true if early return to activity was the primary surgical indication.

• Immobilization protocols following screw fixation have not been well studied. • As with conservative treatment, immobilization of the thumb is not required (Buijze et al., 2014). • Length of immobilization is dictated by injury characteristics (fracture acuity, degree of comminution, concomitant injury), operative factors (stability of fixation), patient factors (comorbid illness, compliance), and surgeon preference. • Union is assessed clinically and radiographically. • Plain radiographs may be inadequate to demonstrate fracture union. • If there is concern regarding union, a postoperative CT scan can be performed (Hannemann et al., 2013). • The union rates described for the operative treatment of scaphoid fractures are extremely high, with most studies reporting a 90% to 100% rate of union (Tait et al., 2016). • Indications and techniques for revision surgery for management of nonunion are beyond the scope of this chapter.

EVIDENCE Assari S, Darvish K, Ilyas A. Biomechanical analysis of second-generation headless compression screws. Injury. 2012;43(7):1159–1165. Second-generation headless compression screws provide better compression than first-generation screws. Of the ones tested, mini Accutrak 2 provided the best compression. Bergh T, Steen K, Lindau T, et al. Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures. Acta Orthopaedica. 2014;86(3):303–309. For the Norwegian population, immediate MRI after a suspected scaphoid fracture was equivalent to casting and a 2-week follow up radiograph as far as direct and indirect costs. Patients with immediate MRI spent less unnecessary days in a cast.

PROCEDURE 25  Scaphoid Fracture Fixation Buijze GA, Goslings JC, Rhemrev S, Weening A, Van Dijkman B, Ring DC. Cast immobilization with and without immobilization of the thumb for nondisplaced scaphoid waist fractures: amulti-center randomized controlled trial: level 2 evidence. EBM Reviews - Cochrane Central Register of Controlled Trials. J Hand Surg. 2012; 37(8):24. Buijze G, Goslings J, Rhemrev S, et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial. J Hand Surg [Am]. 2014;39(4):621–627. Level 1 evidence demonstrating that thumb immobilization does not improve union rates for cast treatment of nondisplaced scaphoid waist fractures. Clementson M, Jørgsholm P, Besjakov J, Thomsen N, Björkman A. Conservative treatment versus arthroscopic-assisted screw fixation of scaphoid waist fractures—a randomized trial with minimum 4-year follow-up. J Hand Surg [Am]. 2015;40(7):1341–1348. At a median follow-up of 6 years, patients treated with immediate screw fixation had similar outcomes to patients treated with cast immobilization except for radiographic signs of radioscaphoid arthritis, which were more common in the surgical group. Dodds S, Panjabi M, Slade J. screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation. J Hand Surg [Am]. 2006;31(3):405–413. Using a cadaveric model, it is shown that the optimally placed screw for scaphoid fixation is a long screw positioned down the central axis of the scaphoid deep into subchondral bone. Duckworth A, Ring D, McQueen M. Assessment of the suspected fracture of the scaphoid. Bone Joint J. 2011;93-B(6):713–719. A review of clinical and diagnostic tests for suspected scaphoid fractures. All radiological tests are better at excluding rather than detecting a true scaphoid fracture. Clinical prediction rules may improve our ability to predict who is likely to have a true fracture prior to radiological testing. Fowler J, Ilyas A. Headless compression screw fixation of scaphoid fractures. Hand Clin. 2010;26(3):351–361. A review article about the evolution and contemporary treatment of scaphoid fractures using headless compression screws. Grewal R, Lutz K, MacDermid J, Suh N. Proximal pole scaphoid fractures: a computed tomographic assessment of outcomes. J Hand Surg [Am]. 2016;41(1):54–58. Of patients with nondisplaced proximal pole scaphoid fractures, 90% healed after an average of 14 weeks of casting. Grewal R, Suh N, MacDermid J. The missed scaphoid fracture–outcomes of delayed cast treatment. J Wrist Surg. 2015;04(04):278–283. Patients presenting between 6 weeks and 6 months after a scaphoid fracture without prior treatment can be successfully managed with cast immobilization alone. A 96% union rate can be achieved with casting times from 11 to 14 weeks. Grewal R, Suh N, MacDermid J. Use of computed tomography to predict union and time to union in acute scaphoid fractures treated nonoperatively. J Hand Surg [Am]. 2013;38(5):872–877. Using CT scan to confirm the state of bony union, several factors were identified that contributed to the risk of delayed or nonunion. These include fracture translation, comminution, humpback deformity, sclerosis, and proximal pole location. Hannemann PFW, Essers BAB, Schots JPM, Dullaert K, Poeze M, Brink PRG. EBM Reviews. Functional outcome and cost-effectiveness of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a cost-utility analysis Orthopedics and biomechanics. Cochrane Central Register of Controlled Trials. BMC Musculoskelet Disord. 2015:16(1). Pulsed electromagnetic field treatment does not offer any benefit over placebo control in the management of acute scaphoid fractures in this Level 1 prospective study. Hannemann P, Brouwers L, van der Zee D, et al. Multiplanar reconstruction computed tomography for diagnosis of scaphoid waist fracture union: a prospective cohort analysis of accuracy and precision. Skeletal Radiol. 2013;42(10):1377–1382. Interobserver agreement using multiplanar reconstruction CT scans for determination of scaphoid union at 12 weeks is significantly better than published results using standard radiographs. Hannemann P, van Wezenbeek M, Kolkman K, et al. CT scan-evaluated outcome of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a randomised, multicentre, double-blind, placebo-controlled trial. Bone Joint J. 2014;96-B(8):1070–1076. Bone healing for nondisplaced scaphoid fractures did not improve with pulsed electromagnetic field using multiplanar reconstructed CT scans for assessment of union. Kang K, Kim H, Park J, Shin Y. Comparison of dorsal and volar percutaneous approaches in acute scaphoid fractures: a meta-analysis. PLOS ONE. 2016;11(9):e0162779. Percutaneous dorsal and volar approaches yield similar results. Langhoff O, Andersen J. Consequences of late immobilization of scaphoid fracture. J Hand Surg [Br]. 1988;13(1):77–79. Delayed cast treatment for more than 4 weeks in proximal pole scaphoid fractures leads to increased complications compared to patients treated within 4 weeks. Mallee W, Henny E, van Dijk C, Kamminga S, van Enst W, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg [Am]. 2014;39(9). 1683–91.e2. A systematic review of clinical examination tests for the diagnosis of scaphoid fractures. Combining anatomic snuffbox tenderness, longitudinal thumb compression, scaphoid tubercle

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PROCEDURE 25  Scaphoid Fracture Fixation tenderness, and pain with ulnar deviation can increase the specificity of these tests while maintaining a high sensitivity. Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, Doornberg JN. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Embase Cochrane Database Syst Rev. 2015 (6), 2015. Article Number: CD010023 McCallister W, Knight J, Kaliappan R, Trumble T. Central placement of the screw in simulated fractures of the scaphoid waist. J Bone Joint Surg [Am]. 2003;85(1):72–77. In this cadaveric study, central placement of the screw in the proximal fragment of the scaphoid offers a biomechanical advantage in the internal fixation of an osteotomy of the scaphoid waist. Meermans G, Verstreken F. A comparison of 2 methods for scaphoid central screw placement from a volar approach. J Hand Surg [Am]. 2011;36(10):1669–1674. Using CT scan data from nonfractured scaphoids, this study showed that central placement throughout the scaphoid with a standard volar approach is not feasible without partially resecting, manipulating, or drilling through the trapezium. Shen L, Tang J, Luo C, Xie X, An Z, Zhang C. Comparison of operative and non-operative treatment of acute undisplaced or minimally-displaced scaphoid fractures: a meta-analysis of randomized controlled trials. PLOS ONE. 2015;10(5):e0125247. A meta-analysis of randomized controlled studies comparing operative to nonoperative treatment of nondisplaced scaphoid fracture demonstrates faster recovery with operative treatment. Swanstrom M, Morse K, Lipman J, Hearns K, Carlson M. Effect of screw perpendicularity on compression in scaphoid waist fractures. J Wrist Surg. 2016. A cadaveric model demonstrating that shorter headless screws inserted approximately perpendicular to the fracture (> 80°) provide better compression than longer screws placed in the central axis of the scaphoid but oblique (< 80°) to the fracture axis. Tait M, Bracey J, Gaston R. Acute scaphoid fractures. JBJS Reviews. 2016;4(9):1. A thorough 2016 evidence-based review of the contemporary management of scaphoid fractures, including investigations, cast treatment, and surgical management. Ten Berg P, Drijkoningen T, Strackee S, Buijze G. Classifications of acute scaphoid fractures: a systematic literature review. J Wrist Surg. 2016;05(02):152–159. A systematic literature review of acute scaphoid fracture classification reveals 13 different systems based on fracture location, displacement, and stability. Trumble T, Gilbert M, Murray L, Smith J, Rafijah G, McCallister W. Displaced scaphoid fractures treated with open reduction and internal fixation with a cannulated screw. J Bone Joint Surg [Am]. 2000;82(5):633–641. Cannulated screw fixation of displaced scaphoid fractures is a safe and effective method of treatment. Verstreken F, Meermans G. Transtrapezial approach for fixation of acute scaphoid fractures: rationale, surgical techniques, and results. J Bone Joint Surg [Am]. 2015;97(10):850–858. A detailed description of retrograde transtrapezial percutaneous fixation with annotated radiographs. Vinnars B, Pietreanu M, Bodestedt Å, Ekenstam F, Gerdin B. Nonoperative compared with operative treatment of acute scaphoid fractures. J Bone Joint Surg [Am]. 2008;90(6):1176–1185. At a median of 10 years after scaphoid fracture treatment with either cast immobilization or retrograde open noncannulated screw fixation, patients were found to have similar outcomes. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. Wong K, von Schroeder H. Delays and poor management of scaphoid fractures: factors contributing to nonunion. J Hand Surg [Am]. 2011;36(9):1471–1474. A retrospective review of patients presenting with scaphoid nonunion reveals a high rate of delayed presentation and incomplete evaluation and treatment from the physician. Fractures showing inadequate progression toward union while being treated in a cast should be considered for surgical intervention. Yin Z, Zhang J, Gong K. Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma. 2015;29(8):e245–e252. When accounting for health care costs and lost productivity, immediate CT scan or MRI are the most cost effective strategies for the diagnosis of suspected scaphoid fractures.

PROCEDURE 26

Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations Tyler Omeis and Bertrand Perey INDICATIONS • An open reduction using a dorsal approach is required for the anatomic realignment of the carpal bones and the repair of associated ligamentous injuries in all perilunate dislocations and fractures.

Examination/Imaging • Clinical history is usually compatible with a high-energy injury to the wrist (Mayfield et al., 1980). • Typically, the wrist is swollen and stiff. • Median nerve function must be documented as a progressive neuropathy may be an indication for urgent surgery. • Median nerve symptoms most often resolve following closed reduction of the dislocation (Adkison and Chapman, 1982). • Standard posteroanterior (PA) and lateral radiographs are obtained to make the diagnosis. Although the radiographic findings are fairly consistent, these injuries can be missed 25% of the time (Herzberg et al. 1993). • For scapholunate (SL) dissociation, a widened SL interval (Fig. 26.1) will be seen along with an increased SL angle greater than 70 degrees (Fig. 26.2). On a lateral radiograph with the wrist in a neutral position the lunate will extend by more than 5 degrees relative to the capitate (DISI deformity). • With dislocation of the midcarpal joint, the PA view will show disruption of the smooth arcs formed by the proximal aspect of the distal carpal row and the distal aspect of the proximal carpal row (Fig. 26.3) (Gilula, 1979). In the face of a perilunate dislocation, the lunate will remain within the lunate facet, whereas the capitate dislocates dorsally from its articulation with the lunate. This is best seen on the lateral view (Fig. 26.4). • When presented with a lunate dislocation, the capitate is usually seen articulating with the lunate facet of the distal radius, whereas the lunate itself is dislocated volarly to the radius. • Advanced imaging may be beneficial if the chronicity of a scapholunate disruption is unclear (magnetic resonance imaging), or when better delineation of bony injuries is required (computed tomography scan). 

INDICATIONS PITFALLS

• A concomitant carpal tunnel release through a volar incision may be required for persistent median nerve symptoms following a closed reduction (Adkison and Chapman, 1982). • An irreducible lunate dislocation may also require a volar approach.

INDICATIONS CONTROVERSIES

• The additional repair of the volar soft tissues about the wrist may provide better long-term results, although this data has not been confirmed in the literature.

TREATMENT OPTIONS

• Most perilunate dislocations should undergo a closed reduction in the emergency room until such time that operating room access for definitive open reduction and internal fixation is available. • Surgical intervention should be performed as promptly as logistics and soft-tissue swelling allow, but may be delayed up to 2 weeks with a successful closed reduction (in the absence of median nerve compression). • There is no role for a simple closed reduction and K-wire fixation for perilunate injuries because of the difficulties in obtaining anatomic reduction and performing ligament repair (Apergis et al., 1997).

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PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

FIG. 26.1  FIG. 26.2 

FIG. 26.3  FIG. 26.4 

SURGICAL ANATOMY • Mayfield described the four stages of progressive ligamentous injury around the lunate (Mayfield et al., 1980): • Stage I: SL disruption. The dorsal part of this ligament is the thickest and strongest and is the portion that warrants repair. • Stage II: lunocapitate dislocation. • Stage III: lunotriquetral (LT) disruption. The volar part of this ligament is the strongest; however, access is difficult and repair is rarely performed. • Stage IV: volar lunate dislocation. All remaining soft tissues may be disrupted from the lunate, making retrieval and reduction difficult. • Mayfield’s initial description was that of a “lesser arc” injury without bony involvement. This classification has been expanded to include greater arc injuries involving

PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

the bony structures around the lunate including the radius (transradial or transstyloid), the scaphoid (transcaphoid), the capitate (transcapitate), and the triquetrum (transtriquetral) (Johnson, 1980). • When a fracture has occurred, the intercarpal ligaments associated with the fractured bone are usually, but not always, spared (e.g., if the scaphoid is fractured, the scapholunate interosseous ligaments [SLIL] are usually intact) (Herzberg et al., 1993). • Complete disruption of the volar radiocarpal ligaments may allow for progressive translocation of the carpus, which carries a poor prognosis. 

POSITIONING • Place the patient supine with the affected extremity on an arm table. • Surgery is usually done under tourniquet control. 

PORTALS/EXPOSURES • For the dorsal approach, use either a standard longitudinal incision over Lister’s tubercle (Fig. 26.5) or a transverse incision over the midcarpal joint (Fig. 26.6). Incise the distal portion of the extensor retinaculum over the second through the fifth compartments (over the carpal bones only). • Retract the extensor tendons to allow for exposure of the capsule (Fig. 26.7). • The dorsal radiocarpal ligament is often avulsed from the distal radius. If possible, attempt not to transect the dorsal wrist ligaments (dorsal radiocarpal and dorsal intercarpal ligament), but rather incise them in the axis of their fibers to maintain their structural integrity (ligament-sparing approach). To do this, make an incision through the capsule from the ulnar border of Lister’s tubercle to the dorsal portion of the triquetrum. The capsule radial to Lister’s tubercle can be incised off the distal radius without compromising the dorsal ligaments. If further distal exposure is required, a second capsular incision can be made from the triquetrum to the distal pole of the scaphoid (Fig. 26.8). 

PORTALS/EXPOSURES PEARLS

• A transverse skin incision over the radiocarpal joint will yield a better cosmetic outcome but must be weighed against the familiarity of a longitudinal skin incision. • Working between extensor compartments will allow for better access to the various carpal bones (e.g., three-fourth interval for SL access, and four-fifth interval for LT access). • Use of blunt self-retainers will facilitate exposure while minimizing injuries to the dorsal sensory nerves.

PORTALS/EXPOSURES PITFALLS

• The dorsal sensory branches of the radial and ulnar nerves need to be protected at all times. • Care should be taken not to incise the entire extensor retinaculum. Pay careful attention to the extensor pollicus longus tendon because this tendon can be easily transected.

FIG. 26.6  FIG. 26.5 

313

314

PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

FIG. 26.7 

PORTALS/EXPOSURES CONTROVERSIES

• A dorsal approach alone will not allow for carpal tunnel decompression. • A standard incision for a carpal tunnel release will be required in any patient presenting with symptoms of median nerve dysfunction secondary to a suspected compressive neuropathy. It can be difficult to differentiate a neuropraxic injury secondary to direct trauma that may not benefit from decompression and a neuropathy secondary to an acute carpal tunnel syndrome. Any patient presenting with a worsening neuropathy should be suspected of having an acute carpal tunnel syndrome requiring decompression. In general, if there is any question of median nerve compression, a release is performed. • Although controversial, a volar approach is required if repair of the volar ligaments and the space of Poirier is to be performed, or in the presence of a volar lunate dislocation that cannot be reduced through a dorsal approach (Muppavarapu and Capo, 2015). • The volar approach is done through an extended carpal tunnel release incision. This longitudinal incision should be in line with the radial side of the ring finger. Once the transverse retinacular ligament has been completely incised, including the distal portion of the forearm fascia, deep dissection proceeds between the digital flexors and the flexor carpi ulnaris tendon. The volar wrist capsule can be seen on the floor of the carpal canal. If a significant tear is seen, it is usually over the midcarpal joint (space of Poirier) (Fig. 26.9). This tear can be repaired (Fig. 26.10), although the clinical benefits of this have not been demonstrated. • Repair of the volar radioscaphocapitate and volar portion of the LT ligament has been advocated by some. Access to these ligaments can be achieved through the volar approach by extending the midcarpal tear proximally in a radial and ulnar direction.

FIG. 26.8 

PROCEDURE Step 1 • Once the joint is exposed, perform a thorough irrigation, debridement, removal of loose chondral fragments, and assessment of the injury pattern. • If a closed reduction was unsuccessful, an open reduction can now be performed. • Traction and elevators are usually successful at reducing the midcarpal joint. • Once the midcarpal joint is reduced, place attention on the reduction of the SL interval. • Reduction of the SL interval is best done using K-wires as joysticks in the scaphoid and the lunate. A minimum size of a 1.6-mm (0.062 inch) wire is recommended. • Reduction is achieved by concomitant extension and supination of the scaphoid with flexion of the lunate (Fig. 26.11). A small pointed reduction clamp can be used. Proper reduction will need to be confirmed using intraoperative fluoroscopy. • Once the SL interval has been reduced, two 1.1-mm (0.045 inch) K-wires should be placed from the scaphoid into the lunate from the radial side. A third K-wire should then be placed from the scaphoid into the capitate maintaining scaphoid extension and midcarpal reduction (Fig. 26.12). • Reduction of the LT interval is done using a similar technique, although this interval often reduces spontaneously when the SL interval and midcarpal joints are reduced. • Place two K-wires from the triquetrum into the lunate from the ulnar side (Fig. 26.13). • The dorsal SL ligament is usually avulsed from the scaphoid and should be repaired using suture anchors or bone tunnels (Fig. 26.14). A No. 2.0 or 3.0 nonabsorbable suture is recommended. • The LT ligament is not usually amenable to repair. • Cut, bend, and bury the K-wires subcutaneously for later removal. • These K-wires will be in very close vicinity to the dorsal sensory branches of the ulnar and radial nerves. Take care during insertion and removal to avoid injury to these nerves. • The dorsal capsule is then closed or repaired followed by skin closure. 

PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

FIG. 26.9 

FIG. 26.10 

A

B FIG. 26.11 

FIG. 26.12 

315

316

PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

STEP 1 PEARLS

• The lunate can be temporarily fixed to the lunate facet of the distal radius in a neutral alignment prior to reducing the scaphoid. This can be done using dorsally placed K-wires through the radius under fluoroscopic control. This may facilitate reduction of the SL interval by decreasing the number of moving segments. STEP 1 PITFALLS

• A separate volar approach may be required to retrieve and reduce a dislocated lunate.

STEP 1 INSTRUMENTATION/ IMPLANTATION

• Fluoroscopic imaging • 1.1-mm (0.045 inch) and 1.6-mm (0.062 inch) K-wires (1.6-mm K-wire for joysticks within the scaphoid and lunate, and 1.1-mm K-wire for transcarpal pinning) • Suture anchors • No. 2.0 or 3.0 nonabsorbable suture

FIG. 26.13 

STEP 1 CONTROVERSIES

• Some surgeons have advocated for the repair of the volar radiocarpal ligaments and closure of the space of Poirier. This can be easily done through an extended carpal tunnel incision by retracting the median nerve and the flexor tendons. The capsular injury can be seen through the floor of the carpal canal at its proximal end. Direct repair of the ligaments is then performed. • Augmentation of the SL repair has been proposed by some surgeons. The most common augmentation is performed using the dorsal intercarpal ligament. This ligament normally crosses the carpus just distal to the SL interval connecting the triquetrum to the distal pole of the scaphoid. Suture anchors can be inserted on either side of the SL interval and used to draw the dorsal intercarpal ligament proximally over the SL ligament.

FIG. 26.14 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The wrist is splinted in a neutral position until the wounds have healed. • Cast immobilization should be carried out for a minimum of 10 weeks. • Following cast removal, the K-wires are removed (be careful of the dorsal sensory nerves), and range-of-motion exercises can begin. • The long-term results for most patients is worse when the SLIL is torn (lesser arc injury) instead of a fracture through the scaphoid (transcaphoid dislocation). Most patients with lesser arc injuries will have some element of SL dissociation on a permanent basis, leading to progressive articular degeneration. • Articular damage to the proximal pole of the capitate is common, leading to midcarpal arthritis. LT issues are rare, thus prompting some surgeons not to internally stabilize this interval. • Less than 50% of patients followed for 10 years have good to excellent results, and less than one-third return to laboring jobs (Forli et al., 2010).

PROCEDURE 26  Dorsal Approach for Open Reduction Internal Fixation of Perilunate Fractures and Dislocations

EVIDENCE Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop. 1982;164:199–207. The authors assessed 55 patients with perilunate injuries after both closed and open reduction of these injuries. In their study, they found that 16% of the carpal injuries had associated median nerve symptoms. One of these patients required a carpal tunnel release to alleviate median nerve symptoms, whereas the remainder of the patients had symptomatic resolution with proper anatomic reduction. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg [Am]. 1980;5:226–241. The definitive cadaveric study on the pathomechanics, ligamentous damage, and degree of carpal instability in perilunate and lunate dislocations. Dislocations occurred in a sequential fashion owing to progressive and specific ligamentous disruptions. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocations and fracture dislocations: a multicenter study. J Hand Surg [Am]. 1993;18:768–779. A retrospective series on 166 perilunate dislocations and fracture-dislocations from seven centers. The diagnosis was missed initially in 41 cases (25%). In cases treated early, the clinical results were satisfactory but the incidence of posttraumatic arthritis was high (56%). The best radiologic results were observed after open reduction and internal fixation. The initial appraisal of both the osseous and ligamentous pathology was very important. Gilula LA. Carpal injuries: analytic approach and case exercises. Am J Roentgenol. 1979;133:503–517. The author of this article reviewed radiographic wrist relationships emphasizing the posteroanterior view and analyzed the three normal arcs, principles of parallelism, and overlapping articular surfaces, enabling physicians interpreting radiographs to make a definitive diagnosis and to detect subtle and complex abnormalities. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracturedislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl. 1997;275:55–59. Findings in 28 cases suggested that perilunate fracture-dislocations are too unstable to be treated with closed reduction. In addition, a combined approach was found effective in the management of dorsal perilunate dislocations. Finally, open reduction presupposes reparation of the torn scapholunate ligament, to obtain normal carpal kinematics. Johnson RP. The acutely injured wrist and its residuals. Clin Orthop Relat Res. 1980;149:33–44. Johnson expands on Mayfield’s description of the pathomechanics of perilunate injuries by discussing the concept of lesser arc and greater arc injuries to distinguish simple perilunate dislocations from perilunate fracture-dislocations. Muppavarapu RC, Capo JT. Perilunate dislocations and fracture dislocations. Hand Clin. 2015;3:399– 408. Muppavarapu and Capo discuss the pathomechanics, diagnosis, and treatment. They review the current literature and discuss the surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament. Current research and data show better results with anatomic restoration of carpal alignment and direct ligament repair. Forli A, Courvoisier A, Wimsey S, et al. Perilunate dislocations and transscaphoid perilunate fracturedislocations: a retrospective study with minimum ten-year follow-up. J Hand Surg [Am]. 2010;35: 62–68. The authors of this study evaluated long-term (minimum 10 years) patient hand function after perilunate dislocations (11 cases) and transscaphoid perilunate fracture dislocations (7 cases). They found that less than 50% of patients had good to excellent results, and less than one-third return to laboring jobs.

317

PROCEDURE 27

Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand Michelle L. Zec, Sebastien Lalonde, and David Pichora GENERAL INDICATIONS

PITFALLS

• Avoid unnecessary internal fixation for stable fracture patterns.

• Failure of nonoperative management • Inability to obtain or maintain a satisfactory closed reduction • Unstable fracture or dislocation patterns • Malrotation or scissoring of the digit • Fractures associated with tendon or ligament avulsions that require surgical repair (e.g., displaced bony mallet, jersey finger, ulnar collateral ligament (UCL) injury of the thumb with associated Stener lesion • Open fractures (that require irrigation and débridement) • Fractures with associated soft-tissue injury (vessel, tendon, nerve, skin) that require surgical management • Multiple hand fractures 

EXAMINATION • Inspect for deformity and evidence of an open fracture or an associated neurovascular injury. • If concerned about potential digital nerve injury, assess two-point discrimination. • Examine the attitude of the fingers: deviation from the usual digital cascade can aid in the diagnosis of both bone and tendon injuries. • Focused assessment should rule out associated ligament and tendon injuries (e.g., Elson test to rule out a central slip injury in proximal interphalangeal joint [PIPJ] injuries). • Assess range of motion (ROM). • Pay attention for scissoring of the injured digit (best performed while asking the patient to slowly flex and extend the fingers). • A local anesthetic block may be required in some patients to facilitate this examination. The tip of each digit should point toward the scaphoid tubercle (Fig. 27.1). • Inspection of the plane of the surfaces of the nails can help identify subtle rotational deformity (Fig. 27.2). 

GENERAL IMAGING • Typically, three views of the injured finger are often necessary to delineate the fracture: posteroanterior (PA), lateral, and oblique radiographs. • Physical examination facilitates the selection of dedicated finger radiographs rather than hand radiographs, which may lack the magnification to capture subtle injuries. • For intra-articular injuries, a computed tomography (CT) scan with 3D reconstruction may be helpful for characterizing the injury, particularly in carpometacarpal (CMC) and PIPJ dislocations. Ordering digital subtraction of adjacent bones allows an unobstructed view of the injured articular surface. 

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

Scaphoid

FIG. 27.1  Each fingertip will point to the scaphoid tubercle with finger flexion. In the setting of malrotation, the fingertip will point away from the scaphoid tubercle and may ‘scissor’ with adjacent digits during flexion. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

A

B

FIG. 27.2A–B  Comparing the relative position of the fingernails with the MCPJs in slight flexion and the PIPJs flexed may detect malrotation when compared with the opposite hand. (A) Normal alignment of the fingernails. (B) Alignment of the finger nails with malrotation of the ring finger. From: Lyn, Everett, Mailhot, Thomas. (2014) Rosen’s emergency medicine : concepts and clinical practice. John Marx (editor). Elsevier: Philadelphia; 7 edn, Chapter 47.

IMAGING FOR SPECIFIC INJURY PATTERNS • PIPJ impaction fractures and fracture dislocations • In an acute injury, a digital block will facilitate radiographic assessment of stability with finger flexion. • Consider CT to assess degree of comminution in intra-articular injuries of this joint. • Traction views may be helpful in impaction injuries.

319

320

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

• Thumb CMC joint injuries: True anteroposterior (AP; Robert view) and true lateral (Gedda view) are ordered to assess injuries of this joint (see Open Reduction and Internal Fixation of First CMC Joint Fracture-Dislocations section). Traction views may be helpful in the setting of comminution. • D2–D5 CMC joints: Due to overlap of adjacent metacarpals on the lateral view, the diagnosis of a CMC dislocation may be missed on plain films. • To obtain a better lateral view of the second and third CMC joints, the hand is slightly supinated. For a lateral of the fourth and fifth CMC joints, the hand is slightly pronated. • Given the consequences of delayed or missed dislocation, these injuries often require CT imaging for characterization. • Intra-articular metacarpal head fractures: The Brewerton view is obtained with the metacarpophalangeal joint (MCPJ) flexed to 65° with the dorsum of the proximal phalanx flat against the radiograph cassette and the beam angled 15° ulnar to radial. 

SURGICAL ANATOMY • The dorsal extensor mechanism must be circumnavigated on dorsal and mid-axial exposures of the digits. Consideration must be given to planning the approach such that key structures are not compromised (Fig. 27.3). • The sagittal bands originate from the volar plates and surround each MCPJ ulnarly and radially before anchoring into the extensor mechanism. • These provide the main driving force for MCPJ extension. • Injury to or failure to repair the radial sagittal band may lead to ulnar subluxation of the finger extensor tendon. • In volar approaches, the flexor tendon apparatus must be carefully exposed, reflected, and worked around to minimize postoperative bow-stringing and loss of motion due to adhesions (Fig. 27.4). • Neurovascular structures at risk (nerves, arteries, dorsal veins) • Proper digital nerves and arteries are protected on volar approaches to the digits (see Fig. 27.4) • Sensory branches of the radial, ulnar (Fig. 27.5A), and median nerve (Fig. 27.5B) are at greater risk with border digits. • Dorsal veins are protected on dorsal exposures of both the metacarpals and the phalanges (Fig. 27.6). • The motor branch of the ulnar nerve courses volarly in the Guyon canal from ulnar to radial around the hook of the hamate and is in close proximity to the fourth and fifth metacarpal bases (Fig. 27.7). It may be at risk during fixation of hamate fractures, hamate hook excision, or D4/D5 CMC fracture dislocations. • The nail bed may be injured with distal phalanx injuries and must be protected during dorsal exposures of the distal interphalangeal joint (DIPJ) and distal phalanx. • As with all fracture fixation, consideration of the deforming forces in the hand facilitates fracture reduction and fixation: • Volar and dorsal tendons act as deforming forces in phalangeal and metacarpal fractures (Fig. 27.8). • The wrist extensor tendons, extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB) and extensor carpi ulnaris (ECU) insert at the base of metacarpals 2, 3, and 5 respectively (Fig. 27.9A–B). • These structures must be protected in the proximal exposure to the dorsal metacarpal. • The ECU tendon is typically responsible for proximal and ulnar displacement of the ulnar-most fragment in an intra-articular fracture of the fifth metacarpal base (Fig. 27.9C) • Bennett fracture: The volar beak ligament is attached to the fracture fragment, while the abductor pollicis longus and adductor pollicis act as deforming forces on the metacarpal. Fig. 27.9D). 

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

Insertion of central band of extensor tendon to base of middle phalanx Slips of long extensor tendon to lateral bands

Triangular aponeurosis

Interosseous muscles

Long extensor tendon

Extensor exansion (hood)

321

Posterior (dorsal) view

Metacarpal bone

Insertion on extensor tendon to base of distal phalanx

Interosseous tendon slip to lateral band

Lateral bands

Lumbrical muscle

Lateral band Insertion of extensor tendon to base of middle phalanx

Part of interosseous tendon passes to base of proximal phalanx and joint capsule

Extensor expansion (hood) Long extensor tendon

Central band

Insertion of extensor tendon to base of distal phalanx

Metacarpal bone

Finger in extension: lateral view Collateral ligaments

Vinculum breve

Vincula longa

Flexor digitorum profundus tendon

Interosseous muscles

Flexor digitorum superficialis tendon

Lumbrical muscle

Collateral ligament Insertion of small deep slip of extensor tendon to proximal phalanx and joint capsule

Extensor tendon

Attachment of interosseous muscle to base of proximal phalanx atnd joint capsule

Palmar ligament (plate) Insertion of lumbrical muscle to extensor tendon

Flexor digitorum superficialis tendon (cut)

Interosseous muscles Lumbrical muscle

Collateral ligaments Finger in flexion: lateral view

Flexor digitorum profundus tendon (cut) Palmar ligament (plate)

Note: Black arrows indicate pull of long extensor tendon; red arrows indicate pull of interosseous and lumbrical muscles; dots indicate axis of rotation of joints

FIG. 27.3  The extensor mechanism of the fingers. For dorsal and mid-axial exposures, the approach must be planned such that key structures are not compromised. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

322

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

FIG. 27.4  Flexor tendon apparatus and volar neurovascular bundles. The A-3 pulley lies directly over the PIP joint. The A-2 and A-4 pulleys lie proximal and distal respectively. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

PCBMN

SBRN

A

LACN

DSBUN

B

FIG. 27.5A–B  (A) Dorsal wrist. The sensory branch of the radial nerve (SBRN) is at risk with dorsal or percutaneous approaches to the first CMC joint, while the dorsal sensory branch of the ulnar nerve (DSBUN) is at risk during approaches to the 4th and 5th CMC joints. (B) Volar wrist. Distal branches on the lateral antebrachial cutaneous nerve (LABCN) may be at risk with approaches to the first CMC joint, while the palmar cutaneous branch of the median nerve (PCBMN) is at risk when utilizing a Wagner incision for the volar approach to the first CMC joint. From: Principles and Practice of Wrist Surgery. 2010. Jennifer Moriatis Wolf, Alexander Y. Shin. Radius/carpus/distal radioulnar joint: Bones and ligaments. Elsevier Saunders.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

323

FIG. 27.6  Dorsal veins and sensory nerves of the hand. The surgeon should attempt to preserve the longitudinal limbs of the dorsal veins. Care is taken to protect dorsal sensory nerve branches. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013 FDQ ODQ Fibrous arch Trans. carpal lig.

ADQ

H

Superf. br., deep br., ulnar n. Piso-hamate lig., cut P FCU

Volar carpal lig., cut Ulnar a.

FIG. 27.7  Guyon’s canal. Distal branches of the ulnar nerve may be at risk with percutaneous treatment of 4th and 5th CMC fracture-dislocations. From: Susan Mackinnon, Christine Novak. 2011. Green’s Operative Hand Surgery. Compression Neuropathies , 2011

324

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

A Proximal phalanx

B

Proximal middle phalanx (metaphysis)

C

Distal middle phalanx

D FIG. 27.8A–D  Angular deformity associated with fractures of the metacarpal and phalanges. (A) Metacarpal fractures typically have apex dorsal angulation secondary to the location of the interosseous muscles. (B) Proximal phalanx fractures have an apex volar angulation. (C and D) The angulation of middle phalanx fractures is dependent on the location of the fracture, relative to the insertion of the FDS tendon: fractures proximal to the insertion (C) will have apex dorsal angulation while those distal (D) will have apex volar angulation. Note tendons to the distal phalanx not illustrated here. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

A

325

B

Hypothenar muscles

Extensor carpi ulnaris

C

Bennett fracture

D

FIG. 27.9A–D  (A) Wrist and finger extensors. (B) Abductor pollicis longus (APL) and extensor carpi ulnaris (ECU) are deforming forces on associated with fractures of the first and fifth metacarpals. The tendons of extensor carpi radialis longus and brevis insert on the bases of the 2nd and 3rd metacarpals respectively and their attachments must be protected (or repaired) when operating near their respective CMC joints. (C) ECU and the hypothenar muscles act as deforming forces in fractures at the base of the 5th metacarpal. (D) APL and adductor pollicis act as deforming forces in fractures at the base of the first metacarpal. From: Neligan, 2013 (1.17b, and fig 7.23), Campbell’s Fig 67-32 Campbell’s Operative Orthopaedics, 13e, Elsevier 2017

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

POSITIONING • The patient is positioned supine with the arm draped free. • The shoulder is abducted and the arm is placed in the center of a radiolucent hand table. • A pneumatic tourniquet (optional) is placed on the arm. • A “lead hand” or Tupper Hand Retractor is useful for volar exposures of the hand. 

PEARLS

• Appropriately position the operating table in the room to facilitate easy use of fluoroscopy when needed. • An awake, cooperative patient with an anesthetic block can participate in ROM assessment during and following fixation. • Tourniquet use is optional if using a WALANT approach (“Wide Awake Local Anesthesia No Tourniquet”).

PITFALLS

• If the patient lacks shoulder, elbow, or wrist ROM, positioning the arm may be difficult and may require the use of an arm table (in lieu of a hand table) and/or strategic use of bolsters.

FIXATION OF EXTRA-ARTICULAR FRACTURES OF THE TUBULAR BONES OF THE HAND Illustrative Examples • Closed reduction and percutaneous pinning of metacarpal neck fractures • Lag screw fixation of proximal phalangeal shaft fracture • Open reduction plate fixation of metacarpal shaft fracture  CONTROVERSIES

• Angulation indications are relative. Several studies support excellent outcomes with greater degrees of angulation, especially with fifth metacarpal neck fractures.

TREATMENT OPTIONS

• Closed reduction and casting/splinting/taping for minimally displaced/stable fractures • Closed reduction and crossed pinning (illustrated here) • Antegrade or retrograde percutaneous intramedullary nailing • Open reduction and mini-condylar plating

PROCEDURE: CLOSED REDUCTION AND PERCUTANEOUS PINNING OF METACARPAL NECK FRACTURES Specific Indications • Unacceptable angulation (Table 27.1) • 25% involvement of articular surface or 1 mm joint step-off • Any rotational deformity • Metacarpal shortening > 5 mm • Pseudoclawing • Multiple metacarpal fractures 

TABLE 27.1 

Finger

Degree of acceptable angulation for fractures of metacarpal shaft and neck Angulation (degrees)

Neck Index

10

Middle

15

Ring

30

Small

40

Shaft Index

0

Middle

0

Ring

20

Small

30

Table 1: Diaz-Garcia R, Waljee JF. Current management of metacarpal fractures. Hand Clin. 2013;29(4):509.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

Portals/Exposures

327

PEARLS

• Dorsal approach to metacarpal neck (when closed reduction is unsuccessful) • Tendon-splitting approach to MCP joint for more distal fractures or for mini-open retrograde intramedullary nail • Similar paratendinous approach described for metacarpal shaft fractures (see Plate Fixation of Metacarpal Shaft Fractures section) 

• Transverse venous tributaries may be cauterized or ligated to aid in retraction. • Juncturae tendinae are repaired upon closure,

Procedure Step 1: Closed Reduction of the Metacarpal Neck

• The dorsal branch of the ulnar nerve is at risk with proximal exposure of the fifth metacarpal during the dorsoulnar approach.

• After evaluating the fracture for rotational deformity, closed reduction of the typical apex-dorsal metacarpal neck fracture is performed using the Jahss maneuver (Fig. 27.10) • The involved finger is fully flexed at 90° degrees at the MCP and PIP joints. • Dorsally directed axial pressure is placed on the proximal phalanx while volarly directed counterpressure is exerted proximal to the fracture on the metacarpal. • The proximal phalanx drives the metacarpal head dorsally, thereby correcting the apex-dorsal neck deformity. • With the finger in the same flexed position, rotational deformity can also be corrected using ligamentotaxis principles by exerting ulnar or radial force on the proximal phalanx. 

PITFALLS

PEARLS

• Longitudinal traction may also aid in disimpacting the fracture, while pressure is directed on the metacarpal head in the direction of reduction (Fig. 27.11). PITFALLS

• If pursuing closed management, do not immobilize the finger in the Jahss position, as this is associated with a high risk of flexion contracture.

Splint

FIG. 27.10  Reduction of an apex-dorsal metacarpal neck fracture using the Jahss manoeuvre. (Lower left). The involved finger is fully flexed to 90 degrees at the MCP and PIP joints. Dorsal directed axial pressure is placed on the proximal phalanx while volarly-directed counter-pressure is exerted proximally on the metacarpal. (Lower right) Arrows depict areas of counter-pressure applied to the molded cast or splint. From: Diaz-Garcia R, Waljee JF. Current management of metacarpal fractures. Hand Clin. 2013;29(4):508

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

INSTRUMENTATION/IMPLANTATION

Step 2: Fluoroscopic Assessment of Reduction • PA and lateral fluoroscopic views are taken to confirm fracture reduction. • In unstable/comminuted patterns, longitudinal traction or reduction pressure on the metacarpal head may need to be maintained during Kirschner wire (K-wire) fixation (Fig. 27.11). 

• See Table 27.2.

PEARLS

• Fluoroscopic views should be performed after the first pin placement to confirm reduction prior to finalization of the construct.

FIG. 27.11  Alternative closed reduction maneuver using longitudinal traction on the affected digit and dorsally directed pressure on the metacarpal head. Arrows indicate the direction of forces. Credit: S. Lalonde

Step 3: Percutaneous K-wire Fixation • Two 0.045-inch K-wires) are drilled retrograde across the fracture in a crossing pattern, starting at the collateral recesses in the distal head fragment. The pins are driven across the opposing cortex in the proximal fragment and are allowed to protrude slightly to achieve stability of the construct (Fig. 27.12). 

Collateral Recesses

FIG. 27.12  Two 0.045 inch K-wires are drilled retrograde across the fracture in a crossing pattern, starting at the collateral recesses in the distal head fragment. Credit: S. Lalonde

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

329

TABLE   Techniques for internal f ixation. 27.2   

Intraosseous wire (gauge)

Kirschner wire (diameter, inches)

Interosseous (lag) screw (mm)

Plate (mm)

Distal Phalanx

28

0.028/0.035

1.0/1.3/1.5

1.3 mm (“hook plate”)

Middle Phalanx

28

0.035

1.3/1.5

1.3/1.5

Proximal Phalanx

26/28

0.045

1.5/2.0

1.5/2.0

Metacarpal

26

0.045/0.062

1.5/2.0

2.0

Carpal

24/26

0.045/0.062

1.5/2.0/2.4

2.0/2.4

Step 4: Final Assessment

PEARLS

• Clinical assessment of rotation is performed as previously described. • Fluoroscopic assessment is performed, with at least two orthogonal views (PA and lateral) confirming pin placement and appropriate reduction. 

• The metacarpal neck-shaft angle is normally 15°. This should serve as a reference when evaluating the adequacy of the reduction.

PITFALLS

• Avoid vigorous manipulation of the involved digit for x-ray positioning to prevent displacement at the fracture.

Additional Steps • Splint: A volar plaster slab is placed extending from the proximal forearm to the tips of the fingers. The wrist and hand are immobilized in the position of safety (see Postoperative Care section). • Weight-bearing status: Non–weight bearing of the affected hand continues until clinical/radiographic fracture union. • Follow-up: K-wires are usually removed at 4 to 6 weeks depending on the degree of clinical and radiographic healing, the stability of the fracture, and soft-tissue considerations. • Rehabilitation: Gentle, controlled, active ROM out of the splint is usually started at 2 to 3 weeks postoperatively. 

PROCEDURE: LAG SCREW FIXATION OF PROXIMAL PHALANGEAL SHAFT FRACTURES Specific Indications Unstable fractures • > 15° sagittal plane deformity (i.e., apex volar, extension deformity) • There is a linear relationship between the degree of proximal phalanx angulation and the resulting extensor lag. • > 10° coronal plane deformity • > 2 mm shortening 

PITFALLS

• Prior to treating patients with ORIF for phalangeal fractures, particularly if plate fixation is used, counsel patients that they may require subsequent removal of hardware and/ or tenolysis once the fracture has healed.

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

TREATMENT OPTIONS

• Closed reduction and splinting/casting • K-wire fixation: May be used percutaneously or combined with open reduction; may be used for direct reduction of fracture fragments or for indirect reduction techniques (e.g., intramedullary fixation). • Lag screw fixation (illustrated here) • Plate fixation: Compression plating, lag screw fixation with neutralization plate, bridge plate • Tension band wiring • External fixation

Portals/Exposures • Dorsal: The skin incision is planned to minimize postoperative scar contracture and optimize surgical exposure; an S- or C-shaped skin incision may be used if a joint will be crossed (Fig. 27.13). • Elevation of the extensor mechanism • Midline: a central incision through the extensor tendon may be performed, with care being taken not to disrupt the insertion of the central slip (Fig. 27.14A). • Paramedian: A paramedian incision may be used that exploits the interval between the central slip and the lateral band (Fig. 27.14B). • Midaxial: The incision is planned by fully flexing the digit and marking out the superior-most aspect of the volar joint creases (Fig. 27.15A). These marks are then connected in a straight line along the superolateral aspect of the digit (Fig. 27.15B). The length of the incision is planned to facilitate optimal exposure of the fracture. The subcutaneous tissues are carefully dissected and the oblique fibers of the lateral band are retracted dorsally to expose the lateral aspect of the phalanx (Fig. 27.16). • Volar (Bruner) Approach: see Proximal Interphalangeal Joint Fracture-Dislocation section. 

PEARLS

• Extensor mechanism: The sagittal bands at the MCP joint, the central slip insertion at the PIP joint, and the triangular ligament at the DIP joint should be preserved whenever possible. • For midaxial incisions: The radial border of the index finger is avoided in favor of the ulnar border. Conversely, the ulnar border of the fifth finger is avoided in favor of the radial border. Such incisions are planned to avoid sensitive scars on pressure-bearing skin surfaces. A single dorsal cutaneous branch of the proper digital nerve crosses the operative field at the junction of the middle and distal one-third of the proximal phalanx; when possible, it should be identified and protected. • Try to preserve the periosteum, which should be elevated only immediately adjacent to the fracture line when feasible; this may help minimize scar formation and fragment devascularization.

A FIG. 27.13 A midline longitudinal incision may be utilized for most dorsal approaches to the proximal phalanx (index) or a curvilinear incision centred over the fracture (long). If the PIPJ requires exposure, a curvilinear ‘C’ or ‘S’ shaped incision is typically utilized (ring and small).

B

FIG. 27.14A–B  Dorsal exposures of the proximal phalanx. A. A midline incision may be utilized, splitting the extensor tendon. B. A paramedian incision may be used by developing the interal between the central slip and the lateral band. From: (A) Browner, Skeletal Trauma, 5th edition. Elsevier. 2014 (B) Mark Miller A. Chhabra Joseph Park Francis Shen David Weiss James Browne Orthopaedic Surgical Approaches, 2nd edition, 2014

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331

PITFALLS A B

B

C

B A

C

A FIG. 27.15A–B  To plan a midaxial incision, fully flex the finger as shown in A. Mark the superior aspect of the joint creases with a marking pen. Extend the finger as shown in B and connect the dots in a straight line. The incision need only be long enough to adequately expose the fracture. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013

• Dorsal skin incisions may be associated with a higher rate of scar formation than midaxial incisions. • Midaxial skin incisions may place the volar neurovascular bundle at risk if the incision is inadvertently placed too volar.

EQUIPMENT

• Have implants available in the event that closed reduction percutaneous pinning (CRPP) is not feasible. • A modular hand system with appropriate plate and screw sizes available (see Table 27.2)

FIG. 27.16  Retract the oblique fibres of the lateral band with two retractors. From: Charles Day and Peter Stern. 2011. Fractures of the Metacarpals and Phalanges. Green’s Operative Hand Surgery.

Procedure Step 1: Reduction and Provisional Fixation • After adequate exposure of the fracture, obtain PA and lateral fluoroscopic views to assess deformity. • Begin by applying longitudinal traction to restore length, followed by MCP joint flexion. • Correct rotational deformity and then angulation in both the sagittal and coronal planes. • Place one (or more) pointed reduction forceps across the fracture to provisionally hold the reduction. Try to avoid placing the tines in the planned position of lag screws. • Provisional fixation may also be provided by K-wires. 

PEARLS

• Coronal plane angulation can be checked by comparison with the adjacent fingers and must be reduced. • Flexing the MCP joint will stabilize the P1 fragment by tightening the collateral ligaments.

PITFALLS

• Placing reduction forceps at the site of the intended screw placement.

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

INSTRUMENTATION/IMPLANTATION

• When utilizing K-wires, consider using cannulated reduction forceps such that optimal forcep application does not impede screw placement. • Both pointed and blunt (i.e., “lobster claw”) reduction forceps are helpful for this step; however, extra caution is required with comminuted fractures.

Step 2: Clinical and Radiographic Assessment of Reduction PEARLS

• Simulate active finger flexion by compressing forearm flexors.

• Assess the cascade of the digits for evidence of rotational deformity (Figs. 27.1 and 27.2); this may also be assessed by using the wrist tenodesis effect (i.e., passive finger flexion with wrist extension). • Assess provisional reduction by obtaining PA and lateral views of the involved digit. • Oblique views may be necessary to ensure adequacy of reduction. 

Step 3: Definitive Fixation PEARLS

• There may be short fissure lines that are not evident on radiographs. Visually inspect the bone for evidence of fissures and direct fixation away from these areas. • Place screws at least two screw head diameters away from the fracture spike, leaving at least one screw diameter on either side of the screw.

• Definitive fixation with lag screws alone necessitates that the fracture length be at least twice the cortical diameter (width) of the bone. • A minimum of two screws must be placed, but three screws are preferable, at equally spaced intervals along the fracture. • Spiral fractures typically require that screws be placed in different planes; moreover, multiplanar screw fixation significantly improves biomechanical stability. • In most instances, screws are placed perpendicular to the fracture plane, in lag mode. • Carefully measure screw lengths, as prominent screw tips are more likely to cause soft-tissue irritation in the hand. • Use a countersink in diaphyseal bone to minimize screw head prominence. 

PITFALLS

• If there is concern about the mechanical stability of the lag screw construct, the fixation may be augmented by the addition of a neutralization plate (see Open Reduction Plate Fixation of Metacarpal Shaft Fractures section). • Screw tips should not converge at the far cortex, as this may weaken fixation or cause fissures to arise if screw holes are in close proximity. • Avoid the use of a countersink in metaphyseal bone, as this may damage the thin cortical bone in this region, thereby compromising screw fixation.

INSTRUMENTATION/IMPLANTATION

• For phalangeal fractures, screws will typically range in size from 1.3 mm to 2.0 mm (see Table 27.2).

Step 4: Final Assessment • Obtain PA, lateral, and oblique views to assess final reduction, screw length, and position (Fig. 27.17). • Confirm correction of rotational deformity, as described earlier. In patients with a regional block or WALANT anesthetic, ask the patient to slowly make a fist to assess for persistent malrotation.  PITFALLS

• If long screws are inadvertently placed, it may be prudent to accept a long screw, rather than risk compromising bony purchase by removing and replacing it with a shorter screw. This would also depend on any structures that may be impinged on by the screw.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

333

FIG. 27.17  Final PA, oblique and lateral views after reduction. From: David Ruchelsman, Randy Bindra, 2014. Skeletal Trauma: Basic Science, Management, and Reconstruction. Fractures and Dislocation of the Hand.

Step 5: Closure • The extensor mechanism must be repaired. A 3-0 or 4-0 absorbable monofilament (slow-resorbing) suture will typically suffice. If a nonabsorbable suture is required, a 3-0 or 4-0 braided filament is less likely to cause overlying soft-tissue irritation. • The skin is closed as per surgeon preference. • Both extensor mechanism and skin closures should be performed, with the goal of enabling early ROM exercises for the patient. 

Additional Steps • Splint: A volar plaster slab is placed extending from the proximal forearm to the tips of the fingers. The wrist and hand are immobilized in the position of safety (see Postoperative Care section). A removable hand-based splint may be fabricated for additional protection during fracture healing. • Weight-bearing status: Non–weight bearing with the affected hand. Weight bearing is progressed following clinical and radiographic signs of union. • Follow-up: Fracture healing is monitored both clinically and radiographically. • Rehabilitation: Early active ROM can begin at the first postoperative visit if the fracture fixation permits. 

PROCEDURE: OPEN REDUCTION PLATE FIXATION OF METACARPAL SHAFT FRACTURES Specific Indications • Unacceptable angulation (Table 27.1) • 25% involvement of articular surface or 1 mm joint step-off • Any rotational deformity causing finger scissoring • Metacarpal shortening > 5 mm • Pseudoclawing • Multiple metacarpal fractures 

CONTROVERSIES

• Angulation indications are relative. Several studies support excellent outcomes with greater degrees of angulation, especially with fifth metacarpal neck fractures.

334

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

TREATMENT OPTIONS

• After review of imaging studies (Fig. 27.18), the treatment plan is formulated: • Closed reduction and casting/splinting/taping for minimally displaced/stable fractures • Open reduction and plate fixation (illustrated here) • Open reduction and lag screw fixation • Cerclage wiring techniques • Closed reduction and percutaneous pinning • Cross pinning • Transverse pinning to other metacarpals • Percutaneous intramedullary nailing/wiring • Percutaneous intramedullary retrograde headless screw

FIG. 27.18  PA, lateral and oblique views of a displaced 5th metacarpal shaft fracture. Credit: D. Pichora

PEARLS

• Dorsal interossei muscles may be partially detached to expose the fracture, but avoid aggressive soft-tissue stripping to maintain vascularity. • Juncturae tendinae are repaired upon closure.

PITFALLS

• Avoid incisions over the extensor tendons and keep the extensor paratenon intact to reduce risk of adhesions. • The dorsal branch of the ulnar nerve is at risk with proximal exposure of the fifth metacarpal during the dorsoulnar approach.

Portals/Exposures • Dorsal approach to metacarpal shaft (Fig. 27.19) • Longitudinal dorsal skin incision parallel to the metacarpal • Incisions are placed radial or ulnar to the midline of the metacarpal to avoid scar formation directly over the extensor tendon. • If the fracture is distal, the planned incision should be made ulnar to the involved metacarpal, thereby avoiding injury to the radial sagittal band, which can lead to ulnar subluxation of the EDC tendon. • If two adjacent metacarpals require ORIF, the incision can be placed between the involved metacarpals. • Protect extensor tendons and juncturae tendinae (see Figs. 27.3 and 27.9) • Protect sensory nerve branches and dorsal veins (see Figs. 27.5 and 27.6) • Retract extensor tendons radially or ulnarly to expose the metacarpal shaft and the fracture. 

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

335

1st metacarpal FIG. 27.19  Skin incision placement for dorsal exposure of metacarpal fractures. From: Mark D. Miller, Bobby Chabra et al 2015 Orthopaedic Surgical Approaches, 2nd Edition.

Procedure: Open Reduction and Plate/Screw Fixation of Metacarpal Shaft Fracture Step 1: Reduction and Initial Fixation • After irrigating the fracture hematoma and removing any interposed tissue in the fracture site, a reduction is performed using longitudinal traction on the finger. • Blunt reduction forceps are used to grasp and reduce the proximal and distal fragments to align the fracture anatomically (Fig. 27.20). • A pointed reduction clamp is then used to fine-tune and hold the reduction, after which the initial forceps are removed. • With an oblique or spiral fracture pattern, initial fixation is obtained with an interfragmentary lag screw (2.0 mm or 2.4 mm) • A countersink may be used to reduce prominence from the screw head. • In a purely transverse fracture, provisional fixation may be obtained instead with one or two small-diameter K-wires (Fig. 27.21). 

PITFALLS

• Avoid placement of a lag screw, which will interfere with the dorsal position of the plate.

INSTRUMENTATION/IMPLANTATION

• The authors prefer to use a modular hand system for definitive fixation, which provides several screw size and plate options to fit various metacarpal sizes

CONTROVERSIES

• In oblique fractures with a long spike, one or two lag screws may be used alone for definitive fixation (see Lag Screw Fixation of Proximal Phalangeal Shaft Fractures section). Outcomes may be similar to plate-screw constructs, but biomechanically less strong, potentially leading to longer periods of immobilization.

336

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

FIG. 27.20  An oblique metacarpal shaft fracture is reduced by gently manipulating the proximal and distal fragments with bone-holding forceps. A pointed reduction forceps is then clamped across the fracture site, securing the reduction. Credit: Lalonde drawing

FIG. 27.21  Provisional K-wire pinning of a transverse metacarpal shaft fracture after reduction using forceps. Credit: S. Lalonde (drawing) PEARLS

Step 2: Clinical and Fluoroscopic Assessment

• During positioning for radiography, position the hand for imaging by grasping the wrist and forearm, thereby avoiding undue strain on the affected digit, which may lead to fracture displacement.

• Orthogonal fluoroscopic views are taken to confirm reduction and plate position prior to final fixation (Fig. 27.22). • Rotational alignment of the involved digit is confirmed by observing for overlapping/ divergence of digits as well as nail plate orientation when the wrist is flexed and extended (see Fig. 27.2). 

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

337

INSTRUMENTATION/IMPLANTATION

• Mini C-arm for fluoroscopy

FIG. 27.22  Intraoperative fluoroscopic views (PA view shown here) are taken to confirm appropriate plate position prior to completing the osteosynthesis. Credit: D. Pichora

Step 3: Definitive Fixation

PITFALLS

• A properly sized low-profile plate is centered over the metacarpal. • Confirmation of plate position can be assisted with fluoroscopy. • In oblique fractures already provisionally fixed with a lag screw, the plate is secured with at least four cortices of fixation proximally and distally, thereby serving as a neutralization plate (Fig. 27.23). • In transverse fractures, compression is achieved by drilling an eccentric hole as per standard AO compression plating techniques5 (Fig. 27.24). 

Addition of a plate-screw construct to a lag screw helps neutralize the shearing forces across the fracture site

• Avoid eccentric position of the plate, as this may result in shorter screws and decrease construct stability. INSTRUMENTATION/IMPLANTATION

• See Table 27.2.

Hole is drilled eccentrically to allow compression across fracture site

shear shear As the screw head engages the plate, this creates a compressive force across the fracture site

FIG. 27.23  An oblique/spiral metacarpal fracture fixed using a lag screw/ neutralization plate construct. The lag screw compresses the fracture and the addition of a plate-screw construct helps neutralizes shearing forces. Credit: S. Lalonde (drawing)

FIG. 27.24  Transverse metacarpal fracture fixed using compression plating technique. Eccentrically drilled screws on either end of the fracture produce a compressive force across the fracture as the screw heads engage the plate interface. Credit: S. Lalonde (drawing)

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

338

Step 4: Final Assessment • Final PA and lateral fluoroscopic views are taken to evaluate hardware position and confirm that there is no displacement at the fracture or missed/secondary fractures (Fig. 27.25). • The lateral view is helpful to assess screw lengths for prominence volarly and evaluate for aberrant intra-articular screws/pins. • The PA view helps assess plate positioning. • ROM of the involved fingers is checked to assess for abnormal movement or hardware impingement. 

A

B

FIG. 27.25  A. Final PA view confirming reduction and appropriate positioning of hardware. B. Final lateral/oblique view confirming reduction and screw length/trajectory. Credit: D. Pichora

Step 5: Closure • The wound is irrigated and hemostasis is ensured. • The skin is closed as per surgeon preference (typically a 4-0 nonabsorbable monofilament suture). 

Additional Steps • Splint: A volar plaster slab is placed extending from the proximal forearm to the tips of the fingers. The wrist and hand are immobilized in the position of safety (see Postoperative Care section). • Weight-bearing status: Non–weight bearing of the affected hand continues until clinical/radiographic fracture union. • Follow-up: Fracture healing is monitored both clinically and radiographically. • Rehabilitation: When the fixation is deemed stable, early controlled active ROM out of the splint is recommended started at the first postoperative visit (∼10–14 days). 

ORIF OF PERIARTICULAR FRACTURES AND DISLOCATIONS OF THE CMC, MCP AND IP JOINTS OF THE HAND Illustrative Examples • Open Reduction and Internal Fixation of First CMC Joint Fracture-Dislocations (Bennett Fracture) • Open Reduction and Internal Fixation of PIP Joint Fracture-Dislocations  PITFALLS

• ORIF is possible only if the marginal fragment is large enough for internal fixation (> 20% of the articular surface, minimal comminution).

PROCEDURE: OPEN REDUCTION AND INTERNAL FIXATION OF FIRST CMC JOINT FRACTURE-DISLOCATIONS (BENNETT FRACTURE) Specific Indications • Failure of closed reduction • Metacarpal shaft displacement

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

TREATMENT OPTIONS

After review of imaging studies (Fig. 27.26), the treatment plan is formulated: • Thumb spica casting for undisplaced Bennett’s fractures • Closed reduction and percutaneous pinning (CRPP) • Open reduction and internal fixation (after failure of CRPP or in chronic fractures; illustrated here) • External fixation

A

339

• Articular step > 2 mm • Impaction in the load-bearing aspect of the joint surface necessitates open reduction. • A relative indication to proceed with ORIF versus CRPP is a fracture fragment that involves > 25% to 30% of the articular surface. 

B

C

D

FIG. 27.26A–D  AP and lateral x-rays of an uninjured first CMC joint. The anatomy of the thumb CMC joint resembles two interlocking saddles (thumb metacarpal and trapezium), which allow motion parallel (abduction and adduction) and perpendicular (pronation and supination). (A) In the AP view, the trapezium is concave and the thumb metacarpal is convex. (B) In the lateral view, the trapezium is convex and the thumb metacarpal is concave. AP (C) and lateral (D) views of a Bennett fracture. From: Nikhil Oak, Jeffrey Lawton (2013), Hand Clinics, Intra-Articular Fractures of the Hand. 2013, Vol 24(4); 535-549.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

340

Flexor pollicis brevis (superior head) Abductor pollicis brevis Extended Wagner incision

Sensory branch of radial nerve Abductor pollicis longus metacarpal insertion

Flexor carpi radialis

A

C

B

FIG. 27.27A–C  (A) The extended Wagner incision, between the glabrous and nonglabrous skin of the thenar eminence. The incision begins at the midmetacarpal level and then curves proximally and ulnarly toward the radial side of the FCR tendon. (B) Note sensory nerve branch identification and protection before exposing the thenar musculature. (C) After retracting the thenar muscles, a longitudinal capsulotomy of the 1st CMC joint is performed exposing the fracture. Note: The sensory branch of the radial nerve, distal branches of the lateral antebrachial cutaneous nerve and the palmar cutaneous branch of the median nerve are all at risk with this exposure. From: James Calandruccio. Fractures, Dislocations and Ligamentous Injuries. Campbell’s Operative Orthopaedics. 2017, 3403-3461

PEARLS

• Care is taken to protect the sensory branches of the radial nerve, lateral antebrachial cutaneous nerve, and the palmar cutaneous branch of the median nerve (see Fig. 27.5). PEARLS

• The articular reduction need not always be perfectly anatomic, whereas reduction of the CMC joint subluxation is critical. • With K-wire fixation, it is not always necessary to secure the Bennett fragment as long as alignment is maintained (Fig. 27.28B). PITFALLS

• The radial artery is at risk in the first webspace when pinning the first metacarpal base to the second metacarpal base. • Compressive forces are 12 times greater at the CMC joint than the tip of the thumb, potentially leading to premature arthritis if incongruence is present at the CMC joint.

INSTRUMENTATION/IMPLANTATION

• Screw fixation permits early active ROM if adequate stability is achieved.

Portals/Exposures When ORIF is necessary: • A Wagner incision is used at the junction of the glabrous and nonglabrous borders of the skin. The incision begins at the mid-metacarpal level and then curves proximally toward the radial side of the FCR tendon (Fig. 27.27A). • The thenar muscles are elevated subperiosteally off the trapezium and first metacarpal and are retracted ulnarly. Fig. 27.27B). • A longitudinal capsulotomy of the 1st CMC joint is performed exposing the fracture (Fig. 27.27C) 

Procedure Step 1: Closed Reduction and Provisional Fixation • The reduction is performed with longitudinal traction, extension of the CMC joint, and pronation and abduction of the metacarpal, with pressure applied in an ulnar direction at the metacarpal base (Fig. 27.28A). • While maintaining traction, the reduction is checked with fluoroscopy. If acceptable, K-wires are placed; if not, a repeat attempt is made. If the second attempt is unsuccessful, an open reduction is performed. • If ORIF is necessary, the fracture is exposed as described earlier. Next: • The fracture is irrigated and any interposed soft tissue or fracture hematoma is removed. • The fracture is inspected and the fixation method (K-wires vs. screws) is selected. • The fracture is provisionally reduced and stabilized with K-wires or with the appropriately sized drill bit. • Several K-wire configurations are possible: most often either through the metacarpal base and into the trapezium or trapezoid or through the thumb metacarpal and into the index metacarpal (Fig. 27.28B). • Screws can be placed (one or two depending on the size of the fragment) to achieve interfragmentary compression. 

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

341

A

B FIG. 27.28A–B  (A) Reduction maneuver for Bennett fracture: 1. longitudinal traction and CMCJ extension, 2. pronation of the metacarpal, 3. Abduction and ulnarward pressure at the metacarpal base. (B) Possible K-wire placement options. Note that the fracture fragment needn’t necessarily be pinned. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

Step 2: Clinical and Radiographic Assessment of Reduction • AP, lateral, and oblique views of both thumbs should be obtained. • A true AP (Roberts) view is taken with the forearm in maximal pronation and the dorsum of the thumb resting on the image intensifier. The beam is then angled 15° from distal to proximal (Fig. 27.29A). • A true lateral (Gedda view) film of the thumb is one in which the sesamoids volar to the thumb MCP joint overlap each other. This is achieved by placing the palm on the image intensifier, then pronating the forearm 15° to 20°. The tube is then angled proximally ∼15° (Fig. 27.29B). 

342

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

A

15–20°

B FIG. 27.29A–B  (A) Robert’s (AP) view of the 1st CMC joint. (B) Gedda (lateral) view of the CMC joint (note: lateral border of the metacarpal is resting on the x-ray plate or image intensifier). Credit: corthopaedicpractice.com. 2010 Volume 21 (6)

Step 3: Definitive Fixation • If provisional K-wire fixation is in a satisfactory position, the wires are bent and cut outside of the skin. • If screw fixation is planned and fluoroscopic assessment of drill bit position demonstrates satisfactory reduction, the drill bit is removed, screw lengths are measured, and then screws inserted. 

Step 4: Final Assessment • Final fluoroscopic views are obtained to confirm reduction of the joint, hardware length, and position. 

Step 5: Closure • The wound is irrigated and hemostasis is ensured. • The capsulotomy is closed with 3-0 PDS (or similar, slow-resorbing suture). • The skin is closed as per surgeon preference (typically a 4-0 nonabsorbable monofilament suture). 

Additional Steps • Splint: A thumb spica splint is placed in the operating room. The patient is changed into a thumb spica cast (wrist in extension, CMC in palmar abduction, MCPJ slightly flexed and IPJ free) at the first postoperative visit. If screw fixation is used, a removable thumb spica splint may be fabricated to permit early active ROM if the fixation is stable enough to permit this. • Weight-bearing status: Non–weight bearing with the affected hand. Weight bearing is progressed following clinical and radiographic signs of union.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

343

• Follow-up: Postoperative films are assessed for maintenance of reduction and fracture union. Percutaneous wires are removed after clinical and radiographic confirmation of union (∼5–6 weeks). • Rehabilitation: Finger and thumb IPJ motion is encouraged while in the cast. Active ROM of the thumb commences upon removal of K-wires. 

PROCEDURE: OPEN REDUCTION AND INTERNAL FIXATION OF PIP JOINT FRACTURE-DISLOCATIONS Specific Indications • Failure of closed treatment to provide a congruent reduction of the joint. This includes most fractures that involve more than 40% of the volar articular surface. • Fracture stability is classified according to the percent of the articular surface of the base of the middle phalanx that is involved (Fig. 27.30): • < 30%: typically stable • 30% to 50%: tenuous, often unstable • > 50%: unstable, with associated dorsal subluxation • Significant articular depression, displacement, or incongruity • During fluoroscopic exam, if > 30° of flexion is required to reduce the subluxation, operative treatment is indicated. 

PITFALLS

• Subluxation may not be obvious on the lateral view. Look for the characteristic V sign of diverging joint surfaces (Fig. 27.31): • When the finger is held in extension, the dorsal cortices of P1 and P2 should be colinear on the lateral view (Fig. 27.32). • Rigid fixation of these fractures may permit early, active ROM, which is critical for preventing stiffness.

CONTROVERSIES

• A concentric PIPJ reduction takes precedence over restoring anatomic joint congruity.

TREATMENT OPTIONS Unstable Tenuous Stable

FIG. 27.30  Radiographic assessment of PIPJ stability following fracture-dislocation. Fractures involving less than 30% of the articular surfaces are typically stable. Fractures involving 30 – 50% of the articular surface may be stable or unstable and are classified as “tenuous”. Fractures involving greater than 50% of the articular surface are unstable and demonstrate dorsal subluxation. From: Neligan P. Plastic surgery. Elsevier Saunders; 2013.

“V” sign

FIG. 27.31  PIPJ injury demonstrating dorsal subluxation of the joint and the lateral “V” sign. From: Neligan.

• Dorsal block splinting • Dorsal block pinning • Dynamic or static external fixation • Bridge plate (with subsequent removal of hardware) • Cerclage wiring • ORIF with K-wire or screw fixation (illustrated here) • Volar plate arthroplasty • Hemi-hamate arthroplasty

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

PEARLS

• Attempt to preserve the A2 and A4 pulleys. They may be partially resected for exposure; however, it is advisable to maintain at least one-half of each pulley to prevent postoperative bowstringing. • If the injury pattern necessitates takedown of either the A2 or A4 pulley, it should be reconstructed prior to wound closure. • When retracting the flexor tendons to expose the volar plate: it is often easier to retract the flexor digitorum profundus (FDP) and one slip of FDS one way, while retracting the other slip of flexor digitorum superficialis (FDS) in the opposite direction. These tendons should be gently retracted with blunt retractors or a Penrose drain. PEARLS

• Adequate exposure may not always require releasing both collateral ligaments (see Fig. 27.35). • Be willing and prepared to change your surgical plan if the degree or extent of comminution makes ORIF impossible: consider cerclage wiring or dynamic external fixator application with extensive comminution. Hemihamate arthroplasty should be considered in the case of significant volar bone loss, as is often seen in chronic/missed injuries. PITFALLS

• After elevation of the bony fragment, any bony defects should be bone grafted with local bone (if available) or autogenous distal radius bone graft. Failing to do so may result in recurrent dorsal subluxation of the middle phalanx. INSTRUMENTATION/IMPLANTATION

• Have implants available for multiple surgical options: the surgical plan may change intraoperatively after exposure, débridement and assessment of the fracture.

FIG. 27.32  (A) PIPJ injury demonstrating dorsal subluxation. The “V” sign is present and the dorsal cortices are not collinear with the finger in extension. (B) Restoration of joint alignment following successful treatment. From: James Calandruccio. Fractures, Dislocations and Ligamentous Injuries. Campbell’s Operative Orthopaedics. 2017 3433-3461

Portals/Exposures • A dorsal approach may be used when the fracture is primarily dorsal. An extensor tendon splitting approach (see Fig. 27.14), extensor tendon reflecting (Chamay) approach, or extensor mechanism sparing approach may be used depending on the extent of exposure required. • A volar (Bruner) is used for volar comminution (most common scenario, illustrated here; Fig. 27.33) • A volar Bruner incision is made, centered over the PIPJ, extending from the MCPJ crease to the DIPJ crease. • The flexor tendon sheath is exposed and the radial and ulnar neurovascular bundles are identified, mobilized, and then retracted. • A rectangular flap is created in the flexor tendon sheath (including the A3 pulley) over the PIP joint, between the A2 and A4 pulleys (Fig. 27.33C–D). • The flexor digitorum profundus and flexor digitorum superficialis tendons are retracted to expose the volar plate. • The accessory collateral ligaments are released (Fig. 27.34A) • The joint is exposed by incising the volar plate distally, leaving a cuff of tissue for subsequent repair. This transverse incision is followed by longitudinal incisions, radially and ulnarly, thereby creating a proximally based flap (Fig. 27.34B). 

Procedure Step 1: Reduction and Provisional Fixation • Hyperextension of the joint exposes the volarly based fracture fragment of the middle phalanx articular surface (Fig. 27.35). • The fracture is irrigated and carefully débrided of any interposed soft tissues or fracture hematoma with a dental pick.

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

A

B

C

D FIG. 27.33A–D  (A) Marking for volar Bruner incision. (B) Exposed flexor tendon sheath with neurovascular structures on either side after elevation of the skin flap. The pulleys are marked with black dashed lines and the ulnar digital neurovascular bundle is marked with a red dashed line (note: the radial bundle is being protected by the Ragnell retractor). (C) The flexor tendons are exposed after a laterally based flap of the C1, A3 and C2 pulleys is designed (dotted with the black marker) and (D) raised and reflected (arrow denotes reflected flap and asterisks mark the vented A2 and A4 pulleys). From: Cheah J, Yao J. Surgical approaches to the proximal interphalangealJoint. J Hand Surg Am 2016; 41 (3); 294-305

FIG. 27.34  (A) Release of ulnar accessory collateral (dashed line demarcates area of release) from volar plate (*). (B) A proximally based flap in volar plate is created. It is then reflected proximally (*) exposing the PIP joint (*). From: Cheah AE, Yao J. Surgical Approaches to the Proximal Interphalangeal Joint J Hand Surg Am. 2016;41(2):294-305.

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

FIG. 27.35  The PIPJ is ‘shotgunned’ open following the release of one or both collateral ligaments. In this instance, one collateral ligament is released proximally (*), and one is left intact (dashed line). The volar plate in marked with a ‘*’, while the ulnar digital nerve is marked with a black arrow. From: Surgical Approaches to the Proximal Interphalangeal Joint Andre Eu-Jin Cheah, Jeffrey Yao, J Hand Surg Am. 2016;41(2):294-305.

• Impacted areas of the joint surface are carefully elevated (Fig. 27.36A–B). • The size of the fragment(s) is evaluated to determine whether screw fixation is feasible. For smaller fragments, cerclage wiring may yield satisfactory results (Fig. 27.36B). • If screw fixation is feasible, the fragment is reduced and is often held in place with direct pressure applied by the surgeon’s thumb. • The drill bit is placed perpendicular to the fracture where possible, and the drill bit is left in situ to assess reduction fluoroscopically. Alternatively, if the fragments are delicate and the joint is congruent on inspection, measure and place the screw prior to fluoroscopic assessment. 

A

B

FIG. 27.36  (A) After exposing the joint, the fracture is evaluated and the treatment plan is selected. (B) The joint surface is carefully elevated and then secured (cerclage wire used here). From: Fig 7c and 8a Oak N. Lawton JN. Intra-Articular Fractures of the Hand. Hand Clin; 2013;29:535–549

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

Step 2: Clinical and Radiographic Assessment of Reduction • PA, lateral, and oblique views of the joint are obtained. • Hardware length is scrutinized to avoid undue irritation to the dorsal extensor tendons. 

Step 3: Definitive Fixation

347

PEARLS

• Screw fixation should not be attempted for fracture fragments that are small or very comminuted. As a rough guide, the fragment should be at least three times the size of the screw diameter.

• If screws are used: measure screw lengths and, if uncertain, confirm screw length with depth gauge in situ on fluoroscopy. • Place screw(s). 

PITFALLS

• A small fragment may be split by a too-large screw; conversely, a K-wire alone may not provide sufficient stability. CONTROVERSIES

Step 4: Final Assessment • After screw or K-wire insertion, check a lateral radiograph to ensure that the hardware does not violate the extensor mechanism (Fig. 27.37). 

• Some authors repair the A3 pulley, while others do not, citing concerns that suture repair may contribute to the formation of additional postoperative adhesions.

FIG. 27.37  Lateral views of (A) cerclage wire fixation and (B) screw fixation. From: 8b - Oak N. Lawton JN. Intra-Articular Fractures of the Hand. Hand Clin; 2013;29:535–549

Step 5: Closure • Following fixation, the volar plate is repaired with a 4-0 nonabsorbable braided suture. • The tendons are placed back into the fibro-osseous tunnel. The A3 pulley is not repaired and the rectangular flap is reapproximated over the tendons prior to skin closure. • The skin is closed as per surgeon preference. 

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PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

Additional Steps • Splint: Splint in safe position (see Postoperative Care section). Transition out of bulky postoperative splint to a hand-based splint within 3 to 5 days of surgery. • Weight-bearing status: Non–weight bearing with the affected hand. Weight bearing is progressed following clinical and radiographic signs of union. • Follow-up: Careful monitoring of postoperative radiographs for the V sign, to ensure maintenance of reduction. Patients are counselled on expected outcomes, based in part on their intraoperative findings and in part on available evidence: functional stability is often achieved, but a return of a full of arc of motion is rare. • Rehabilitation: The surgeon’s comfort with the stability of the fixation will determine when early ROM may begin. Typically, early active flexion begins under hand therapy guidance at the first postoperative visit. Early postoperative visits provide an essential opportunity to reinforce the importance of hand therapy to optimize postoperative function. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Postoperative Care • In general, the hand must be immobilized in the position of safety: • 30° of wrist extension. • 70° to 90° of MCP flexion. • Interphalangeal joint in full extension. • Whenever possible, fracture fixation should allow early, controlled, active mobilization. • Patients will typically be non–weight bearing on the injured extremity. • Instruct patients to keep the limb elevated for the first 24 to 48 hours (and then as needed) to minimize postoperative swelling. 

Expected Outcomes

POSTOP PEARLS

• Have the patient assessed by a hand therapist at the first post-op visit. Hand therapists play an invaluable role in patient education and rehabilitation. Consider hand therapy referral for any (or all of) the following: splint fabrication, edema management, scar management, as well as for instruction and guidance on rehabilitation exercises. • Counsel patients that they may need removal of hardware and tenolysis, particularly following implantation of any plates in the hand. • Most fracture patterns often require “3 views” on post-op radiographs to adequately assess fracture healing: PA, lateral and oblique views.”

• Robust outcome studies comparing different forms of fracture fixation are largely lacking in the literature. • It is agreed upon that extra-articular shaft fractures have generally favorable outcomes, regardless of the mode of treatment. • Whereas nonsurgical treatment may lead to higher rates of malunion and immobilization-related stiffness, operative treatment risks infection and prominent hardware or tendon adhesions/rupture. • Intra-articular fractures, and particularly fracture-dislocations of the PIP and CMC joint of the fingers, have uniformly less favorable outcomes compared with their extra-articular counterparts. • Fracture-dislocations of the first CMC joint fair better than those of the fingers, potentially due to the thumb’s multiplanar arc of motion. • Although operative fixation (CRPP or ORIF) is generally recommended for significant fracture displacement or articular incongruity, such recommendations are controversial and are based on smaller case series. • While there is currently a lack of high-level evidence available to guide treatment, conventional wisdom and orthopaedic fracture management principles still apply; namely, timely diagnosis and appropriate treatment, which permits an early return to active ROM, will often yield the most favorable outcome for the patient.

POSTOP PITFALLS

• Inadequate edema control may contribute to postoperative wound healing problems and will invariably delay mobilization. • Not recognizing or dismissing the early signs of chronic regional pain syndrome (CRPS): • Burning or throbbing pain • Disproportionate pain • Sensitivity to touch or cold • Cutaneous changes: shiny skin, altered nail or hair growth, discoloration • Alteration in skin temperature: increased perspiration, cold or mottled hand

PROCEDURE 27  Open Reduction and Internal Fixation of Fractures and Dislocations of the Hand

POSTOP INSTRUMENTATION/IMPLANTATION

• Percutaneous K-wires are typically removed in the clinic. POSTOP CONTROVERSIES

• A delicate balance exists between preventing stiffness and adequately protecting the fracture while healing – the surgeon’s comfort with the stability of the fixation achieved should guide this decisionmaking. It is important to communicate any concerns with the overall stability of the fixation to the hand therapist looking after the patient.

EVIDENCE Bloom JMP, Hammert WC. Evidence-based medicine: metacarpal fractures. Plast Reconstr Surg. 2014;133:1252–1260. This is a recent literature review of best available evidence for the management of metacarpal fractures. The authors review studies investigating non-operative management, operative management and non-operative vs. operative management. They present papers with levels of evidence ranging from I to V. They discuss study limitations for several of the works presented ranging from study design, to limited sample sizes, to lack of use of standard outcome measures. Cheah AE, Yao J. Surgical approaches to the proximal interphalangeal joint. J Hand Surg [Am]. 2016;41(2):294–305. Excellent clinical photographs of surgical exposures of the PIP joint. Gonzalez RM, Hammert WC. Dorsal fracture-dislocations of the proximal interphalangeal joint. J Hand Surg [Am]. 2015;40(12):2453–2455. This recent paper reviews recent evidence for the management of dorsal fracture-dislocations of the PIP joint. They observed that most of the evidence was limited to retrospective or prospective case series, with limited number of patients and follow-up. They also commented that many studies have mixed cohorts (both acute and chronic injuries) as well as different injury patterns (e.g. pilon type fractures of the base of the middle phalanx), making it difficult to compare techniques. Jupiter J, Ring DC, eds. AO Manual of Fracture Management: Hand and Wrist. New York: Thieme; 2005. For readers looking for a more comprehensive review of the management of fractures of the hand, the relevant chapters in Green’s (Chapters 7 and 8) as well as the AO Manual will serve as a useful starting point. While not exclusively evidence based, Green’s chapters do summarize classic and current literature on expected outcomes utilizing the techniques described. The AO Manual is a succinct guide to the management of numerous fracture patterns and clearly illustrates key principles for successful fracture management. Middleton SD, McNiven N, Griffin EJ, Anakwe RE, Oliver CW. Long-term patient-reported outcomes following Bennett fractures. Bone Joint J. 2015;97-B(7):1004–1006. This retrospective case series evaluated long-term outcomes following K-wire fixation of displaced Bennett fractures treated. At a mean follow-up time of 11.5 years (range: 3.4 to 18.5), the 62 patients available for follow-up reported “excellent functional outcomes and high levels of satisfaction”. Outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in addition to a satisfaction questionnaire. Level of Evidence: Therapeutic IV. Nuland K, Charette R, Rodner CM. Operative treatment of unstable long oblique proximal phalanx fractures. J Hand Surg [Am]. 2016;41(1):120–121. This brief review looks at some of the available evidence to guide the treatment of displaced, phalangeal shaft fractures. The authors conclude that evidence regarding operative treatment of proximal phalanx fractures is limited to underpowered, retrospective case series, that often combine different fracture patterns, and may address very specific procedures. They note that the literature does not support the routine use of plate and screw fixation in treating proximal phalanx fractures. They also report that the current evidence does not demonstrate the superiority of CRPP over screw-only fixation (or vice versa) in the treatment of proximal phalanx fractures. Sammer DM, Husain T, Ramirez R. Selection of appropriate treatment options for hand fractures. Hand Clin. 2013;29(4):501–505. This provides a brief overview of levels of evidence in the literature, while acknowledging that for ORIF of hand fractures there is a paucity of high-quality randomized controlled trials. In the absence of high-level evidence, the authors advocate a principle based approach for surgeons to apply when managing hand fractures and provide evidence in support of these principles. The four principles reviewed are: Anatomic reduction of articular fractures, restoration of anatomic relationships in extra-articular fractures, stable fixation that minimizes soft tissue injury and institution of early motion. They conclude by cautioning that though current evidence to guide clinical decision-making is relatively low, this does not mean that current evidence is not useful, rather that extra care should be given to how this evidence is interpreted and applied. Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Philadelphia: Elsevier; 2016.

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PROCEDURE 28

Femoral Neck: Closed Reduction and Internal Fixation (CRIF) Mohit Bhandari, Herman Johal, and Mark Phillips INDICATIONS • Minimally displaced or displaced femoral neck fractures (AO Type 31-B1, B2, or B3) •  Anatomic closed reduction can be achieved using a fracture table or manual reduction. • Patient is ambulatory. 

INDICATIONS PITFALLS

• Risk of avascular necrosis increases with fracture displacement. • Risk of nonunion increases with the Pauwel angle. • Consider the use of cancellous screws for fixation for Pauwel type I and type II fractures with good bone quality. • Consider the use of a sliding hip screw for fixation for Pauwel type II and type III osteoporotic, base of neck, displaced, or comminuted fractures. • For older, osteoporotic patients or those with substantial fracture displacement, hip arthroplasty (total or hemi-arthroplasty) may be a better option.

INDICATIONS CONTROVERSIES

• The orthopedic community lacks consensus regarding an optimal fixation method between sliding hip screw and cancellous screws for femoral neck fractures. • Cancellous screws may provide greater torsional stability, yet may result in implant failure due to bending and vertical shear loads. • Sliding hip screws may provide greater fracture stability, yet they may be associated with a higher risk of nonunion compared to cancellous screws (Bhandari et al., 2009).

TREATMENT OPTIONS

• Closed reduction and fixation using a sliding hip screw (SHS). • Closed reduction and fixation using cancellous screws (typically, three partially threaded cancellous screws in an inverted triangle formation) (FAITH Investigators, 2017).

EXAMINATION AND IMAGING • Clinically, the patient’s fractured limb is typically shortened and externally rotated. • Both anteroposterior (AP) and lateral radiographs should be assessed to determine fracture displacement. • These two imaging angles are also important in determining appropriate placement of the internal fixation devices—either cancellous screws or sliding hip screw (SHS). 

SURGICAL ANATOMY • A majority of the blood supply to the femoral head typically comes from the medial femoral circumflex artery through three to four branches (retinacular vessels) that run posteriorly and superiorly along the femoral neck (Fig. 28.1). • The blood supply to the femoral head is at risk from fracture displacement as well as during fixation. • The collum-center-diaphysis (CCD) angle formed by the angle of the femoral neck and shaft is an important measurement, particularly for the SHS, to ensure appropriate implant positioning. • A radiograph of the uninjured contralateral side can help with preoperative measurement. 

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PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

3

4

1 2

A

B FIG. 28.1  From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449.

POSITIONING • Patients can be positioned using a fracture table or a conventional table. • On a fracture table, the patient is typically supine, with the contralateral leg flexed and externally rotated at the hip and held in a leg positioner. Alternately, the patient is placed in a traction boot and scissored (flexed or extended) to facilitate fluoroscopy access (Fig. 28.2). • On a conventional radiolucent table, the patient is typically supine with a folded sheet placed under the injured hip to facilitate surgical access and intraoperative imaging. • The ipsilateral arm is best positioned elevated and secured across the chest. • The pelvis should be raised using a folded sheet under the ipsilateral buttock and placed on the edge of the table if using a conventional table. 

FIG. 28.2  From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449.

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PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

POSITIONING PEARLS

• Lateral positioning could be used in obese patients to provide easier access to the proximal femur. • Free-draping the surgical leg can facilitate conversion to open reduction of the femoral neck through either an anterolateral (modified Hardinge) or separate anterior (Smith-Peterson) approach. • As part of positioning, ensure that reduction can be achieved with traction of the involved limb by examining with fluoroscopy prior to prepping and draping. The surgeon can plan for the use of intraoperative adjuncts based on the quality of reduction achieved.

POSITIONING PITFALLS

• Intraoperative imaging may be compromised if the contralateral limb was not positioned appropriately to allow fluoroscopic access. • If free draping the leg on a conventional table, ensure that adequate assistance is available to provide traction to obtain and maintain a reduction intraoperatively.

POSITIONING EQUIPMENT

• Fracture table (or conventional table with folded blankets if fracture table is not available) • If positioning lateral, a beanbag and/or kidney bolsters will be needed to secure and maintain a lateral decubitus position.

POSITIONING CONTROVERSIES

• Positioning on a fracture table versus a conventional table has not been directly examined. Both techniques are acceptable based on resources and equipment availability.

PORTALS/EXPOSURES • Following closed reduction, a lateral approach should be used to insert the SHS or cancellous screws. • The lateral approach can be performed using an incision starting at the greater trochanter and extending distally. • The incision splits the skin, subcutaneous tissue, and the iliotibial tract in line with the long axis of the femur. The vastus lateralis can either be split or preserved by being elevated anteriorly. 

PORTALS/EXPOSURES PEARLS

• Alternatively, cancellous screws may each be placed percutaneously through a stab wound and guided by fluoroscopy.

PORTALS/EXPOSURES PITFALLS

• If elevating the vastus lateralis (as opposed to splitting), watch for perforating branches of the deep femoral artery coming through the fascia. These may retract behind the fascia and continue to bleed if not managed appropriately.

PORTALS/EXPOSURES EQUIPMENT

• Broad retractors (Bennett or wide Hohmann retractors) assist in retraction of the vastus lateralis.

PORTALS/EXPOSURES CONTROVERSIES

• N/A

PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

PROCEDURE Step 1: Closed Reduction • Apply traction along the long axis of the femur. • Following traction, the leg should be internally rotated to achieve reduction. 

STEP 1 PEARLS

• If simple traction and internal rotation does not achieve reduction, the Leadbetter maneuver can also be used. • Start with the leg in abduction with lateral traction and external rotation. Then, bring the leg back to the neutral position though internal rotation. Decrease the traction to allow impaction of the fragments. In cases that do not reduce easily, repeated and vigorous attempts must be avoided and open reduction is indicated.

STEP 1 PITFALLS

• Avoid repeated vigorous attempts at closed reduction. • In the case that adequate reduction was not achieved, open reduction must be used (Ghayoumi et al., 2015).

STEP 1 INSTRUMENTATION/IMPLANTATION

• The result needs to be checked using AP and lateral imaging to ensure appropriate reduction.

STEP 1 CONTROVERSIES

• N/A

Step 2: Guidewire Insertion • Use the C-arm AP view to determine the CCD angle (Fig. 28.3). • SHS: Insert central guidewire using the appropriately angled wire insertion guide (based on preoperative measurement of CCD angle of the contralateral hip). • The central guidewire should enter the femoral head subchondral bone and reach to roughly 1 cm short of the articular surface (Fig. 28.4). • Cancellous screws: The guidewires may be placed either freehand or using an aiming device. • If an aiming device is used, a central guidewire may need to be placed first to position the aiming device. This is followed by placing an additional three wires (one for each cancellous screw) peripherally around the central wire. One wire is placed inferiorly and two are placed superiorly in an inverted triangle. • Once the three screw guidewires are placed, the central wire and aiming device can be removed. • If placing wires freehand, begin with the inferior guidewire, placed along the inferior border of the femoral neck (calcar), to allow it to work as a buttress. The superior wires are then placed parallel to the first wire. 

STEP 2 PEARLS

• A guidewire may be placed along the anterior femoral neck as a reference for anteversion. • An additional reference point for femoral neck anteversion includes the perineal post if the fracture table is used. • SHSs: The guidewire should be placed in a central position in both AP and lateral planes to achieve a tip-apex distance (TAD) of < 25 mm with the final construct. This is measured by adding the distance between the tip of the SHS to the apex of the femoral head on both the AP and lateral fluoroscopic images. • Cancellous screws: Ensure that the three guidewires are placed as peripherally as possible within the femoral neck to achieve the most stable construct using cancellous screws (Baumgaertner et al., 1995).

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PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

STEP 2 PITFALLS

• Avoid intraarticular breach of the wires (and screws) by using fluoroscopy to ensure that the guidewires sit within the femoral head in all planes. • SHS: If the screw is not placed in the center of the femoral head (i.e., TAD > 25 mm), there is a possibility of failure due to screw cutout (Fig. 28.5). • The chance of failure due to cutout of the SHS is of greater concern for osteoporotic bone. • An antirotation wire (and/or cancellous screw) may need to be placed proximal to the central SHS guidewire to prevent fracture displacement (rotation) during SHS insertion. This should be placed parallel to the initial wire placed. • Cancellous screws: Ensure that the peripherally placed wires do not breach the femoral neck along their course. The posterior, superior wire is at particularly high risk and may need to be placed slightly lower to optimize its position and rigidity of the construct. • Nonparallel placement of the guidewires may compromise the ability of the fracture to compress and heal.

STEP 2 INSTRUMENTATION/IMPLANTATION

• Instruments available in each of the SHS and cancellous screw sets. • Ensure that the appropriate-diameter threaded guidewires are used to facilitate the rest of the cannulated instrumentation for the particular set being used.

STEP 2 CONTROVERSIES

• It is possible to use either two or four cancellous screws for internal fixation; however, evidence has shown that the inverted-triangle formation with three screws is optimal.

FIG. 28.3  From Huppertz A, Radmer S, Wagner M, Roessler T, Hamm B, Sparmann M. Computed tomography for preoperative planning in total hip arthroplasty: what radiologists need to know. Skeletal Radiol. 2014;43(8):1041– 1051. doi:10.1007/s00256-014-1853-2.

PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

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FIG. 28.4 From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448– 449.

Step 3: Screw Predrilling • SHS: Predrill hole to the desired length of the screw (approximately 1 cm away from the subchondral bone) using a cannulated reamer tool (Fig. 28.6) • Cancellous screws: Three holes should be predrilled over the placed guidewires with a cannulated drill bit. Typically, only the lateral cortex needs to be drilled due to the osteoporotic nature of the bone. 

Xap

STEP 3 PEARLS

• Use the drill on forward, even when removing the drill, to avoid losing the treaded guidewire placement. • SHS: Measure the length of the guidewire to set the cannulated reamer tool to the appropriate depth and avoid overreaming. • Ensure that the shoulder of the reamer engages the lateral cortex to facilitate the barrel of the SHS plate.

STEP 3 PITFALLS

• In younger patients with higher-quality bone, the entire length of the wire (up to the threads) may need to be drilled and tapped prior to screw insertion to avoid fracture displacement or rotation (Gupta et al., 2016; Slobogean et al., 2015).

Dap

Xlat

STEP 3 INSTRUMENTATION/ IMPLANTATION Dlat

FIG. 28.5 From Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg. 1995 Jul;77(7):1058–1064.

• N/A

STEP 3 CONTROVERSIES

• N/A

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PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

Step 4: Screw Insertion

STEP 4 PEARLS

• SHS: If additional rotational stability is required, an antirotation wire and cannulated screw can be placed above the SHS. This screw must be parallel to the SHS in both the AP and lateral planes, and inserted prior to the SHS. • Cancellous screws: The order of screw insertion can modulate reduction if needed, with the initial screw being placed where any residual distraction still exists. • Partially threaded screws should be used to achieve compression at the fracture site. The length of the threads (typically 16 mm vs. 32 mm) should be chosen to ensure that all threads cross the fracture site. • Only in cases of significant comminution along the neck may fully threaded screws prove beneficial, as this may prevent excessive shortening at the fracture site. • Washers may be placed with the cancellous screws to prevent breach at the lateral femoral cortex.

• SHS: The screw is then placed using the T-handle insertion tool and inserted along the guidewire (Fig. 28.7). • Once the screw has been inserted completely, the T-handle of the insertion tool must typically be parallel to the long axis of the femur to accommodate placement of the SHS side plate in the next step (Fig. 28.7). • Cancellous screws: Three cancellous screws should be inserted over the guidewires to ensure accurate placement. The size of these screws can range from 6.5 to 8.0 mm depending on the manufacturer (Fig. 28.8). 

STEP 4 PITFALLS

• Careless/forceful insertion of the screw may lead to fracture distraction. • Risk of nonunion increases with fixation rigidity.

STEP 4 CONTROVERSIES

• Use of fully threaded cancellous screws should be done with caution, due to the increased risk of fracture site nonunion.

FIG. 28.6 From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449.

FIG. 28.7  From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449.

PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

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FIG. 28.8  From Satish B, Ranganadham A, Ramalingam K, Tripathy S. Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients. Indian J Orthop. 2013;47(2):174. doi:10.4103/0019-5413.108912.

Step 5: SHS Plate Application • A typical SHS plate construct will consist of a two-hole plate for distal fixation. The plate should match the CCD angle chosen for the initial guidewire insertion. • The barrel of the plate is positioned over the lag screw that has already been inserted (using the guidewire for alignment). • Use an impactor to position the plate over the screw and along the lateral cortex of the femur. • Two cortical screws are then placed distally in the plate to affix the plate in place (Fig. 28.9). 

STEP 5 PEARLS

• Proper alignment for the T-handle during lag screw insertion (in line with the long axis of the femur) facilitates easy insertion of the SHS barrel and side plate. • Once the barrel is placed over the lag screw, ensure that the remainder of the plate sits appropriately in line with the femoral shaft. It can be rotated slightly to adjust if needed, however attention must be paid to ensure that the fracture is not malrotated in doing so.

STEP 5 PITFALLS

• If the initial guidewire was not placed at the correct CCD angle, placement of the SHS side plate may malreduce the fracture with respect to varus or valgus alignment.

STEP 5 CONTROVERSIES

• Longer side plates may be used but do not offer an additional advantage.

FIG. 28.9 From Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449.

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PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF)

Additional Steps • SHS: An additional cannulated screw can be placed directly above (and parallel to) the SHS if added rotational stability is desired. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The overall goals of postoperative care for femoral neck fracture patients is to ensure appropriate healing without complication. • Returning hip function is also a top priority, which may be aided by physical therapy.

POSTOP PEARLS

• Internal fixation is a less invasive procedure than arthroplasty, which may allow for a more optimal recovery period.

POSTOP PITFALLS

• The major complications associated with femoral neck fracture management include delayed/nonunion, avascular necrosis, and revision owing to implant failure (FAITH Investigators, 2017; Gupta. et al., 2016). • Internal fixation has shown relatively high rates of reoperation, which are continually being investigated for streamlining of procedures to limit the their reoperation rates (Swiontkowski et al., 1987).

POSTOP INSTRUMENTATION/IMPLANTATION

• N/A

POSTOP CONTROVERSIES

• There is a lack of consensus regarding the postoperative outcome differences between SHS use and cancellous screw use within the orthopedic community despite an increasing volume of evidence investigating this comparison (Bhandari et al., 2009; Slobogean et al., 2015). • There is evidence that shows a possible benefit of SHS versus cancellous screws regarding a decrease in the need for revision surgery for certain patient populations (FAITH Investigators, 2017).

EVIDENCE Bhandari M, Tornetta P, Hanson B, Swiontkowski MF. Optimal internal fixation for femoral neck fractures: multiple screws or sliding hip screws? J Orthop Trauma. 2009;23(6):403–407. This study presents a comprehensive systematic review of literature regarding internal fixation methods for femoral neck fractures. It provides justification and evidence of outcomes following both SHS and cancellous screw fixation, as well as the biologic rationale behind these treatments. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg. 1995;77(7):1058–1064. This study specifically highlights the importance of tip to apex measurements when conducting internal fixation for hip fractures. This measurement is a valuable tool in determining and preventing the possibility for future failure of fixation. FAITH Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017. epub ahead of print. The FAITH trial is the largest trial to date investigating the use of cancellous screws or sliding hip screws for hip fracture fixation. The results demonstrated that sliding hip screws showed no advantage over cancellous screws with respect to reoperation rates, however; some groups of patients (smokers and those with displaced or base-of-neck fractures) might do better with a sliding hip screw than with cancellous screws. Ghayoumi P, Kandemir U, Morshed S. Evidence based update: Open versus closed reduction. Injury. 2015;46(3):467–473. Open reduction was shown to not provide significant benefit when closed reduction is an option. This provides crucial information suggesting that closed reduction should always be considered first and open reduction used only if closed reduction cannot feasibly be achieved. Gupta M, Arya R-K, Kumar S, Jain V-K, Sinha S, Naik A-K. Comparative study of multiple cancellous screws versus sliding hip screws in femoral neck fractures of young adults. Chinese J Traumatol. 2016;19(4):209–212.

PROCEDURE 28  Femoral Neck: Closed Reduction and Internal Fixation (CRIF) This study is one of the most recent investigations comparing cancellous screws and SHSs. Their results demonstrated similar results for both internal fixation methods within younger patients. This evidence is important in demonstrating the unclear differences of outcomes between SHSs and cancellous screws within this population. Hodgson S. AO principles of fracture management. Ann R Coll Surg Engl. 2009;91(5):448–449. The AO Principles of Fracture Management series provides an incredibly comprehensive review of the techniques and options for closed reduction and internal fixation. This resource provides much of the technical information found within this chapter regarding the procedures and steps required for internal fixation using both a SHS or cancellous screws. Slobogean GP, Sprague SA, Scott T, McKee M, Bhandari M. Management of young femoral neck fractures: Is there a consensus? Injury. 2015;46(3):435–440. The qualitative analysis of surgeon perceptions regarding femoral neck fracture management in the young provides a valuable overview of perceptions within the orthopedic community. This survey demonstrated that cancellous screws are the preferred treatment option for undisplaced fractures, while there is no consensus regarding the use of sliding hip screws or cancellous screws for internal fixation of displaced femoral neck fractures. Swiontkowski MF, Harrington RM, Keller TS, et al. Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res. 1987;5:433–444. This investigation presents details regarding the strength and structural properties of internal fixation, and is one of the original articles to investigate the construct strength of internal fixation with screws. This study provides the rationale for the screw fixation methods used within this chapter.

359

PROCEDURE 29

Femoral Neck: Open Reduction and Internal Fixation Adrian Huang and Saam Morshed INDICATIONS CONTROVERSIES

• Multiple treatment options for displaced fractures in elderly individuals exist. A history of groin pain and/or radiographic evidence of degenerative joint disease may favor arthroplasty over internal fixation in this group of patients.

360

INDICATIONS • Displaced fractures of the femoral neck in physiologically young adults (< 65 years of age) 

EXAMINATION AND IMAGING • Clinical Examination • History of presenting illness • Young patients typically present with high-energy trauma, such as a motor vehicle accident or a fall from height, while elderly patients have a history of a low-energy mechanism, such as a ground-level fall. • Subjective • The patient will complain of groin pain, though pain may also be referred to the knee. • Objective • Patients may hold the affected extremity in a position of flexion and external rotation. • Shortening of the injured leg is usually present. • Palpation of the greater trochanter and pubic rami may elicit tenderness and can provide clues as to the nature of the injury (intertrochanteric versus femoral neck fracture and associated injuries, such as pubic rami fractures). • “Logrolling” (internal and external rotation in an extended position) and axial loading of the affected leg produces significant pain and should be done with care. • Elderly individuals with a femoral neck fracture owing to a low-energy fall should have a thorough head-to-toe examination. In addition, appropriate laboratory and radiographic investigations should be ordered to rule out any underlying causes of the trauma (e.g., transient ischemic attack/cerebrovascular accident, congestive heart failure, myocardial infarction) as well as any associated injuries, such as subdural hematoma and ipsilateral upper extremity injury. • Similarly, young patients with hip fractures owing to high-energy trauma should be assessed and resuscitated according to Advanced Trauma Life Support (ATLS) guidelines. They should be thoroughly assessed for concomitant injuries with a high index of suspicion, especially ipsilateral long bone, pelvic, and spinal injuries. • Imaging • Standard imaging includes anteroposterior (AP) views of the hip with the hip in 15° of internal rotation (Fig. 29.1) and a shoot through the lateral view of the affected hip (Fig. 29.2) • The images should be evaluated for impaction, displacement, and posterior comminution (best appreciated on the lateral) as well as for signs of degenerative joint disease (i.e., joint space narrowing, osteophytes, subchondral cysts, or sclerosis) and associated pelvic ring injuries. • Comparison with the contralateral hip may allow detection of subtle impaction or displacement. • Images should be radiologically classified according to one of the following: • Garden Classification (Fig. 29.3).

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

FIG. 29.2 

FIG. 29.1 

Grade I

Grade II

Grade III

Grade IV

FIG. 29.3  From Browner BD, Jupiter JB, Levine AM, et al, editors: Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 4. Philadelphia, 2009, Elsevier



• Stage 1: Incomplete fracture • Stage 2: Complete fracture without displacement • Stage 3: Complete fracture with partial displacement • Stage 4: Complete fracture with full displacement • Pauwel Index (Fig. 29.4).

361

362

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

< 30°

30° – 50°

Type I

Type II

> 50°

Type III

FIG. 29.4  From Azar, Canale, and Beaty: Campbell’s Orthopaedics, ed 13. Philadelphia, 2017, Elsevier.







TREATMENT OPTIONS

• Multiple cannulated screws • Fixed-angle device (sliding hip screw [SHS], intramedullary nail, blade plate)



• Type 1: ≤ 30° • Type 2: > 30°, ≤ 50° • Type 3: > 50° • While the Garden classification is useful in classifying fractures as “stable” (1 and 2) or “unstable” (3 and 4), which can guide decision-making on the need for an open versus closed reduction, the Pauwel classification has been shown to be predictive of outcomes. • Computed tomography (CT) • CT may be used in the diagnosis of femoral neck fractures and is often already available for individuals involved in high-energy trauma who have undergone CT scanning of the pelvis. • The ability of CT to detect occult femoral neck fractures is dependent on slice thickness and image orientation and has been shown to be less accurate in diagnosis than magnetic resonance imaging (MRI). • Magnetic resonance imaging • MRI is as accurate as radionuclide bone scanning in the diagnosis of occult femoral neck fracture, with increased sensitivity when performed in the first 24 hours following injury. • It is useful in assessing for other causes of hip pain—including osteonecrosis, stress fracture, and neoplasia—in individuals with an atypical presentation. • MRI avoids the radioactive exposure associated with technetium bone scans and CT. 

SURGICAL ANATOMY • Osseous anatomy • The neck-shaft angle of the proximal femur in adults is 130° ± 7°. • The average anteversion of the femoral neck with respect to the shaft is 10°. • When viewed from the lateral side, the femoral neck lies anterior to the mid-axis of the proximal femur due to a large posterior overhang of the greater trochanter. • This must be kept in mind when inserting fixation devices to avoid posterior penetration of the femoral neck. • The calcar femorale is a dense, vertical plate of bone arising from the cortex under the lesser trochanter in the posteromedial femur and projecting laterally to the greater trochanter (Fig. 29.5).

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation



• It is thicker medially than laterally and is the site of origin of strong internal trabeculations that support the weight-bearing dome of the femoral head. • The calcar femorale acts to reinforce the posteroinferior femoral neck; unrecognized comminution of this region may lead to failure of fixation. • The weakest bone in the proximal femur lies in the anterosuperior region of the femoral neck and head. • Vascular anatomy (Fig. 29.6) • The arterial supply of the femoral neck and head consists of: • An extracapsular arterial ring at the base of the femoral neck formed by branches of the medial and lateral femoral circumflex arteries • The retinacular vessels, which originate from branches of the extracapsular ring that ascend into the femoral neck. The epiphyseal arteries arise from the subsynovial intracapsular arterial ring of which the lateral epiphyseal artery, the terminal branch of the medial femoral circumflex artery, supplies the majority of the femoral head. Intracapsular anastomosis of the retinacular vessels occurs to form the subsynovial intracapsular arterial ring.

Anterior

Medial

Calcar femorale

FIG. 29.5 

Subsynovial intraarticular (intracapsular) arterial ring Ascending cervical arteries

Anterior

Posterior

Foveal artery

Subsynovial intraarticular (intracapsular) arterial ring

Medial femoral circumflex artery

Ascending cervical arteries

Lateral femoral circumflex artery

Medial femoral circumflex artery

Femoral artery

A

B FIG. 29.6 

Lateral ascending cervical arteries

363

364

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

• The artery of the ligamentum teres (negligible importance in adults) • Close proximity of the retinacular arteries to the femoral neck puts these at risk during femoral neck fracture as well as during open reduction of these injuries. 

POSITIONING POSITIONING PEARLS

• Ensure that proper AP and lateral fluoroscopic images can be obtained prior to prepping and draping the extremity.

POSITIONING PITFALLS

• Avoid placement of radiopaque table clamps and positioning aids that may interfere with intraoperative fluoroscopy.

POSITIONING EQUIPMENT

• Closed reduction and internal fixation may be performed on a traction fracture table; however, open reduction and internal fixation (ORIF) of femoral neck fractures is recommended in the supine position on a radiolucent table regardless of the fixation method chosen in order to aid in manipulative reduction of the fracture (Fig. 29.7). • After induction of regional or general anesthesia and the placement of a Foley catheter, the patient is transferred to the radiolucent table. • A long hip bump should be placed under the ipsilateral hip; the leg should then placed on a radiolucent foam ramp. • The fluoroscopy unit is now positioned on the contralateral side to ensure that proper AP and lateral images of the affected hip can be obtained. • The entire extremity, from pelvis to toe, is prepped and free draped. • A traction pin may be placed, if required, in the distal femur. Traction using a 5/64thinch wire tensioned with a Kirschner bow is recommended. 

• A hip bump will allow the injured side to be elevated out of the plane of the well hip for improved cross-table lateral imaging.

POSITIONING CONTROVERSIES

• Supine on a fracture table versus freelegged prep. Those who advocate use of a fracture table will cite the lack of need for an assistant for maintaining traction and holding the reduction. Advocates of the free-legged technique will cite the ability to manipulate the extremity in multiple planes in order to facilitate reduction, particularly in more complex, unstable fracture variants.

FIG. 29.7 

PORTALS/EXPOSURES • Two options for exposures are available. The first uses a single incision for both reduction and fixation through an anterolateral Watson-Jones approach. The second uses a two-incision technique with an anterior approach to the hip for open reduction and a lateral approach to the femur for internal fixation. Choice depends on surgeon preference. • Single incision technique (Video 1) • Both open reduction and internal fixation can be achieved through a single skin incision. • A Watson-Jones anterolateral approach to the hip is used, as described by Ly and Swiontkowski. • Incision • A lateral incision is centered over the greater trochanter. From the proximal tip of the trochanter, the incision courses proximally and anteriorly toward the anterior superior iliac spine (Fig. 29.8) • Superficial dissection

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

365

FIG. 29.8 



• The fascia lata is incised in line with the skin incision. • The interval between the tensor fascia lata and gluteus medius is developed. The tensor fascia lata is retracted anteriorly while the gluteus medius is retracted posteriorly. • Deep dissection • The hip capsule is now visible and is split anteriorly over the femoral neck and dissected off the intertrochanteric ridge. • After open reduction of the femoral neck, internal fixation with either cannulated screws or SHS can be placed through this same incision. The origin of the vastus lateralis can be elevated from the intertrochanteric ridge allowing access to the lateral wall of the proximal femur. • Two-incision technique (Video 2) • A two-incision technique involving an anterior approach to the hip combined with a lateral approach to the proximal femur is used for ORIF of femoral neck fractures. • The anterior approach to the hip is used for open reduction while the lateral approach to the proximal femur is used for implant placement. • We prefer the Molnar-Routt modification of the anterior approach to the hip. • Incision • This modified Smith-Petersen exposure uses only the caudal limb of the originally described exposure. • The incision is based from the anterior superior iliac spine, paralleling the palpable interval between the tensor fascia and sartorius muscles. • The straight incision is approximately 12 cm in length. • Superficial dissection • The lateral femoral cutaneous nerve bundles are identified and protected as they course in an arcade pattern beneath the superficial fascial layer. • The sartorius muscle is retracted medially and the tensor fascia muscle is retracted laterally. • The rectus femoris tendon is incised and tagged (Fig. 29.9). • This allows the muscle belly to be retracted distally without extending the deep dissection further. • The ascending branches of the lateral femoral circumflex vessels may be visualized and ligated if necessary during deep dissection. • Deep dissection • The iliocapsularis muscle is locally excised, and the iliopsoas muscle is elevated and retracted medially, visualizing the anterior joint capsule. • With the anterior hip capsule exposed, a T-shaped capsulotomy, which can be based proximal or distal, depending on the location of the fracture, is made in order to expose the fracture. • At this point, the fracture should be readily apparent. 

PORTALS/EXPOSURES PEARLS

• In the anterior approach to the hip, a tenotomy of the head of the rectus femoris can assist with visualization in the anterior approach to the hip and is particularly useful for proximal neck fractures. • A Watson-Jones approach may be useful in cases with peritrochanteric extension or extensive comminution, as it may provide more extensile visualization of the proximal femur.

PORTALS/EXPOSURES PITFALLS

• Avoid placement of retractors over the superior or under the inferior aspect of the femoral neck (such as Hohmann or Cobra retractors), as they may injure residual blood supply to the femoral head by way of the retinacular vessels of the lateral epiphyseal artery.

PORTALS/EXPOSURES CONTROVERSIES

• Anterior versus anterolateral approach to the femoral neck. An anterior approach to the femoral neck has the benefit of better visualization at the cost of requiring a twoincision approach for the operation. With an anterolateral approach, both the reduction and fixation of the fracture can be done with the same incision. • Open reduction versus closed reduction and internal fixation. While an open reduction allows direct visualization and confirmation of a quality reduction, this may be at the expense of additional insult to the blood supply to the femoral head and neck. Clinical studies have not shown one or the other approach to be superior.

366

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

FIG. 29.9 

STEP 1 PEARLS

• In elderly patients with nondisplaced (Garden type 1–2) fractures, care must be taken to prevent inadvertent conversion to a displaced (Garden 3–4) fracture.

STEP 1 PITFALLS

• Repeated attempts at closed reduction should be avoided; only a single attempt should be made.

PROCEDURE: CLOSED REDUCTION AND INTERNAL FIXATION Step 1: Closed Reduction • This may be performed on the fracture table or free-legged, as described previously. • We prefer the Flynn modification of the Leadbetter maneuver. • The hip is flexed to 90°, with a slight amount of abduction. • Gentle traction is applied in the long axis of the femoral neck. • With traction maintained, the hip joint is extended and internally rotated down to the bed (or to a comparable degree as the contralateral leg). • Reduction of the fracture is confirmed by restoration of the normal S-shaped curves of the cortex formed by the concave femoral neck and convex femoral head (Fig. 29.10).

STEP 1 CONTROVERSIES

• The effect of intracapsular hematoma on femoral head blood supply and rates of osteonecrosis is controversial; hip aspiration has not been shown to affect clinical outcome. We do not routinely perform hip aspiration or percutaneous capsulotomy during closed reduction with internal fixation procedures.

A

Undisplaced

B

Displaced FIG. 29.10 

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation



367

• A varus reduction should not be accepted owing to increased rates of failure of fixation. • After confirming anatomic reduction with fluoroscopy, internal fixation is achieved with either multiple cannulated screws via a percutaneous approach or a SHS using a subvastus lateral approach to the femur. Both techniques are described below (Step 2). 

PROCEDURE: OPEN REDUCTION AND INTERNAL FIXATION Step 1: Open Reduction • Failing a closed reduction, an open reduction must be performed. • If required, a traction pin using a 5/64th-inch wire may be placed in the distal, anterior femur and tensioned with a Kirschner bow. Ten to fifteen pounds of weight are placed in traction over a traction bow. • A modified anterior approach to the hip is used, as described earlier. • The fracture site is exposed and cleared of debris, including hematoma and any bony fragments. • Tools useful in reduction include terminally threaded half pins (Schanz pins) for control of the independent fragments, bone-reduction clamps, and mini-fragment plating systems. • Provisional fixation can be achieved with retrograde Kirschner wires into the femoral neck. A mini-fragment unicortical plate can also be placed over the anterior inferior femoral neck to aid in reduction and buttress fixation (Fig. 29.11). 

STEP 1 PEARLS

• Anatomic reduction is the most strongly correlated predictor of healing. • Posterior comminution and initial displacement are both associated with poor outcomes.

STEP 1 INSTRUMENTATION/ IMPLANTATION

• 2.7-mm reconstruction plate or dynamic compression plate • 2.5- to 3.0-mm terminally threaded half pins • Pointed Weber clamp or Farebeuf clamp

STEP 1 CONTROVERSIES

• Early versus late treatment of femoral neck fractures. The literature has not supported an emergent approach to operative fixation of high-energy femoral neck fractures in the young.

FIG. 29.11 

Step 2: Internal Fixation • The approach for internal fixation differs depending on the type of implant used. • Sliding Hip Screw • If performing fixation with an SHS with a single-incision technique, the distal limb of the Watson-Jones approach can be used, as described earlier. When using a two-incision technique, a subvastus lateralis lateral approach is used when making the second counter-incision to the anterior approach to the hip. • The origin of the vastus lateralis can be elevated from the intertrochanteric ridge, allowing access to the lateral wall of the proximal femur in either the single- or two-incision technique.

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

368

Step 2: Sliding Hip Screw • The appropriate fixed-angle guide (most commonly for a 135° angle plate) is placed flush along the lateral cortex of the femur. The starting point of the threaded guidewire should be at the midpoint of the AP diameter of the femur and roughly in line with the tip of the lesser trochanter. • Using a power driver, a 3.2-mm threaded guidewire is inserted, aiming for the center of the femoral head on both the AP and lateral projections (Fig. 29.12A). The wire is advanced to the level of the subchondral bone (Fig. 29.12B). • After confirmation that the tip of the wire is in the center of the femoral head on both AP and lateral images, the measuring device is used to determine the length of the lag screw. • A 2.4-mm threaded guide pin is inserted superior and parallel to the initial guide pin (Fig. 29.13). This will prevent rotation of the femoral head during lag screw insertion and compression. • The 3.2-mm guidewire is advanced a further 5 mm into the subchondral bone of the femoral head. • The reamer is set to the depth measured for the lag screw and attached to the power driver. Reaming is done under image intensification, ensuring that the wire is not being advanced into the joint or pelvis, until the stop reaches the lateral cortex of the femur. • If the guidewire is withdrawn during reaming, the guide pin placement instrument may be inserted backward into the femur and the guide pin reinserted.

A

B FIG. 29.12A–B 

FIG. 29.13 

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

• Attach the lag screw tap to the T-handle and tap to the desired depth of the lag screw. • A lag screw of the measured length is then inserted over the guidewire using the centering sleeve. Insertion of the lag screw is finished with the handle of the T-handle correctly positioned in relation to the femoral shaft. This will allow keying in of the side plate over the lag screw. • After confirmation of the depth of the screw in both planes, the centering sleeve and guidewire are removed.

Step 2: Internal Fixation with Multiple Cannulated Screws • Once a reduction has been achieved, percutaneous fixation with three cannulated screws in an inverted triangular pattern is performed (Fig. 29.14). • The greater trochanter and the anterior and posterior aspects of the femoral shaft are marked on the skin with a sterile pen and, under fluoroscopic guidance, the lesser level of the lesser trochanter is marked on the skin. Again under fluoroscopy, the angle of a retrograde screw is approximated. • Once the starting point is found for the first screw, make a small 4- to 5-cm incision through the skin. The fascia is then split in line with the incision and the first 3.2-mm threaded guidewire is inserted in the position of the most distal screw (Fig. 29.15A). • The wire is advanced into the subchondral bone of the femoral head (Fig. 29.15B).

FIG. 29.14 

A

B FIG. 29.15A–B 

369

370

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

STEP 2A PEARLS

• A 3.2-mm threaded guidewire is driven into the femoral head along the anterior aspect of the femoral neck to determine femoral anteversion and to act as a positioning wire. • After insertion of the lag screw in a sliding hip screw, the sum of the tip-apex distances on the AP and lateral images should measure 25 mm or less to prevent failure of fixation through lag screw cutout (Fig. 29.21). • SHSs with side plate (rarely more than a twohole side plate required)

STEP 2 PITFALLS

• Failure to place an antirotation screw prior to fixation placement may result in fracture malreduction. • All guidewires and screws must be placed at or above the level of the lesser trochanter. This will avoid creation of a stress riser and subsequent subtrochanteric fracture.

• The position of the wire is confirmed with fluoroscopy. It should be centered in the neck on the lateral image and rest along the medial cortex of the femoral neck. • If a change in position is necessary, the same cortical hole should be used to avoid creating a stress riser in the lateral femoral cortex. • Using a fixed guide in an inverted triangular pattern, a second guidewire is placed. On the AP image, this wire should be in the middle of the femoral neck, and it should rest along the posterior cortex of the femoral neck on the lateral projection (Fig. 29.16). • Using the measuring device included in the cannulated screw set, the screw length is measured off the guidewires and 5 mm is subtracted to allow for fracture compression (Fig. 29.17). • A third wire is then placed parallel to the second on the AP projection and anterior to it on the lateral image, creating an inverted triangle pattern (Fig. 29.18). • Using the 4.5-mm cannulated drill bit, drilling is done over the guidewires under fluoroscopic guidance to within 1 cm of the tip of the wires to prevent joint penetration. • Final tightening of the screws should be performed using the hand driver, with care taken not to fracture or penetrate the lateral cortex with the screw head, tightening the most superior screw first to avoid loss of reduction (Fig. 29.19). • The guidewires and the positioning wire are then removed.

STEP 2B PEARLS

• Non-self-tapping 7.0-mm cannulated screws are preferred when fixing with multiple cannulated screws; these are less likely to perforate cortices. • Placement of a fully threaded cannulated screw may be required in areas of comminution, such as the posterior neck. Otherwise, partially threaded screws should be used (Fig. 29.20A–B).

Screw 1 Screw 2 Screw 2 Screw 1

STEP 2 CONTROVERSIES

• Alternative configurations for screw placement and placement with more than three screws at a time. • SHS versus multiple cannulated screws; currently neither has been proven superior. • Alternative fixation devices such as blade plates, cephalomedullary nails, and helical blades can be used. However, there is no evidence suggesting superiority of any single implant choice. Therefore, choice should be guided by surgeon familiarity as to which can be applied in a technically proficient manner.

AP position Lateral position Screw 1 Screw 2 FIG. 29.16 

FIG. 29.17 

Inferior Midneck

Midline Posterior

FIG. 29.19  FIG. 29.18 

A

B FIG. 29.20A–B 

A

Tip apex distance = A + B

B

FIG. 29.21 

372

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

• Fluoroscopy is used to ensure that the screws are not within the hip joint. • Closure • The wound is irrigated and hemostasis is achieved using electrocautery. If open reduction has been performed, the joint capsule is not closed. The fascia and subcutaneous tissues are closed in layers using interrupted 1-0 and 2-0 Vicryl sutures, respectively. The skin is closed with 3-0 nylon and ¾-inch butterfly closures and a sterile dressing is applied. We do not routinely use a drain. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative pain control typically takes the form of patient-controlled analgesia and is progressed to oral analgesia as tolerated. • Intravenous antibiotics are continued for 24 hours postoperatively. • Weight-bearing status involves protected weight bearing limited to the weight of the affected limb for 12 weeks. The exception to this is stable fractures (valgus impacted fractures), for which immediate weight bearing is allowed. • Physiotherapy and occupational therapy teams begin rehabilitation on the first postoperative day, at which time patients may sit at the bedside or in a chair. • Active-assisted hip and knee range of motion exercises are started immediately. If a rectus tenotomy is performed, active hip flexion is limited for 6 weeks. • Hip girdle and lower extremity strengthening is begun once pain is no longer an issue.

Complications • Radiographs are performed directly postoperatively prior to reversal of anesthesia and at 6 and 12 weeks to monitor for evidence of implant or union problems. • Complications of femoral neck fractures treated by internal fixation can be divided into local and systemic complications. • Local complications include infection, failure of fixation, nonunion, and osteonecrosis. • Superficial wound infections occur in approximately 1% of hip fractures and can generally be treated successfully with intravenous antibiotics effective against Gram-positive organisms. Septic arthritis and osteomyelitis are rare complications. • Early failure of fixation with bone erosion may suggest the diagnosis of deep infection, as union will not occur in the presence of active infection. Confirmation of infection is made by hip joint aspiration or synovial biopsy for culture. • Treatment involves early irrigation and débridement with placement of local antibiotics followed by a 6-week course of systemic antibiotic therapy. Revision of fixation or conversion to arthroplasty may take place once there is a normal white blood cell count, erythrocyte sedimentation rate, and C-reactive protein and negative intraoperative frozen sections confirm eradication of infection. • Early failure of fixation is most commonly due to technical errors during fracture fixation or a failure to recognize fracture characteristics that lead to increased instability. • Patients tend to complain of groin or buttock pain. Radiographs showing fracture settling, peri-implant radiolucencies, or backing out of the implants confirm the diagnosis. • Treatment depends on the patient’s age, functional demands, medical condition, and bone density. In young individuals with good bone stock, revision of fixation is warranted, while arthroplasty is the treatment of choice in low-demand patients with osteopenia. • Nonunion is a rare complication of undisplaced femoral neck fractures but complicates up to 30% of displaced fractures. • Diagnosis may be suspected in patients who continue to complain of pain 3 to 6 months after fixation and may be confirmed by CT. • A complete review of treatment of femoral neck nonunion is outside the scope of this text but generally takes the form of arthroplasty in elderly individuals and revision of fixation with vascularized bone grafting and/or intertrochanteric osteotomy for younger patients.

PROCEDURE 29  Femoral Neck: Open Reduction and Internal Fixation

• Rates of osteonecrosis following femoral neck fracture vary and are affected by displacement, timing, and adequacy of reduction and fixation method. Avascular necrosis and nonunion occur in approximately 10% of undisplaced fractures and up to two-thirds of displaced fractures. • Early diagnosis is made using MRI or CT (MRI may be difficult due to implant artifact), while bone sclerosis, subchondral collapse, and eventual degenerative joint disease can be visualized on plain radiographs. • Treatment of osteonecrosis is dictated by the patient’s symptoms and location of the necrotic bone. • Systemic complications include mortality and venous thromboembolism. • Mortality rates following hip fracture vary and are influenced by age, gender, medical and psychiatric condition, preinjury functional status, and presence of end-stage renal disease. For most elderly individuals, a mortality rate of 25% in the first year is a reasonable value to remember during discussions with patients and families. • All patients at our institution receive chemoprophylaxis with low-molecular-weight heparin starting the first day after admission. It is stopped at the appropriate time interval to allow for fracture fixation and is restarted on the first postoperative day and continued for 2 weeks postoperative.

EVIDENCE Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg [Am]. 2006;77(7):1058– 1064. Chua D, Jaglal SB, Schatzker J. Predictors of early failure of fixation in the treatment of displaced subcapital hip fractures. J Orthop Trauma. 1998;12(4):230–234. Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. Injury. 2005;36(1):131–141. Flynn M. A new method of reduction of fractures of the neck of the femur based on anatomical studies of the hip joint. Injury. 1974;5(4):309–317. Garden RS. Low-angle fixation in fractures of the femoral neck. Bone Joint J. 1961;43-B(4):647–663. Ghayoumi P, Kandemir U, Morshed S. Evidence based update: open versus closed reduction. Injury. 2015;46(3):467–473. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg [Am]. 2004;86-A(8):1711–1716. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury. 2015;46(8):1557–1561. Liporace F. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg [Am]. 2008;90(8):1654–1656. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg [Am]. 1994;76(1):15. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg [Am]. 2008;90(10):2254–2266. Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997;340:172–180. Mohan R, Karthikeyan R, Sonanis SV. Dynamic hip screw: does side make a difference? Effects of clockwise torque on right and left DHS. Injury. 2000;31(9):697–699. Molnar RB, Routt MLC. Open reduction of intracapsular hip fractures using a modified Smith-Petersen surgical exposure. J Orthop Trauma. 2007;21(7):490–494. Nowakowski AM, Ochsner PE, Majewski M. Classification of femoral neck fractures according to Pauwels: interpretation and confusion—Reinterpretation: a simplified classification based on mechanical considerations. JBiSE. 2010;03(06):638–643. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg [Am]. 1993;75(3):395–401. Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343:230–238.

POSTOP CONTROVERSIES

• Optimal treatment of loss of reduction or nonunion: One must consider the patient’s physiologic age, activity level, and goals in selecting a solution, which could include revision ORIF, bone grafting (vascular vs. nonvascular), osteotomy, or arthroplasty.

373

PROCEDURE 30

Treatment of Hip Dislocations and Femoral Head Fractures Joseph B. Cohen and H. Claude Sagi INDICATIONS • Hip dislocations • Closed reduction for simple hip dislocations is typically achieved with adequate anesthesia. Reduction should be obtained within 6 hours of injury to reduce risk of osteonecrosis. • A computed tomography (CT) scan should be obtained after reduction to evaluate for loose osteochondral fragments and minimally displaced fractures not seen on plain radiographs. • Operative treatment should be undertaken for nonconcentric reductions or if more than 2 reduction attempts have failed to locate the hip. • Femoral head fractures • Femoral head fractures are usually created from a shearing force from the acetabulum as the hip is dislocating. • Operative treatment is clearly indicated for fracture dislocations that are irreducible, concomitant neck fractures, fractures that are suprafoveal (involve the weight-bearing dome), and fractures that result in an unstable hip joint. 

INDICATIONS PITFALLS

• Failure to reduce the hip within 6 to 12 hours may lead to increased rates of osteonecrosis and/or posttraumatic arthritis. • Hip reduction should be prioritized over other musculoskeletal injuries.

INDICATIONS CONTROVERSIES

• Timing of surgical intervention for nonconcentric reductions is still controversial. • Controversy exists as to the optimal management of infrafoveal fractures, either in isolation or associated with a femoral neck or acetabular fracture. Improved outcomes are seen with nonoperative management if adequately reduced or fragment excision compared with open reduction and internal fixation (ORIF). • Elderly patients may benefit from hemiarthroplasty or total hip arthroplasty.

EXAMINATION AND IMAGING • The leg is typically shortened, adducted, and internally rotated in posterior hip dislocations and is shortened, abducted, and externally rotated in anterior hip dislocations. Fractures of the femoral head or neck may alter the expected position of the leg. • Document a thorough neurovascular examination, with special attention paid to the function of the sciatic nerve. • Examine overlying skin for open wounds, Morel-Lavalee lesions, or previous surgical incisions.

374

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

• Imaging • Obtain anteroposterior (AP) pelvis and Judet views of the acetabulum (Fig. 30.1). • CT scan obtained postreduction to better visualize fractures (Fig. 30.2A–C). •  Fig. 30.1 shows a reduced hip with an infrafoveal femoral head fracture. Fig. 30.2A–C shows CT cuts demonstrating a small posterior wall fracture. Fig. 30.2D is an intraoperative fluoroscopy image during an examination under anesthesia showing instability. 

TREATMENT OPTIONS

• Hip dislocations: If hip is congruent and stable postreduction, it can be treated nonsurgically. • Anterior: Recommend limiting hip extension and external rotation postreduction. Weight bearing may be advanced as pain allows. Monitor for posttraumatic arthritis 15% to 63% and avascular necrosis (AVN) 8% to 15%. Dislocation with damage to the femoral head has a poorer outcome. • Posterior: Recommend limiting hip flexion, adduction, and internal rotation. Weight bearing may be advanced as pain allows. Posttraumatic arthritis seen in 19% to 53% of patients and AVN in 10% to 15%. • Femoral head fractures: Usually associated with a posterior hip dislocation, creating a predominantly anterior head fracture. • Pipkin I: Infrafoveal • Nonsurgical: Small fragments that are not incarcerated within the joint or that are anatomically reduced following hip reduction may be treated nonoperatively. • Surgical: Recommended if the fragment is large enough to be stabilized with internal fixation, if not anatomically reduced, or results in hip instability. Similar results have been observed with fragment excision and ORIF. • Pipkin II: Intrafoveal or suprafoveal • Nonsurgical: Little role for nonoperative management. • Surgical: Anatomic reduction and stable internal fixation recommended for most fractures, as the weight-bearing dome is involved and accurate reduction is crucial for joint congruity. • Pipkin III: Any femoral head fracture associated with a femoral neck fracture • Nonsurgical: No role for nonsurgical management. • Surgical: Reduction and fixation of the neck is of critical importance and should be done prior to femoral head fixation. Once the neck is fixed, management of the femoral head should be undertaken as if the femoral head were isolated. • Pipkin IV: Any femoral head fracture associated with an acetabular fracture • Nonsurgical: No role for nonsurgical management, as hip instability is present in nearly all cases. • Surgical: Treatment algorithm is based on the type of posterior wall fragment. Large posterior wall fractures should always be rigidly fixed. Small posterior rim fractures can be examined under anesthesia after reduction and fixation of the femoral head. Fractures that result in instability should be stabilized and securely fixed. • Arthroplasty may be indicated for elderly or osteoporotic patients or those whose definitive treatment was delayed and are at increased risk of osteonecrosis (Fig. 30.3A–B). Fig. 30.3 demonstrates a femoral head fracture that was irreducible and had a significant delay to surgery. Hemiarthroplasty was performed owing to high risk of osteonecrosis.

FIG. 30.1 

375

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

376

B A

C D FIG. 30.2A–D 

A

B FIG. 30.3A–B 

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

SURGICAL ANATOMY • The surgeon should be familiar with the muscular intervals and location of neurovascular structures around the hip as well as the blood supply to the femoral head. • Posterior approaches • Allow for fixation of the acetabulum and femoral head through one approach. • Blood supply to the femoral head should be preserved by avoiding disruption of the quadratus femoris muscle. • The sciatic nerve typically is anterior to the piriformis and posterior to the obturator internus. Care should be taken to identify and protect the nerve if exposure of the posterior column is needed (Fig. 30.4). • Anterior approaches • Generally favored for visualization of the predominantly anterior femoral head fragment. • The lateral femoral cutaneous nerve has a variable path after its exit from the pelvis. Incising the tensor fascia lateral to the tensor sartorial interval can help avoid iatrogenic nerve injury. • The ascending branch of the lateral femoral circumflex artery and its accompanying veins need to be identified and ligated. 

Gluteus medius Piriformis Superior gemellus

Obturator internus Inferior gemellus Quadratus femoris

Medial femoral circumflex artery Vastus lateralis

FIG. 30.4 

POSITIONING • Anterior: Supine with the ipsilateral leg draped free on a radiolucent table. Specialty tables that can apply traction to the affected leg can be used but are not required (Fig. 30.5). • Posterior: Lateral for the Gibson or Kocher-Langenbeck approach. Although a digastric trochanteric osteotomy can be performed prone, this position is not appropriate for a surgical hip dislocation. The leg should be draped into the surgical field (Fig. 30.6A). 

377

378

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

POSITIONING PEARLS

• Supine: Prep a wide surgical field, with medial extent being the umbilicus, the lower rib cage superiorly, and as far posterior as the table will allow. Exclude the perineum with adherent drapes. A sacral bump can help increase hip extension during dislocation. • Lateral: Allows for arthroplasty if the fracture is not reconstructible.

POSITIONING PITFALLS

• Supine: Does not allow for repair of posterior structures damaged (capsule, labrum, wall fractures). • Lateral: Intraoperative imaging of the acetabulum is more difficult to obtain if the posterior wall requires fixation. More difficult to expose the distal posterior column for plate application if a large posterior wall fracture is present.

FIG. 30.5 

POSITIONING EQUIPMENT

• Supine: Radiolucent table, folded blankets under the sacrum to aid in hip extension. • Lateral: Hip positioners, beanbag, or rolled blankets to stabilize the pelvis and torso. Axillary roll one handbreadth from the axilla to avoid compression of axillary structures. Sterile bag anteriorly to place the foot and leg after dislocation.

A

POSITIONING CONTROVERSIES

• Supine: Theoretical risk of further damage to the femoral head blood supply if the approach used is opposite the direction of the dislocation. However, rates of AVN between the two approaches are similar. Requires separate approach if posterior wall requires fixation. • Lateral: If polytraumatized, it may be more appropriate to remain supine.

B FIG. 30.6A–B  PORTALS/EXPOSURES PEARLS

• Smith-Petersen: Ligation of the ascending lateral femoral circumflex is routinely required. Rectus tenotomy can significantly improve visualization and should be repaired at the end of the case (Fig. 30.7A–B). Dislocation with the foot dropped into a sterile bag on the ipsilateral side to allow for hip extension (Fig. 30.7C). • Gibson: Take time to find the true intermuscular interval to avoid entering the gluteus maximus. Exploit and extend the traumatic capsulotomy anteriorly.

PORTALS/EXPOSURES • Anterior: Interval between the tensor fascia and the sartorius superficially, and the gluteus medius and the rectus femoris deep. Requires ligation of the ascending branch of the lateral femoral circumflex artery. Avoid damage to the lateral femoral cutaneous nerve by incising the fascia directly over the tensor muscle. T-capsulotomy made with horizontal limb made along the superior border, with care taken to not incise the labrum. Heavy suture can be used to tag and retract the capsule (Fig. 30.6B).

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

• Posterior: The gluteus maximus is a broad muscle that covers the posterior hip. It can be spared (Gibson) or split (Kocher-Langenbeck) to approach the posterior hip. If using the true internervous plane between the tensor fascia muscle and the gluteus maximus (Gibson), damage to the gluteal neurovascular bundle is less likely and direct access to the anterior ilium is improved.  PORTALS/EXPOSURES PITFALLS

• Smith-Petersen requires a separate approach to repair the posterior wall if needed. May be associated with higher rate of heterotopic ossification (HO). • Gibson: Avoid damage to the gluteal neurovascular structures. Can leave the piriformis attached to decrease risk of inadvertent damage to the femoral head blood supply. If planning on placing a reconstruction plate along the posterior column, the exposure must be increased by detaching the external rotators approximately 1 cm from the insertion on the lateral femur. The superior border of the quadratus should not be violated. PORTALS/EXPOSURES EQUIPMENT

• Smith-Petersen: Deep retractors, 2.0-mm or 2.4-mm screws, or headless compression screws, heavy suture • Gibson: Oscillating saw, cannulated 4.5-mm screws for repair of the osteotomy, 2.0-mm or 2.4-mm screws, or headless compression screws PORTALS/EXPOSURES CONTROVERSIES

• Functional outcomes are similar between the two approaches. Choice depends largely on surgeon comfort and associated fractures/injuries.

A

B

C FIG. 30.7A–C  (A and B, Courtesy of Sean Nork, MD.)

379

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

380

PROCEDURE

STEP 1 PEARLS

• Make a small incision in the iliotibial band fascia and feel for the anterior aspect of the maximus to ensure that the fascial incision is in the right location. Localize the vessels that perforate the fascia, which typically mark the interval. STEP 1 PITFALLS

• Care should be taken not to disrupt the blood supply to the femoral head. STEP 1 INSTRUMENTATION/ IMPLANTATION

• Charnley self-retaining retractor, Hohmann or Cobra retractors, elevators, pituitary rongeurs

Case Study: 43 Male status post high-speed motor vehicle collision (Fig. 30.8A–C). Radiographs and CT scan demonstrating Pipkin IV.

Step 1: Gibson Approach • Superficial exposure: Identify the greater trochanter and the anterior superior iliac spine as superficial landmarks. The incision is lateral along the proximal femur and extends toward the ilium (Fig. 30.9). Once through subcutaneous tissue, carefully identify the fascia overlying the tensor muscle and gluteus maximus. Identify the vessels perforating the fascia, which serve as a marker for the interval (Fig. 30.10). Split the fascia precisely in the intermuscular interval (Fig. 30.11). The gluteus medius will be immediately underneath. • Deep exposure: Find the interval between the gluteus minimus and piriformis by placing a curved or Cobra retractor underneath the gluteus medius (Fig. 30.12). Once the piriformis has been identified, dissection can be continued cranially and the minimus can be elevated or debrided if significantly damaged. 

STEP 1 CONTROVERSIES

• The transgluteal approach (Kocher-Langenbeck) can also be used but results in a more difficult exposure of the anterior capsule and puts the gluteal neurovascular bundle at risk.

A

B

C FIG. 30.8A–C 

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

FIG. 30.9 

TFL

381

FIG. 30.10 

GMed GMax

GMed GMin Pi

FIG. 30.11 

Step 2: Trochanteric Osteotomy and Surgical Dislocation • Once the surrounding musculature has been identified, the trochanteric osteotomy can be performed (Fig. 30.13A). Internally rotate the leg before making the osteotomy cut. This allows the surgeon to bring the saw away from the gluteal musculature (Fig. 30.13B). • Predrilling under fluoroscopy with the appropriately sized drill for later repair is recommended to increase ease of anatomic reduction and fixation (Fig. 30.14). • The vastus ridge is identified and serves as a target for the distal extent of the osteotomy. The vastus lateralis insertion and gluteus medius should remain attached to the trochanter, creating a digastric fragment. • An oscillating saw is used to make a cut parallel to the lateral cortex of the femur, exiting distal to the vastus ridge and lateral to the piriformis to protect the femoral head blood supply (Fig. 30.15). • The trochanter can now slide anteriorly with the medius and minimus attached, allowing sufficient anterior exposure of the joint capsule in preparation for dislocation (Fig. 30.16). • The traumatic capsulotomy is identified and extended anteriorly. A T- or Z-shaped capsulotomy is made along the neck and the hip is extended and externally rotated, dislocating the hip anteriorly (Fig. 30.17A–C). 

FIG. 30.12 

STEP 2 PEARLS

• Following the osteotomy, there should be some residual medial trochanter attached to the femur. • Cool the saw blade to prevent thermal necrosis and minimize risk of nonunion. • Drill the head with a 2.0-mm drill to assess for bleeding. • If the posterior wall is also fractured, leave the capsule and labrum attached in order to preserve the blood supply to the fractured fragment. • Pin the femoral neck in Pipkin III fractures prior to dislocation.

STEP 2 PITFALLS

• Extension of the osteotomy into the piriformis fossa puts the blood supply at risk. • Avoid iatrogenic damage to the inferior retinaculum.

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Oscillating saw, broad and flat osteotome

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

382

Gluteus medius

Piriformis Capsule Obturator internus

Gluteus minimus

FIG. 30.15 

A

B FIG. 30.13A–B 

Intact Labrum Intact Capsule

Rim Fragment

FIG. 30.16 

FIG. 30.14 

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

383

Capsule

Gluteus medius Gluteus minimus

Piriformis Obturator internus

B

A

C FIG. 30.17A–C 

Step 3: Fracture Preparation and Fixation • With the femoral head dislocated, the fracture fragments are cleaned of debris and reduced anatomically and provisionally held with Kirschner wires (K-wires; Fig. 30.18) • Definitive fixation is performed with headless compression screws or mini-fragment 2.7-mm lag screws with the heads countersunk (Fig. 30.19). • The hip is then reduced. If a posterior wall fracture is present, it can be repaired with spring plates and/or a reconstruction plate depending on the size of the fragment (Fig. 30.20A–B) • The capsule and labrum should be repaired with suture or suture anchors if needed. 

STEP 3 PEARLS

• Suture anchors can be used to repair the capsule and labrum if the posterior wall is too small for internal fixation. • Check to make sure that the tynes of the spring plate are not intraarticular. • Osteochondral pieces should be placed in saline if they are removed from the surgical wound.

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

384

FIG. 30.18 

FIG. 30.19 

A FIG. 30.21 

STEP 3 PITFALLS

• Failure to countersink or bury the screw head can lead to painful hardware. Washers should not be used.

STEP 3 INSTRUMENTATION/ IMPLANTATION

B FIG. 30.20A–B 

• 0.62 K-wires, 2.7-mm screws, small pointed reduction clamps • Three-hole 1/3 tubular plate fashioned into a spring plate (Fig. 30.21)

STEP 3 CONTROVERSIES

• Some authors argue that repair of small wall fractures or labral injuries is not necessary.

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

Step 4: Osteotomy Repair and Closure •  Once the femoral head is reduced and the posterior wall or capsule/labrum is repaired, the osteotomy can be fixed. • Identify the location of predrilled holes with 2.0-mm K-wires (Fig. 30.22). • Reduce the osteotomy and provisionally hold with 2.0-mm K-wires. •  Place pointed reduction clamp perpendicular to the osteotomy to preliminarily compress. • Sequentially replace the K-wires with 4.5-mm partially threaded screws and confirm reduction and screw placement with fluoroscopy (Fig. 30.23). 

STEP 4 PEARLS

• Predrilling allows for quick and accurate repair of the osteotomy. • Leaving the vastus attached counteracts the pull of the abductors and decreases risk of trochanteric nonunion.

STEP 4 PITFALLS

• Wiring is not needed and can lead to hardware irritation.

STEP 4 INSTRUMENTATION/ IMPLANTATION

• 2.0-mm K-wires, 4.5-mm partially threaded screws

FIG. 30.22 

FIG. 30.23 

385

386

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Hip dislocations • Patients with simple dislocations can resume weight bearing as dictated by pain and do not need hip motion precautions. • Anterior dislocations frequently have impaction. • Femoral head fractures • At risk for AVN, posttraumatic arthritis, and HO. • Recommend range of motion as tolerated, with use of a continuous passive motion machine if available to improve circulation of joint fluid. • Weight of leg foot flat protected weight bearing for 12 weeks.

POSTOP PEARLS

• Encourage active and passive motion of the hip to promote synovial fluid circulation and improve cartilage nutrition. • Avoid resisted hip abduction to protect the osteotomy. • Counsel patients that AVN may occur at a variety of time frames; it has been described to occur up to 5 years postinjury.

POSTOP PITFALLS

• Nonsteroidal antiinflammatory drugs for HO prophylaxis can increase the risk of nonunion and should be avoided.

POSTOP CONTROVERSIES

• Some authors advocate for sciatic nerve exploration in palsies that do not show signs of recovery. • Use of magnetic resonance imaging to detect AVN • Radiation for HO prophylaxis in high-risk patients

EVIDENCE DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral head fractures. J Bone Joint Surg [Am]. 1980;62(6):960–964. Thirteen out of 15 anterior hip dislocations had some injury to the femoral head that were related to poor overall outcome. Radiographic evidence was evident in 10 of those patients. The two remaining patients were noted to have excellent results. Holmes JW, Solberg B, Olson SA, et al. Biomechanical consequences of excision of displaced Pipkin femoral head fractures. J Orthop Trauma. 2000;14(2):149–150. Cadaveric study investigating biomechanical consequences of femoral head fragment excision. No significant change in load detected between Pipkin type I fractures and intact specimens. Gavaskar AS, Tummala N. Ganz surgical dislocation of the hip is a safe technique for operative treatment of Pipkin fractures. Results of a prospective trial. J Orthop Trauma. 2015;29:544–548. No cases of osteonecrosis were observed in this prospective series of 28 patients. Giannoudis PV, Kontakis G, Koutras C, et al. Management, complications and clinical results of femoral head fractures. Injury. 2009;40:1245–1251. Systematic review of the current literature, which includes the study of 453 femoral head fractures. Neither the trochanteric osteotomy done through a Gibson approach nor the Smith-Petersen approach demonstrates an increased risk of AVN. Pipkin I fractures tended to do better with fragment excision versus ORIF. The Kocher-Langenbeck approach had a twofold increase in risk for AVN versus the Gibson or Smith-Petersen approaches. Hougard K, Thomsen PB. Traumatic posterior dislocation of the hip—Prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg. 1986;106(1):32–35. A total of 98 patients with posterior hip dislocations were reviewed with a minimum 5-year followup. AVN was found in only 4.8% of the hips reduced within 6 hours, but AVN was found in 54.9% of the hips reduced more than 6 hours after the injury. Kellam P, Ostrum RF. Systematic review and meta-analysis of avascular necrosis and posttraumatic arthritis after traumatic hip dislocation. J Orthop Trauma. 2016;30:10–16. Meta-analysis calculating the overall event rate of AVN and posttraumatic arthritis after hip dislocation. The odds ratio of AVN for hip dislocation reduced after 12 hours versus reduced before 12 hours was 5.6.

PROCEDURE 30  Treatment of Hip Dislocations and Femoral Head Fractures Masse A, Aprato A, Ganz R, et al. Surgical hip dislocation is a reliable approach for treatment of femoral head fractures. Clin Orthop Relat Res. 2015;473:3744–3751. Seventeen patients underwent ORIF for displaced femoral head fractures. Clinical results were similar to reported outcomes treated with other approaches. There was a lower rate of posttraumatic arthritis but a higher rate of HO. Solberg BD, Moon CN, Franco DP. Use of trochanteric flip osteotomy improves outcomes in Pipkin IV fractures. Clin Orthop Relat Res. 2009;467:929–933. Stannard JP, Harris HW, Volgas DA, Alonso JE. Functional outcome of patients with femoral head fractures associated with hip dislocations. Clin Orthop Relat Res. 2000;(377):44–56. Twenty-six patients were evaluated using radiographs and a validated outcome scoring system. The study showed no difference between patients who had closed reduction and fixation before 24 hours compared with patients who had their surgical procedure greater than 24 hours after admission. The transgluteal approach had a higher risk of AVN compared with the anterior approach. Swiontkowski MF, Thorpe M, Seiler JG, Hansen ST. Operative management of displaced femoral head fractures: a case matched comparison of anterior versus posterior approaches for Pipkin I and Pipkin II fractures. J Orthop Trauma. 1992;6(4):437–442. Retrospective analysis of 43 femoral head fractures. Twelve anterior approaches and 12 posterior approaches had 2-year follow-up and were compared. There were no cases of AVN in the anterior group, with similar clinical and functional results. Of note, the Smith-Petersen approach had a higher rate of HO. Wang CG, Li YM, Zhang HF, Li ZJ. Anterior approach versus posterior approach for Pipkin I and II femoral head fractures: a systematic review and meta-analysis. Int J Surg. 2016;27:176–181. Meta-analysis of controlled clinical trials comparing anterior versus posterior approaches. Anterior approaches had a significantly higher rate of HO compared with posterior approaches. No detectable differences in rates of AVN, posttraumatic arthritis, or general postoperative complications.

387

PROCEDURE 31

Femoral Neck Fractures: Hemiarthroplasty Tyler R.S. MacGregor and Markku T. Nousiainen

PITFALLS

• Complex fracture patterns, including intertrochanteric or calcar extension CONTROVERSIES

• When to attempt internal fixation instead of arthroplasty • Use of monopolar, bipolar, or total hip arthroplasty—differing physiologic ages, osteopenic bone, presence of acetabular arthritis • Use of cemented or uncemented component • Use of tranexamic acid, either topical or systemic • Surgical approach

INDICATIONS • Displaced intracapsular fractures of the femoral neck in elderly patients with osteoporotic bone; pathologic fracture of femoral neck • Failed internal fixation, malunion, nonunion, and/or osteonecrosis of femoral neck/ head in elderly patient 

EXAMINATION/IMAGING • True anteroposterior (AP) pelvis, AP (Fig. 31.1) and lateral plain film radiographs should be obtained of the injured hip; AP radiograph of contralateral hip is useful for templating purposes. • Computed tomography is useful in determining the presence of complex fracture patterns and their location. 

FIG. 31.1 

TREATMENT OPTIONS

• Cemented or uncemented components with a monopolar or bipolar articulation may be used, with varying articulation sizes and materials available. • Approaches include anterior, anterolateral, posterior, and direct lateral (described here). General wisdom dictates that the approach used should be that with which the surgeon is most comfortable or familiar.

388

SURGICAL ANATOMY • Anatomic structures specific to the direct lateral approach to the hip are noted here. • Incision through the tensor fascia lata/iliotibial band reveals the abductor musculature, which is split at the anterior one-third, posterior two-thirds junction and subsequently reflected off the proximal femur incorporating a small sleeve of the anterior portion of vastus lateralis (Fig. 31.2). • The interval between the abductors and capsule is identified and exposed, and a Tcapsulotomy is performed. • The surgeon must be aware of the proximity of the superior gluteal nerve during the abductor split. 

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

389

Gluteus medius Vastus lateralis

Greater trochanter

FIG. 31.2  From Miller: Orthopaedic Surgical Approaches, 2nd Edition, Elsevier, 2013.

PREOPERATIVE PLANNING • If you fail to plan, plan to fail. • Planning may be done on acetate images with radiographic templates or electronically, using a variety of commercially available templating suites. • An estimate of stem size and offset can be obtained by placing a trial component template into the proximal femoral canal on images of the noninjured hip; head size can also be measured by templating the inner diameter of the acetabulum. 

POSITIONING • The patient is placed in the lateral decubitus position on a padded table with post supports (Fig. 31.3). • The anterior post support is placed on the pubic symphysis. • The posterior post is placed on the sacrum. • Pillows are placed between the legs. • The upper body is belted securely with an axillary roll on the dependent side, with pressure areas supported and well padded. 

PEARLS

• Pressure mat on operating table • Anterior support cephalad enough to allow full hip flexion for femoral canal exposure and assessment of hip stability • Posterior support cephalad enough to allow adequate exposure

PITFALLS

• Preparation and draping of the limb and buttock must be posterior and cephalad enough to allow wound exposure.

Anterior support

EQUIPMENT Posterior support

FIG. 31.3 

• Pressure mat • Side supports • Pillows • Bolsters, posts, or beanbag

390

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

PORTALS/EXPOSURES

PEARLS

• In order to facilitate visualization, a Hohmann retractor can be carefully inserted into the plane between the abductors and the capsule just anterior to the anterior wall of the acetabulum. The anterior arm of the Charnley retractor can be placed underneath the anterior third of the gluteus medius and minimus tendon. A Meyerding retractor can help reflect the vastus lateralis off the anterior hip capsule. • The apex of the capsulotomy should be placed at 12:00 on the acetabular rim; doing so allows an easier reduction of the trial and definitive arthroplasty components.

• An approximate 10-cm lateral longitudinal incision is made, centered on the greater trochanter extending distally in line with the femoral shaft, just past the vastus ridge and proximal to the greater trochanter (Fig. 31.4). • The tensor fascia lata/iliotibial band is split distally in line with the femur and proximally in line with its muscle fibers (Fig. 31.5). Anterior superior iliac spine

Pubic tubercle Neck of femur Greater trochanter

PITFALLS

• Not leaving a cuff of abductor tendon on the proximal femur for reconstruction may result in poor repair strength. Repair through bone tunnels in the trochanter in this circumstance is an option.

Posterior superior iliac spine FIG. 31.4  From Miller: Orthopaedic Surgical Approaches, 2nd Edition, Elsevier, 2013.

Gluteus medius

Vastus lateralis

Fascia lata

FIG. 31.5  From Miller: Orthopaedic Surgical Approaches, 2nd Edition, Elsevier, 2013.

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

• Retractors are used to hold the tensor fascia lata/iliotibial band; removal of greater trochanteric bursa facilitates visualisation of gluteus medius and a portion of proximal vastus lateralis (Fig. 31.6). • Curved Mayo scissors are used to split the interval between the anterior one-third and posterior two-thirds of the gluteus medius just proximal to the greater trochanter. Langenbeck retractors are inserted into this split to visualize the gluteus minimus tendon. • Starting proximally and working distally, the gluteus minimus is split in line with its fibers and the plane between the abductors and capsule is identified and developed. Care is taken to leave a cuff of medius tendon anterior to its insertion onto the greater trochanter to facilitate repair at time of closure. An anterior sleeve of vastus lateralis is created off the anterior hip capsule and is mobilized (Fig. 31.6). • The exposed capsule is split in line with the femoral neck and reflected off its insertion onto the proximal femur, creating an inverted T-capsulotomy. The corners are tagged with #1 Vicryl suture to aid in exposure and for later repair. • Further external rotation exposes the femoral neck. 

Gluteus medius Vastus lateralis

Greater trochanter

FIG. 31.6  From Miller: Orthopaedic Surgical Approaches, 2nd Edition, Elsevier, 2013.

391

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

392

INSTRUMENTATION

PROCEDURE

• Standard hip arthroplasty instrumentation is used.

Step 1: Femoral Neck Cut and Excision of Femoral Head

PEARLS

• Identification of the lesser trochanter/base of the neck is mandatory for assessing location of the neck cut. • Inspect the acetabulum and capsule for bony fragments—ensure complete removal. • Lavage the acetabulum for small debris; remove excess ligamentum teres if present. • Place a swab/gauze in the acetabulum when working on the femur to keep it free from debris and/or cement (but ensure its removal during implantation).

• The femoral neck is cut at the desired height, which is determined by preoperative templating specific to the chosen implant. Cutting the neck first allows for easier exposure and removal of the femoral head (Fig. 31.7). • The femoral head is removed using a corkscrew device, tenaculum forceps, or a dislocating skid (Fig. 31.8). • The femoral head is measured for implant sizing. • The femoral head is measured against the femoral head gauge (Fig. 31.9). • A trial head of the same size is placed on an introducer. • The trial head is then inserted into the acetabulum to ensure that the fit is appropriate (Fig. 31.10). 

PITFALLS

• Cutting into or fracturing the greater trochanter when cutting the femoral neck. • Damage to the acetabulum with corkscrew or skid when removing the femoral head. • Damage to the femoral neck/calcar by levering with the corkscrew shaft.

Retractors

Saw Femoral neck cut FIG. 31.8 

FIG. 31.7 

FIG. 31.9 

FIG. 31.10 

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

Step 2: Bone Preparation and Trialing • Bone preparation is specific to the implants used. • A clean-up femoral neck cut to remove any residual femoral neck fracture fragments is performed as required. • The line of the cut should match the inclination between the neck and stem of the femoral component. • A box osteotome is used to help prepare the femur for appropriate positioning of the first broach. • Following the use of a canal finder, sequential broaching is used to clear the femoral canal of remaining cancellous bone and ensure an appropriate fit between the implanted prosthesis and the bone. • The broach handle is then removed from the broach and the trial trunnion with appropriate offset is placed on the top of the broach. • The trial monopolar/bipolar head is then placed on the trunnion. Some systems may have a trial bipolar head that is placed directly on the trunnion. • The hip is then reduced and checked to ensure appropriate soft-tissue tension, stability, and appropriate fit of the head within the acetabulum (Fig. 31.11). The hip should have an appropriate range of motion and be stable in extension/external rotation, slight flexion/external rotation, and flexion/adduction/internal rotation. 

FIG. 31.11 

393

PEARLS

• Stability is the primary aim—trial through a full range of motion. • Length is guided by the distance from the tip of the greater trochanter to the center of the femoral head axis and hip offset. • Anteversion of the femoral component should be approximately 15° but may have to be modified depending on the patient’s anatomy. PITFALLS

• Lack of familiarity with implant system being used

PEARLS

• Some surgeons may prefer to trial again after stem implantation for final head-neck length assessment. • Ensure that the patient has adequate muscle relaxation during surgery to facilitate reduction maneuvers.

394

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

Step 3: Implantation and Reduction

PEARLS

• Use of a distal centralizer on the stem can aid in avoiding varus malpositioning. • The use of third-generation cementation techniques enhances outcomes. PITFALLS

• If the trial prosthesis cannot be reduced, check the following: • Soft-tissue interposition. • Components too long—retrial with shorter neck length; remove implant and recut neck. • Head component too large—confirm head and acetabular size. • If the trial prosthesis is reducible but is unstable, check the following: • Debris in acetabulum • Components too short or inadequate offset—retrial, implant higher offset components to achieve stability. • Components malpositioned—assess position of dislocation and antevert or retrovert according to posterior or anterior instability. • Check for iatrogenic fracture—calcar, greater trochanter, femoral shaft, acetabulum.

FIG. 31.12 

FIG. 31.14 

• After removal of the broach, the canal is cleaned with a brush and normal saline (Fig. 31.12). A second look at the acetabulum is taken after washing to ensure that there is no debris; a sponge is then reinserted for protection during cementation. • A cement plug is inserted into the femoral canal sufficiently distal to ensure an appropriate cement mantle (approximately 1–2 cm) between the tip of the stem and the plug (Fig. 31.13). • The canal is then dried and cement is introduced in a retrograde fashion from the plug, proximally to the cut surface of the femur, using a cement gun (Fig. 31.14). • The cement is pressurized (Fig. 31.15) and the stem is introduced into the cement mantle, maintaining appropriate anteversion and avoiding varus positioning. • Any excess cement that escapes from the proximal femur is removed and the cement is allowed to polymerize. The previously inserted sponge is removed from the acetabulum. • The definitive head component is then impacted onto the trunnion of the stem. • The hip is reduced by means of grasping the neck of the femoral component between the index and middle fingers and, with gentle traction, guiding the head component into the acetabulum, taking care not to damage the articular cartilage. • With the hip reduced and with stability confirmed, a layered closure is performed.  CONTROVERSIES

• Reliance on soft -tissue repair for stability. The surgeon should aim for stability of the components alone prior to soft-tissue repair.

FIG. 31.13 

FIG. 31.15 

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty

Step 4: Closure • The capsular corners are closed by tying the previously inserted Vicryl stay sutures together followed by a running #1 Vicryl closure of the capsulotomy. • The gluteus minimus is then closed as a separate layer with #1 Vicryl followed by reattachment of the gluteus medius to its tendinous insertion on the greater trochanter. We insert a full-thickness reinforcing #1 Vicryl figure 8–type suture at the apex of the greater trochanter, catching Sharpey fibers, and run the fascia of the vastus lateralis to complete our deep closure. • The remainder of the layers are closed anatomically. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Day 1 • Hemoglobin, electrolytes, renal function • Thromboprophylaxis (continued for a minimum of 15 days depending on the patient’s co-morbidities) • Antibiotic prophylaxis • Radiographs: AP pelvis, AP and lateral of the hip • Mobilization and physiotherapy • Full weight bearing should be the standard of care. • Standard hip arthroplasty precautions can be taken.

EVIDENCE Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg [Am]. 2003;85:1673–1681. Arthroplasty significantly reduces the risk of revision surgery but has increased infection rates, blood loss, and operative time. Goh SK, Samuel M, Su DH, Chan ES, Yeo SJ. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture. J Arthroplasty. 2009;24(3):400– 406. Grosso M, Danoff J, Murtaugh T, Trofa D, Sawires A, Macaulay W. Hemiarthroplasty for displaced femoral neck fractures in the elderly has a low conversion rate. J Arthroplasty. 2016;(16):30342–30344. pii: S0883-5403. No advantage of bipolar prosthesis, lower rate of prosthetic fracture with the use of cemented stems, a lower reoperation rate in elderly patients, and a higher conversion rate for younger patients were the main findings. Heetveld MJ, Rogmark C, Frihagen F, Keating J. Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence? J Orthop Trauma. 2009;23(6):395–402. Review. Kouyoumdjian P, Dhenin A, Dupeyron A, Coulomb R, Asencio G. Periprosthetic fracture in the elderly with anatomic modular cementless hemiarthroplasty. Orthop Traumatol Surg Res. 2016;102(6):701–705. Cementless hemiarthroplasty resulted in a higher rate of periprosthetic fracture. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg [Am]. 2006;88:249–260. The article makes the case that arthroplasty is clinically superior and more cost-effective compared to reduction and fixation in healthy older patients. Lee C, Freeman R, Edmondson M, Rogers BA. The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study. Injury. 2015;46(10):1978–1982. The article asserts that tranexamic acid reduces the need for blood transfusions following hemiarthroplasty for the treatment of hip fractures. Lu Q, Tang G, Zhao X, Guo S, Cai B, Li Q. Hemiarthroplasty versus internal fixation in super-aged patients with undisplaced femoral neck fractures: a 5-year follow-up of randomized controlled trial. Arch Orthop Trauma Surg. 2016. In the study covered by this article, hemiarthroplasty demonstrated less postoperative complications, lower reoperation rates, and overall better functional recovery in super-aged patients with nondisplaced femoral neck fractures. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg. 2006;14:287–293. The article advises that choice of treatment option must be based on individual patient mental status, living arrangement, level of independence and activity, and bone and joint quality. Macaulay W, Nellans KW, Garvin KL, et al. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty. 2008;23(6 suppl 1):2–8.

395

PEARLS

• If repair of the abductors is poor with sutures through the tendinous cuff, consider passing sutures through bone tunnels in the greater trochanter.

PITFALLS

• Care must be taken during transfer of the patient—maintain leg abduction, avoid external rotation.

396

PROCEDURE 31  Femoral Neck Fractures: Hemiarthroplasty Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Bone Joint J. 2016;98-B(3):291–297. A review article examining the evidence regarding treatment of displaced femoral neck fractures in elderly patients. Sayed-Noor A, Hanas A, Sköldenberg O, Mukka S. Abductor muscle function and trochanteric tenderness after hemiarthroplasty for femoral neck fracture. J Orthop Trauma. 2016;30(6):e194–e200. A direct lateral approach did not affect abductor muscle strength, the incidence of trochanteric tenderness, or clinical outcome but was associated with a higher incidence of Trendelenburg sign and limp. Sharma V, Awasthi B, Kumar K, Kohli N, Katoch P. Outcome analysis of hemiarthroplasty vs. total hip replacement in displaced femoral neck fractures in the elderly. J Clin Diagn Res. 2016;10(5):RC11–13. Findings included shorter operating time, less blood loss, and fewer postoperative complications for hemiarthroplasty but with a poorer 1-year functional outcome compared to total hip arthroplasty. Sprowson A, Jensen C, Chambers S, et al. The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: the Fractured Hip Infection trial. Bone Joint J. 2016;98-B(11):1534–1541. Compared with standard low-dose single-antibiotic cement, the use of high-dose dual-antibioticimpregnated cement significantly reduces infection rate.

PROCEDURE 32

Femoral Neck Fractures: Arthroplasty Jill M. Martin and Andrew H. Schmidt INDICATIONS

PITFALLS

• Strong evidence-based indications for arthroplasty : • Patients older than 60 years • Preexisting osteoarthritis • Pathologic fracture • Fractures with posterior femoral neck or calcar comminution • Rheumatoid arthritis • Renal failure patients • Failed internal fixation • Malunion/nonunion • Osteonecrosis • More controversial indications • Younger patients (those 25 mm 

PITFALLS

• An SHS is not indicated for an intertrochanteric fracture with reverse obliquity or a pure subtrochanteric fracture. These fractures are absolute indications for an IMHS (long or short).

412

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

A

B

C FIG. 33.4 

EXAMINATION/IMAGING • Full femoral radiographs in anteroposterior (AP) and lateral views, including the joints above and below the fracture, are obtained. • Computed tomography is less likely required (unless a femoral neck fracture is suspected and cannot be confirmed with conventional radiographs). 

SURGICAL ANATOMY • Tensor fascia lata, glutei (medius + minimus), vastus lateralis, perforators (particularly the first perforator), and lateral intramuscular septum • Ascending branch of the lateral circumflex femoral artery (Fig. 33.5) 

POSITIONING

FIG. 33.5 

• Anesthesia is induced prior to moving the patient to the fracture table. • The patient is placed in the supine position on an orthopedic fracture table, with boot traction on the affected limb (Fig. 33.6). • A well-padded table and perineal post (pressure point) is the usual ***. • The foot is secured nicely in the boot, so that it will not slip out intra operatively when traction is applied to the leg. • The patient’s body (trunk) is secured with a belt. • The affected limb is kept aligned with traction, while the other limb can be placed in a hemilithotomy position (see Fig. 33.6). 

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

FIG. 33.6 

PEARLS

• Align the testes to prevent injury from the perineal post. • Position the image intensifier to obtain clear images in both the AP and lateral views. • Tilting the table 10° to 15° to the nonoperative side will help to align the femoral anteversion parallel to the floor. This allows the screw direction to be parallel to the floor. • Surgical instruments and accessories (suction, diathermy) should be placed away from the imaging field.

PITFALLS

• A well-padded and large post is important to prevent traction-related complications. • The incidence of pudendal nerve palsy with numbness has been reported to range from 1.9% to 27.6% due to excessive and/or prolonged traction. Return of neurologic function can be unpredictable, however, and some patients experience only partial recovery or suffer permanent dysfunction.

CONTROVERSIES

• There are very few concerns with the well leg in a hemilithotomy position provided that the term is short (< 2 hours). Hemilithotomy positioning of the uninjured leg on a traction table has been associated with peroneal nerve palsy and compartment syndrome. Direct external calf compression and vascular hypoperfusion are believed to be the two primary causes of compartment syndrome in this setting.

EQUIPMENT

• Fracture table, including traction • Post and boot • Belt to stabilize the patient (if required) • Make sure that the leg of the fracture table does not interfere with images obtained by the image intensifier.

413

414

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

EXPOSURE

PEARLS

• It is advisable to mark the direction of the guide pin over the skin before making the incision. • Minimize excessive use of diathermy. • Sharp, careful dissection is preferred (respect the tissues). • Ligate/cauterize the bleeding points and perforators. • Watch for the ascending branch of the lateral circumflex femoral artery.

PITFALLS

• Minimize soft-tissue dissection at the site of comminution, particularly the medial fragment. • The idea is to reduce and span the fragments and allow healing to occur (minimizes the risk of devitalizing the bone fragments).

• The landmark for the incision is the greater trochanteric ridge (Fig. 33.7). • A lateral incision (10–15 cm) is made. • The fascia lata is opened and the vastus lateralis muscle is reflected anteromedially (Fig. 33.8). • A Hohmann retractor is placed in the inferior border of the vastus lateralis at the attachment to the lateral intermuscular septum so that the muscle can be elevated instead of dividing it (less morbidity). That retractor is directed anteriorly so that the muscle is elevated medially. • Another retractor can be inserted through the same entry and directed posteriorly to help expose the femur. • An incision can also be made in the vastus lateralis to divide it, if required, with slightly increased morbidity and weakness. 

FIG. 33.8 

FIG. 33.7  PEARLS

• It is important to ensure that the initial guidewire is measured within 5 mm from the articular surface of the femoral head to successfully anticipate the proper TAD index (Fig. 33.13). It is preferable to err posterior inferiorly with the guidewire. • The TAD index is crucial. • The TAD index is determined by combining the distance from the guide pin tip to the apex of the femoral head on AP and lateral views (see Fig. 33.13). • Cutout is higher with a TAD index greater than 25 mm and much less with a TAD index less than 25 mm. • Once the first pin is successfully inserted, another antirotation pin should be inserted similar but cephalic to the first one to prevent rotation of the neck of the femur, especially during SHS insertion. • Placing a pin parallel to the femoral neck in the lateral radiograph helps to define the femoral neck anteversion. Placing the pin parallel to the floor by tilting the bed slightly to the nonfractured side helps produce an excellent TAD in the final radiographs.

PROCEDURE Step 1: Reduction • Closed reduction is attempted first (usually successful; Fig. 33.9A and B). • Traction will improve the shortening and varus deformities. • Neutral rotation is usually required, but slight internal rotation is occasionally required and will help to close the gap medially to some extent. • This does not require as extreme a position in internal rotation as femoral neck reduction—usually, more neutral rotation. • The surgeon must be aware of excessive internal rotation. • Closed reduction must be confirmed by AP and lateral images prior to initiating the surgery (see Fig. 33.9A and B). • Failure to achieve closed reduction mandates open reduction. • Obtain an open reduction if closed reduction is not achieved primarily. Usually, this is done through the same incision, placing wires as a joy stick to manipulate the fracture fragments and reduce them, or through the use of a blunt bone hook to hold the reduction. Reduction clamps can also be used with one end on the greater trochanter and the other end medially on the calcar (Figs. 33.10–33.12). 

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

A

415

B FIG. 33.9 

FIG. 33.10 

FIG. 33.12  PITFALLS

• Anterior or superior placement of the pins gives a high chance of cutout (i.e., high TAD index). • Malposition of the TSP or poor size choice (i.e., too short) will still allow the proximal part to displace laterally. • Usually, a well-placed TSP device provides excellent stability in lateral wall blowouts.

INSTRUMENTATION/IMPLANTATION

FIG. 33.11 

• Guide pin size 2.0 mm with trocar tip, length 150 mm • 130° to 150° angle guide available in the set • SHS measuring device (Fig. 33.14) • SHS triple reamer (see Fig. 33.14) • SHS centering sleeve (see Fig. 33.14) • SHS tap • Connecting SHS with different length options available • T-handle wrench for SHS insertion • Limited contact dynamic compression plate (LC-DCP) SHS plate with variable hole number options • Impactor • SHS set (Fig. 33.15)

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

416

Xap

Dap

Xlat Dlat

FIG. 33.13  FIG. 33.14 

FIG. 33.15 

Step 2 • Insert anteversion wire in order to determine the femoral neck anteversion by inserting a guide pin anterior to the femoral neck (Fig. 33.16). • The entry for the guide pin can be drilled using a 4.5-mm drill bit (for better control and centralization of the pin). • Once the 2-mm pin is inserted via the 4.5-mm hole into the perfect center-center position, a 135° → 150° guide is centered over the femoral shaft and the correct angle plate is determined; note that 135° is the most common (Fig. 33.17). 

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

417

FIG. 33.16 

FIG. 33.17 

Step 3: Measure, Ream, Insert the Screw and the Plate • The length of the pin is measured (Fig. 33.18), keeping in mind the fracture gap and distance of the pin tip from the articular surface. • The triple reamer is adjusted to a desirable length (usually equal to the measured guide pin) and the pin hole is reamed (Fig. 33.19). • The bone is tapped, depending on bone quality (tapping not required with osteoporosis). • If the guidewire is removed accidentally, it should be reinserted. To reinsert the wire, push the centering sleeve into the reamed hole and slide an SHS into the sleeve (Fig. 33.20). • The SHS chosen—usually 5 to 10 mm shorter than the reamed length to allow for compression—is inserted to the desired position (in subchondral bone), keeping in mind that the handle of the screw insertion device should be parallel with the femoral shaft at the final screw position (Fig. 33.21). • Note: A screw 10 mm shorter is chosen if significant compression is expected at the fracture area. • The SHS side plate is then slid over the SHS, making sure of its position over the femoral shaft (Fig. 33.22). • The plate is impacted to its final position once it engages smoothly with the screw. • The plate is held to the femur using plate-holding forceps as required. • The first cortical screw is drilled into the second proximal hole of the SHS plate to hold the plate in place (Fig. 33.23). 

PEARLS

• Always use the image intensifier as a guide to locate the implant within the bone (pin, reamer, or screw). • Oblique images might be useful in case of suspicion of joint penetration. • Anticipate future cutout through measurement of the TAD index, as described earlier. If it is greater than 25 mm, review the position of the SHS and insert to obtain the correct TAD (< 25 mm total).

PITFALLS

• Avoid eccentric positioning of the guide pin, as it is related to screw penetration of the joint. • Staged insertion of the guide pin helps to reduce joint penetration. • Tapping helps minimize fracture displacement that sometimes occurs with screw insertional torque.

418

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

FIG. 33.19  FIG. 33.18 

FIG. 33.20 

FIG. 33.21 

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

FIG. 33.22 

Step 4: Trochanteric Stabilizing Plate (TSP) Placement • Once initial fixation of the SHS plate is achieved, the TSP is slid over the SHS plate. • A proper-length TSP is selected (usually short or small). • The TSP is inserted over the SHS plate until it fits and supports the lateral trochanteric wall. • Complete attachment of the TSP over the SHS plate must be ensured. • A cortical screw is drilled through the proximal first, third, and fourth holes of both plates (fitting over each other). • Then a 6.5-mm screw can be drilled and inserted through the TSP into the neck and head of the femur cephalic to the standard SHS. • Fixation is completed by drilling the rest of the cortical screws in the SHS plate if a plate with more than four holes is chosen (Fig. 33.4B and C).  PEARLS

• Make sure that both the SHS plate and TSP are central over the femur. • No further dissection is needed to position the TSP against the bone. • With certain types of TSP, a tension band can be used with or without screws (especially in severely comminuted greater trochanter fractures).

PITFALLS

• Avoid overcontouring of the TSP that might over-reduce the trochanter and thus affect the abductor mechanism. • Avoid excessive hip abductor dissection. • Usually, screws and wires are not required in the trochanter (the TSP is truly a buttress plate).

CONTROVERSIES

• Choosing the size of the TSP. • Smaller seems to be better tolerated by the patient as the larger ones tend to create issues of trochanteric bursitis when lying on that side. • The plate must be large enough to prevent displacement of the femoral shaft.

FIG. 33.23 

419

420

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation

Step 5: Closure • The wound is irrigated thoroughly and the need for bone grafting is judged (usually not required). • Drains for the wound are optional. • The wound is covered with a light pressure dressing.  CONTROVERSIES

Some prefer a longer period before mobilization with weight bearing; thus, the controversies are: • Timing of motion • Timing of weight bearing • Assessing union

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is mobilized the first postoperative day by sitting in a chair and standing. • Mobilization progresses from 50% weight bearing (sometimes difficult in the elderly) to full weight bearing (with walker or crutches) as tolerated. • Hip and knee exercises and muscle strengthening for hip abductors and flexors plus knee flexors and extensors are instituted.

EVIDENCE Babst R, Renner N, Biedermann M, et al. Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures. J Orthop Trauma. 1998;12(6):392–399. The objective was to evaluate whether the implantation of the modular trochanter stabilizing plate (TSP) in addition to the dynamic hip screw (DHS) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures. This is a prospective clinical study. Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP superimposed on the regular DHS at the institution between July 1991 and July 1993. Five patients died before the first follow-up, one patient was lost to follow-up, and another patient refused follow-up. Thus, 39 patients were followed for at least 12 months (mean, 14 months; range, 12–20 months). The fractures treated were classified according to the OTA classification, which is based on the AO classification. Of the fractures, 17 were 31-A2.2, 7 were 31-A2.3, and 14 were 31-A3.3 fractures. Lateralization of the greater trochanter was successfully prevented in all fractures. Limited fracture impaction was found in 90% (n = 35) of the patients with telescoping of 9.5 mm (range 0–30 mm), resulting in mean limb shortening of 5.37 mm (range, 0–14.9 mm). Four patients suffered limb shortening exceeding 15 mm (range, 15.6–21.3 mm). Functional results were excellent and good in 87% of patients and fair in 13% according to the Salvati-Wilson score. All fractures had healed 6 months after the operation. Three complications required a secondary procedure: one from not inserting a second screw parallel to the sliding hip screw to prevent rotation of the head-neck fragment (“antirotation screw”), one because of deep infection, and one because of a refracture after premature implant removal. Conclusion: In unstable pertrochanteric fractures with a small or missing lateral cortical buttress, the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment. Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90% of these patients. Butt MS, Krikler SJ, Nafie S, Ali MS. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury. 1995;26(9):615–618. The article covers a prospective, randomized controlled trial comparing the results of treatment with a dynamic hip screw (DHS) and a gamma nail in 95 consecutive patients with peritrochanteric fractures of the femur. The DHS was used in 48 patients, the gamma nail in 47. Clinical and radiologic outcomes were similar, but the gamma nail was associated with a higher incidence of complications, in particular, fracture of the femur below the implant in eight cases. Cascio BM, Buchowski JM, Frassica FJ. Well-limb compartment syndrome after prolonged lateral decubitus positioning: a report of two cases. J Bone Joint Surg [Am]. 2004;86(9):2038–2040. Hsu CE, Chiu YC, Tsai SH, Lin TC, Lee MH, Huang KC. Trochanter stabilising plate improves treatment outcomes in AO/OTA 31-A2 intertrochanteric fractures with critical thin femoral lateral walls. Injury. 2015;46(6):1047–1053. https://doi.org/10.1016/j.injury.2015.03.007. Epub 2015 Mar 10. A total of 252 A2 fractures treated with DHS or DHS and TSP (DHS-TSP) during January 2000 and June 2013 were enrolled in this study. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for postoperative lateral wall fracture (PLWF) in 205 patients who were treated with DHS alone. The risk factor found to be associated with PLWF was used to include 171 patients who were at high risk of PLWF. Standard univariate and multivariate analyses were performed to evaluate the effect of TSP on treatment outcomes. Lateral wall thickness was found to be the main risk factor for PLWF in A2 fractures. A lateral wall thickness of 2.24 cm was found to be the best cutoff point to determine which patients were at high risk for PLWF. In 171 patients with a lateral wall thickness less than 2.24 cm, patients treated with DHS-TSP had significantly decreased lag screw sliding distances, PLWF rate, and reoperation rate (P = 0.028, < 0.001 and P = 0.003, respectively) compared with the corresponding values of those treated with DHS alone. In the multivariate analysis, TSP decreased the reoperation rate by 13 times compared with that of patients who were treated with DHS alone.

PROCEDURE 33  Unstable Intertrochanteric Hip Fractures Plate Fixation Lateral wall thickness is the main risk factor for PLWF in A2 fractures treated with DHS. Use of TSP in A2 fractures with critical thin lateral wall thickness < 2.24 cm can significantly decrease the lag screw sliding distances, PLWF rate, and reoperation rate. Reindl R, Harvey EJ, Berry GK, Rahme E, Canadian Orthopaedic Trauma Society (COTS). Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Joint Surg [Am]. 2015;97(23):1905–1912. https://doi.org/10.2106/JBJS.N.01007. This prospective randomized multicenter study was designed to compare the clinical and radiographic outcomes of patients who had been treated with a traditional extramedullary hip screw for an unstable (AO/OTA 31-A2) intertrochanteric hip fracture with those of patients who had been treated with the newer intramedullary device for the same injury. The Lower Extremity Measure (LEM) was used as the primary hip-specific outcome tool. The Functional Independence Measure (FIM), the timed “Up & Go” (TUG) test, as well as a timed 2-minute walk test were used as secondary clinical outcome tools. Specific radiographic parameters were collected to assess for fracture movement, heterotopic ossification, and implant failure. No significant differences were noted between the intramedullary and extramedullary treatment arms with regard to either the primary or secondary clinical outcome tools. The radiographic parameters favored the intramedullary treatment arm, which had less femoral neck shortening. Therefore, the use of the intramedullary devices led to better radiographic outcomes in this study. However, this did not translate to improved functional outcomes. Sanders D, Bryant D, MacLeod M, et al. A Multicenter RCT Comparing the Intertan Device Versus the Sliding Hip Screw in the Treatment of Geriatric Hip Fractures: Results Depend on Preinjury Functional Level. Presented at the 31st Annual Meeting of the Orthopaedic Trauma Association; 2015. San Diego, California. A total of 249 patients 55 years of age or older with AO/OTA 31A1 (43) and AO/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. Shetty A, Ballal A, Sadasivan AK, Hegde A. Dynamic hip screw with trochanteric stablization plate fixation of unstable inter-trochanteric fractures: a prospective study of functional and radiological outcomes. J Clin Diagn Res. 2016;10(9):RC06–RC08. A prospective study was conducted with a total of 32 patients between the ages of 30 to 70 years with Evan Jensen unstable and very unstable types of intertrochanteric fractures between August 2013 to March 2015. They underwent open reduction and SHS and TSP fixation. They were started on full weight-bearing mobilization on postoperative day three. They were reviewed at postoperative weeks 3, 6, 12, and 24. Hip mobilization and rehabilitation exercises were instituted during the course of reviews. Radiographs were taken to assess fracture union and hip function was evaluated during follow-ups. At the end of 24 weeks, degree of radiographic union was scored as per the Radiological Union Score for Hip (RUSH). Hip function was scored with the Harris Hip Score. Fifteen patients had RUSH scores between 10 and 20 and 17 patients had scores between 20 and 30 points. RUSH score had a mean of 21.03 ± 2.132 points. Nine of 32 patients had excellent results as per Harris Hip Score, 10 had good, 9 had fair, and 4 had poor results. On comparison of Harris Hip Score with RUSH score: Interval between 10 and 20 points, of 15 patients; 2 had excellent results, 5 had good, 5 had fair, and 3 had poor results. Of 17 patients between 20 and 30 points, 7 had excellent, 5 had good, 4 had fair, and 1 had poor results. The conclusion was that SHS and TSP fixation of unstable intertrochanteric fractures is an effective technique with good radiologic and functional outcome.

421

PROCEDURE 34

Intertrochanteric Hip Fractures: Intramedullary Nailing Wade Gofton and Steven Papp PITFALLS

• Meta-analysis comparing extramedullary devices to intramedullary devices demonstrated no significant advantages, with higher complication rates (intraoperative complications and late femoral fractures, especially with early nails) (Parker and Handoll, 2005). • Newer generation nail constructs appear to have lower late complication rates than early sliding nails (Parker and Handoll, 2005).

A

INDICATIONS • To stabilize intertrochanteric hip fractures to facilitate pain control, early mobilization, and union • Intramedullary devices have been advocated over sliding hip screws for the treatment of more unstable intertrochanteric patterns (OTA 31-A3: reverse intertrochanteric hip fracture with extension into greater trochanter) (Kregor et al., 2005; Rokito et al., 1993). 

EXAMINATION/IMAGING • Plain radiographs • Anteroposterior (AP) and cross-table lateral hip (Fig. 34.1A), AP pelvis (Fig. 34.1B), traction views, or full-length femur views should be obtained. • The AP and lateral views are used to assess for signs that may suggest greater instability and potential difficulty in achieving a closed reduction or maintaining reduction: • Increased number of fracture fragments • Posteromedial comminution • Significant posterior displacement of the proximal segment or “posterior sag” • Loss of lateral femoral cortex integrity • The AP pelvis view shows alignment of the normal side to assist in determining an adequate reduction (see Fig. 34.1B). • In significantly comminuted and displaced fractures, a preoperative traction view can improve understanding of the fracture pattern, aiding in preoperative planning (Fig. 34.2). • If the fracture pattern warrants, or surgeon preference is for a full-length nail, fulllength films should be obtained to assess anatomy and femoral bow. 

B FIG. 34.1 

422

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

423

CONTROVERSIES

• Although intramedullary hip screw devices may have outcomes similar to extramedullary devices in stable fracture patterns, the outcomes in more complex 31-A2 fractures remain unclear at present. • Increasing evidence suggests reduced femoral neck shortening and improved mobility with intramedullary devices (Pajarinen et al. 2005; Hardy et al. 1998; Ahrengart et al. 2002); however, a recent randomized, controlled trial by Reindl et al. (2015) did not observe a difference in timed up and go. • There is evidence that younger patients may have improved functional outcomes with intramedullary devices (Sanders et al. 2017). • With modern design, no difference in intramedullary nail peripros­thetic fractures between short and long nails have been recorded; however, long nails can cost up to 45% more (Socci et al. 2017). • No significant differences in the rates of periprosthetic fractures between short and long nails have been recorded at 1, 2, or 5 years (Lindvall et al. 2016; Klewona et al. 2014); however, longer nails can cost up to 45% more than short nails (Lindvall et al. 2016).

FIG. 34.2 

SURGICAL ANATOMY • Gluteus medius • The gluteus medius originates from the iliac wing inferior to the crest, inserting into the lateral and superior surfaces of the greater trochanter. • The muscle belly is at risk of injury if a soft-tissue protector is not used when reaming. • The tendon insertion is often partially compromised by the start point opening reamer, but ensuring that subsequent reamer tips are placed intraosseously prior to reaming and use of a soft tissue protector will minimize further injury. • Superior gluteal nerve • The superior gluteal nerve arises from the lumbosacral plexus, exiting the greater sciatic notch superior to the piriformis and dividing into a superior and an inferior branch. • The superior branch follows the line of origin of the gluteus minimus and supplies it and the gluteus medius. The inferior branch crosses obliquely between the gluteus minimus and medius, supplying both, and terminates in the tensor fascia muscle, which it also supplies. • The inferior limb is in close proximity to the path between the skin insertion point and the trochanteric start point; it is at risk when the limb is in lower degrees of flexion and adduction (Ozsoy et al., 2007). Fig. 34.3 shows the usual location of the nail entry in relation to the superior gluteal nerve when the hip is in the extended position. 

TREATMENT OPTIONS

• Open reduction and internal fixation options include extramedullary sliding hip screws or fixed-angle devices for more unstable patterns. • Routine and minimal-incision open techniques have been described.

PEARLS

• In morbidly obese patients, taping the pannus toward the nonoperative side can improve imaging. • Ensuring that the nonoperative leg is clear of the C-arm will allow for switching between the AP and lateral views with minimal effort.

PITFALLS

• Abduction of the operative leg to achieve reduction will limit access to the start point and potentially block nail insertion.

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

424

EQUIPMENT

• Fracture table with well-padded perineal post • The fluoroscopy monitor is positioned at the foot of the bed to allow both the surgeon and the fluoroscopic technician to view the image. • Cautery and suction are also positioned at the end of the bed so they are out of the way of the C-arm.

Piriformis Trochanteric start point

Gluteus minimus Gluteus medius Nail

Insertion guide

Inferior branch of superior gluteal nerve FIG. 34.3 

PEARLS

• The start point skin incision will need to be more proximal in obese patients. • Passing sequential reamer tips into the femur manually before power reaming will avoid unintended abductor injury and eccentric reaming of the start point.

PITFALLS

• Making the starting incision proximal to the wire can lead to soft-tissue impingement of the percutaneous locking guide on the soft tissue, especially in larger patients.

A

POSITIONING • Although there is a trend toward free femoral nailing, supine positioning on a fracture table simplifies reduction and placement of the sliding screw in isolated intertrochanteric hip fractures. • The involved leg is placed in traction and reduced (Fig. 34.4A). • Shifting the torso to the opposite side and adducting the leg as much as possible while maintaining the reduction will make it easier to access the start point and insert the nail. • The uninvolved leg is flexed, abducted, and externally rotated to allow C-arm access (Fig. 34.4B). • The ipsilateral arm is held across the body to improve access to the start point. 

B FIG. 34.4 

PEARLS

• Characteristic displacement is posterior sag: the distal femur shortens in external rotation and is medially translated by the adductors; the head and neck displace into varus and translate posteriorly into the posterior inter­ trochanteric comminution (Carr, 2007).

PORTALS/EXPOSURES • Lateral reduction or sliding screw portal • If an anatomic closed reduction cannot be obtained, a reduction can often be effected through the lateral incision intended for the sliding screw. • The probable screw insertion site (usually 1–2 cm distal to the lesser trochanter) can be determined using implant-specific fluoroscopic guides or by laying a guidewire along the neck at approximately 130 degrees to the shaft (Fig. 34.5).

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

• Sharply dissect through skin, subcutaneous tissue, and fascia lata. Careful blunt dissection to the lateral femur is usually sufficient to allow for placement of reduction tools. • Large retractors or bone clamps passed around the medial side of the femur should be avoided to preserve soft tissue; however, they are rarely required. • Start point portal • The start point portal may be identified percutaneously with fluoroscopy. • In the average patient, the starting wire enters the skin 4 to 5 cm proximal to the greater trochanter, in line with or slightly posterior to the axis of the femur. • The start point is dependent on the implant, but in general it is either at or just off the tip of the trochanter in the AP plane (Fig. 34.6A) and either in line with the midshaft of the femur or slightly posterior in the lateral plane (Fig. 34.6B). • Make a 2-cm incision in line with and distal to the guidewire through the skin and fascia, then bluntly dissect to the tip of the trochanter. 

B

A FIG. 34.5 

A

B FIG. 34.6 

425

PITFALLS

• In unstable fractures, excessive internal rotation of the limb can result in malreduction.

426

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

PROCEDURE INSTRUMENTATION/IMPLANTATION

• Small bone hook • Jocher elevator • Weber bone reduction clamp • If the reduction cannot be maintained, carefully place a Weber reduction clamp with one arm slid posterior to the trochanter, and the other arm placed on the anterior cortex of the distal segment. Application of a gentle rotational force will hold the reduction after removal of the bone hook, but this force must usually be maintained until placement of the nail.

Step 1: Obtaining Reduction • It is almost universally recommended to obtain an anatomic reduction prior to fixation. Usually, this can be achieved with gentle longitudinal traction with the leg externally rotated, followed by internal rotation. • If a closed reduction cannot be obtained after one or two attempts, then an open soft tissue–preserving technique can be used to obtain an anatomic reduction. • Utilizing the lateral portal (Fig. 34.7A), place a small bone hook around the medial shaft distal to the lesser trochanter to lateralize the shaft and disimpact the fracture (Fig. 34.7B and 34.7C). A small elevator can be inserted anteriorly in the fracture line to elevate and reduce the head neck fragment. Release of the lateral retraction at this point usually results in maintenance of the reduction (Carr, 2007). 

PEARLS

• When there is a large posteromedial fragment or comminution, an intramedullary reduction tool may be required to guide the starting wire or long guidewire into the distal segment. PITFALLS

• In a poorly positioned or large patient, it is common for the starting wire to be directed medially toward the lesser trochanter. Reaming in this position compromises the final reduction and increases the risk of medial cortex perforation.

A

B

C FIG. 34.7 

Step 2: Start Point/Canal Preparation • Identify the start point percutaneously in both the AP and lateral plane and advance the starting wire with a wire driver. • If the fracture exits through the planned start point, the wire can usually be passed by hand. • In simple patterns without comminution, the opening reamer may displace the reduction, or the fracture may open sufficiently to allow the reamer to pass without reaming a channel for the nail. When the nail is passed, the reduction will be lost, usually resulting in a varus malreduction. • A varus malreduction can be avoided by utilizing a side plate construct instead of a nail for the simple patterns that exit at the start point, or making a larger proximal incision to allow the placement of a clamp to prevent opening of the fracture during reaming (Fig. 34.8).

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

• Fluoroscopy is used to confirm that the starting wire is centered in the canal of the distal segment, and the opening reamer is used with its soft tissue protector. • If a long nail is planned, pass a guidewire and use fluoroscopy to ensure that it is seated centrally in the distal femur on both the AP and lateral view. Sequential reamers may be required to ensure an appropriate-sized nail can be passed. 

A

B FIG. 34.8 

Step 3: Nail Insertion • When using a longer nail with an anterior bow, rotating the nail 90 degrees (such that the anterior bow is medial) may help avoid iatrogenic medial perforation (Ricci et al., 2006) (Fig. 34.9). • The nail can usually be passed gently by hand, requiring a gentle mallet for final seating. • Fluoroscopy and, depending on the system, a peripheral guide can be used to determine the appropriate depth of nail insertion. • In elderly patients, there is often an increased anterior femoral bow; when using an implant with a low radius of curvature in these patients, there is a high risk of perforation of the distal anterior cortex. • Consideration should be given to sizing the nail slightly shorter than a normal femoral nail and carefully monitoring this during insertion. 

FIG. 34.9 

427

428

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

INSTRUMENTATION/IMPLANTATION

Step 4A: Sliding Screw Placement • The sliding screw should ideally pass through the center of the neck (Fig. 34.10A) and be positioned subchondrally in the AP (Fig. 34.10B) and lateral planes. • Baumgaertner et al. (1995) demonstrated reduced “cut-out” rates if the tip-apex distance was less than 25 mm; this is presumed to hold true for intramedullary devices in the elderly patient (Geller et al., 2009). • While biomechanical evidence suggests that inferior placement of the screw on the AP X-ray and central placement on the lateral may improve axial and torsional stiffness (Kuzyk et al. 2012), this has not been demonstrated in a clinical study. 

• Starting guidewire • Opening reamer • Soft-tissue protector • Intramedullary reduction tool

B

A

FIG. 34.10  CONTROVERSIES

• Length of nail required: it has been argued that the invariably associated osteopenia should be considered pathologic, requiring “whole” bone fixation. • The authors usually use a medium-length nail in this age group to avoid the risk of distal anterior cortex perforation, but use longer nails for unstable patterns (transverse intertrochanteric, reverse obliquity, or significant subtrochanteric extension). • Although tip-apex distance (TAD) has been proved valuable in avoiding failure, some have advocated a variation, calcar-TAD, which targets inferior placement of the screw/blade, but has not been proved to reduce failure rates (Socci et al., 2017). PEARLS

• After reduction, evaluating the lateral film to determine femoral anteversion relative to the perineal post can simplify subsequent guide pin insertion. Turning the image to place the post perpendicular to the floor will indicate the amount of angulation required to be centered in the head (see Fig. 34.1A).

Step 4B: Blade Placement • Use of helical blades may be associated with “cut-through” with medial perforation of the articular surface without loss of reduction as opposed to “cut-out” (Frei et al., 2012). • “Cut-through” may be reduced if full blade trajectory is not predrilled and the tip of blade is left a minimum of 10 mm from the articular surface (Frei et al., 2012; Brunner et al., 2008). 

Step 5: Locking Screw Placement • Distal locking screw placement may be done through the guide for shorter nails or freehand for long nails. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The goal of fixation is to facilitate early motion and function. Taking time to ensure that an anatomic reduction and appropriate hardware and sliding screw placement are achieved should allow almost all patterns to be weight bearing as tolerated. • Fractures that extend into the subtrochanteric region, especially in the setting of medial comminution at the level of the nail taper, may require greater caution in postoperative weight bearing. •  Unless contraindicated, patients receive postoperative deep venous thrombosis prophylaxis; however, the precise form of prophylaxis remains controversial (Handoll et al., 2002) and patient specific. • Postoperative imaging is repeated at 2 and 6 weeks and 3 months. • Potential postoperative complications

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing

• Screw cutout: Cutout rates with intramedullary nailing are similar to those with plate-screw constructs (Parker and Handoll, 2005), and we advise that, similar to plate-screw constructs, the tip-apex distance be less than 25 mm (Baumgaertner et al., 1995). • Early femoral fractures: Rates were reported as high as 5% for first-generation constructs (Parker and Handoll, 2005). These fractures can often be managed with distal locking of the implant or use of a longer implant. It is believed that improved design and technique (over-reaming and gentle nail insertion) have reduced these complications. • Late femoral fractures: Studies suggest that this devastating complication is more frequent with intramedullary nailing than with plate-screw constructs (Parker and Handoll, 2005). Again, it is believed that with newer designs this complication rate may be reduced. • Distal femoral cortical perforation: Elderly patients and some ethnic groups tend to have femurs with an increased femoral bow. Understanding the implant’s design, careful patient selection, monitoring the tip of the nail during insertion, and use of newer nail designs with better matched radii of curvature may reduce this complication. PITFALLS

• Multiple attempts at distal locking screw insertion can create a local stress riser and increase fracture risk.

CONTROVERSIES

• When using a long nail, the need for distal locking screws in stable patterns is unclear.

EVIDENCE Ahrengart L, Törnkvist H, Fornander P, et al. A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res. 2002;401:209–222. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg [Am]. 1995;77:1058–1064. (Level III evidence.) Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of unstable proximal femur fractures–3 cases of postoperative perforation of the helical blade into the hip joint. J Orthop Trauma. 2008;22:731–736. Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma. 2007;21:485–489. (Level IV evidence.) Den Hartog BD, Bartal E, Cooke F. Treatment of the unstable intertrochanteric fracture: effect of the placement of the screw, its angle of insertion, and osteotomy. J Bone Joint Surg [Am]. 1991;73:726– 733. Frei HC, Hotz T, Cadosch D, Rudin M, Käch K. Central head perforation, or “cut through,” caused by the helical blade of the proximal femoral nail antirotation. J Orthop Trauma. 2012;26:102–107. Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2009. [Epub ahead of print]. (Level III evidence.) Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD000305. 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-A:618–630. Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma. 2014;28:391–397. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable peritrochanteric femoral fractures. J Orthop Trauma. 2005;19:63–66. Kumar AJ, Parmar VN, Kolpattil S, Humad S, Williams SC, Harper WM. Significance of hip rotation on measurement of “Tip Apex Distance” during fixation of extracapsular proximal femoral fractures. Injury. 2007;38:792–796.

429

PITFALLS

• If the screw is not central in the femoral head, it may appear to be subchondral on some views when in fact it is intraarticular (Kumar et al., 2007). • Appropriately positioning the guidewire before reaming allows for the correction and optimal final screw position. CONTROVERSIES

• Because the best bone is in the posteroinferior segment of the head, some have advocated for placement of the screw in this quadrant; however, this will compromise the tip-apex distance and may risk rotatory fixation failure (Den Hartog et al., 1991).

430

PROCEDURE 34  Intertrochanteric Hip Fractures: Intramedullary Nailing Lindvall E, Ghaffar S, Martirosian A, Husak L. Short vs long intramedullary nails in the treatment of pertrochanteric hip fractures. J Orthop Trauma. 2016;30:119–124. Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg [Am]. 2007;89: 829–834. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing postoperative rehabilitation. J Bone Joint Surg [Br]. 2005;87-B:76–81. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2005;(4):CD000093. Reindl R, Harvey EJ, Berry GK, Rahme E. Canadian Orthopaedic Trauma Society (COTS). Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Joint Surg [Am]. 2015;97:1905–1912. Ricci WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20:663–667. (Level II evidence.) Rokito AS, Koval KJ, Zuckerman JD. Technical pitfalls in the use of the sliding hip screw for fixation of intertrochanteric hip fractures. Contemp Orthop. 1993;26:349–356. Sanders D , Bryant D, Tieszer C, et al. A multicenter randomized control trial comparing a novel intramedullary device (InterTAN) versus conventional treatment (Sliding Hip Screw) of Geriatric Hip Fractures. J Orthop Trauma. 2017;31(1):1–8. http://doi: 10.1097/BOT.0000000000000713. Socci AR, Casemyr NE, Leslie MP, Baumgartner MR. Implant options for the treatment of treatment of intertrochanteric hip fractures of the hip: rationale evidence, rationale. Bone Joint J. 2017; 99-B:128–133.

PROCEDURE 35

Open Reduction and Internal Fixation of Subtrochanteric Fractures Rohit Bansal, Damian Clark and Paul Duffy INDICATIONS

INDICATIONS PITFALLS

• Osteoporotic bone • Noncompliant patient • Differentiating a nonunion from a delayed union • Optimizing general well being, malnutrition, and cessation of smoking

• Subtrochanteric fracture • Nonunion of subtrochanteric fracture • Malunion of subtrochanteric fracture 

EXAMINATION AND IMAGING • If managing a nonunion, consider the underlying etiology. • Careful examination of the rotation of the contralateral limb prior to patient positioning will avoid malrotation. • Perform investigation—including C-reactive protein (CRP) and erythrocyte sedimentation rate/plasma viscosity (ESR/PV) tests and biopsy—to ascertain the role of infection in previous failed fixation.

FIG. 35.1  Example of a blade plate used for subtrochanteric fracture fixation.

TREATMENT OPTIONS

• Blade plate (Fig. 35.1) • Locking plate (Fig. 35.2) • Intramedullary nail (cephalomedullary or reconstruction nail) • Surgical anatomy

FIG. 35.2  Example of proximal femur locking plate as primary management of subtrochanteric fracture fixation.

• The surgical approach is a direct lateral approach to the proximal femur. • Skin and fat are incised. A narrow channel is cleared over the iliotibial band, which is then incised. • The vastus lateralis is mobilized with a hockey stick incision (the anterior fibers are kept intact). • Care is taken to protect where possible or tie off perforators. • If using a blade plate, the entry site for the 95° plate is usually just proximal to the most prominent point on the trochanteric ridge. Note the entry point of the blade plate in Fig. 35.1.  

POSITIONING • Lateral or supine on traction table (Fig. 35.3)  431

432

PROCEDURE 35  Open Reduction and Internal Fixation of Subtrochanteric Fractures

FIG. 35.3  Traction table used in lateral position. POSITIONING PEARLS

• Consider the position of the proximal fragment. If the lesser trochanter remains attached to the proximal fragment, then this will be flexed and externally rotated owing to the action of the iliopsoas. • If the lesser trochanter is fractured, then the proximal fragment will be externally rotated by the action of the short external rotators. • If a fixed flexion deformity of the hip is preexistent, then it may be helpful to flex the hip by raising the torso on the fracture table. Alternatively, the patient may be positioned laterally on the radiolucent table. POSITIONING PITFALLS

• Rotation is more difficult to judge in the lateral position. • Ensure adequate biplanar visualization and access for the C-arm prior to draping (particularly on the radiolucent table). POSITIONING EQUIPMENT

• Radiolucent table or fracture table PORTALS/EXPOSURES PEARLS

• Ensure adequate exposure of the entry point for the blade. The incision extends a little more proximal than the familiar sliding hip screw (SHS) incision. • Take care when handling the perforators; if they are incised and retract medially, they are difficult to locate and cause major hemorrhage. • Avoid stripping the medial side of the femur. • Maintain blood supply and biology wherever possible.

PROCEDURE 35  Open Reduction and Internal Fixation of Subtrochanteric Fractures

PROCEDURE Step 1: Plan Device Size and Position   • The importance of planning the position of the blade plate cannot be overstated, as it is both a reduction and fixation device. Planning begins by obtain radiographs of the contralateral hip to ascertain the normal neck-shaft angle. Templating the blade plate on the normal side will allow to estimate the entry point and the length of the blade. The entry point should be at least 10 to 15 mm distal from the inferior-central femoral head. • The AO blade plates are available in a 95° and 130° angled plate for use in proximal femoral fractures. There are osteotomy plates, which are available in 90°, 100°, 110°, 120°, and 130°. The AO blade plates are available in 10-mm blade length increments; and shaft lengths from 5 to 26 holes. We describe the use of the 95° plate for fixation of subtrochanteric fractures. • Usually, the entry site for the 95° plate will be just proximal to the most prominent lateral point on the greater trochanter. • Reduction ways to calculate the reduction are particularly useful when deformity is present. One method is to hold the plate with a Kocher and superimpose it over the hip on fluoroscopy (maintain the same entry point as described earlier). If a 40° correction of the fracture is required, place the plate so that there is a 40° angle between the shaft of the plate and the shaft of the femur. Then, switch the image to the other fluoroscopy screen. Now, use your osteotome to create a channel in the femoral neck where the blade of the plate appears in your template (that you left on the other screen). The deformity is at the center of rotation of your correction so that a rotational correction can be made without translation. Another method is to hold the plate with a Kocher over the normal hip. This will give you an indication of where the entry point of the tip of the plate should be if normal anatomy is restored. STEP 1 PEARLS

• The importance of planning the position of the blade plate cannot be overstated, as it is both a reduction and fixation device. • Obtain radiographs of the contralateral hip to ascertain the normal neck-shaft angle. • AO blade plates come in a 95° and 130° angled plate for use in proximal femoral fractures. There are also 90°, 100°, 110°, 120°, and 130° osteotomy plates available. We describe the use of the 95° plate for fixation of subtrochanteric fractures. • Usually, the entry site for the 95° plate will be just proximal to the most prominent lateral point on the femur. • Plan the length of the blade on the radiograph. The tip of the blade should be 10 to 15 mm from the inferior-central femoral head. • Check that blade plates that you require are available. The AO blade plates are available in 10-mm blade length increments; shaft lengths are available from 5 to 26 holes. • There are other ways to calculate the reduction, particularly useful when deformity is present. One method is to hold the plate with a Kocher and superimpose it over the hip on fluoroscopy (maintain the same entry point as described earlier). If a 40° correction of the fracture is required, place the plate so that there is a 40° angle between the shaft of the plate and the shaft of the femur. Then, switch the image to the other fluoroscopy screen. Now, use your osteotome to create a channel in the femoral neck where the blade of the plate appears in your template (which you left on the other screen). The deformity is at the center of rotation of your correction so that a rotational correction can be made without translation. • Another method is to hold the plate with a Kocher over the normal hip. This will give you an indication of where the entry point of the tip of the plate should be if normal anatomy is restored. STEP 1 PITFALLS

• There is a tendency to undercorrect. It is safer to leave the fracture in valgus than varus; thus, be bold with the correction. • If the plate position is not templated, then this may result in malreduction. STEP 1 INSTRUMENTATION/IMPLANTATION

• Blade plate—various angles are available STEP 1 CONTROVERSIES

• A balance between soft tissue preservation and perfect reduction is important to prevent devascularization. Importance of medial soft tissue cannot be overemphasized.

Step 2 • Remove any preexisting hardware • Broken cephalomedullary device (Fig. 35.4) • Broken 95° dynamic condylar screw (DCS; Fig. 35.5) 

433

434

PROCEDURE 35  Open Reduction and Internal Fixation of Subtrochanteric Fractures

STEP 2 PEARLS

• Review the previous operative chart. Have a plan for removal of nails with the original insertion device and a nail removal set as well as broken screw removal set.

STEP 2 PITFALLS

• Overreliance on the original insertion device. • Not familiar with the inserted device. • With cephalomedullary nails, is there a set screw securing the hip screw in place?

STEP 2 INSTRUMENTATION/IMPLANTATION

• If revising a cephalomedullary nail, then review the operative technique for the implant to be removed. • Have available the insertion device for the implant to be removed. Have available the nail removal set; various commercial options are available. STEP 2 CONTROVERSIES

• Removal of broken cephalomedullary device may need extensive distal exposure • Removal of distal failed/ broken cephalomedullary device needs to be planned pre-operatively.

FIG. 35.4  Broken cephalomedullary device.

FIG. 35.5  Broken 95° dynamic condylar screw.

Step 3 • Reduction • A cerclage wire is used to reduce the fracture and is then plated over (Figs. 35.6 and 35.7). 

STEP 3 PEARLS

• The blade plate itself is a powerful reduction tool; plan the position of the blade carefully. • A cerclage wire may be used as a reduction tool and then plated over. • In revision cases, abundant callus may be present. Judicious use of an osteotome and periosteal elevator may be required to mobilize the fracture. Avoid devitalizing tissues and remove what callus is necessary to restore fracture mobility. STEP 3 PITFALLS

• Although it is a powerful ally, the blade plate can be a force for evil. A malpositioned blade plate will malreduce for the fracture.

PROCEDURE 35  Open Reduction and Internal Fixation of Subtrochanteric Fractures

435

FIG. 35.6  Example of ball spiked pusher to reduce the fracture and a cer- FIG. 35.7 Example of blade plate insertion after maintenance of anatomic clage wire to hold it. reduction. STEP 3 INSTRUMENTATION/IMPLANTATION

• Large reduction clamps • Cerclage wire • Osteotomes • Periosteal elevators • Steinmann/Schanz pins • Ball point pusher STEP 3 CONTROVERSIES

• Controversies: • Minimal soft tissue dissection for removal of implant. • Bleeding bone edges. • Minimal devascularization of medial soft tissue for passing the cerclage wire. • Minimal periosteal stripping. STEP 4 PEARLS

• Guidewires can be placed up the femoral neck to confirm a satisfactory trajectory prior to insertion of the seating chisel. There is a 95° guide that may be helpful in planning this position. • The seating chisel does not remove bone. An erroneously placed chisel can be repositioned, although this does present additional difficulty and risk. • Insert the plate into the tract from your seating chisel with attention to follow the same tract. • Implant the plate—as it is pulled down, it will create the correction that you planned. • Attain fixation in the proximal fragment with a screw in addition to the blade before making a reduction with the plate. • Use large fracture-reduction clamps to pull down the plate to the shaft if compression is required (Hey Groves or Verbrugge). This will enable you to make full use of the articulated tensioning device. • If the articulated tensioning device will not be used for compression, then the plate may be pulled down with a screw. STEP 4 PITFALLS

• When inserting the plate into the tract from your seating chisel, incorrect placement can occur. It is possible to place the plate erroneously; thus, it should be placed with careful attention to follow the tract. • The seating chisel can penetrate the anterior cortex. The weight of the chisel may contribute to the tip being directed out of the anterior cortex of the femoral neck. STEP 4 INSTRUMENTATION/IMPLANTATION

• Verbrugge bone holding forceps • AO femoral distractor • Collinear clamp

436

PROCEDURE 35  Open Reduction and Internal Fixation of Subtrochanteric Fractures

STEP 4 CONTROVERSIES

• Minimize soft-tissue devascularization while using instruments to hold the blade plate to bone and maintain reduction.

FIG. 35.8  Fracture compressed with articulated tensioning device.

Step 4 • Implant the device (Fig. 35.7). 

Step 5 • Compression of the fracture with the articulated tensioning device (Fig. 35.8). STEP 5 PEARLS

• When using the articulated tensioning device, always place the distal “post screw” bicortical to minimize the chance of cutout. • Four large-fragment screws with eight cortices is the minimum fixation required in the shaft. STEP 5 PITFALLS

• The articulated tensioning device reads the compression as green/yellow/red. Enter the red zone only if you have good bone quality and bicortical fixation with the post screw. POSTOP PEARLS

• Expect a prolonged period for union. • Computed tomography should be scheduled for 4 months postoperatively if there is any doubt regarding union. POSTOP PITFALLS

• These fractures may be very slow to unite. In some cases the implant may break before union despite good alignment and absence of infection.

EVIDENCE Tornetta IIIP, McQueen MM, Rockwood and Green’s fractures in adults. Lippincott Williams & Wilkins; 2019;343:230–238. Wang J, Ma XL, Ma JX et al. Biomechanical analysis of four types of internal fixation in subtrochanteric fracture models. Orthop Surg. 2014;6(2):128–136. Floyd JC, O’toole RV, Stall A et al. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009;1;23(9):628–633. Hoskins W, Bingham R, Joseph S et al. Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome. Injury. 2015;46(9):1992–1995.

PROCEDURE 36

Subtrochanteric Femur Fractures: Intramedullary Nailing Steven Papp and Wade Gofton INDICATIONS

PITFALLS

• Most subtrochanteric femur fractures (types IA and IB) (Fig. 36.1) • This device is an excellent choice for: • Comminuted, high-energy fractures (Wiss and Brien, 1992) • Low-energy, osteoporotic fractures (Robinson et al., 2005) • Fractures with diaphyseal extension (Cheng et al., 2005) • Fractures with peritrochanteric extension • Pathologic fractures 

• Proximal extension into the femoral neck or head may preclude adequate proximal fixation. • Pathologic fractures not amenable or sensitive to local control (typically radiation) will even­ tually fail, and a tumor prosthesis should be considered in these special situations.

CONTROVERSIES

• Historically, proximal fracture extension into the piriformis fossa (type II) was a contraindication to this technique (see Fig. 36.1). Careful technique can overcome this problem, and an intramedullary (IM) device may still be used.

IA

IB

IIA

IIB

FIG. 36.1  Modified from Robinson CM, Houshian S, Khan LAK. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg [Am]. 2005;87:2217–2226.

EXAMINATION/IMAGING • Assessment • Advanced Trauma Life Support protocol and a secondary survey should be completed in patients with this fracture, commonly secondary to high-energy trauma. • Contiguous injuries to the pelvis or knee should be ruled out. • Radiology • High-quality imaging should include an anteroposterior (AP) view of the pelvis and AP and lateral views of the femur, including the knee. • Typically, these fractures have significant varus and flexion deformity (Fig. 36.2). • The fracture pattern, including extension into the piriformis fossa, femoral neck, or trochanteric region, can occur and should be noted in the preoperative plan. Fig. 36.3 shows an AP radiograph of a reverse obliquity fracture with extension into the proximal segment (arrow). • Preoperative templating should be performed so that the appropriately sized intramedullary (IM) nail can be made available. Specifically, it is important to document: • Femoral length • Canal diameter • Neck-shaft angle 

TREATMENT OPTIONS

• Intramedullary nail (first-generation nail in selected cases) • Blade plate • Dynamic condylar plate • Proximal femoral locking plate 437

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

438

A

B FIG. 36.2 

FIG. 36.3 

PEARLS

SURGICAL ANATOMY

• Supine on fracture table • Using a well-leg holder instead of the scissoring technique allows easier movement of the C-arm. • A small open reduction may be necessary to overcome varus deformity; plan for the incision necessary for the cephalic screw insertion and use this incision to perform reduction using a bone hook or clamp.

• The initial start point is found by inserting the guide pin in percutaneous fashion through the hip abductors. • Note the proximity of the superior gluteal nerve and the potential risk of injury (Fig. 36.4). • The nerve stays 5 cm proximal to the tip of the trochanter. • Fracture deformity depends on all the muscles around the hip and the location of the fracture. • Classically, the psoas and abductor muscle vectors on the proximal fragment can lead to abduction, flexion, and external rotation of the proximal fragment (Fig. 36.5). 

Gluteus medius

Superior gluteal nerve

Gluteus minimus

FIG. 36.4 

FIG. 36.5  Modified from Russell TA, Taylor JC. Subtrochanteric fractures of the femur. In: Browner BD, Jupiter JB, Levine AM, Trafton PG (eds). Skeletal Trauma, ed 2. Philadelphia: Saunders, 1992:1836.

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

POSITIONING

439

PITFALLS

• There are several alternatives. • Lateral positioning on a radiolucent table with the leg prepared free is an excellent choice. • This position makes start point insertion easier. • It also allows hip flexion, which aids in fracture reduction, bringing the distal segment closer to the flexed proximal segment (Fig. 36.6). • Protects superior gluteal nerve. • Alternatively, supine or lateral positioning on a fracture table can be used. • With supine positioning, a small bolster is used under the posterior superior iliac spine to slightly roll the patient away and make start point insertion easier by avoiding the table (which is often in the way) (Fig. 36.7, arrow). Place the opposite leg in a well-leg holder. • The upper torso is rolled away and the lower leg placed in some adduction to allow for easier start point insertion. 

• Lateral • Make sure the site is prepared wide. • Judging rotation of the femur when inserting distal locking screws is more challenging. • Supine on fracture table • Positioning supine on the fracture table with the leg in traction/adduction and the perineal post at the level of the fracture can push the fracture into varus (Fig. 36.8). • Using too much traction to overcome deforming forces is tempting. This can lead to skin necrosis and pudendal or femoral nerve palsy. CONTROVERSIES

• Lateral positioning makes start point insertion, fracture reduction, and nail insertion much easier. However, fracture table placement in the supine position is acceptable. This may be easier when no skilled surgical assistants are available.

A

B FIG. 36.6 

440

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

Perineal post FIG. 36.7 

FIG. 36.8  PEARLS

• Minimize stripping at the level of the fracture site while performing a reduction.

PITFALLS

• Be careful about starting too proximally, putting the superior gluteal nerve at risk (see Fig. 36.4).

PORTALS/EXPOSURES • Make a small incision 3 to 4 cm proximal to the greater trochanter. • Obtaining the start point with the proximal fragment still in varus is more difficult. Note the angle of insertion of the guidewire in Fig. 36.9A. • We find it much easier to reduce the fracture (either by closed or open means) prior to making the start point incision. This makes guidewire insertion (and each subsequent step) much easier (Fig. 36.9B). • Make a second small incision near the level of proximal screw insertion if necessary, and use this incision to reduce the fracture. • A compliment of reduction instruments are available for use through the lower incision (Fig. 36.10). These reduction clamps are used to assist in the reduction of the fracture (Fig. 36.11).

A

B FIG. 36.9 

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

FIG. 36.10 

A

B

C FIG. 36.11 

441

442

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

A

B

C

D FIG. 36.12 

PEARLS

• Spend time achieving the perfect start point to avoid malreduction at time of nail insertion. PITFALLS

• Varus malreduction is common (French and Tornetta, 1998). • Unlike many isthmus fractures, for which reamers and/or a nail will facilitate reduction, passage of the reamer without reduction can result in eccentric reaming and worsening of the deformity.

• Some surgeons prefer to make the proximal portal and prepare the proximal femur prior to reduction. Then “percutaneous” and “intramedullary” reduction techniques are used to reduce the proximal fragment. This technique can be used by experienced surgeons, but we have found it to be difficult. • This technique leads to acceptance of inferior fracture reduction in many cases. Note the insertion of a nail in “percutaneous fashion,” with unacceptable reduction in both varus and flexion, in Fig. 36.12A–D. • Eventual construct failure results (Fig. 36.13), and in this case required conversion to blade plate fixation (Fig. 36.14). 

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

443

FIG. 36.13 

A

B FIG. 36.14  INSTRUMENTATION/IMPLANTATION

PROCEDURE Step 1 • Identify the start point landmark 3 to 4 cm superior to the greater trochanter using imaging. • Different possible points include the medial trochanter (blue dot), lateral trochanter (black dot), trochanteric fossa (red dot; often referred to as the piriformis fossa in many texts and manuals), and femoral neck (green dot) (Fig. 36.15). • Make a small incision and insert the guide pin onto the medial tip of the trochanter. Fig. 36.16 shows a reconstruction nail with a widened proximal nail portion and 5 degrees proximal lateral bend. • Confirm good positioning of the guide pin on both AP (Fig. 36.17A) and lateral (Fig. 36.17B) images before advancing the wire. • Note that the lateral start point should be placed on the medial trochanter to allow passage of cephalic screws into the femoral neck and head (Fig. 36.18). 

• A start point at the medial tip of the trochanter (as described here) relies on the use of a nail device with a 3- to 5-degree lateral bend at the proximal end (see Fig. 36.16). If nail bend is different, this may affect the start point and reduction (Ostrum et al., 2005). CONTROVERSIES

• Much controversy exists over the best start point. The medial trochanter offers both the least soft-tissue damage and the easiest point to maintain a reduction and avoid varus (Dora et al., 2001). PEARLS

• Preoperative templating and intraoperative “feel” and fluoroscopic images are used to decide on nail width (see Fig. 36.21).

444

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

IM nail widened proximally

FIG. 36.15 

FIG. 36.16 

A

B FIG. 36.17 

FIG. 36.18 

3- to 5-degree lateral bend

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

445

Step 2 • Using the proximal femur opening reamer (available on most sets), open the femur to the level of the lesser trochanter (Fig. 36.19A). • Advance the guide pin into the proximal femur (Fig. 36.19B and C). • Some nail sets allow the proximal reamer to be left in position and used as percutaneous access for reaming (Fig. 36.19D). 

A

B

C

D FIG. 36.19 

Step 3

PITFALLS

• Pass the guidewire down the femoral canal to the level of the knee (Fig. 36.20). • Pass the reamer down the femoral diaphysis (Fig. 36.21). Ream the femur until diaphyseal chatter is felt over the segment of the isthmus. 

• When passing the guidewire, check a lateral radiograph of the knee to ensure that the guidewire is central and the reamer will not perforate the anterior femoral cortex, leaving a stress riser for a supracondylar femur fracture. • Because of the proximal fracture location (leaving the isthmus intact) and the mismatch of most nails with the femoral bow, the distal tip of the reamer and ultimately the nail may ride very anterior in the supracondylar region (Egol et al., 2004). • If the anterior femoral cortex is perforated distally (Fig. 36.22), supracondylar fracture of the femur is a potential intraoperative or postoperative complication (Ostrum and Levy, 2005).

446

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

FIG. 36.20 

FIG. 36.21 

A

B

FIG. 36.22  From Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures. J Orthop Trauma. 2005;19:656–660. Special thanks to Don Aker for help with images. INSTRUMENTATION/IMPLANTATION

• Note that the proximal portion of the nail is wider and stronger in the subtrochanteric region (see Fig. 36.16). • Nail failure is most likely to occur in the proximal nail (where most stress is located) or at the locking screws. • Increasing the width of the nail inserted is recommended, but may not improve the biomechanical strength of the overall construct in proximal femur fractures where the forces exist over the proximal nail (which does not change in size).

Step 4 • Measure nail length and then insert the appropriate nail over the guidewire. • When inserting the nail, be aware that rotational adjustments made may lead to malrotation when locking the nail (Fig. 36.23). • If this occurs, the nail must be backed out, rotated, and then reinserted. Fig. 36.24 shows nail insertion performed and rotated so that the proximal femoral locking screws can be inserted into the femoral head. • Seat the nail to an appropriate height. • Through a second incision, insert guide pins into the femoral head under fluoroscopic visualization (Fig. 36.25A and B).

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

• Confirm central neck and head position on AP and lateral radiographs. • Measure, drill, and insert cephalic proximal locking screws into the femoral head (Fig. 36.25C and D). • These screws should be placed centrally on two views or slightly biased inferiorly and posteriorly. 

A

B FIG. 36.23 

A

B FIG. 36.24 

447

PEARLS

• Check the nail length at the distal end before locking the nail proximally. If the cephalic screw is running inferior in the neck and superior in the head, the proximal femur may be in varus (Fig. 36.26).

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

448

A

B

C

D

FIG. 36.25 

Cephalic screws superior in femoral head

FIG. 36.26 

Step 5 • Once the nail is locked proximally, remove the proximal nail guide. • When nailing on the fracture table, this will allow the leg to be changed from a position of adduction to abduction to allow easier insertion of the distal locking screw. • Using the “perfect circle” technique, make a small incision at the level of the distal locking hole. Drill a hole (Fig. 36.27A) and insert a distal locking screw into the nail in the distal metaphysis (Fig. 36.27B). • Preoperative (Fig. 36.28A) and postoperative (Fig. 36.28B and C) radiographs are examined to confirm goals of excellent reduction and good hardware placement. 

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

A

B FIG. 36.27 

A

B

C FIG. 36.28 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Antibiotic prophylaxis is given (e.g., 3 doses of Ancef). • Anticoagulation is given for a duration of 7 to 14 days. • Weight bearing, as tolerated, is permitted for simple fracture patterns. Limited weight bearing is recommended for more comminuted fractures. • The patient is regularly followed up to fracture union. • Complications include infection, proximal screw cutout or failure, nail breakage, nonunion, malrotation, and shortening. • Without complications, acceptable functional results can be expected.

449

450

PROCEDURE 36  Subtrochanteric Femur Fractures: Intramedullary Nailing

EVIDENCE Cheng MT, Chiu FY, Chuag TY, et al. Treatment of complex subtrochanteric fracture with the long Gamma AP locking nail. J Trauma. 2005;58:304–311. Dora C, Leunig M, Beck M, Rothenfluh D, Ganz R. Entry point soft tissue damage in antegrade femoral nailing: a cadaver study. J Orthop Trauma. 2001;15:488–493. Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004;18:410–415. French BG, Tornetta III P. Use of interlocked cephalomedullary nail for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998;348:95–100. Kang S, McAndrew MP, Johnson KD. The reconstruction nail for complex fractures of the proximal femur. J Orthop Trauma. 1995;9:453–463. Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures. J Orthop Trauma. 2005;19:656–660. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005;19:681–686. Ozsoy MH, Basarir K, Bayramoglu A, Erdemli B, Tuccar E, Eksioglu MF. Risk of superior gluteal nerve and gluteus medius muscle injury during femoral nail insertion. J Bone Joint Surg [Am]. 2007;89:829– 834. Robinson CM, Houshian S, Khan LAK. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg [Am]. 2005;87:2217–2226. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Clin Orthop Relat Res. 1992;283:231–236.

PROCEDURE 37

Femoral Shaft Fractures: Intramedullary Nailing Chad P. Coles INDICATIONS

PITFALLS

• Reamed, antegrade, statically locked intramedullary (IM) nailing should be considered the treatment of choice for all adult femoral shaft fractures. • Relative indications for retrograde IM nailing include: • Bilateral femoral shaft fractures • Ipsilateral femoral neck fracture • Ipsilateral acetabulum fracture • Ipsilateral tibial shaft fracture (floating knee) • Morbid obesity • Pregnancy 

• Multiple long-bone fractures may preclude intramedullary (IM) nailing of all fractures at a single setting owing to increased risk of fat embolism. • Severe pulmonary injury may be exacerbated by IM nailing. • Altered femoral anatomy or small canal dimensions may prevent successful nail insertion.

EXAMINATION/IMAGING

CONTROVERSIES

• In addition to resuscitation of the trauma patient by Advanced Trauma Life Support or similar protocol, and complete history and physical examination, focused examination of the injured extremity should include: • Vascular examination for distal pulses and capillary refill • Neurologic examination, including motor and sensory function • Inspection of soft-tissue envelope for evidence of open fracture, including posterior tissues • Examination of ipsilateral foot, ankle, knee, and hip to exclude associated injury • Imaging should include anteroposterior (AP) and lateral plain radiographs of the femur. •  These radiographs seldom include good-quality images of the hip and knee joints, which are essential to detect associated fractures. Fig. 37.1 shows typical AP (Fig. 37.1A) and lateral (Fig. 37.1B) radiographs demonstrating femoral shaft fracture, but poorly visualizing hip and knee joints.

A

• With a severe pulmonary injury or a polytraumatized patient, initial external fixation followed by staged conversion to an IM nail may be indicated. • Skeletal immaturity with open physes is a contraindication to antegrade IM nailing through the piriformis fossa, owing to an increased risk of avascular necrosis of the femoral head. Nailing through the trochanteric tip reduces this risk.

B FIG. 37.1 

451

452

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

FIG. 37.2 

TREATMENT OPTIONS

• Antegrade IM nailing • Retrograde IM nailing • Temporary external fixation followed by IM nailing • Open reduction and internal fixation with plate and screws PEARLS

• Ensure that the patient’s hip is positioned far enough laterally to overhang the edge of the table to prevent impingement of the reamer and nail on the operating table. • If a computed tomography scan of the pelvis has been performed as part of the trauma assessment, look closely at the femoral neck for evidence of occult fracture (Fig. 37.4). • Based on preoperative images, obtain an estimate of canal dimension on the lateral image, and an estimate of canal length, particularly in individuals of large or small stature. Ensure that you have an adequate inventory of nail sizes prior to proceeding to surgery! PITFALLS

• One or two surgical assistants are typically required to adequately apply traction and manipulate the fracture into a reduced position while the femur is reamed and nailed. • If assistance is limited, use of a fracture table may be necessary.

FIG. 37.3 

• Coronal plane (Hoffa) fractures of the distal femur (as seen in the computed tomography scan in Fig. 37.2) and femoral neck fractures (Fig. 37.3) frequently occur with high-energy femoral shaft fractures, and they are easily overlooked on plain radiographs. 

SURGICAL ANATOMY • The piriformis (or trochanteric) fossa lies just medial to the tip of the greater trochanter, and slightly posterior to the femoral neck, in line with the medullary canal of the femur on both AP (Fig. 37.5A) and lateral (Fig. 37.5B) views. • The lateral ascending branch of the medial femoral circumflex artery runs just medial to the piriformis fossa, and its branches are at risk (Fig. 37.6). The piriformis and obturator internus tendon insertions are also potentially at risk. • The femur has a natural anterior bow that typically increases with advancing age. 

FIG. 37.4 

A

B FIG. 37.5 

454

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

Piriformis tendon Joint capsule insertion

Medial femoral circumflex artery

FIG. 37.6  EQUIPMENT

• Flat-topped radiolucent table • Rolled flannel blanket or 3-L saline bag to elevate the ipsilateral hemipelvis • Radiolucent ramp pillow or stack of flannels for under the leg • Fine-wire tensioned traction bow for traction (if desired) • Fluoroscopic imager CONTROVERSIES

• Use of a fracture table to apply traction, while quite limiting in the flexibility to manipulate fracture fragments, may facilitate restoration of length and alignment without requiring skilled assistants. • Lateral positioning on a fracture table may be helpful for trochanteric access in morbidly obese patients, although setup is time consuming, and lateral positioning may result in respiratory compromise.

POSITIONING • Femoral nailing is typically performed with the patient in the supine position on a flattopped radiolucent table (Fig. 37.7). • Free draping on a radiolucent table provides optimal freedom for access to, and manipulation of, the fracture for debridement (if open) and reduction. • This position is also very useful for treatment of any associated ipsilateral lower extremity injuries (e.g., femoral neck or condyle, tibial plateau, ankle). • Use of a standard radiolucent table also avoids the added time of fracture table setup, rigidity of positioning once in traction on a fracture table, as well as potential pudendal nerve palsy from the perineal post. • A rolled flannel blanket or 3-L saline bag is placed beneath the buttock on the operative side, with the affected hip overhanging the edge of the table. Elevation of the hemipelvis on this “bump” facilitates surgical access as well as fluoroscopic imaging on the lateral view, providing a more true lateral view of the femoral neck, as well as avoiding overlap of the contralateral leg (Fig. 37.8). • The leg and torso are adducted, exposing the trochanter for surgical access. The ipsilateral arm is draped over the chest to avoid interference with reaming and nail insertion (Fig. 37.9).

FIG. 37.7 

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

FIG. 37.8 

FIG. 37.9 

FIG. 37.10 

• The leg is draped freely over a radiolucent bump to allow fracture manipulation and reduction. • Traction can be applied manually, or via a tensioned fine-wire traction bow across the distal femur with a 20-pound weight over the end of the surgical table (Fig. 37.10). • A fluoroscopic imager on the contralateral side provides AP and lateral images. 

455

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

456 PITFALLS

• An improper start point will result in eccentric nail position, potentially resulting in iatrogenic fracture of the shaft or femoral neck, and may result in malreduction. INSTRUMENTATION

• Percutaneous nail insertion requires appropriate instrumentation, with a longer nail insertion arm, particularly in more obese patients.

PORTALS/EXPOSURES • A percutaneous technique is used. • No initial incision is made. • A skin start point, typically midway between the tip of the trochanter and the iliac crest and slightly posterior to the line of the femur, is selected (Fig. 37.11). • A percutaneously placed guidewire is used to identify the ideal start point in the piriformis fossa (or alternatively on the trochanter), and position is confirmed on biplanar fluoroscopic images (Fig. 37.12). • Once proper position is achieved, a 2-cm skin incision is made to incorporate the guidewire. 

PEARLS

• With the anterior bow of the femur, a skin start point slightly more posterior will assist in aligning with the femoral canal on the lateral image. • Manual adduction of the leg and proximal femur will assist in proper positioning and alignment of the initial guidewire with the femoral canal on the AP image. • With experience, the piriformis fossa has a distinctive feel on palpation with the tip of the guidewire, which assists in rapid localization with limited use of fluoroscopy. CONTROVERSIES

• Alternatively, a trochanteric entry point may be used. This is only appropriate with a nail system designed for trochanteric insertion; otherwise, varus malreduction will occur. • A trochanteric entry portal is believed, by some, to be easier and quicker to locate. The offset entry angle may also be of some benefit in obese patients. No functional advantage or disadvantage for either technique has been documented, so this is often determined by personal preference or type of nailing system available.

A

FIG. 37.11 

B FIG. 37.12 

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

PROCEDURE Step 1 • Once the desired starting point is established and confirmed on biplanar fluoroscopy, insert the guidewire to the level of the lesser trochanter. • Then use a larger, cannulated drill to drill over the guidewire to open the proximal femur. • Remove the drill and wire and insert a ball-tipped reaming wire into the femoral canal. Confirm the intramedullary position on biplanar fluoroscopy, and then advance the wire toward the fracture site. 

Step 2 • Perform indirect reduction of the fracture with a combination of either manual traction or a tensioned fine-wire traction bow and weights, as well as manipulation of the fracture to restore alignment. • Various-sized rolled towels and surgical bumps can be positioned to align the femur in the sagittal plane (Fig. 37.13). • A towel around the thigh, with counter-pressure from a padded hammer, can facilitate reduction of translational deformity (Fig. 37.14). • Rarely more direct percutaneous manipulation of the fracture with a ball-spiked pusher or a unicortical Shantz pin may be necessary (Fig. 37.15).

FIG. 37.14 

FIG. 37.13 

A

B FIG. 37.15 

457

458

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

FIG. 37.16 

x

FIG. 37.17 

PEARLS

• Taking the time to ensure proper entry portal position will help avoid malreduction and potential iatrogenic fracture. • Know your equipment! Every nailing system has slightly different entry position and systems. PITFALLS

• Too medial a start point may increase the risk of iatrogenic femoral neck fracture. • Too lateral a start point may lead to varus malreduction, particularly with proximal femur fractures.

x

• The reaming wire is now passed across the fracture site. • The navigation across the fracture gap can be facilitated by a bend at the tip of the reaming wire to allow the wire to be “steered” across the gap. • Alternatively, an intramedullary reduction tool can be used to more directly reduce the fracture and guide the wire (Fig. 37.16). • Then advance the reaming wire to a position centered in the distal segment on both the AP and lateral views, at the level of the physeal scar. • With the fracture held at an appropriately reduced length, select the nail length by either a reverse measuring device, a radiolucent ruler, or measurement from a second, equal-length guide rod and Kocher clamp (Fig. 37.17). 

INSTRUMENTATION/IMPLANTATION

Step 3

• An assortment of various-sized sterile positioning bumps is key. • A tensioned fine-wire traction bow and 20-pound weight facilitate application of longitudinal traction and replace the ongoing efforts of a surgical assistant. • A ball-spiked pusher or unicortical Shantz pin may be useful for more direct manipulation of fracture fragments, if necessary.

• Then sequentially ream the femoral canal, starting with a relatively small reamer (8 or 9 mm), and increasing in 0.5-mm increments until the desired cortical chatter or nail size is encountered. • The canal is typically over-reamed by 1 mm beyond the selected nail diameter. Depending on the nail system and size of nail, the trochanteric region may need to be reamed to a larger size to accept the broader head of the nail. • It is imperative that the fracture be held in a reduced position during reaming, or eccentric reaming and malreduction will occur. 

PEARLS

Step 4

• The fracture must be held in a reduced position during reaming to avoid eccentric reaming and malreduction. • Slow advance of the reamer will avoid incarceration in the canal.

• Depending on the nail system, the ball-tipped reaming rod may need to be exchanged prior to nail insertion. • Insert the nail by hand initially, and then gently advance it with a mallet.

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

459

PITFALLS

• Never ream without a ball-tipped reaming rod in place! In the event of a broken or incarcerated reamer, this can be key in successful retrieval. • Reaming with the fracture malreduced will result in eccentric reaming and malreduction. INSTRUMENTATION/IMPLANTATION

• Always use a ball-tipped reaming wire. • Sharp reamers are key to avoiding fat embolism, thermal necrosis, and incarceration. • Newer generation reamers with sharp, deep flutes, an acorn-shaped reamer head, and a smaller diameter shaft reduce intramedullary pressure and risk of fat embolism (Fig. 37.18). FIG. 37.18 

PEARLS

• The fracture site is imaged during nail passage to ensure the fracture is aligned and the nail advances without causing iatrogenic fracture. • Then seat the nail to the appropriate depth; confirm proper positioning at the knee and hip, as well as the fracture reduction. 

Step 5 • Lock the nail proximally with the targeted guides, confirm rotational alignment of the limb, and then lock the nail distally using either a radiolucent drill, or preferably, a freehand technique. • A lateral image centered over the distal locking holes, with the imager horizontal to the floor and perfectly perpendicular to the nail, is critical. Then rotate the leg rotated by the proximal insertion arm to obtain an image of perfectly circular locking holes. • With the drill hand lowered out of the way of the imager, center the drill bit tip in the hole, with the drill bit perpendicular to the nail (Fig. 37.19). • Keeping the drill bit tip pressed against the femur to avoid slipping, raise the drill hand to a horizontal position, level with the floor, and drill the hole. • With the drill bit in place, temporarily disengage the drill hand-piece and take an image to confirm passage of the drill bit through the locking hole. Then remove the drill bit, select an appropriate length screw, and insert it. 

A

B FIG. 37.19 

• While advancing the nail, take care not to strike the end of the reaming wire and inadvertently advance the wire into the knee joint. PITFALLS

• Particularly in elderly patients with an exaggerated femoral bow, a relatively straighter nail may inadvertently perforate the anterior cortex of the femur. As the nail enters the distal third of the femur, confirm proper passage of the nail within the femoral canal on a lateral image. PEARLS

• Always ensure that the reaming wire is removed prior to attempting placement of locking screws! • Prior to leaving the operating room, confirm the following three criteria: • Absence of a femoral neck fracture • Length and rotational alignment of the limb • Stability of the knee ligaments

460

PROCEDURE 37  Femoral Shaft Fractures: Intramedullary Nailing

POSTOPERATIVE CARE AND EXPECTED OUTCOMES •  Perioperative antibiotics and venous thromboembolism prophylaxis are recommended. • Patients should be appropriately monitored postoperatively to observe for sequelae of fat embolism and resultant pulmonary dysfunction. • Early hip and knee range of motion are initiated, as well as crutch mobilization. Typically, patients are permitted weight-bearing as tolerated. • Initial healing rates over 90% are expected, with good long-term functional results. In the event of aseptic nonunion, a single exchange nailing procedure is sufficient to achieve successful union in the majority of cases.

EVIDENCE Bhandari M, Guyatt GH, Khera V, Kulkarni AV, Sprague S, Schemitch EH. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res. 2003;407:187–198. A level IV retrospective case-control study comparing femoral fractures treated with reamed intramedullary nail or plate fixation in patients with severe head injury, showing no increase in mortality with IM nail. Bone LB, Anders MJ, Rohrbacher BJ. Treatment of femoral fractures in the multiply injured patient with thoracic injury. Clin Orthop Relat Res. 1998;347:57–61. Landmark Level I randomized controlled trial showing a significant decrease in pulmonary morbidity with early stabilization of femoral fractures in multiply injured patients. Canadian Orthopaedic Trauma Society. Nonunion following intramedullary nailing of the femur with and without reaming: results of a multicenter randomized clinical trial. J Bone Joint Surg [Am]. 2003;85:2093–2096. Level I multicentered randomized controlled trial showing a 4.5 times increased relative risk of nonunion with unreamed intramedullary nailing of the femur compared with reamed nailing. Canadian Orthopaedic Trauma Society. Reamed versus unreamed intramedullary nailing of the femur: comparison of the rate of ARDS in multiple injured patients. J Orthop Trauma. 2006;20:384–387. Level II, small prospective randomized trial showing no increased risk of acute respiratory distress syndrome (ARDS) in multiply injured patients with reamed intramedullary nailing compared to unreamed nailing. Crowley DJ, Kanakaris NK, Giannoudis P. Femoral diaphyseal aseptic non-unions: is there an ideal method of treatment? Injury. 2007;38(suppl 2):S55–S63. Level III systematic review showing exchange intramedullary nailing remains the treatment of choice for aseptic nonunion of the femur. Egol KA, Change EY, Cyitkovic J, Kummer FJ, Koval KJ. Mismatch of current intramedullary nails with the anterior bow of the femur. J Orthop Trauma. 2004;18:410–415. Anatomic review of 892 cadaveric femora showing mismatch between the anatomic radius of curvature and that of current femoral nail designs. EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246:491–499. Level I multicentered randomized controlled trial in multiply injured patients showing advantage of intramedullary nailing in stable patients, but increased risk of pulmonary complications in borderline patients when compared with initial external fixation. Gausepohl T, Pennig D, Koebke J, Harnoss S. Antegrade femoral nailing: an anatomical determination of the correct entry point. Injury. 2002;33:701–705. Cadaveric study showing anatomic landmarks for entry portal directly aligned with the femoral canal. Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20:482–484. Level IV retrospective review of 50 cases showing safety of trochanteric tip entry antegrade intramedullary nailing of adolescent femur fractures. Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53:452–461. Level IV retrospective cohort study examining the impact of adopting a damage control approach in multiply injured patients. Ricci WM, Schwappach J, Tucker M, et al. Trochanteric versus piriformis entry portal for the treatment of femoral shaft fractures. J Orthop Trauma. 2006;20:663–667. Level II prospective cohort study showing comparable clinical results with trochanteric versus piriformis entry point, with reduced fluoroscopy and operative times in obese patients.

PROCEDURE 38

Femoral Shaft Uniplanar and Multiplanar Plating Saad M. AlQahtani and Hans J. Kreder INDICATIONS • Metaphyseal femoral fractures are commonly plated; nailing is preferred for most femoral diaphyseal fractures. • Inability to insert a femoral nail leaves plating as an option. • Obstruction of the femoral canal by a prosthesis (although a short nail can be docked onto some prosthetic implants) • Deformity of the femur • Deformity at the insertion site • Excessive bowing of the femoral shaft may preclude nailing without a femoral osteotomy • Desire to avoid intramedullary instrumentation in a compromised polytrauma patient • Bilateral femoral shaft fractures • Severe associated chest injury • No image intensifier is available • Requires direct open reduction • SIGN nail alternative • Desire to minimize radiation exposure, such as early pregnancy • Requires direct open reduction • Need for compression • Certain nonunions (especially proximal or distal in the metaphyseal regions) • Plating and compression around a nail • Deformity correction • Rarely absolute stability for acute femoral fracture 

INDICATIONS PITFALLS

• Both simple fractures (transverse, short oblique, and spiral) and multifragmentary or comminuted femoral shaft fractures are most commonly treated with relative stability, which is best achieved with intramedullary nailing. Absolute stability with fracture site compression is best reserved for certain nonunion repairs, especially those involving the metaphyseal regions of the proximal or distal femur. • Plate fixation of the femoral shaft is associated with three inherent problems compared with intramedullary nailing: • Nails provide multiplanar stabilization, as they resist angular forces equally well in the sagittal and coronal plane, whereas plates are weakest in the plane perpendicular to the broad surface of the plate (i.e., in the coronal plane for a laterally applied plate), increasing the risk of varus deformity or fixation failure. For simple or short comminuted fracture patterns, the strain at the fracture site is inherently high and is best resisted with multiplanar fixation (such as a nail) in a relative stability construct. • A tight-fitting nail provides some resistance to strain independent of screws by virtue of the interference fit within the intramedullary canal. However, a typical plate construct relies only on screw fixation to anchor it against the bone, creating a potential source of construct failure by screw pullout. Screw pullout can be minimized by using a longer plate with spaced fixation above and below the fracture zone. • For relative stability, a long working length is required. The position of the locking screws in a full-length nail provides a long working length opportunity by design. With plate fixation, the working length of the construct must be carefully planned. A common error is to create a working length that is too short, resulting in high strain at the fracture site, risking nonunion and implant failure.

461

462

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

INDICATIONS CONTROVERSIES

• Femoral shaft fracture management in the context of a polytrauma patient; early total care (ETC) versus damage control (DCO) • Femoral fractures should be stabilized urgently to minimize blood loss, pain, soft-tissue injury, and the risk of complications such as fat embolus syndrome. • Stabilization options include intramedullary (IM) nailing, plating, external fixation, and, rarely, skeletal traction. Because IM nailing is the option associated with the highest systemic stress, alternatives such as plating are considered when early total care is thought to be contraindicated. However, there is uncertainty regarding when one strategy should be employed versus another. • Metaphyseal nailing versus plating • Retrograde nailing is preferred by some to fixed-angle plating for supracondylar femur fractures. • While nailing is generally preferred for femoral fractures below the lesser trochanter, a pertrochanteric fracture can be treated with either a nail or a plate. • Uniplanar versus multiplanar fixation • When a uniplanar (single) plate is not expected to limit strain across fracture fragments to less than the requisite 10% required for relative stability, multiplanar fixation should be considered. Options include an IM nail (alone or in addition to a plate) or adding a second plate or strut graft. Multiplanar fixation should be considered in any high-strain environment, especially when associated with poorquality bone or when slow healing is expected (such as with a bisphosphonate fracture). • The position of the second plate in a multiplanar construct can be extramedullary or intramedullary. The relative merits and indications of one strategy versus the other have yet to be clarified. Moreover, some prefer strut grafts to a second plate in a multiplanar construct. • When to use absolute stability in a femoral plating construct • Absolute stability requires that strain across fracture fragments must be limited to less than 2%. This is rarely achievable in fixation of an acute femoral fracture. Moreover, some soft-tissue stripping is generally required for direct reduction of the fracture fragments. If absolute stability is attempted and not achieved, the result is a high-strain environment that leads to nonunion and early implant failure (Fig. 38.1A–B). • Absolute stability is an appropriate strategy for managing most simple nonunions in the femoral metaphysis. Usually, compression is applied with an articulated tensioning device (ATD) to achieve the requisite fracture site strain of less than 2% (Fig. 38.2A–B) • When to use locking screws in femoral plating • In the metaphyseal region, a fixed-angle construct is required to avoid varus deformity and failure. • Locking screw plate constructs provide fixed-angle fixation at the metaphysis similar to older fixedangle implants (angled blade plate or dynamic condylar screw plate constructs). • In the diaphysis, locking screws improve screw pullout, especially in osteoporotic bone. However, locking screws also increase construct stiffness that may adversely affect fracture site strain. • Using a long plate and spaced fixation with nonlocking screws is an alternative method of improving screw pullout that does not increase construct stiffness and fracture site strain. The use of far cortical locking screws and similar devices is controversial and may be unnecessary. • Weight bearing after femoral shaft fixation • Unless the articular surface is involved, most patients with nailed or plated femoral shaft fractures should be mobilized with weight bearing as tolerated, especially in elderly patients. There is little evidence to support restricted mobility, yet some surgeons limit weight bearing for variable periods of time. • Management of acute femoral defects after debridement of open fractures • Options for acute management of femoral fracture gaps due to bone loss include fixation out to length versus acute shortening. Given modern options for gap management (Masquelet technique, bone transport, vascularized fibular graft), most surgeons prefer to fix the fracture out to length, fill the gap with antibiotic cement acutely, and then manage the defect with definitive techniques later. However, acute shortening and subsequent bone transport is preferred by some.

TREATMENT OPTIONS

• When plating a femoral fracture, the following basic treatment options must be considered: • Absolute stability (simple nonunion) or relative stability (most acute femoral fractures) • Is a fixed-angle construct needed (metaphyseal locking screw/plate, angled blade plate, dynamic condylar plate)? • Is multiplanar fixation required (i.e., is this a high-strain environment)? • How will the plate be secured to bone in the presence of an existing prosthesis or a femoral deformity?

EXAMINATION AND IMAGING • Management of femoral fractures demands a thorough evaluation of the following: •  The femoral neck and distal intercondylar region. Plain anteroposterior (AP) and lateral films of the entire femur, including the hip and knee joints, are essential. If required, these may be supplemented with a computed tomography (CT) scan, especially in high-energy trauma. •  The femoral bow. Especially in older individuals, or with metabolic bone disease, a high femoral bow may not match conventional nails or femoral plates. When encountered, management options include modification of the implant (or selection of an alternative implant) to match the existing femoral contour, or correction of

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

A

B

FIG. 38.1 A, Preoperative anteroposterior (AP) radiograph of the right femur in a 70-year-old male construction worker with bilateral femoral shaft fractures and a severe chest injury. Both femoral fractures were plated simultaneously with two surgical teams to minimize the risk of fat embolization. B, Postoperative AP radiograph of the right femur at 6 months postplating with absolute stability technique. Failure to achieve absolute stability has created a high-strain environment and early failure. The opposite femoral fracture was treated with relative stability and healed uneventfully.

A

B

FIG. 38.2  A, Anteroposterior (AP) radiograph of the proximal femur in a 45-year-old male with femoral nonunion and broken nail at 1 year. The surgical strategy for a simple nonunion is absolute stability with compression. B, AP radiograph at 6 months postoperative fixation with fixed-angle plate and compression using articulated tensioning device (ATD). The white arrow points to the screw hole used for the ATD.

the excessive bow through the fracture site (or an osteotomy) to match the femur to the available implant. Both the coronal and sagittal planes need to be considered (Fig. 38.4). • In a periprosthetic fracture, an assessment of implant stability and potential interface wear is required. One also needs to consider how the plate will be fixed to the bone in the implant region (Fig. 38.3). 

463

464

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

FIG. 38.3 Anteroposterior (AP) plain radiograph of a periprosthetic femoral fracture in a 64-year-old female pedestrian struck by a motor vehicle. The hip replacement had been functioning well for over 2 years.

FIG. 38.4  Anteroposterior (AP) radiograph of the proximal femur of a 73-yearold male with metastatic prostate cancer showing a pathologic fracture in the context of a high sagittal plane femoral bow that must be considered when planning a surgical strategy.

SURGICAL ANATOMY • Bony landmarks (see Fig. 38.13) • Greater trochanter • Femoral shaft • Lateral femoral epicondyle • Patella • Medial femoral epicondyle (with medial exposure) • Muscles and fascia (see Fig. 38.13) • Vastus lateralis • Gluteus maximus • Iliotibial band • Lateral intermuscular septum • Vastus medialis (with medial exposure) • Nerves • The sciatic and femoral nerves are not generally at risk, as they are a considerable distance from the surgical approach. • The lateral femoral cutaneous nerve is at risk if an AP pin is inserted as a reduction aid, as with a large femoral distractor. The course of the nerve is quite variable. An adequate incision and blunt dissection is required to avoid damaging the nerve during pin insertion. • Blood vessels • The genicular branches in the distal lateral portal • Perforating branches of the profunda femoral artery in the proximal portal and with fracture reduction incisions • Saphenous vein (with medial exposure) 

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

465

POSITIONING • A radiolucent table facilitates intraoperative imaging for minimally invasive submuscular plating. • The patient may be positioned in the lateral decubitus position (Fig. 38.5) or supine depending on surgeon preference. • If supine, a padded bump is placed under the ipsilateral hip to neutralize hip rotation. • The affected leg is prepped and draped free. • The groin is isolated with an adhesive plastic drape. • The C-arm is positioned opposite to the operative side. 

Flexion: Move distal fragment to match flexed proximal segment

FIG. 38.5  Lateral position on a radiolucent table facilitates reduction in a subtrochanteric femoral fracture where the proximal fragment is often flexed, abducted, and externally rotated.

POSITIONING PEARLS

• Lateral position: Many surgeons prefer the lateral position for femoral plating, especially when the fracture involves the subtrochanteric region, where the proximal fragment is often flexed. In the lateral position, the distal segment can easily be moved to match the flexed proximal segment, thereby reducing the fracture (see Fig. 38.5). Obtaining a lateral of the femoral head and neck requires the fluoroscopy arm to be positioned “over the top” when in the lateral position (Fig. 38.6C). • Supine position: In isolated femoral fractures, a bump under the ipsilateral side that provides approximately 20° of internal rotation is helpful (Fig. 38.6A). If multiple extremity injuries need to be addressed in a polytrauma patient, the supine position is often preferred to the lateral position. When both femurs are being operated on, it is helpful to place a central bump under the sacrum (if not contraindicated by spine or other injuries). This raises both femurs up off the operating table and allows full access to the greater trochanter for femoral nailing or plating. • Planned use of a large femoral distractor: While a large femoral distractor can be applied in the lateral position, it is much easier to use it in the supine position in a way that minimizes interference with fixation implants (plate or nail).

POSITIONING EQUIPMENT

• Radiolucent table • Flannel sheets, foam devices, beanbag, and so forth, for bumping up in the supine position or for securing the position in full lateral positioning • Fluoroscopy C-arm

POSITIONING PITFALLS

• While some surgeons bump the affected buttock up high into a “floppy lateral” for supine positioning, one must carefully consider how this may affect the lateral image if fixation up into the head and neck is required. Excessive rotation makes obtaining a lateral of the head and neck difficult. If the orientation of the neck is beyond parallel to the floor, the only way to obtain a lateral along the neck is by the overthe-top fluoroscopy position. Most units cannot move more than a limited number of degrees over the top (Fig. 38.6B). • In the lateral position, if the patient falls backward owing to an inadequately secured pelvis, the result is like an excessively bumped supine position, as discussed earlier (Fig. 38.6B). Ideal is a full lateral position, although it is better to err toward the patient falling slightly forward than backward. • Draping with split sheets allows circumferential access to the entire femoral shaft and is preferred. Avoid draping only the lateral side of the femur (e.g., a transparent “shower curtain” sheet sometimes used with a fracture table). If reduction adjuncts are required to manipulate the fracture (e.g., a large femoral distractor), this cannot easily be applied without proper access to the entire femur.

POSITIONING CONTROVERSIES

• The use of a lateral position versus a supine position for femoral plating is a matter of surgeon preference. Most experienced trauma surgeons prefer the lateral position on a radiolucent table for subtrochanteric fractures owing to the ability to more easily reduce the flexed, abducted, and externally rotated position of the proximal fragment by moving the distal fragment to match it (see Fig. 38.5). • While most trauma surgeons prefer to use a radiolucent table, some surgeons advocate the use of a traction table for femoral plating.

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

466

C

C 1 1

2

4

3

3

2

4 5

5

14

14

12

13

13

12

B

A

C

1 2 3

14 5 4

13 12

C

FIG. 38.6  A, In the supine position, optimal bumping up of the affected buttock should place the femoral neck no more than parallel to the floor, which allows for a lateral image to be taken along the femoral neck with the fluoroscopy unit arm under the table (imaging along the red arrow). B, Excessive bumping up of the buttock in the supine position can cause the femoral neck to be oriented in a plane that precludes a good lateral fluoroscopic shot owing to limits of the unit both over the top (dashed arrow) and under the table (solid arrow). C, In the full lateral position (femoral condyles perpendicular to the floor), imaging along the femoral neck (dashed arrow) is well within the “over the top” range of most fluoroscopy units.

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

467

PORTALS/EXPOSURES • A minimally invasive submuscular lateral approach is used for most femoral plating. In all periprosthetic cases and in many acute fracture cases, the plate should span the entire length of the femur to optimize the strain environment and to minimize the risk of screw pullout. The areas that require exposure include (see Fig. 38.13): • The lateral distal femoral condylar region • The lateral greater trochanteric region • Some limited percutaneous or open manipulation of the fracture site may be required to achieve an accurate reduction in a simple fracture pattern. • Portals used to apply a large femoral distractor (if needed) • Proximally, the pin is placed anterior to posterior in a portal made in the intertrochanteric/subtrochanteric region (similar to AP locking of a retrograde femoral nail; Fig. 38.7A). Care must be taken to avoid injury to the lateral femoral cutaneous nerve. An adequately sized incision (5 cm or a length approximately twice the depth from skin to bone, depending on body habitus) is generally made over the tensor fascia muscle and blunt dissection is carried out after looking for the nerve. The course of the nerve is variable and can cross the tensor fascia muscle. • Distally, the pin is usually placed medial to lateral to avoid interfering with plating of the lateral side. Pin position in the posterior and distal limit of the femoral canal is ideal to avoid interference with hardware placement (Fig. 38.7B). • Rarely, a medial approach may be required in addition to a lateral approach: • For managing associated medial femoral condyle fractures • For multiplanar fixation (additional plate, nail, or strut graft) 

PORTALS/EXPOSURES PEARLS

• Fracture site • In femoral fractures that involve a longer comminuted fracture segment (Fig. 38.8), any exposure of the fracture site is absolutely contraindicated. • Accurate reduction of a simple fracture (see Fig. 38.4) is required to limit fracture site strain to less than 10% (beyond which there is a risk of nonunion). The least invasive technique to achieve such a reduction should be employed. • For distal femoral fractures, the plate position tends to be along the anterior third of the lateral femur (Fig. 38.12A). • For proximal femoral fractures, because of normal anatomic femoral neck anteversion, the plate may need to be placed more posteriorly if fixation up into the head and neck is planned. • It is often possible to overlap a posteriorly placed plate from the proximal femur with one placed anteriorly along the distal femur if required (preexisting implant or, rarely, a surgical plan that involves two plates). In a small individual, or if plates have not been positioned optimally, it may not be possible to overlap the plates.

PORTALS/EXPOSURES PITFALLS

• In the distal exposure portal, failure to ligate the genicular vessels can result in significant bleeding. • In the proximal plate exposure, perforating branches of the profunda femoral artery may be encountered. Failure to recognize and ligate these vessels can cause inadvertently torn vessels to retract behind the lateral intermuscular septum, where they are difficult to retrieve and ligate. • The proximal portal for insertion of a large femoral distractor pin requires adequate exposure to avoid injury to neurovascular structures. Percutaneous pin placement is not recommended. PORTALS/EXPOSURES CONTROVERSIES PORTALS/EXPOSURES EQUIPMENT

• Fluoroscopy • Standard scalpel, forceps, electrocautery equipment • Self-retaining retractors • Small Hohmann retractors • Large femoral distractor

• In severe open fractures of the femur, the submuscular plating portals may already be exposed by the injury. Some advocate the use of antibiotic cement or antibiotic slurry to coat any hardware (such as a plate) that will be placed into the wound to minimize the risk of hardware colonization by any residual bacteria. However, there is no consensus and little evidence to date regarding this practice.

468

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

B Flexion/extension (derotation) Length

A

Varus/ valgus

C

Abduction (poller screw)

FIG. 38.7  A, Proximal large distractor pin insertion site (red dot). A correctly placed anterior to posterior pin for a large femoral distractor will not interfere with either femoral nailing or plating. B, Distal large femoral distractor pin insertion site. When needed, the pin can be placed posteriorly in the distal femur (solid red dot), where it will not interfere with nail or plate insertion. Placement of the pin in this position requires careful intraoperative fluoroscopy with a true lateral that overlaps the femoral condyles and shows the Blumensaat line. Alternatively, the pin can be more easily placed through the epicondyle more anteriorly (spotted dot) or through the shaft more proximally. However, it may interfere with hardware placement in these positions. C, A large femoral distractor can help reduce a femoral fracture in multiple planes. Rotation needs to be correct before application, as there is little ability to adjust rotation once the device is applied.

STEP 1 PEARLS

• Muscle paralysis is essential to achieving and maintaining reduction during fixation, especially in large muscular individuals. This requires preoperative discussion with the anesthesia team regarding endotracheal intubation, and so forth. • Lateral positioning is an important maneuver for reducing proximal femoral fractures (see Fig. 38.5). • Supine positioning is easier if a femoral distractor is to be used for maintaining reduction (Fig. 38.7). • Avoid long protruding ends when cerclage wiring is used, and try to fold the end posteriorly away from where the plate will be passed to make it easier to place the plate over the top of the wire instead of over the top of the end of the wire. • Cerclage wiring (only used for simple fracture patterns) tends to achieve a better reduction and holds the fracture reduction more securely than pointed reduction forceps or collinear clamps. Moreover, a cerclage wire is less likely to interfere with plate placement than forceps or clamps.

PROCEDURE Step 1: Fracture Reduction • Objectives of reduction • Restoration of three-dimensional spacial relationship between the hip and the knee joint • Coronal plane femoral reduction is critical because of the large varus forces that the femur is subjected to. Slight proximal femur valgus is preferable to varus malreduction. • Maintenance of reduction during plate application • Overview • Reduction requires control of either the proximal or distal fragment (ideally both). • Indirect reduction and relative stability are used for most fractures (see Fig. 38.8). A large femoral distractor is well suited to holding the fracture in a reduced position (see Fig. 38.7). However, in simple fracture patterns (see Fig. 38.3), direct reduction with minimal soft-tissue dissection is often required to achieve an accurate apposition of fracture fragments, which serves to minimize strain (Fig. 38.10). 

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

469

STEP 1 PITFALLS

FIG. 38.8  Anteroposterior (AP) and lateral plain radiographs 6 months after plating a long comminuted fracture segment (red arrow) with indirect reduction and a relative stability construct and without disturbing the fracture site.

Principles of Relative Stability Violated

• Multifragmentary fracture segment (see Fig. 38.8): In a comminuted fracture, avoid exposing any of the fracture fragments of the comminuted segment. This will jeopardize healing by causing soft-tissue stripping and, if fixation is added to the comminuted section, stress concentration results in an adverse high-strain environment (Fig. 38.9). • Simple fracture segment (see Fig. 38.3). The cerclage wire is a reduction aid when used in simple fracture patterns. It can be removed after fixation if desired. However, it may safely be left in situ without fear of causing a high-strain environment at the fracture site. Moreover, there is no significant adverse biologic effect from minimally invasive wiring used as a reduction aid. • Avoid using larger cerclage cables that interfere more with blood supply and that may create an adverse biomechanical environment in some situations. • Do not use large serrated bone holding clamps for fracture reduction, even in an open fracture. There are better alternatives; the soft tissue, periosteal, and bone trauma incurred with the use of these instruments impairs blood supply that is critical for bone healing and the immune response to any bacterial contamination of the wound. STEP 1 INSTRUMENTATION/ IMPLANTATION

High Strain >10%

FIG. 38.9  A high-strain environment is created by partial fixation within a comminuted fracture segment. Moreover, the associated soft-tissue stripping further compromises blood supply and healing ability. This construct went on to predictable failure within 6 months.

• Indirect reduction • Manual manipulation/traction • Bumps • Femoral distractor (see Fig. 38.7) • Ball spike pusher • Small terminally threaded (≈ 2.5 mm) Steinmann pins for percutaneous unicortical fracture manipulation • Larger bicortically placed Steinmann pins (≈5 mm) for gross deformity correction • Right-angled retractors • Sharp bone hook • Large pointed reduction forceps • Minimally invasive wire passer • Collinear clamp • Direct reduction with minimal soft-tissue dissection (only applicable to simple fracture patterns; to be avoided in multifragmentary/ comminuted patterns) • Minimally invasive cerclage wiring (see Fig. 38.10) • Minimally invasive application of pointed reduction forceps or collinear clamp STEP 1 CONTROVERSIES

• Some surgeons attempt to achieve absolute stability in simple femoral shaft fracture patterns. While this may be successful in selected young patients with excellent bone quality, if absolute stability (fracture site strain of < 2%) is not achieved, a high-strain environment results and early failure follows (see Fig. 38.1).

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

470

A

B

C

D

E FIG. 38.10  A, Example of a minimally invasive wire passer. B, Use of minimally invasive wire passer in a cadaver model. The second arm of the device is being inserted over the front of the femur with the posterior arm already in place. C, The arms of the wire passer have been reconnected and the wire has been passed around the femur. The device can now be sequentially withdrawn and the wire tightened. D, The device has been withdrawn and the wire is about to be tightened. E, The cerclage wire has been tightened and the fracture is now reduced. Once the wire has been bent over, a plate can be applied to the reduced fracture and over the top of the wire.

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

FIG. 38.11  Intraoperative photo that demonstrates sliding a plate from proximal to distal. In this case, a dynamic condylar plate is being slid submuscularly, with the fixation surface facing laterally. It will be rotated 180° to insert the fixed-angle portion into the screw that was previously placed into the proximal femur. A handle was created using a second dynamic condylar plate and connecting it temporarily to the fixation plate via a long lag screw.

Step 2: Lateral Plating of the Reduced Femoral Fracture • The lateral plate is applied after fracture reduction in the submuscular plane. • Plate length • Full-length plating of the femur for all periprosthetic fractures is recommended. • While there is no biomechanical or biologic downside to using a full-length plate for nonperiprosthetic fractures, the cost may be higher for longer implants. • For nonperiprosthetic fractures, most surgeons recommend spaced fixation above and below the fracture with a plate at least two-thirds the length of the femur or at least three times the length of a comminuted fracture segment (whichever is greater). • Fixed-angle plate or a standard plate • Fractures close to the metaphysis require a fixed-angle plate (e.g., angled blade plate, dynamic condylar screw/plate, locking plate) to minimize the risk of varus deformity. • Uniplanar or multiplanar fixation • Multiplanar fixation is recommended if a high-strain environment is anticipated with uniplanar fixation (i.e., short comminuted fracture segment near the edge of a hip or knee implant), especially when very slow healing is expected (i.e., in a bisphosphonate associated fracture). • A long plate with a distal fixed-angle construct needs to be contoured to fit the greater trochanteric flare proximally (Fig. 38.15). Similarly, if a plate is slid from the proximal end down, it must be contoured to fit the distal flare of the femur. • Once the fracture has been reduced and the proximal and distal portals are created on the lateral side of the femur as described earlier, the plate is usually slid up from the distal portal or it can be slid down from above (Fig. 38.11). • Check plate position along the lateral surface in both portals. • Under direct vision and palpation through each portal • In both AP and lateral planes using fluoroscopy • Recheck and adjust fracture reduction before inserting screws into the lateral plate. • Minor adjustments in coronal plane alignment can be made by pulling the fracture toward the plate with screws or specially designed threaded devices inserted through the plate (see Fig. 38.12B). Recheck fracture reduction and plate position along the entire length of the femur after each manipulation.

471

472

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

• Apply fixation to the plate to maintain position. • Create a fixed-angle construct first if required for a metaphyseal fracture (Fig. 38.14). Consider placement relative to any planned multiplanar endosteal fixation. • Recheck fracture reduction before inserting fixation into the other segment of the femur (usually nonlocking screws) above the location for any possible planned endosteal multiplanar fixation (plate or strut graft). • Place screws into both fracture segments in a spaced configuration above and below the fracture, but retain a long working length across the fracture segment (see Fig. 38.15).  STEP 2 PEARLS

• When the lateral intramuscular septum is intact, aim the plate posteriorly when sliding it under the vastus lateralis, as this will tend to keep it within the opposite portal instead of sliding anteriorly into the vastus muscle from where it can be difficult to retrieve and may injure the muscle. • When checking the position of the plate along the lateral surface of the femur using fluoroscopy (see Fig. 38.12A), a true AP may be difficult to interpret and may mask minor fracture displacement (see Fig. 38.12B). Rotate the C-arm until the plate is visualized on the edge along the femoral surface (see Fig. 38.12B) to better appreciate any malreduction. • If a second medial extramedullary or endosteal plate is planned, allow space anteriorly by placing posterior screws into the lateral plate initially (see Fig. 38.14). • When contouring a long plate to fit the proximal or distal femoral flare, slight overcontouring is preferable to undercontouring, as slight valgus is preferable to varus. • In periprosthetic fractures, thought must be given to how the plate will be secured in the region of the implant. STEP 2 PITFALLS

• A short-plate construct with inadequate working length often leads to screw pullout and a high-strain environment (see Fig. 38.9). The only downside of a long-plate construct is the increased cost and the need to properly contour the plate. • A straight lateral plate (or even a curved plate) may not fit well in the middle section of a highly bowed femur in the sagittal plane, even if the proximal and distal ends of the plate are properly positioned. This can result in unicortical screws or screws missing the femur altogether, leading to early loss of fixation and screw pullout. • Always check the lateral view and adjust the plate position such that bicortical screws can be placed in critical fixation areas. • Use of nonlocking screws allows these to be aimed into an optimal bone position. Multiaxial locking screws allow some flexibility in this regard as well but confer no particular advantage over spaced fixation with nonlocking screws inserted through a long plate. STEP 2 INSTRUMENTATION/IMPLANTATION

• Proximal or distal anatomic fixed-angle plates or standard plates. Bowed plates are preferable to match the femoral bow. • Locking and nonlocking screw/plate options • Cerclage cables and other ancillary fixation constructs to be placed around femoral implants STEP 2 CONTROVERSIES

• Some surgeons prefer locking screws in the diaphysis. Given the potential adverse biomechanical consequences, far cortical locking and other screw designs have been advocated by some. • A long plate with spaced nonlocking screw fixation minimizes the risk of screw pullout. • Multiplanar fixation can be used to optimize the local strain environment if a high-strain situation is anticipated. • While most surgeons advocate spaced fixation and a long plate, there is no consensus or good scientific data regarding the exact parameters of plate length and the number and position of screws. • While multiplanar fixation is helpful to optimize strain, it is required only for high-strain situations. There is debate regarding when multiplanar fixation is necessary. It should be considered in the following circumstances: • Short comminuted fracture segment (especially if adjacent to a hip or knee prosthesis). An accurate reduction helps reduce strain across a simple fracture pattern and a long comminuted segment inherently represents a low-strain environment that generally heals well with simple bridge plating. However, a short comminuted segment is associated with high strain, as neither situation applies. • Revision of failed fixation • Slow healing is expected (e.g., bisphosphonate-associated fracture, advanced age, etc.). • There is no consensus regarding the type of multiplanar fixation. Options include: • Endosteal nail, plate, or strut graft • Extramedullary plate or strut graft

A

B FIG. 38.12  A, The correct position for a left distal femoral plate along the anterior lateral surface (blue structure). An anteroposterior (AP) fluoroscopy shot parallel to the edge of the plate provides a more accurate assessment of plate position as compared with a true AP of the distal femur (see Fig. 38.13). B, Two fluoroscopic views of the distal femur after plate insertion. Note that the view along the edge of the plate demonstrates a malposition that might produce valgus deformity if not corrected. The deformity is difficult to appreciate on the true AP view of the knee. The deformity can be corrected by adjusting the fracture position with manual or percutaneous manipulation or by pulling the bone to the plate with a temporary screw or threaded pulling device inserted through the plate at an appropriate position near, but distal to, the fracture site.

Patella

Rectus Femoris Vastus Lateralis Femoral shaft

Gl ma uteus xim us

Greater trochanter

Lateral Epicondyle

FIG. 38.13  Lateral surface anatomy in a patient with an open femur fracture. Submuscular plating portals and fracture reduction incisions may be made through open wounds, if present, or along the femoral shaft (dotted white line).

474

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

FIG. 38.14  Cadaver specimen showing lateral plate in situ with posterior locking screw. This placement is unlikely to interfere with insertion of a medial endosteal (or extramedullary) plate (or strut graft) if required. The head is to the right.

FIG. 38.15  Plate contouring to accommodate the greater trochanteric flare or the distal femoral condylar flare is performed before submuscular plating by holding the plate along the femoral cortex and sequentially bending until the contour is accurate. Thus, removal and reinsertion to perfect the contour is minimized. Note the cerclage wires that were used in each case to obtain an accurate reduction of these simple fracture patterns that were treated with a relative stability construct with healing by callus formation, as expected.

Step 3: Multiplanar Fixation (If Required) • Multiplanar fixation can be achieved with the following: • Extramedullary strut graft or plate • IM nail alone or a nail in conjunction with a lateral plate • IM strut graft or plate • The use of an IM plate was first described, to the best of our knowledge, by Mast and Ganz in the mid- to late 1980s. Their concept was to augment a lateral distal femoral plate by substituting an inadequate medial cortex of pathologic or comminuted bone with an endosteal plate (so-called composite fixation). They described placing the plate through the fracture site medially. We have modified this technique to be less invasive and will describe it in detail in the following section. • Multiplanar fixation with endosteal plating as an adjunct to a lateral plate is applicable mainly to distal metaphyseal femoral fractures (Fig. 38.16). • First, the lateral plate is secured with one or more key locking screws distally to create a fixed-angle construct (see Fig. 38.14). • Next, the lateral plate is secured proximally, taking care to leave room for the planned endosteal plate. • Determine the appropriate width and length of the endosteal plate. • A lateral fluoroscopic view of the femur with the plate held on the skin to ensure that the width of plate will fit into the femoral canal is helpful for determining plate width. • Apply the plate to the skin on the side nearest the fluoroscopy source (which will result in relative plate magnification) for a conservative estimate of fit. • A 3.5-mm plate will be sufficient in most cases, although in small individuals, a 2.7-mm plate may be required. The original description involved a narrow 4.5-mm dynamic compression plate. • We recommend bypassing the fracture proximally by at least 3 cortical widths or twice the fracture length, whichever is greater (Fig. 38.17).

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

A

Immediate full activity and weight bearing as tolerated

B FIG. 38.16  A, Preoperative plain oblique radiographs of a 104-year-old female who suffered a mechanical fall. She lives independently in a condominium and uses a cane indoors and a walker for longer distances. The knee replacement had been functioning well for over 10 years. B, Anteroposterior (AP) and lateral films taken 6 months following multiplanar fixation with a lateral plate and an endosteal 3.5-mm plate. The patient was allowed immediate weight bearing as tolerated. She was ready for discharge to rehabilitation on day 7 and returned home independently 6 weeks later. At this writing, she is 106 years old and remains ambulatory with a walker, although she now resides in an assisted-living retirement home. Ideally, the lateral plate should have been a few holes longer to protect the entire femur and thereby minimize the stress riser effect at the top of the construct.

• Distally, contour the plate so that the most distal plate hole is flush with the medial cortical wall (Fig. 38.18). The most distal hole should remain accessible for a screw to be inserted. • Insert the plate. • Use an osteotome of appropriate width to make an entry portal on the medial side approximately 5 mm proximal to the articular margin and 10 mm posterior to the anterior articular margin (Fig. 38.19).

475

476

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

FIG. 38.17  Proximal and distal fluoroscopy shots in a cadaver model. The plate length is determined before contouring by holding it up to the femur on the anteroposterior view. First, the distal position is secured and then the plate is selected so that the plate will bypass the fracture by an appropriate amount.

FIG. 38.18  The plate is then contoured until it matches the endosteal surface on anteroposterior view fluoroscopy.

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

477

A

B FIG. 38.19  A, Cadaver specimen showing medial side with a small longitudinal incision made just distal to the medial epicondyle. An osteotome is being inserted to create a channel for the endosteal plate as appreciated on the corresponding fluoroscopy view (B). The head is to the left in (A).



• Slide the plate proximally under fluoroscopic control to ensure that it does not exit laterally through the fracture site (Fig. 38.20). • Leave the distal portion of the plate outside the cortex (it should be flush with it) such that the distal end of the plate is a few millimeters proximal to the articular margin. • Medial cortex substitution • The lateral plate has already been secured proximally and distally in step 2. • The endosteal plate is pushed toward the medial cortex proximally with screws placed through the lateral plate. • If a 3.5 limited-contact dynamic compression plate (LC-DCP) is used, the 4.5-mm cortical screws can be passed through a hole in the 3.5-mm plate, although this is not essential. It is not possible to pass a screw through an endosteal 2.7-mm plate. A screw passing adjacent to the endosteal plate is usually sufficient to push it against the medial endosteal surface. • If a “through screw” is not possible, the endosteal plate should be pushed medially at the proximal end with a locking screw secured into the lateral plate. • Otherwise, it is not necessary to use locking screws in the femoral diaphysis, as discussed earlier. • The IM plate is then secured distally with a single screw through the distal hole of the plate (Fig. 38.21). • Final lateral plate fixation • The lateral plate is then definitively secured with spaced fixation above and below the fracture as required (see Fig. 38.16). 

STEP 3 PEARLS

• To minimize the risk of the endosteal plate exiting the canal through the fracture site, a slight overcontour of the proximal plate is suggested. • If endosteal plate removal is thought to be required, leaving the plate slightly prominent distally and applying minimal fixation through the plate is advisable (Fig. 38.23).

STEP 3 PITFALLS

• Do not end both plates at the same level to avoid a stress riser. • Unless early implant removal is planned, ensure that the distal portion of the endosteal plate is not prominent by overcontouring it to avoid irritation (Figs. 38.22, 38.23).

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

478

STEP 3 INSTRUMENTATION/IMPLANTATION

• 3.5-mm or 2.7-mm low-contact compression plates and screws (4.5-mm LC-DCP may be used in large individuals) • Large plate bender • Osteotomes

STEP 3 CONTROVERSIES

• To date, there have been few reports of clinical endosteal plate use for acute fractures. • To the best of our knowledge, the insertion of the endosteal plate has previously only been described through the fracture or tumor site. We have not yet reported in a peer-reviewed publication our experience with the technique described earlier. • The optimal length and width of the endosteal plate relative to the femoral canal size and fracture pattern have yet to be elucidated. • The following require further investigation: • How important is it to push the plate onto the medial endosteal surface? • Are biomechanics improved by placing screws through the endosteal plate from the lateral side? • Should the endosteal plate be secured proximally and distally?

A

B

C

FIG. 38.20  A, The plate is inserted into the channel previously created by the osteotome using a mallet, as seen in the clinical photograph of a cadaver model (A). The head is to the right. The corresponding fluoroscopy images (B, C) show the plate advancing across the fracture site. Care must be taken to ensure that it does not exit through the fracture site. Slight overcontouring of the proximal end of the plate toward the medial cortex is helpful in this regard.

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

A

B FIG. 38.21  A, Clinical photograph of a cadaver model with distal screw insertion into the distal hole of the medial endosteal plate. The head is to the left. The corresponding fluoroscopy shot (B) is shown.

FIG. 38.22  Anteroposterior (AP) radiograph of the right knee of a 58-year-old male taken 6 months after multiplanar fixation with a lateral and an endosteal plate. The distal portion of the plate would ideally be contoured to be less prominent medially. This patient is asymptomatic, although the plate and screw are palpable.

479

480

PROCEDURE 38  Femoral Shaft Uniplanar and Multiplanar Plating

FIG. 38.23  Six-month anteroposterior (AP) radiograph of the right knee after fixation of a supracondylar femur fracture in a 76-year-old female polytrauma victim. Given the preexisting advanced knee arthritis, we felt that leaving the endosteal plate accessible medially would facilitate removal for a total knee replacement. At 18 months following injury, she remains mobile and has declined further surgery to date.

Step 4: Wound Closure • Devitalized muscle is debrided to minimize risk of heterotopic ossification and infection. • Tight closure of the fascia lata to prevent muscle herniation is important. • Wound is closed in layers to prevent dead space, especially in obese patients. • Suture or staples for skin 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Early range of motion for hip and knee joint • The patient is mobilized with walking aids. • Weight bearing as tolerated is allowed immediately in most cases. • Sutures or staples are removed between 2 and 3 weeks after surgery. POSTOP CONTROVERSIES

• Weight bearing is restricted by some surgeons.

EVIDENCE Angelini A, Battiato C. Combination of low-contact cerclage wiring and osteosynthesis in the treatment of femoral fractures. Eur J Orthop Surg Traumatol. 2016;26(4):397–406. Hildebrand F, vam Griensven M, Huberlang M, et al. Is there an impact of concomitant injuries and timing of fixation? A focused review of clinical and experimental evidence. J Orthop Trauma. 2016;30:104–112. Mast J, Jakob R, Ganz R. Substitution. In: Planning and Reduction Technique in Fracture Surgery. Berlin: Springer Verlag; 1989:201–251. Phillips J, Zirkle LG, Gosselin RA. Achieving locked intramedullary fixation of long bone fractures: technology for the developing world. Int Orthop. 2012;36:2007–2013. Rudin D, Manestar M, Ulrich O, Erhardt J, Grob K. The anatomical course of the lateral femoral cutaneous nerve with special attention to the anterior approach to the hip joint. J Bone Joint Surg [Am]. 2016;98(7):561–567. Zdero R, Walker R, Waddell JP, Schemitsch EH. Biomechanical evaluation of periprosthetic femoral fracture fixation. J Bone Joint Surg [Am]. 2008;90(5):1068–1077.

PROCEDURE 39

Supracondylar Femur Fractures Robert C. Jacobs and Michael Blankstein OPEN REDUCTION AND INTERNAL FIXATION Indications • Displaced/irreducible fracture • Unstable/comminuted fracture • Intraarticular fractures (partial or complete) • Open fractures • Polytrauma (staged after external fixation) • Pathologic fractures • Bilateral femur fractures • Ipsilateral tibial fractures • Vascular compromise (may be staged) • Associated knee ligament injuries 

EXAMINATION/IMAGING • A detailed history and physical examination is critical to rule out open fracture and vascular or nerve injury. • The minimum imaging required is high-quality anteroposterior (AP) and lateral radiographs. However, oblique views are useful preoperatively and intraoperatively. • Traction or splinted views (AP and lateral) can greatly aid in preoperative planning. • Imaging of the uninjured femur/knee can assist with preoperative templating (rotational alignment). • Computed tomography (CT) scans (with 3D reconstruction) are critically important, especially in high-energy injuries, as there is a significant rate of coronal plane condylar fractures that can be difficult to appreciate on plain radiographs (Fig. 39.1A–C). 

SURGICAL ANATOMY • The most important structure at risk is the superficial femoral artery posteriorly, which enters the popliteal fossa around 10 cm proximal to the knee joint as it passes through the Hunter canal. • Soft tissues • The quadriceps muscle anteriorly (rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis) is separated from the posterior compartment (hamstring muscles) by the medial and lateral intermuscular septa. These large muscles shorten the fracture, and their force must be overcome in reduction techniques (Fig. 39.2A). • The gastrocnemius muscles attach to the posterior femoral condyles and create an extension force to the condyles. This produces the typical deformity of supracondylar femur fractures, which is extension and shortening (Fig. 39.2B). 

PITFALLS

• Medically unstable patients • Nonambulatory patients • Severe osteopenia (device/technique sensitive) • Inadequate imaging

CONTROVERSIES

• AO 33A-type fracture patterns and periprosthetic fractures above a total knee arthroplasty: both open reduction and internal fixation (ORIF) and retrograde intramedullary nailing have good outcomes. • Comminuted intraarticular fractures in lowdemand elderly patients: ORIF with plate fixation, ORIF with intramedullary nail fixation, and distal femoral replacement with hinged knee prosthesis are viable treatment options. • Postsurgical weight-bearing status in the elderly. Weight bearing as tolerated for intraarticular fracture patterns of the femur after ORIF does not yet have robust supporting clinical data, however.

TREATMENT OPTIONS

• ORIF is the workhorse treatment for this fracture pattern. Successful outcomes can be obtained with numerous devices depending on the fracture type, bone quality, and surgical experience. • Distal femoral locking plate (including both standard and variable-angle systems) • Retrograde intramedullary nail (after ORIF of the articular surface if indicated) • Less Invasive Stabilization System (LISS) plate • Condylar blade plate • Dynamic condylar screw (DCS) • Alternative non-ORIF options include: • Cast • Brace • Distal femoral replacement and hinged total knee arthroplasty • External fixator • Circular frame

481

PROCEDURE 39  Supracondylar Femur Fractures

482

B

A

C FIG. 39.1A–C 

PEARLS

• Knee-spanning external fixation in the setting of polytrauma or hemodynamic instability gives time for advanced imaging and adequate preoperative planning, especially in AO 33C-type fractures. Draw out the expected plate location before drilling the proximal-most fixation pins to avoid overlapping surgical fields. Place the proximal fixation pins in the AP direction to decrease lateral stress concentration adjacent to the future plate. • Prep the limb as high as possible and use a sterile tourniquet during the entire case. If necessary, do the articular reduction under tourniquet control and deflate for the reduction of the condyles to the shaft. • Preparation and exposure of the ipsilateral iliac crest may be useful if bone grafting is anticipated. • A perfect lateral of the contralateral knee followed by an AP of the contralateral hip is extremely useful in determining rotational alignment in comminuted metaphyseal fracture patterns. • Use of a femoral distractor or external fixator can greatly aid in reduction of the fracture (especially intraarticular components). • Place the distractor out of the area for plating. One pin should be placed at the level of the lesser trochanter laterally and the second in the lateral proximal tibia. Distract with the knee in approximately 20° of flexion.

PROCEDURE 39  Supracondylar Femur Fractures

483

PITFALLS

A

B

FIG. 39.2A,B  A, modified from Neer CS 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg [Am]. 1967;49(4):591–613.

FIG. 39.3 

25° 10°

FIG. 39.4 

• This is a technically demanding fracture— thorough knowledge of deforming forces, complications, implant limitations, and surgical technique is required. • Avoid use of a traction table, as it will tension the muscle and make exposure and reduction more difficult. Lack of chemical paralysis intraoperatively can have a similar effect. • Bone • The distal femur has many unique features that are critical to understand for reduction and fixation techniques. • The metaphysis widens at the end of the femoral diaphysis and supports the femoral condyles. Anteriorly, the shallow articular trochlea between the condyles provides a contact surface for the patella. Posteriorly, the intercondylar fossa separates the condyles and is the attachment area for the cruciate ligaments. • In the lateral projection, the femoral shaft aligns with the anterior half of the lateral condyle (Fig. 39.3). • The distal femur is trapezoidal when viewed end on (Fig. 39.4). • The lateral femoral condyle is larger anterior to posterior than the medial condyle and has a flat lateral surface (see Fig. 39.4). • The medial condyle is wider posteriorly and more angulated. • This is important in placing fixation devices to avoid errant hardware placement (see Fig. 39.12) and to avoid malreductions such as medial translation (golf club deformity). • The alignment of the knee joint is parallel to the ground, with the anatomic axis of the femur averaging 9° of valgus (range, 7–11°). • The medial femoral condyle articulates with the concave medial tibial plateau, whereas the lateral condyle articulates with the convex lateral tibial plateau. • Lateral imaging taken a few degrees in either direction from true lateral in the sagittal plan can assist in identification of the condyles.

484

PROCEDURE 39  Supracondylar Femur Fractures

EQUIPMENT

• Use of a radiolucent support—such as a triangle, adjustable support, or rolled-up sheeting—will reduce the effect of the gastrocnemius muscles and aid reduction attempts. • Large pointed reduction clamps, periarticular clamps of multiple sizes (with spiked disk washers) and Kirschner wires (K-wires) are frequently necessary. Cobb elevators, ball spiked pushers, and radiolucent Hohmann retractors are other useful adjuncts.

CONTROVERSIES

• Some surgeons prefer a lateral position; however, this makes AP imaging slightly more difficult. • Débridement of open, comminuted fractures until free of contamination is mandatory; however, there is debate to the degree of bony fragment removal required.

PEARLS

• Preoperative planning will give a better understanding of the fracture, the exposure required, and the equipment necessary for reduction and fixation. • Start with articular exposure to reduce blood loss and unnecessary dissection. • A combined lateral and small medial approach may have less morbidity than an extensile exposure, especially with coronal plane fractures of the medial condyle (Hoffa fragment) (see Fig. 39.1A–C). • The use of minimally invasive techniques when possible significantly decreases surgical morbidity, especially when bridge plating metaphyseal comminution.

PITFALLS

• Careful use of an ipsilateral hip bump and leg ramp is important; failure to understand how each will deform the fracture can lead to malreduction. • Failure to obtain perfect lateral knee and AP hip imaging of the contralateral leg before surgical positioning can make for a more challenging operation.

FIG. 39.5 

POSITIONING • The most widely accepted position for fixation of supracondylar femur fractures is with the patient supine on a radiolucent table. This allows for C-arm fluoroscopy intraoperatively from the contralateral side. • The operative hip can be elevated on a sandbag, towel bump, or intravenous solution bag with a foam ramp or towel roll under the leg to rotate the femur and knee into a true AP projection. • The knee is usually draped free with a sterile tourniquet and partially flexed over a radiolucent support (Fig. 39.5). 

EXPOSURE • Most AO 33A-type fractures and those periprosthetic femur fractures above a total knee arthroplasty can be reduced and stabilized through a single lateral approach (extensile or minimally invasive). • Displaced intraarticular fractures and coronal plane fractures of the articular surface (regardless of degree of displacement) require a more extensive exposure. • Surgical technique should include careful soft-tissue handling, indirect reduction where possible, anatomic articular reconstruction, and restoration of limb length, rotation, and alignment. • Bone grafts can be used where necessary. However, caution should be used in the setting of open fractures. • Stable fixation allows for early active rehabilitation. • Lateral Approach • A straight lateral incision is made over the distal femur extending to the midpoint of the lateral condyle (Fig. 39.6A). The incision should stay anterior to the lateral collateral ligament. • Proximally, the incision can be extended as high as necessary depending on the length of the fracture, reduction technique, and implant chosen (Fig. 39.6B). The proximal incision is completed after the articular reduction has been achieved if possible. • Whenever possible, perform a minimally invasive lateral approach of the distal portion of the incision with the proximal fixation achieved through percutaneous screw placement after submuscular plating. • Distally, the incision can be extended across the knee joint and then curved anteriorly, crossing the Gerdy tubercle if needed. • The fascia lata is incised in line with the skin incision, and the anterior fibers of the iliotibial band (IT) are divided distally. The approach continues through the joint capsule and synovium, taking care to ligate the superior lateral geniculate artery and not damage the lateral meniscus.

PROCEDURE 39  Supracondylar Femur Fractures

A

B FIG. 39.6A–B 

A

B FIG. 39.7A–B 

• Next, the vastus lateralis is elevated from the intermuscular septum and any perforating vessels are ligated (Fig. 39.7A–B). Only as much soft tissue is elevated as necessary for the reduction and fixation. • After reduction and stabilization of the articular component of the fracture, image intensification and reduction maneuvers may eliminate the need for extensive proximal dissection. • Submuscular application of the plate and percutaneous screw placement will avoid disruption of the metaphyseal/shaft portions of the fracture. • Swashbuckler Approach (Fig. 39.8A–C) • Another popular option for visualization of the articular surface in AO-33C type fractures. • It uses the midline incision for a total knee arthroplasty but fades slightly laterally when carried proximally. The vastus lateralis is elevated from the intermuscular septum and femur with the IT band retracted laterally (Fig. 39.8A). • The elevated vastus (and remainder of quadriceps and patella) is then retracted medially with Hohmann retractors placed medial to the femoral shaft (Fig. 39.8B).

485

PROCEDURE 39  Supracondylar Femur Fractures

486

Quadriceps reflected medially

Quadriceps tendon Vastus lateralis

Patella medially everted

A

C

B

FIG. 39.8A–C  Modified from Starr AJ, Jones AL, Reinert CM. The “swashbuckler”: a modified anterior approach for fractures of the distal femur. J Orthop Trauma. 1999;13(2):138–40; and Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010 Oct;18(10):597–607.

MCL

Vastus medialis FIG. 39.9 

• The articular reduction and fixation can be completed prior to introduction of the lateral plate through the surgical incision. Additional stab incisions can be used to place wires and screws for definitive fixation (Fig. 39.8C). • Anterolateral Approach • This skin incision begins distally just lateral to the tibial tubercle and proceeds proximally just lateral to the patella and continues to fade laterally into the lateral approach to the femur. • The vastus lateralis can be split or elevated off of the intermuscular septum and a lateral parapatellar arthrotomy made, allowing the vastus to be retracted medially. The confluent fascia of the vastus and IT band is divided and the incision becomes in line with the IT band fibers as it progresses proximally. • Splitting the vastus will enhance articular visualization compared to the lateral approach but also may increase adhesions postoperatively. • Articular visualization is similar to the swashbuckler approach but with improved ability to place lateral hardware and access the posterior lateral femoral condyle. • Medial Approach • In the case of complex medial condyle fractures or coronal plane fractures (Hoffa fractures) a second medial incision is occasionally necessary. • A straight medial skin incision is made over the medial femoral condyle and anterior to the adductor tubercle. The fascia is incised in line with the incision and the vastus medialis is elevated from the intramuscular septum (Fig. 39.9). Any perforators and the medial superior geniculate artery are ligated.

PROCEDURE 39  Supracondylar Femur Fractures

• The incision continues through the capsule and synovium to the joint. The surgeon must stay anterior to the medial collateral ligament (MCL) and respect the medial meniscus at the joint level and the superficial femoral artery and vein approximately 10 cm above the joint line (Hunter canal). • This approach can also be performed using minimally invasive plate osteosynthesis (MIPO) techniques with good functional outcomes. • Coronal fractures require interfragmentary compression with countersunk screws below the articular surface (see Fig. 39.1C) 

PROCEDURE Step 1: Temporary Anatomic Reduction of the Joint • Of paramount importance is anatomic reduction of the articular surface. This usually requires direct visualization and is best aided by C-arm fluoroscopy. • Provisional fixation of articular fragments is best achieved by multiple K-wires. These should be placed outside of articular areas where possible. They can also be placed percutaneously where necessary. • Larger K-wires or threaded pins can be used as joysticks in each condyle to aid in reduction. • Fragments are secured and compressed with the use of pointed and ball spike periarticular reduction clamps. 

Step 2: Definitive Articular Stabilization • After temporary anatomic reduction with K-wires, definitive stabilization of the articular portion of the fracture should take place. • Generally speaking, articular fragments can be lagged together with 3.5-mm, fully threaded cortical screws. This should be done outside of the plate when possible to maximize interfragmentary compression. • These screws are placed near the peripheral margins of the condyles, especially anteriorly and posteriorly, as this is where better fixation can be obtained (Fig. 39.10). Sometimes it is necessary to countersink screw heads to avoid interference with the fixation device. • It is critical to know the location of the definitive fixation device at this point in order to avoid placing screws on the lateral condyle in this location or have hardware in the track of the fixation device. Marking the footprint of the definitive plate is a useful exercise (see Fig. 39.10) • Coronal fractures (Hoffa type) need to be fixed in a lag fashion from anterior to posterior and frequently by countersinking the screw heads below the articular surface. • Once the articular surface is reconstructed, the plate can be secured to the femoral shaft. • Alternatively, solid or cannulated screws larger than 3.5 mm can be used to provide interfragmentary compression. These larger screws may perform better in poorquality bone but may interfere with additional fixation. 

487

PEARLS

• Allowing the articular fragments to remain in a slightly shortened position during reduction and interfragmentary compression can reduce the deforming forces of the gastrocnemius and quadriceps muscles. • Large pointed reduction forceps are invaluable for manipulating the condyles against one another or holding a temporary reduction. • A good location to judge rotational reduction of the condyles is in the notch and on the anterior articular margin of the femur at the fracture site. • Femoral distractors or external fixators aid greatly in neutralizing forces on the articular fragments. • Large periarticular reduction clamps with spiked disks can be used to compress intercondylar fracture patterns when placed over the center of condylar rotation. This is especially useful in osteoporotic bone.

PITFALLS

• Watch for intercondylar comminution, as narrowing the condyles will lead to poor functional outcome. Tricortical grafts work best to span bone gaps. • A pointed Weber clamp placed anterior to the midline of the femoral condyles in the coronal plane will compress the well-visualized trochlear reduction while gapping open the poorly visualized posterior intercondylar notch. Consider using an additional pointed Weber clamp posterior to the axis of rotation or a centrally located periarticular clamp with spiked disks. PEARLS

• If wholly articular fragments need to be stabilized, small-fragment screws should be used and countersunk below the articular cartilage. • Once the AP image is taken, subsequent x-rays rolled ∼25° toward the surgeon can evaluate hardware penetration of the medial condylar surfaces (Fig. 39.11A–B).

PITFALLS

• Remember the trapezoidal shape of the distal femur. The distal-most two anterior screws within the plate and any lag screws placed anterior to an appropriately positioned plate risk penetration of the anteromedial cortex (Figs. 39.4, 39.12). Errant screws may not be apparent on AP imaging alone. • Watch for distal posterior screws penetrating the femoral notch (Fig. 39.13). The distal-most posterior screw within the plate frequently cannot exceed 30 mm. If there is concern for violation of the notch (Fig. 39.14A–B) a flexed knee, notch view, can be obtained to confirm hardware placement (Fig. 39.14C).

FIG. 39.10 

PROCEDURE 39  Supracondylar Femur Fractures

488

A

B FIG. 39.11A–B 

PEARLS

• The plate may also be applied anatomically and securely to the condyles first; then, the final reduction of the fracture may be achieved by simply securing the plate to the shaft proximally. • When inserting percutaneous screws, consider tying a suture to the head of the screw to prevent the screw from being lost in the soft tissue. • Plates with longer working lengths impart better strain environments for fracture healing but can be more challenging to align proximally (especially in obese patients). • Alignment of the limb may be checked with fluoroscopy intraoperatively by running a Bovie cord from the center of the femoral head over the knee and onto the tibial shaft to the ankle. (see Fig. 39.21A). FIG. 39.12 

PITFALLS

• Placement of the plate too posteriorly will result in the common deformity of medial translation of the condyles because the femur is wider posteriorly. Care must be taken with the initial plate position (see Figs. 39.15, 39.17, and 39.27). • Minor differences in anatomy exist between patients; preoperative templating can help avoid malreductions. • The central screw (in locked plating systems) and the blade (angled blade plate) must be parallel to the distal femoral articular surface in the AP projection. The plate must be parallel to the anterior cortex of the distal fragment on lateral imaging. Attention to these parameters is critical to the ultimate femoral alignment in terms of varus/valgus and flexion/extension.

FIG. 39.13 

PROCEDURE 39  Supracondylar Femur Fractures

A

489

B

C FIG. 39.14A–C 

Step 3A: Control of the Condyles with the Plate (Distal Fixation)

PITFALLS—cont’d

• A number of devices are available for plate fixation of the distal femur. Surgeons should be familiar with the advantages and disadvantages of each system. • Most systems are available in both titanium and stainless steel. There is increasing evidence that titanium locked plates have better outcomes with respect to nonunion rate. • Locked Condylar Plate (multiple manufacturers have systems; Figs. 39.15–39.18) • Anatomically contoured and designed to be placed anteriorly on the lateral femoral condyle in line with the femoral shaft. • It can be inserted percutaneously with or without the use of an outrigger guide arm. • Specific indications include patients with osteoporosis and metaphyseal comminution, with diaphyseal fixation options for cortical and locking screws.

• The locked condylar plate sits quite distally on the femur. Recognition of the cortical densities that make up the floor of the trochlear groove and the Blumensaat line on lateral radiographs help ensure appropriate positioning of implants. • In cases of severe comminution, it is advisable to minimize dissection in the metaphyseal zone. Care must be taken to restore length, alignment, and rotation. The opposite limb may be used as a guide to length. Preoperative examination of the opposite leg’s rotation may aid in judgment of the plate’s rotational position on the shaft.

PROCEDURE 39  Supracondylar Femur Fractures

490

A

B

C FIG. 39.15 

FIG. 39.16 

A

B FIG. 39.17A–B 

PROCEDURE 39  Supracondylar Femur Fractures

A

491

B FIG. 39.18A–B 

PEARLS

FIG. 39.19 



• It can act as an internal fixator and sit just off of the periosteum so as not to further disrupt cortical blood flow. • With respect to locked condylar plating, robust outcome data is available and its use is applicable to nearly all distal femoral fracture patterns. • Variable Angle LCP (Synthes, Paoli, PA; Figs. 39.13, 39.14, 39.20, 39.21) • Similar to the standard limited compression plate (LCP), this newer technology allows locked screw placement in the distal articular block targeting bone within a 15° cone of motion from each locking screw hole. • It is particularly useful in highly comminuted fractures with bone loss and limited bone stock for distal fixation (Su Type II periprosthetic fractures). • Midterm and long-term outcome data is lacking at present. • Angled Blade Plate (Fig. 39.19, left) • Historically favorable results with correct application (as well as the dynamic compression screw; see Fig. 39.19, right). • The blade plate is a good choice for young patients with good bone quality and no medial comminution when applied using the articulating tensioner. • It is the most technically demanding, although accurate placement of the chisel is improved with a cannulated guide. • There is minimal bone loss in the condyles from placement, but application cannot be performed percutaneously and requires full lateral exposure. • Its use is contraindicated in AO 33 B1, B2, B3, and C3 fracture patterns. 

• When using the MIPO technique, preliminary creation of “the box” (two guidewires, plate, and femoral shaft) can greatly assist in establishing the correct length and coronal alignment on AP imaging. Subsequent lateral imaging allows for additional correction of rotational and sagittal plane deformities (see Fig. 39.20A–F). • Bridge plates should be 2 to 3 times longer than the zone of comminution that they span. Shorter plates have a higher incidence of failure. • Screw density should be less than 0.5 proximal to the articular fixation. A space of at least three empty holes should bridge the area of metaphyseal comminution. • Avoid cross-threading locking screws as off-axis locked screw placement weakens fixation. This is particularly relevant when using variable-angle locking systems.

492

PROCEDURE 39  Supracondylar Femur Fractures

Step 3B: Plating Technique • Lateral Compression Plate (Synthes, Paoli, PA) • The central screw needs to be parallel to both the anterior and the distal condylar surfaces. One K-wire can be placed on each of these surfaces to aid proper ­alignment. • The distal guide is placed on the lateral condyle with the central guide (for the 7.3-mm screw) in place (see Fig. 39.15A). The plate sits anatomically on the lateral condylar surface generally, with the distal anterior hole just proximal and posterior from the articular margin. • A central guidewire (2.5 mm) is placed through the guide and parallel to both the distal femoral articular surface and the anterior condylar axis (usually ∼10° internally rotated from the horizontal plane; see Fig. 39.15B) Biplanar fluoroscopy should be used to verify that the guidewire is parallel to the joint in both the AP and lateral imaging. • The guide should be placed in its anatomically designed position if possible. If lag screw fixation limits plate application, consider revising the screw trajectory or burying the screw heads below the level of the plate. • At this point, the distal guide can be removed or a second guidewire placed to set the flexion/extension (see Fig. 39.15C). This is generally the distal anterior hole; the guide position is confirmed on lateral fluoroscopy. The anterior and posterior surface of the guide should parallel the distal femoral cortex. • These two K-wires are driven up to the medial cortex and the required length of plate is measured. An appropriate-length plate is chosen to allow at least eight cortices of fixation proximal to the fracture. This can be checked with an AP fluoroscopy image of the plate on the skin and from preoperative templating. • With an open technique, the proximal exposure may now be completed. For more extensive/proximal fractures, removal of the sterile tourniquet may be necessary at this point. More commonly, the remainder of the exposure is limited to percutaneous stab incisions over the proximal diaphysis. • The guide is removed and the plate (with the previously used guides mounted on the plate) is applied firmly to the condyles. The plate position on the condyles is verified with fluoroscopy. At this point, a third guidewire may be placed and then proximal reduction completed. This may be held with either a clamp and/or Kwires proximally (see Fig. 39.16) • The central 7.3-mm locking screw is placed first, as this will allow for adjustment of flexion/extension if necessary (see Fig. 39.17A). Then, one or two of the 5.0-mm locking screws are placed to stabilize the distal construct (see Fig. 39.17B). • Proximal fixation can be completed with standard nonlocking screws to reduce the shaft to the plate (see Fig. 39.18A). All proximal fixation can be standard cortical screws if the patient has good bone quality. If not, locking screws should be used in bicortical fashion and spaced appropriately (see Fig. 39.18B). • Nonlocking screws should always be placed before locking screws. • A “whirlybird,” or long cortical, can be used to dial in the degree of coronal correction with subsequent fixation using bicortical locked screws as necessary. • Distal and proximal fixation is completed and final imaging is reviewed. • The author’s preferred technique is to use an MIPO approach for appropriate fracture patterns whenever possible. This is combined with proximal MIPO principles for diaphyseal fixation after appropriate articular exposure and reduction. This minimizes additional morbidity from a full open approach, especially when used with guide arms for reliable proximal fixation and MIPO screw techniques (see Fig. 39.20A–F). • MIPO LCP (e.g., AO 33A-type fracture pattern, Su Type 1 or 2 fracture pattern). • Full muscular paralysis is achieved with coordination from anesthesia.

PROCEDURE 39  Supracondylar Femur Fractures

A

B

C

D

E

F FIG. 39.20A–F 



• The fracture is brought out to length with manual traction or tibial traction and appropriately placed towel bumps to counteract the deforming muscular forces (see Fig. 39.21A). • A small distal/lateral exposure (as described previously) is made and the previously measured plate is slid under the vastus on the periosteum (Fig. 39.22). The distal wire guides are left in place to allow greater control with retrograde plate passage. • The plate is aligned distally and secured using a wire through the central guide. • A small incision is made under fluoroscopy to assist with proximal plate delivery. The locked guidewire is then inserted proximally and the plate is centered on the diaphysis. The fracture is pulled out to length and temporarily secured proximally with a K-wire or drill bit so as not to lose its central position on the shaft. • Plate position and fracture reduction are verified on both AP and lateral projections. • Temporary fixation of the plate in this manner has created “the box” (two guidewires, plate, and femoral shaft). Minor corrections to fracture alignment can still be made at this time, but significant angular or length corrections require wire removal, re-reduction and reestablishment of the box (see Fig. 39.20A–F).

493

494

PROCEDURE 39  Supracondylar Femur Fractures

A

B

C FIG. 39.21 

• The fixation is then completed percutaneously (Fig. 39.23). • Final imaging is reviewed for anatomic articular reduction, length, alignment, and rotation compared to contralateral preoperative imaging. • For fractures that have difficulty maintaining an acceptable reduction in this manner, a carefully placed femoral distractor can be invaluable. Also, reduction can be assisted with percutaneous Shantz pins (Fig. 39.24) • Alternatively, the plate may be secured to the condyles distally in an anatomic alignment as previously described. Then, the final reduction of the shaft is achieved with manipulation and the use of nonlocking screws to draw the bone to the plate (see Fig. 39.18). •  Fig. 39.25A–C shows a case example of a severely comminuted supracondylar femur fracture using articular reconstruction (Fig. 39.25A), spanning fixation (Fig. 39.25B), and delayed bone grafting (Fig. 39.25C). 

PROCEDURE 39  Supracondylar Femur Fractures

FIG. 39.22 

FIG. 39.24 

FIG. 39.23 

A

B

C FIG. 39.25A–C 

495

496

PROCEDURE 39  Supracondylar Femur Fractures

PITFALLS

• Avoid the use of long-leg splints, as this increases the lever arm at the fracture site and may lead to early failure of fixation. • To avoid stiffness and poor functional outcome, begin early supervised knee range of motion (provided secure fixation). • In the elderly population, distal femur fractures have similar morbidity to hip fractures; restricting weight-bearing status for a prolonged period is not advised. • In cases with significant medial comminution, full weight bearing should be delayed until fracture healing is underway; varus collapse is still possible even with fixed-angle devices. Do not hesitate to use a medial plate, a bone graft, or even a medial cortical strut in cases of severe comminution and osteopenia. Fig. 39.27 shows an intramedullary fibular graft used in such a case.

Step 3C: Alternative Devices for Distal Fixation • The LISS (Synthes, Paoli, PA) uses a plate similar to the LCP (Fig. 39.26A); distal plate holes are lettered and diaphyseal plate holes are numbered. It also has an outrigger (guide) for proximal locking (Fig. 39.26B) but uses unicortical proximal locking screws instead of bicortical. • It is used in a percutaneous fashion proximally similar to the description above. • Reduction of the fracture must be achieved provisionally with a femoral distractor, spanning fixator, or tibial traction pin prior to plating. This can also be accomplished after control of the condyles by the plate. There is a tendency for the weight of the guide to cause external rotation of the condyles on the shaft; when properly positioned, the guide should be internally rotated approximately 10° relative to the femoral shaft (Fig. 39.26C). • It has titanium and stainless steel options and has good clinical data supporting its use. However, more recent literature has shown superiority to DCS systems for fracture union while having more hardware failures. • Angled Blade Plate • The approach is similar to the LCP; however, the blade plate cannot be applied percutaneously. • After anatomic condylar reduction, the position of the blade is determined. The guide wires for the cannulated chisel should be placed 1 cm proximal from the distal articular surface in the middle third of the anterior half of the lateral femoral condyle (see Fig. 39.3). It should be parallel to the distal articular surface and to the anterior articular surface. • The seating chisel should follow the guidewires proximal to the distal articular surface (respecting bony landmarks to keep the chisel out of the notch). The chisel is advanced and pulled back frequently to avoid trapping it in the condyles. The optimal length should be determined without penetrating the medial cortex. •  Incorrect rotation of the chisel on lateral imaging will induce sagittal plane ­deformity. • The appropriate-length plate and blade are seated in the distal femur, and a 6.5mm cancellous screw in the plate is added to the distal fixation to aid in control of rotation. The condyles are reduced to the shaft, and the plate is secured with compression when possible (unless comminution is present). 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Early range of motion is important for good functional outcomes. • Most elderly patients should begin mobilization with weight bearing as tolerated immediately. • Younger patients, highly comminuted and intra-articular fracture patterns have historically been treated with protected weight bearing for up to 3 months. With locked fixed-angle plating systems, earlier progressive weight bearing is becoming more accepted. • Patients should be followed with serial radiographs until union, which generally approaches 85% to 95% depending on patient factors.

ACKNOWLEDGMENTS The authors would like to acknowledge Drs. Craig Bartlett, Nathan Endres, and Patrick Schottel for provision of select case examples.

PROCEDURE 39  Supracondylar Femur Fractures

A

B

10°

C FIG. 39.26A–C 

FIG. 39.27 

497

498

PROCEDURE 39  Supracondylar Femur Fractures

EVIDENCE Poole WEC, Wilson DGG, Guthrie HC, et al. ‘Modern’ distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure: five-year experience from a United Kingdom major trauma centre. Bone Joint J. 2017;99-B(7):951–957. Retrospective review of 127 distal femur fractures in patients with mean age of 73 years. A total of 84% were allowed full weight bearing with 95% union and 3% revision for hardware failure. The patient cohort compares similarly to those with hip fractures in terms of follow-up rate and 1-year mortality. Combined periprosthetic and native knees. (Level 3 evidence). Ali F, Saleh M. Treatment of isolated complex distal femoral fractures by external fixation. Injury. 2000;31(3):139–146. Retrospective case series of 13 patients (mix of AO 33A and C types) treated definitively in external fixation for distal femur fractures with 30-month follow-up in the setting of severe soft-tissue injury. Seven patients received limited articular fixation, while all received external fixation for definitive treatment. Good or excellent outcomes in 9 of 13 and 4 failures. (Level 4 evidence). Nork SE, Segina DN, Aflatoon K, et al. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg [Am]. 2005;87(3). 564–569. Retrospective review of prospectively collected 202 distal femur fractures evaluating the association between intercondylar and coronal plane fractures in distal femur fractures. A total of 38% of the cohort had coronal plane fractures occurring in a 3:1 ratio laterally versus medially. Coronal plane fractures were diagnosed twice as often with CT imaging compared to plain radiographs. (Level 2 evidence). Ricci WM, Collinge C, Streubel PN, et al. A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures. J Orthop Trauma. 2013;27(12):722–725. Retrospective review from 2 Level 1 trauma centers with 29 GA II and III fractures treated with more versus less aggressive débridement of bone fragments in AO 33A and C fractures. Less aggressive débridement patients healed more often (92% vs. 35%) without a difference in infection rate. (Level 3 evidence). Bolhofner BR, Carmen B, Clifford P. The results of open reduction and internal fixation of distal femur fractures using a biologic (indirect) reduction technique. J Orthop Trauma. 1996;10(6):372–377. Prospective review of 57 fractures fixed with a blade plate and condylar buttress plate. There was a 100% union rate using an indirect reduction technique with biologic preservation of the fracture site. Younger patients and less complicated fracture patterns (AO 33A vs. AO 33C) had better functional outcomes. (Level 4 evidence). Ricci WM, Loftus T, Cox C, et al. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006;20(3):190–196. Technique paper with prospective case series of 22 AO 33A fractures above a well-fixed total knee arthroplasty. Union was achieved in the index procedure in 86% of patients with alignment < 5° from anatomic in 20 of 22 fractures at time of surgery. Diabetics had higher rates of complications. (Level 4 evidence). 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. Technique paper describing initial success with an anterior approach to the distal femur. Outcome data not provided. (Level 5 evidence). Swentik A, Tucker M, Jones T. Percutaneous application of a medial plate for dual plate stabilization of supracondylar femur fractures. J Orthop Trauma. 2018;32(1):e31–e35. Technique paper describing minimally invasive approach for stabilization of comminuted, unstable distal femur fractures. Eleven patients were treated with good clinical outcomes and an average ROM of 106°. (Level 4 evidence). Au B, Groundland J, Stoops TK, et al. Comparison of 3 methods for maintaining inter-fragmentary compression after fracture reduction and fixation. J Orthop Trauma. 2017;31(4):210–213. Biomechanical analysis of AO 33B fracture pattern. The fracture was reduced with a clamp and secured with lag screws and a plate versus locking screws through a plate. The highest maintained compression was found in screws placed in a lag technique outside of the plate. (Level 4 evidence). Rodriguez EK, Boulton C, Weaver MJ, et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures. Injury. 2014;45(3):554–559. Retrospective review of 283 distal femur fractures from three Level 1 trauma centers. Multivariate analysis demonstrates that obesity, open fracture, infection, and stainless steel instrumentation are independent risk factors for nonunion. (Level 3 evidence). Vallier HA, Immler W. Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma. 2012;26(6):327–332. Retrospective review of 71 distal femur fractures (32 treated with blade plate and 39 with LCP). No statistically different rate of nonunion or hardware failure. Symptomatic implants were removed more often in LCP than in blade plate. (Level 3 evidence).

PROCEDURE 39  Supracondylar Femur Fractures Ricci WM, Streubel PN, Morshed S, et al. Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases. J Orthop Trauma. 2014;28(2):83–89. Multicenter retrospective review of 335 AO 33A or C fractures treated with locked plates. Multivariate analysis identified for reoperation risks such as open fracture, smoking, obesity, and short plate length. (Level 2 evidence). Norris BL, Lang G, Russell TAT, et al. Absolute versus relative fracture fixation: impact on fracture healing. J Orthop Trauma. 2018;32(suppl 1):S12–S16. Review paper regarding fracture healing using absolute and relative fixation constructs. Specific discussion on use of plates as bridge constructs, working length, screw density, and fixation strategies. (Level 5 evidence). Kim SM, Yeom JW, Song HK, et al. Lateral locked plating for distal femur fractures by low-energy trauma: what makes a difference in healing? Int Orthop. 2018 Dec;42(12):2907–2914. Retrospective case series of 73 AO 33A fractures treated with lateral locked plates. Multivariate analysis demonstrated significantly higher rate of delayed union, construct failure, and nonunion, with increasing screw density in the plate where it spans the fracture. (Level 4 evidence). Gallagher B, Silva MJ, Ricci WM. Effect of off-axis screw insertion, insertion torque, and plate contouring on locked screw strength. J Orthop Trauma. 2014;28(7):427–432. Biomechanical study evaluating off-axis locked screw insertion and its effect on load to failure. Screw-plate interface strength is maximized with orthogonal locked insertion. Strength is decreased with loose insertion, cross-threading, and locking mechanism distortion. (Level 4 evidence). Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma. 2004;18(8):509–520. Retrospective review of prospective data of 103 fractures (AO 33 and AO 32) treated with LISS plates. There was a 93% union rate and good functional outcomes. A total of 18 patients required additional surgical procedures irrigation and debridement, bone grafting, hardware removals). (Level 4 evidence). Canadian Orthopaedic Trauma Society. Are locking constructs in distal femoral fractures always best? A prospective multicenter randomized controlled trial comparing the less invasive stabilization system with the minimally invasive dynamic condylar screw system. J Orthop Trauma. 2016;30(1):e1–e6. Prospective multicenter random controlled trial comparing minimally invasive LISS versus DCP treatment of AO 33A1 to C2 fractures. A total of 52% of LISS plated fractures healed without reoperation versus 91% of DCS fractures. The authors recommend bicortical locking bridge plates over unicortical locking or DCP systems. (Level 2 evidence).

499

PROCEDURE 40

Supracondylar Femur Fractures: Retrograde Intramedullary Nailing Adrian Z. Kurz and Brad Petrisor

PITFALLS

• Relative contraindications • Subtrochanteric fracture • Limited knee mobility • Patella baja • Open fracture • Closed box total knee arthroplasty • Significant articular comminution

TREATMENT OPTIONS

• Options for intramedullary devices include retrograde intramedullary nail or a supracondylar intramedullary nail. • Other options discussed elsewhere include open reduction internal fixation with lateral locked plating, 95-degree dynamic condylar screw, or blade-plate fixation. These can be done through traditional open approaches or minimally invasive approaches. • Temporary spanning external fixation may be used in damage control orthopedics in a multiply injured patient or if soft-tissue compromise precludes immediate definitive fixation. If an intramedullary nail is to be used after external fixation for definitive fixation, the time lapse for the construct exchange should be as soon as possible to decrease the risk of intramedullary sepsis (Bhandari et al., 2005). • Nonoperative management in traction may be indicated in patients with severe medical contraindications to surgery.

500

INDICATIONS • Retrograde intramedullary nailing is an option in AO/OTA Classification type 33A, 33C1, or 33C2 femur fractures (i.e., supracondylar femur fractures with or without intercondylar fracture and without significant condylar comminution). The supracondylar fracture line must be proximal enough to allow placement of at least two distal locking screws. • Relative indications for retrograde nailing: • Multiply injured patients or polytrauma • Bilateral femur fractures • Morbid obesity • Ipsilateral femoral neck, acetabular, patellar, or tibia fracture • Distal metaphyseal fractures (not enough space for two distal locking screws in an anterograde nail) • Associated spine fracture • Ipsilateral through-knee amputation 

EXAMINATION/IMAGING • Physical examination • The typical mechanism of injury is an axial load with combined varus, valgus, or a rotational force. • This can result from a low-energy injury, such as a simple fall as seen in older patients with osteoporotic bone, or from high-energy trauma as seen in the younger patient population. • The physical examination must be complete, including a thorough assessment to rule out the possibility of additional injuries. In all trauma situations Advanced Trauma Life Support guidelines (ATLS) (American College of Surgeons, 2002) should be initiated and carried out as per guidelines. • Assess for the possible presence of concomitant fracture of the pelvis, ipsilateral acetabulum, femoral neck, femoral shaft, patella, tibial plateau, and tibial shaft. • Ligamentous stability of the ipsilateral knee must also be assessed, although this may be difficult in the acute injury period owing to pain and instability of the fracture, and is best assessed intraoperatively once the fracture has been stabilized. • The femoral and popliteal arteries are at risk of injury (especially in the setting of posterior dislocation of the knee), and circulation should be assessed by palpation of the popliteal, dorsalis pedis, and posterior tibialis pulses. If pulses are questionable or equivocal, perform an ankle brachial index (ABI). If the ABI is 1.2, a computed tomography (CT) angiogram is readily available in most centers and is the next best investigative method for a possible arterial injury. • Also assess sensory and motor function of the affected limb. • On inspection, tenderness, swelling, and deformity are typical findings. Look for an open fracture. The typical deformity in distal femur fractures is a combination of shortening, apex posterior angulation (gastrocnemius muscle vector pulls the distal fragment into extension), and posterior displacement of the distal fragment. Gross deformity should be gently reduced and can be held with a splint or gentle traction at the surgeon’s choice. This allows for pain control and easier patient transfers during imaging.

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

A

B FIG. 40.1 

• Open fractures can occur, most commonly through the anterior thigh, and may result in disruption of the quadriceps musculature or tendon. • Plain radiographs • Minimum imaging includes anteroposterior (AP) (Fig. 40.1A) and lateral (Fig. 40.1B) views of the knee, femur, and hip, as well as an AP view of the pelvis. In high energy trauma, an ipsilateral hip fracture must be ruled out in the setting of a femur fracture. A thorough history and examination with the aid of dedicated orthogonal hip radiographs are imperative. Other techniques include consideration of a fine cut CT of the hip in question. This can be added to the trauma radiographic workup which frequently includes a CT of the pelvis. Furthermore, using fluoroscopy to image the ipsilateral hip intraoperatively prior to the start of the case and at the end of the case can be helpful in identifying ipsilateral hip fractures. • Additional 45-degree oblique views of the fracture site should be considered for evaluation of complex intraarticular fractures or fractures not clearly delineated on standard views. • The fracture pattern must be assessed for displacement, alignment, comminution, intraarticular involvement, and joint line congruity. • Computed tomography is useful for diagnosis and preoperative planning of suspected complex intraarticular fractures and osteochondral lesions. Three-dimensional CT reconstruction of the articular fracture does aid in preoperative planning. • Preoperative CT angiogram is useful and readily available in the setting of diminished or absent pulses, an expanding hematoma, or arterial bleeding through an open wound. Intraoperative on-table angiography may be used to identify a vascular injury if warranted. 

SURGICAL ANATOMY • Bony anatomy (Fig. 40.2) • “Supracondylar” implies a zone between the femoral condyles and the distal diaphyseal-metaphyseal junction (distal 9–15 cm of femur). • The femur flares in the coronal plane into the medial and lateral condyles, and in the sagittal plane the condyles extend posteriorly.

501

502

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

A

B FIG. 40.2 

Illiotibial tract Quadriceps femoris tendon Patellar retinaculum Patellar ligament

Quadriceps muscles Rectus femoris Vastus medialis Vastus intermedius Vastus lateralis Hamstring muscles Adductor magnus Biceps femoris Semitendinosus Semimembranosus

Plantaris

Gastrocnemius

Sartorius

FIG. 40.3 

• The central axis of the femoral shaft projects onto the center of the intercondylar notch, 0.5 to 1 cm anterior to the origin of the posterior cruciate ligament, at the margin of the patellofemoral articular surface. • There is an anterior bow to the femoral shaft. • The femoral shaft is normally at 9 degrees (range 7–11 degrees) of valgus relative to the distal femoral condylar surface. • Normal rotation is when the posterior condylar surfaces are in the coronal plane when the femoral neck is anteverted by 10 degrees (range 8–14 degrees). • Tendon and ligament attachments to the distal femur (Fig. 40.3) • The quadriceps (rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis), hamstrings (biceps femoris, semitendinosus, semimembranosus), adductor magnus, and medial and lateral heads of the gastrocnemius the primary deforming forces acting on the distal femur (shortening, posterior displacement with apex posterior angulation).

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

503

Femoral artery and vein

Sciatic nerve Common peroneal nerve

Adductor hiatus

Superior lateral genicular artery

Superior medial genicular artery

FIG. 40.5 

FIG. 40.4 

• Neurovascular structures (Fig. 40.4) • The femoral artery and vein pass from anterior to posterior through the adductor hiatus of the adductor magnus adjacent to the distal medial femur in the high supracondylar region. The vessels then wind posteriorly through the popliteal fossa. • Superior lateral and superior medial genicular arteries branch off from the femoral artery near the superior border of the femoral condyles and course anteriorly, encircling the condyles. • The sciatic nerve is adjacent to the posterior femoral cortex in the supracondylar region. The common peroneal nerve then branches off in a lateral direction whereas the main tibial branch remains posterior midline. 

POSITIONING • Place the patient supine on a radiolucent flat-top table, allowing unrestricted fluoroscopic imaging along the entire length of the femur (Fig. 40.5). • Fluoroscopy is positioned from the nonoperative side perpendicular to the patient, which allows for AP, lateral, and femoral notch views as required (Fig. 40.6), as well as operative space. • A bump may be placed under the ipsilateral hip to allow neutral rotation of the operative leg. • A sterile radiolucent triangle device can be used throughout the case. This allows 90 degrees of knee flexion (see Fig. 40.5). The foot is allowed to hang just above the bed as this allows for intraoperative manual traction and manipulation of the leg. A rolled up gown pack can be used as an alternative or an adjuvant to help reduce the deforming apex posterior position of the fracture. • The operative leg is prepared and draped free up to the level of the iliac crest. This allows for proximal locking of a retrograde femoral nail. • No tourniquet is used. The tourniquet may impede the proximal locking screws. Heat necrosis may occur during reaming with an inflated tourniquet. 

PORTALS/EXPOSURES • Retrograde supracondylar nails can be inserted using a mini-open technique or through an open exposure of the nail entry site. • Mini-open technique may be used for supracondylar fractures (AO/OTA type 33A) or nondisplaced intercondylar fractures (AO/OTA type 33C1) that can be reduced anatomically by closed means with the aid of fluoroscopy. • An open approach technique must be used for anatomic reduction of displaced intercondylar fractures (AO/OTA type 33C2).

PEARLS

• A bump is usually placed under the ipsilateral hip. • Use a fully “image intensifier friendly” bed allowing for full uninterrupted imaging from the pelvis to the knee. • A sterile radiolucent triangle allows for quick intraoperative adjustments to leg positioning. • A rolled up gown pack could be used instead of a triangle and placed under the apex posterior deforming position of the supracondylar femur fracture.

PITFALLS

• Poor positioning: ignoring the setup of the patient (i.e., a bump under ipsilateral hip, radiolucent triangle) will deter the surgeon’s ability to control the limb intraoperatively. • Bringing in the fluoroscopy on the operative side of the patient INSTRUMENTATION

• A working soft-tissue cannula is available to use to protect both the soft tissue (patella tendon) and the bone (patellar cartilage) during retrograde reaming of the femur. This cannula also acts as a funnel allowing bone debris to exit the knee. CONTROVERSIES

• A midline skin incision versus parapatellar tendon skin incision • Parapatellar approach, medial or lateral versus a patella-splitting approach to gain access to the femur • Mini-open (AO/OTA type 33A) versus full open approach (AO/OTA type 33C)

504

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

Patella Incision

Patellar Tendon

FIG. 40.6 

FIG. 40.7 

• Open technique (AO/OTA type 33C2) • Standard midline longitudinal skin incision • Metzenbaum scissors for blunt dissection and layer identification to aid closure • Medial parapatellar arthrotomy allowing an easy capsular closure and clear exposure of the intraarticular femoral fracture • Mini-open technique (Fig. 40.7) • A small skin incision (>5 cm) • Metzenbaum scissors for blunt dissection and layer identification to aid closure • A working soft-tissue cannula is used to protect the patella tendon and the patella cartilage during reaming.  PITFALLS

• Avoid posterior guidewire placement and reaming as this may disrupt the attachment of the posterior cruciate ligament. • Use a protection sleeve within the intercondylar notch while reaming as it protects the cartilage from the reamer and also functions as a funnel for reamer debris to exit the knee joint.

INSTRUMENTATION/IMPLANTATION

• There are two options for supracondylar femur fractures in respect to intramedullary nail choice. Either a standard femoral nail used in retrograde fashion or a “supracondylar” nail may be used. The supracondylar nail is typically available in short or long nail length with more screw options in the distal nail for better fixation in osteoporotic bone around the metaphyseal-diaphyseal area.

PROCEDURE Step 1 • An AO/OTA type 33C fracture must be turned into an AO/OTA type 33A fracture prior to introduction of an intramedullary nail. For displaced intercondylar fractures, the reduction can be visualized directly through an open exposure of the distal femoral joint surface in order to obtain anatomic reduction of the joint surface or, if using a percutaneous technique, the reduction is confirmed with fluoroscopy. • Temporary fixation of the condylar fragments may be achieved with percutaneously placed Kirschner wires inserted across the fracture line or a large tenaculum clamp placed across the condyles on either side of the fracture line. The nail can then be passed. • Definitive fixation of the intercondylar fracture can be achieved prior to fixation of the supracondylar fracture by lagging the medial and lateral condyles together with at least two partially threaded 6.5-mm cancellous screws. These screws can be inserted percutaneously across the fracture line in the anterior and posterior aspects of the condyles. This is to leave enough space when inserting the nail, taking care to avoid any nail obstruction (Fig. 40.8). The Kirschner wires should then be removed. 

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

Cancellous screws

Intercondylar fracture

Posterior cruciate ligament

Anterior cruciate ligament

FIG. 40.8 

505

FIG. 40.9 

Step 2 • The next step is to fix the supracondylar fracture. • Reduction of the supracondylar fracture may be achieved by manual traction or a variety of more direct methods. • A gown pack can be used under the apex posterior deformity to resist the deforming force of the gastrocnemius, which is typical of supracondylar femur fractures. • More invasive methods include a traction pin inserted in the coronal plane of the anterior femoral condyle. The anterior pin placement, with traction, creates a vector force that corrects the apex posterior deformity of the distal fragment. • Other options include Steinmann pins, which are inserted into both femoral condyles adjacent to the patella in an anterior to posterior direction in order to manipulate the distal femoral fragment. • Furthermore, a femoral distracter can be useful, but take care to ensure the Schanz pins are not an obstruction to passing the nail. • The intercondylar notch is exposed using either the mini-open technique or the open technique as described. • In both techniques, the nail start point (Fig. 40.9) is identified as the point 0.6 mm to 1.2 cm anterior to the femoral insertion of the posterior cruciate ligament (PCL) (Carmack et al., 2003; Krupp et al., 2003). Alternatively, there is a distinct ridge palpable just anterior to the PCL that can be used as the AP landmark. • In the medial to lateral plane, the site is either equidistant between the articular margins of the condyles or 1 to 2 mm medial (Carmack et al., 2003; Krupp et al., 2003). • In the mini-open technique, fluoroscopy is used to confirm the start point. • Use an AP view of the knee to determine the medial to lateral start point. The start point is in the middle of the intercondylar notch (Fig. 40.10). Then, use a lateral view of the knee to determine the anterior to posterior start point. The start point is just anterior to Blumensaat’s line (Fig. 40.11). Furthermore, make a final check to show that the start point is aligned with the center line of the femoral canal on both the AP and lateral views of the knee. • Next, a guide pin is inserted at the start point with fluoroscopic guidance, advanced proximally, centered in the femoral canal to a depth of 10 cm. • The rigid overdrill is then passed over the guidewire to open the femoral canal (Fig. 40.12). 

PEARLS

• Blocking screws may be used to help guide the reamer and nail centrally in the distal femur. This will decrease the effective canal size and help with reduction. Either 4.5-mm cortical screws or temporary Steinmann pins may be used. Blocking screws are inserted in the concavity of the deformity. • When inserting the anterior-posterior proximal locking screw, avoid medial dissection. Incise only the skin, and use blunt dissection down to bone. This is to avoid neurovascular injury to the femoral bundle. • Avoid ending the nail at or below the lesser trochanter, as this may cause a stress concentration point. • If there is a concomitant hip fracture being treated with a sliding hip screw, consider ending the nail distal enough to allow the sliding hip screw construct to be used and also to overlap the nail. • If cannulated screws are being used proximally for a concomitant intracapsular hip fracture, be sure to place the nail slightly more proximal to the screw insertion sites to also decrease the risk of a stress concentration point.

506

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

FIG. 40.10 

Blumensaat’s line

A

B FIG. 40.11 

FIG. 40.12 

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

507

Insertion handle screw

Nail

Insertion handle

A

FIG. 40.13 

Distal cross screw insertion jig

B FIG. 40.14 

Step 3 • Insert the long ball tip guidewire into the femoral shaft through the entry point created by the opening reamer. Advance the guidewire across the fracture site (Fig. 40.13). Confirm placement with fluoroscopy with orthogonal views. • There are two options available for the nail construct in supracondylar femur fractures. A standard femoral nail can be used in retrograde fashion, or a supracondylar nail (SCN) can be used. The benefit of an SCN nail is the added distal locking screw options for use in osteoporotic bone. The SCN has a short and long option. The short supracondylar nail extends only to the distal extent of the femoral shaft bow. The full-length nail is designed to extend to a point just proximal to the lesser trochanter of the femur such that the most proximal locking screw is level with the lesser trochanter. It is important when positioning the longer nails to plan ahead and leave enough space proximally to allow the passage of a sliding hip screw or cannulated screws. •  Fig. 40.14A shows the nail and nail adapter setup. •  Fig. 40.14B shows the nail and targeting arm setup. • Now ream sequentially in 0.5-mm increments until cortical chatter is obtained. Upream 1 to 1.5 mm greater than the diameter of the nail to be inserted. The purpose of the ball tip guidewire is to stop the reamer head from advancing beyond the end of the guidewire, and furthermore to facilitate removal of the reamer head in the event it breaks. • Mount the nail of choice on its insertion handle and insert it over the guidewire into the reamed canal, taking care to orient the nail properly so as to match the bow of the implant with the anterior bow of the femoral shaft. Advance the nail across the fracture site and into the desired position (Fig. 40.15). • The distal end of the nail should be placed deep to the articular surface of (and at the least flush with) the intercondylar notch so as not to impinge on the patellar articular surface (Morgan et al., 1999). • Now use the targeting arm to insert the distal locking screws percutaneously (Fig. 40.16), with fluoroscopic guidance of screw placement in the AP (Fig. 40.17A) and lateral (Fig. 40.17B) views. A minimum of three screws should be used.

PITFALLS

• Do not lose the proximal locking screw in the thigh soft tissue: this may extend the operative time significantly and put the femoral neurovascular bundle at risk. Avoid this by either using a self-holding screwdriver (locks the screw onto the tip of the driver), or tying absorbable suture around the screw neck to act as a leash in the case of screw disengagement from the screwdriver within the thigh soft tissue. • Test the distal cross-screw jig for correct alignment with the cross-screw holes prior to insertion and confirm that it is fixed tightly to the nail and prior to drilling as loosening may occur with nail insertion. If there is any play in the setup, the jig may not accurately place the screw within the appropriate hole in the nail and cause iatrogenic mechanical weakening of the implant leading to higher risk of failure.

508

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

A

B FIG. 40.15 

FIG. 40.16 

A

B FIG. 40.17 

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

A

B FIG. 40.18 

• This step locks the distal fracture fragment firmly to the nail, and now final adjustments can be made for the length, alignment, and rotation with respect to the proximal femoral fragment. • Insertion of proximal locking screws may vary according to the type of implant used. • For short SCN, a proximal targeting arm mounted on the nail should be used, and the screws are inserted lateral to medial. • For the long SCN femoral nail used in retrograde fashion, only the freehand technique can be employed. Insert the screws into the proximal holes using perfect circle technique with fluoroscopic aid. • Then disassemble the targeting arm from the nail and perform a layered closure. • Postoperative radiographs are taken using full-length femur views both in AP (Fig. 40.18A) and lateral (Fig. 40.18B) views to ensure correct alignment. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Place the patient in an extension knee immobilizer splint for protection prior to being awakened from general anesthetic. • Physiotherapy may be initiated immediately, addressing range of motion of the hip, knee, and ankle joints. Patients should start early range of motion with knee flexion as soon as it is tolerable and may do so with or without the use of a continuous passive motion machine within 24 to 48 hours of their surgery. • More active therapies, including weight-bearing activities and quadriceps and hamstrings strengthening exercises, should be initiated gradually and with consideration of postoperative clinical assessment as well as the character and stability of the original fracture. • Patients should be permitted touch weight bearing initially and may continue to wear the knee immobilizer splint with weight-bearing activity until fully weight bearing. • With gradually progressive weight bearing, patients with AO/OTA type A fracture may be allowed to fully bear weight at 4 to 6 weeks.

509

510

PROCEDURE 40  Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

• Patients with AO/OTA type C1 and C2 fracture should not be allowed to fully bear weight for at least 12 weeks. • Postoperative complications specific to retrograde nailing in distal femur fractures include early and late complications. • Early complications: knee sepsis (higher in open fractures), knee stiffness • Late complications: patellofemoral arthritis (important not to ream patella), knee stiffness, prominent nail, synovial metallosis, heterotopic ossification

EVIDENCE American College of Surgeons. Advanced Trauma Life Support Manual. 6th ed. Chicago: American College of Surgeons; 2002. Bhandari M, Zlowodzki M, Tornetta 3rd P, Schmidt A, Templeman DC. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma. 2005;19:140–144. Systematic review of available trials resulting in a grade C recommendation of early exchange to intramedullary nail. Carmack DB, Moed BR, Kingston C, Zmurko M, Watson JT, Richardson M. Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study. J Trauma. 2003;55:692– 695. Experimental cadaver study. (Level V evidence.) Krupp RJ, Malkani AL, Goodin RA, Voor MJ. Optimal entry point for retrograde femoral nailing. J Orthop Trauma. 2003;17:100–105. Experimental cadaver study. (Level V evidence.) Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A. Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma. 1999;13:13–16. Experimental cadaver study. (Level V evidence.)

PROCEDURE 41

Knee Dislocations Daniel B. Whelan INDICATIONS Urgent—Within Hours • Irreducible dislocation • Open dislocation (Fig. 41.1) • Vascular injury • Associated compartment syndrome 

Semi-urgent/Emergent—Within Days • Avulsion injury (± bone) • Associated articular fractures • Bucket handle meniscus tear • Subluxed joint • Extensor mechanism disruption 

Elective—Within Weeks to Months • More than one ligament • Chronic instability complaints 

EXAMINATION AND IMAGING • Every patient should have thorough and serial neurovascular examinations of the affected limb, including peripheral pulses, ankle brachial index (ABI), and the function of the common peroneal nerve and tibial nerve. We strongly recommend the ABI as a screening tool for any patients with suspected multiligament injury. Further vascular investigation (angiography) should be performed with an ABI less than 0.9 or in any patient with evidence of dysvascularity, that is, hard and soft signs of vascular injury. • Hard signs of vascular injury: pulsatile bleeding, expanding hematoma, absent distal pulses, limb cold and pale, palpable thrill and audible bruit. • Soft-tissue integrity should be assessed (anterior, posterior, medial, and lateral). • Compartment syndrome should be ruled out with neurovascular evaluation, passive stretch test, and palpation of compartments. • Other injury should be ruled out: Advanced Trauma Life Support (ATLS) protocol, associated limb or joint, nonmusculoskeletal injuries. •  Standard anteroposterior, lateral and, if possible, Merchant radiographic views should be done to rule out avulsion injuries and repeated at every visit to make sure that the joint is concentrically reduced. Anterior or posterior subluxation of the tibia should be looked for on lateral and Merchant views. Initial prereduction radiographs, if possible, can help predict which ligaments are injured. • Computed tomography (CT) scans can be done to better evaluate avulsion injuries or other associated fractures. • Magnetic resonance imaging (MRI) should be done to precisely evaluate tendon and ligament injuries as well as meniscal tears. Bone bruises can help identify the pattern of injury and which ligaments are torn. • In the chronic setting, 3-foot standing radiographs should be done to rule out any malalignment that could potentially be corrected prior to ligament reconstruction. Stress views can also be valuable in chronic cases to better evaluate coronal plane laxity, although no standard values have been defined in the current literature. 

PITFALLS

• Relative indications for surgery • Associated hypermobility • May not reduce in extension • Obesity • Poorly managed in ill-fitting brace or splint (Fig. 41.2) • Professional or high-demand athlete • Polytrauma • Relative contraindications for surgery • Polytrauma patients with significant head injury • Incidence of heterotopic ossification may be increased in these patients. • Medical comorbidities • Pediatric patients with open growth plates • Smokers

CONTROVERSIES

• Timing of surgery: Early (< 3 weeks) surgery has been strongly recommended in an evidence-based review of literature, as it affords repair of injured structures while avoiding the difficulties imposed by scar formation as well as retraction and impaired integrity of tissues. In another review, early surgery has been suggested to cause undue stiffness and a staged approach is favored.

TREATMENT OPTIONS

• Nonoperative treatment with physiotherapy and a hinged brace can be an option for lowdemand patients and patients with significant medical comorbidities. • For polytrauma patients temporarily unfit for surgery and for whom a stable reduction cannot be maintained, a temporary external fixator can be used. • Fixators may also be employed adjunctively (and temporarily) in patients with concomitant vascular injury requiring reconstruction or those with associated large open wounds requiring multiple washouts and/or grafting procedures (Fig. 41.3). • Surgical repair and/or reconstruction is the mainstay of treatment for most patients. Repair can be attempted within 3 weeks for medial and lateral structures. Reconstruction should be attempted if injuries are older than 3 weeks and for most cruciate ligament injuries.

511

512

PROCEDURE 41  Knee Dislocations

FIG. 41.1 

FIG. 41.2 

FIG. 41.3 

SURGICAL ANATOMY • Anterior cruciate ligament (ACL) • The ACL is composed of an anteromedial (AM) bundle, which is taut in flexion, and a posterolateral (PL) bundle, which is taut in extension. • The ACL’s femoral origin is on the lateral femoral condyle, posterior to the lateral ridge. • The AM bundle origin is in the proximal aspect of the footprint, while the PL bundle origin is in the distal part. • Posterior cruciate ligament (PCL) • The posterior cruciate ligament is composed of the anterolateral (AL) bundle and the posteromedial (PM) bundle. The PM bundle origin is on the medial femoral condyle, with its distal edge 5.8 mm proximal to the articular surface. The AL bundle origin is 12.1 mm proximal and medial to the PM bundle. Both bundles insert on the posterior tibial sulcus below the articular cartilage.

PROCEDURE 41  Knee Dislocations

FIG. 41.4 

• Medial side (Fig. 41.4) • The superficial medial collateral ligament (MCL) is the primary stabilizer of valgus stress at every flexion angle. It runs in the second layer of the medial side of the knee, under the sartorius fascia, gracilis, and semitendinosis. Its femoral origin is 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle. It has two tibial attachments, one 1.2 cm distal to the joint line and the other 6 cm distal to the joint line, slightly posterior to the insertion of the pes anserinus. • The deep MCL is in the third layer of the medial side of the knee, under the superficial MCL, the semimembranosus, the medial patellofemoral ligament, and the posterior oblique ligament (POL). It attaches to the medial meniscus via the coronary ligament and blends posteriorly with the posterior capsule. Its femoral origin is 12.6 mm distal to the origin of the superficial MCL and its tibial insertion is 3.2 mm distal to the joint line. • The POL is a reinforcement of the posteromedial capsule. It resists valgus and internal tibial rotation in full extension. It lies in the second layer of the medial side of the knee. Its femoral origin lies 7.7 mm distal and 2.9 mm anterior to the gastrocnemius tubercle. Its tibial attachment is on the posteromedial tibia, slightly anterior to the attachment of the semimembranosus. • Lateral side (Fig. 41.5) • The three main stabilizers of the posterolateral corner are the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament. • The LCL is the primary varus stabilizer of the knee. Its femoral origin is 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle. It attaches distally on the fibular head, anterior to the biceps femoris insertion. • The popliteus is a secondary varus stabilizer and a primary external rotation stabilizer of the knee. Its femoral origin is 18.5 mm anterior and distal to the lateral femoral epicondyle. It attaches distally on the posteromedial tibia. • The popliteofibular ligament, also called the arcuate ligament, consists of two divisions originating from the musculotendinous portion of the popliteus. The anterior division attaches 2.8 mm distal to the fibular styloid process and the posterior division attaches 1.6 mm distal to the fibular styloid process. • The surgeon should know the course of the common peroneal nerve as well as the posterior neurovascular structures. 

FIG. 41.5 

513

514

PROCEDURE 41  Knee Dislocations

PEARLS

• General anesthetic is preferred for long procedures. • Local-anesthetic catheters may be used but should be maintained at low dose levels to avoid chronic deactivation of innervated muscles. • A Foley catheter should be strongly considered. • Opposite limb palsies are not uncommon with these prolonged procedures. Appropriate caution when positioning and padding nonoperative limbs (including the upper extremities) is warranted. In particular, when using a proprietary leg holder, a flexed contralateral hip and knee puts the femoral nerve at significant risk in prolonged procedures. • If a vascular surgical procedure is required, the opposite limb should be prepped and draped as well to allow for saphenous vein harvest. The ipsilateral foot should also be accessible to allow for assessment of reperfusion.

PITFALLS

POSITIONING • The patient is placed in the supine position. • A bolster is used to bring the knee to 90° of flexion. A lateral post is also used to keep the knee straight and maintain the intercondylar notch parallel to the floor (Fig. 41.6). • A tourniquet is inflated on the upper thigh. • The ipsilateral lower limb is prepped, as well as the contralateral limb, if needed for autograft. 

A

• Bony prominences should be padded and frequent passive range of motion (ROM) of the elbows should be done for long procedures. EQUIPMENT

• Radiolucent table • Bolsters • Tourniquet • Proprietary leg holder (optional) CONTROVERSIES

• The use of a lateral post or leg holder each have their own advantages. • The lateral post allows for a faster setup and positioning, the ability to move the leg freely during the surgery, the ability to hyperflex the knee, and the ease of putting the leg in a figure-of-four position. It also avoids the potential contralateral limb neuropathy associated with hip and knee flexion. • The use of a leg holder allows for better opening of the PM compartment. PEARLS

• Transverse incisions for portals may improve cosmesis but are difficult to extend for potential arthrotomy. Therefore, vertical incisions are preferred for these complex cases. • PM and PL portals should be done with the knee at 90° of flexion and while maintaining the tibia anteriorly reduced. • The peroneal nerve is most consistently found at the fibular neck. Anatomic variations are more common at the more proximal exit of the nerve at the biceps femoris.

B FIG. 41.6 

PORTALS/EXPOSURES • Standard AM and AL portals are used for arthroscopy. Chondral and meniscal damage are documented and addressed. Torn cruciate ligaments are debrided and the intercondylar notch is cleared. • All exposures to follow are described with the knee at 90° of flexion. • In the case of PCL reconstruction, the posterior tibial sulcus is exposed with cautery. A 70° arthroscope is useful to improve visualization. • A PM portal can be used for visualization and debridement of the PCL’s tibial insertion. • From the AL portal, the camera is directed into the PM compartment. A PM portal is made 1 cm posterior to the medial femoral condyle and 1 cm proximal to the joint line under direct visualization with a spinal needle. • If necessary, a PL portal can be made 1 cm posterior to the lateral femoral condyle and 1 cm proximal to the joint line—again, under direct visualization with a spinal needle. • If ACL reconstruction is needed and the chosen graft is a bone–patellar tendon graft, a straight longitudinal incision from the inferior pole of the patella down to the tibial tubercle centered on the medial side of the patellar tendon is made for patellar tendon harvest.

PROCEDURE 41  Knee Dislocations

• If MCL reconstruction is needed, that incision can be extended further inferior to the pes anserinus insertion. • Another separate longitudinal 4- to 5-cm incision just above the medial epicondyle is made. • The vastus medialis fascia is incised in line with the incision and the muscle belly is elevated laterally. • The capsule is incised to expose the medial epicondyle. • If lateral structures are to be addressed, a curved incision starting slightly anterior to the lateral epicondyle and extending distally midway between the Gerdy tubercle and the fibular head is made. • Cosmesis is improved if this incision is straight, with the knee in extension. • The common peroneal nerve is then found either at the fibular neck or proximally posterior to the biceps femoris. The nerve is then isolated and protected with a Penrose drain. A formal neurolysis may be considered in the setting of a preoperative palsy. • The fibular head is then exposed anteriorly and posteriorly. Blunt dissection is used to free the space behind the fibular head and between the tibia and lateral gastrocnemius. • Proximally, the iliotibial band is incised longitudinally and the underlying lateral capsule exposed. The capsule is also divided longitudinally superior to the lateral epicondyle. • If required, fasciotomies should never be incorporated with incisions to avoid contamination of the joint. 

515

PITFALLS

• Capsulotomies for medial and lateral exposures should be done after most of the arthroscopic work is done. • Frequent palpation of the compartments should be done during the procedure. • PM portals are often too anterior or too distal, both of which can prevent adequate access to the PCL sulcus posteriorly. • PL portals are rarely required and should be undertaken with care owing to the proximity of the peroneal nerve.

EQUIPMENT

• A standard set of retractors should be used. • 70° arthroscope • Arthroscopic electrocautery • Arthroscopic cannulas • Length of 75 mm or less is recommended. Longer cannulas (≥ 80 mm) can make it more difficult to maneuver instruments or access the posterior aspect of the knee.

PROCEDURE Step 1: Graft Harvest/Preparation • We prefer to use autograft bone-patellar tendon-bone (BTB) autograft for the ACL, ipsilateral hamstrings for the MCL, contralateral hamstrings or allograft for the lateral structures, and Achilles tendon allograft for the PCL. • BTB harvest • The anterior incision is brought down to the epitenon, which is incised longitudinally in the center of the tendon. The epitenon layer should be well isolated to allow closure at the end of the procedure. • Fibers of the patellar tendon are sharply split longitudinally to create a 10-mm wide graft in the center of the tendon. • A micro-oscillating saw and curved osteotomes are used to harvest a tibial bone block of 25 to 30 mm length by 10 mm width by 10 mm depth. • The saw is then used to harvest a patellar bone block of 20 mm length by 10 mm width by 10 mm depth. • The length of the graft is then measured. Bone blocks are beveled to facilitate later graft passage. • Two drill holes are made on each bone block and strong nonabsorbable sutures are passed in each hole. • Hamstrings harvest/preparation • The sartorius fascia is split above the gracilis at their attachment point. • Tendon hooks are used to pull the gracilis and semitendinosus from the incision, taking great care to free any adhesions. • Tendon strippers are then used to release tendons proximally. • The remaining muscle is scratched off the harvested tendons. • Tendons are then cut from their attachment sites if harvested from the contralateral side. If used for the MCL, their distal attachment is preserved. • Each of the free ends of the tendons are then weaved through with strong nonabsorbable running locking sutures to make a double stranded graft. • Allograft • The Achilles tendon bone block is preserved and fashioned to make a 25-mmlong by 10-mm-wide bone block. • If a double-bundle PCL reconstruction is chosen, the tendon is split longitudinally and both ends are weaved through with a strong nonabsorbable running locking suture (Fig. 41.7). • Grafts diameters are then measured to plan tunnel sizes. 

PITFALLS

• The patellar bone block should not have a depth of more than 10 mm to reduce the risk of patellar fracture. • The depth of the tibial bone block should be kept shallow to avoid interference with the PCL tunnel, which would compromise the PCL fixation or potentially cause an iatrogenic fracture.

INSTRUMENTATION/IMPLANTATION

• Micro-oscillating saw • 2.5-mm drill bit • Tendon hook • Tendon stripper • Strong nonabsorbable sutures

CONTROVERSIES

• Some surgeons avoid hamstring autografts in cases of MCL injury, as they potentially provide dynamic stability to the medial side of the knee. • Always avoid hamstring harvest in cases of previous ipsilateral vascular exploration or repair of the popliteal artery. • The use of contralateral autograft is controversial. • Contralateral autografts are less expensive and potentially integrate better but can potentially cause contralateral limb morbidity. • Allografts avoid the morbidity and the surgical time related to contralateral autograft harvest but are more expensive and potentially do not integrate well.

516

PROCEDURE 41  Knee Dislocations

PEARLS

• Tunnel sizes should match the diameters of the grafts except for the PCL, which can be overdrilled by 1 mm for an easier graft passage. • Isometry is an important consideration for collateral ligament reconstruction. We advocate the use of anatomic landmarks to provide initial localization of femoral tunnels for both the LCL and MCL. Isometry of these grafts should also be assessed to avoid graft loosening or overconstraint. Behavior of grafts under flexion and extension can be verified with Kirschner-wires and #5 suture (or similarly wide sutures) prior to drilling. • Tunnel collision is a significant potential problem in multiligament surgery. In general, the tunnels most likely to collide are the femoral ACL and LCL, femoral PCL and MCL, tibial ACL and PCL, as well as potentially the tibial popliteal bypass and the PCL. Dilators or drills can be placed in already drilled tunnels (and before graft passage) to avoid tunnel collisions. • ACL and LCL femoral tunnel collisions are common and can be avoided by directing the LCL more proximal and 35° anteriorly. • PCL and MCL femoral tunnel collision similarly is common and can be avoided by directing the MCL tunnel 40° proximally and 20° to 40° anteriorly. • If tunnel collisions happen, alternate strategies for fixation should be considered. • In our experience, collisions between the ACL and PCL tibial tunnel are rare. We routinely use a standard ACL guide set to 45° to 50° for the ACL and 60° to 65° for the PCL. ACL tibial tunnel starting points are kept relatively more posterior and proximal; PCL tibial starting points are relatively more anterior and distal. • A lower PCL tunnel starting point on the tibia minimizes the killer curve.

FIG. 41.7 

Step 2: Drilling Tunnels • ACL • The tibial tunnel should be drilled, aiming at the posterior part of the ACL footprint. The tunnel should be centered on the anteromedial tibia, anterior to the pes anserinus. • The angle of the tibial guide must be adjusted to make a tunnel that fits the length of the graft. • The femoral tunnel can be drilled using a transtibial technique, an AM portal or an outside-in technique. The tunnel should be posterior to the lateral intercondylar ridge and slightly superior to the lateral bifurcate ridge. • PCL • The tibial tunnel starts below the tibial tubercle on the AM aspect of the tibia and exits at the posterior tibial sulcus. • A stopper like a PCL protection guide should be used to protect the posterior neurovascular bundle (Fig. 41.8).

PITFALLS

• The benefits of double-bundle PCL reconstruction must be balanced with the risks of tunnel collisions when also reconstructing the MCL. • Failure to prepare tunnel apertures, especially in PCL reconstruction, can lead to graft attenuation and early rupture due to the killer turn. An adequate set of curettes and rasps is essential to avoid this complication. • Most common errors in tunnel malposition • PCL tibial tunnel’s intraarticular aperture too proximal and/or medial • PCL femoral intraarticular aperture too posterior and inferior • MCL and LCL femoral apertures neither anatomic nor isometric

FIG. 41.8 

PROCEDURE 41  Knee Dislocations

• The femoral tunnel can be drilled using an outside-in technique, aiming for the PCL footprint on the medial femoral condyle. • Rasps should be used to smooth the tunnels’ apertures to facilitate graft passage and avoid graft attenuation caused by the killer turn. • MCL • Native MCL can be repaired with sutures in the case of a midsubstance tear or anchors in the case of an avulsion. • For reconstruction, a 25- to 30-mm blind femoral tunnel should be drilled 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle along the interepicondylar axis. • POL • In the acute setting, the PM capsule should be repaired. • In the chronic setting, if there is valgus instability in full extension, POL should be reconstructed. • A blind femoral tunnel is drilled 7.7 mm distal and 2.9 mm anterior to the gastrocnemius tubercle. The blind tibial tunnel is drilled on the PM tibia, slightly anterior to the attachment of the semimembranosus. • PLC • LCL • An anterior to posterior tunnel is drilled on the fibular head. • A 25- to 30-mm blind tunnel is drilled at the lateral epicondyle, along the intercondylar axis. • Popliteus • A tunnel from anterior to posterior, starting at the Gerdy tubercle and aiming medially, is made. • A soft-tissue retractor should be used to protect the neurovascular structures. • A tunnel in the lateral femoral condyle is made, starting at the popliteus sulcus and aiming extraarticular. 

Step 3: Graft Fixation • The surgeon should be familiar with many different types of fixation (interference screws, suspension buttons, screw posts with washers, staples). • We use metal interference screws for grafts with bone blocs and bioabsorbable screws for soft-tissue grafts. • Grafts should be tensioned during complete ROM before fixation. • For double-bundle PCL constructs, in general, the tibial side of the graft should be fixed first so that the two femoral limbs can be tensioned and fixed independently. Our preferred technique is to fix the AL bundle first at 90° of flexion and then the PM bundle at 30° of flexion. • The tibial step-off should be palpated to make sure that the joint is not overreduced. • Then, the ACL should be fixed at 30° of flexion. • The popliteus should be fixed in valgus, 30° of flexion, and internal rotation. • The LCL should be fixed in valgus and 30° of flexion. • For the MCL, the distally attached hamstrings are tied around a 4.5-mm cortical screw and soft-tissue washer at the distal point of insertion of the superficial MCL. The femoral side should then be fixed in varus at 30° of flexion. Anchors should be added 12 mm distal to the articular surface to recreate the second tibial point of insertion of the MCL. • The POL should be fixed in varus in full extension. • In general, interference screw sizes are line to line for soft-tissue grafts and undersized by 1 or 2 mm for grafts with bone block. 

517

INSTRUMENTATION/IMPLANTATION

• Cannulated drill bits • Tunnel dilators • ACL and PCL drill guides • Soft-tissue retractor, such as a tablespoon • Tunnel rasps and curettes

CONTROVERSIES

• PCL femoral tunnels can be drilled with the inside-out or outside-in technique. • Both techniques have been found to have equal ability to put the femoral tunnel within the PCL femoral footprint. • PCL reconstruction can be done with a singleor double-bundle graft. • Double-bundle reconstructions have been shown to decrease the posterior subluxation by 1.4 mm, but it is unclear whether this is clinically significant because no differences have been shown for subjective scores compared to the single-bundle reconstruction. • The PCL tibial tunnel can be made either with a transtibial or inlay technique. • Even though some studies report better results with the inlay technique, there is no in vivo evidence of increased graft failure with the transtibial technique. • The author’s preferred technique is doublebundle transtibial PCL reconstruction using the outside-in technique for the femoral tunnel.

PEARLS

• A supplementary extra-cortical type of fixation (such as a screw and washer) can be used to augment fixation for bioabsorbable screws or in cases of poor host bone quality.

INSTRUMENTATION/IMPLANTATION

• Full set of interference screws, metal and bioabsorbable • Staples • 4.5-mm cortical screws with metal and softtissue washers • Button for suspension CONTROVERSIES

• Graft fixation sequence: In general, it is recommended that the PCL be the first graft fixed. Although there are no clear guidelines in the literature, we routinely then proceed to ACL fixation, then collateral fixation. In rare cases of four-ligament injury, there is no evidence to direct the sequence of collateral ligament fixation. • Some surgeons prefer extra-cortical fixation only to avoid the presence of anything other than graft material within a tunnel that could prevent or compromise ingrowth. • A supplementary extra-cortical type of fixation (such as screw and washer) can be used for bioabsorbable screws or poor host bone quality.

518

PROCEDURE 41  Knee Dislocations

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Good-quality immediate postoperative radiographs should be obtained. • Postoperative antibiotic prophylaxis for at least 24 hours and thromboprophylaxis for 4 weeks should be ordered. • Splints • We prefer using a straight splint for the first 6 weeks, with patients not wearing the brace only for physiotherapy (Fig. 41.9). • From 6 to 12 weeks, a dynamic brace is used to allow ROM with the brace on. • In the case of PCL reconstruction, a dynamic brace can be used to prevent posterior subluxation of the tibia (Fig. 41.10). • For reconstruction of a collateral ligament, a valgus or varus offloading brace can be employed. • The brace should be worn at least 6 months. • Range of motion • We allow 0° to 90° starting at postoperative day 3. • In the case of PCL reconstruction, prone ROM should be employed for 6 weeks (Fig. 41.11). • Progress to flexion beyond 90° after 8 to 12 weeks. • Weight bearing and strengthening • The patient should be allowed to do touch weight bearing with the foot flat for the first 6 weeks. • No active strengthening before 3 months • In the case of PCL reconstructions, active and resisted ROM should be avoided for 9 months. • Return to sports in general is not permitted before 9 months but preferably 12 months minimum. • Patients usually gain ROM of 0° to 120° of flexion. • PCL and collateral laxity, with firm endpoints, is typical at follow-up. • Patients should not expect to return to high-level activity. • In general, the outcome of multiligament reconstructions is somewhat less optimistic than that for single-ligament injuries.

A

B FIG. 41.9 

PROCEDURE 41  Knee Dislocations

• Early surgery seems to afford better outcomes than delayed surgery (> 3 months). • Complications are not infrequent and include the following: • Acute: Stiffness, heterotopic ossification (Fig. 41.12), infection, deep vein thrombosis, numbness, motor deficit • Chronic: recurrent instability

Spring

5 F

1 2

3

4

A

B FIG. 41.10 

FIG. 41.11 

519

520

PROCEDURE 41  Knee Dislocations

A

B FIG. 41.12 

EVIDENCE Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res. 1975;106:216–231. James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res. 2014;472(9):2644–2657. LaPrade RF, Wijdicks CA. Surgical technique. Development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012;470:806–814. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med. 2003;31:854–860. LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med. 2015;43:3077–3092. Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidencebased systematic review. Arthroscopy. 2009;25(4):430–438. Mook WR, Miller MD, Diduch DR, et al. Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg [Am]. 2009;91(12):2946–2957. Moatshe G, Brady AW, Slette EL, et al. Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med. 2017;45(3):563–569. Tompkins M, Keller TC, Milewski MD, et al. Anatomic femoral tunnels in posterior cruciate ligament reconstruction: inside-out versus outside-in drilling. Am J Sports Med. 2013;41(1):43–50. Yoon KH, Bae DK, Song SJ, et al. A prospective randomized study comparing arthroscopic singlebundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med. 2011;39(3):474–480.

PROCEDURE 42

Operative Treatment of Fractures of the Patella Vu Le and Trevor Stone • Operative treatment of displaced patella fractures is the standard of care to prevent complications of nonunion and loss of extensor mechanism function associated with nonoperative treatment and prolonged knee immobilization. • Current techniques include open reduction and internal fixation with screws or various forms of anterior tension band techniques and partial or total patellectomy. • Several studies and a systematic review suggest that biodegradable materials are not superior to traditional metal implants and hence the role for biodegradable implants as primary fixation techniques is limited (Sayum Filho et al., 2015).

INDICATIONS • Extensor mechanism disruption • Open fractures of the patella • A fracture gap greater than 3 mm • An articular step greater than 2 mm 

CONTROVERSIES

• The acceptable size of articular gaps and steps in the patella has been extrapolated from other joints in the body.

EXAMINATION/IMAGING Physical Examination • Examine open knee wounds thoroughly to determine whether they communicate with the fracture site or the knee joint. • Testing for active knee extension is key in the decision to proceed with surgery. It can be difficult to distinguish between lack of active extension owing to pain and incompetent extensor mechanism, particularly in the first 24 to 48 hours after injury. In cases with limited fracture displacement, repeat examination is very useful. • Avoid full active or passive range of motion of the affected knee until imaging has been obtained owing to the potential for further injury to the patellar retinaculum or further fracture displacement. • Ligamentous examination of the knee is important to exclude concurrent injuries. • Thoroughly examine the adjacent joints—the hip and ankle. 

Imaging Studies • Anteroposterior, lateral, and sunrise views of the affected patella should be obtained (Fig. 42.1). • A lateral radiograph helps determine fracture displacement and congruity of the articular surface. • Patella alta may be a sign of patellar tendon rupture, whereas patella baja may indicate injury to the quadriceps tendon in the absence of an obvious patella fracture, but with clinical extensor mechanism disruption. • Magnetic resonance imaging may be used to identify marginal patella fractures, free osteochondral fragments, or concurrent ligamentous injuries, but is rarely required. • Computed tomography may be used to evaluate associated distal femoral or proximal tibial intraarticular fractures. • A bone scan may help in the identification of stress fractures of the patella. 

521

PROCEDURE 42  Operative Treatment of Fractures of the Patella

522

A

B

C FIG. 42 1 

SURGICAL ANATOMY

TREATMENT OPTIONS

• Lag screw technique • Anterior tension band • Cannulated screws • Kirschner wires (K-wires) • Plate Fixation • Patellectomy • Complete • Partial

• The patella is a subcutaneous bone with minimal soft-tissue covering. The largest sesamoid bone of the body, it lies within the fascia lata and the fibers of the quadriceps tendon. • The upper three-fourths of the posterior surface of the patella is covered with articular cartilage that is divided into major medial and lateral facets. • The patella is served by both extraosseous and intraosseous vascular systems. • The primary blood supply to the patella is from branches of the geniculate anastomotic system around the knee (Fig. 42.2A). • The superior portion of this vascular ring passes anterior to the quadriceps tendon, whereas the inferior portion passes posterior to the patellar ligament through the fat pad. • The primary intraosseous blood supply of the patella enters the bone through the middle of the anterior portion of the body of the patella and through the distal pole (Fig. 42.2B). • This relationship is important to understand and relate to the development of osteonecrosis secondary to a patella fracture. • The patella is surrounded and anchored by a strong retinaculum derived from the deep fibers of the tensor fascia lata in combination with fibers from the vastus medialis, vastus lateralis, iliotibial tract, and patellofemoral ligaments (Fig. 42.3). • The retinaculum inserts directly into the proximal tibia and serves as an auxiliary extensor of the knee along with the iliotibial band. • The patellar tendon originates at the apex of the patella and inserts onto the tibial tubercle, blending with the patellar retinaculum and the iliotibial tract fibers (see Fig. 42.3). 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

523

Geniculate anastomotic system

A

B FIG. 42.2 

Vastus lateralis Iliotibial tract

Vastus medialis

Patella

Patellofemoral ligaments

FIG. 42.3 

POSITIONING • Perform the procedure with the patient in the supine position on a radiolucent table with a tourniquet on the proximal thigh (Fig. 42.4A and B). • Prior to tourniquet inflation, gentle traction on the quadriceps/patellar fragment will keep the tendon nearer to anatomic length prior to reduction. • Place a bump under the ipsilateral hip to help internally rotate the knee to a neutral position. • A radiolucent leg ramp or positioner can be used to facilitate the use of fluoroscopy, in particular obtaining a lateral view. • The leg must be free-draped to allow easy flexion/extension of the knee throughout the surgery (Fig. 42.4C). • Prepare the leg from the lower leg to the upper part of the thigh. 

PEARLS

• Flex the knee before inflation of the tourniquet to decrease tension on the quadriceps. • Place a bump under the ipsilateral hip to prevent external rotation of the limb. • Ensure the leg is draped free for easy flexion/ extension. PITFALLS

• Intraoperative fluoroscopy access can be difficult without adequate planning.

PROCEDURE 42  Operative Treatment of Fractures of the Patella

524

A

B

C FIG. 42.4 

PEARLS

• Consider subsequent procedures when planning the incision. • Exposure of the retinacula is important to aid in repair. PITFALLS

• The incision must not be carried deep into the patellar tendon or quadriceps tendon. INSTRUMENTATION

• Self-retainers aid in exposure when placed both proximally and distally (Fig. 42.6). • Rakes and skin hooks can be used for additional retraction. CONTROVERSIES

• The traditional surgical approach has been a transverse incision over the midportion of the patella to give access to the retinaculum without developing flaps. • This does not take into consideration the incision needed for total knee arthroplasty in the future.

PORTALS/EXPOSURES • A straight midline vertical incision is most commonly used (Fig. 42.5A). •  It is important to consider any subsequent procedures when planning the incision. • For example, exposure may be needed for subsequent removal of hardware and/ or a total knee arthroplasty. • Medial and lateral full-thickness flaps are developed and exposure of both retinacula is obtained (Fig. 42.5B). •  Tagging sutures may be placed in each retinaculum to aid with retraction (Fig. 42.5C). • These sutures can subsequently be used for repair at the end of the case. • A lateral parapatellar arthrotomy may be performed to increase exposure and aid in fracture reduction. • Existing traumatic retinacular tears should be incorporated when possible. 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

A

B

C FIG. 42.5 

FIG. 42.6 

PROCEDURE: IRRIGATION AND DEBRIDEMENT OF OPEN FRACTURES • Open fractures should be treated as a surgical emergency. • Because of the risk of bone and intraarticular infections, irrigation and debridement of the fracture should be performed within 12 to 24 hours.

525

526

PROCEDURE 42  Operative Treatment of Fractures of the Patella

Step 1 • The surgical incision should ideally incorporate the open wound. • Resect all nonviable tissue and bone fragments with the exception of large osteochondral fragments, which may need to be retained. 

Step 2 PEARLS

• Open fractures require urgent surgical attention. • The wound may require repeat irrigation and debridement before definitive fixation. • Nonviable tissue and bone fragments should be discarded.

• Gross contamination of the wound and patient medical status may delay rigid fixation. • Appropriate antibiotic coverage is required. • Repeat irrigation and debridement may be required in heavily contaminated wounds. • Intraoperative cultures are generally not needed unless there are physical signs of active infection. • The knee may be packed and left open or closed over a drain. • Adequate soft-tissue coverage is achieved with local or soft-tissue transfer. 

PROCEDURE: ANTERIOR TENSION BAND TECHNIQUE • The goals of operative treatment are to obtain an anatomic reduction, maintain the reduction with internal fixation until bony union occurs, and restore the extensor mechanism of the fractured patella (Fig. 42.7). • In theory, an anterior tension band converts distracting forces caused by the quadriceps into compressive forces at the articular surface; however, recent study has shown this may not be accurate.

A

B FIG. 42.7 

Step 1 • A direct midline or medial parapatellar incision is used. • Expose all fracture fragments and clear any remaining hematoma or debris. • Inspect the knee joint for loose bone fragments and address any associated cartilage injury. • Extend the knee to assist in reduction of the fragments. • Reduce and hold the fracture with reduction clamps and evaluate the reduction at the articular surface. 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

Step 2

527

PEARLS

• Kirschner wires (K-wires) can be placed in antegrade or retrograde fashion. • K-wires or screws should be inserted approximately 5 mm from the anterior cortical surface of the patella, near its midsubstance and parallel in the coronal and sagittal planes (Fig. 42.8A). • Before advancing across the fracture, ensure that the fracture is reduced using both fluoroscopy (anteroposterior and lateral) and direct visualization or digital palpation of the fracture by inserting a finger under the patella. • A 14- or 16-gauge angiocatheter is used as a wire passer for the cerclage wire. It is passed through both the quadriceps and patella tendon adjacent to the bone to minimize soft tissue interposition by the wire (Fig. 42.8B). • It is important to place the wire as close to the patella as possible. • An 18-gauge wire is then passed through the soft tissues using the angiocatheter as a passer. • The arms of the wire are crossed over the anterior surface of the patella in a figure-of-eight fashion (Fig. 42.8C). • The tension band can also be placed in an uncrossed manner. • A single wire with two knots, or two wires with two knots, helps tension both sides of the fracture equally. • It is important to ensure that the articular surface of the patella is adequately reduced by visual or digital palpation and/or with the use of fluoroscopy.  INSTRUMENTATION/IMPLANTATION

• This procedure is ideal for transverse or minimally comminuted fractures. • The theoretic benefit of the tension band is to convert distracting forces into compressive forces. • Confirm reduction with both fluoroscopy and digital palpation. • A single wire with two knots, or two wires with two knots, helps tension both sides of the fracture equally. • Reduction forceps and smaller boneholding forceps are useful for achieving and maintaining reduction. • The knee can be internally rotated to visualize the medial patellar facet fluoroscopically and externally rotated to visualize the lateral patellar facet fluoroscopically.

PITFALLS

• Implants may fail, especially if postoperative mobilization is too aggressive. • Both arms of the tension band must be tightened simultaneously. • Hardware may need to be removed if it is not buried in the soft tissues.

• K-wires and 1.2-mm (18-gauge) wire • Reduction forceps and smaller bone-holding forceps are useful for achieving and maintaining reduction. • Angiocatheters (14- or 16-gauge) are helpful for passing the wire through the proximal and distal soft tissue. • Small-fragment instrument set as well as 4.0-mm cannulated screws • A mini-fragment set, headless screws, and bioabsorbable implants may be useful in stabilizing smaller osteochondral fragments.

Drill

K-wire

Quadriceps tendon

Patella

Patellar tendon

A

B

K-wires Patella fracture reduced

Cerclage wire

C FIG. 42.8 

Angiocatheter

528

PROCEDURE 42  Operative Treatment of Fractures of the Patella

Step 3 • If the reduction is satisfactory, use a heavy needle driver to slowly tension the wire on both sides. • Tighten sequentially the medial and lateral limbs of the figure-of-eight wires to apply tension equally across the fracture site. • Unilateral tightening may cause asymmetric compression and not reduce the excess slack in the other arm of the loop. • Overtightening of the wires can lead to failure of the wire, malreduction, and/or comminution of the fracture pattern. • Cut the ends of the parallel K-wires, and bend them 180 degrees over the tension band loop, and bury the superior and inferior ends in the bone to prevent migration (Fig. 42.9). 

A

B FIG. 42.9 

Step 4 • Once the patella is reconstructed, repair the medial and lateral retinacula beginning at their respective apex and work back to the patella using a heavy (#1 or #2) absorbable suture. • Test the fixation by taking the knee through a range of motion (ROM) before closing the wound. This can be used to guide the postoperative rehabilitation. • Close the subcutaneous layer with a running 2-0 absorbable suture; skin closure is at the discretion of the surgeon (staples/suture). • Use intraoperative fluoroscopy or x-ray to assess the reduction and placement of all implants before closure.

Variations • 4.0-mm cannulated screws can be used instead of K-wires (Fig. 42.10). • A mini-fragment set, headless screws, and bioabsorbable implants may be useful in stabilizing smaller osteochondral fragments (Fig. 42.11). 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

A

B FIG. 42.10 

A

B

C FIG 42.11 

529

530

PROCEDURE 42  Operative Treatment of Fractures of the Patella

PEARLS

PROCEDURE: LAG SCREWS

• Lag screws are ideal for transverse, two-part fractures with good bone quality. • Confirm reduction with both fluoroscopy and digital palpation.

•  Lag screws are best suited for simple transverse fractures with large fragments (Fig. 42.12). • They can be placed in an anterograde or retrograde fashion. • Cannulated screws can be combined with tension band or cerclage wires.

Step 1

PITFALLS

• Use a direct midline or medial parapatellar incision. • Identify fracture fragments and evacuate hematoma. 

• Lag screws do not have a tension band effect on the articular surface and can lead to gapping at the articular surface. • Screw heads may cut through the patellar cortex.

Step 2 • Perform reduction and secure with the use of reduction forceps. • Confirm reduction with both fluoroscopy and digital palpation of the articular surface. 

Step 3 • Place drill holes across the fracture in a fashion similar to the anterior tension band technique, ideally perpendicular to the fracture orientation to avoid shear forces. • Measure the length of the screw, ensuring the threads will not cross the fracture line. • Place a partially threaded 4.0-mm cancellous screw across the fracture and compress the fracture. • Alternately, a fully threaded cortical screw can be used in lag fashion by drilling a gliding hole in the near fragment. • Place a second screw in a similar fashion parallel to the first (Fig. 42.11). • A washer (or a short one-third tubular plate) may be used to ensure the screw does not cut through the cortex. • Using cannulated screws, a tension band wire may be passed through the screws and tied, resulting in a combined stronger construct (Fig. 42.12). • If you intend to put cerclage wires or sutures through cannulated screws, then the screw should be within the bone at both ends so that the cable or suture is on bone for compression and to avoid the wire or suture being abraded by the end of the screw.

A

B FIG. 42.12 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

Variations

INSTRUMENTATION/IMPLANTATION

• A simple vertical fracture is a good indication for lag screw fixation. 

PROCEDURE: CERCLAGE WIRING • Primarily used for severely comminuted fractures not amenable to the above techniques; indirect reduction methods can address these injuries.

• Small-fragment/cannulated screws • Reduction clamps/forceps • 18-gauge wire and wire instruments • Fluoroscopy CONTROVERSIES

Multiple Fragment Fractures • For patella fractures with multiple fragments, a cerclage wire technique may be used to reduce the fracture when there are no large fragments that are amenable to anterior tension banding or screw fixation (Fig. 42.13). • Pass the wire through a wire passer or a 16-gauge angiocatheter in the soft tissue surrounding the patella immediately adjacent to the bone. • Perform manual reduction without clamps and reduce the articular surface while gradually tightening the cerclage wire. • Perform the anterior tension band technique performed as described. 

A

531

• Use of screws alone risks implant failure/cutout.

PEARLS

• Cerclage wiring is ideal for severely comminuted fractures. • Larger fragments can be lagged together, then surrounded by a tension band. • An anterior tension band placed through the cannulated portion of 4.0- or 4.5-mm screws for fixation may be useful in osteoporotic or pathologic bone.

B FIG. 42.13  PITFALLS

Multiple Major Fracture Lines • If the fracture presents with more than one major fracture line, reduce and fix the minor fragments to make two main fragments that can be treated using the tension band technique. • Lag screws, K-wires, or bioabsorbable pins may be used to hold the minor fragments whereas an anterior tension band is used to repair the major fragments (Fig. 42.14). 

Inferior Pole Fractures • Inferior pole fractures are usually nonarticular and can be reduced with a cerclage wire and lag screw fixation. • Insert the cerclage wire into the midsagittal portion of the patellar tendon immediately adjacent to the inferior pole fragment. • Obtain reduction by tightening the cerclage wire. 

• Cerclage wiring may disrupt the blood supply to the patella.

532

PROCEDURE 42  Operative Treatment of Fractures of the Patella

A

B FIG. 42.14 

PROCEDURE: PLATE FIXATION (LOCKED PLATING) • The addition of locking plate technology to the orthopedic armamentarium has many new applications and the patella is another such example. • Even with availability of locking plate technology, when possible, interfragmentary compression with lag screws remains the preferred technique and reliance on locking screws only when this cannot be achieved. • This technique is ideal in fractures not amenable to tension band constructs • Previously nonreconstructable, comminuted fractures may be feasibly fixed by this method, avoiding patellectomy and maintaining the knee extensor mechanism with the mechanical advantage afforded by the patella (Fig. 42.15).

FIG. 42.15 

PROCEDURE 42  Operative Treatment of Fractures of the Patella

Step 1 • A direct midline skin incision is used followed by development of full-thickness fasciocutaneous flaps. • Identify and expose all fracture fragments, and remove fracture hematoma. • A lateral parapatellar arthrotomy may be performed at this stage for additional exposure, incorporating any existing tears in the lateral retinaculum. • Inspect the knee joint for loose fragments and any concomitant pathology. 

Step 2 • The knee is kept in extension to detension the extensor mechanism. • Perform anatomic reduction of all articular fragments, with assessment both directly through the lateral parapatellar arthrotomy and indirectly via digital palpation of the articular surface and intraoperative fluoroscopic imaging. • Provisional fixation of large fragments can be achieved with sharp reduction clamps and K-wires. • Smaller fragments are amenable to small-caliber K-wire fixation. • Take care to place temporary fixation out of the zone of definitive plate and screw placement. 

Step 3 • A mesh plate is selected and templated to the patella. • The plate should be cut to size but allow screw fixation of all fracture fragments. It should also extend beyond the anterior surface of the patella to the superior, inferior, and lateral surfaces to allow a second plane of screw fixation. • Take care not to transfix or encroach upon the quadriceps tendon insertion or patellar tendon origin. • Then contour the plate to fit the patella and minimize hardware prominence. • Interfragmentary compression with lag screw technique should be used when feasible, through plate holes along the superior, inferior, and lateral margins of the patella. • Where interfragmentary compression is not possible or bone quality does not allow adequate screw purchase, then use fixed-angle locking screws. • Screws must not penetrate the articular surface and this can be verified by direct visualization, digital palpation, and/or fluoroscopically (Fig. 42.16). 

A

B FIG. 42.16 

533

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PROCEDURE 42  Operative Treatment of Fractures of the Patella

Step 4 • The knee should be cycled through its range of motion under live fluoroscopy and direct visualization to verify stable fixation of the patella and extensor mechanism. Final x-rays are also taken at this time. • Then irrigate the wound and knee joint to remove any residual bony debris. 

Step 5 • Wound closure should include retinacular repair with absorbable #1 braided sutures. • Then perform skin and subcutaneous closure in the usual fashion. 

Step 6 • The knee is then immobilized in a hinged knee brace locked in extension, with the patient permitted to weight bear as tolerated in the brace. 

PROCEDURE: PATELLECTOMY (PARTIAL AND TOTAL) • Partial patellectomy and repair of the soft tissue envelope are required in injuries that involve severe comminution of one pole and are not amenable to internal fixation. • In cases of severe comminution of the proximal or distal pole, resection with tendon reattachment can be performed. • Total patellectomy may rarely be needed for highly displaced and comminuted patella fractures that are not amenable to internal fixation. • All techniques of salvage should be attempted before a patellectomy is chosen. • Theorized advantages include shorter immobilization, a less complicated surgical technique, and an earlier return to work. • Full-thickness skin flaps and retention of all viable portions of the patella tendon and extensor mechanism are a necessity. • The tendon repair is the most critical part of the surgical procedure. • Repair the patellar tendon using heavy Mersilene or Ethibond (Ethicon Inc., Somerville, NJ) suture with a woven stitch (Bunnell or Krackow). • Multiple procedures are designed to reconstruct both the patellar and quadriceps tendons. Details of these procedures are outside the scope of this textbook, and readers are encouraged to consult other sources to determine which procedure is best for their patient. 

PARTIAL PATELLECTOMY: SUPERIOR AND INFERIOR POLES

PEARLS

• Excessive tension on the repair should be avoided. • Passive range of motion, then directly observed active range of motion, should be used for at least 4 weeks. • Weight bearing in an extension brace is allowed immediately.

PITFALLS

• Symptomatic hardware and its subsequent removal is common. • Nonunion can be avoided with bone grafting of large defects.

• After debriding/removing bone, drill three holes down the long axis of the remaining patella through the midsubstance. • The tendon is reapproximated at the level of the articular surface and not the anterior cortex, and a locking stitch is performed through the tendon. • It is extremely important to obtain the proper alignment of the distal fragment during reduction and fixation to prevent tilting of the patella and increased contact forces on the femoral condyles. • Extension or slight flexion of the knee and visualization of the articular surface can help prevent a malreduction. • Owing to the forces generated across the patella by the extensor mechanism, the partial patellectomy should be protected with some form of secondary reinforcement with either a box wire, Mersilene tape, or fascia around the patella and through the patellar tendon or proximal tibia. • The construct should be tested through a full range of motion and the fragments observed for motion or loss of reduction. • Repair retinacular defects with absorbable #1 suture in figure-of-eight interrupted sutures, and close the wound in layers. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Good to excellent clinical results (50%–80%) have been reported with anterior tension band wiring (Hung et al., 1985). • Lag screw fixation yields less fracture displacement versus traditional tension band wiring (Burvant, 1994; Carpenter, 1997).

PROCEDURE 42  Operative Treatment of Fractures of the Patella

• Tension band wiring and tension band wiring through cannulated screws are among the strongest constructs. • Substitution of monofilament wires with braided cables yields more reliable fracture fixation with cyclic loading (Scilaris, 1998). • Biodegradable implants are not superior to metal implants in patella fracture fixation (Sayum Filho et al., 2015). • Locked plating is equivalent to cannulated screw with tension band constructs (Banks et al., 2013) and superior to traditional tension band wiring (Wurm et al., 2015). • Some authors have found no difference in clinical or radiographic outcome and fewer procedures for hardware removal with the use of biodegradable implants compared with metallic wires (Chen et al., 1998). • Reviews of partial patellectomy have demonstrated that near-normal outcomes were seen when large fragments were retained and the articular surface was maintained. Multiple studies advocate for retention of large fragments, which seems to improve clinical results. • Previous studies showed less satisfactory clinical outcomes, extensor lag, and patellofemoral arthritis are more common when a partial or total patellectomy is performed, but this has been recently called into question (Bonnaig et al., 2015). • Regardless of fixation method, long-term data suggest ongoing symptoms and functional impairment after patella fracture open reduction and internal fixation.

EVIDENCE Banks KE, Ambrose CG, Wheeless JS, Tissue CM, Sen M. An alternative patellar fracture fixation: a biomechanical study. J Orthop Trauma. 2013;27(6):345–351. Bonnaig NS, Casstevens C, Archdeacon MT, et al. Fix it or discard it? A retrospective analysis of functional outcomes after surgically treated patella fractures comparing ORIF with partial patellectomy. J Orthop Trauma. 2015;29(2):80–84. Burvant JG, Thomas KA, Alexander R, Harris MB. Evaluation of methods of internal fixation of transverse patella fractures: a biomechanical study. J Orthop Trauma. 1994;8(2):147–153. Carpenter JE, Kasman RA, Patel N, Lee ML, Goldstein SA. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma. 1997;11(5):351–356. Chang S-M, Ji X-L. Open reduction and internal fixation of displaced patella inferior pole fractures with anterior tension band wiring through cannulated screws. J Orthop Trauma. 2011;25(6):366–370. Chen A, Hou C, Bao J, et al. Comparison of biodegradable and metallic tension-band fixation for patella fractures: 38 patients followed for 2 years. Acta Orthop Scand. 1998;69(1):39–42. Hambright DS, Walley KC, Hall A, Appleton PT, Rodriguez EK. Difficult patella fractures treated with the multiple wire and tension band technique. J Orthop Trauma. 2016;31(2):e66–e72. Hung LK, Chan KM, Chow YN, Leung PC. Fractured patella: operative treatment using the tension band principle. Injury. 1985;16(5):343–347. https://doi.org/10.1016/0020-1383(85)90144-5. Lorich DG, Warner SJ, Schottel PC, Shaffer AD, Lazaro LE, Helfet DL. Multiplanar fixation for patella fractures using a low-profile mesh plate. J Orthop Trauma. 2015;29(12):e504–e510. Sayum Filho J, Lenza M, Teixeira de Carvalho R., Pires O.G.N., Cohen M., Belloti J.C.. Interventions for treating fractures of the patella in adults. Cochrane Database Syst Rev. 2015;(2):CD009651. Scilaris TA, Grantham JL, Prayson MJ, Marshall MP, Hamilton JJ, Williams JL. Biomechanical comparison of fixation methods in transverse patella fractures. J Orthop Trauma. 1998;12:356–359. Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343:230–238. Taylor BC, Mehta S, Castaneda J, French BG, Blanchard C. Plating of patella fractures: techniques and outcomes. J Orthop Trauma. 2014;28(9):e231–e235. Thelen S, Schneppendahl J, Jopen E, et al. Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures. Injury. 2012;43(8):1290–1295. Wild M, Eichler C, Thelen S, Jungbluth P, Windolf J, Hakimi M. Fixed-angle plate osteosynthesis of the patella—an alternative to tension wiring? Clin Biomech. 2010;25(4):341–347. Wurm S, Augat P, Buhren V. Biomechanical assessment of locked plating for the fixation of patella fractures. J Orthop Trauma. 2015;29(9):e305–e308.

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PROCEDURE 43

Patella Fractures: Plating Diren Arsoy, Johanna Charlotte Emilie Donders, and David L. Helfet INDICATIONS Nonoperative Indications • Nondisplaced articular fractures with an intact extensor mechanism and no extensor lag 

Operative Indications • Articular displacement of more than 2 mm • Articular fragment diastasis of more than 5 mm 

INDICATIONS PITFALLS

• Choice of operative fixation must account for patient characteristics and fracture pattern. • Contraindications for operative treatment include the following: • Highly compromised soft-tissue envelope • Severe medical comorbidities • Joint ankylosis • Active infection • Nonambulatory status

INDICATIONS CONTROVERSIES

• Outcomes following operative treatment of patella fractures using various forms of tension band construct have been unsatisfactory despite low rates of nonunion, malunion, and failures. • Challenges for treatment of patella fractures include the following: • Achieving anatomic articular reduction • Restoring extensor mechanism function • Limiting disruption to vascularity • Minimizing soft-tissue irritation from implant

TREATMENT OPTIONS

• Nonoperative treatment • 4 to 6 weeks of immobilization in a cast or brace locked in full extension followed by progressive range of motion (ROM) • Total or partial patellectomy • We do not recommend partial patellectomy for isolated inferior pole fractures owing to the high risk for patella baja and disruption of patellar vascularity. • Open reduction and internal fixation (ORIF) • An isolated extraarticular inferior pole fracture can be repaired with nonabsorbable polyester sutures similar to repair of a patella tendon disruption. • Plating techniques have shown promise in biomechanical studies. • Increased load to failure • Smaller fracture gap displacements with motion • As a result, a mesh plate construct has evolved into our preferred technique for displaced articular fractures. • The technique includes the following: • Lateral parapatellar approach that enables direct articular visualization and protects patella vascularity • A low-profile rim plate that allows multiplanar and interfragmentary screw fixation, augmentation of inferior pole comminution via patella tendon suturing to the plate, and less soft-tissue irritation • This fixation construct for patella fractures results in significant improvements in clinical and objective functional outcomes.

536

PROCEDURE 43  Patella Fractures: Plating

EXAMINATION AND IMAGING • Preoperative clinical examination of the patient reveals pain, swelling, crepitus, and inability to extend the knee actively. •  Plain radiographs (anteroposterior [AP], lateral) and computed tomography (CT) scans should be obtained for each patient prior to surgical intervention and used for planning of all cases.9 • Magnetic resonance imaging (MRI) may be useful when nonoperative treatment is considered (assessment of osteochondral injuries and retinacular tears). 

SURGICAL ANATOMY • The patella has a triangular shape with its base proximal and the apex pointed inferiorly (Figs. 43.1–43.3). • The proximal three-fourths of the posterior surface is covered with hyaline cartilage, whereas the inferior pole is extraarticular. • The quadriceps tendon inserts into the base of the patella proximally. • The inferior pole is the origin of the patellar tendon, which inserts onto the tibial tubercle.

FIG. 43.1  Anteroposterior and lateral radiographs.

FIG. 43.2  Computed tomography scan.

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PROCEDURE 43  Patella Fractures: Plating

FIG. 43.3  Three-dimensional reconstruction views.

Superior geniculate

Lateral superior geniculate

Medial superior geniculate

Lateral inferior geniculate

Anterior tibial recurrent

Medial inferior geniculate

FIG. 43.4  Blood supply of the patella. (From Miller: DeLee & Drez’s Orthopaedic Sports Medicine, 5th Edition.)

• Lateral and medial expansions of the vastus medialis and lateralis form the retinaculae. • Contributions from six arteries form a peripatellar vascular ring (supreme geniculate, four geniculate arteries, recurrent anterior tibial artery). • The majority of the intraosseous blood supply is provided by the midpatellar and polar vessel systems. • The polar vessels travel from distal to proximal to enter the patella through the inferior pole; they are the predominant vascular supply to the patella. • In 80% of the cadaveric specimens, the polar vessels enter from inferomedial. • As a result, we prefer a lateral parapatellar approach to avoid the inferomedial polar vessels. 

POSITIONING POSITIONING PEARLS

• A bump underneath the ipsilateral hip will help internally rotate the knee so that the patella faces anterior.

• The patient is placed supine on a radiolucent table with an ipsilateral bump beneath the hip so that the patella points straight to the ceiling. • A tourniquet may be used and is applied to the proximal thigh. • The extremity is prepped and draped in the usual orthopedic fashion. • A bump is placed under the knee to allow 20° to 30° of knee flexion and to facilitate lateral fluoroscopic imaging. 

PROCEDURE 43  Patella Fractures: Plating

539

POSITIONING PITFALLS

• If a tourniquet is used, shortening of the quadriceps tendon may hinder reduction of comminuted fractures. • In cases of tourniquet utilization, flex the knee up before inflating the tourniquet to advance the patella.

POSITIONING EQUIPMENT

• Radiolucent table • Tourniquet • Bump

PORTALS/EXPOSURES Lateral Parapatellar Approach and Temporary Reduction • A midline longitudinal incision down to the level of the retinaculum • In cases of open fractures, the traumatic wound needs to be incorporated and extended distally and proximally as needed. • Medial and lateral tissue flaps are raised to expose the extent of the retinacular tears. • A lateral parapatellar arthrotomy is made originating from the retinacular tear that is often present (Fig. 43.5). • Inversion of the patella allows for adequate exposure of the articular surface that will assist with an anatomic reduction and adequate visualization while placing the implants.

PORTALS/EXPOSURES PEARLS

• We prefer a lateral parapatellar approach, as it allows patellar inversion and visualization of the entire articular surface. • In addition, this approach preserves the inferomedial polar vessels as the predominant vascular blood supply to the patella. • 2.0-mm, fully threaded Kirschner wires (K-wires) are used as joysticks to reduce smaller osteochondral defects to each other.

PORTALS/EXPOSURES PITFALLS

Right leg

• Be prepared to use a different approach (i.e., medial parapatellar) in the case of significant traumatic wounds/arthrotomy.

PORTALS/EXPOSURES EQUIPMENT

• 2.0-mm threaded K-wires • Pointed reduction clamps

Arthrotomy incision

FIG. 43.5  Outline of the arthrotomy incision.

540

PROCEDURE 43  Patella Fractures: Plating

PORTALS/EXPOSURES CONTROVERSIES

• Exposure via retinacular tears allows for only limited visualization of the articular surface. • The indirect reduction of the articular surface relies on the reduction of the dorsal cortex and can be misleading. • If this approach is used, true lateral radiographs of each facet are needed to assess reduction of the articular surface.

• The fracture hematoma is evacuated. • The soft tissue underneath the quadriceps and patellar tendon is excised to expose the bony edge of the patella proximally and distally. • 2.0-mm K-wires are used as joysticks to reduce smaller osteochondral fragments to larger ones (Fig. 43.6). • Pointed reduction clamps are then used to reduce the stable fragments to each other to prepare for final plate fixation. • Additional K-wires can be used for temporary fixation. • Make every attempt to salvage smaller osteochondral fragments. 

FIG. 43.6  Provisional fixation with K-wires.

PROCEDURE STEP 1 PEARLS

• The malleability of the mesh plate allows finetuning of the mesh construct according to the fracture pattern.

STEP 1 PITFALLS

• There is no one-size-fits-all mesh construct; the surgeon needs to be able to accommodate for various patellar dimensions and fracture patterns.

Step 1: Plate Preparation • A 2.4/2.7-mm uncut mesh plate (Depuy Synthes; West Chester, PA) is cut to size such that the final implant fits as a mesh around the reduced patella to cover the lateral, superior, and inferior rim as well as the anterior cortical surface (Figs. 43.7 and 43.8). • The plate has a superior and inferior limb that are bent to contour beneath the patellar tendon distally and quadriceps tendon proximally so that it lies flush with the bony edge of the patella. • Two anterior limbs span over the anterior surface of the patella.

STEP 1 INSTRUMENTATION/ IMPLANTATION

• 2.4/2.7-mm mesh plate (Depuy Synthes; West Chester, PA) • Plier to bend the plate in different planes • Wire cutter to cut the plate as needed

FIG. 43.7  Uncut mesh plate.

PROCEDURE 43  Patella Fractures: Plating

541

• The plate can be modified to accommodate various fracture patterns and fragments (Fig. 43.9). • This provides access to multiplanar screw fixation with a low-profile implant. 

FIG. 43.9  Mesh plate adjusted to fit onto the patella.

FIG. 43.8  Cut mesh plate to accommodate the shape of the patella.

Step 2: Plate Placement and Screw Fixation • Circumferential placement around the lateral half of the patella is achieved next (Fig. 43.10). • In situ bending with screwdrivers allows for further fine-tuning adjustments to ensure adequate fit. • Initial plate fixation to the lateral patella is achieved via transverse bicortical 2.4-mm cortical screws across the superior and inferior poles. • Antegrade and retrograde plate fixation using 2.7-mm screws follows next. • This provides compression across the fracture fragments and achieves absolute stability.

STEP 2 PEARLS

• In situ modifications to the plate allow for fragment-specific fixation. • The mesh construct has tight fit coverage over the lateral half of the patella, thereby minimizing soft-tissue irritation. • Lateral to medial screws will stabilize the fracture with relative stability and allow the surgeon to sequentially remove provisional K-wires and pointed reduction clamps. • In osteoporotic bone (commonly, the comminuted inferior pole) anterior to posterior variable-angle locking screws can be used. • 2.4-mm cortical screws will suck down the plate onto the patella in the case of residual plate prominence. STEP 2 PITFALLS

• Beware of clearing the infra- and suprapatellar fat pad just enough so that the proximal and distal limbs of the plate lie flush with the edge of the bony patella without soft-tissue interposition. • Pay attention to the anterior limbs to conform along the anterior patellar cortex, thereby avoiding prominent hardware. • Remove provisional K-wires as you go to free up patellar bone stock for permanent screw fixation. FIG. 43.10  Circumferential placement of mesh plate.

542

PROCEDURE 43  Patella Fractures: Plating

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Pliers • Screwdrivers to use as plate benders • 2.4-mm variable-angle locking screws and cortical screws • 2.7-mm variable-angle locking screws and cortical screws • 1.8-mm drill bit for 2.4-mm screws • 2.0-mm drill bit for 2.7-mm screws

• Finally, anterior to posterior screws, often 2.4-mm locked, are placed through the transverse limbs to enhance plate fixation along the anterior patellar surface (Figs. 43.11 and 43.12). • Provisional K-wires and pointed reduction clamps can be removed sequentially while placing screws in different planes. • Fluoroscopic imaging (AP and lateral views) verifies satisfactory hardware placement with adequate articular reduction (Figs. 43.13 and 43.14). 

FIG. 43.11  Anterior to posterior screws along the anterior patellar surface.

FIG. 43.12 Patellar inversion reveals adequate reduction of the articular surface.

FIG. 43.13  Final anteroposterior fluoroscopic image.

PROCEDURE 43  Patella Fractures: Plating

Step 3: Soft-Tissue Repairs (Patellar Tendon Suturing and Retinacular Repair) • To address inferior pole comminution (present in 90% of cases), we augment the mesh construct with two #5 FiberWire (Arthrex; Naples, FL) sutures. • These are threaded underneath the superior and inferior transverse limbs of the plate. We then pass them as a Krackow suture through the medial and lateral edge of the patellar tendon (Fig. 43.15). • The lateral arthrotomy and retinacular tears are repaired with #2 FiberWire sutures (Figs. 43.16 and 43.17). • The skin and subcutaneous layers are closed in the usual fashion. • A bulky sterile cotton dressing is applied and the knee is braced, locked in full extension. 

543

STEP 3 PEARLS

• The #5 FiberWire Krackow sutures are tied with the knee in full extension. • As you range the knee, obtain lateral fluoroscopic imaging to confirm a stable fixation construct with no signs of articular gapping and hardware failure. STEP 3 INSTRUMENTATION/ IMPLANTATION

• #5 and #2 FiberWire suture (Arthrex; Naples, FL) STEP 3 CONTROVERSIES

• There continues to be a debate about whether to incorporate comminuted pole fractures or to excise. • We believe that every effort should be made to salvage comminuted pole fractures to not jeopardize a satisfactory outcome. • Low-profile mesh plating for the patella with augmentation via Krackow sutures is a suitable construct for the majority of patella fractures and addresses inferior pole comminution.

FIG. 43.14  Final lateral fluoroscopic image.

FIG. 43.15  Krackow sutures to augment the mesh plate construct. FIG. 43.16  Retinacular/arthrotomy repair with #2 FiberWire suture.

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PROCEDURE 43  Patella Fractures: Plating

FIG. 43.17  Arthrotomy closure with Krackow-mesh plate suture construct in place.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOP PEARLS

• Patients are allowed immediate weight bearing as tolerated. • Keep the knee locked in extension for 4 weeks postoperatively. POSTOP INSTRUMENTATION/ IMPLANTATION

• Hinged knee brace

• We allow immediate weight bearing as tolerated in a knee brace locked in extension. • At the 2-week postoperative visit, straight leg raises and isometric quadriceps contraction are initiated while knee ROM exercises are strictly prohibited. • At the 4-week visit, a hinged knee brace is unlocked. • Active and passive ROM exercises as well as no resistance stationary biking are allowed. • At the 2-month visit, a chondromalacia patella–strengthening protocol that incorporates quadriceps, hamstring, and calf resistance exercises is added to the therapy regimen. • Clinical and radiographic surveillance of patients include visits at 3, 6, and 12 months postoperatively. POSTOP CONTROVERSIES

• While some authors recommend early ROM exercises, this exposes the fixation construct to high stresses that may promote early failure. • In our experience, delaying ROM for the initial 4 weeks allows adequate fracture healing without compromising final knee ROM.

EVIDENCE Harris RM. Fractures of the patella and injuries to the extensor mechanism. In: Bucholz RW, Heckman JD, Court-Brown CM, et al., eds. Rockwood and Green’s Fractures in Adults. 6th ed; 2006:1969–1998. Hoshino CM, Tran W, Tiberi JV, et al. Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires. J Bone Joint Surg [Am]. 2013;95:653–659. Lazaro LE, Wellman DS, Klinger CE, et al. Quantitative and qualitative assessment of bone perfusion and arterial contributions in a patellar fracture model using gadolinium-enhanced magnetic resonance imaging: a cadaveric study. J Bone Joint Surg [Am]. 2013;95:e1401–e1407. Lazaro LE, Wellman DS, Pardee NC, et al. Effect of computerized tomography on classification and treatment plan for patellar fractures. J Orthop Trauma. 2013;27:336–344. Lazaro LE, Wellman DS, Sauro G, et al. Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment. J Bone Joint Surg [Am]. 2013;95:e96 1–8. LeBrun CT, Langford JR, Sagi HC. Functional outcomes after operatively treated patella fractures. J Orthop Trauma. 2012;26:422–426. Lorich DG, Warner SJ, Schottel PC, Shaffer AD, Lazaro LE, Helfet DL. Multiplanar fixation for patella fractures using a low-profile mesh plate. J Orthop Trauma. 2015;29:e504–e510. Thelen S, Schneppendahl J, Jopen E, et al. Biomechanical cadaver testing of a fixed-angle plate in comparison to tension wiring and screw fixation in transverse patella fractures. Injury. 2012;43:1290– 1295. Veselko M, Kastelec M. Inferior patellar pole avulsion fractures: osteosynthesis compared with pole resection. Surgical technique. J Bone Joint Surg [Am]. 2005;87(suppl 1):113–121. Wurm S, Augat P, Buhren V. Biomechanical assessment of locked plating for the fixation of patella fractures. J Orthop Trauma. 2015;29:e305–e308.

PROCEDURE 44

Proximal Tibia ORIF: Anterior Approaches Darryl N. Ramoutar, Peter J. O’Brien, and Kelly A. Lefaivre Open Reduction and Internal Fixation INDICATIONS • Absolute indications • Open injuries • Compartment syndrome • Fractures associated with vascular injuries • Relative indications • Displaced bicondylar and medial plateau fractures • Lateral plateau fractures with associated joint instability or displacement of the articular surface that is not submeniscal • Any fracture associated with greater than 10 degrees of varus or valgus misalignment of the knee • Condylar widening of greater than 5 mm • Fracture-dislocations of the knee • Polytraumatized patients 

EXAMINATION/IMAGING

PITFALLS

• Any fracture in the metaphysis and epiphysis of the tibia should be evaluated for evidence of vascular injury, as well as for signs and symptoms of compartment syndrome. • Medial and bicondylar plateau fractures are higher energy, and more unstable. These need to be evaluated as though all are fracturedislocations of the knee, with the associated risk.

CONTROVERSIES

• Many authors would consider severe softtissue injury as a temporary contraindication to open reduction and internal fixation (ORIF), and advocate the use of temporary external fixation in that setting. Special attention should be paid to the anteromedial skin in this setting, as it is most susceptible to injury.

Physical Examination • Perform a screening medical and trauma examinations for other injuries. • Examine the affected extremity. • Check the alignment of the extremity. • Assess the condition of the skin (swelling, blistering, shearing injury, bruising). • Examine the knee for intraarticular swelling. • Occult extension into the plateau or other injury may cause hemarthrosis. • Perform a neurologic examination. • Perform a vascular examination, including ankle-brachial index (ABI) compared to contralateral side, is performed. An ABI of 1). • If there is clear ischemia, angiography can be useful in localizing the area of injury. However, if further studies are going to cause an unacceptable delay in vascular exploration and revascularization, on-table techniques should be used. • Reexamination at regular intervals is required, as compartment syndrome can occur 24 hours or more after injury. • Examine the joints above and below the injury. 

Imaging Studies • Radiographs • Anteroposterior (AP) (Fig. 44.1A) and lateral (Fig. 44.1B) views of the knee • Focused images allow evaluation of fracture anatomy and planes, comminution, and displacement. Other injuries around the knee are also evaluated (patella, distal femur). • Distance of fracture lines from the plateau and tubercle is assessed. • AP and lateral views of the tibia: Long-leg images allow assessment of alignment of the extremity and distal extent of the injury and angulation through the fracture. • Plateau view: A film shot 10 degrees caudad is in plane with the normal slope of the tibia, and can be helpful in delineating hidden extension into the plateau or tibial spine.

545

546

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

A

B FIG. 44.1 

A

B FIG. 44.2 

• Oblique views of the knee: Although these have been largely replaced by computed tomography (CT) scans, additional views can be helpful in characterizing the extension of the fracture lines into the plateau. • Traction and stress views: These are not practical in the assessment of a conscious patient, but with the use of fluoroscopy can be helpful in identifying fracture anatomy and ligamentous injuries in an anesthetized patient in the operating room. • Computed tomography • Periarticular injuries require thin-cut CT images in order to best delineate articular components; they are a standard part of the evaluation of proximal tibia fractures. • Sagittal and coronal reformats are best for characterizing articular injuries, as the axial cuts are in plane with the injury (Fig. 44.2). Axial cuts are useful for planning

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

approaches for fixation utilizing the three-column theory of plateau fractures (Luo et al., 2010). • CT scanning provides three-dimensional information and is very helpful in planning reduction and fixation techniques (Karunakar et al., 2002). • Most would not consider necessary for preoperative planning in a pure metaphyseal injury. • Magnetic resonance imaging (MRI) • MRI allows identification of meniscal and ligamentous injuries associated with the tibial plateau fracture. • It is advocated by some authors as routine in all high-energy injuries but has not been shown to have an effect on treatment outcome. • Controversy exists as to timing of MRI because once fixation occurs, artifact may impair image evaluation. Examination under anesthesia (EUA) after fixation may be an alternative to MRI for ligamentous assessment. 

SURGICAL ANATOMY • Fracture/tibial anatomy • The lateral plateau is slightly higher than the medial plateau, forming a varus angle of 3 degrees with the tibial shaft. • The lateral plateau is smaller and convex, whereas the medial plateau is larger and concave. • The weight-bearing axis is such that 60% or more of weight passes through the medial tibial plateau, which leads to denser subchondral bone on the medial side. • The AO/ASIF/OTA classification distinguishes between nonarticular (or extraarticular), partial articular, and complete articular fractures, then subdivides these classifications based on the amount of comminution (Fig. 44.3A). • The Schatzker classification is more descriptive in the specifics of ­articular injury and is more useful in planning of open reduction and internal fixation (Fig. 44.3B). • Skin anatomy • Examination of the soft tissue is very important for planning timing of surgery and placement of the incisions. • The anteromedial soft-tissue envelope (Fig. 44.4), which is directly subcutaneous, is at highest risk. • Meniscus • The meniscus is likely to be involved in displaced plateau fractures and needs to be addressed in the approach. • The lateral meniscus, which is smaller in circumference than the medial meniscus, covers a larger portion of the articular surface (Fig. 44.5). • Popliteal artery (Fig. 44.6) • The popliteal artery is anchored proximally by the tendinous insertion of the adductor magnus and distally by the tendon of the soleus as it descends from the tibial plateau. • Before the fibrous arch of the soleus, it divides into the anterior tibial artery (anterior compartment), posterior tibial artery (deep and superficial posterior compartments), and peroneal artery (lateral compartment). • Common peroneal and tibial nerves (see Fig. 44.6) • These nerves separate in the upper popliteal fossa, and the tibial nerve runs into the deep posterior compartment. • The common peroneal nerve crosses posterior to the lateral head of the gastrocnemius; becomes subcutaneous around the distal head of the fibula and then divides into deep and superficial branches. • Muscular anatomy (Fig. 44.7) • The anterior compartment covers the anterolateral tibia, with the anteromedial tibia lying directly subcutaneous. • The lateral compartment is posterior to the anterior compartment around the fibula. • The deep and superficial posterior compartments are posterior to the tibia. 

547

TREATMENT OPTIONS

• Hinged cast brace • Requires adequate reduction and stability for early range of motion • Definitive external fixation • In the setting of very unstable injuries where definitive ORIF is contraindicated, this may be necessary. • May be combined with limited ORIF of the articular component • Knee range of motion should be started as soon as stability allows. • Intramedullary nail fixation • Can be considered in extraarticular proximal tibia fractures

1 Avulsion Extraarticular

2 Metaphyseal

3 Comminuted Metaphyseal

1 Pure split Partial articular

2 Pure depression, metaphyseal

3 Split depression

2 Articular simple, metaphyseal comminuted

3 Articular comminution

1 Simple Complete articular

A

B

Type I split

Type II split-depression

Type III Central depression

Type IV Split fracture, medial plateau

Type V Bicondylar fracture

Type VI Dislocation of metaphysis and diaphysis

FIG. 44.3  Modified from Berkson EM, Virkus WW. High energy tibial plateau fractures. J Am Acad Orthop Surg. 2006;114:20–31.

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

549

Popliteal artery and vein Tibial nerve Lateral genicular arteries

Medial genicular arteries

Common peroneal nerve

FIG. 44.6 

FIG. 44.4  Superficial posterior

Back of knee Fibula Medial meniscus

Plane of cut section

Lateral meniscus

Deep posterior Lateral

Front of knee FIG. 44.5 

Anterior

FIG. 44.7  Modified from Grant JCB. Grant’s Atlas of Anatomy, 5th ed. Baltimore: Williams and Wilkins, 1962.

POSITIONING • Patient positioning is dictated by the fracture anatomy and the planned reduction and fixation. • For the anterior approaches, place the patient supine on a radiolucent table (Fig. 44.8A). • Use of a small bolster depends on the planned approach or approaches. • Place a tourniquet high on the operative thigh. • The use of a sterile knee flexion bolster will allow positioning of the limb in flexion or extension. • Figure-of-four positioning of the limb can be used for a posteromedial approach. • Alternatively, positioning may be done with flexion of the bed to allow the lower leg to hang free (Fig. 44.8B). • Some fracture patterns dictate the need for prone positioning and a direct posterior approach. 

PEARLS

• When used, a positioning triangle should be placed on the distal thigh, not in the popliteal fossa, allowing the soft tissue posteriorly to “fall away.” • The large fluoroscopy machine should be brought in from the opposite side of the bed. PITFALLS

• Prolonged positioning with a rigid triangular bolster behind the knee may compromise vascularity even in the absence of tourniquet use, and should be avoided. Adequate padding should be utilized on the bolster. EQUIPMENT

• The use of a radiolucent knee flexion bolster triangle is ideal. The availability of a multiangle triangle device, or triangles in multiple sizes, can be useful.

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

550

A

B FIG. 44.8 

PORTALS/EXPOSURES

CONTROVERSIES

• Some surgeons prefer the use of a table that flexes, which allows the affected leg to hang off of the end of the bed. This allows traction on the leg and the use of gravity in the reduction. PEARLS

• If a fasciotomy is performed, plan ahead for incisions needed for internal fixation. • Traction sutures in the meniscus allow better visual­ ization of the plateau in a submeniscal approach. • Protection and repair of the meniscus at the end of the procedure is key for outcome of repair of lateral tibial plateau fractures. • A femoral distractor can be placed either medially or laterally. depending on the fracture configuration (laterally for lateral fractures, medially for medial or bicondylar fractures). PITFALLS

• The dual incision (simultaneous anterolateral and posteromedial approaches) has become the standard in bicondylar tibial plateau fractures (Fig. 44.12). • Medial-sided plates cannot be placed through a midline incision, because the medial dissection required risks the soft tissue envelope.

FIG. 44.9 

• Direct anterior midline approach • This approach is not recommended because of the extensive soft-tissue stripping required to access the lateral and medial tibial plateaus. • Anterolateral approach to proximal tibia • An S-shaped incision is made from the posterior aspect of the lateral condyle of the femur, across at the level of the joint, and extended distally about one fingerbreadth lateral to the crest of the tibia over the appropriate length to expose the fracture (Fig. 44.9). • The proximal end of the incision should be used only when needed, as the distal two-thirds of the incision (similar to a hockey stick incision) is often sufficient. • Take care to stay lateral to the anterior border of the tibia (∼1 cm) to avoid an ­incision directly over subcutaneous bone. • Length of the skin incision is dictated by fracture anatomy and planned fixation. • If a minimally invasive plating technique is planned, use the middle extent of this incision. • In extraarticular fractures, use the middistal portion of the incision. • Then release the anterior compartment from the tibial shaft and under the tibial plateau. • This technique leaves the iliotibial band (ITB) attached to the lateral plateau fragment, and protects its vascularity (Fig. 44.10). • Careful subperiosteal dissection protects the neurovascular supply of the anterior compartment.

FIG. 44.10 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches



• For visualization of the articular surface, palpate the lateral meniscus and perform a careful submeniscal capsulotomy. • If the coronary ligament of the lateral meniscus is intact, incise it and retract the meniscus proximally. • Medial approach to the tibia • This can be performed with the patient supine, either over a bolster or in a figureof-four position. • Make a skin incision over the posteromedial tibia, posterior to the pes anserinus and its tendons, and anterior to the gastrocnemius (Fig. 44.11A). • Carry the dissection down to the interval between the semimembranosus and the medial head of the gastrocnemius (Fig. 44.11B). • The pes anserinus tendons can be retracted distally or released and later repaired, if needed. • Take care not to violate the deep portion of the medial collateral ligament. • The release of some of the medial head of the gastrocnemius can improve exposure, but beware of the medial inferior genicular artery. • A very limited intraarticular view is obtained with this approach, and the reduction is typically extraarticular; therefore, an arthrotomy is not routine. 

CONTROVERSIES

• The insertion of the ITB can be left in place (see Fig. 44.10), as described here, or elevated (Fig. 44.13) with a continuous sleeve with the anterior compartment of the lower leg. There is a theoretic risk to the vascularity of the plateau fragment with elevation, and the authors prefer to leave it attached. • If the articular injury is very medial in the lateral plateau, and not submeniscal, the anterior horn of the lateral meniscus can be released and retracted laterally with the dissection, provided it is appropriately repaired. • The incision can be S-shaped as described here, or straight or hockey stick–shaped. We have found the S-shaped incision most extensile.

Medial collateral ligament

Medial epicondyle

Joint capsule

Popliteal artery, vein, and nerve

Superficial medial ligament

Retractor on anterior gastrocemius (medial head)

Skin incision Fracture line

A

Pes anserinus insertion

B

Semimembranosus Retract pes anserinus distally

FIG. 44.11  Modified from www.aofoundation.org.

FIG. 44.12 

551

FIG. 44.13 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

552

PROCEDURE

PEARLS

• When elevating depressed articular fragments, it is important to bring as much subchondral bone with the articular cartilage as possible. Once compressed with the tamp and supported with graft or substitute, this will provide the best support to the articular surface. • Always plan the eventual placement of implants prior to placing temporary fixation. This includes K-wires, interfragmentary screws, and femoral distractor pins. • If an external fixator is in place prior to the start of the procedure, it can be used as a distraction device. • A femoral distractor with one pin placed in the distal femur and one in the tibia distal to the zone of injury and planned fixation can help with fracture alignment and reduction.

Step 1: Reduction of the Articular Surface • Split or split-depression lateral tibial plateau fractures • The split in the plateau gives access to the depressed articular portion (Fig. 44.14A). This can be elevated using an elevator or punch (Fig. 44.14B). • The elevated fragments can be temporarily held in place using Kirschner wires (K-wires). The bone defect that is created under the elevated articular segment needs to be supported with bone graft or bone graft substitute. • Once the elevated fragments are held in place, close the split portion of the fracture and provisionally hold it in place using a periarticular reduction clamp or a large-fragment reduction clamp. • Next, place provisional K-wires from medial to lateral in order to be out of the way of the plate (Fig. 44.15A). • Alternatively, wires can be placed anterolateral to medial away from the anticipated position of the plate, but the authors prefer the former.

A

B FIG. 44.14 

A

B FIG. 44.15 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches



• The reduction can be judged via the submeniscal view and also by using fluoroscopy (Fig. 44.15B). • Pure depression lateral tibial plateau fractures • This injury pattern is less common and requires that a metaphyseal window (2 cm × 2 cm) be made to access the depressed fragments. • This window can be made with osteotomes and needs to be large enough to allow access with instruments. • Three sides are released completely, with the fourth acting as a hinge. • Once accessed, elevate the depressed fragments and assess them radiographically. • These are provisionally held with K-wires. • Here again, the defect that has been created needs to be supported by appropriate bone graft or substitute prior to definitive fixation. • Isolated medial tibial plateau fractures • In these injuries, the fracture typically exits into the intercondylar notch, or onto the medial edge of the lateral plateau. • Reduce the medial fracture at the metaphysis (Fig. 44.16), and radiographically check the alignment of the articular surface and the tibia overall. • This reduction is held provisionally with K-wires through the wound or a reduction clamp through a small lateral incision. • Bicondylar tibial plateau fractures • The reduction of the articular surface in these injuries requires the use of two incisions unless the medial tibial plateau is nondisplaced or there is a large simple fragment that can be manipulated with a minimal incision and a reduction clamp. •  Generally the medial side is a simpler pattern and should be reduced and ­provisionally fixed first. The lateral side usually has a split-depression pattern and can be treated as such once the medial side has been reduced and ­stabilized. • A femoral distractor is placed, and the condylar fragments are reduced to each other and held together with a periarticular reduction clamp (Fig. 44.17A and B). • Here again, provisional subarticular K-wires are used to hold the fragments together (Fig. 44.17C). • Extraarticular proximal tibia fractures • Generally, closed reduction and percutaneous plate fixation is appropriate.

Reduction clamp

K-wires

FIG. 44.16 

553

PITFALLS

• In the setting of significant extraarticular comminution, the injury area should be bridged and the limb aligned. An attempt at an extensive anatomic ORIF of extraarticular fragments will compromise the biology of the fracture zone and lead to a higher risk of infection, nonunion, and malunion. • If the eminences are involved and displaced, these need to be addressed. They can be fixed with sutures passed through tunnels or screws if large enough. • With a powerful reduction clamp and articular comminution, overcompression of the condyles is possible and should be avoided. INSTRUMENTATION/IMPLANTATION

• A small tamp and large periosteal elevators (needed to elevate depressed articular fragments) • A large-fragment reduction clamp or a periarticular reduction clamp • A femoral distractor • Large-caliber K-wires CONTROVERSIES

• The technique described here involves reduction and fixation of the less comminuted condyle to the shaft first, followed by management of the more complex component. However, for some fracture patterns others may choose to reduce and fix the articular components of both condyles together first, followed by reduction and fixation of the articular block to the shaft.

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

554

A

B

C FIG. 44.17 

PEARLS

• The use of a tamp will allow for the maximum density of subarticular autogenous graft. • With the use of new injectable graft substitutes, this step can be done after plate fixation. • If bone graft substitutes are not available, any split-depression fracture should include draping of the iliac crest for bone graft. PITFALLS

• Failure to place graft prior to reducing the split in the condyle may require revision of the fixation midprocedure as this structural support is necessary. CONTROVERSIES

• There is level I clinical evidence for superiority of calcium phosphate cements in the radiographic support of articular fragments (Russell and Leighton, 2008). • Given the decreased morbidity and decreased surgical time, we favor the use of calcium phosphate paste in most cases.

Step 2: Placement of Bone Graft or Bone Graft Substitute • Split or split-depression lateral tibial plateau fractures • In a pure split fracture, this step is unnecessary. In a split-depression fracture, the void left after the elevation of the articular surface must be filled in order to structurally support the elevated articular surface (Fig. 44.18A). • Historically, this has been done with autogenous bone graft or donor allograft bone chips, but the options have evolved over time. • If autograft is going to be placed, this must be done prior to reduction of the split fragment (Fig. 44.18B). • Bone graft substitutes are also generally placed prior to closure of the split component, but some can be placed after. • Many osteoconductive structural bone substitutes are available on the market for this purpose. • Bone substitute pastes (i.e., calcium phosphate) have a consistency prior to drying that allows the injection of the substance through a small opening, and thus can be placed after the split is closed. • Pure depression lateral tibial plateau fractures • The support that the bone graft or graft substitute provides is equally essential here. • The cortical window used in Step 1 is used for placement of graft before closure of the cortical window. • Here again, injectable substitute bone graft allows placement at any time during the procedure. • Bicondylar tibial plateau fractures • In this fracture pattern, the creation of a single proximal fragment with this step is very important. • If a locked lateral plate is planned, this is the only chance to obtain compression between fragments. • Again, placement of the screws needs to be planned carefully to allow for placement of plates. 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

A

555

B FIG. 44.18 

Step 3: Fixation of Articular Surface • Split or split-depression lateral tibial plateau fractures • In a pure split fracture, fixation with large fragment AO screws with washers is sufficient, and this can often be done through a minimal incision (Fig. 44.19). • In a split-depression fracture, placement of provisional interfragmentary screws can compress the split fragment and allow placement of a plate without a clamp in place. • If a locked plate is planned, then this is the only chance to obtain compression between fragments. • Screws typically are placed lateral to medial. The number of screws needed depends on the fracture. • Large-fragment or small-fragment screws are appropriate; cannulated screws are useful in some instances. • Drilling can be done under fluoroscopic guidance to ensure that the drill is passing directly subchondral in order for the screws to act as a raft under the articular surface. • The ultimate plate must be chosen prior to this step, in order to ensure that the heads of these interfragmentary screws do not interfere with the plate. • Alternatively, careful positioning of the plate can allow interfragmentary screws to be placed through the plate to act both as a raft as well as to allow compression of the split component. • Pure depression lateral tibial plateau fractures • Once the depressed portion is elevated, place a raft of small-fragment screws subchondrally to support it (Fig. 44.20). • Plate fixation generally is not needed. • Isolated medial tibial plateau fractures • Although there is typically no impaction that needs to be addressed in these injuries, interfragmentary screws can be placed for compression at this stage. • Bicondylar tibial plateau fractures • In this fracture pattern, the next step is dictated by the fracture anatomy. • If a dual plating is planned, and the medial fragment is simple enough to allow for a metaphyseal reduction, then buttress plating of the medial fragment should be done prior to reduction of the two condyles together. • If the medial fracture is very simple, and a single lateral locked plate is planned, then the medial side is reduced to the lateral side using a reduction clamp, and fixation is placed between the condyles. • If a locked lateral plate is planned, this is the only chance to obtain compression between fragments. • Again, placement of the screws needs to be planned carefully to allow for placement of plates (Fig. 44.21).

PEARLS

• Satisfactory reduction of the articular surface must be obtained prior to placement of any intercondylar screws. • Careful fluoroscopy in the AP (10 degrees caudad) and lateral views will ensure that screws are out of the joint. • If a nonrafting proximal tibial plate is planned (i.e., less invasive stabilization system [LISS] plate), more subchondral screws are required at this stage.

PITFALLS

• The ideal position for subchondral screws at this stage will frequently be in the desired location for a periarticular plate, which has a specific anatomic location for fit. • If a locked plate is planned, the trajectory of the screws must be considered at this step, because screws through the plate cannot be redirected in a locked plate.

INSTRUMENTATION/IMPLANTATION

• Large-fragment AO screws • Small-fragment AO screws • 6.5-mm cannulated screws • Appropriate washers

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

556

INSTRUMENTATION/IMPLANTATION

• Periarticular precontoured plating system, either locking or nonlocking • Minimally invasive locked lateral plating system • Appropriate familiarity with the system, and availability of a scrub nurse who is also familiar, is essential. • Small-fragment set





• If the metaphyseal comminution on the medial side precludes a reliable extraarticular reduction there, then creation of a single proximal fragment can be done with a reduction clamp and the condyles fixed to each other at this step. • Extraarticular proximal tibia fractures • Generally, a laterally based precountoured locking plate is used for fixation. 

PEARLS

• Locked plating systems alone do not allow compression between fragments or revision of the reduction. • Locking screws will not compress the plate onto the tibia. • Inappropriate placement of a precontoured plate, and use of a compression screw or device, can lead to malreduction.

B

A

C FIG. 44.19 

CONTROVERSIES

• The timing of definitive fixation is controversial, and many would advocate a staged approach for all higher energy injuries. • We have found that avoiding injured anteromedial skin is possible, and have been aggressive in early ORIF provided incisions can be placed away from blisters. • Use of unilateral locking plate versus dual plating for comminuted bicondylar fractures: some literature suggests similar outcomes (Chang et al., 2016); some suggest higher incidence of loss of reduction with a unilateral locking plate (Weaver et al., 2012; Yoo et al., 2010). • In our experience, dual plating is recommended unless the medial fracture is simple and/or undisplaced.

A

B FIG. 44.20  Modified from www.aofoundation.org.

A

B FIG. 44.21 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

Step 4: Definitive Stabilization • Split or split-depression lateral tibial plateau fractures • A pure split fracture, if simple and if the bone is strong, can adequately be addressed with interfragmentary screws as definitive fixation. •  A split-depression fracture requires additional support for the depressed ­fragment. • There has been an evolution from standard plating systems to precontoured periarticular plating systems. • Generally, nonlocking plate technology is sufficient for this fracture pattern in patients with normal bone strength. Locking plates have the advantage of improved stability in osteoporotic bone. • Multiple small-fragment screws in a small-fragment plate provide better rafting than large-fragment screws in a large-fragment plate, and we favor their use in split-depression fractures. • The plate is placed over the lateral aspect of the exposed tibia, and a provisional K-wire is placed through either a screw hole or a specific wire hole, if the system supports it (Fig. 44.22A). • The distal end of the plate is secured to the shaft fragment first. • The subchondral screws are placed under fluoroscopic control (Fig. 44.22B). Remaining metaphyseal screws are then placed in the plate (Fig. 44.22C). • With the approach described here, the plate is placed over the ITB. If the ITB has been elevated, the plate is placed beneath it. This allows radiographic evaluation of the plate position to ensure that the screws are in the appropriate subchondral position (Fig. 44.23). • Pure depression lateral tibial plateau fractures • A subchondral raft of screws is typically sufficient in this setting. • Isolated medial tibial plateau fractures • A single posteromedial buttress plate is sufficient in the majority of these injuries (Fig. 44.24). • Medially based precontoured plates, or standard small-fragment plates, can be used. • Bicondylar tibial plateau fractures • There are multiple options here, and decision-making depends on the fracture anatomy and displacement. • In a fracture with comminution of the medial fracture at the metaphysis, dual plating is recommended (Fig. 44.25). • In this setting, the medial fragment should be buttressed with a small-fragment buttress plate first (Fig. 44.26A). • Next, the lateral side is reduced and plated with a periarticular plate similar to the method outlined above (Fig. 44.26B and 44.26C). • If there is extensive metaphyseal comminution, a minimally invasive plating system can be used to minimize soft-tissue stripping. • If the fracture is simple on the medial side (e.g., no comminution), the medial side may be reduced closed using a medial-sided femoral distractor or a reduction clamp. • In this setting, it is appropriate to use a single laterally based locked device (Fig. 44.27) (Yao et al., 2015). • This can be either an open plating system or a minimally invasive system. • Extraarticular proximal tibia fractures • The preferred method for extraarticular fractures is to perform a closed reduction with traction over a bump. • Minimally invasive plating techniques (i.e., LISS) allow for fixation without extensive stripping of the fracture site (Ricci et al., 2004). • Specialized equipment (threaded push-pull device) can be used to pull the diaphysis to the locked plate, which can be used as a reduction aid. 

557

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

558

A

B

C FIG. 44.22 

A

B FIG. 44.23 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

A

B FIG. 44.24 

A

B FIG. 44.25 

559

560

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

A

B

C

FIG. 44.26  Modified from www.aofoundation.org.

FIG. 44.27  Modified from www.aofoundation.org.

PEARLS

• The loss of articular reduction in initially stable fixation is rare. • The most common site of nonunion or malunion is at the metaphysis of a high-energy fracture. PITFALLS

• Because of proximity to the knee and the tenuous soft-tissue envelope around the proximal tibia, postoperative infections should be treated aggressively. Failure to treat an infection adequately, or to follow a patient closely, may result in soft-tissue loss, an infected nonunion, or septic arthritis of the knee.

Step 5: Closure • Copiously irrigate the wounds. • Deflate the tourniquet to allow for hemostasis and to minimize the chances of a postoperative hematoma. • Carefully repair the meniscus to the coronary ligament. • If the entire lateral exposure has been elevated as a sleeve, then pass the meniscal suture through it at measured intervals and tie it down when the sleeve is repaired (Fig. 44.28A). • If possible, the anterior compartment should be tacked over the lateral plate. If the ITB has been elevated and the plate placed beneath it, then repair the entire lateral layer (ITB, anterior compartment of lower leg) over the plate in a single layer (Fig. 44.28B). • Close the subcutaneous layer with interrupted absorbable suture. • Close the skin carefully and without tension. 

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

561

Meniscus Coronary ligament

A

Sutures

Sutures

Lateral plate

B FIG. 44.28 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES Postoperative Care • Wounds should be dressed with a sterile, nonbulky dressing. • The patient should be followed closely for wound complications and be seen in the clinic at 10 to 14 days postoperatively. • The leg should be placed in a rehabilitation brace, with no restrictions on range of motion unless there was a posterior shear injury. • Rehabilitation is the key to a good outcome in these cases, and active range of motion should be unrestricted and early. • The patient should be mobilized non–weight-bearing, or toe-touch weight-bearing, dependent on stability of the fracture pattern and fixation. • The patient should be counseled on ankle range-of-motion exercises to avoid the development of an equinus contracture. • Weight-bearing status should be advanced based on evidence of union, which typically occurs at 12 weeks. • Once weight-bearing status is advanced, the patient should be referred to physical therapy for gait retraining, proprioception retraining, and strengthening. 

Expected Outcomes • Outcome is determined by patient, injury, and surgical factors. • Results are dependent on reconstitution of normal alignment and articular reduction (Barei et al., 2006). • Long-term results are less favorable in higher energy injury patterns, but are overall very favorable (Rademakers et al., 2007).

CONTROVERSIES

• No convincing evidence suggests a risk of deep venous thrombosis (DVT), pulmonary embolism, or mortality with these injuries, and no clear guidelines exist for DVT prophylaxis. • At our institution, we do not routinely give prophylaxis to patients without major risk factors for DVT.

562

PROCEDURE 44  Proximal Tibia ORIF: Anterior Approaches

EVIDENCE 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;88:1712–1721. Level IV evidence that medial and lateral plating of bicondylar tibial plateau fractures through two incisions is associated with satisfactory outcome. Accuracy of articular reduction is associated with outcome. Chang H, Zhu Y, Zheng Z, et al. Meta-analysis shows that highly comminuted bicondylar tibial plateau fractures treated by single lateral locking plate give similar outcomes as dual plate fixation. Int Orthop. 2016;40:2129–2141. Level II evidence suggesting that both strategies of fixation are acceptable for these fractures, but recommending a need for further high quality randomized controlled trials (RCTs). Karunakar MA, Egol KA, Peindl R, et al. Split depression tibial plateau fractures: a biomechanical study. J Orthop Trauma. 2002;16:172–177. Biomechanical data supporting the use of a raft of subchondral screws to support elevated articular fragments and to delay weight-bearing after surgery for 10 to 12 weeks. Luo CF, Sun H, Zhang B, et al. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24:683–692. Level IV evidence supporting the three-column concept for approaches and fixation of complex tibial plateau fractures. Rademakers MV, Kerkhoffs GM, Sierevelt IN, et al. Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results. J Orthop Trauma. 2007;21:5–10. Level IV evidence that the long-term outcome of tibial plateau fractures is excellent following the use of standard surgical techniques. Malalignment of more than 5 degrees is associated with a higher risk of posttraumatic osteoarthritis. Ricci WM, Rudski JR, Borrelli J. Treatment of complex proximal tibia fractures using the less invasive stabilization system. J Orthop Trauma. 2004;18:521–527. Level IV evidence that a laterally placed locking plate can be used to treat complex tibial plateau fractures without the need for an additional medial buttress plate. Russell TA, Leighton RK. Comparison of autogenous bone graft and endothermic calcium phosphate ­cement for defect augmentation in tibial plateau fractures. J Bone Joint Surg [Am]. 2008;90:2057– 2061. Grade A recommendation for the use of calcium phosphate cement as a bone graft substitute for support of elevated articular fragments. (Level I study.) Weaver MJ, Harris MB, Strom AC, et al. Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury. 2012;43:864–869. Level III evidence suggesting that for bicondylar plateau fractures with a medial coronal fracture line there is a higher rate of subsidence and loss of reduction when lateral locked plating is employed alone compared with dual plating. Yao Y, Lv H, Zan J, et al. A comparison of lateral fixation versus dual plating for simple bicondylar fractures. Knee. 2015;22:225–229. Level I RCT: locking plate versus dual plating for bicondylar tibial plateau fractures with a relatively intact medial condyle demonstrating similar clinical, functional, and radiologic outcomes in both groups, but lower blood loss, operative duration, hospital stay, and delayed union in the locking plate group. Yoo BJ, Beingessner DM, Barei DP. Stabilization of the posteromedial fragment of bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods. J Orthop Trauma. 2010;69:148–155. Biomechanical study comparing different single and dual nonlocking and locking plating techniques in the bicondylar tibial plateau fracture pattern and load to failure of the posteromedial fragment. The authors concluded that dual plating with a conventional nonlocking plate construct tolerated higher loads and this was likely owing to the unreliable penetration of this fragment by lateral locking screws.

PROCEDURE 45

Fractures of the Posterior Tibial Plateau Peter J. O’Brien and Mark Miller

The three-column concept of tibial plateau fracture patterns is important for identifying and emphasizing shear fracture patterns that involve the posterior aspect of the tibial plateau. Most tibial plateau fractures involve the lateral tibial plateau, the medial plateau, or both (bicondylar) and are treated through an anterolateral with or without a posteromedial approach. This chapter deals with those fracture patterns that involve primarily the posterior column of the tibial plateau. They generally require reduction and fixation through approaches that expose the posterior aspect of the proximal tibia. Most posterior shear fractures involve the medial tibial plateau with or without extension to the posterior aspect of the lateral plateau. These fractures can generally be treated through a posteromedial approach, which will be described in the first part of this chapter. A small percentage of lateral tibial plateau fractures involve primarily the posterior aspect of the lateral plateau and require exposure of the posterior aspect of the lateral plateau only. That approach will be described in the second part of this chapter. The classic approach to the posterior aspect of the knee is through the popliteal fossa. This approach is excellent for managing posterior cruciate avulsion fractures. It requires dissection and exposure of the neurovascular bundle. That approach is not necessary for shear fractures of the posterior tibial plateau and will not be described here.

POSTEROMEDIAL APPROACH INDICATIONS • Shearing type fractures of the posterior tibial plateau involving the medial plateau with or without extension to the lateral plateau. 

EXAMINATION/IMAGING Plain X-Rays (AP/LAT) (Fig. 45.1A–B) • Full-length radiographs should be obtained to assess the terminal extent of the fracture and the columns involved. • Traction/stress radiographs can be helpful in assessing fracture morphology and associated ligamentous injuries, but are difficult to obtain in an awake patient. Consider obtaining these views intraoperatively, immediately after induction of general anesthesia, to guide surgical decision-making. 

PITFALLS

Failure to recognize an associated vascular or neurologic injury Failure to recognize an associated ligamentous or meniscal injury

CONTROVERSIES

• Injuries that require a posterior buttress plate cannot be managed with a medial approach. • Bicondylar fractures with a small posteromedial fragment can be managed with a limited posteromedial approach. • Injuries that are associated with a particularly significant soft-tissue injury are often treated using a staged surgical protocol with initial closed reduction and application of an external fixator prior to definitive management. A recent Canadian publication has demonstrated the safety and efficacy of early definitive management of these injuries in most patients. (Unno et al., 2017)

Computed Tomography (CT) (Fig. 45.2) • Generally considered mandatory to assess articular involvement, fracture comminution, presence of intraarticular loose bodies, and the fracture morphology 

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B FIG. 45.1 

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B FIG. 45.2 

PROCEDURE 45  Fractures of the Posterior Tibial Plateau

FIG. 45.3 

CT ANGIOGRAM • Should be obtained in the setting of questionable vascular examination distal to the site of injury or abnormal ankle-brachial index (ABI 3.5 cm above the joint line with a ruptured and unrepairable deltoid ligament (Boden et al., 1989). • Positive intraoperative Cotton test and modified Cotton test following malleolar fixation. • Increase in tibiofibular clear space > 1 mm on intraoperative external rotation stress view (Jenkinson, 2005). 

Examination/Imaging • Physical examination findings suggestive of an acute syndesmotic injury: • Tenderness and ecchymosis over the medial ankle and deltoid ligament. • Pain and tenderness over the anterior aspect of the distal tibiofibular joint. • Pain with compression of the tibia and fibula at the level of the calf and/or syndesmosis (squeeze test) (Teitz and Harrington, 1998). • Pain, swelling, ecchymosis, and deformity over the lateral and medial malleolus in the setting of an associated bony injury/fracture. 

Imaging • Plain radiographic views include anteroposterior (AP), mortise, and lateral views of the ankle as well as full-length AP and lateral views of the tibia and fibula to rule out proximal injuries and fractures. •  Traditional plain film parameters used to assess syndesmosis integrity include (Gardner et al., 2006; Harper and Keller, 2007):

PEARLS

• Syndesmotic injuries are often underappreciated in terms of their prevalence, the difficulty of obtaining an anatomic reduction, and the potential negative impact that these injuries can have on a patient’s long-term function. • The level of the fibular fracture should not be used to rule in or rule out syndesmosis injuries, as this has shown to be unreliable (Nielson et al., 2004). • Preoperative and intraoperative static imaging frequently miss syndesmosis injuries (Jenkinson et al., 2005). • Open reduction should be at least considered in all cases of documented syndesmosis injuries. • Syndesmotic malreduction is common and one of the most important predictors of poor outcome (Weening and Bhandari, 2005).

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PEARLS

• The syndesmosis must be assessed intraoperatively when treating all ankle fractures. • Intraoperative stress testing of the syndesmosis is of paramount importance in correctly assessing syndesmosis stability and is not replaced by preoperative plain radiographs or advanced imaging. • Diastasis of the syndesmosis occurs both in the coronal and sagittal planes. Sagittal instability and diastasis is most affected (Xenos et al., 1995; Candal-Couto et al., 2004). • If a posterior malleolus fracture is present, the PITFL is likely intact (Gardner et al., 2006).

• Tibiofibular clear space (AP and mortise) less than 6 mm. The distance between the medial border of the fibula and the lateral border of the posterior tibia at the incisura, 1 cm above the tibiotalar joint. • Tibiofibular overlap AP and mortise greater than 6 mm (AP, or 42% of the fibular width) and/or greater than 1mm (mortise), respectively. The overlap of the lateral malleolus and anterior tibial tubercle 1 cm above the tibiotalar joint. • Medial clear space (mortise) less than 5 mm. The distance between the medial border of the talus and lateral border of the medial malleolus at the level of the talar dome. • Plain radiographic views are also scrutinized for loose fragments in the syndesmosis or fractures of the anterolateral aspect of the distal tibia (Fig. 55.2). • Intraoperatively, these fragments are often much larger than what is appreciated on plain radiographs. • Radiographic views of the uninjured contralateral ankle are used for comparison. • Certain authors have found this comparative method to be the most accurate (Shah et al., 2012). • External rotation mortise stress views • The tibia is grasped and stabilized by the examiner while a gentle and constant external rotation force is applied to the neutral ankle under live fluoroscopy. • Advanced imaging • Preoperative computed tomography (CT) can detect small tibiofibular diastasis not evident on plain films (Fig. 55.3) (Ebraheim et al., 1997). • Postoperative CT scan detects syndesmosis malreduction not seen with intraoperative fluoroscopy (Fig. 55.4) (Gardner et al., 2006; Sagi et al., 2012). • Magnetic resonance imaging, when compared with the gold standard of ankle arthroscopy, had a sensitivity and specificity of 100% and 93%, respectively, for diagnosis of AITFL rupture (Oae et al., 2003). • Evidence • Diagnosis of syndesmosis injuries using physical examination and plain radiographic imaging has been shown to be unreliable (Clanton et al., 2016; Beumer et al., 2004). •  In purely soft-tissue syndesmosis injuries (without associated fracture), the squeeze test had a specificity of 88% and anterior syndesmosis tenderness had a sensitivity of 92% (Sman et al., 2015). 

FIG. 55.2 Syndesmosis injury associated with anterolateral distal tibia avulsion fragment. From Espinosa N, Smerek JP, Myerson MS. Acute and chronic syndesmosis injuries: pathomechanisms, diagnosis and management. Foot Ankle Clin 2006;11:642.

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FIG. 55.3  Advanced imaging such as computed tomography may detect distal tibiofibular disruptions not seen on plain radiographs. From Mosier-LaClair S, Pike H, Pomeroy G. Syndesmosis injuries: acute, chronic, new techniques for failed management. Foot Ankle Clinic 2002;7:553.

Syndesmosis mal reduction with rearward fibula

Posterior lip malreduced FIG. 55.4  Syndesmosis malreduction secondary to malreduction of posterior malleolus fracture. From Palmanovich E, Brin YS, Kish B, Nyska M, Hetsroni I. Value of early postoperative computed tomography assessment in ankle fractures defining joint congruity and criticizing the need for early revision surgery. J Foot Ankle Surg. 2016;55:468.

Positioning • The patient is placed in the supine position on a radiolucent operating table. • To improve visualization of the lateral ankle, a positioning pack, sandbag, or saline bag can be placed under the ipsilateral hip or thigh. • In cases in which a posterolateral approach is necessary, the patient can be placed in the lateral decubitus or prone position. • A thigh tourniquet is applied and inflated as needed. 

Exposures and Approaches • Lower extremity soft-tissue swelling is assessed preoperatively and the decision to proceed with temporizing or definitive surgical fixation is made. • Using plain and advanced imaging, the exposure will be determined by the fibula and/or tibia fracture location and pattern. • Combinations of posteromedial, direct lateral, anterolateral, posterolateral, or medial approaches may be used.

PITFALLS

• Plain radiographs can detect complete syndesmotic disruption (Joy et al., 1974; Pettrone et al., 1983; Sarkisian and Cody, 1976) but will often miss subtle injuries and disruptions (Ebraheim et al., 1997). • The variability in the shape and contour of the incisura can lead to misdiagnosing syndesmosis disruption and instability (Elgafy et al., 2010). • Repeated studies have shown that plain radiographs are likely not adequate to confirm appropriate syndesmosis reduction while CT is much more sensitive (Gardner et al., 2006; Sagi et al., 2012).

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PEARLS

• Open reduction and fixation of an unstable posterior malleolus fracture affords greater stability to the syndesmosis than syndesmotic screws (Miller et al., 2009; Gardner et al., 2006).

PITFALLS

• In the presence of a syndesmosis injury, malreduction of osseous fragments will lead to an unreducible or malreduced syndesmosis (Gardner et al., 2015). • Rotational malreduction of the lateral malleolus relative to the distal tibia is difficult to detect fluoroscopically (Marmor et al., 2011).

• A direct lateral or anterolateral approach to the fibula and ankle allows access to the fibula, anterolateral distal tibia, and the anterior ligaments of the syndesmosis (Video 55.1). • A posterolateral approach allows access to the fibula, the posterior tibia, and posterior elements of the syndesmosis. • A single oblique lateral incision can also be used, which allows access to both the posterior malleolus and anterior aspects of the syndesmosis (Choi et al., 2015; McGoldrick et al., 2016). 

Procedure: Open Syndesmotic Reduction and Fixation Step 1: Malleolar Reduction and Fixation • The lateral malleolus is anatomically reduced and internally fixed to restore lateral column length and rotation relative to the distal tibia. • The medial malleolus fracture is anatomically reduced and internally fixed. • The posterior malleolus fracture is reassessed fluoroscopically; the decision to perform an open reduction and internal fixation is then made. 

Step 2: Intraoperative Syndesmosis Disruption and Stability Testing • Once malleolar reduction and fixation have been achieved, intraoperative fluoroscopy is used to reevaluate static radiographic parameters, which are compared to the preoperative plain imaging. • Comparative static plain radiography using the uninjured contralateral ankle can also be used and may be more accurate. • Intraoperative stress testing should be performed (Jenkinson et al., 2005). • External rotation stress testing is performed, looking for tibiofibular clear space widening, talar shift, and medial clear space widening (> 2 mm; Videos 55.2 and 55.3). • The syndesmosis can be distracted by inserting a Cobb elevator into the joint and applying an external rotation and posterior force (Fig. 55.5) • An anterior to posterior and direct lateral fibular distraction stress test can be performed with the ankle in 15° of internal rotation by grasping the fibula with a sharp reduction clamp and applying a gentle lateral or posterior distraction force under direct visualization or under live fluoroscopy (Cotton, 1910). • Translation in both the coronal plane (AP, mortise) and the sagittal plane (lateral) should be tested intraoperatively (Candal-Couto et al., 2004). • Direct evaluation of the distal tibiofibular joint and syndesmotic ligaments via arthroscopy has also been described (Sri-Ram and Robinson, 2005; Takao et al., 2003). 

FIG. 55.5  Syndesmosis injury demonstrated intraoperatively by placing a Cobb elevator within the joint and applying an external rotation stress force.

PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches

Video 55.1 Open approach to the syndesmosis. Video 55.2 Intraoperative external stress test—Clinical. Video 55.3 Intraoperative external stress test—Fluoroscopy.

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Step 3: Open Anterior Syndesmotic Reduction • Following malleolar reduction and fixation, if syndesmotic instability persists, open reduction of the syndesmosis is performed. • The anterior syndesmosis and AITFL are approached through the anterolateral incision. • A full-thickness cutaneous flap is elevated anteriorly. • The extensor retinaculum is encountered and released from the anterior surface of the distal fibula, which allows direct visualization of the anterior syndesmotic ligaments (Fig. 55.6). • The tibiotalar joint is inspected for impaction injuries, chondral damage, and loose bodies. • The syndesmosis is opened, irrigated, and debrided of hematoma, soft tissue, and bony fragments. • The syndesmosis is then directly reduced. • The anteromedial edge of the fibular cartilage is aligned with its counterpart on the anterolateral tibia (Sagi et al., 2012). • Above the level of the joint, the fibula is directly observed in its reduced position within the incisura (Miller et al., 2009). • Fluoroscopy is used to confirm that the talus is anatomically reduced under the tibial plafond. • The reduction is held in position with a pelvic reduction clamp, reduction tenaculum, or with manual compression at the level of the syndesmosis. • Correct clamp positioning is paramount in order to obtain an anatomic reduction. • Pelvic clamps and tenaculums have a tendency to overcompress the syndesmosis (Miller et al., 2013). •  Phisitkul et al. (2012) found that the most accurate reductions were obtained when clamp tines were placed on the lateral malleolar ridge of the fibula and the center of the anteroposterior width of the tibia 10 mm above the joint. • A study by Haynes et al. (2016) found a clamp reduction force of 130N to be ideal while 88N and 163N led to undercompression and overcompression, respectively. • Reduction clamps that are placed too proximal or distal may result in coronal plane malreduction (Gardner et al., 2007). • Foot position (neutral vs. 10° of dorsiflexion) during syndesmosis reduction and fixation remains an unresolved area of controversy (Tornetta et al., 2001; Nault et al., 2016). 

FIG. 55.6 Anterolateral approach demonstrating avulsed anterior inferior tibiofibular ligament. From Coughlin M, Saltzman C, and Anderson R, eds. Mann’s Surgery of the Foot and Ankle, 2-Volume Set. 9th ed. Expert Consult. Philadelphia: Elsevier; 2014:1585.

PITFALLS

• Small changes in tine position can dramatically alter the position of the fibula within the syndesmosis (Miller et al., 2009; Phisitkul et al., 2012). • Syndesmosis instability and the direction of malreduction are difficult to detect even in the hands of experienced surgeons (Lucas et al., 2016). • Although both open and closed methods of syndesmosis reduction are described, the rate of malreduction following closed reduction is significantly higher (Sagi et al., 2012).

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Step 4: Syndesmotic Stabilization Syndesmotic Screw Stabilization • Following syndesmosis reduction, one (or two) fully threaded 3.5-mm (or 4.5-mm) screw is advanced across the syndesmosis. • The patient’s size and bone quality should be taken into account when choosing the size of the screws and number of cortices, with larger patients or poorer bone quality requiring greater fixation. • Screw placement should be 2 to 5 cm proximal to the tibiotalar joint (McBryde et al., 1997; Kukreti et al., 2005). • Screw trajectory should be 30° oblique in the coronal plane from posterolateral to anteromedial and parallel to the tibial plafond (Fig. 55.7) (Muller et al., 1991; Zalavras and Thordarson, 2007). • Screws should be tricortical or quadricortical and should not be lagged to avoid overcompression of the syndesmosis. • Quadricortical screws allow for easier access for later removal.

Evidence: Syndesmotic Screw Stabilization. • Although screw fixation is considered the gold standard for syndesmosis fixation, concerns remain regarding rigidly fixing a structure that has inherent physiologic motion as well as screw loosening, screw breakage, and the need for secondary procedures to remove the hardware. •  Studies have suggested that larger-diameter screws have increased strength, are less likely to break, and their larger head makes removal easier (Hoiness and Stromsoe, 2004). • Small-fragment screws potentially cause less soft-tissue and bony injury when they loosen and may be less likely to require removal. • However, multiple studies have shown no difference in functional or radiographic outcome when comparing screw diameter, material, or number of cortices (Thompson and Gesink, 2000; Beumer et al., 2005). • Studies have shown equal functional outcomes and range of motion when comparing metallic and bioabsorbable syndesmotic screws, although the latter have shown a potential increase in total complications (van der Eng et al., 2015). 

Dynamic Syndesmotic Suture Button Fixation • Following anatomic reduction of the malleolar fractures and the syndesmosis, for the TightRope system (Arthrex, Naples, FL; available at www.ankletightrope.com), a 3.5-mm quadricortical drill hole is made from the fibula into the tibia approximately 2 cm above the tibiotalar joint.

A

30°

B

C

FIG. 55.7  Syndesmosis screw trajectory. From Carr JB, Trafton PG. Malleolar fractures and soft tissue injuries of the ankle. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia: W. B. Saunders; 2012:320-332.

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• TightRope is composed of two #5 braided polyester sutures stretching between two stainless steel buttons. • The drilling trajectory follows an oblique angle of approximately 30° from posterolateral to anteromedial, parallel to the tibiotalar joint. • A long straight needle is advanced through the drill hole, shuttling the leading pullthrough sutures of the TightRope system (Fig. 55.8A–B). • Under fluoroscopic guidance, the oblong button is pulled through the medial tibial cortex and deployed into position. • Using the pulley sutures, the lateral button is pulled into position on the lateral cortex of the fibula (through or outside the plate if fibular bone permits; Fig. 55.9).

Evidence: Suture-Button Fixation. • Certain studies have shown faster return to work, improved ankle scores at 3 months and 1 year, and less secondary procedures required for implant removal (Thornes et al., 2005; Schepers, 2012). • Several studies have shown a trend toward improved outcomes when compared with screw fixation. However, these studies lacked statistical power (Laflamme et al., 2015; Coetzee and Ebeling, 2009).

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B

FIG. 55.8 (A,B)  The TightRope (Arthrex, Naples, FL) being deployed with postoperative radiographs. From Pena FA, Coetzee JC. Ankle syndesmosis injuries. Foot Ankle Clin 2006;11:44.

FIG. 55.9  Intraoperative photograph of the TightRope (Arthrex, Naples, FL). From Rigby RB, Cottom JM. Does the Arthrex TightRope provide maintenance of the distal tibiofibular syndesmosis? A 2 year follow up of 64 TightRopes in 37 patients. J Foot Ankle Surg. 2013;52:563.

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• A cadaveric study compared one 3.5-mm syndesmotic screw, 1-suture-button construct, and 2-divergent-suture-button construct and found that all provided comparable rotational stability. Screw fixation allowed for the smallest amount of posterior translation while the 2-divergent-button construct allowed for the most translation and was thought to be insufficient in providing stability in the sagittal plane (Clanton et al., 2016). • Complications include the following: swelling and tenderness over the medial and lateral buttons, requiring hardware removal (Willmott and David, 2009); osteolysis; button subsidence; tibial tunnel enlargement (Degroot et al., 2011); recurrent diastasis; and synostosis (Treon et al., 2011). • The rate of implant removal is between 0% and 25% (Schepers, 2012). 

Anterior Inferior Tibiofibular Ligament Repair • Following malleolar reduction and fixation, the AITFL is exposed. • The ligament is 20 to 30 mm in length, 18 mm in width, and 2 to 4 mm thick. • In the majority of cases, it is avulsed from its fibular insertion; however, tibial avulsion can also occur. • Depending on the avulsion site, the insertion or the origin is prepared with a rongeur and a 3.5-mm suture anchor with two FiberWire sutures is advanced into position. • A modified Mason-Allen suture is then used to secure the ligament to bone. • The soft-tissue repair is augmented with either a syndesmotic screw or syndesmotic suture button fixation described earlier. • Other techniques of AITFL repair have been described, including primary suture repair with syndesmotic screw augmentation (Babis et al., 2000), repair with staple augmentation (Cedell, 1965; Kelikian, 1985), and AITFL reconstruction using extensor tendons of the lesser toes (Nelson, 2006). 

Posterior Inferior Tibiofibular Ligament Repair (as described by Little et al., 2015) • The patient is placed prone or in the lateral decubitus position. • A posterolateral approach is developed using the interval between the peroneals and flexor hallucis longus. • The fibula is anatomically reduced and fixed with a posterolateral or direct lateral plate depending on the fracture pattern. • The syndesmosis is stressed intraoperatively; if found to be deficient, the approach can be further developed onto the posterior aspect of the tibia in order to expose the PITFL. • The avulsed PITFL tissue sleeve is repaired to the posterior tibia with a 3.5-mm cortical screw with a soft-tissue washer. • An external rotation stress test under fluoroscopy is then performed. If there is increased lateral talar tilt or > 5 mm medial clear space widening, the deep and superficial components of the deltoid ligament should also be repaired. PEARLS

• The surgeon must be mindful that all described fixation methods tend to lead to overcompression of the syndesmosis (Schon et al., 2016).

Evidence: Posterior Inferior Tibiofibular Ligament Repair. • Little et al. (2015) compared 45 patients with SER-IV ankle fractures with syndesmosis injuries. Half of the patients were treated with syndesmosis screws; the other half had an anatomic repair of PITFL ± deltoid ligament. The ligamentous repair group had lower rates of syndesmotic malreduction (33.3% vs. 7.4%) and secondary operative procedures (78% vs. 11%). 

Intraoperative Syndesmosis Assessment: Following Fixation • Following reduction and stabilization of the syndesmosis, static radiographic parameters are reassessed. • An external rotation or fibular distraction stress view is performed. • Less than 1 mm of tibiofibular diastasis confirms syndesmosis stability (Fig. 55.10 and Videos 55.4 and 55.5).

PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches

Video 55.4 Intraoperative external stress test—Following repair. Video 55.5 Intraoperative external stress test—Following repair.

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FIG. 55.10  Following bony fixation, a lateral distraction test can be performed to assess syndesmosis integrity. From Carr JB, Trafton PG: Malleolar fractures and soft tissue injuries of the ankle. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia: W. B. Saunders; 2012:320-332.

• Summers et al. (2013) described a plain radiographic technique using preoperative mortise and perfect lateral radiographs of the uninjured ankle. The mortise was used to judge lateral malleolus length and rotation. On the lateral view, the distance between the posterior surface of the posterior malleolus and the overlying fibula were used to judge syndesmosis reduction. • Intraoperative three-dimensional fluoroscopic imaging has been shown to improve detection of syndesmotic malreduction when compared with plain radiographs and stress imaging (Franke et al., 2012). • Although open syndesmotic reduction leads to lower malreduction rates, the rates remain high. This has prompted certain authors to suggest that either routine intraoperative or postoperative CT be used to assess syndesmosis reduction (Sagi et al., 2012). 

Deltoid Ligament Repair • Deltoid ligamentous complex repair in the setting of ankle fracture and syndesmosis fixation is controversial. • Up to 40% of ankle fractures have deltoid ligament disruption (Hintermann et al., 2000). • Significant medial ankle swelling and ecchymosis is often seen following deltoid ligamentous complex disruption (Fig. 55.11). • Preoperative plain radiographs and stress views are scrutinized for syndesmosis disruption and medial clear space widening (Fig. 55.12). • Following bony reduction and stabilization, an external rotation stress view is performed looking for residual medial space widening. • A 4-cm longitudinal incision is centered over the anterior aspect of the medial malleolus starting approximately 2 cm above the distal point of the malleolus. • The superficial and deep deltoid ligaments are identified. • The deltoid fibers are often avulsed from the medial malleolus, leaving it bare. • The deltoid is often folded into the medial recess (Fig. 55.13) • One or two 3.5-mm suture anchors are advanced into the medial malleolus 0.5 to 1 cm proximal to its distal edge. • The superficial and deep deltoid ligaments are repaired as a sheath with a horizontal mattress or Mason-Allen suture (Fig. 55.14). 

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FIG. 55.11  Medial ankle ecchymosis associated with acute deltoid ligamentous complex disruption.

FIG. 55.12  Increased tibiofibular and medial clear space.

FIG. 55.13  Superficial and deep deltoid ligamentous disruption is identified. An associated talus osteochondral injury is also appreciated.

PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches

FIG. 55.14  The superficial and deep deltoid ligaments are repaired with a 3.5-mm suture anchor.

Postoperative Management • The lower leg is dressed appropriately and a three-sided plaster splint is applied. • The patient is made non–weight bearing and discharged home the same day, pain permitting. • The patient is seen at 2 weeks postoperatively for removal of splint, wound assessment, and removal of sutures and staples, soft tissue permitting. • Initiation of weight bearing and management of the syndesmosis screw is an area of controversy. Treatment options include the following: • Non–weight bearing for 12 weeks, allowing the syndesmotic ligaments to heal and avoid hardware complications. • Weight bearing is allowed at 6 to 8 weeks postoperatively, but screw breakage or loosening may occur with potential screw removal being required. • Weight bearing is allowed at 6 to 8 weeks postoperatively with splints and braces and scheduled elective or symptomatic syndesmosis screw removal.

Evidence: Postoperative Management • Studies have been unable to show a significant advantage of routine screw removal before weight bearing versus allowing screws to break following weight bearing (Hsu, et al., 2011; Hamid et al., 2009). • Early screw removal has been associated with recurrence of syndesmosis diastasis (Ebraheim et al., 1997; Reckling et al., 1981). • A retrospective study by Manjoo et al. (2010) reviewed 106 patients following syndesmosis fixation and found that patients with fractured, loosened, or removed screws scored better on the Lower Extremity Measure Questionnaire and the Olerud Molander Ankle Score compared with patients with intact hardware. The authors recommended screw removal at 6 months if still intact. • The cost of elective screw removal is not insignificant and was found to be approximately $3600 per patient when considering only operating room time (Lalli et al., 2015). • The optimal time to routine screw removal is not currently known (Van Vlijmen et al., 2015; Hsu et al., 2011). • Currently, the most popular treatment protocol among members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot & Ankle Society (AOFAS) is syndesmosis fixation using one or two 3.5-mm screws, engaging four cortices that are removed electively at 3 months (Bava et al., 2010). 

Outcomes: Syndesmosis • Several studies have shown the rate of syndesmosis malreduction to be between 16% and 50% (Gardner et al., 2006; Sagi et al., 2012; Weening et al., 2005). • Syndesmosis malreduction and subsequent instability is associated with poor longterm outcomes (Pettrone et al., 1983; Leeds and Erlich, 1984; Chissell and Jones, 1995).

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•  In a study looking at variables affecting outcome—including fixation technique, screw size, and number of cortices—the only predictor of outcome was syndesmosis malreduction, which was associated with a negative outcome (Weening et al., 2005). • Postoperative synostosis is a frequent complication but does not seem to affect functional outcome (Droog et al., 2015). 

ANKLE FRACTURES—POSTERIOR APPROACHES Introduction • Surgical indications for a posterior malleolus fracture include a displaced fracture fragment measuring greater than 25% to 33% in the anteroposterior dimension of the distal tibial articular surface (Grantham, 1990; Carr, 2003). • Both posteromedial and posterolateral approaches have been described for fixing posterior malleolar fractures (Marsh and Saltzman, 2001; Talbot et al., 2005). • Whether the posterior malleolus fracture requires fixation is a controversial topic. Some authors have found surgical fixation to have no impact on functional outcome or ankle stability (Harper and Hardin, 1988; Langenhuijsen et al., 2002), while others have shown significant improvements following surgical fixation (Jaskulka et al., 1989). • A study surveying surgical practices found significant variability in the management of posterior malleolar fractures among orthopedic surgeons (Gardner et al., 2011). • A study by Drijfhout et al. (2015) found that in posterior malleolar fractures treated with a percutaneous reduction followed by anterior to posterior screw fixation, 42% of patients were left with an articular gap greater than 1 mm. Huber et al. found that direct reduction of the posterior malleolus achieved an anatomic reduction in a significantly greater percentage of cases when compared with indirect percutaneous reductions with anterior to posterior screws (83% vs. 27%). 

Surgical Anatomy • The PITFL originates from the posterolateral tubercle of the distal tibia (Volkmann tubercle) and inserts into the posterior surface of the distal fibula. • The sural nerve anatomy is highly variable. It crosses the lateral border of the Achilles tendon 9.8 cm proximal to its insertion in the calcaneus (Webb et al., 2000); at 7 cm proximal to the tip of the lateral malleolus, it is located 26 mm posterior to the edge of the fibula and gives off lateral calcaneal branches in the retromalleolar region (Lawrence and Botte, 1994). • A cadaveric study found the tibialis anterior tendon to be the most commonly injured structure. It was injured 52% of the time from Kirschner wires inserted from posterior to anterior during open fixation of posterior malleolar fractures (Karbassi et al., 2016). 

Posterolateral Approach (Hoppenfeld and deBoer, 1994; Talbot et al., 2005; Tornetta et al., 2011) Indications • AO 44 B3, C1, C2, and C3 fractures requiring reduction and fixation of the posterior malleolus. • Lauge-Hansen supination external rotation 4 injuries. • Posterior malleolar fracture associated with posterior ankle instability on plain films or advanced imaging. 

Positioning • For access to the posterior, lateral, and medial malleoli, the patient is placed in the prone position with a bump under the ipsilateral thigh/hip. • A foam cushion can be placed under the distal aspect of the lower leg to allow knee flexion and maximal ankle dorsiflexion. • If fixation of the medial malleolus is not required, the lateral decubitus position is also acceptable. • A thigh tourniquet is applied and inflated as needed. 

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Approach (Fig. 55.15) • An 8- to 12-cm longitudinal incision is made between the lateral border of the Achilles tendon and just medial to the posterior border of the fibula. • The sural nerve and small saphenous vein are visualized and protected. • The peroneal tendon sheath is incised and the tendons are retracted medially in order to address the lateral malleolar fracture. The lateral malleolar fracture may be fixed immediately or exposed and addressed later.

A1

A2

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E2

FIG. 55.15  Posterolateral approach to the ankle. From Coughlin M, Saltzman C, and Anderson R, eds. Mann’s Surgery of the Foot and Ankle, 2-Volume Set. 9th ed. Expert Consult. Philadelphia: Elsevier; 2014:2019.

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• The interval between the peroneal tendons, Achilles tendon, and flexor hallucis longus (FHL) tendon is developed. • The FHL tendon is bluntly elevated off the posterior aspect of the distal tibia and interosseous membrane and the muscle belly retracted medially, exposing the fracture. • Peroneal arterial branches should be identified and avoided. • Care is taken to identify the PITFL without damaging the ligament. The fracture fragment may be booked open in the medial to lateral direction. • The posterior malleolar fracture is usually displaced proximal and lateral due to the pull of the PITFL. • A dental pick, bone tamp, or picador ball spike can then be used to reduce the fracture fragment while applying dorsiflexion to the ankle. The reduction is held with Kirschner wires and confirmed fluoroscopically. • Lag screw ± an undercontoured buttress plating fixation can then be applied. • Using this approach, Tornetta et al. (2011) had a 22% complication rate, including a 9.7% rate of skin edge necrosis and 4.2% rate of sural nerve injuries. Similarly, Verhage et al. (2016) had a 4% sural nerve injury rate, all of whom recovered and a 2% superficial wound infection rate. 

Posteromedial Approach Indications • AO 44 A3 fractures with posterior comminution and/or posterior extension of a medial malleolar fracture. • Supination adduction ankle fractures with posterior extension or comminution. 

Positioning • The patient is placed in the supine position on a radiolucent operating room table. • If the lateral ankle is to be approached first, a positioning pack, sandbag, or saline bag can be placed under the ipsilateral hip or thigh and removed during the case. • A thigh tourniquet is applied and inflated as needed. 

Approach • An 8- to 12-cm longitudinal incision is made between the medial border of the Achilles tendon and the posteromedial border of the distal tibia and follows the course of the posterior tibial tendon distally. • Full-thickness flaps are developed, which help prevent postoperative wound complications. • Sharp dissection is carried through subcutaneous fat onto the deep fascia of the posteromedial muscle bellies, tendons, and neurovascular bundle. • Incise the posteromedial retinaculum, leaving a cuff for later repair. • For more posteromedial access, the interval between the tibialis posterior and flexor digitorum longus (FDL) can be used while more posterolateral access is achieved by exploiting the interval between the FDL and FHL, although this latter interval requires exposure and protection of the posteromedial neurovascular bundle. • Other posteromedial approaches have included dissecting the tibialis posterior and FDL in order to retract them anteriorly to improve exposure (Mizel and Temple, 2004) or complete soft-tissue release of the posterior malleolus with lateral subluxation of the talus (Grantham, 1990).

EVIDENCE Babis GC, Papagelopoulos PJ, Tsarouchas J, et al. Operative treatment for Maisonneuve fracture of the proximal fibula. Orthopedics. 2000;23:687–690. Bava E, Charlton T, Thordarson D. Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons. Am J Orthop (Belle Mead, NJ). 2010;39:242–246. Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227–234. Beumer A, Campo MM, Niesing R, Day J, Kleinrensink G-J, Swierstra BA. Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury. 2005;36:60–64.

PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches Boden SD, Labrapoulos P, McCowin P, et al. Mechanical considerations for the syndesmosis screw. A cadaveric study. J Bone Joint Surg [Am]. 1989;71:1548–1555. Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ. Instability of the tibio-fibular syndesmosis: Have we been pulling in the wrong direction? Injury. 2004;35(8):814–818. Carr J. Malleolar fractures and soft tissue injuries of the ankle. In: 3rd ed. Browner B, Jupiter J, Levine A, Trafton P, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. Vol. 2. Philadelphia: Elsevier Science; 2003:2307–2374. Cedell CA. Outward rotation-supination injuries of the ankle. Clin Orthop Rel Res. 1965;42:97–100. Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. J Bone Joint Surg [Br]. 1995;77:435–438. Choi JY, Kim JH, Ko HT, Suh JS. Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture. J Foot Ankle Surg. 2015;54:559–564. Clanton TO, Williams BT, Backus JD, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int. 2017: 38(1): 66–75. Coetzee J, Ebeling P. Treatment of syndesmoses disruptions: a prospective, randomized study comparing conventional screw fixation vs TightRope fiber wire fixation—medium term results. South Afr Orthop J. 2009;8:32–37. Cotton FJ. The foot and ankle. In: Fractures and Joint Dislocations. Philadelphia: WB Saunders; 1910. Danis R. Les fractures malleolaires. In: Danis R, ed. Theorie Et Pratique De L’osteosynthese. Paris: Masson; 1949. Degroot H, Al-Omari AA, El Ghazaly SA. Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int. 2011;32:250–256. Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. Foot Ankle Int. 2015;36:673– 678. Droog R, Verhage SM, Hoogendoorn JM. Incidence and clinical relevance of tibiofibular synostosis in fracture of the ankle which have been treated surgically. Bone Joint J. 2015;97-B(7):945–949. Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997;18:693–698. Edwards Jr GS, DeLee JC. Ankle diastasis without fracture. Foot Ankle. 1984;4:305–312. Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol. 2010;39(6):559–564. Franke J, von Recum J, Suda AJ, Grutzner PA, Wendl K. Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Joint Surg [Am]. 2012;94:1386–1390. Grantham SA. Trimalleolar ankle fractures and open ankle fractures. Instr Course Lect. 1990;39:105– 111. Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32(4):385–393. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788–792. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165–171. Gardner MJ, Graves ML, Higgins TF, Nork SE. Technical consideration in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg. 2015;23:510–518. Hamid N, Loeffler BJ, Braddy W, Kellam JF, Cohen BE, Bosse MJ. Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg [Br]. 2009;91(8):1069–1073. Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg [Am]. 1988;70:1348–1356. Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10:156–160. Haynes J, Cherney S, Spraggs-Hughes A, McAndrew CM, Ricci WM, Gardner MJ. Increased reduction clamp force associated with syndesmotic overcompression. Foot Ankle Int. 2016;37(7):722–729. Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg [Br]. 2000;82(3):345–351. Hoiness P, Stromsoe KJ. Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation. J Orthop Trauma. 2004;18:331–337. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 2nd ed. Philadelphia: J. B. Lippincott Company; 1994. Hsu YT, Wu CC, Lee WC, Fan KF, Tseng IC, Lee PC. Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function. Int Orthop. 2011;35(3):359–364. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565–1570. Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005;19(9):604–609. Jones M, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Rel Res. 2007;455:173–175.

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PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches Joy G, Patzakis MJ, Harvey Jr JP. Precise evaluation of the reduction of severe ankle fractures. J Bone Joint Surg. 1974;56-A:979–993. Karbassi JA, Braziel A, Garas PK, Patel AR. Open reduction internal fixation of posterior malleolus fractures and iatrogenic injuries. A cadaveric study. Foot Ankle Spec. 2016. Epub ahead of print. Kelikian H. Disorders of the Ankle. Philadelphia: WB Saunders; 1985. Kukreti S, Faraj A, Miles J. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury. 2005;36:1121–1124. Laflamme M, Belzile EL, Bedard L, van den Bekerom MPJ, Glazebrook M, Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015;29:216–223. Lalli TA, Matthews LJ, Hanselman AE, Hubbard DF, Bramer MA, Santrock RD. Economic impact of syndesmosis hardware removal. Foot. 2015;25(3):131–133. Langenhuijsen JF, Heetveld MJ, Ultee JM, et al. Results of ankle fractures with involvement of the posterior tibial margin. J Trauma. 2002;53:55–60. Lauge-Hansen N, Ankelbrud I. Genetisk Diagnose Og Reposition. Dissertation, Copenhagen, Munksgaard; 1942. Lawrence SJ, Botte MJ. The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications. Foot Ankle Int. 1994;15(9):490–494. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg [Am]. 1984;66:490–503. Little MMT, Berkes MB, Schottel PC, et al. Anatomic fixation of supination external rotation type IV equivalent ankle fractures. J Orthop Trauma. 2015;29:250–255. Lucas DE, Watson BC, Simpson GA, Berlet GC, Hyer CF. Arthroscopic Evaluation of Syndesmotic Instability and Malreduction; 2016. Foot & Ankle Specialist. Epub. Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma. 2010;24(1):2–6. Marmor M, Hansen E, Han HK, Buckley J, Matityahu A. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot Ankle Int. 2011;32(6):616–622. Marsh JL, Saltzman C. Ankle fractures. In: 5th ed. Bucholz R, Heckman J, eds. Rockwood and Green’s Fractures in Adults. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2001:2001–2090. McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int. 1997;18:262–266. McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1328–1337. McGoldrick NP, Murphy EP, Kearns SR. Single oblique incision for simultaneous open reduction and internal fixation of the posterior malleolus and anterior syndesmosis. J Foot Ankle Surg. 2016;55(3):664–667. Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009;30(5):419–426. Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma. 2013;27:100–106. Mizel MS, Temple HT. Technique tip: revisit to a surgical approach to allow direct fixation of fractures of the posterior and medial malleolus. Foot Ankle Int. 2004;25:440–442. Muller ME, Algower M, Schneider R, et al. Malleolar fractures. In: Manual of Internal Fixation. 3rd ed. New York: Springer-Verlag; 1991:595–612. Nault M-L, Marien M, Hebert-Davies J, et al. MRI quantification of the impact of ankle position on syndesmosis anatomy. Foot Ankle Int. Epub. 2016. Nelson OA. Examination and repair of the AITFL in transmalleolar fractures. J Orthop Trauma. 2006;20(9):637–643. Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous membrane tears to the level of the fracture. J Orthop Trauma. 2004;18:68–74. Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003;227(1):155–161. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994;10:558–560. Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg. 1983;65-A:667–677. Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL. Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg [Am]. 2012;94(24):2256–2261. Porter DA, May BD, Berney T. Functional outcome after operative treatment for ankle fractures in young athletes: a retrospective case series. Foot Ankle Int. 2008;29(9):887–894. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg. 1976;58A:356–357. Reckling FW, McNamara GR, DeSmet AA. Problems in the diagnosis and treatment of ankle injuries. J Trauma. 1981;21:943–950. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow up. J Orthop Trauma. 2012;26(7):439–443.

PROCEDURE 55  Ankle Fractures: Syndesmosis and Posterior Approaches Sarkisian JS, Cody GW. Closed treatment of ankle fractures: a new criterion for evaluation–a review of 250 cases. J Trauma. 1976;16:323–326. Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop. 2012;36(6):1199–1206. Schon JM, Williams BT, Venderley MB, et al. A 3-D CT analysis of screw and suture-button fixation of the syndesmosis. Foot Ankle Int. 2016. Epub ahead of print. Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int. 2012;33(10):870–876. Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med. 2015;49(5):323–329. Sri-Ram K, Robinson AH. Arthroscopic assessment of the syndesmosis following ankle fracture. Injury. 2005;36(5):675–678. Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma. 2013;27(4):196–200. Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis: the role of arthroscopy of the ankle. J Bone Joint Surg Br. 2003;85(3):324–329. Talbot M, Steenblock TR, Cole PA. Posterolateral approach for open reduction and internal fixation of trimalleolar ankle fractures. Can J Surg. 2005;48(6):487–490. Teitz CC, Harrington RM. A biochemical analysis of the squeeze test for sprains of the syndesmotic ligaments of the ankle. Foot Ankle Int. 1998;19:489–492. Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws. Foot Ankle Int. 2000;21:736–741. Thornes B, Shannon F, Guiney AM, Hession P, Masterson E. Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clin Orthop Relat Res. 2005;431:207–212. Tornetta III P, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg [Am]. 2001;83(4):489–492. Tornetta P, Ricci W, Nork S, Collinge C, Steen B. The posterolateral approach to the tibia for displaced posterior malleolar injuries. J Orthop Trauma. 2011;25:123–126. Treon K, Beastall JE, Kumar K, Hope MJ. Complications of ankle syndesmosis stabilisation using a tightrope. J Bone Joint Surg [Br]. 2011;93B:62e. van der Eng DM, Schep NW, Schepers T. Bioabsorbable versus metallic screw fixation for tibiofibular syndesmotic ruptures: a meta analysis. J Foot Ankle Surg. 2015;54(4):657–662. Van Vlijmen, Denk K, Van Kampen A, Jaarsma RL. Long-term results after ankle syndesmosis injuries. Orthopedics. 2015;38(11):e1001–e1006. Verhage SM, Boot F, Schipper IB, Hoogendoorn JM. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J. 2016;98-B:812–817. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int. 2000;21:475–477. Weber BG. Die Verletzungen Des Oberen Sprunggelenkes. 2nd ed. Berne: Verlag Hans Huber; 1972. Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19(2):102–108. Willmott HJS, David BS. Outcome and complications of treatment of ankle diastasis with tightrope fixation. Injury. 2009;40(11):1204–1206. Xenos J, Hopkinson WJ, Mulligan ME, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation and radiographic assessment. J Bone Joint Surg. 1995;77A:847–856. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007;15:330–339. (June (6).

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Fractures of the Talus: Screw Fixation Michel A. Taylor, Greg Berry, Max Talbot, and David W. Sanders INTRODUCTION • Talus fractures have traditionally been challenging injuries for orthopedic surgeons for a number of reasons: • Displaced fractures of the talar neck were considered surgical emergencies as time to reduction was thought to play a role in the risk of developing avascular necrosis (AVN). • Talus fractures are relatively infrequent injuries, representing approximately 1% to 2.5% of all fractures (Santavirta et al., 1984; Vallier, 2015). • Surgical reduction and fixation are technically challenging. • Talus fractures are associated with high-energy injury mechanisms and are often accompanied by other injuries in a polytrauma scenario. • Up to 25% of talus fractures are open fractures and the risk increases with fracture displacement (Canale 1978; Hawkins 1970; Vallier et al., 2014). • Poor outcomes secondary to AVN and posttraumatic arthritis are common. • Our understanding of talus fractures and their management has evolved over time. • More recent evidence suggests that the time to reduction is less of a risk factor for AVN (Lindvall et al., 2004; Vallier et al., 2004; Dodd and Lefaivre, 2015). • A two incision approach (plus or minus malleolar osteotomies) has improved the ease and accuracy of reduction. • Smaller and more adaptable implants have widened fixation options. • Because the talus articulates with the tibia, fibula, calcaneus, and navicular, any residual malalignment, even when minimal, results in abnormal contact stresses and perturbed motion across the hindfoot complex (Daniels et al., 1996; ­Sangeorzan et al., 1992). • AVN and posttraumatic arthrosis continue to be relatively frequent complications (Lindvall et al., 2004; Vallier et al., 2003, 2004). • Talus fractures can be divided by anatomic location: neck, body, and lateral and posterior processes. • Talar neck fractures are defined as those occurring anterior to the lateral process, whereas fractures of the body occur through or posterior to this process. • On the plantar side of the talus, talar neck fractures may involve the tarsal canal or the middle facet of the subtalar joint. • Talar body fractures involve the posterior facet of the subtalar joint in addition to the tibiotalar joint on its dorsal surface (Inoguchi et al., 1996). • Talar body fractures are frequently associated with talar neck fractures (Vallier et al., 2003). • The most widely referenced classification system for talar neck fractures is the Hawkins Classification (1970). It is based on fracture displacement and adjacent joint involvement and predicts the outcome with regard to AVN. • Type I: Nondisplaced fracture; risk of AVN: 0 to 13% • Type II: Fracture displacement with subluxation or dislocation of the subtalar joint: 20% to 50% • Type III: Dislocation of the ankle and subtalar joints: 20% to 100% • Type IV: A type III fracture/dislocation pattern with talonavicular subluxation or dislocation: 70% to 100%

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PROCEDURE 56  Fractures of the Talus: Screw Fixation

• Although infrequently used in practice, talar body fractures were classified by Boyd and Knight according to the fracture pattern and surrounding joint involvement. • Type 1: Coronal or sagittal shear fractures, subdivided into 1A, 1B, 1C, and 1D subtypes based on the presence of fracture and/or joint displacement • Type 2: Horizontal shear fractures, divided into 2A and 2B subtypes based on fracture displacement (Boyd and Knight, 1942) (Fig. 56.1) • Screw fixation alone is appropriate when fixing relatively simple fracture patterns, patterns amenable to percutaneous fixation, and small osteochondral fragments. Plate fixation is more appropriate when dealing with areas of bony comminution and fixation requiring bone grafting. A combination of both plate and screw constructs can also be utilized (Fig. 56.2). 

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PEARLS

• Although time to reduction and fixation has not been correlated to the eventual incidence of AVN following a fracture of the talar neck, indications remain for the emergent reduction of a displaced fracture, including skin compromise and impending necrosis, vascular and/or neurologic compromise from compression or tension, and open injuries. • Closed or percutaneous manipulation of closed fractures can be utilized for the initial reduction, followed by formal open reduction and internal fixation when soft tissues are amenable and the necessary equipment is available. • In the case of irreducible dislocation, open reduction and fixation should be carried out immediately.

D

FIG. 56.1  Classification of talar body fractures based on shear fracture pattern. (A) Sagittal shear (B) Coronal shear (C) Horizontal shear (D) comminuted. (Copyright Jesse C. DeLee; In Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle, 9th edition. Elsevier/Saunders, 2014.)

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B

C

FIG. 56.2  Talus fractures fixation can include screws only, plates only, or a combination, depending on the location, pattern, and level of comminution of the fracture. (A) Screws only, (B) plates only or (C) a combination. (From Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Basic Science, Management and Reconstruction, 3rd edition. Philadelphia: WB Saunders, 2003.)

INDICATIONS • Indications for nonoperative management of talus fractures are rare but can include nondisplaced talar neck (Hawkins type 1), body and lateral process fractures with well aligned and congruent joints, or in patients deemed medically unfit for an operative procedure. • These patients can be treated non–weight bearing with cast immobilization for 6 to 12 weeks followed by progressive weight bearing and range-of-motion exercises. • Talar neck fractures

PROCEDURE 56  Fractures of the Talus: Screw Fixation

714



• Displaced talar neck fractures (Hawkins types II–IV) require surgery if the patient’s overall condition permits it. • Talar body fractures • Displaced talar body fractures require open reduction and internal fixation. • More than 1 mm of articular displacement is an indication for surgical fixation. • Lateral process fractures • Displaced (>2 mm) lateral process fractures involving main fragments require surgery. • The degree of comminution will determine the strategy for displaced fractures; simple fractures can be reduced and internally fixed, whereas comminuted fractures not amenable to fixation can be excised.

Examination/Imaging • Physical examination reveals circumferential swelling of the hindfoot in all types of talus fractures. • Talar neck fractures (Fig. 56.3) • Gross deformity is noted in cases of dislocation of the subtalar joint, typically posteromedially. • Tension on the flexor tendons will cause toe flexion deformity, and plantar sensation may be decreased if the tibial nerve is affected. • Open injuries typically occur on the medial hindfoot and may include extrusion of the talar body • Tenderness will be global. • Talar body fractures (Fig. 56.4) • Deformity is less frequent unless a dislocation is present. • Tenderness will be global around the ankle. • Skin and neurovascular compromise are rare. • Lateral process fractures • Tenderness will be maximal just distal and anterior to the tip of the lateral malleolus. • Unless a careful physical examination is performed, these fractures can be missed because they are difficult to see on plain radiographs (Fig. 56.5). • Radiographic imaging of talus fractures includes anteroposterior (AP), lateral, and oblique views of the foot, as well as AP, lateral, mortise, and Canale views of the ankle.

A

B FIG. 56.3 

PROCEDURE 56  Fractures of the Talus: Screw Fixation

A

B

C FIG. 56.4 

A

B FIG. 56.5 

715

716

PROCEDURE 56  Fractures of the Talus: Screw Fixation

• A Canale view of the hindfoot is obtained by placing the ankle in equinus, with the foot pronated 15° (lateral border is raised off the table), and the beam angled cephalad 15° from vertical (i.e., toward the heel) (Fig. 56.6). • The precise degree and direction of displacement, as well as associated injuries, in all three fracture types can be ascertained with computed tomography (CT) scanning of the hindfoot, including multiplanar reconstructions. • Following reduction and surgical fixation, intraoperative radiographs should include AP, lateral, and oblique views of the foot as well as AP, lateral, mortise, and Canale views of the ankle. 

75o 15o

A

B FIG. 56.6 Position of the foot and s-ray beam when performing a Canale view of the hindfoot. (A) Position of the foot and Xray beam (B) when performing a Canale view. (From Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Basic Science, Management and Reconstruction, 3rd edition. Philadelphia, WB Saunders. 2003:2381, Fig. 60-5.)

PEARLS

• Talar fractures associated with joint incongruity or soft-tissue compromise must undergo a closed reduction. Closed reduction becomes increasingly difficult with increased fracture severity. • Adequate exposure is critical in obtaining an anatomic reduction in order to optimize results.

SURGICAL ANATOMY • The talus articulates with the tibia, fibula, calcaneus, and navicular (Fig. 56.7). • Because of these articulations, the talus plays a key role in hindfoot weight bearing and motion, with approximately two-thirds of it covered in articular cartilage. Therefore, any displaced fracture is likely to involve an articular surface. • In addition, this broad coverage with cartilage limits the zones available for blood supply penetration, making postinjury AVN a significant problem in both talar body and talar neck fractures. • Furthermore, the cartilage surfaces limit the options for screw and plate fixation and positioning.

PROCEDURE 56  Fractures of the Talus: Screw Fixation

Tibia

717

Tibia

Talus

Fibula Calcaneus

Fibula Talus

A

B FIG. 56.7 

• The talus has three sources of extraosseous blood supply (Fig. 56.8): the anterior (dorsalis pedis) and posterior tibial arteries and the peroneal artery (Mulfinger and Trueta 1970). • These vessels perfuse the talus over the 30% that is not covered in articular cartilage and are the sole blood supply because the talus has no muscular or tendinous insertions. • The artery of the tarsal canal provides supply to the majority of the body, both directly and via the deltoid branch (which supplies the medial third of the body). • The primary zones of entry into the talus are the superior and inferior surfaces of the neck and the medial part of the body. Care must be taken to limit or avoid iatrogenic injury to the remaining blood supply when dissecting in these areas. 

Posterior tibial artery

Perforating peroneal artery

PITFALLS

• Failure to identify and appropriately reduce and stabilize dorsal and medial comminution of the talar neck can lead to varus and extension deformities. • The talar neck is a medial structure; a traditional sinus tarsi approach from the anterior aspect of the lateral malleolus toward the base of the fourth metatarsal will require more dissection across the sinus tarsi and thus place the blood supply to the talus at risk. It is far preferable to proceed to a second approach rather than extend the dissection through a single one and increase the risk of osteonecrosis.

Perforating branch Peroneal artery Fibula

Anterior tibial artery

Lateral malleolar artery

Talus

Artery of the tarsal canal

Talus

Calcaneus

Lateral tarsal artery

A

B FIG. 56.8 

718

PROCEDURE 56  Fractures of the Talus: Screw Fixation

PROCEDURE: TALAR NECK FRACTURE Step 1: Positioning • The patient is positioned supine on a radiolucent table; a bump may be placed under the ipsilateral hip. • For posterolateral-to-anteromedial screw placement, the patient can be placed in the supine, lateral decubitus, or prone position on a radiolucent table. • A tourniquet is placed around the thigh and inflated. • Fluoroscopy is brought in from the contralateral side. 

Step 2: Approach • A dual anteromedial and anterolateral approach is required in the majority of cases to ensure an anatomic reduction (Fig. 56.9). • The subtalar joint and facets can be exposed from the lateral approach, whereas the medial approach allows access to the ankle, talonavicular joint, and medial comminution. • For posterolateral-to-anteromedial screw placement, a separate posterolateral approach is required.

Lateral approach

Posterior tibial tendon Medial approach

A

Anterior tibial tendon

B

FIG. 56.9  Dual anteromedial and anterolateral approach for anatomic reduction and fixation of talar neck fractures. (A) Schematic (B) clinical photograph. (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Page 642, Fig. 4A.)

Step 2.1: Anteromedial Approach • The incision is placed between the tibialis anterior and tibialis posterior tendons and extends from the anterior aspect of the medial malleolus to the navicular down the medial border of the first ray. • This incision can be extended proximally if a medial malleolar osteotomy is required. • The superficial deltoid is encountered and protected. • Anterior to the deltoid ligament, the talonavicular joint capsule is sharply incised in line with the skin incision. • The dorsomedial talar neck and the anteromedial aspect of the talar body can now be visualized (Fig. 56.10). • Plantarflexion of the ankle can also bring the majority of the talar dome into view. • At this point, a medial malleolar osteotomy may be performed for better visualization, reduction, and fixation, particularly if the fracture extends beyond the sagittal midline of the talar dome (Fig. 56.11). • The anteromedial approach is extended proximally. • The anterior and posterior shoulders of the malleolus are identified through small arthrotomies through which Hohmann retractors are inserted to protect the articular cartilage as well as the tibialis posterior tendon and posteromedial neurovascular bundle.

PROCEDURE 56  Fractures of the Talus: Screw Fixation

719

FIG. 56.10  Anteromedial approach to a talar neck fracture exposing medial aspect of talus. (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Page 642, Fig. 4B.)

FIG. 56.11  A medial malleolar osteotomy improves visualization and access to talar body and neck fractures. (From Weinfeld SB. Surgical approaches to the talus. Foot Ankle Clin. 2004;9:703–708. Page 705, Fig. 3; Early JS. Talus fracture management. Foot Ankle Clin Am. 2008;13:635–657. Page 647, Fig. 7A.)



• Kirschner wires (K-wires) can be inserted as guides to the level of the osteotomy, with confirmation using fluoroscopy. • Predrilling is performed using a 2.5-mm drill bit, followed by a straight or chevron osteotomy via an oscillating saw to the subchondral bone. The osteotomy is carefully completed through the articular surface with an osteotome. • Irrigation of cut surfaces with the oscillating saw may help prevent thermal necrosis. • The malleolus is retracted inferiorly to gain exposure to the neck and the body of the talus. The deltoid ligament must not be injured to preserve the blood supply. Posteriorly, the posterior tibial tendon sheath may need to be dissected away to facilitate sufficient mobilization. 

Step 2.2: Anterolateral Approach • A longitudinal incision extends proximal to the ankle joint, from the anteromedial aspect of the fibula down the axis of the fourth ray. • At the proximal end of the incision, the superficial peroneal nerve may cross the surgical field and should be isolated and protected. • The anterior compartment fascia and extensor retinaculum are encountered and incised longitudinally. • The tendons of peroneus tertius, extensor digitorum longus, and extensor hallucis longus are retracted medially. • The extensor digitorum brevis is elevated anteriorly and retracted. • The lateral aspect of the talar neck, lateral process of the talus, and lateral aspect of the talar body are visualized. • Although infrequently needed, depending on the fracture pattern, a fibular osteotomy may be performed at this point. • An oblique osteotomy is performed starting above the tibial plafond and ending just above the level of the joint. • The anteroinferior tibifibular (AITFL) and anterior talofibular (ATFL) ligaments are sectioned and the fibula is opened posteriorly. • Following talar fixation, the fibula is reduced and fixed and the AITFL and ATFL are repaired. 

720

PROCEDURE 56  Fractures of the Talus: Screw Fixation

Step 2.3: Posterolateral Approach • If the fracture is truly nondisplaced and noncomminuted, percutaneous posterior to anterior screw fixation can be performed. • If the fracture is displaced, dual anterolateral and anteromedial approaches are required to obtain an anatomic reduction. • To gain access to the posterior/lateral tubercle of the talus, an approach centered between the lateral border of the Achilles tendon and the peroneal tendons is utilized. • A 1- to 2-cm longitudinal incision is made 1 cm lateral to the Achilles tendon. • Blunt dissection is carried down onto the posterior capsule of the ankle. • The ideal posterolateral start point, which would enable a screw trajectory perpendicular to the fracture line, is chosen using fluoroscopic views. 

Step 3: Reduction • All intraarticular bone fragments are excised from the ankle and subtalar joints. • Reduction is obtained by gaining a cortical read on simple fracture surfaces, typically from the lateral side. • The talar neck is a four-sided structure. Particular care must be taken in cases involving medial comminution as what appears to be an anatomic reduction on the lateral side may still involve malreduction on the other three surfaces. • Reduction is maintained provisionally with K-wire fixation. • The quality of the reduction is then evaluated with intraoperative imaging on AP, lateral, oblique, and Canale views. 

Step 4: Fixation • Once an anatomic reduction is obtained, definitive fixation can involve a variety of implants. Small- and mini-fragment implants, and hand/foot modular (1.5- to 2.7-mm implants) plates and screws are typically utilized. • In relatively simple fracture patterns, compressive fixation can be obtained using a combination of position screw and lag screw techniques. One technique involves a lag screw directed from the talar head posteriorly toward the body. This technique requires countersinking of the screw heads (Fig. 56.12). • Another technique is to direct the screws from the posterolateral talar tubercle anteriorly toward the talar head (Fig. 56.13). • Partially threaded cannulated or solid screws (3.5–4.5 mm) are used to generate compression across the fracture.

FIG. 56.12  Anterior-to-posterior partially threaded and position screws for simple talar neck fracture. (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Page 642, Fig. 4C and D.)

PROCEDURE 56  Fractures of the Talus: Screw Fixation

FIG. 56.13 

• This technique is limited to simple fracture patterns for two reasons: (1) as the aim is to generate compression across the fracture, comminuted fractures will tend to collapse, leading to malalignment; and (2) the reduction must be obtained either closed or through a single lateral approach as the patient is in a lateral decubitus or prone position. • A combination of a posterior-to-anterior screw on the medial side with an anteriorto-posterior screw on the lateral side has also been described. • In comminuted fracture patterns, compression is avoided to prevent collapse. Fixation options include position (and not lag) screws combined with fixed-angle plate devices on the medial and lateral sides of the neck. • Fig. 56.14 shows oblique (Fig. 56.14A) and lateral (Fig. 56.14B) views following fixation. A lateral 2.7-mm titanium plate and two medial position screws (one 3.5 mm and one 2.7 mm) were used to maintain reduction. This fracture involved significant medial neck comminution. An associated comminuted medial malleolar fracture was fixed with screws and the tension band technique. 

A

B FIG. 56.14 

721

722

PROCEDURE 56  Fractures of the Talus: Screw Fixation

Step 4.1: Anterior-to-Posterior Fixation • Once the fracture is reduced, preliminary fixation is achieved with K-wires. • Countersunk cannulated screws, solid stainless screws, or headless screws may be used. • When screws are inserted into the talar head, countersinking becomes a critical technical step. • A fully threaded positional screw should be placed on the medial side of the talar neck to avoid displacement, compression and subsequent shortening, and varus malalignment. The screw head lies on the medial edge of the talonavicular articular surface. • A lag screw is advanced from just lateral to the talar articular surface, along the lateral side of the neck to be used to generate compression across the fracture. • Parallelism of the screws is not necessary and often the screws converge or cross into the talar body. Crossing screws are likely in the context of comminution (Fig. 56.15). 

FIG. 56.15  Anterior-to-posterior screws for talar neck fracture. A position screw is placed medially and countersunk whereas a lag screw is placed laterally.  (From Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Basic Science, Management and Reconstruction, 3rd edition. Philadelphia: WB Saunders, 2003:2391, Fig. 60-12A). Screws may cross in the presence of comminution. (From Brunner CF, Weber BG. Special Techniques in Internal Fixation. Berlin: Springer-Verlag, 1982. In Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle, 9th edition. Elsevier/ Saunders, 2014.)

Step 4.2: Posterolateral Approach with Posterior-to-Anterior Screw Fixation (Trillat et al., 1970) • The anatomic reduction of the talar neck is confirmed fluoroscopically. • K-wires are advanced from the posterior/lateral talar tubercle (a posterolateral structure) along the longitudinal axis of the talus perpendicular to the fracture. • Alternating between lateral and Canale radiographic views, two K-wires are advanced down the axis of the talus. • After the position of the K-wires and the maintenance of the reduction are confirmed fluoroscopically, the drill is advanced over the wires. • Two 4.5-mm cannulated screws are advanced over the K-wires; a washer can be used as needed. • Conversely, the K-wires can be removed at this stage and a solid stainless steel screw can be advanced under fluoroscopic guidance. 

PROCEDURE 56  Fractures of the Talus: Screw Fixation

Step 4: Closure and Splinting • Final imaging is performed to confirm accuracy of reduction and implant position. • Bone grafting with autograft or allograft may be required to maintain length on the side of comminution. • Range of motion is tested to evaluate fracture stability and to guide postoperative rehabilitation exercises. • The wounds are closed in layers, and dressing and plaster splint applied with the ankle in neutral position. 

723

PEARLS

• Definitive screw fixation can be performed using countersinking or with headless differential-pitch screws. • Implants are composed of stainless steel or titanium; the latter are compatible with magnetic resonance imaging, which in theory will allow for confirmation of posttraumatic osteonecrosis. • A posterior-to-anterior screw is more likely to be perpendicular to the fracture line based on its trajectory compared with an anterior to posterior screw (Fig. 56.16). PITFALLS

FIG. 56.16  Anterior-to-posterior screws are less likely to be perpendicular to the fracture line, which could lead to gapping of the fracture. (From Swanson TV, Bray TJ, Holmes GB. Fractures of the talar neck. A mechanical study of fixation. J Bone Joint Surg Am. 1992;74:544–551. In Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle, 9th edition. Elsevier/Saunders, 2014.)

PROCEDURE: TALAR BODY FRACTURES • Represent 13% to 20% of talus fractures. • Typically occur secondary to axial compression secondary to falling from a significant height. • Are often associated with talar neck fractures.

Step 1: Approach • A single anteromedial, anterolateral, posteromedial, or posterolateral approach may be utilized for simple, isolated talar body fractures. • Combined anteromedial and anterolateral approaches are required for complex fracture patterns. • Anteromedial and Anterolateral Approaches: See above 

Step 2: Reduction and Fixation • The fracture site is cleaned of intervening soft tissue and intervening cartilage and then an anatomic reduction is obtained. • The reduction is provisionally held with K-wires oriented perpendicular to the fracture and the reduction is confirmed fluoroscopically. • Sagittal plane articular fractures can be fixed with small fragment (2.4, 2.7, or 3.5 mm) lag screws advanced from medial to lateral (Fig. 56.17). • Small articular fragments may be secured with 1.5 mm, 2 mm, or 2.4 mm countersunk screws or headless screws. • For isolated body fractures with an intact lateral process, an extraarticular 3.5-mm cortical screw or cannulated screw can be advanced from the lateral talar neck into the posterior talar body. • If a malleolar osteotomy was performed, it is fixed with a screw and/or plate. • Bone grafting is performed, as required. 

• During an open approach to the talar neck, care must be taken to avoid excessive stripping of dorsal talar neck vasculature and to preserve the deltoid branches to the talus. • When using posterior-to-anterior talar screw placement, care must be taken to avoid the sural nerve superficially and to remain lateral to the flexor hallucis longus tendon to protect the posterior tibial neurovascular bundle. The heads of the screws must be seated on the posterolateral talar tubercle, avoiding impingement at both the ankle and subtalar joints with ankle plantarflexion. • It is important that the medial malleolar osteotomy enter the tibial plafond slightly lateral to its junction with the malleolus. Incursion laterally will injure the weightbearing surface of the ankle, whereas medial placement will prevent adequate visualization of the dome of the talus.

724

PROCEDURE 56  Fractures of the Talus: Screw Fixation

A

B

FIG. 56.17  (A) Coronal CT scan showing a sagittal fracture involving the talar body. (B) The fracture was fixed with a lateral-to-medial screw. (From Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle, 9th edition. Philadelphia: Elsevier/Saunders, 2014.)

Step 3: Closure • The wounds are closed over drains, if required. • Some authors recommend a modified Allgower-Donati suture technique (Vallier, 2015; White and Babikian, 2000). • The wounds are dressed appropriately and the foot and ankle are splinted in a neutral position. 

Step 4: Follow-up • Sutures are removed at 2 to 3 weeks and range-of-motion exercises can begin. • The patient is kept non–weight bearing for 8 to 12 weeks, depending on fracture pattern, location, and fixation. • Frequent early clinic visits are recommended for check of soft tissue, assessment of radiographs, and compliance with weight-bearing instructions. 

PROCEDURE: LATERAL PROCESS FRACTURES Step 1: Approach • A laterally based incision is made extending from the tip of the lateral malleolus down the axis of the fourth metatarsal. • This approach should allow for access to the lateral process of the talus, but also to the lateral talar neck and the posterior facet of the subtalar joint. • The extensor digitorum brevis is encountered and elevated anteriorly. • The tibiotalar capsule is incised longitudinally. 

Step 2: Fracture Assessment and Screw Fixation • The lateral talar dome and lateral process are visualized. • The hemarthrosis is evacuated and the fracture site identified (Fig. 56.18). • Assess the tibiotalar joint and subtalar joint for impaction injuries. • Small unrepairable fracture fragments and denuded cartilage can be excised. • Lateral process fractures are often associated with talar neck and/or body fractures (Vallier, 2015; Vallier et al., 2004; Vallier et al., 2004). • Simple fracture patterns with fragments adequate for fixation are anatomically reduced and fixed with a lag screw technique using mini-fragment, hand/foot modular implants, or headless screws with differential pitch (Fig. 56.19). • Postoperative radiographs of the bilateral lateral process fractures display screw fixation on the right (Fig. 56.20A and B) and excision of fragments on the left (Fig. 56.20C). 

PROCEDURE 56  Fractures of the Talus: Screw Fixation

A

725

B

FIG. 56.18  Lateral process fracture fragment seen with (A) coronal CT scan and (B) exposed and reflected intraoperatively. (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Elsevier. Page 650, Fig. 11B and C.)

FIG. 56.19  Lateral process fracture reduced and fixed with compression screw. (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Page 650, Fig. 11D.)

PROCEDURE 56  Fractures of the Talus: Screw Fixation

726

A

B

C FIG. 56.20 

PROCEDURE: POSTERIOR PROCESS FRACTURES Step 1: Approach • A posteromedial approach is performed between the medial border of the Achilles tendon and the posterior edge of the medial malleolus (Fig. 56.21). • The deep fascia is encountered and incised. • Deep dissection is between flexor digitorum longus and the neurovascular bundle or anterior to flexor hallucis longus and adjacent to the neurovascular bundle. 

Step 2: Screw Fixation • The hemarthrosis is evacuated and the fracture site identified. • The fracture site is cleared of small denuded cartilage, small unrepairable fracture fragments, and soft tissue. • A traction pin can be placed in a remote location such as the distal tibia or calcaneus in order to help with the reduction. • Depending on size, simple fracture patterns can be fixed using small fragment, mini-fragment, hand/foot modular implants directed from posterior to anterior. • Small articular fragments can be fixed with countersunk mini-fragment screws or headless screws with differential pitch. 

PROCEDURE 56  Fractures of the Talus: Screw Fixation

A

B

FIG. 56.21  Posteromedial approach to posterior talar process fracture. (A) CT scan and (B) clinical photograph (From Early JS. Talus fracture management. Foot Ankle Clin. 2008;13:635–657. Page 653, Fig. 13A and B.)

POSTOPERATIVE CARE •  Postoperative immobilization is maintained for 7 to 10 days until wounds have healed. • Gentle range-of-motion exercises of the ankle, subtalar, and transverse tarsal joints are begun under the supervision of a physiotherapist. • Depending on radiographic evidence of healing, non–weight bearing is continued for 10 to 12 weeks. • At 10 to 12 weeks, touch-down weight bearing can begin, and strengthening and proprioception exercises are added to the rehabilitation regimen. 

EVIDENCE: IMPLANT AND TECHNIQUE SPECIFIC • A cadaver study by Attiah et al. compared the biomechanical performance of three anterior-to-posterior screws, two cannulated posterior-to-anterior screws, and one anterior-to-posterior screw with a medial fixed angle plate in a comminuted talar neck fracture. They found no difference between the three fixation methods and all exceeded the theoretical stress across the talar neck during active motion (1.4 kN). • A cadaver study by Charlson et al. compared two solid partially threaded posteriorto-anterior cancellous screws with a four-hole 2.0-mm mini-fragment plate on the lateral talar neck secured with 2.7-mm screws combined with a 2.7-mm fully threaded medial lag screw. They assessed the fixation in a comminuted talar neck model. The posterior-to-anterior screws were found to have significant higher load to failure compared with plate and screw fixation. • A cadaver study by Swanson et al. compared four different fixation methods in 40 cadavers with simple talar neck fractures. Two posterior-to-anterior screws provided higher loads to failure compared with anterior to posterior screws. • A cadaver study by Karakasli et al. compared two anterior-to-posterior fully threaded variable pitch headless screws with a medial 2.7-mm two-hole locking plate in a simple talar neck fracture model. Headless variable pitch screw fixation was found to have lower failure displacement compared with plate fixation. There was no difference in failure stiffness, yield stiffness, yield load, or ultimate load between the two techniques.

727

728

PROCEDURE 56  Fractures of the Talus: Screw Fixation

• A study by Wang et al. tried to define the ideal start point for posterolateral talar screw insertion. They found that the ideal position in the “posterolateral window” was bound medially by the posterior tubercle of the talus, laterally by the posterior border of the lateral malleolus, superiorly by the articular surface of the trochlea, and inferiorly by the posterior calcaneal facet. The size of the window was approximately 1.89 cm by 0.91 cm. The ideal position of the ankle for safe screw insertion was a neutral position. 

EXPECTED CLINICAL OUTCOMES • Early complications include superficial (3.3%) and deep (5%) infection and wound dehiscence (3%) (Vallier et al., 2004). • Delayed union (1.7%) and nonunion (3.3%) are more likely to occur in open fractures and following nonanatomic reductions (Lindvall et al., 2004; Vallier et al., 2004). • The overall rate of osteonecrosis ranges from 20% to 64%, and its prevalence is associated with Hawkins type II and III fractures, open fractures, and increased comminution (Vallier et al., 2004). • Posttraumatic osteoarthritis of the ankle (0 to 18%), subtalar joint (15% to 40%), or both (0 to 57%) are relatively common long-term complications of talar neck fractures (Lindvall et al., 2004; Vallier et al., 2004). • The majority of patients (80%) experience mild or moderate chronic pain (Lindvall et al., 2004). • A recent study by Beltran et al. retrospectively reviewed 24 consecutive talar neck fractures treated with posterior-to-anterior screw fixation at a minimum of 12 months follow-up. They reported six (five transient and one permanent) sural nerve injuries and one hardware revision procedure for talonavicular joint impingement. Of patients, 43% developed AVN and 33% of these revascularized and 62% of patients developed subtalar arthrosis. • A recent metaanalysis on talar neck fractures by Dodd and Lefaivre reviewed 26 studies (980 fractures) that met their inclusion criteria. They found an overall rate of AVN of 31.2% and 24.9% in articles published before and after the year 2000, respectively. They also found that the most substantial risk increase for AVN is seen between Hawkins II and Hawkins III fractures. Only 3 of 26 studies performed statistical analysis to compare early versus delayed definitive fixation and found no correlation between timing of surgery and rates of AVN. The rate of posttraumatic subtalar osteoarthritis at 2 years was approximately 81%. • Talar body fractures are associated with a 38% rate of AVN and this rate rises to 55% when associated with talar neck fracture (Vallier et al., 2003). The rate of posttraumatic arthritis of the ankle (65%) and of the subtalar joint (35%) is higher following talar body fractures compared with talar neck fractures.

EVIDENCE Attiah M, Sanders DW, Valdivia G, Ferreira L, MacLeod MD, Johnson JA. Comminuted talar neck fractures: a mechanical comparison of fixation techniques. J Orthop Trauma. 2007;21(1):47–51. Beltran MJ, Mitchell PM, Collinge CA. Posterior to anteriorly directed screws for management of talar neck fractures. Foot Ankle Int. 2016;37(10):1130–1136. Boyd HB, Knight RA. Fractures of the astragalus. South Med J. 1942;35:160–167. Canale ST, Kelly FB. Fractures of the neck of the talus: long-term evaluation of 71 cases. J Bone Joint Surg Am. 1978;60:143–156. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int. 2006;27(5):340–343. Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck: its effect on the position of the foot and subtalar motion. J Bone Joint Surg [Am]. 1996;78:1559–1567. Dodd A, Lefaivre K. Outcomes of talar neck fractures: a systematic review and meta-analysis. J Orthop Trauma. 2015;29:210–215. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg [Am]. 1970;52:991–1002. Inoguchi S, Ogawa K, Usami N. Classification of fractures of the talus: clear differentiation between neck and body fractures. Foot Ankle Int. 1996;17:748–750. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg [Am]. 2004;86:2229–2234. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg [Br]. 1970;52:160–167.

PROCEDURE 56  Fractures of the Talus: Screw Fixation Sangeorzan BJ, Wagner UA, Harrington RM, Tencer AF. Contact characteristics of the subtalar joint: the effect of talar neck misalignment. J Orthop Res. 1992;10:544–551. Santavirta S, Seitsalo S, Kiviluoto O, et al. Fractures of the talus. J Trauma. 1984;24:986–998. Smith C, Nork S, Sangeorzan BJ. The extruded talus: the results of reimplantation. J Bone Joint Surg [Am]. 2006;88:2418–2424. Swanson TV, Bray TJ, Holmes GB. Fractures of the talar neck. A mechanical study of fixation. J Bone Joint Surg Am. 1992;74(4):544–551. Trillat A, Bousquet G, Lapeyre B. Les fractures-separations totales du col ou corps de l’astragale: interet du visage par voie posterieure. Rev Chir Orthop Reparatrice Appar Mot. 1970;56:529–536. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan B. Talar neck fractures: results and outcomes. J Bone Joint Surg [Am]. 2004;86:1616–1624. Vallier HA, Nork SE, Benirschke SK, et al. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2004;86(suppl 1):180–192. Vallier HA, Nork SE, Benirschke SK, Sangeorzan B. Surgical treatment of talar body fractures. J Bone Joint Surg [Am]. 2003;85:1716–1724. Vallier HA, Reichard SG, Boyd AJ, et al. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014;96:192–197. Vallier HA. Fractures of the talus: state of the art. J Orthop Trauma. 2015;29:385–392. Wang Z, Qu W, Wang D, Zhou Z, Yu M, Zhou D. Talar neck fractures: anatomic landmarks of suitable position for posterolateral screw insertion. Acta Orthop Traumatol Turc. 2015;49(3):326–330. White RR, Babikian GM. Tibia: shaft. In: Ruedi TP, Murphy WM, eds. AO Principles of Fracture Management. New York: Thieme; 2000:525–526.

729

PROCEDURE 57

Talus Fractures: Open Reduction and Internal Fixation (Plating) Uma E. Erard and Bruce J. Sangeorzan

INDICATIONS PITFALLS

• Missed diagnosis, as in the case of a subtalar dislocation that does not get a postreduction computed tomography (CT) scan. Among other injuries, a minimally displaced talar neck fracture may be present and difficult to detect on postreduction radiographs (Figs. 57.1 and 57.2).

INDICATIONS • Talar neck fractures not amenable to screw fixation • Significant comminution • Bone loss 

INDICATIONS CONTROVERSIES

• Timing of fixation • Vallier et al. performed a retrospective review of 39 patients with displaced talar neck fractures who underwent open reduction and internal fixation (ORIF) and found no correlation between timing of surgery and avascular necrosis (AVN). • Bellamy et al. performed a retrospective trauma registry review on talus fractures and redemonstrated these findings that AVN was not correlated with time to final fixation, with average time to definitive fixation being 12.9 days.

FIG. 57.1 

FIG. 57.2 

730

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

EXAMINATION AND IMAGING • Physical examination of the injured extremity should include a careful assessment of the skin and any areas of tenting or local pressure, as this may result in necrosis. • Any laceration or defect in the soft tissue should be carefully examined for the presence of an open fracture. • A full neurovascular examination should be performed. • Three views of the foot and ankle: anteroposterior (AP), lateral, and mortise (Figs. 57.3–57.5) • CT scan offers a three-dimensional image for surgical planning purposes and can further elucidate areas of bone loss, articular involvement, and comminution (Fig. 57.6). • Radiographs of the contralateral extremity, if uninjured, can give the surgeon an idea of the patient’s anatomy with respect to the appearance of the talus and overall hindfoot and midfoot alignment to serve as a template for reconstruction. • Intraoperatively, prior to positioning and draping, a Canale view of the contralateral talus can be useful if there is significant comminution of the injured talus precluding the use of cortical reads for length, alignment, and rotation (Figs. 57.7 and 57.8). 

FIG. 57.3 

731

TREATMENT OPTIONS

• Dual approach ORIF using mini-fragment plates • Talar neck–specific plate • Single approach combined with percutaneous screw fixation • Posterior-to-anterior screw fixation • External fixation

FIG. 57.4 

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

732

FIG. 57.5  FIG. 57.6 

75°

15°

FIG. 57.8  FIG. 57.7 

SURGICAL ANATOMY • A total of 60% of the talus is covered with articular cartilage. • Owing to the large amount of articular cartilage, the blood supply to the talus is tenuous. • There are multiple components to the talus: the head, neck, body, lateral process, and posterior process (Fig. 57.9). • The anatomy of the talar neck is unique. The talar head is deviated 15° to 20° medially through the neck, which creates an area of weakness leading to fracture. The

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating) Anterior Articular surface with medial malleolus

Articular surface with distal end of tibia

Anterior

Articular surface for navicular

A

Articular surface for calcaneonavicular ligament

Medial tubercle

Head

Articular surface for navicular Anterior calcaneal surface

Sulcus tali

Neck

733

Posterior Middle calcaneal surface Groove for flexor hallucis longus

Lateral tubercle Body Groove for flexor hallucis longus

Posterior process of talus

B

Posterior

Posterior calcaneal surface

FIG. 57.9 

lateral neck is concave. The neck is the only portion of the talus that is not covered in articular cartilage, allowing for plate placement. • The average plantar deviation is 24°. • The neck body angle is 140° to 150°. • The talus has seven articulations and plays an integral role in ankle, hindfoot, and midfoot motion. • The tibia—plafond and medial malleolus • The fibula • The calcaneus—posterior, middle, and anterior facets • The navicular 

POSITIONING • Supine, with a bump under the ipsilateral hip to avoid external rotation that will make the lateral incisions difficult. • “Bone foam” or something similar to allow for elevation of the operative limb above the nonoperative limb, which will help with lateral radiographs. • The contralateral extremity is padded and gently taped down to prevent movement during surgery. • Fluoroscope in from the contralateral side (Fig. 57.10). • Radiolucent triangles can be useful for AP views of the foot and for elevation of the limb to allow for posterolateral screw insertion. • The bed can be “airplaned” if necessary to allow for lateral imaging in the case of excessive hip external rotation resistant to hip bumps. • The patient’s foot should be at the end of the table. 

POSITIONING PEARLS

• Getting an AP/oblique of the foot and the Canale view will require either use of a radiolucent triangle or the surgeon or assistant bending the knee to allow for the appropriate angles with the fluoroscope (Fig. 57.11) • A padded Mayo stand or padded radiolucent triangle can also be used to allow access to the posterolateral ankle if screw fixation from posterior to anterior is needed. • “C-armor” draping or something similar can be useful when multiple lateral images will be taken. POSITIONING PITFALLS

• Not bumping the hip will make lateral exposure more difficult. • If the operative limb is not elevated above the nonoperative limb, lateral fluoroscopy will be difficult. • Not bringing the patient to the end of the bed may make use of fluoroscopy difficult. POSITIONING EQUIPMENT

• Hip bump • Thigh tourniquet • Bone Foam or something similar • Radiolucent triangle • Foam padding for the contralateral extremity • A padded Mayo stand if desired FIG. 57.10 

734

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

PORTALS/EXPOSURES PEARLS

• When there is extension of the fracture into the body, appropriate planning of the medial incision can allow for medial malleolus osteotomy if needed. • In the case of an associated lateral process fracture, the anterolateral incision can be shifted slightly laterally. • Dual incisions are generally necessary, as reduction is difficult to gauge just using medial and lateral exposures. Interposed fracture fragments preclude anatomic reduction and, therefore, require open removal. This is especially true in the case of fracture comminution. • The talonavicular joint capsule can be incised. This allows for placement of headless screws directed from the talar head in a lateral direction. • It is possible to access the subtalar joint through the lateral incision if dissection is carried in a plan­tar direction. This can be employed when the subtalar joint has been dislocated and osteocho­ ndral fragments are interposed in the joint. PORTALS/EXPOSURES PITFALLS

• Multiple planes of dissection can cause wound compromise. Full thickness flaps should be employed while keeping in mind the surrounding anatomy. • Excessive plantar dissection along the neck can disrupt the blood supply in the anteromedial incision. • Violation of the anterior portion of the deltoid should be avoided in the anteromedial incision. • Placing the medial incision too anterior can preclude extension of the incision proximally in the case in which a medial malleolus osteotomy is necessary. • The lateral branch of the superficial peroneal nerve passes directly through the proximal anterolateral surgical approach and should be identified and protected. • The saphenous vein and nerve are in danger with the medial approach and should be identified and protected.

FIG. 57.11 

PORTALS/EXPOSURES • Anterolateral approach • Skin incision in line with the fourth ray (Fig. 57.12) • Full-thickness flaps • The superficial peroneal nerve is in danger with this approach and should be identified and mobilized in the plantar direction. • The extensor digitorum brevis muscle is identified and split, allowing for later repair. • This allows access to the talus and subtalar joint. • Anteromedial approach • Skin incision between tibialis anterior and tibialis posterior tendons heading toward the base of the first metatarsal just anterior to the medial malleolus (Fig. 57.12). • The saphenous nerve and vein are present in this dissection and should be identified and protected. • The anterior third of the deltoid should also be recognized and avoided as well. • This allows for direct access to the talar neck, talonavicular joint, and subtalar joint. • Medial malleolus osteotomy (Fig. 57.13)

FIG. 57.12  FIG. 57.13  (Courtesy of Thomas Dowd, MD.)

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

• This can be employed in the case of a complex fracture that extends into the body. • This requires extension of the anteromedial exposure. • The osteotomy should be carefully planned to allow access to the desired portion of the talus. • The medial malleolus should be drilled and tapped for later screw fixation prior to osteotomy. 

735

PORTALS/EXPOSURES EQUIPMENT

• Senn retractors—sharp and dull • Hohmann retractors • Kirschner wires (K-wires) • Irrigation • Fraser tip suction

PROCEDURE Step 1: Perform Dual Incision Approach • Perform full thickness flaps • Protect surrounding neurovascular structures • Avoid excessive soft-tissue stripping STEP 1 PEARLS

• Full-thickness flaps are vitally important; undermining of tissue should be avoided. STEP 1 PITFALLS

• Neurovascular structures are at risk with each exposure. • Creating multiple soft-tissue planes can predispose the patient to wound issues. • Devascularizing the talus due to excessive soft-tissue stripping • Self-retaining retractors can cause tissue necrosis. STEP 1 INSTRUMENTATION/IMPLANTATION

• Handheld retractors

Step 2: Fracture Disimpaction and Joint Distraction for Reduction and Joint Visualization • Disimpaction of the talar body fragments using K-wires and lamina spreader. Kwires are placed in the head and body pieces and a lamina spreader is used to distract across the fracture site and rotate fragments back into position (Figs. 57.14 and 57.15).

STEP 2 PEARLS

• Prolonged use of self-retaining retractors can cause tissue necrosis. • External fixation or a femoral distractor can be helpful tools for articular distraction and reduction of deformity when a significant amount of comminution is present.

STEP 2 PITFALLS

• External fixation or femoral distractor should be placed, keeping in mind that in-line axial distraction is important to avoid hindering reduction of the head fragment to the body fragment and vice versa. • Placement of the calcaneal pins should be performed from the medial side with blunt dissection to bone to avoid damage to the medial neurovascular bundle.

STEP 2 INSTRUMENTATION/ IMPLANTATION

FIG. 57.14 

• Small or medium external fixator (4- to 5-mm pins) • K-wires • Lamina spreaders • Hintermann distractor • Femoral distractor

736

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

• External fixation spanning the ankle and subtalar joints can also be used to allow for distraction across the subtalar joint to improve visualization of the articular reduction. • A medially based external fixator with an additional 4-mm Schanz pin in the cuneiforms can aid in reduction of a medially comminuted fracture causing a varus deformity. • A Hintermann distractor can also be used for distraction purposes to regain length/ alignment/rotation (Fig. 57.16). 

FIG. 57.15 

STEP 3 PEARLS

• The classic deformity is varus and extension due to medial and dorsal comminution (Figs. 57.17–57.20). • Varus deformity will result in lateral column overload and decreased eversion of the hindfoot. • The reduction is assessed from the lateral side most commonly; in the case of medial comminution, there will be a medial gap that may necessitate bone grafting after definitive fixation. • There are cases in which the lateral neck is comminuted, in which case a medial cortical read can be used (Fig. 57.21).

FIG. 57.16 

Step 3: Rotate Head and Body Fragments as Indicated by Fracture Pattern • Use fluoroscopy and direct visualization re-align the head and body to anatomic location • Use cortical reads as available • Use medial and lateral incisions to judge reduction. In some cases, while the lateral fracture line may appear reduced, the medial fracture line will not be, requiring adjustment. 

STEP 3 PITFALLS

• Malreduction due to unrecognized comminution

STEP 3 INSTRUMENTATION/ IMPLANTATION

• Dental picks • K-wires • Schanz pins as joysticks if needed FIG. 57.17 

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

FIG. 57.18 

FIG. 57.19 

FIG. 57.20 

Step 4: Provisional Fixation • Place multiple K-wires once length, alignment, and rotation are restored. • Check fluoroscopy and compare to contralateral un-injures Canale view if available. 

FIG. 57.21 

737

738

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

STEP 4 PEARLS

• Multiple K-wires to control rotation of head and body fragments • These can be placed in an anterior to posterior and posterior to anterior direction if desired (Fig. 57.22). • The body can be pinned to the tibia once it is reduced to allow for a stable base to rebuild the neck to the head. STEP 4 PITFALLS

• Malreduction of the neck • Compression using lag screw or lag technique across comminution, thus creating a malreduction STEP 4 INSTRUMENTATION/ IMPLANTATION

• 0.045 and 0.062 K-wires • Wires specific to cannulated systems if desired FIG. 57.22 

Step 5: Final Fixation STEP 5 PEARLS

• Screw fixation from the medial side can be placed within the medial talonavicular joint if screw heads are recessed below the level of the joint (Figs 57.23–57.25). • This is facilitated by headless compression screws. • When placing a plate laterally, it should be bent 50° to 70° depending on the anatomy to fit the contour of the neck. • Medial plates generally do not require plate bending, but there is less real estate for plate placement medially. • Address concomitant malleolar fractures following final fixation of the talus. • Incisions should be planned accordingly.

• Mini-fragment or talus-specific plate fixation from the lateral, medial, or both sides of the talus (Figs. 57.24 and 57.25). • If bone stock is not adequate to allow for fixation within the talus, external fixation or bridge plating can be used to maintain length and bridge comminution. • Bone graft should be placed in defects after restoration or length, alignment, and rotation. • Address surrounding fractures (Fig. 57.26). 

STEP 5 PITFALLS

• Violation of the subtalar joint with screw fixation—can be assessed with lateral radiograph. • Plate impingement can occur on both the medial and lateral malleoli. • The ankle should be taken through a full range of motion after fixation is placed to include plantarflexion/dorsiflexion/inversion/ eversion to ensure that there is no hardware impingement. • Placement of compression screws across areas of comminution can cause malreduction and hindfoot deformity. FIG. 57.23 

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

STEP 5 INSTRUMENTATION/ IMPLANTATION

• Mini-fragment plates, 2.0/2.4 • Blade plate • Talar neck–specific implants • Cannulated or solid screws

STEP 5 CONTROVERSIES

FIG. 57.24 

FIG. 57.25 

• Bridge plating with subsequent removal of hardware can be useful in the case of significant comminution, with plans for hardware removal and maintenance of some degree of motion (Fig. 57.27). • Primary subtalar and/or talonavicular fusion can be considered in the case of delayed diagnosis and severe comminution.

FIG. 57.26 

739

740

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

FIG. 57.27 

Additional Steps • Bone grafting of defect • Meticulous closure • Incisional wound vac if desired 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Well-padded L&U splint for 2 weeks postoperatively • Two-week follow-up for wound check and suture removal if soft tissues are amenable; if there is any question, leave the sutures in for an additional week. • Transition to short-leg cast, non–weight bearing for an additional 6 weeks. • At 6 to 8 weeks, obtain radiographs postoperatively and if radiographic healing is present without evidence of hardware complication, the patient is placed in a controlled ankle movement (CAM) boot and gradual weight bearing is initiated. • The patient is followed every 3 months with radiographs to monitor union, hardware, and any signs of osteonecrosis.

POSTOP PEARLS

• Postoperative AP ankle radiographs can be used to assess for revascularization of the talus. • Noncompliance with weight-bearing restrictions can result in hardware failure and fracture nonunion. Long-leg casting can be used to limit the noncompliant patient.

POSTOP PITFALLS

• Osteonecrosis • Nonunion • Subtalar/tibiotalar degenerative changes • Talar head chondrolysis • Talonavicular degenerative changes: Chen et al. reviewed 16 isolated talonavicular fusions. Eight of the patients had posttraumatic degeneration, three of which were specifically due to a talus fracture. • Varus malunion • Should be evaluated by CT, as radiographs can underestimate the deformity. • Can address with medial opening wedge osteotomy.

PROCEDURE 57  Talus Fractures: Open Reduction and Internal Fixation (Plating)

POSTOP CONTROVERSIES

• Hawkins sign: Subchondral lucency of the talus best seen on the mortise view at 6 to 8 weeks postoperatively. • Indicative of revascularization of the talus following fracture and correlates with reestablishment of blood supply and subchondral bone resorption. • The early prognostic value of the Hawkins sign is questionable. MRI should be considered in the case of a negative Hawkins sign at the 12-week mark.

EVIDENCE Bellamy JL, Keeling JJ, Wenke J, Hsu JR. Does a longer delay in fixation of talus fractures cause osteonecrosis? J Surg Orthop Adv. 2011;20:34–37. Chan G, Sanders DW, Yuan X, Jenkinson RJ, Willits K. Clinical accuracy of imaging techniques for talar neck malunion. J Orthop Trauma. 2008;22:415–418. Chen CH, Huang PJ, Chen TB, et al. Isolated talonavicular arthrodesis for talonavicular arthritis. Foot Ankle Int. 2001;22:633–636. Chen H, Liu W, Deng L, Song W. The prognostic value of the Hawkins sign and diagnostic value of MRI after talar neck fractures. Foot Ankle Int. 2014;35:1255–1261. Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion. J Bone Joint Surg [Am]. 1996;78:1559–1567. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg [Am]. 2004;86-A. 2229–2234. Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma. 2003;17:513–520. Thomas RH, Daniels TR. Primary fusion as salvage following talar neck fracture: a case report. Foot Ankle Int. 2003;24:368–371. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg [Am]. 2004;86-A. 1616–1624.

741

PROCEDURE 58

Calcaneus Fractures: Open Reduction and Internal Fixation Richard E. Buckley INDICATIONS CONTROVERSIES

• Age greater than 60 years (risk vs. benefit of surgery is questionable) • Worker’s compensation: outcomes in patients on worker’s compensation are much less good • Minimally invasive reduction with percutaneous fixation is becoming more standard for displaced calcaneal fractures.

TREATMENT OPTIONS

• Nonoperative treatment is advised for older patients, and for patients with less injury or nondisplaced intraarticular fractures. If Böhler’s angle is greater than 15 degrees, the patient will do relatively well regardless of operative or nonoperative treatment if the joint is not displaced. • Nonoperative care is also advised in the medically unwell, such as patients with diabetes or peripheral vascular disease, and for smokers unwilling to stop smoking. • Operative techniques can be performed with a full open technique or percutaneous techniques. Percutaneous techniques may be used for those cases with large calcaneal fragments or in the marginal medical patient where a full open reduction may result in skin or wound complications. • Results of operative treatment for displaced intraarticular calcaneal fractures have shown improvement over nonoperative care in certain groups of patients, especially those who are young, female, have simple fractures, and have fractures that have very accurate reductions. Those patients in whom operative treatment has been shown to not make a difference include older patients, worker’s compensation patients, or those in whom Böhler’s angle is near normal. • Minimally invasive reduction and percutaneous fixation is becoming more popular, especially with patient groups that include: older patients with poor foot shape, patients with poor soft tissues, younger recalcitrant smokers, and simple fracture types. • Primary subtalar fusion is also an option for patients with severely comminuted Sanders type 4 displaced intraarticular calcaneal fractures as outcomes are similar to open reduction with internal fixation (ORIF).

• Open fractures • Displaced intraarticular posterior facet fractures • Fracture-dislocations • Significant change of shape or morphologic shift in calcaneal structure such that footwear would be problematic

Examination/Imaging • Physical examination • Calcaneal fractures involve a severe amount of soft-tissue injury with the impaction of the heel to a hard surface upon which it has landed. The soft-tissue injury that results from the impact is often as bad as, or worse than, the calcaneal fracture beneath the skin. • Careful observation for open wounds—especially medially beneath the sustentaculum tali and posteriorly around the Achilles tendon insertion—is mandatory. • Appearance of soft-tissue blisters will often occur over the initial 48 hours. These may be serous or hemorrhagic. The fracture can produce significant soft-tissue tenting. • Continual careful physical examination and observation for compartment syndrome of the foot is mandatory. This would be manifest by increasing pain above and beyond what would be normal for this injury, sensory changes distally into the foot, and/or pain with stretching of the digits of the foot. • Plain radiographs: lateral of the foot and Harris axial view • The lateral radiograph (Fig. 58.1A) identifies the significance of impaction (Böhler’s angle loss). The normal Böhler’s angle is between 25 and 40 degrees. Any loss of Böhlers angle to less than 15 degrees is a significant injury, as those patients with a Böhlers angle that is greater than 15 degrees can often be treated nonoperatively with no associated significant articular surface disruption.

B

A 742

FIG 58.1 

PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

A

743

B FIG 58.2 

Facets

Calcaneus

Angle of Gissane

Sustentaculum tali

PEARLS

Calcaneal tuberosity

A

B FIG 58.3 

• The Harris axial view (if taken well) may show the articular surface, the primary fracture line, or the number of pieces of the posterior facet (Fig. 58.1B). It will also demonstrate the size of the “constant” piece that is used to act as a solid piece of bone for later reconstruction of the rest of the calcaneus. • Computerized tomography • Obtaining 2-mm axial (Fig. 58.2A) and coronal (Fig. 58.2B) cuts of both the normal and injured foot is advised. • These will allow careful evaluation of the posterior facet, calcaneocuboid joint, and calcaneal tuberosity, which is very important for preoperative planning. 

SURGICAL ANATOMY • Bony anatomy (Fig. 58.3A) • The posterior facet is the largest of the three facets with a very small middle and anterior facet medially on top of the sustentaculum tali. • The crucial angle of Gissane is the point where the lateral process of the talus articulates with the lateral and anterior posterior facets (Fig. 58.3B).

• The extended lateral soft-tissue approach is not acceptable while there is marked swelling in the 3- to 10-day period immediately after the injury. Surgery at 1 to 3 days is recommended for percutaneous techniques as this type of surgery has a much smaller subtalar (sinus tarsi) approach and is difficult after 3 weeks. Open reduction with internal fixation (ORIF) is much better in the period after this (10–17 days), when soft tissues have settled, but late surgery (after 21 days) is also not advised because of fracture healing. • Multiple assistants and surgical adjuncts, such as Kirschner wires (K-wires), laminar spreaders, and joy sticks are very useful for helping to obtain and maintain reductions.

PITFALLS

• The soft-tissue flap must be treated with utmost care for both surgical approach and closure to prevent infection and wound breakdown. • Calcaneal fractures that present with open wounds have a much higher infection rate and should be internally fixed only when soft tissues allow and the wounds have been debrided.

PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

744

Posterior tibial artery and vein

Sural nerve Peroneal artery

Tibial nerve

Fibulocalcaneal ligament

Achilles tendon

Fibula Base of 5th metatarsal

L-shaped incision

Achilles tendon Calcaneal tuberosity

FIG 58.5 

FIG 58.4  EQUIPMENT

• Extra equipment, such as laminar spreaders, Schanz pins, fluoroscopy, reduction clamps, and bone graft substitute, are often useful. • Special precontoured calcaneal plates or locking plates may be used in fractures with more comminution.

• Neurovascular anatomy (Fig. 58.4) • There is no internervous intermuscular plane, but it is thought that there is a watershed area between the vascular supply involving the peroneal artery laterally and superiorly and the posterior tibial artery (from the heel pad). • The sural nerve runs in the superior portion of the full-thickness flap that is provided by the extended L approach. • Musculotendinous anatomy (see Fig. 58.4) • The insertion of the Achilles tendon on the calcaneal tuberosity is the strongest tendinous structure of the hindfoot. • The fibulocalcaneal ligament inserts on the calcaneus, restricting subtalar motion. • The peroneal tendons, which extend along the lateral border of the calcaneus, are held in place by the peroneal tubercle and retinaculum. 

POSITIONING • Lateral positioning of the patient is advised, with careful padding of all bony prominences. The upright foot should be somewhat posterior for easy access. • A tourniquet is used high on the operative leg. • A glove on the toe is advised (to prevent infection). • If bilateral calcaneal fracture surgery is necessary, the prone position may be used, but this author prefers individually fixing calcaneal fractures in the lateral position, followed by turning the patient and proceeding with repositioning for the other foot. 

PORTALS/EXPOSURES • The skin incision is an extended L approach based on a full-thickness flap that relies on subperiosteal dissection. • It is usually initiated midway between the fibula and the Achilles tendon (Fig. 58.5), extending down to the lateral aspect of the distal calcaneus, where there is a change in skin texture (the glabrous/nonglabrous border) to the base of the 5th metatarsal. • The sural nerve should be in the superior portion of the flap with the peroneals, and the lateral abductor muscle should be avoided with careful dissection along the plantar surface of the foot. • The lateral wall should be protected within the exposure so it has soft-tissue and bony attachment. • The peroneal tendons are found and protected, and the peroneal retinaculum is incised so the tendons can be reflected proximally. • The calcaneal fibular ligament is resected, as is the lateral subtalar capsule.

PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

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PEARLS

FIG 58.6 

• If the subtalar (sinus tarsi) approach is to be used, then the posterior half of the Grice approach is used and skin worries are minimized as it is a much more resilient approach than the extended L approach. 

PROCEDURE Step 1 • The lateral wall is carefully protected and reflected, either inferiorly or posteriorly, as it acts as a measure of reduction when it is replaced. • Large pieces of posterior facet are protected with soft-tissue attachments, especially posteriorly, but if they are free they should be marked for repositioning and removed for reassembly on the back operating table. • The crucial angle of Gissane is an important anatomic landmark; the posterior facet should be lifted up until it is reduced to this bony landmark. • Reduction generally starts working from medial to lateral in the subtalar joint of the calcaneus, and working anterior to posterior in the anatomic calcaneus. If it is in two large pieces, then a single lag screw fixation can now be planned. Fig. 58.7 shows reduction with a plate, lag screws, and K-wires. 

• K-wires are placed into the lateral process of talus, fibula, or distal calcaneus or cuboid to help with visualization (Fig. 58.6). • Removal of soft tissue from the subtalar region anterior to the posterior facet allows easy access to the anterior process of the calcaneus. • If articular pieces are to be removed from the posterior facet, they should be marked for easy repositioning and replacement.

PITFALLS

• Soft-tissue attachment should be kept on all bony anatomic parts where possible. • Without adequate retraction, distraction, or use of reduction tools, the calcaneal tuberosity continues to fall into the joint, making joint reduction very difficult. • Varus deformity is common after surgery and the surgeon must be very aware of this problem.

PEARLS

• Removal of all clot will allow for accurate reduction. The use of K-wires as joysticks can sometimes help with reduction. • Lag screw fixation should be used to hold the bony fragments in the subchondral region. • Reduction of the joint then allows for repositioning of the tuberosity beneath the joint region to achieve height, length, and width of the calcaneus.

PITFALLS

• The calcaneus is often under-reduced (Böhler’s angle is not restored on the fractured side), so it is worthwhile having preoperative radiographs (and computed tomography [CT] scans) of the normal calcaneus for reference. CONTROVERSIES

FIG 58.7 

• K-wires may be used for temporary and/ or permanent fixation. After the reduction is maintained, they are removed. Threaded K-wires are also useful for permanent fixation, either holding the posterior facet reduced (these are often very small pieces) or drilling through the posterior and plantar surface of the calcaneal tuberosity. These K-wires act as both a reduction tool (push K-wire) and as a reminder to the patient that they are not to walk on their newly reconstructed heel bone.

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PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

CONTROVERSIES

• The use of bone substitute to fill a metaphyseal defect is controversial. • With the advent of more stable fixation and more peripherally placed fixation, most surgeons have not been filling the large defect in the central portion of the calcaneus. PEARLS

• The surgeon’s hand on the medial aspect of the foot on the medial wall of the sustentaculum (downside of the foot) often can feel the restoration of medial height. Threaded K-wires can maintain this. • K-wires placed through the reflected flap beneath the crucial angle of Gissane are also useful. • Screws from the modular hand set are useful for placement beneath the subchondral joint surface as lag screws.

Step 2 • With the posterior facet reconstructed (having worked from medial to lateral), it is now important to achieve adequate height of the joint surface in relation to the calcaneal tuberosity. The calcaneal height is often not surgically restored. • Important aids that are helpful include the crucial angle of Gissane, the surgeon’s fingers on the sustentaculum tali, and repositioning the lateral calcaneal wall, which has been reflected in the approach. • By using reduction techniques, such as Schanz pins, threaded K-wires (as push Kwires), or laminar spreaders, the calcaneal joint height is achieved and checked, both clinically and under fluoroscopy. • Varus and valgus alignment of the heel must also be checked (Fig. 58.8). 

PITFALLS

• If the surgeon does not carefully check with the use of fluoroscopy for varus malposition, the foot may be positioned in a shortened supinated position with heel varus. This is very detrimental to future function of the foot.

PEARLS

• Lag screws can be reliably placed into the good bone of the medial sustentaculum, as this bone is the thickest. These screws are usually 45 to 50 mm for a large foot. • Individual screws do not work as well as screws placed through plates, creating more compression and narrowing of the lateral wall. • Thinner plates, smaller screws, and smaller implants are advised, with the implants avoiding the apex of the L-shaped incision and thereby providing a smaller chance of late wound breakdown and visible hardware.

FIG 58.8 

Step 3 • Once the reduction has been achieved and checked under fluoroscopy and held in place with a temporary K-wire cage fixation, the large central cavity (on average 5–10 mL) can be filled with bone substitute, as seen in the postoperative radiograph in Fig. 58.9. • The preferred substance is a calcium phosphate bone substitute product that has compressive strength to resist the loss of Böhler’s angle or loss of height of the posterior facet, but incorporates quickly to promote early fracture healing. 

FIG 58.9 

PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

Step 4 • The lateral wall is put back into place, demonstrating that appropriate height of the posterior facet in relation to the tuberosity and the anterior process has been achieved. Select a plate that fits the lateral aspect of the calcaneus for peripheral fixation. • Place screws around the periphery of the calcaneus. • The best screw placement for subchondral lag screw placement is anterior and medial, angled slightly inferiorly into the sustentaculum tali, and medially across the tuberosity into the good bone on the medial side of the calcaneal tuberosity. • Carefully assess the subchondral surface before closure to ensure there is no hardware in the subtalar joint, as there is a high incidence of placing screws into the joint because of the unusual surface anatomy of the posterior facet. • Carefully assess to ensure reduction of the posterior facet with intraoperative radiographs (Fig. 58.10A and 10B) or with postoperative CT scans (Fig. 58.10C). 

B

A

C FIG 58.10 

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PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation

Step 5 • The extended L incision is closed with two layers without tension over a drain. • Multiple interrupted mattress stitches evenly distributing stress and skin tension are imperative to avoid necrosis at the apex of the incision. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES PEARLS

• The extended L flap often needs to be advanced by using subcutaneous stitches that pull the anterior flap back to the posterior flap. This allows the skin edges to be closed without tension. • The subtalar (sinus tarsi) approach does not have the concern of high rates of wound breakdown and is preferred in patients with medical issues, recalcitrant smokers, and patients with bad soft tissues. PITFALLS

• If the wound is closed under tension, wound breakdown is certain to occur. • The use of negative pressure wound therapy (NPWT) may assist in wound closure in these instances. CONTROVERSIES

• Many types of plates exist for calcaneal fixation. Locking plates are good for badly comminuted fractures, as there is little else to hold the reduction in place. However, the use of small one-third tubular plates or smaller profile plates is advisable. • Threaded K-wires and Steinman pins left out through the skin are controversial. Patient compliance is anecdotally better with K-wires through the posterior heel pad. • The use of percutaneous screw placement over wires is possible, but the reductions must be assured. Limited open approaches sometimes set the surgeon up for less than optimal reductions. • Some surgeons favor careful radiologic assessment of reduction of the posterior facet intraoperatively, whereas others rely on postoperative CT scans for assurance of reduction.

CONTROVERSIES

• Use of the NPWT dressing for postoperative wound dressing management is controversial. • Unroofing or popping of blisters is also controversial. Some surgeons prefer to allow blisters to epithelialize before breaking them. They are left in position after the case is completed if not broken during the case. • The role of minimal invasive surgery with percutaneous reduction is just being elucidated, but early work is very hopeful that wound complications can be radically lowered.

• Once skin is closed, the foot is positioned in a well-padded posterior splint to ensure the foot is at 90 degrees. • The postoperative splint at 90 degrees ensures easy access for appropriate coronal and axial images under CT scanning. • Elevation, rest, ice, and compression are important for 2 to 10 days as the wound settles. During this time, smoking cessation is very important as well. • Early motion is started after the wound settles (2–14 days) and stitch removal occurs sometime between 21 and 28 days. There is no rush to remove stitches because wound dehiscence is common, especially at the apex of the extended L approach. • Range of motion is encouraged with non–weight bearing for 10 to 12 weeks. • Serial radiographs at 3, 6, and 12 weeks are recommended, with weight bearing instituted after that. • Physiotherapy may be important for optimizing the outcome of a difficult fracture repair. • Long-term outcomes for young patients with simple fractures demonstrate return to most functions, including heavy labor. However, it is unusual for any person to be able to run long distances after this injury. • Comminuted fractures in heavy laborers will result in loss of their particular heavy labor occupations 50% of the time. • Sedentary workers are reliably back to work at 6 months, but heavy laborers are often out 6 months to 1 year before returning to work. • Over the long term, it is not uncommon that antiinflammatory medication is used weekly. Also, custom orthotics and good-quality shoes and boots become important.

EVIDENCE Abidi NA, Dhawan S, Gruen GS, et al. Wound-healing risk factors after open reduction and internal ­fixation of calcaneal fractures. Foot Ankle Int. 1998;19:856–861. Grade-B recommendation demonstrating wound healing problems in different patient populations. This was based on a small review article, level IV study. (Grade 2 recommendation.). Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced ­intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95(15):1351–1357. Grade B recommendation demonstrating that operative treatment of displaced intraarticular ­fractures was no better than nonoperative treatment (underpowered Level II study) except in ­radiographic long-term outcomes. (Grade 1 recommendation.). Bajammal SS, Zlowodzki M, Lelwica A, et al. The use of calcium phosphate bone cement in fracture treatment: a meta analysis of randomized trials. J Bone Joint Surg [Am]. 2008;90:1186–1196. Grade-B recommendation as this meta-analysis looked at randomized controlled trial (RCT) ­evidence only. It suggests that bone substitutes may help in preventing collapse of reconstructed heel fractures. (Grade 2 recommendation.). Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of ­displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg [Am]. 2002;10:1733–1744. Grade-B recommendation that there were small differences only in long-term patient outcomes between the patients with displaced intraarticular calcaneal fractures treated operatively or nonoperatively. This randomized prospective trial (underpowered level II study) showed certain groups of patients had better outcomes with operative care (younger patients, females, non– worker’s compensation patients, simpler fractures). (Grade 1 recommendation.). Buckley RE, Tough S. Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg. 2004;12:172–178. Grade-B review article discussing patient factors and fracture factors affecting outcome of patients with displaced intraarticular calcaneal fractures. (Grade 2 recommendation.). Howard JL, Buckley R, McCormack R, et al. Complications following management of displaced ­intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma. 2003;17:241–249. Grade-B recommendation demonstrating which patients had more problems and concerns with patient outcome. All patients with complications, whether treated nonoperatively or operatively,

PROCEDURE 58  Calcaneus Fractures: Open Reduction and Internal Fixation had less good outcomes than operatively or nonoperatively treated patients who had no complications. This is based on an underpowered level II study. (Grade 1 recommendation.). Hsu A, Anderson R, Cohen B. Advances in surgical management of intraarticular calcaneal fractures. J Am Acad Orthop Surg. 2015;23(7):399–407. Grade B recommendation from a review article describing RCTs with ORIF or minimally invasive reductions with percutaneous fixation of displaced calcaneal fractures. (Grade 1 recommendation.). Johal H, Buckley R, Le I, et al. A prospective randomized controlled trial of bioresorbable calcium phosphate paste (Alpha BSM) in displaced intra-articular calcaneal fractures. J Trauma. 2009;67:875–882. Grade-B recommendation in a prospective RCT. It shows that calcium phosphate bone substitute can prevent collapse of Böhler’s angle after ORIF of heel fractures. (Grade 2 recommendation.). Loucks C, Buckley R. Bohler’s angle: correlation with outcome in displaced intra-articular calcaneal fractures. J Orthop Trauma. 1999;13:554–558. Grade-B recommendation for the use of Böhlers angle as a measuring tool in calcaneal fractures to look at outcome based on a randomized controlled trial (level II study). The data with this study are underpowered. (Grade 2 recommendation.). Sharr P, Mangupli M, Winson I, et al. Current management options for displaced intra-articular cal­ caneal fractures: Non-operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review. Foot and Ankle Surgery. 2016;22:1–8. Grade B recommendation for the treatment of displaced intraarticular calcaneal fractures. Review article is based on multiple randomized trials (level II study), all underpowered (Grade 2 recommendation.). Tufescu TV, Buckley R. Age, gender, work capability and worker’s compensation in patients with ­displaced intraarticular calcaneal fractures. J Orthop Trauma. 2001;15:275–279. Grade A recommendation for identifying that Worker’s Compensation Board (WCB) patients with displaced intraarticular calcaneal fractures are different patients than the regular fracture population that are not WCB clients. This is based on a prospective randomized trial, which was underpowered (level II study). (Grade 1 recommendation.). Van Tetering EA, Buckley RE. Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data. Foot Ankle Int. 2004;25:733–738. Grade-B recommendation demonstrating that calcaneal fracture patients score poorly based on Short Form-36 long-term outcomes versus other patients with orthopedic maladies (back pain, arthroplasty, ankle injury). This is based on an underpowered level II randomized controlled trial. (Grade 1 recommendation.). Xiangping L, Qi L, Shengmao H, et al. Operative versus nonoperative treatment for displaced intraarticular calcaneal fractures: a meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2016;55:821–828. Grade B recommendation from a meta-analysis of all of the RCTs on this subject to this date (824 patients). This under-powered study does not have the power to prescribe treatment for this patient population. (Grade 1 recommendation.).

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PROCEDURE 59

Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation Stephen Hunt INDICATIONS PITFALLS

INDICATIONS

• Nonstress view imaging does not exclude midfoot instability. • Non–weight-bearing CT scans do not exclude midfoot instability. • Ligamentous injuries can occur with or without a “Fleck Sign.” • First metatarsal stability can be very difficult to assess on static imaging. • Many injuries are best assessed with bilateral comparative views.

• Tarsometatarsal joint (TMT) injuries include a variety of bone and ligament injuries. The overall goal is to obtain proper joint alignment and maintain joint stability. Preservation of normal foot biomechanics, by preserving the longitudinal and coronal arches of the foot, may limit devastating posttraumatic arthritis of the midfoot. • Unstable TMT injuries are generally operative injuries. • Nonoperative care is reserved for TMT injuries that do not demonstrate instability on appropriate stress view imaging. • Minimal displacement on a non–weight-bearing computed tomography (CT) does rule out an unstable TMT injury • Instability or intraarticular displacement greater than 2 mm requires operative repair. 

INDICATIONS CONTROVERSIES

EXAMINATION/IMAGING

• Patient factors (age, comorbid conditions, operative risk) may significantly influence the decision to proceed with operative repair. • Bridge plating across joints is an alternative to conventional screw-only fixation.

Physical Examination • TMT stability is assessed by clinical examination and dedicated radiographic imaging. • Clinical examination is an important predictor of Lisfranc injury. • Pain over the dorsum of the foot at the TMT junction • Extensive midfoot swelling (Figs. 59.1 and 59.2) • Pain with plantarflexion or dorsiflexion of individual metatarsals (Fig. 59.3) • Mechanism of injury can include inversion, eversion, plantarflexion, dorsiflexion, and crush mechanisms. • Ability to do a single-leg heel raise on the affected limb is a good clinical indication of sufficient midfoot stability. 

FIG. 59.1  Dorsal swelling and ecchymosis from TMT injury.

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FIG. 59.2 

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

FIG. 59.3  Lisfranc stability can be evaluated by alternating dorsiflexion and plantarflexion of the metatarsals.

Imaging Studies • Radiographic investigations include plain film imaging, dedicated stress views and CT scans of the foot: • Standard views: anteroposterior (AP), lateral, and 30-degree oblique radiographs of the foot. • Stress views may include: • Bilateral AP foot weight bearing (Figs 59.4 and 59.5) • Simulated weight bearing—plantar pressure applied by x-ray technologist or clinician with x-ray cassette • Static or dynamic stress view by manipulating the foot into supination-pronation or adduction-abduction while keeping the hindfoot immobile. • CT scan of foot • Midfoot instability should be assumed until stability can be demonstrated with stress view imaging or clinical examination (Figs. 59.4 and 59.5). •  Fig. 59.4 is a non–weight-bearing view. Fig. 59.5 is the same foot while weight bearing. • Note the subluxation of the first TMT and lateral translation of the lesser metatarsals. • When any doubt exists, a bilateral view can be very helpful in identifying subtle injuries. • The following relationships should be maintained in a stable midfoot. • Note: these relationships must also be maintained on stress view imaging. • AP view (Fig. 59.6) • First MT aligns with medial cuneiform, both medially and laterally. • The medial border of the second MT should be aligned with the medial edge of the middle cuneiform. • Lateral view (Fig. 59.7) • The second TMT joint aligns on its dorsal surface uninterrupted with the tarsal bone proximally and the MT base distally. • Dorsal displacement of the MT is abnormal. • Plantar displacement greater than 1 mm is abnormal. • Internal oblique view (300) (Fig. 59.8) • This view is mainly used to assess the third, fourth, and fifth MTs. • The medial border of the third MT is aligned with the medial edge of the lateral cuneiform. • The medial border of the fourth MT is aligned with the medial border of the cuboid. • Any disturbance of the normal alignment on any one radiographic investigation may indicate a Lisfranc injury. • Avulsion fractures around the TMT joint—the “Fleck Sign” an avulsion of the medial base of the second MT from the attachment of the Lisfranc ligament (Figs. 59.9 and 59.10)

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

TREATMENT OPTIONS

• Nonoperative care • Conventional open reduction and internal fixation (ORIF) with position screws • Bridge plating • Primary fusion • Indirect reduction (percutaneous wires, external fixation)

FIG. 59.4  TMT injury in non–weight-bearing film.

FIG. 59.6 



• Widening of first MT interspace • Fracture of the second MT base • Crush injury to the cuboid or medial cuneiform (Figs. 59.11 and 59.12) • Fracture of the navicular tuberosity • CT maybe useful for assessing the extent of metatarsal comminution and other subtle injuries. Standard (Fig. 59.13) and three-dimensional images are shown (Fig. 59.14). 

FIG. 59.5  The same foot demonstrates instability on a weight-bearing film.

FIG. 59.7 

FIG. 59.8 

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

FIG. 59.12 

FIG. 59.9 

FIG. 59.13  FIG. 59.10 

FIG. 59.11 

FIG. 59.14 

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

SURGICAL ANATOMY •  The TMT joint is complex and is divided into the medial and lateral columns (Fig. 59.15). • The medial column is further divided into the medial and middle legs. • The medial leg includes the first MT and medial cuneiform. This leg has three times more motion than the middle leg. • The middle leg is composed of the second and third MT and the middle and lateral cuneiforms. This leg is rigid; it acts as the fulcrum against which the middle leg and lateral columns move. • The lateral column, consisting of the fourth and fifth MT and the cuboid, is the most mobile unit of the forefoot and is critical for a comfortable gait. • The stability of the transmetatarsal arch depends on the base of second metatarsal fitting closely with its three adjacent articulations. • The proximal end of the second MT is 1 cm more proximal than the proximal end of the first MT. Similarly, the proximal end of the second MT is 0.5 cm more proximal than the proximal end of the third MT. • Additional stability of the TMT joint complex is provided by the dorsal and plantar interosseous capsuloligamentous restraints (Figs. 59.16 and 59.17). • The bases of the second through fifth MTs are bound by dense transverse metatarsal interosseous ligaments, with the dorsal ligaments weaker than the plantar ligaments. • There are no intermetatarsal ligaments between the first and second MT. • The base of the second MT is joined to the first TMT joint by a medial interosseous ligament. The ligament courses from the plantar aspect of the medial cuneiform to the plantar aspect of the second MT base. This ligament is also known as the Lisfranc ligament. • This is the largest ligament of the forefoot complex and the only support between the medial leg and the middle leg and lateral column. • Nerves and arteries must be protected (Fig. 59.18). 

Dorsal view Tibialis anterior Extensor hallucis longus Extensor digitorum longus Talus Navicular Cuneiform bones: medial middle lateral Metatarsal bones

Calcaneus Cuboid

Intermetatarsal ligaments

Recessed metatarsal 1

2

FIG. 59.15 

3

4

5

FIG. 59.16 

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

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Plantar view Flexor hallucis longus Flexor digitorum longus Tibialis posterior Tibialis anterior Lisfranc ligament Intermetatarsal ligaments

Medial dorsal cutaneous nerve Dorsalis pedis artery Medial branch of deep peroneal nerve

FIG. 59.17 

Intermediate dorsal cutaneous nerve Arcuate artery

FIG. 59.18

POSITIONING

POSITIONING PEARLS

• The patient is positioned supine, with a bump under the affected hip (Fig. 59.19). • Ensure a radiolucent foot bed for appropriate imaging. • Thigh or calf tourniquet (250–300 mm Hg) • A rectangular leg pad (5–10 cm thick) to raise the affected leg 

• Wedge the hip to prevent excessive external rotation. • Raising the foot on a rectangular pad avoids interference from the contralateral foot during drilling and imaging.

POSITIONING PITFALLS

• Imaging the foot with the patient supine and knee extended requires significant manipulation of the C-arm and may result in disorienting projections of the midfoot. • Consider flexing the knee and have the foot resting flat against the operating table during imaging for more conventional views of the foot. POSITIONING EQUIPMENT

FIG. 59.19 

PORTALS/EXPOSURES • Most Lisfranc injuries can be fixed through either a one-incision or two-incision approach (Figs. 59.20 and 59.21). • The first and second TMT joints can be approached through a single dorsal incision. In some situations the third TMT can also be addressed through the same incision. Injuries involving all five TMT joints or extensive comminution of lateral rays, should be approached through a two-incision approach. • Use fluoroscopy to identify the Lisfranc joint if unfamiliar with bone landmarks.

• Intraoperative fluoroscopy • Radiolucent foot bed • Radiolucent foam pad to elevate the foot above the uninjured foot

PORTALS/EXPOSURES PEARLS

• TMT injuries involving the medial three metatarsals can generally be fixed through a single dorsal incision • More extensive TMT injuries require a twoincision approach.

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

PORTALS/EXPOSURES PITFALLS

• Failure to clear the Lisfranc joint of debris may prevent an anatomic reduction. • Ensure the second MT is reduced in both the dorsal-to-plantar plane and medial-to lateral-plane. • Overreduction of the second MT often results in dorsal displacement. • Blocks to reduction include joint surface impaction, fracture fragments, tendinous interpostion, and entrapped capsule.



• Incise skin at the level of the TMT and between the first and second metatarsals. • Alternatively an incision can be made directly over the second metatarsal if work on the third metatarsal is anticipated. • After dividing skin, isolate and protect the superficial peroneal nerve and dorsal sensory nerves (Fig. 59.22). These nerves are very superficial in this layer. • Incise the inferior extensor retinaculum. The neurovascular bundle can be found between extensor hallicus longus (EHL) and extensor hallicus brevis (EHB). • Retract EHL and EHB medially • Identify and protect the terminal branch of the deep peroneal nerve and dorsalis pedis as they dive between the first and second metatarsals several millimeters distal to the Lisfranc joint. • The incision can be extended proximally to evaluate intercuneiform joint stability. • When using a two incision approach: • The first incision should be between the first and second metatarsal. • The second incision should be centered between the third and fourth metatarsal at the level of the TMT joint (Fig. 59.23). • Take care to protect distal branches of the superficial peroneal nerve during exposure. Retract EDL and either split or retract EDB for exposure. A separate stab-incision is used to when installing screws between the medial cuneiform and base of second metatarsal, as well as between the medial and intermediate cuneiform bones. 

Medial incision FIG. 59.21  Lateral incision

EHL

FIG. 59.20 

Distal

Superficial cutaneous branch superficial peroneal nerve

FIG. 59.22 

Proximal

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation Superficial cutaneous nerve

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STEP 1 PEARLS

• Use a smooth blunt elevator inserted into the joint to evaluate stability STEP 1 PITFALLS

• Failure to identify intercuneiform instability can result in persistent midfoot instability despite reconstruction.

Distal EDB

Proximal

FIG. 59.23 

PROCEDURE Step 1 • Carefully define the extent of ligamentous injury. • Evaluate the stability of the TMT and cuneiform joints under fluoroscopy or direct vision using a blunt elevator (Fig. 59.24). • Work medial to lateral, proximal to distal. • First evaluate the stability of the intercuneiform joints (Fig. 59.25). • Follow with evaluation of the first TMT (Fig. 59.26), then second TMT, and continue to work across the midfoot (Fig. 59.27). 

FIG. 59.24  Intraoperative AP fluoroscopic image of foot.

FIG. 59.25  Cuneiform instability.

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

FIG. 59.26  First TMT instability.

FIG. 59.27  Forefoot stressed in abduction. Note subluxation of first TMT joint and lateral subluxation of lesser metatarsals. There is a proximal fracture of the second metatarsal.

STEP 2 PEARLS

Step 2

• If unstable, stabilize the intercuneiform joints before addressing the TMT joints.

• Assess and repair the cuneiforms (Fig. 59.28). • If unstable, stabilize the intercuneiform joints. • This is done under fluoroscopic guidance through a separate medial stab incision. 

STEP 2 CONTROVERSIES

• Primary fusion versus ORIF of primarily ligamentous TMT injuries are still being debated.

FIG. 59.28  Intercuneiform stabilization.

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

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Step 3

STEP 3 PEARLS

• Assess stability of the first TMT. • If unstable, stabilize the first TMT in neutral abduction-adduction and neutral plantarflexion-dorsiflexion (Fig. 59.29). • If doubt exists about neutral position, compare it against the contralateral side. 

• Anatomic reduction of the first TMT is critical to overall reduction of the foot. • Avulsion or rupture of the dorsal capsule of the first TMT is a good indication that fixation will be necessary. STEP 3 PITFALLS

• Abduction of the first TMT will prevent anatomic reduction of the midfoot. • In TMT dislocations, the first TMT tends to rest in an abducted position. This needs to be reduced before fixation is placed. STEP 3 INSTRUMENTATION/ IMPLANTATION

• If bridge plates are used, they should be low profile. • Position screws should be countersunk to avoid tendon irritation. STEP 3 CONTROVERSIES

• Bridge plates, which are more bulky, may contribute to hardware irritation and require subsequent hardware removal. STEP 4 PEARLS

FIG. 59.29  First TMT stabilized.

Step 4 • Reduce the Lisfranc complex by reducing the base of second metatarsal to the first metatarsal and medial cuneiform. • Reduction of the second MT to the medial cuneiform is obtained with pointed bone reduction forceps (Fig. 59.30). • Comminuted fractures of the base of second metatarsal may need to be reconstructed before reducing the Lisfranc complex (Figs. 59.31 and 59.32). • Install a screw from the medial cuneiform into the base of the second metatarsal. • Consider temporary placement of a K-wire to hold the reduction during screw installation. 

• Use a pointed bone reduction forceps to reduce the second metatarsal to the first metatarsal (Fig. 59.33). • Consider using a pituitary rongeur to clear the Lisfranc joint. STEP 4 PITFALLS

• Failure to clear the Lisfranc joint of debris can prevent reduction. • Overcompression of the Lisfranc complex may result in dorsal displacement of the second metatarsal. • Do not forget during debridement and fixation that the dorsalis pedis courses between the first and second metatarsals. STEP 4 CONTROVERSIES

• Use of 3.5-mm cannulated or cortical screws versus 4-mm cancellous screws • The use of cannulated screws allows for accurate screw placement with the aid of the positional guidewire. This prevents multiple drill holes and iatrogenic fracture of the small bones of the forefoot. However, the guidewires with this size of screw are often very flexible and sometimes difficult to control. If bent, the wires may break during drilling or impede screw placement • As one becomes accustomed to the correct placement of the screws, noncannulated screws may be used, which are generally stronger and less likely to break. • Consider using positional Kirschner wires (K-wires) placed outside the screw trajectory to maintain reduction during drilling operations.

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

FIG. 59.30  Reducing the second metatarsal to the first metatarsal and medial cuneiform.

FIG. 59.31  Stabilizing the second metatarsal. Bridge plating second metatarsal comminution.

FIG. 59.33  FIG. 59.32  Bridge plates installed.

STEP 5 PEARLS

• When placing a retrograde screw from an MT into its respective proximal cuneiform, a small notch or trough is made in the dorsal cortex of the MT at least 1 to 1.5 cm distal to the joint with a countersink or rongeur. This notch prevents the screw head from pointcontacting the dorsal surface of the MT, which can potentially propagate a fracture of the dorsal cortex as the screw is tightened. It also prevents screw head prominence and possible irritation of the overlying extensor tendon.

Step 5 • Stabilize the remainder of the midfoot. • The third ray can be stabilized with position screws or bridge plates (Fig. 59.34). • It may be necessary to make a second incision for reduction or fixation. 

PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

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STEP 5 PITFALLS

• Persistent subluxation of the lateral metatarsals may be an indication that the medial metatarsals are not anatomically reduced. STEP 6 PEARLS

• Lateral metatarsals are quite mobile and may be held reduced with percutaneous wires, 1.6 mm to 2 mm. STEP 6 PITFALLS

• Rigid fixation of the lateral TMT joints is poorly tolerated. • Percutaneous wires may be susceptible to infection and must be carefully accommodated inside casting and immobilization devices. COMPLICATIONS FIG. 59.34  Bridge plating an unstable TMT injury.

Step 6 • If the fourth and fifth metatarsals remain unstable they may be stabilized with percutaneous wires (Figs. 59.35, 59.36, and 59.37). • Standard wound closure of all incisions; start with the medial incision as it can present the greatest challenge to close in a swollen foot (Fig. 59.38). 

• TMT injuries can lead to significant gait disturbance and post traumatic arthritis. • Even with anatomic reduction of the joints, a significant proportion of patients will continue to have pain and stiffness.

FIG. 59.35 

FIG. 59.36 

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PROCEDURE 59  Repair of Tarsometatarsal Joint (Lisfranc) Fracture Dislocation

FIG. 59.37 

POSTOPERATIVE CONTROVERSIES

• There is significant variability regarding when to resume weight bearing. The decision is influenced by injury severity, bone quality, and patient factors. • Most clinicians will resume full weight bearing by 3 months. It is uncommon to permit weight bearing before 6 weeks. • There is significant controversy whether hardware removal improves patient outcome.

FIG. 59.38 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative treatment begins with a well-padded plaster splint. • Wound check, suture removal, and immobilization at 2 weeks • 6 weeks non–weight bearing—cast or removable walking boot • If percutaneous pins were used, remove these at the 6- to 8-week interval. • Reassess weight bearing at 6 to 8 weeks with radiographs and clinical examination. • Progress to full weight bearing by 3 months.

EVIDENCE Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg [Am]. 2000;82:1609–1618. This paper was a retrospective review of 48 patients with both ligamentous and combined ligamentous and osseous injuries who were followed for outcomes for an average of 52 months. Results showed that stable anatomic reduction of the fracture-dislocation leads to the best long-term outcomes. These patients were shown to have less arthritis and better American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores. (Level IV evidence.) Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction internal fixation. A prospective, randomized study. J Bone Joint Surg [Am]. 2006;88:514–520. This prospective randomized trial compared open reduction and internal fixation (ORIF) to partial fusion in purely ligamentous Lisfranc injuries. Results in 41 patients showed that primary arthrodesis obtained better short- and medium-term outcomes than ORIF when compared on average at 42.5 months. (Level I evidence.) Myerson MS, Fisher RT, Burgess AR, et al. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6:225–242. This case series reviewed 72 patients with fracture-dislocations of the TMT joint. The authors suggested that a major determinant of outcome is an anatomic reduction. TMT joint instability and posttraumatic degenerative changes accounted for long-term symptoms. (Level IV evidence.) Smith N, Stone C, Furey A. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic review and meta-analysis. Clin Orthop Relat Res. 2016;474(6):1445–1452. This paper is a systematic review and meta-analysis of the ongoing debate between primary fusion and open reduction and internal fixation. Patient functional outcome, reduction quality, reoperation rate, and hardware removal rate were specifically investigated and open reduction and internal fixation was associated with higher hardware removal rates. Overall, the authors described a need for new well-designed trials to provide data on these questions. (Level I evidence.) Stavlas P, Roberts CS, Xypnitos FN, et al. The role of reduction and internal fixation of Lisfranc fracturedislocations: a systematic review of the literature. Int Orthop. 2010;34(8):1083–1091. This systematic review discusses the natural history, surgical management patterns, and functional outcome of TMT Injuries. It is a good review of current techniques, injury patterns, and management principles of ligamentous and osseoligamentous injuries. (Level I evidence.) Van Koperen PJ, de Jong VM, Luitse JSK, et al. Functional outcomes after temporary bridging with locking plates in Lisfranc injuries. J Foot Ankle Surg. 2016;55(5):922–926. This 34-patient retrospective cohort study compares results of bridge plating with conventional screw fixation of TMT injuries. Patient satisfaction and functional outcome were higher in the bridge plating group; however, hardware removal and posttraumatic arthritis rates were similar. Methodologic shortcomings limit the applicability of the study’s data. (Level IV evidence.)

PROCEDURE 60

Compartment Syndrome Abdel-Rahman Lawendy, Michel A. Taylor, and David W. Sanders INDICATIONS • Compartment syndrome is caused by elevated intracompartmental pressure (ICP) leading to microvascular compromise. Without decompression of the compartment, ischemia and cell death occur. • The impact of increased compartment pressures and their sequelae have long been recognized, but the current understanding of acute compartment syndrome was developed in the 1970s. Acute compartment syndrome is considered to be the result of raised tissue pressure within a closed osseofascial compartment compromising microcirculatory perfusion. • Surgical decompression of the affected compartment by fasciotomy was suggested over 100 years ago (Volkmann, 1881). The utility of fasciotomy as prophylaxis against the development of contractures was later demonstrated in experimental studies as well as clinical use (Rorabeck, 1984). To this day, fasciotomy remains the only established treatment for managing an acute compartment syndrome. 

Pathophysiology of Acute Compartment Syndrome • Compartment syndromes occur when the tissue pressure within an enclosed space exceeds the capillary perfusion pressure, leading to microvascular compromise and ischemia. As ICP rises, there is a disruption of microvascular perfusion, reducing oxygen and nutrient delivery to a point where perfusion no longer meets the tissue demand. • Three major theories attempt to explain the pathophysiology of microvascular dysfunction and ischemia: • The critical closing pressure theory suggests there is a critical pressure at which active closure of small arterioles will occur as the transmural pressure (the difference between intravascular pressure and tissue pressure) drops. • The microvascular occlusion theory proposes the existence of an absolute compartment pressure that results in compartment syndrome. Because normal capillary pressure at rest is approximately 25 mm Hg, an increase in tissue pressure to a similar level is thought to reduce capillary blood flow, leading to ischemia and eventual muscle necrosis. • According to the arteriovenous (AV) gradient theory, an increase in tissue pressure will reduce the AV pressure gradient, resulting in reduced blood flow. As the level of skeletal muscle blood flow is reduced, the metabolic demands of the tissue are no longer met and damage occurs. • The high metabolic demand of skeletal muscle makes it the most vulnerable tissue in a limb affected by acute compartment syndrome. Both the magnitude and duration of increased compartment pressure have major effects on muscle viability. The reduced local blood flow to skeletal muscle causes ischemia and eventually leads to cell death. • Although ischemia is the predominant mechanism in the development of compartment syndrome, other factors are also important. • Recent evidence suggests that most compartment syndromes are the result of a “low-flow” ischemic mechanism, in contrast to complete ischemia. Because the tissue pressure does not exceed the systolic blood pressure, there is the potential for some continued perfusion in the affected compartment. This phenomenon is analogous to a reperfusion injury following complete ischemia, and includes the release of reactive oxygen metabolites as well as pronounced neutrophil activation (Lawendy et al., 2011; Sadasivan et al., 1997).

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A HIGH INDEX OF SUSPICION AND SERIAL CLINICAL EVALUATIONS ARE MANDATORY

Specifics of diagnosis by extremity segment are listed below. • Foot • Difficult diagnosis • Usually occurs with crush injury • Massive swelling, sensory deficits common • Leg • Most common anatomic site of compartment syndrome • Anterior and lateral compartments most commonly affected • Thigh • Tense swelling • Anterior most common (Schwartz et al., 1989) • Hand • Similar to foot • Tense swelling, “intrinsic minus” position, sensory deficits • Forearm • Volar compartment most common • Many etiologies—line injuries, bites, burns, and so forth • Arm • Uncommon for compartment syndrome • Pediatric • Difficult diagnosis (Mars and Hadley, 1998) • Increasing narcotic requirements may be only sign

• Neutrophil activation further contributes to microvascular dysfunction and blood flow abnormalities in acute compartment syndrome. • Evidence suggests that both inflammation and ischemia cause cellular injury in acute compartment syndrome. Prolonged pressure elevation exacerbates microcirculatory impairment, increases reperfusion injury, and markedly depletes intramuscular highenergy phosphates, with resultant irreversible ultrastructural tissue damage. • Indications for surgical treatment of compartment syndrome include the presence of compartment syndrome, or an impending compartment syndrome. • Because of the severe adverse consequences of a missed compartment syndrome, most orthopedic surgeons recommend an inclusive approach to surgical treatment. Any patient with signs of, or significant risk factors for, compartment syndrome should be considered for fasciotomy independent of anatomic location. • Possible exceptions include compartment syndrome of the foot, as some surgeons feel the negative sequelae of fasciotomy may potentially exceed the benefit. However, clear cases of compartment syndrome of the foot are nonetheless best treated with fasciotomy.

EXAMINATION/IMAGING • Early diagnosis of acute compartment syndrome is critical to its successful management and subsequent clinical outcome. Failure of timely diagnosis is the single most important cause of adverse outcomes (Matsen et al., 1980; McQueen et al., 1996). • Early diagnosis of compartment syndrome is facilitated by recognition of patient risk factors, understanding of the early clinical symptoms of compartment syndrome, and the judicious use of compartment pressure monitoring (McQueen et al., 1996). Risk factors for the development of acute compartment syndrome include male gender, age less than 35, tibial fracture, high-energy forearm fracture, high-energy femoral diaphyseal fracture, and bleeding diathesis or anticoagulation. • Missed or late diagnosis of acute compartment syndrome can result in serious complications such as muscle infarction, muscle contracture, secondary deformity, weakness, and neurologic dysfunction (Matsen et al., 1980). Other less-common sequelae include infection, gram-negative sepsis, amputation, and end-organ involvement. • Time from onset to necrosis varies, with an accepted upper limit of 6 hours. Determination of the exact time of onset of acute compartment syndrome is often difficult, as it may not parallel the onset of injury. Thus, ongoing assessment of the patient at risk is important in identifying a potential delayed-onset acute compartment syndrome. • Missed or late diagnosis is often a result of clinical inexperience, lack of suspicion, or a confusing clinical presentation. Altered pain perception, as seen with changes in level of consciousness, regional anesthesia, patient-controlled analgesia, and nerve injury, are all risk factors for late diagnosis. Maintaining an appropriate index of suspicion is important in preventing the negative sequelae of late-diagnosed acute compartment syndrome as well as malpractice litigation. 

Clinical Diagnosis • Disproportionate pain relative to the injury and pain on passive muscle stretch (PPS) are recognized as the first symptoms of acute compartment syndrome. Progressively increasing analgesia requirements may be a sign of disproportionate pain and an underlying compartment syndrome. • Pain that is produced on plantar flexion of the foot or toes in an individual with an anterior acute compartment syndrome of the leg is an example of PPS. Both pain out of proportion to injury and PPS are the most sensitive clinical findings (19%) and are often the only findings that precede ischemic dysfunction in the nerves and muscles of the affected compartment. Although the specificity of both pain measures is high (97%), the sensitivity is disturbingly poor (19%). • Pain as a diagnostic criterion fails to identify a high percentage of individuals with acute compartment syndrome (Ulmer, 2002). The low false-positive rate suggests that the absence of pain is a more useful measure in ruling out acute compartment syndrome. However, an adequate level of suspicion must be maintained as the absence of pain may indicate individual variation, altered states of pain perception,

PROCEDURE 60  Compartment Syndrome

compartment syndrome of the deep posterior compartment, or missed acute compartment syndrome that has resulted in altered sensation. • Sensory changes are first noted approximately 1 hour after the onset of ischemia. • Hypesthesias and paresthesias in the dermatomal distribution of the nerve(s) of the involved compartment are typically the first neurologic signs of acute compartment syndrome. As a clinical measure of acute compartment syndrome, paresthesia has a sensitivity of 13% and a specificity of 98% (Ulmer, 2002). Hypesthesias and paresthesias of the first web space indicate involvement of the deep peroneal nerve and anterior compartment syndrome, whereas numbness of the dorsum of the foot may indicate lateral compartment syndrome with compression of the superficial peroneal nerve. These signs may also be caused by direct trauma to the nerve. • Paresis and/or paralysis of the muscles of the involved compartment are considered to be signs of a late acute compartment syndrome that is less likely to respond to fasciotomy. • A swollen, tense compartment resulting from increased ICP is recognized as an early physical sign of acute compartment syndrome. These findings may not be evident with isolated involvement of a deep compartment. Dressings and casts should be removed to accurately assess swelling. The lack of a pulse is not a feature of acute compartment syndrome, and the presence of a pulse does not exclude it. • Diagnosis of acute compartment syndrome requires careful evaluation of the entire clinical presentation. Ulmer (2002) found that the probability of acute compartment syndrome rose from approximately 25% when either pain, PPS, paresthesia, or paresis was present to 93% when three of these clinical findings were present concurrently. As noted, individual symptoms and signs are far from perfect in the diagnosis of compartment syndrome, but require careful interpretation owing to the tragic sequelae of a misdiagnosis. 

Compartment Pressure Monitoring • Measurement of ICP is a valuable tool for providing objective criteria for the diagnosis of acute compartment syndrome. • To ensure accurate ICP measurements, proper technique is crucial. ICP measurements should be taken at the level of the fracture as well as at sites up to 5 cm proximal and distal to the injury, to capture the peak ICP value (Heckman et al., 1994). Pressures should also be measured in the other compartments of the affected limb to ensure that a compartment syndrome is not missed. • Techniques for measuring ICP include needle manometer, wick catheter, slit catheter, and electronic transducer–tipped catheters. • The needle manometer consists of a 20-mL syringe full of air that is attached to a column that contains both air and saline. The ICP is the pressure required to flatten the meniscus between the saline and the air. Although this technique is simple and low cost, it is the least reliable as the needle can easily be occluded. • The wick catheter is an adaptation of the needle manometer in which fibers project from the end of the catheter. The fibers prevent tissue plugging, thus maintaining patency of the catheter to improve accuracy. • There has been recent interest in the role of carbon monoxide (CO) as a potential adjuvant treatment for compartment syndrome. CO is an important mediator of cell signaling and possesses antiischemic, antioxidant, antiinflammatory and vasodilatory properties (Kim et al., 2006). Delivery, dose, and toxicity have limited the clinical use of CO. • Carbon monoxide-releasing molecules (CORMs) can be used to deliver CO in a controlled manner without increasing carboxyhemoglobin concentrations. • Application of CORM-3 has been found to diminish compartment syndrome-associated tissue injury and leukocyte activation and blocked the systemic release of TNF-α, a proinflammatory cytokine, in a rat model of compartment syndrome (Lawendy et al., 2014). • The slit catheter is another modification of the needle manometer technique that relies on the principle of increased surface area and increased patency. The tip of the catheter is cut longitudinally, forming plastic petals. A fluid column connected to a transducer measures pressure. Advantages of the slit catheter in-

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CONTROVERSIES

• The role of ICP measurement in acute compartment syndrome remains controversial. The comparative benefit of ICP measurements relative to clinical assessment is unclear. • Nonetheless, ICP monitoring is a valuable diagnostic tool. Continuous compartment pressure monitoring decreases the delay to fasciotomy and may therefore decrease the longterm complications of the disorder. ICP monitoring confirms clinical findings in difficult cases.

TREATMENT OPTIONS

• Fasciotomy of the involved compartments remains the “gold standard” for treatment of compartment syndrome. • Nonoperative measures have a limited role. Little dispute exists regarding the severe consequences of delaying fasciotomy once the diagnosis of compartment syndrome has been made. Medical management at this time is restricted to an adjunctive role supplemental to fasciotomy. • The therapeutic effects of mannitol have been investigated in animal studies. Case studies have reported success at averting fasciotomy in the context of clinically diagnosed compartment syndrome. • Hyperbaric oxygen is thought to reduce edema within the affected compartment by oxygen-induced vasoconstriction while maintaining oxygen perfusion at lower perfusion pressure. Although this may be an effective adjunct to fasciotomy, it has limited availability. A recent review of the literature found that hyperbaric oxygen is effective in improving wound healing, reducing amputation rate, and lowering surgical procedure rate. • Tissue ultrafiltration has been used to reduce ICP by reducing fluid volume. Although clinical trials are needed, medical techniques may prove effective in patients presenting with an impending compartment syndrome.

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clude prolonged use owing to the open design of the catheter tip and the ability to break up blood clots in vivo by the application of pressure over the catheter tip. Accuracy is similar to the wick catheter. • Transducer-tipped catheters, designed with the transducer housed in the catheter tip, have improved the accuracy of compartment pressure measurements. These include the solid-state transducer intracompartmental catheter, an infusion-based system, and the electronic transducer-tipped system. Electronic techniques are independent of limb position and the height of the pressure transducer and do not require calibration. Disadvantages of these devices are cost and difficulty with resterilization. • The indications for ICP measurement, as described by McQueen et al. in 1996, include the following: • Unconscious patients • Difficult-to-assess patients, such as young children • Patients with equivocal signs and symptoms, especially when accompanied by nerve injury • Patients with multiple injuries • To avoid missed compartment syndromes, McQueen et al. later expanded the indications for ICP monitoring to include all tibial diaphyseal fractures, especially those in young men; high-energy distal radial and forearm diaphyseal fractures in young patients; high-energy fractures of the tibial metaphysis; and soft-tissue injury or bleeding diathesis. • Although ICP monitoring is utilized in the diagnosis of acute compartment syndrome, a specific pressure threshold at which fasciotomy is necessary remains controversial. The threshold ICP for decompression has been listed as 30, 40, and 45 mm Hg. In 1975, it was proposed that differential pressure (DP) is indicative of tissue ischemia, and suggested that tissue ischemia began when the difference between ICP and DP was 20 mm Hg. In 1996, it was recommended that the threshold DP be 30 mm Hg based on the retrospective observation that this value led to no apparent missed cases of acute compartment syndrome. Many trauma surgeons prefer DP to the use of an absolute ICP threshold. The advantages of a differential pressure threshold include better utility in hypotensive trauma patients, and a lower overall fasciotomy rate compared with an absolute pressure threshold. • A recent study by Whitney et al., looked at false-positive rates of compartment syndrome diagnosis based on one-time intracompartmental pressure measurements alone. When using a ΔP threshold of 30 and 20 mm Hg they reported a false-positive rate of 35% and 24%, respectively. • Near-infrared (NIR) spectroscopy is being examined as a noninvasive measurement of ischemia in compartment syndrome. NIR spectroscopy works by transmitting light that passes through the skin but is absorbed by hemoglobin. The amount of light absorbed by hemoglobin is dependent on the redox state of the iron molecule in hemoglobin, such that NIR spectroscopy can continuously measure tissue oxygenation. Infrared imaging has also been proposed as an additional diagnostic tool. It was found that temperature differences between the thigh and the foot showed a unique pattern in individuals with acute compartment syndrome. Despite the promise of both NIR and infrared imaging, further research is needed prior to routine clinical use. 

SURGICAL ANATOMY • Classically the foot is considered to have four main compartments: the forefoot or interosseous compartment, lying dorsal and between the metatarsals, the medial compartment; which lies on the surface of the hallux; the lateral compartment on the lateral aspect of the fifth metatarsal; and the central compartment, which lies on the plantar surface of the foot (Fig. 60.1). • In anatomic studies, nine discrete anatomic compartments exist. The central compartment (calcaneal) is divided into superficial and deep by the transverse septum of the hindfoot, whereas each interosseous muscle and the adductor hallucis are defined within a separate compartment.

PROCEDURE 60  Compartment Syndrome Interosseous Compartment Medial Lateral aspect of first metatarsal shaft

Dorsal Metatarsals and interosseous fascia

Plantar Interosseous fascia

Medial Compartment Lateral compartment

Dorsal

Dorsal

Inferior surface of first metatarsal shaft

Fifth metatarsal shaft Lateral Plantar aponeurosis

Medial Extension of plantar aponeurosis Lateral Intermuscular septum Plantar aponeurosis Inferior

Medial Intermuscular septum Interosseous fascia Intermuscular septum Lateral Dorsal Central Compartment

FIG. 60.1  Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

• However, fluid can flow freely between the layers of the central compartment such that we consider the central compartment as a single compartment with respect to surgical release. In a recent cadaveric study, a medial midfoot fasciotomy provided sufficient decompression of the plantar and flexor compartments. • The leg is divided into four compartments: anterior, lateral, and posterior deep and superficial (Fig. 60. 2). Anterior compartment Fibula Anterior intermuscular septum Lateral compartment Posterior intermuscular septum Superficial posterior compartment

Tibia

Interosseous membrane Deep posterior compartment Transverse intermuscular septum

FIG. 60.2 

• The anterior compartment contains the extensor muscles of the foot and ankle. The compartment is bounded medially by the extensor surface of the tibia, laterally by the intermuscular septum, and posteriorly by the extensor surface of the fibula and the interosseous membrane. The anterior compartment is completely enclosed by the deep fascia of the leg. • The lateral compartment contains the peroneal muscles, which evert the foot. Its medial border is the fibula, whereas the intermuscular septum surrounds this compartment both anteriorly and posteriorly.

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Medial intermuscular septum

Anterior compartment

Lateral intermuscular septum

Medial compartment

Posterior compartment FIG. 60.3 

• The posterior compartments house the flexors of the foot and ankle. Both deep and superficial groups of muscle are included, separated by a fascial layer. The posterior compartments are separated from the other compartments in the leg by a dense fibro-osseous complex. The fibula and the posterior intermuscular septum divide the posterior compartments from the lateral compartment. Anteriorly, the posterior compartments are separated from the extensor compartment by the interosseous membrane and the posterior surface of the tibia. • The thigh is divided into three muscle groups. The adductors lie medial, the extensors of the knee occupy the anterior segment of the thigh, and the flexors sit posterior. The extensor compartment is separated from the hip and the adductors by a thin medial intermuscular septum (Fig. 60.3). The very dense lateral intermuscular septum divides the anterior and posterior compartments and is bound by the fascia lata. The adductors and flexors are not separated by a septum. • Ten hand compartments have been described, including the thenar, hypothenar, adductor pollicis, and interosseous compartments: four dorsal and three volar (Fig. 60.4). Each interosseous muscle is encased in a tough investing fascial layer and hence is considered as a separate compartment. The thenar fascia, a septum, and the first metacarpal surround the thenar compartment. The hypothenar compartment is similarly contained by its fascia, a septum, and the fifth metacarpal. • The forearm consists of the volar flexor compartment, the dorsal extensor compartment, and the mobile wad (Fig. 60.5). • The flexor compartment sits anterior to the ulna, radius, and interosseous membrane. The antebrachial fascia binds the volar compartment anteriorly. The flexor compartment is arranged in three separate layers. The superficial layer contains the common flexor origin, made up of the pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The middle layer consists of the flexor digitorum superficialis, and the deep layer is composed of the flexor digitorum profundus, flexor pollicis longus, and pronator quadratus. Thenar compartment Hypothenar compartment Volar interosseous compartments (3) First metacarpal

Fifth metacarpal Dorsal interosseous compartments (4)

Adductor pollicis compartment FIG. 60.4 

PROCEDURE 60  Compartment Syndrome

Volar flexor compartment Mobile wad

Ulna Radius Dorsal extensor compartment

Interosseous membrane FIG. 60.5 

• The dorsal compartment of the forearm sits dorsal to the radius, ulna, and interosseous membrane and consists of the finger, thumb, and wrist extensors. The four superficial extensors include the anconeus, extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis. The deep muscles include the abductor pollicis longus, extensor pollicis brevis and longus, supinator, and extensor indicis. • The mobile wad, which is demarcated by a connective tissue septum from the antebrachial fascia, contains the brachioradialis and extensor carpi radialis longus and brevis. • The three compartments mentioned above are all surrounded by dense fascia. The deep forearm compartments are contained by the stiff interosseous membrane and bone; hence the deepest muscles (flexor digitorum profundus and flexor pollicis longus) are often most severely affected. • The carpal canal, despite being open at both ends, is considered to be an independent physiologic compartment in that fluid within this region does not communicate freely proximally or distally as it is bound by synovium. • The upper arm anatomically is divided into the anterior flexor and posterior extensor compartments (Fig. 60.6). The anterior flexor compartment contains the coracobrachialis, the biceps brachii, and the brachialis. The posterior extensor compartment consists of the triceps brachii. The lateral and medial intermuscular septa divide these compartments in the distal two-thirds of the arm. The humerus also acts as a boundary between the compartments. 

Anterior compartment Medial intermuscular septum

Lateral intermuscular septum Posterior compartment

Humerus FIG. 60.6 

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POSITIONING • For compartment syndrome of the foot, the patient is positioned supine with the limb prepared and draped free; the limb is raised, and a tourniquet is applied and not insufflated. The limb is externally rotated, and a medial approach to the foot is utilized for compartment release. • For compartment syndrome of the leg, positioning depends on the surgical technique. • For a single-incision fasciotomy, the patient is positioned supine with a bump under the ipsilateral hip. A tourniquet is applied and not insufflated. The limb is prepared and draped free. • For a two-incision fasciotomy, the patient is positioned supine, and a tourniquet is applied and not insufflated. The limb is prepared and draped free. • For compartment syndrome of the thigh, the patient is positioned supine, exposing the limb from the iliac crest to the knee joint. • For compartment syndrome of the hand, the patient is positioned supine, and the use of an arm board is helpful. A tourniquet should be available. • For compartment syndrome of the forearm, the patient is positioned supine with the arm extended onto an arm board. A tourniquet is kept available. • For compartment syndrome of the upper arm, the patient is placed in the beach chair position with the limb prepared and draped free. Access to the medial clavicle should be available in case vascular control is needed. 

EXPOSURES • Information on portals and exposures for the surgical treatment of compartment syndrome is contained in the descriptions of the various procedures per anatomic segment below. 

Surgical Treatment of Compartment Syndrome PROCEDURE: THE FOOT Step 1 • A long medial incision centered over abductor hallucis affords sufficient access to the central compartment of the foot. • The medial tubercle of the calcaneus is palpated; the incision is extended approximately 7 cm to allow full fasciotomy of the adductor up to the great toe. 

Step 2 • Incise the fascia longitudinally; distally, the fascia will coalesce with the medial belly of the flexor hallucis brevis, which is similarly released. • Take care not to injure the plantar vessels and nerves, which enter the compartment proximally, approximately a fingerbreadth below the medial malleolus. 

Step 3 • The medial-sided release gives access to the medial, plantar, and lateral compartments. • Release the dorsal interosseous compartment using two dorsal longitudinal incisions, one between the first and third and one between the fourth and fifth metatarsals, for the dorsal intrinsic compartments (Fig. 60.7). 

PROCEDURE 60  Compartment Syndrome

B Plantar interosseous fascia

A

C

Medial extension of plantar aponeurosis

Intermuscular septum

FIG. 60.7  Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

SURGICAL TECHNIQUES FOR COMPARTMENT SYNDROME OF THE LEG • Three techniques are most commonly described: two-incision fasciotomy, singleincision perifibular fasciotomy, and fibulectomy. • Our preferred method is the double-incision technique, which allows for adequate visualization of all compartments, assessment of muscle viability, and sufficient surgical control to avoid neurovascular structures. • The single-incision, four-compartment fasciotomy without fibulectomy can be useful in cases in which soft-tissue trauma or contamination is of concern, including situations in which only a single vessel perfuses the leg, or when flap coverage may be necessary. • In a recent article, Tornetta et al., described an intraoperative algorithm for selectively releasing the posterior compartments of the leg. They measured compartment pressures of all four compartments prior to releasing only the anterior and lateral compartments. Following fasciotomy, they remeasured the posterior compartments pressures and calculated ΔP. If ΔP was less than 30 mm Hg, they proceeded with a standard medial incision posterior release and if greater than 30 mm Hg, the patient was admitted and monitored every 2 hours for changes in neurologic or motor function of the lower limb. Of the 37 patients, 3 patients had ΔP less than 30 mm Hg and proceeded to medial fasciotomy and 34 patients were monitored. None of the 34 patients required a subsequent posterior compartment release. The ΔP of the superior and deep posterior compartments increased an average of 26 ± 9 mm Hg and 31 ± 11 mm Hg, respectively, following anterior and lateral compartment release. • Four-compartment release with fibulectomy can be performed through one lateral incision. This technique takes advantage of the fascial anatomy because all the fascial membranes insert onto the fibula. However, this method may place the peroneal vessels at risk, and sacrifices the fibula, which is usually unnecessary.

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• Both the double- and single-incision technique are sufficiently effective at decreasing ICP. A recent cadaveric study by Neal et al., compared a single incision versus dual incision technique when decompressing all four compartments of the leg. They found both were equally effective at decompressing all compartments including the deep posterior compartment. Once adequately decompressed, it was not possible to elevate pressures within the deep posterior compartment. • Subcutaneous fasciotomy is a technique in which the fascia is incised blindly with dissecting scissors through a small skin incision. Advantages to this technique include technical ease and cosmesis. However, access to the deep posterior compartment and the neurovascular bundle is limited, and the intact skin bridge may not allow for complete decompression. •  Small-incision fasciotomy as well as endoscopically assisted fasciotomies may have a role in chronic exertional compartment syndrome. However, these techniques should not be used in acute compartment syndrome as recurrence of limbthreatening ischemia may occur despite fascial release when the skin is left intact. In acute compartment syndrome, release of the skin as well as complete fascial release achieves the greatest decrease in ICP. 

PROCEDURE: SINGLE-INCISION FASCIOTOMY FOR THE LEG Step 1 • Make a single longitudinal, lateral incision in line with the fibula. Extend the incision from the fibular head to 3 cm proximal to the lateral malleolus. The superficial peroneal nerve is at risk toward the distal aspect of the incision. • Skin flaps are developed anteriorly, and a longitudinal fasciotomy of the anterior and lateral compartments is performed with dissecting scissors. Next, a posterior flap is developed and a fasciotomy of the superficial posterior compartment is performed. • Identify the interval between the superficial and lateral compartments distally, and develop this interval proximally by detaching the soleus from the fibula. Subperiosteally, dissect the flexor hallucis longus from the fibula. 

Step 2 • At this point, all four compartments have been decompressed. However, on occasion the tibialis posterior exists within a self-contained fascial envelope, and therefore it is beneficial to continue the deep dissection until the tibialis posterior is decompressed. • Retract the muscle and the peroneal vessels posteriorly. Identify the fascial attachment of the tibialis posterior muscle to the fibula and incise it longitudinally. 

Step 3 • Wounds are packed open, or the skin may be loosely closed over suction drains. 

PROCEDURE: TWO-INCISION FASCIOTOMY FOR THE LEG Step 1 • Make a 25-cm incision in the anterior compartment, centered halfway between the fibular shaft and the crest of the tibia. Use subcutaneous dissection for wide exposure of the fascial compartment. • Expose the lateral intermuscular septum and identify the superficial peroneal nerve lying posterior to the septum. • Using dissecting scissors, release the anterior compartment proximally and distally in line with the tibialis anterior. Access the lateral compartment and perform a fasciotomy of the lateral compartment proximally and distally in line with the fibular shaft (Fig. 60.8). 

PROCEDURE 60  Compartment Syndrome

Tibia Saphenous nerve and vein Anterior intermuscular septum

A

B

FIG. 60.8 Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

Step 2 • Make a second longitudinal incision 2 cm posterior to the posterior margin of the tibia. • Elevate skin flaps and ensure the saphenous vein and nerve are identified and protected. • Identify the septum between the deep and superficial posterior compartments and release the fascia over the gastrocnemius-soleus complex over its entire length. 

Step 3 • Make another fascial incision over the flexor digitorum longus muscle and release the entire deep posterior compartment (Fig. 60.9).

A Anterior compartment Anterolateral approach

Posteromedial approach

Lateral compartment Superficial posterior compartment

B

Deep posterior compartment

FIG. 60.9 Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

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PROCEDURE 60  Compartment Syndrome

• As the dissection is carried proximally, if the soleus bridge extends more than halfway down the tibia, release this extended origin. • After release of the posterior compartment, identify the tibialis posterior muscle compartment. If increased tension is evident in this compartment, release it over the extent of the muscle belly. 

Step 4 • The wound is packed open and a posterior plaster splint is applied with the foot plantigrade. 

PROCEDURE: THE THIGH Step 1 • The incision extends from the vastus ridge to the lateral epicondyle. Incise the iliotibial band along its entire length. • The vastus lateralis will often herniate out of the wound upon incising the fascia. Assess muscle for viability. Dissect the vastus lateralis off the lateral intermuscular septum. • Perforating vessels are coagulated as they are encountered in the dissection. • Incise the lateral intermuscular septum for the length of the incision. 

Step 2 • Once the anterior and posterior compartments are released, measure the pressure of the medial compartment. If elevated, the adductor compartment can be approached through a medial incision that courses along the saphenous vein, medial to the sartorius muscle, followed by incision of the medial intermuscular septum. 

PROCEDURE: THE HAND Step 1 • Surgical decompression of the hand can be achieved using two dorsal incisions that allow access to the interosseous compartments. • Consider carpal tunnel release or release of the ulnar nerve at Guyon’s canal. Thenar and hypothenar incisions are made as needed for fasciotomy. 

Step 2 • Release the dorsal, volar, and adductor compartments through two longitudinal incisions on the dorsum of the hand over the ring finger and index finger metacarpals (Fig. 60.10). Extend the incisions along both sides of the metacarpals, incising the dorsal interosseous muscle fascia.

FIG. 60.10  Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

PROCEDURE 60  Compartment Syndrome

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• Release the first volar compartment and adductor compartment by dissecting along the radial aspect of the index finger. If further decompression is needed, open the thenar and hypothenar compartments by longitudinal incisions along the radial aspect of the thumb metacarpal and the ulnar aspect of the small finger metacarpal. 

Step 3 • Wounds remain open and are bound loosely with saline-soaked gauze. • Stabilize fractures at the time of fasciotomy to avoid the need for casting. • Repeat irrigation and debridement in 48 hours. 

PROCEDURE: THE FOREARM Step 1 • A curvilinear incision for combined exposure of the median and ulnar nerve is utilized. • Make an anterior curvilinear incision medial and proximal to the biceps tendon, crossing the elbow flexion crease at an oblique angle. Carry the incision distally into the palm, again crossing the flexion crease at an angle to avoid contracture. • Position this incision to allow access for carpal tunnel release (Fig. 60.11). If the ulnar nerve is affected, use a distal volar ulnar approach for exploration in Guyon’s canal (Allan et al., 1985). 

Volar radial approach

Ulnar nerve

Volar ulnar approach

FIG. 60.11  Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

Step 2 • Proximally, the lacertus fibrosis is divided; here the brachial artery may be explored as needed. Continue dissection distally to release the superficial volar compartment throughout the entire length of the incision. • Identify and retract ulnarly the flexor carpi ulnaris along with the underlying neurovascular bundle. Retract the flexor digitorum superficialis and median nerve medially to expose the deep compartment. Incise the fascia and epimysium longitudinally over the flexor digitorum profundus. • Continue dissection, incising the transverse carpal ligament along the ulnar border of the palmaris longus tendon and median nerve. Muscle should be examined for perfusion, color, consistency, and contractility. Resect muscle that is necrotic. 

Step 3 • At this point, assess pressure in the posterior compartment. • Usually, decompression of the volar compartment is sufficient to decompress the forearm. However, if involvement in the dorsal compartment persists despite full release of the volar compartment, a second dorsal incision is needed. • Begin the incision distal to the lateral epicondyle between the extensor digitorum communis and extensor carpi radialis brevis, extending distally. • Undermine the subcutaneous tissue and the fascia overlying the mobile wad and release the extensor retinaculum (Fig. 60.12). 

Step 4 • The limb may be dressed with a sterile moist dressing and splint. 

CONTROVERSIES

• The absolute requirement to release the carpal tunnel in isolated forearm compartment syndrome remains controversial. No reports exist of compartment syndrome inducing carpal tunnel syndrome. In an anatomic study of compartment syndrome, elevated forearm tissue pressures did not readily transmit to the carpal tunnel. Nonetheless, many surgeons routinely release the carpal tunnel in the setting of acute forearm compartment syndrome. • The median nerve may be entrapped proximally between the heads of the pronator teres or the proximal edge of the flexor digitorum superficialis, although the fibrous edge should not be contracted in the acute setting unless a severe burn or electrocution is involved. • In the rare event of high-voltage limb electrocution, the deep compartments should be fully explored as the deep muscles are preferentially injured because the electrical resistance of bone can transmit significant thermal injury.

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PROCEDURE 60  Compartment Syndrome Flexor Flexor digitorum carpiulnaris sublimis

Flexor carpi radialis

Brachioradialis

Extensor carpi radialis brevis

Volar ulnar approach

Volar radial approach

FIG. 60.12  Redrawn from Twaddle BC, Amendola A. Compartment syndromes. In Browner BD, Jupiter JB, Levine AM, et al (eds). Skeletal Trauma, ed 4, vol 1. Philadelphia: Elsevier Saunders, 2009:341–366.

PROCEDURE: THE UPPER ARM Step 1 • Make a longitudinal incision over the tip of the coracoid process and extend it distally and laterally in line with the deltopectoral groove to the deltoid insertion. Continue the incision distally, following the anterolateral border of the biceps. • Access the fascia over the pectoralis major, deltoid, and biceps in the proximal superficial dissection. • Incise the deep fascia of the arm in line with the skin. Develop the interval between the biceps brachii and the brachialis to release the deep fascia. • The musculocutaneous nerve and anterior circumflex humeral artery cross the field medial to lateral. 

Step 2 • Once the anterior fasciotomy is complete, internally rotate the arm to access the posterior compartment. • The incision is landmarked from the acromion to the olecrenon fossa. Begin the incision 10 cm below the acromion and longitudinal midline on the posterior aspect of the arm. • Incise fascia over the lateral and long head distally, exposing the triceps tendon. Proximally, split the two heads bluntly and retract the lateral head laterally and the long head medially. This exposes the deep head of the triceps, and its fascia can be released as necessary. • The radial nerve and the profunda brachii lie in the proximal end of the wound. 

Step 3 • Assess the muscle, pack wounds, and apply a noncompressive dressing. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Our routine is to re-examine the limb in the operating room in 48 hours for debridement of necrotic muscle, as necessary, and wound management. • Management of fasciotomy wounds has included primary closure, delayed closure, healing by secondary intention, or split-thickness skin grafting. Grafting may be necessary in approximately 50% of patients. • Some recent advances in fasciotomy wound management include the “shoelace” or “bootstrap” technique, as well as vacuum-assisted wound closure.

PROCEDURE 60  Compartment Syndrome

• The bootstrap technique involves placement of an elastic tape running back and forth across the wound to apply gentle tension to the wound edges. • Commercially available devices may be used or, alternatively, vascular vessel loops can be run between simple surgical staples. • This technique is thought to decrease the necessity of skin grafting by preventing retraction of the skin away from the wound margins, thereby facilitating delayed primary closure. However, the technique may be slow to advance the wound margins such that up to 2 weeks may be necessary before closure can be achieved. •   Vacuum-assisted wound closure is similarly useful at gently tensioning the wound margins, and may also reduce wound contamination, maintain tissue hydration, and reduce tissue necrosis. Long-term complications of fasciotomy include wound complications such as decreased sensibility, tendon tethering, recurrent local ulceration (Fitzgerald et al., 2000), chronic swelling, and muscle herniation. Postoperatively, approximately onefourth of patients will have to significantly change their lifestyles and one-tenth will have to change occupation (Fitzgerald et al., 2000).

EVIDENCE Allan MJ, Steingold RF, Kotecha M, et al. The importance of the deep volar compartment in crush injuries of the forearm. Injury. 1985;16:273–275. This study discusses the diagnostic pitfalls and use of intracompartmental monitoring. (Level IV evidence.) Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg. 2000;53:690–693. Heckman MM, Whitesides TE, Grewe SR, et al. Compartment pressure in association with closed tibial fractures: the relationship between tissue pressure, compartment, and the distance from the site of fracture. J Bone Joint Surg [Am]. 1994;76:1285–1292. This in vivo research study measuring intracompartmental pressure at various intervals from the fracture determined that proximity was important to accuracy of measurement. (Level II evidence.) Kim HP, Ryter SW, Choi AM. Annu Rev Pharmacol Toxicol. 2006;46:411–449. Lawendy AR, Bihari A, Sanders DW, Potter RF, Cepinskas G. The severity of microvascular dysfunction due to compartment syndrome is diminished by the systemic application of CO-releasing molecule-3. J Orthop Trauma. 2014;28(11):e263–e268. Lawendy AR, Sanders DW, Bihari A, et al. Compartment syndrome-induced microvascular dysfunction: an experimental rodent model. Can J Surg. 2011;54:194–200. This research paper denoted the role of inflammation and low-flow ischemia in compartment syndrome. Mars M, Hadley GP. Raised compartmental pressure in children: a basis for management. Injury. 1998;29:183–185. This clinical paper noted the risk of missed compartment syndrome in children and the need for a high index of suspicion. (Level IV evidence.) Matsen FA, Winquist RA, Krugmire RB. Diagnosis and management of compartmental syndromes. J Bone Joint Surg [Am]. 1980;62:286–291. This classic paper defined traditional diagnostic strategies and treatment. (Level IV evidence.) McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg [Br]. 1996;78:95–98. This clinical prospective series defined a role for pressure measurement and noted the benefit of early surgery. (Level II evidence.) Mubarak SJ, Owen CA. Double incision fasciotomy of the leg for decompression of compartment syndromes. J Bone Joint Surg [Am]. 1977;59:1854–1857. The authors presented a good technical discussion of fasciotomy. (Level IV evidence.) Neal M, Henebry A, Mamczak CN, et al. The efficacy of a single-incision versus two-incision fourcompartment fasciotomy of the leg: a cadaveric model. J Orthop Trauma. 2016;30(5):e164–168. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg [Br]. 1984;66:93. This review offered a good practical approach to diagnosis and treatment of compartment syndrome of the leg. (Level IV evidence.) Sadasivan KK, Carden DL, Moore MB, Korthuis RJ. Neutrophil mediated microvascular injury in acute, experimental compartment syndrome. Clin Orthop Relat Res. 1997;(339):206. This research paper denoted the role of inflammation and low-flow ischemia in compartment syndrome. Schwartz JT, Brumback RJ, Lakatos R, et al. Acute compartment syndromes of the thigh: a spectrum of injury. J Bone Joint Surg [Am]. 1989;71:392–400. This clinical series of thigh compartment syndromes demonstrated the rarity of adverse sequelae in contrast to that found for the lower leg in the literature. (Level IV evidence.)

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PROCEDURE 60  Compartment Syndrome Tornetta 3rd P, Puskas BL, Wang K. Compartment syndrome of the leg associated with fracture: an algorithm to avoid releasing the posterior compartments. J Orthop Trauma. 2016;30(7):381–386. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are the clinical findings predictive of the disorder? J Orthop Trauma. 2002;16:572–577. This useful clinical paper considered the sensitivity, specificity, and predictive values of clinical examination for compartment syndrome. The paper provided additional material to consider adjunctive diagnostic strategies. (Level II evidence.) Volkmann R. Ischaemic muscle paralyses and contractures. Clin Orthop Relat Res. 1881;(50):5. This historical article, while not considered good medical evidence, is a classic in compartment syndrome. Whitney A, O’Toole RV, Hui E, et al. Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome? Trauma Acute Care Surg. 2014;76(2):479–483.

PROCEDURE 61

Pelvic External Fixation Patrick Henry INDICATIONS • Resuscitation: Stabilization of unstable pelvis fractures in hemodynamically unstable patient. • Pain control: Stabilization of pelvis fractures that are relatively stable but too painful to allow mobilization or upright posture. • Reduction maneuver: Application of supra-acetabular external fixator pins can allow for manipulation of the hemipelvis to help reconstitute the shape of the pelvis. This can be followed by open reduction and internal fixation (ORIF). • Temporary management: As part of damage control orthopedics, temporary external fixation (ex-fix) application in the acute care setting until definitive/complex ORIF can be planned and conducted in the optimal surgical environment. • Definitive management: Ideal for anterior, unstable pelvic ring disruptions for which adequate closed reductions can be achieved. 

EXAMINATION AND IMAGING • In the conscious patient, gentle internal and external force on the anterior superior iliac spine (ASIS) will be painful. • In the unconscious patient, manual force on the pelvis may illicit palpable crepitus or detectable motion of the unstable pelvis. • Rule out open fracture, which includes inspection of the skin (which involves rolling the patient to assess the sacral area, and a perineal exam), a vaginal examination in females, and a digital rectal examination (palpating for bony fragments and inspecting for blood). • Motor examination to assess for neurologic injury • All physical examination findings (both positive and negative) should be performed and documented prior to any surgical intervention. • An anteroposterior (AP) pelvis radiograph can often provide the diagnosis and is frequently the only radiographic view obtained in the acute setting in a severely injured patient. Inlet and outlet views provide more information on degree and direction of displacement. • A two-dimensional (2D) computed tomography (CT) scan provides more detailed fracture pattern information. • In a pelvis with multiple and significantly displaced fracture lines, a three-­dimensional (3D) CT can provide a picture that can simplify comprehension of the overall fracture pattern. However, smaller and nondisplaced fracture lines will not be visible on a 3D CT scan. Therefore, if using 3D CT, always review the 2D CT. 

SURGICAL ANATOMY • The pelvis has a complex geometry. The complexity is increased with displaced fractures, which deform the symmetry of the pelvis. The surgeon should be familiar with the pelvic shape, slope of the iliac wings, curvature of the crest, fluoroscopic appearance and positions, fracture pattern, and safe channels for pin placement. • The most common technique is supra-acetabular pin placement, for which the surgeon relies heavily on fluoroscopy. Once the patient is positioned, it is always wise to ensure that the desired fluoroscopic images can be taken prior to prepping/draping and certainly before incising the patient. • For supra-acetabular pin placement (Fig. 61.1), the structures at risk include the lateral femoral cutaneous nerve (LFCN), hip joint, femoral nerve and vessels, and sciatic notch. 779

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PROCEDURE 61  Pelvic External Fixation Lateral femoral cutaneous nerve Femoral nerve vein and artery Anterior superior iliac spine

Supra-acetabular pin Anterior inferior iliac spine

FIG. 61.1 

Pin Iliac tubercle Anterior superior iliac spine

Lateral femoral cutaneous nerve

FIG. 61.2 

• For iliac crest pins (Fig. 61.2), fluoroscopy is not mandatory, making this the recommended technique in a trauma bay setting or any environment with no fluoroscopy available. The structures at risk include the hip joint and LFCN. However, the most common issue is the placement of pins that do not have good (or any) bone purchase—­particularly if fluoroscopy is not used. 

POSITIONING • Supine on a radiolucent table • Some surgeons prefer that a folded sheet be placed under the pelvis/sacrum, though this is not mandatory. • In order to perform skeletal traction, it is helpful to prep one or both legs into the sterile field. 

PORTALS/EXPOSURE Supra-acetabular pins • Incision: The incision is made lateral to the anterior inferior iliac spine (AIIS), as the pins are directed medially toward the posterior superior iliac spine (PSIS). Fluoroscopy is helpful in planning accurate incision location. Some surgeons suggest a transverse incision, in line with the typical direction that reduction maneuvers are performed once the pins are in place (Fig. 61.3).

PROCEDURE 61  Pelvic External Fixation

ASIS

781

Incision location

ASIS

Retracted lateral femoral cutaneous nerve

Patellar alignment FIG. 61.3 

• Dissection: Percutaneous technique is an option, but this does not protect the LCFN. To minimize risk to the LCFN, make the incision 3 to 4 cm and perform blunt dissection down to bone using narrow retractors. The LCFN does not need to be identified, but this technique will reduce the risk of iatrogenic injury. 

Iliac crest pins • One 5- to 6-cm incision along the iliac crest (Fig. 61.4) or • Multiple “stab” incisions for each pin along the iliac crest 

PEARLS

• To ensure that appropriate images can be obtained, take fluoroscopic images once the patient is positioned but prior to prepping and draping. • If using a percutaneous technique, to protect the LCFN, use a drill guide with a blunt or semi-sharp trocar to push down to the AIIS. Then, drill and insert the pins through the drill guide. • Transverse incisions in line with the planned reduction maneuver minimize pressure on the skin and the need for making “release” incisions if skin becomes too tight on one side of the pin after the reduction maneuver. • A cut syringe can make a good radiolucent drill sleeve. • In displaced fractures, traction may be helpful to reduce the pelvis/hemipelvis to a more natural position, which could aid pin placement. Ensure that the leg used for traction is prepped into the sterile field.

Single incision along crest or Transverse pin incisions

FIG. 61.4 

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PROCEDURE 61  Pelvic External Fixation

PROCEDURE Step 1: Determination of Hemipelvis Orientation • Review preoperative imaging to estimate approximate insertion angles of pin placement. This will help orient the surgeon during actual placement. • Take fluoroscopic images prior to prepping the patient to confirm pin placement direction. Due to displacement, the standard fluoroscopic views used in the pelvis may need to be altered to properly visualize the hemipelvis and may be different when working on the right versus the left hemipelvis. An experienced fluoroscopy technician is extremely helpful during these cases. 

Step 2: Pin Placement • Supra-acetabular pins (Fig. 61.5A–E) • The pin starts at the AIIS and is directed along the column of bone connecting the AIIS to the PSIS. • Use fluoroscopy to determine the ideal trajectory and starting point. While this can be estimated using the AP view, the ideal view is a direct shot down the planned trajectory, which involves a special view that some surgeons refer to as the “outlet-oblique” view and others refer to as the “teardrop/outlet-oblique view.” This combines the pelvic outlet view and the obturator oblique view used in acetabular fractures. When in the correct orientation, the column of bone connecting the AIIS to the PSIS appears as a teardrop shape, with the floor of the teardrop representing the cortical bone above the greater sciatic notch (Fig. 61.5B). • Select the pin to be used. Ensure that the pin selected is long enough to reach the planned depth and still have adequate protrusion from the skin after insertion. Pin diameters of 5 mm are most common but 6-mm pins can be used in this region. • Make the incision as described earlier for supra-acetabular pin placement. Incision placement can be aided by obtaining the obturator-oblique view and locating the start point on the skin with the tip of a wire, pin, or clamp. • Use a drill sleeve with trocar to palpate the AIIS region. Once palpating bone, remove the trocar. • While not absolutely necessary, to most accurately visualize the trajectory prior to drilling, use the “teardrop” fluoroscopy view. One can orient the drill sleeve such that the fluoroscopy shot is straight down the sleeve (Fig. 61.5C). To drill, however, the fluoroscopy unit will need to be moved out of the way to make room for the drill and the surgeon’s hand. Hold the sleeve steady during this process. • If using self-tapping pins, drill through the cortex only. It is not necessary to drill the entire planned length of the pin. Note: Before drilling, have the pin ready. • Keeping the drill sleeve steady and in place, remove the drill and insert the pin. Inserting the pin by hand is recommended: if oriented generally in the correct direction, the pin can often “find its way” down the cortical channel. Inserting under power has greater risk of the pin breaking through the cortex if the trajectory is not perfect. • Use fluoroscopy periodically to confirm proper pin trajectory. Once placed, take extra views (AP, obturator-oblique, iliac-oblique, and outlet-oblique/teardrop view) to confirm appropriate depth (iliac-oblique view) and that it has not breached the cortex in any location (obturator-oblique and/or “teardrop” view; Fig. 61.5D–E). • The depth of the pin should be at least to just above the greater sciatic notch, but for more control of posterior fractures, they can be inserted all the way to the PSIS if the correct starting point and trajectory are used. • Perform the same steps on the contralateral hemipelvis. • Typically, only one pin per side is necessary. A second pin can be added with a starting point just proximal to the first pin between the AIIS and the ASIS. • Iliac crest pins (Fig. 61.6A–C) • Note: This technique is no longer commonly used. One benefit of this technique is that it is possible without fluoroscopy. However, fluoroscopy does make the process much easier and with more accurate pin placement.

PROCEDURE 61  Pelvic External Fixation

A

B

C

D

E FIG. 61.5  A–E

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PROCEDURE 61  Pelvic External Fixation

784

A

B

C FIG. 61.6  A–C



• Two to three pins are inserted per crest. • 5-mm pins are used. • Make incisions as described earlier in the Portals/Exposure section. • Place the first/anterior pin approximately 2 cm posterior to the ASIS. • The starting point is slightly medial on the crest; owing to the overhang of the lateral crest (which can be assessed on preoperative imaging) a lateral starting point may not allow appropriate pin trajectory/depth. • Self-drilling pins may be used. If so, start the pin on power, but insert the pin by hand. Doing so allows the pin to “find its way” between the inner and outer tables. • A drill may also be used to perforate the cortex. It is not necessary to drill the entire length of the pin. Use a drill sleeve and perforate the cortex; once the cortex is breached, keep the drill sleeve steady, remove the drill, and insert the pin by hand through the drill sleeve. • Space the pins out by 1.5 to 2 cm. • If available, fluoroscopy should be used to confirm pin placement and fracture reduction (see Fig. 61.6A–B). •  Fig. 61.6C shows the appearance and location of the pins on the upper lateral abdomen when using iliac crest pin placement. 

Step 3: Reduction and External Frame Application • Manipulate the hemipelvis using the pins; an anatomic reduction may be impossible depending on the fracture pattern. Reduction should be visualized in the AP, inlet, and outlet views. Pay attention not only to the anterior reduction but also the reduction of the posterior pelvis.

PROCEDURE 61  Pelvic External Fixation

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•  A simple “A” frame is most common; however, a single pin-to-pin bar may be possible and is more rigid. Ensure that the bars and clamps are placed far enough from the skin such that they do not press directly on the skin. Be cognizant that when sitting up, the upper thighs will rise toward the supra-acetabular pins/clamps. Therefore, avoid placing clamps and/or bars too close to the upper thighs. Otherwise, the ability of the patient to assume a sitting position will be compromised. • If necessary, place relaxing incisions on the skin around the pins to avoid skin necrosis. • Note: Control of reduction posteriorly is improved by longer supra-acetabular pins. However, significant posterior instability (especially vertical) is not well controlled by an external fixator regardless of how well it is placed. Early follow-up imaging at intervals should be performed to monitor the reduction if definitive management is planned using an external fixator, as loss of reduction is common in highly unstable fractures (especially with significant posterior instability). 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Daily pin care is mandatory to cleanse the pin and remove crusting; normal saline is satisfactory. • Pin site drainage is common. If there is drainage, the pin or pin cluster should be wrapped with a 4- to 6-inch gauze roll to create a bulky dressing to absorb the drainage and stabilize the soft tissues around the pin (see Fig. 61.6C). • Complications • Pin site infection: Ensure that there is no deep abscess. Treat with wound care, including pin cleaning and frequent dressing changes; antibiotics may also be used. If there is pin loosening, it should be removed and reinserted. • Loss of reduction: This is common in highly unstable fractures. Adding posterior stabilization (i.e., sacroiliac screws or a C-clamp) reduces the likelihood of loss of reduction. Early follow-up imaging at intervals should be performed to monitor the reduction status. Revision surgery and external fixator application versus ORIF may be required.

PITFALLS

• Owing to both distorted pelvic geometry and the presence of fracture lines across planned pin trajectories, pin placement can be challenging or impossible in the face of iliac wing fractures and/or associated acetabular fractures. • Fracture reduction is common with posterior instability, which may or may not be appreciated on initial imaging. Check the reduction early (within 1–2 days) of external-fixator application with a full pelvic series of radiographs (AP, inlet/outlet) and then at regular intervals to ensure that the reduction is maintained. • Do not attempt supra-acetabular pin placement without fluoroscopy.

EVIDENCE Calafi LA, Routt ML. Anterior pelvic external fixation: is there an optimal placement for the supra-­ acetabular pin? Am J Orthop (Belle Mead NJ). 2013;42(12):E125–E127. Gansslen A, Pohlemann T, Krettek C. Supraacetabular external fixation for pelvic ring fractures. Eur J Trauma. 2006;5:489–499 (Level IV evidence). Lidder S, Heidari N, Gänsslen A, Grechenig W. Radiological landmarks for the safe extra-capsular placement of supra-acetabular half pins for external fixation. Surg Radiol Anat. 2013;35(2):131–135. Rommens P, Hessmann M. External fixation for the injured pelvic ring. In: Tile M, Helfet D, Kellam J, eds. Fractures of the Pelvis and Acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003:203–216 (Level V evidence).

PEARLS

• Ensure that the fluoroscopy technician can obtain the desired views prior to prepping/ draping the patient. • Pilot drill holes are helpful to start the pin insertion process. • A sleeve/trocar system using a guide that allows drilling and pin insertion through the same guide makes it easier to find the drill hole. • Insert the pin by hand, which allows the pin to “find its way” within the cortical walls of the planned trajectory. • Use long pins (200 mm). The 5-mm pins are adequate; however, 6-mm pins are possible in the supra-acetabular region.

PROCEDURE 62

Pelvic Supraacetabular External Fixation Andrew Furey and Chris Hamilton

INDICATIONS PITFALLS

• Unstable, critically ill patients • Requires fluoroscopy, therefore unable to insert supraacetabular pins in emergency department • Some patients will require a second operation for definitive open reduction and internal fixation. • Pin placement may complicate future surgical approaches for pelvic ring or acetabular fractures (e.g., ilioinguinal, iliofemoral). • Anterior frame placement will prohibit prone positioning for posterior pelvis or spinal fixation.

INDICATIONS • External fixation is a critical part of the orthopedic armamentarium required when managing pelvic trauma. • Temporary stabilization of a hemodynamically compromised trauma patient secondary to an unstable pelvic injury • Definitive stabilization of an unstable pelvic injury requiring anterior fixation when open reduction and internal fixation is contraindicated (e.g., soft-tissue injury, open wounds, bladder injury, suprapubic catheter) 

INDICATIONS CONTROVERSIES • Supraacetabular pins provide biomechanically superior fixation of the pelvis compared with traditional anterior iliac crest pins, with decreased movement across an unstable sacroiliac joint.1 • Increased density of supraacetabular bone can improve fixation in osteoporotic bone. • Combined with distraction to reduce and treat displaced vertically stable lateral compression fractures.2 • Computed tomography (CT) to assess bony corridors for pin placement and fully delineate injury pattern • Placement before or after trauma laparotomy 

EXAMINATION/IMAGING

TREATMENT OPTIONS

• Nonoperative management in stable pelvic fracture • Temporary circumferential pelvic compression with appropriately placed pelvic binder or sheet (centered over greater trochanters) • Acute open reduction and internal fixation • Skeletal traction in vertically unstable fracture pattern

• Unstable pelvic injuries are most often the result of high-energy trauma. A full evaluation and resuscitation complying with Advanced Trauma Life Support principles should be conducted to stabilize the trauma patient and detect simultaneous injuries. • Specific attention should be paid to peripelvic soft-tissue and organ systems. • Urologic, gynecologic, vascular, intraabdominal, and rectal injuries will require a multidisciplinary approach with the appropriate surgeons involved in both acute and definitive management. • Pelvic soft-tissue envelope must be thoroughly assessed (including vaginal and rectal examinations) for open and significant closed (Morel-Lavallee lesion) injuries. • An adequate anteroposterior (AP) pelvic radiograph is usually sufficient in the hemodynamically unstable patient (Figs. 62.1 and 62.2). • In the stable patient, further imaging will provide additional useful information • Inlet and outlet radiographs plus or minus Judet views in the setting of concomitant acetabular fracture • CT will assess bony corridors for pin placement and further delineate the injury pattern, which will aid in operative planning for both temporary external fixation and definitive management. 

SURGICAL ANATOMY • Supraacetabular pin start point is between the anterior superior iliac spine (ASIS) and anterior inferior iliac spine (AIIS). • Start point at least 2 cm above the hip joint; average superior extent of hip capsule above the joint reported to be 16 mm (range, 11–20 mm).3 • Lateral femoral cutaneous nerve has a variable course through start point (Fig. 62.3). • In a cadaver study, 60% of lateral femoral cutaneous nerves ran medial to a supraacetabular pin and 40% ran lateral.3 • Mean distance from pin was 10 mm (range, 2–25 mm).3 786

PROCEDURE 62  Pelvic Supraacetabular External Fixation

FIG. 62.1 

FIG. 62.2  Lateral femoral cutaneous nerve Femoral nerve vein and artery Anterior superior iliac spine

Supraacetabular pin Anterior inferior iliac spine

FIG. 62.3 

787

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PROCEDURE 62  Pelvic Supraacetabular External Fixation

POSITIONING PEARLS

• Appreciate variations in pelvic anatomy prior to beginning procedure. • Appreciate any associated pelvic wing or acetabular fractures which may exist. POSITIONING PITFALLS

• Obese patient will make all steps more challenging. • Lack of area of skin preparation. POSITIONING EQUIPMENT

• Radiolucent table • Fluoroscopy • Optional: Skeletal traction pins, traction bow and bed attachments. POSITIONING CONTROVERSIES

• If posterior iliosacral fixation is planned in the same sitting, it could be performed before or after anterior external fixation. • If required, should trauma laparotomy be performed before or after? PORTALS/EXPOSURES PEARLS

• Vertical spreading of soft tissues through the stab incision will minimize the risk to the lateral femoral cutaneous nerve. PORTALS/EXPOSURES PITFALLS

• Be careful to avoid the lateral femoral cutaneous nerve. • Pins should be positioned toward the sciatic notch, but not through it, allowing patients to bend their knees.

• Femoral neurovascular bundle should be well medial to the pin; mean nerve and artery distance from pin: 35 mm and 45 mm, respectively.3 • Greater sciatic notch at risk with misdirected pin 

POSITIONING • Radiolucent table • Supine position • Ensure adequate required fluoroscopic views (discussed below) prior to sterile preparation. • Folded sheets may be required to manipulate pelvis or lumbar spine to facilitate adequate imaging. • Consider leaving pelvic binder sheet in place to maintain/aid in reduction. Sterile preparation through working portals cut out of the sheet do not diminish its function and allow placement of external fixation pins, percutaneous iliosacral screws, and access for pelvic angiography.4 • Sterile preparation and draping of skin from xiphoid to proximal thigh; isolate ­perineum. • Consider free draping lower extremity if manipulation or traction will aid in reduction, particularly in vertically unstable fracture patterns. 

PORTALS/EXPOSURES • Essential fluoroscopic views required prior to sterile preparation: • Obturator outlet view for start point (Fig. 62.4). On average, 20° to 30° of outlet tilt and 20° C-arm roll away from the side of interest. This must be directly parallel with the osseous corridor, appearing as narrow as possible. The teardrop must be superior to the acetabular dome and the greater sciatic notch. The inner table cortex should have no double density. • Iliac oblique view (Fig. 62.5). Clear view of the superior gluteal notch required to ensure trajectory of pin is passing superiorly. • Obturator inlet view (Fig. 62.6). Perpendicular view to corridor from above ensuring passage of pin without penetrating the inner or outer table. • Following sterile preparation, a perfect obturator oblique view is obtained; a pin is then used to locate the center of the radiographic teardrop on the overlying skin. • A small vertical stab incision (∼1 cm) is made, and the soft tissues are bluntly dissected down to bone. 

PORTALS/EXPOSURES EQUIPMENT

• Cannulated guide and screwdriver can be helpful.

PORTALS/EXPOSURES CONTROVERSIES

• Use of a larger incision to allow complete protection of the left femoral cutaneous nerve. • Transverse incision may allow for decreased skin pressure when rotational pelvic deformity is reduced.

FIG. 62.4 

PROCEDURE 62  Pelvic Supraacetabular External Fixation

FIG. 62.5 

FIG. 62.6 

PROCEDURE STEP 1: Pin Insertion • A drill guide is placed through the incision directly down to bone. • Obturator outlet view (Fig. 62.7) is used to confirm that the start point is centered in teardrop. • Care must be taken to ensure the guide is centered in the bony column (medial/ lateral) and at least 2 cm superior to the acetabular dome (to avoid hip capsule perforation3). • An appropriately sized drill (3.2 mm for a 5.0-mm pin) is used through the drill guide and advanced approximately 5 cm when the correct trajectory is confirmed. • Drill is generally aimed superiorly and medially; however, fluoroscopy must be used to determine the exact trajectory.

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PROCEDURE 62  Pelvic Supraacetabular External Fixation

STEP 1 PEARLS

• A rotated hemipelvis will alter pin trajectory; therefore, appropriate fluoroscopic views are critical. • Appreciate that there may be a difference in the pin trajectory in a rotated contralateral hemipelvis. • Consider moving the C-arm to the other side of the table to aid in contralateral hemipelvis pin placement in a nonacute situation.

• Keeping the drill guide in place, the drill is exchanged for a long (at least 250 mm) large-diameter (at least 5.0 mm) partially threaded pin. • Pin is advanced under fluoroscopic visualization. • Iliac oblique view (Fig. 62.5) to ensure the pin is passing 1.0 to 2.0 cm above the superior gluteal notch • Obturator inlet view (Fig. 62.6) to ensure pin remains in bone along its length • A second pin is placed in the contralateral hemipelvis in the same manner (Figs. 62.8 and 62.9). 

STEP 1 INSTRUMENTATION/ IMPLANTATION

• 5.0-mm Schanz pins or large partially threaded pin as per manufacturer’s instructions for external fixation set

FIG. 62.7 

FIG. 62.8 

PROCEDURE 62  Pelvic Supraacetabular External Fixation

791

FIG. 62.9 

STEP 2: Pelvic Reduction and Frame Assembly

STEP 2 PEARLS

• Supraacetabular pins allow for superior control of the hemipelvis for reduction maneuvers. • Reduction of rotational and sagittal plane (flexion/extension) deformity can often be achieved with manual pin manipulation. • Vertical hemipelvis deformity may require manual or skeletal traction. • A femoral distractor can be connected to the supraacetabular pins to allow for some additional posterior pelvis control.5 • Long sleeves of femoral distractor are advanced down to bone over the pins to allow maximal posterior control with an anterior external fixator. • When reduction is felt to be acceptable, apply manufacturer appropriate frame. • One curved carbon fiber rod or two straight carbon fiber rods are typically used, with appropriate connectors. • Incisions should be reassessed after the frame is applied to ensure there are no areas of skin pressure. • Large incisions can be partially closed around the pins and relaxing incisions are made if required. 

• Use of long pins (at least 250 mm) is important to ensure maximal fixation in bone. • If pin ends are cut, protective caps must be placed. • Connectors and rods must be placed far enough from the skin to allow for swelling of local tissues and the abdomen. • Frame assembly should allow for abdominal access for potential laparotomy and groin access for angiography or urgent vascular access.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Bulky dressing made over pin sites to absorb drainage and stabilize soft tissues around pins (Fig. 62.10) • Daily pin site care with normal saline • 24 hours of intravenous antibiotics (i.e., first-generation cephalosporin) postoperatively • Consider additional use of antibiotics only in the presence of further signs of infection (purulent and/or foul discharge). • When an infection is diagnosed, ensure there is no soft-tissue tension around the pin, and drainage of any abscess collection is mandatory. • Deep venous thrombosis prophylaxis as dictated by institutional protocols and other injuries

• Large or pelvic external fixation set • Optional: Femoral distractor

STEP 2 PITFALLS

• Frame construct may obstruct hip flexion and prevent sitting or ambulation in a patient treated definitively with a supraacetabular external fixator.

792

PROCEDURE 62  Pelvic Supraacetabular External Fixation

FIG. 62.10 

EVIDENCE Shapiro AMJ, Lakey JRT, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343:230– 238. Owing to the nature of these injuries, it is difficult to conduct robust clinical trials. Our treatment is based on the available clinical, anatomic, and biomechanical literature combined with our experience and that gained from others. Kim WY, Hearn TC, Seleem O, Mahalingam E, Tile M. Effect of pin location on stability of pelvic external fixation. Clin Orthop. 1999;361:237–244. This biomechanical study found decreased motion across the sacroiliac joint when a pelvic external fixator was applied with anteroinferior (supraacetabular) pins compared with anterosuperior (iliac crest) pins in a cadaveric unstable pelvic ring injury model. Bellabarba C, Ricci WM, Bolhofner BR. Distraction external fixation in lateral compression pelvic fractures. J Orthop Trauma. 2006;20(suppl 1):S7–S14. Haidukewych GJ, Kumar S, Prpa B. Placement of half-pins for supra-acetabular external fixation: an anatomic study. Clin Orthop. 2003;411:269–273. This prospective cohort study used supraacetabular pelvic external fixators to treat lateral compression pelvic fractures. The distraction force provided a reduction of all hemipelves with no delayed unions or nonunions with an average time to healing of 8 weeks and average time to assisted ambulation of 12 days (Level IV evidence). Gardner MJ, Osgood G, Molnar R, Chip Routt ML. Percutaneous pelvic fixation using working portals in a circumferential pelvic antishock sheet. J Orthop Trauma. 2009;23(9):668–674. (Level V evidence). In this anatomic study, 5-mm Schanz pins were placed under fluoroscopic guidance into the supraacetabular pin position for a pelvic external fixator in cadaveric pelves. Dissection was then done to measure mean distances from the pins to critical and neurovascular structures. Gardner MJ, Nork SE. Stabilization of unstable pelvic fractures with supraacetabular compression external fixation. J Orthop Trauma. 2007;21(4):269–273. (Level V evidence).

PROCEDURE 63

Anterior Pelvic Internal Fixation Ross K. Leighton and Karine Bourduas INDICATIONS

PITFALLS

• The main indication for anterior pelvic fixation is a diastasis of the pubic symphysis greater than 2.5 cm, indicating a disruption of the posterior pelvic ring. These “open book” pelvic injuries are usually the result of a high-energy trauma and may require simultaneous posterior fixation of the sacroiliac (SI) joint in the presence of an unstable posterior pelvic ring (Fig. 63.1, open book with SI screw). • Displaced parasymphyseal or rami fractures associated with an unstable pelvic ring may also require fixation; the anterior fixation helping to stabilize the posterior fixation. • Anterior and posterior ring fixation is necessary in vertically unstable injuries. 

FIG. 63.1 

EXAMINATION/IMAGING • Follow Advanced Trauma Life Support principles. • The condition of the soft-tissue envelope must be assessed carefully for open fractures, severe crush injury (Morel-Lavallée lesion), as well as urologic, vaginal, rectal, intraabdominal, and neurovascular injuries, because they will alter management. These other injuries should be suspected and managed with a multidisciplinary team approach. • Testing for stability of the pelvis can be done once by gentle rotational force on the iliac crests by the most senior trauma surgeon. • Radiographic evaluation should include anteroposterior (AP), inlet and outlet views. • Computed tomography (CT) is routinely done as part of pelvic ring injury evaluation of high-energy trauma in most centers. It helps delineate the fracture pattern and assesses posterior instability. • Urologic contrast studies, CT angiogram, and angiography are performed when indicated.

Surgical Anatomy • On each side of the pubic symphysis, the upper border of the superior ramus presents a crest followed by the pubic tubercle. The inguinal ligament originates from the pubic tubercle and inserts on the anterior superior iliac spine.

• High-energy trauma and hemodynamically unstable patients • Soft-tissue compromise (open fractures, crush injuries) • Suprapubic catheterization and/or bladder injury • Osteoporosis, poor bone quality • Severe comminution • Associated posterior pelvic ring instability

NONOPERATIVE TREATMENT

• Stable pelvic ring with symphysis diastasis less than 2.5 cm • Low-energy pubic rami fractures without posterior ring instability OPERATIVE OPTIONS

• External fixation • Internal anterior pelvic fixator • Open reduction internal fixation • Retrograde superior ramus medullary screw • Minimally invasive internal fixation

CONTROVERSIES

• External fixation is preferred in the presence of significant soft-tissue compromise, intraabdominal procedures, or contamination following suprapubic catheterization. It may be used as temporary or definitive fixation. • With concomitant urethral injury, consider anterior plating at the time of or within 48 hours of suprapubic catheter insertion to minimize the risk of infection. 793

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PROCEDURE 63  Anterior Pelvic Internal Fixation

Rectus abdominis muscles

Linea alba

Pubic tubercles FIG. 63.2 

Space of Retzius Symphysis pubis

Bladder FIG. 63.3 

• The rectus abdominis muscle originates from the symphysis and pubic crest. It is contained in the rectus sheath, which is thick anteriorly but of variable thickness posteriorly below the level of the arcuate line (Fig. 63.2, rectus anatomy). • The linea alba lies in the midline of the rectus abdominis. It provides an avascular plane for dissection and good strong tissue that aids in closure. • The bladder lies just behind the symphysis. The retropubic space, also named the space of Retzius, is a potential avascular space between the back of the pubic bone and the anterior wall of the bladder (Fig. 63.3, pelvic anatomy with bladder). • The inferior epigastric arteries arise from the external iliac arteries immediately above the inguinal ligament, and ascend obliquely along the medial margin of the abdominal inguinal ring. If the dissection is continued laterally, the spermatic cords/round ligaments, the adjacent ilioinguinal nerves, and the superficial inguinal rings will be encountered (Fig. 63.4, vessels and nerves). 

PROCEDURE 63  Anterior Pelvic Internal Fixation

795

Ilioinguinal nerve Inferior epigastric arteries

Superficial inguinal ring

A

Spermatic cord

B FIG. 63.4 

POSITIONING

PEARLS

• General anesthetic • Supine position • Radiolucent table, posterior radiolucent bolster if posterior screws are also required • C-arm fluoroscopic imaging • Foley catheter • Shaved incision site and urogenital triangle

• A radiolucent table is essential. The patient should be placed truly level on the table with no twisting or rotation because this helps ensure accurate reduction. • For very obese patients, the patient can be tilted head down to allow the intraabdominal contents to fall away from the operative field.

Portals/Exposures • The approach for the anterior part of the pelvic ring allows visualization of the entire symphysis, both pubic bodies and superior pubic ramus. This approach can also be used for percutaneous screw fixation. • A Foley catheter should be inserted preoperatively to facilitate identification of the bladder and minimize the risk of bladder injury. • A curved Pfannenstiel incision is made in line with the skin creases 2 cm cephalad to the pubic symphysis, approximately 15 cm long (Fig. 63.5, Pfannenstiel incision) • The subcutaneous tissues are incised in line with the skin incision down to the anterior rectus sheath. • The linea alba is incised longitudinally, taking care to avoid the underlying bladder and peritoneal cavity. The muscle bellies of the rectus abdominis are retracted and the retropubic space is exposed by blunt dissection (Fig. 63.6, dissection). • The base of the bladder and urethra can be identified by palpation of the Foley catheter. The bladder is protected throughout with a malleable retractor and sponge loosely packed in the retropubic space. • The insertion of the rectus abdominis is often avulsed on the side of the injury, and this defect should be incorporated into the exposure to minimize further stripping of the muscle insertion. • A pointed Hohmann retractor is placed obliquely over the pubic tubercle to retract the muscle and the distal aspect of the rectus abdominis. • The rectus abdominis is elevated laterally enough for placement of the fixation, usually past the pubic tubercle, preserving as much of the rectus abdominis anterior insertion as possible. This dissection is performed subperiosteally (Fig. 63.7, rectus elevation).

PITFALLS

• Ensure adequate space to perform AP, inlet and outlet views, prior to preparing and draping. • A lateral view may also be required if posterior stabilization is planned.

796

PROCEDURE 63  Anterior Pelvic Internal Fixation

Vertical incision

Rectus abdominis fascia

Linea alba

FIG. 63.6 

FIG. 63.5 

Rectus abdominis

Malleable retractor

PEARLS

• Extending the incision and superficial dissection laterally will facilitate exposure of the deep structures in obese patients. • If necessary, the incision may be extended to expose the whole of the superior pubic ramus all the way to the acetabulum via the modified Stoppa approach or the ilium and SI joint via the ilioinguinal approach. PITFALLS

• If extension laterally is required, care must be taken during lateral dissection along the superior pubic ramus to prevent damage to the corona mortis. This is a variable anastomosis between the external iliac and obturator vessels that can result in profuse bleeding if inadvertently damaged owing to retraction of the vessel ends into inaccessible positions. • Separation of the bladder from the posterior symphysis may be difficult if adhesions have formed secondary to previous trauma or surgery. If the bladder is damaged, urologic consultation should be obtained, and repair may be required. • The posterior rectus sheath is variable at this level, but if present it needs to be divided, taking care to keep the dissection extraperitoneal.

Bladder (retracted with sponge)

Pubic bone

FIG. 63.7 

• Care must be taken during lateral dissection to avoid damage to the spermatic cord/round ligament and the accompanying ilioinguinal nerve. If the inferior ­epigastric vessels are crossing the surgical field, they may require ligation or cauterization. • Fixation of the mid-portion of the superior pubic ramus is possible through this approach, but fractures of the lateral portion of the superior pubic ramus require a more extensile approach. 

PROCEDURE 63  Anterior Pelvic Internal Fixation

797

PROCEDURE Step 1: Reduction • Reduction forceps are placed with a point on each pubic tubercle (Fig. 63.8, clamp). • The position of each point can be adjusted, depending on the degree of external rotation, posterior and cephalad displacement that needs to be corrected. • If reduction is difficult, the points of the forceps may be placed in the obturator foramen on each side. This allows a better hold to provide a three-dimensional reduction of the pelvis. • With significant posterior and cephalad displacement, 3.5-mm screws can be inserted into each pubic body in an anterior-posterior direction (avoiding the eventual sites of the definitive fixation screws) and a Farabeuf or similar reduction clamp can be applied to facilitate reduction (Fig. 63.9, screw-to-screw pelvic clamp). •  Anatomic reduction should be the aim, particularly if posterior fixation is also planned. • Reduction is confirmed with AP, inlet, and outlet views. • A wide variety of specialized instruments should be available to facilitate reduction. These should include various pointed forceps, screws, and combination clamps with a variety of curves and offsets (Fig. 63.10, clamps). 

PITFALLS

• Malreduction anteriorly will make it impossible to achieve anatomic reduction posteriorly. • Failure to recognize posterior injury is a major cause of anterior fixation failure.

Weber clamp

Pubic tubercle

Symphysis pubis

FIG. 63.10 

FIG. 63.8 

A

B FIG. 63.9 

PROCEDURE 63  Anterior Pelvic Internal Fixation

798

A

B

C FIG. 63.11 

Step 2: Fixation CONTROVERSIES

• Some authors advocate less-secure fixation to allow “physiologic” movement of the pelvis. However, less-secure methods of fixation have an increased rate of malunion and hardware failure.

• For anterior ring instability with significant diastasis of the symphysis, a contoured pubic symphysis plate is placed on the superior border of the symphysis (Fig. 63.11, symphysis plates). • A two-plate construct can be used anteriorly to provide further stability, especially in the presence of a contraindication to posterior fixation (e.g., significant soft-tissue compromise). • If two plates are used, they should be placed orthogonally so that one lies on the superior and one on the anterior border of the pubic body and superior ramus.

PROCEDURE 63  Anterior Pelvic Internal Fixation

FIG. 63.12 

799

FIG. 63.13 

FIG. 63.14 

• For fixation of the pubic rami, a pelvic reconstruction plate can be used by extending the approach laterally as necessary (modified Stoppa or ilioinguinal approach). Depending on the fracture pattern, a 3.5-mm retrograde pubic rami screw can also be used (Fig. 63.12, reconstruction plate for anterior fixation augmented posteriorly with sacroiliac screws [Fig. 63.13, Rami screw]). • As previously mentioned, associated posterior instability should be supplemented by appropriate posterior fixation (Fig. 63.14, bilateral SI fixation). 

Step 3: Closure • Prior to closure the wound is irrigated and the bladder inspected for signs of injury. • The rectus abdominis is repaired with a figure of 8 or a continuous suture (0 or 1 vicryl) on a blunt needle. • The subcutaneous layer is closed with interrupted absorbable sutures (2 0 vicryl), then skin closure is performed with interrupted nylon sutures or staples. 

PEARLS

• Avoid any defects in the deep-layer closure to reduce the risk of postoperative hernia. PITFALLS

• If both anterior and posterior fixation are required, fix the anterior injury anatomically first, then address the posterior injury. The anterior wound should be left open during posterior fixation to allow adjustments to be made if posterior reduction is not possible.

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PROCEDURE 63  Anterior Pelvic Internal Fixation

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Antibiotics are routinely continued for 24 hours. • If the bladder is repaired, antibiotics are continued until the catheter is removed. • A drain can be left for 24 hours at the surgeon’s preference. • Low-molecular-weight heparin is given until the patient is mobile and then replaced with an oral anticoagulant for a total of 28 days or until mobile. • The patient is mobilized with toe touch weight bearing on the side of the affected SI joint for at least 6 weeks. • Radiographs should be taken postoperatively at 2 weeks and monthly thereafter to ensure that there is no loss of fixation. • Routine plate removal is unnecessary. However, removal may be required if complications arise, such as a loose screw or a fractured plate fracture that is bothersome (10%–12%).

REFERENCES Court-Brown CM, Tornetta III P, Heckman JD, McQueen MM, McKee M, Ricci WM. Rockwood and Green’s Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins; 2014. Excellent text reference for aspiring pelvic surgeons. This reference also provides all the standard references for in-depth reading on this subject. Gänsslen A, Krettek C. Retrograde transpubic screw fixation of transpubic instabilities. Oper Orthop Traumatol. 2006;18(4):330–340. Illustrates a very effective technique of rami screw insertion and stabilization. Very well illustrated technique paper. Grotz MRW, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1–13. These noted experts in pelvic reconstructive surgery discuss the history and epidemiology of pelvic fractures and a safe and effective approach to stabilization. Leighton RK. Nonunions and Malunions of the Pelvis. Operative orthopedics. Philadelphia: Lippincott; 1988. This chapter illustrates the steps required to safely and effectively correct and stabilize malunions of the pelvis. Approaches to the anterior and posterior pelvic ring are detailed. Oh HK, Choo SK, Kim JJ, Lee M. Stoppa approach for anterior plate fixation in unstable pelvic ring injury. Clin Orthop Surg. 2016;8(3):243–248. The Stoppa approach is well detailed with its advantages and disadvantages. The indications presented here remain absolute. However, the Stoppa approach combined with the lateral window of the ilioinguinal approach can reach most anterior pelvic ring injuries as discussed in other references. Papakostidis C, Kanakaris NK, Kontakis G, Giannoudis PV. Pelvic ring disruptions: treatment modalities and analysis of outcomes. Int Orthop. 2009;33(2):329–338. An excellent discussion of the outcome of different modalities of pelvic ring fixation. Analytic techniques are used to assess different types of fixation. Sagi HC, Papp S. Comparativer radiographic and clinical outcome of two-hole and multi-hole symphyseal plating. J Orthop Trauma. 2008;22(6):373–378. Excellent discussion of how we have come to use a minimum of a six-hole plate for symphyseal fixation. Historical examples of two- and four-hole plate fixation. Sagi HC, Coniglione FM, Stanford JH. Examination under anesthetic for occult pelvic ring instability. J Orthop Trauma. 2011;25(9):529–536. Illustrates the importance of the clinical examination of the pelvic ring at patient presentation to the emergency department. Also suggests the pelvis should not be repeatedly examined by numerous physicians in the trauma team. Once is enough! Starr AJ, Nakatani T, Reinert CM, Cederberg K. Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure? J Orthop Trauma. 2008;22(2):81–87. Starr et al. really propelled percutaneous fixation of the pelvic ring into the present with the publication of this paper. Techniques with their pros and cons are well detailed. Tile M, Helfet D, Kellam J. Fractures of the Pelvis and Acetabulum. Philadelphia: Lippincott Williams & Wilkins; 2003. The authors discuss the pelvis and acetabulum and truly illustrate the difficulties associated with the concept of internal fixation. The concepts here have been referenced by many since publication and it remains a must read for potential pelvic reconstructive surgeons. Tucker MC, Nork SE, Simonian PT, Routt C, Jr ML. Simple anterior pelvic external fixation. J Trauma Acute Care Surg. 2000;49(6):989. An excellent approach to the anterior pelvic ring and the acceptable technique of damage control with external fixation of the unstable pelvic fractures.

PROCEDURE 64

Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach Pierre Guy OPEN REDUCTION AND INTERNAL FIXATION USING THE ANTERIOR INTRAPELVIC (AIP) APPROACH Introduction • This approach is done ± the lateral window of the ilioinguinal approach ± anterior superior iliac spine (ASIS) osteotomy. • First described for pelvic ring and acetabulum fracture fixation (Hirvensalo et al., 1993; Cole and Bolhofner, 1994) • The interior intrapelvic approach (AIP) is also called: • Extended use of the ilioinguinal medial window • The “Stoppa” approach • The ilio-anterior approach • Advantage: access to the medial aspect of innominate bone The approach is increasingly used by surgeons because of: • familiarity with surgical anatomy (Cole et al., 1994; Hirvensalo et al., 1993) • frequency of elderly fracture patterns (Ferguson et al., 2010) • number of scientific publications (Archdeacon et al., 2013; Sagi and Bolhofner, 2015) • availability of specific surgical instruments and implants (Guy, 2015) 

INDICATIONS General indications • Displaced acetabulum fractures with medial translation ± roof impaction (Fig. 64.1) • Most: Anterior column (wall) fractures, associated anterior with posterior hemitransverse • Many: Associated both columns and transverse fractures

Some

most

many

most

many

FIG. 64.1 

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PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach



• Some: T-shaped fractures • Some: ORIF in combination with posterior approach • Some: ORIF in combination with an acute/revision total hip arthroplasty • Contraindications: • Fractures of the posterior acetabulum (rare exceptions: Kistler and Sagi, 2015) • Past pelvic surgery /disease (relative contraindications) • Previous laparotomy or pelvic surgery to: rectum, gynecological, bladder, prostate, retroperitoneum • Previous abdominal wall hernia repair, mesh repair • Previous pelvic radiotherapy • Known pelvic lymphadenopathy 

PITFALLS

• Previous pelvic surgery/disease increases complexity of dissection, safe identification of anatomic structures, and risk of bleeding. • Requires thorough knowledge of abdominal and pelvic retroperitoneal anatomy • Should not be used as the sole approach for acetabulum fractures involving mainly posterior elements (see Fig. 64.1)

CONTROVERSIES

• Fractures with roof impaction at increased risk of ORIF failure • Internal fixation versus primary total hip arthroplasty in the elderly is an unresolved decision

EXAMINATION/IMAGING Physical Examination • Goals: Identify/rule out associated injuries and assess fitness for surgery. • Advanced Trauma Life Support (ATLS) and examination to rule out distant injury and injury to local abdominal/pelvic organs • Rule out injury to neurologic and vascular systems. • Assess soft tissues: Open skin, closed degloving injury (Morel-Lavallée lesion) • Assess general health, comorbidities, functional demands, and previous pelvic surgery or disease. 

Plain Radiography • Pelvis anteroposterior (AP), pelvis Judet views or computed tomography (CT) Judet views—volume-rendered from CT (Fig. 64.2) • Allows acetabulum fracture classification and associated injuries • Other imaging as indicated by findings on ATLS (chest, spine, limbs) • Intraoperative C-arm imaging knowledge and skills are essential. 

FIG. 64.2 

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

Computed Tomography and Magnetic Resonance Imaging • Axial CT with two-dimensional reconstruction required in preoperative planning (Fig. 64.3, Video 64.1A–C) • CT 3D: Surface-rendered three-dimensional reconstructions useful in preoperative planning (Fig. 64.4, Video 64.2) • Magnetic resonance imaging (MRI) presently yields no useful information. It is often not practical in an acute trauma setting. 

A

B FIG. 64.3  A–B

A

B

D

C

E FIG. 64.4  A–E

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PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

TREATMENT OPTIONS

CLASSIFICATION OF ACETABULUM FRACTURES

• Operative indications depend on fracture location (weight bearing or not), instability (present or future), incongruity (> 2-mm step poorly tolerated). Note that extensive roof comminution and poor bone stock could be an indication for total hip arthroplasty, which can be combined with column stabilization through AIP. • Nonoperative treatment is advocated for undisplaced/minimally displaced fractures (congruent femoral head and acetabulum on all views out of traction, displacement < 2 mm in weight-bearing area, or > 2 mm and congruent in non–weight-bearing area—i.e., secondary congruence with gap. Patients with significant comorbidities may be best treated nonoperatively.

• The Letournel classification is important for decision-making. • AIP is used for fracture types listed (see Fig. 64.1). • Imaging assists classification: injury to walls, columns, roof, obturator foramen, teardrop displacement, iliac crest fracture extension • Imaging additionally helps identification of: • Roof impaction (at weight-bearing portion of acetabulum) • Quadrilateral plate involvement and its detachment from a column • Intraarticular loose body • Height of posterior column (PC) fracture: High? Low? Accessible through AIP? Requiring reduction and fixation at all? • Posterior wall injury • Associated pelvic ring injuries: sacroiliac (SI) joint, sacrum, rami, symphysis pubis 

SURGICAL ANATOMY PEARLS

• Preoperative review of imaging and planning for reduction and fixation to strong, thick sections of bone or within medullary screw pathways • Knowledge of soft-tissue anatomy allows safe maximization of surgical approach for reduction and fixation. • Supine position with slight Trendelenberg moves abdominal contents away from operative site (Fig. 64.5). • A free-draped operated leg allows hip-knee flexion and soft-tissue relaxation for adequate visualization and to avoid injury. Note that hip flexion will result in increased sciatic nerve tension.

• Bony anatomy • Thorough knowledge of the normal anatomy of the innominate bone is a priority. • Knowledge of the thicker bone regions for screw purchase and the intramedullary screw paths is necessary. • Thorough study of patient’s preoperative imaging is crucial. • Soft-tissue anatomy •  Knowledge of abdominal wall layers, rectus abdominis muscle and adjacent sheaths, and peritoneal cavity (Fig. 64.6C) • Knowledge of pelvic and retroperitoneal anatomical structures—bladder, uterus, rectum; vessels—external iliacs, obturators, corona mortis anastomosis; nerves— femoral, obturator, sciatic, pudendal (Fig. 64.6B and Fig. 64.7) 

POSITIONING • Radiolucent table, supine, arms out at 90°, slight Trendelenberg (head down) to move abdominal contents proximally. Surgeon stands on the opposite side of the injury. A few rolled towels are placed under the sacrum to allow hip extension. A Foley catheter is placed (Fig. 64.5). • Large C-arm (12 inches or 30 cm) sterile draped in surgical field, on the same side as the injury • The lower limb on the injured side is free draped; the hip and knee are flexed and rested on a padded triangle to relax external iliac vessels and the femoral nerve (note that this could tension the sciatic nerve; Fig. 64.5). Draping should allow access to the suprapubic area and to the iliac crest in case access through the lateral window is required. 

FIG. 64.5 

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

PROCEDURE: ANTERIOR INTRAPELVIC APPROACH • Read the following steps along with concurrently viewing Video 64.3. • Localize the umbilicus, linea alba, symphysis pubis/pubic body, ASIS, and iliac crest. • Plan a 10- to 12-cm transverse lower abdominal (Pfannenstiel) incision 2 cm proximal to symphysis pubis. (If a midline incision has already been done, use it with caution; Fig. 64.6A.) • Develop large subcutaneous flaps proximally and distally superficial to the anterior rectus abdominis sheath (10–12 cm proximally and distally over the pubis body). • Identify the linea alba (visualization or palpation) and incise it longitudinally from the symphysis pubis, 10 to 12 cm up to (but outside of) the anterior reflection of the peritoneum, staying in preperitoneal space. Note that there is no posterior sheath to the rectus abdominis at this level (Fig. 64.6B–C and Fig. 64.7A). • Elevate the rectus heads on both sides distally, off superiorly and 1 to 2 cm anteriorly on the pubic body. Keep the anterior rectus sheath in continuity distally. • Identify the retropubic space (of Retzius). Mobilize and protect the bladder. • Extend the dissection laterally, elevating the rectus head from the pubic body up to the pubic tubercle. Incise and elevate the lacunar and Cooper ligaments. Place a narrow spike bone lever retractor (Hohmann-like) just lateral to the pubic tubercle (Fig. 64.7B).

A

B Above Arcuate Line Rectus m.

Linea alba

Ant. rectus sheath

Peritoneum

Int. oblique m. Ext. oblique m. Transversus m. Transversalis fascia

Below Arcuate Line

C

Peritoneum FIG. 64.6  A–C

Int. oblique m. Ext. oblique m. Transversus m. Transversalis fascia

805

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

806

A

B

H Head

C

D FIG. 64.7  A–D

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

807

E FIG. 64.7, cont’d  E

• Continue laterally and elevate the Cooper ligament and pectineus muscle from the superior ramus (the Cooper ligament is continuous with the iliopectineal fascia). • Identify and relax external iliac vessels. Hip and knee flexion will assist in relaxing those vessels. In addition, providing early reduction and provisional fixation of the anterior column (AC) and lateralization of the medially displaced femoral head will relax local vessels, muscles, and nerves (see T-handle and lateral traction, discussed later) (Fig. 64.8). • Visualize the iliopectineal fascia (if intact, its fibers align perpendicular to the pelvic brim; note underlying brownish-red fibers of the iliacus muscle). • Identify and ligate the corona mortis vessels (venous and arterial anastomoses between external iliac and obturator vascular systems). • Identify the obturator neurovascular (NV) bundle and generously mobilize it proximally and distally to allow it to lie loosely in the surgical field for the surgeon to work around it. • Protect the surrounding structures and incise the iliopectineal fascia from posterior to anterior along the pelvic brim (Fig. 64.7C; AC fracture line often runs along the pelvic brim). • Elevate the iliacus muscle from the inner iliac fossa from medial to lateral—intraosseous vascular anastomosis at the posterior third of the pelvic brim is identified when present and covered with bone wax for hemostasis. • Continue dissection posteriorly along the pelvic brim and iliac fossa up to the level of the anterior SI ligaments. The pelvic brim will suddenly change from sagittal to coronal orientation as dissection progresses posteriorly. • Carefully identify and protect the external iliac vessels posteriorly along with adjacent vessels (superior gluteals, iliolumbar). • Place a long L-shaped retractor medial to the external iliac vessels and psoas, which are relaxed by hip flexion. Bring the retractor down to the pelvic brim, then translate it proximal and lateral to SI joint (Fig. 64.7D).

PEARLS

• A long split of the linea alba: superiorly up to, but outside of, the peritoneal reflection (10–12 cm) down to the symphysis greatly facilitates visualization of the pelvic brim from the SI joint to the symphysis pubis anteriorly and from the pelvic brim to the lesser notch distally. • Generous mobilization of both rectus heads from the superior and anterior pubic body • Pharmacologic paralysis (by anesthetic drugs) relaxes the abdominal wall, iliopsoas muscles. • Hip and knee flexion relax the external iliac vessels, femoral nerve, and iliopsoas muscles. • Early provisional reduction of the AC also relaxes tension on vessels. • Obturator NV bundle: early identification, generous proximal and distal mobilization. Frequent need to ligate the obturator vein. • Detach the entire iliopectineal fascia from SI joint to symphysis pubis.

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PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

PITFALLS

• Extend the incision proximally but avoid entering the peritoneum—stay preperitoneal. • Localize the external iliac vessels and retract them proximally prior to incising the iliopectineal fascia. • Avoid long periods of traction/lateral compression on the external iliac vessels. • Avoid retraction of the obturator nerve. • Identify the frequent intraosseous vascular anastomosis in the iliac fossa at the posterior third of the pelvic brim. Hemostasis with bone wax.

• Place large Kirschner wire(s) (K-wires) medial to the retractor to prevent its displacement and preserve exposure (Fig. 64.7D) • A bone lever (Hohmann-like) retractor can be placed for a short period of time under the psoas muscle/femoral nerve/iliac vessels hooking in the psoas gutter to expose the pectineal eminence and anterior wall. The hip is flexed to relax structures (Fig. 64.7E). • Maximize lighting and visualization throughout the procedure and specifically from here on: retract bladder and midline organs covered by peritoneum away from surgical field using a head light or retractor light. • Turn to dissection of the PC and quadrilateral plate. • Working on both sides of mobilized obturator NV bundle, elevate the obturator internus (OI) muscle from the pelvic brim and inner quadrilateral plate. The muscle is often hematoma filled—avoid retraction of the obturator NV bundle. • Continue OI elevation posteriorly to the greater sciatic notch and distally to the ischial spine and lesser notch. Avoid injury to the superior gluteal NV bundle at the top of the greater sciatic notch. • Place a blunt lever retractor in either the greater or lesser sciatic notch to reach the pelvic organs, leaving the obturator NV bundle free in the wound (Fig. 64.7E). • Proceed to reduction. 

PROCEDURE: REDUCTION AND FIXATION • Many fracture lines and patterns can be addressed through this approach: AC fractures with medial femoral head displacement (see Fig. 64.1) and some associated PC fractures. The AIP additionally often requires use of the lateral window of the ilioinguinal approach (see later discussion), supplemented with osteotomy of the anterior superior iliac spine (see later discussion) to access all parts of the inner innominate bone. • Anatomic reduction and rigid fixation is the goal. • The preferred sequence for reduction and fixation is: • Reduce columns: AC, then PC (provisionally fix) • Reduce and buttress roof impaction (if present) • Definitive column fixation • Reduce and fix rami and wall fractures (if present) • Lateral traction: Once the approach is completed, lateral traction of the femoral head is applied to assist reduction. It can also be applied early in the approach to relieve tension on the external iliac vessels. • Insert a Schantz pin percutaneously through the lateral cortex of the proximal femur just distal to the vastus lateralis ridge, aiming toward the femoral head and neck (Fig. 64.8). • Reduce the femoral head under the intact roof of the acetabulum or to the appropriate offset. • The Schantz pin and T-handle are either held by an assistant or attached to operating table (Fig. 64.8). • AC reduction: Precise column reduction will need to supplement lateral traction described earlier. It typically requires internal rotation and flexion of the AC fragment. The techniques are listed here. • Internally rotate with percutaneous Schantz pin or Farabeuf clamp at the iliac crest. • Push on the pelvis brim with a spiked pusher (i.e., picador). • Close down the pelvic brim fracture line with an angled jaw clamp between the superior pelvic brim and quadrilateral plate or between the pelvic brim and obturator canal (Fig. 64.9). • Provisionally fix with K-wire or place a single screw to minimize clamp crowding. • PC and quadrilateral plate (QP) reduction: Typically, medial to lateral translation of the PC and QP and abduction angulation of the PC are required to restore its alignment. • Push on the inner surface of the PC with a spiked pusher. • Insert an asymetric reduction clamp (Fig. 64.10, Smith & Nephew, Nashville, USA) through the AIP window and percutaneously laterally above the acetabulum. Alternately, place medially over the pelvic brim through the lateral window (see later discussion) to translate PC/QP and percutaneously laterally, as discussed earlier.

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

FIG. 64.8 

FIG. 64.9 

809

810

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

FIG. 64.10 





• Insert angled reduction clamp through the AIP window (Fig. 64.11A–B): one tyne placed on the pelvic brim, then either adjacent to the greater notch (high PC fracture, see Fig. 64.11A ) or hooked on the ischial spine (lower PC fracture, see Fig. 64.11B). • Provisionally fix with K-wire or place a single screw to minimize clamp crowding.

Pelvic reduction clamp

Fracture high in posterior column

A

B

Pelvic reduction clamp

FIG. 64.11  A–B Anatomic drawings on the left are modified from Sagi et al. J Orthop Trauma 2010.

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

A

B

C

D

F

E

G

H FIG. 64.12  A–H

• Roof reduction (if required) • Many malalignments of the acetabulum roof (“gull wing” sign) will improve with AC reduction (i.e., not all gull wing signs are roof impactions). • If a roof impaction persists after AC reduction, it must be reduced and buttressed. • Gently mobilize the roof fragment through the fracture. (Option 1: Fig. 64.12F–G) • Reduce the AC and PC to first create a contained environment for roof reduction. (Option 2: Fig. 64.12A–E) • Localize the roof impaction with Judet views with a K-wire or instrument. • Perform a corticotomy at that location on the pelvic brim and use a bone graft tamp to push the roof fragment (Fig. 64.12A–C). • Control reduction by C-arm with Judet views (Fig. 64.12D). Use a near-full lateral (∼ faux-profile) view to monitor reduction in the sagittal plane (Fig. 64.12H). • Place provisional buttress wires; then, definitively fix with rafting screws. Bone substitute may be used in addition to screw fixation (Fig. 64.12E). • Another described technique involves complete reduction of the roof through the fracture line prior to column reduction. This is typically used when roof impaction blocks AC/PC reduction.

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PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

• Definitive column fixation follows principles of rigid fixation of articular fragments typically with lag screws and a neutralization plate or buttress plate. Lag screws alone are usually avoided. In occasional cases of severe comminution, buttress plating also serves in reduction. Bridge plating is typically reserved for nonarticular segments (e.g., rami fractures) if anatomic reduction and rigid fixation are not feasible. Fixation strategies for various components of an injury listed here. • Isolated lag screws • AC: From ASIS to PSIS (percutanoulsy; Fig. 64.13A–B, white arrow) • PC: Horizontal PC screw inserted from medial to lateral at posterior portion of the pelvic brim close to the SI joint to lag a high PC fracture. Note that a vertical PC screw from pelvic brim to ischial tuberosity cannot be inserted through the AIP. This requires a lateral window (see later discussion). • AC to PC: Screw from base of the pectineal eminence to the ischial spine. Described by Letournel, the mid-portion of this screw is intraarticular in the cotyloid fossa, in a non–weight-bearing location (Letournel et al., 1993). Starting point is at the distal part of the pectineal eminence (Fig. 64.15A and C), which is exposed through the AIP with hip flexion and lateral retraction of the mobilized

FIG. 64.13  A–B

FIG. 64.14 

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

A

B

C

D FIG. 64.15  A–D

iliac vessels, psoas muscle, and femoral nerve by a bone lever retractor in the psoas gutter. The surgeon uses the free hand to palpate the QP down to the ischial spine. The drill is advanced in oscillating mode, aiming for the ischial spine or lesser notch (distally). The surgeon aims to keep the drill just under the the medial cortex of the QP (Fig. 64.15C). The surgeon must avoid cortical breach and injury to the obturator NV bundle. • Confirm drill position to be in non–weight-bearing portion of the joint with the C-arm aligned with the axis of the drill, showing the drill adjacent and lateral to the ilioischial line and below the equator of the femoral head (see Fig. 64.15C–D). On iliac view, the drill must enter the ischial spine or lesser notch (Fig. 64.15E). Replace the drill by a screw once the position is confirmed (see Fig. 64.15D–F). • Plate fixation • Suprapectineal plate: This plate lies on the superior (horizontal) portion of the pelvic brim and can start from a point lateral to the SI joint, along the length of the brim and pubic ramus, and across the symphysis pubis as needed (Fig. 64.16 “SP”). It buttresses the anterior column fractures and bridges rami/pubic body fractures. Lag screws through the plate connect the AC to the PC or in ABC fractures to the sciatic spur. Note that a PC screw from the pelvic brim to ischial tuberosity cannot be inserted through the AIP. This requires a lateral window (see later discussion).

813

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

814

• Infrapectineal plate: This plate lies on the medial (vertical) portion of the pelvic brim and can start just anterior to the SI joint, along the medial surface of the pelvic brim, curving superiorly (avoiding the obturator nerve and canal) onto the posterior-superior surface of the pubic ramus (Fig. 64.16) Curving it in this manner also facilitates screw fixation in the anterior portion of the plate. This plate connects and maintains the relationship between ACs and PCs. It buttresses portions of the PC or of the QP, which extend up to the brim. Screw placement follows anterior and posterior safe zones (Guy, 2010) (Fig. 64.16D). • PC/QP buttress plate: Originally described by Mast (Mast et al., 1989), this plate, in the shape of a “7,” starts from the iliac fossa and pelvic brim and curves down to buttress the PC and QP from its undercontouring (Fig. 64.16 “QP”).

A

B

C

D FIG. 64.16 

FIG. 64.17 

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

FIG. 64.18 

FIG. 64.19 

FIG. 64.20 

• Specialized plates: These have been developed by vendors with shape contouring to more closely match the typical topography of the pelvic brim (Fig. 64.19). Some additionally combine contouring and a buttress function to the PC/QP with a biplanar design. Note that insertion of plates acting in two planes requires attention to plate position and contact to maximize the bridging or buttressing effect. Caveats: (1) Fixing the PC to a vertical plate that does not contact it risks medially displacing the column through a lag effect. (2) The use of a biplanar plate as the main strategy to achieve fracture reduction is strongly discouraged. The case below (Fig. 64.20) demonstrates the inability to reduce a fracture with a plate (referred case). Reduction should precede fixation.

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A

B

C

D

E

F FIG. 64.21  A–F

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

• Anterior wall plates: In some situations, buttress or spring plates can be used to secure fixation of anterior wall fractures (Fig. 64.12E). • Wound closure • Final radiographs to confirm reduction and fixation and to complete instrument count • Hemostasis is secured at the conclusion of the procedure and the surgical site is thoroughly irritated. Vital structures are examined (vessels, nerves, bladder, peritoneum) to rule out injury. PITFALLS

• Careful reduction of roof impaction with a bone tamp to avoid intraarticular penetration of the tamp. Mobilization/loosening of fragment through the fracture site can help avoid this. • A PC screw from the pelvic brim to ischial tuberosity cannot be inserted through the AIP. This requires a lateral window. • Fixing the PC to a vertical plate that does not contact it risks medial displacement of the column through a lag effect. • Biplanar plates should not serve as the main strategy to achieve fracture reduction. Use of traction and reduction instruments should prevail. Reduction should precede fixation (Fig. 64.20 shows a case where a biplanar plate was unsuccessfully used as the sole reduction tool).

817

EQUIPMENT

• A radiolucent operating table allowing Trendelenberg, 12-inch (30-cm) diameter C-arm • Cell saver and tranexamic acid frequently used • A Schantz pin with T-handle ± a system that is fixed to the OR table for lateral traction • Deep retractors, fiber-optic lighting headlamp or direct wound lighting • Specialized pelvic reduction clamps • Small-fragment reconstruction plates and screws ± specialized plates. Large cannulated screws.

CONTROVERSIES

• Column fixation precedes roof impaction reduction and fixation: the roof fragment should be at least mobilized before column reduction, particularly if it blocks column reduction.

PEARLS

• Column fixation precedes roof impaction reduction and fixation. • Roof impaction location is confirmed by instrument and C-arm prior to reduction. • Roof reduction is confirmed on Judet and faux-profile views. • The linea alba is typically closed with a strong suture (#1 PDS loop preferred) in running locking fashion. A second row is placed in high body mass index (BMI) patients. 

PROCEDURE: ADDING LATERAL WINDOW FROM ILIOINGUINAL APPROACH • In approximately 50% of cases in which an AIP approach is used, the surgeon must gain access to iliac fossa and pelvic brim from the lateral window of the ilioinguinal approach (Sagi et al., 2010). • Indications • AC fractures extending to the iliac crest • PC fractures requiring vertical PC screw fixation from the pelvic brim down • Positioning and draping for the AIP approach will have allowed for access to the iliac crest.

Approach • Start a curved incision from the ASIS extending posteriorly, lateral to the palpable edge of the crest. At mid-crest, curve the incision proximally across the abdominal musculature to facilitate the line of sight to the posterior iliac fossa and SI joint • Elevate the abdominal oblique muscles from the iliac crest, then the iliacus muscle from the inner iliac table from the SI joint posteriorly to pectineal eminence. • Facilitate access to the iliac fossa with hip flexion and access to the inner pelvis through release of the iliopectineal fascia, part of the AIP approach. Complete release of the intact parts of the fascia. • Remove the iliac fossa retractor from the AIP approach. • Place a Hohmann retractor at the top of the iliac crest and over (medial to) the pelvic brim. • Control hemostasis at the pelvic brim intraosseous perforator if encountered. 

PEARLS

• In positioning and preparing for an AIP approach, allow access to the ipsilateral iliac crest to access the lateral window of the ilioinguinal approach in case it is needed (see Fig. 64.5). • Identify the frequent intraosseous vascular anastomosis in the iliac fossa at the posterior third of the pelvic brim. Hemostasis is achieved with bone wax.

818

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

Reduction

PITFALLS

• Increased dissection results in increased bleeding • Inability to visualize medial to the psoas gutter • Placement of the vertical PC screw without C-arm control • Placement of the PC/QP buttress plate away from the medial bone or over the sciatic notch

INSTRUMENTATION/IMPLANTATION

• As listed earlier. • Final C-arm radiographs to confirm reduction and fixation and to complete instrument count • Wound irrigation and hemostasis • Wound closure in layers with large diameter resorbable sutures fixing the abdominal musculature to the abductor muscle fascia, or to crest itself through drill holes PEARLS

• Reduce the AC from posterior to anterior (SI joint and posterior crest to the ASIS). • PC screw: Identify the correct starting point and monitor vertical PC screw placement by C-arm as described.

• AC techniques • Reduce comminuted AC segments extending to the iliac crest with Weber clamps. • Place Shantz pin/Farabeuf clamp at the iliac to manipulate the AC. • Reduce typical sciatic buttress fragment at the posterior pelvic brim. • Provisionally fix with K-wire or place single screws to minimize clamp crowding. • Use a reduction plate on the inner table to reduce the AC fracture line and provide a buttress. • PC techniques • Insert an asymmetric reduction clamp (see Fig. 64.10) through the lateral window medially over the pelvic brim and percutaneously laterally above the acetabulum to translate the PC/QP laterally. • Combine a spiked pusher (from AIP, pushing laterally) with a colinear clamp (from the lateral window) distally placed in the greater or lesser notch and proximally placed at the brim to realign PC fractures. • Similar to above, replace colinear clamp with a bone hook. 

Fixation • AC fixation • Screws across the fracture lines at the iliac crest • Anterior inferior iliac spine (AIIS) to posterior inferior iliac spine (PIIS) screw (LC2 screw; see Fig. 64.13): regular cortical screw versus larger cannulated screw placed percutaneously with C-arm • Contoured reconstruction plate along the inner aspect of the iliac crest • Suprapectineal buttress plate at the pelvic brim, as described in the AIP • PC fixation • Vertical PC screw: Start from a point approximately 3 cm anterior and 3 cm lateral to the anterior corner of the SI joint (Shahulhameed et al., 2010), aim distally down the posterior column (the drill hand will likely touch the patient’s ribs). Monitor under fluoroscopic control, keeping the drill bit: • On AP view: Lateral and adjacent to ilioischial line • On iliac oblique view: Down the posterior column but adjacent to the joint • On obturator view: Within the posterior column (tendency will be to exit precociously, posteriorly) • On modified inlet view (in patient has sufficient lumbar lordosis): Keep the drill bit within the PC (Osterhoff et al., 2015) • PC/QP buttress plate: The plate is contoured in the shape of a “7,” as described in the AIP section. 

PROCEDURE: ADDING ANTERIOR SUPERIOR ILIAC SPINE OSTEOTOMY • The lateral window will give limited access to the psoas gutter, pectineal eminence, and anterior wall of the acetabulum. This can be facilitated by extension of the lateral window through an iliofemoral approach (vertically along the anterior hip and thigh) and an osteotomy of the ASIS (Sagi and Bolhofner, 2015). This osteotomy preserves the ASIS abdominal wall and inguinal attachments and acts as a digastric osteotomy of sorts by medialization of the ASIS. This improves visualization of the iliac fossa from the SI joint to the pubic root (Sheean et al., 2017).

Indications • AC fractures extending medial to the psoas gutter • Anterior wall fractures not accessible through the AIP alone  PEARLS

Positioning and Draping

• Isolation of ASIS with medial and lateral clamps or retractors • Use of a curved osteotome to ensure an anteriorly directed osteotomy

• Same as AIP/lateral window 

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

Approach • Extend the lateral window of the ilioinguinal, curving the incision distally from the ASIS, continuing in the interval between the sartorius and tensor fascia lata. • Elevate the anterior-most portion of the iliacus muscle (medially) and the tensor fascia lata (laterally) from their respective iliac bone tables. • Place a curved clamp medially and laterally along the bony tables to a point just distal to ASIS. In some cases, visualize and protect the lateral femoral cutaneous nerve. • Use a curved osteotome, the width of the iliac crest, aiming first distally then anteriorly to exit a few centimeters distally, between the ASIS and AIIS. • Mobilize the ASIS medially, bringing with it the abdominal wall musculature and sartorius and the inguinal ligament. • Visualize, reduce, and fix fractures of the AC down to the pubic root and fractures of the anterior wall. • Use in combination with the AIP window for more medial fractures. • Repair osteotomy with single 3.5-mm cortical screw purchasing along the crest • Close in layers as per the lateral window approach. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Routine antibiotic and venous thromboembolism (VTE) prophylaxis • Early removal of Foley catheter, when feasible, to prevent iatrogenic urinary tract infection (UTI) • No heterotopic bone prophylaxis measures required • Non–weight bearing (toe touch weight bearing) for 8 to 12 weeks

EVIDENCE There are few higher-level evidence studies to guide treatment decisions. Many cohort studies, one randomized controlled trial (RCT), and one systematic review and meta-analysis of four studies have been published favoring the AIP over ilioinguinal for quality of reduction, surgical time, bleeding, and complications. No RCTs comparing AIP to total hip arthroplasty or to nonoperative care have been completed yet.

Classification and Epidemiology Ferguson TA, Patel R, Bhandari M, et al. Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. J Bone Joint Surg Br. 2010;92:250–257. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg [Am]. 1964;46:1615–1646. The “classic” article that describes the original classification scheme for acetabular fractures by the masters. A must read for any surgeon performing acetabular fracture surgery.

AIP Approach Bible JE, Choxi AA, Kadakia RJ, et al. Quantification of bony pelvic exposure through the modified Stoppa approach. J Orthop Trauma. 2014;28(6):320–323. This cadaveric study defines the areas of the pelvis that can be accessed and repaired from the anterior approach, the potential structures that may be compromised, and the maneuvers through which exposure may be safely maximized. Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994;305:112–123. Guy P. Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery. J Orthop Trauma. 2015;29(suppl 2):S1–S5. This review article in a Journal of Orthopaedic Trauma supplement dedicated to this topic describes the evolution of the Stoppa approach, including the recent advances in techniques, implants, screw placement and trajectories, and outcomes. Guy P, Al-Otaibi M, Harvey EJ, et al. The ‘safe zone’ for extra-articular screw placement during intrapelvic acetabular surgery. J Orthop Trauma. 2010;24:279–283. This CT-based study of 93 scans defined the safe area for screw placement to avoid the hip joint when operating from an anterior approach. Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic fractures. Clin Orthop Relat Res. 1993;297:28–32. Kistler BJ1. Sagi HC Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach. J Orthop Trauma. 2015;29(suppl 2):S14–S19.

PITFALLS

• Avoid extensive dissection distal to the ASIS. • Avoid extensive medial retraction to increase medial visualization (use the AIP window).

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PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

Clinical Studies Andersen RC, O’Toole RV, Nascone JW, et al. Modified Stoppa approach for acetabular fractures with anterior and posterior column displacement: quantification of radiographic reduction and analysis of interobserver variability. J Orthop Trauma. 2010;24:271–278. Archdeacon MT, Kazemi N, Collinge C, et al. Treatment of protrusio fractures of the acetabulum in patients 70 years and older. J Orthop Trauma. 2013;27:256–261. Bastian JD, Tannast M, Siebenrock KA, et al. Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach. Injury. 2013;44:1793–1798. Chesser TJ, Eardley W, Mattin A, Lindh AM, Acharya M, Ward AJ. The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome. J Orthop Trauma. 2015;29(suppl 2):S25–S28. The results reported in this paper on 56 patients treated with anterior approaches alone suggest that the use of dual approaches using the lateral two windows and/or a midline anterior intrapelvic approach has a relatively low complication rate and can lead to anatomic reconstructions in 71% of patients. Elmadag M, Guzel Y, Aksoy Y, Arazi M. Surgical treatment of displaced acetabular fractures using a modified stoppa approach. Orthopedics. 2016;39(2):e340–e345. Hirvensalo E, Lindahl J, Kiljunen V. Modified and new approaches for pelvic and acetabular surgery. Injury. 2007;38:431–441. Isaacson MJ, Taylor BC, French BG, et al. Treatment of acetabulum fractures through the modified stoppa approach: strategies and outcomes. Clin Orthop Relat Res. 2014. Ismail HD, Djaja YP, Fiolin J. Minimally invasive plate osteosynthesis on anterior pelvic ring injury and anterior column acetabular fracture. J Clin Orthop Trauma. 2017;8(3):232–240. Jakob M, Droeser R, Zobrist R, et al. A less invasive anterior intrapelvic approach for the treatment of acetabular fractures and pelvic ring injuries. J Trauma. 2006;60:1364–1370. Khoury A1, Weill Y, Mosheiff R. The Stoppa approach for acetabular fracture. Oper Orthop Traumatol. 2012;24(4-5):439–448. Kim HY, Yang DS, Park CK, Choy WS. Modified Stoppa approach for surgical treatment of acetabular fracture. Clin Orthop Surg. 2015;7(1):29–38. Laflamme GY, Hebert-Davies J, Rouleau D, et al. Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate. Injury. 2011;42:1130–1134. A retrospective review of 21 cases treated with buttress plating of the quadrilateral plate. Although a perfect reduction was obtained in only half of the cases, functional outcome was good and only two patients needed conversion to arthroplasty. Ma K, Luan F, Wang X, et al. Randomized, controlled trial of the modified Stoppa versus the ilioinguinal approach for acetabular fractures. Orthopedics. 2013;36:e1307–e1315. This randomized trial of 60 patients compared the Stoppa approach to the ilioinguinal approach and found that most outcome parameters, including fracture reduction and functional outcome, were similar. However, patients treated with the Stoppa approach had less blood loss, shorter operative times, and a lower transfusion rate. Thus, the authors recommend it as their favored approach. Meena S, Sharma PK, Mittal S, Sharma J, Chowdhury B. Modified Stoppa approach versus ilioinguinal approach for anterior acetabular fractures; a systematic review and meta-analysis. Bull Emerg Trauma. 2017;5(1):6–12. A thorough and comprehensive review of the higher-quality articles on this topic. Ponsen KJ, Joosse P, Schigt A, et al. Internal fracture fixation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results. J Trauma. 2006;61:662–667. Qureshi AA, Archdeacon MT, Jenkins MA, et al. Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation. J Orthop Trauma. 2004;18:175–178. Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of acetabular fractures. J Orthop Trauma. 2010;24:263–270. Shazar N, Eshed I, Ackshota N, et al. Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches. J Orthop Trauma. 2014;28:313–319. Tannast M1, Siebenrock KA. [Operative treatment of T-type fractures of the acetabulum via surgical hip dislocation or Stoppa approach]. Oper Orthop Traumatol. 2009;21(3):251–269. Vikmanis A, Vikmanis A, Jakusonoka R, et al. Mid-term outcome of patients with pelvic and acetabular fractures following internal fixation through a modified Stoppa approach. Acta orthop Belg. 2013;79:660–666.

Iliac Window Osterhoff G, Amiri S, Unno F, et al. The “Down the PC” view–A new tool to assess screw positioning in the posterior column of the acetabulum. Injury. 2015;46(8):1625–1628. This cadaveric study determined the surgeon’s ability to detect perforation of posterior column screws. They found that the “Down the PC” view, based on reproducible radiographic landmarks, dramatically enhanced the reliability of the surgeon to detect screw perforation/joint penetration. Shahulhameed A, Roberts CS, Pomeroy CL, Acland RD, Giannoudis PV. Mapping the columns of the acetabulum--implications for percutaneous fixation. Injury. 2010;41(4):339–342.

PROCEDURE 64  Acetabulum Fracture Fixation Through the Anterior Intrapelvic (Stoppa) Approach

ASIS Osteotomy Mast, Jeffrey, et al. Planning and Reduction Technique in Fracture Surgery. Springer; 1989. Sagi HC, Bolhofner B. Osteotomy of the anterior superior iliac spine as an adjunct to improve access and visualization through the lateral window. J Orthop Trauma. 2015;29(8):e266–e269. This technique article describes the use of an ASIS osteotomy to significantly enhance the exposure of the anterior pelvis, especially the internal iliac fossa and anterior aspect of the sacroiliac joint. Sheean AJ1, Hurley RK, Collinge CA, Beltran MJ. Increased anterior column exposure using the anterior intrapelvic approach combined with an anterior superior iliac spine osteotomy: a cadaveric study. J Orthop Trauma. 2017;31(11):565–569.

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PROCEDURE 65

Sacroiliac Joint Injuries: Iliosacral Screws Milton Lee (Chip) Routt, Jr.

INDICATIONS PITFALLS

• Accurate assessment of SI joint instability is based on physical examination, plain pelvic radiographs, computed tomography (CT) scans, and dynamic imaging during stress examination. • Complete and incomplete SI joint instability is commonly noted on pelvic imaging. • SI joint instability may not be obvious if the pelvic imaging was performed after a circumferential pelvic wrap was applied; the pelvic wrap often produces an accurate SI joint reduction.

INDICATIONS CONTROVERSIES

• Controversy still exists in reliably diagnosing and safely treating incomplete posterior pelvic injuries. • The role of posterior pelvic instability in chronic symptomatic symphysis pubis instability remains controversial.

INDICATIONS • Unstable sacroiliac (SI) joint traumatic disruptions • Unstable SI fracture-dislocations • Symptomatic sacroiliac joint arthritis • Symptomatic chronic posterior pelvic instability 

EXAMINATION/IMAGING • The physical examination identifies open wounds, closed degloving injuries, ecchymoses, prior scars, urethral meatal blood, rectal blood, vaginal-labial injuries, and neurovascular injuries. • Manual compression toward the midline applied over each iliac crest during the physical examination reveals instability. • For the injured patient, anteroposterior (AP) pelvic radiograph prior to circumferential pelvic wrapping • Same patient, AP pelvic radiograph after wrap application • The pelvic CT reveals injury sites, displacements, deformities, body habitus, hematoma location and extent, and associated injuries. 

SURGICAL ANATOMY TREATMENT OPTIONS

• Closed reduction and percutaneous fixation (CRPF) is used whenever possible. • CRPF relies routinely on intraoperative fluoroscopy to both assess the reduction and direct the iliosacral screw insertion. • Usually incomplete SI joint injuries will indirectly reduce when the anterior pelvic injury is reduced, or when the precisely oriented lag screw compresses the residual SI joint distraction. • Open reduction internal fixation (ORIF) of the SI joint is selected when closed reduction techniques fail or are not possible. • Open reduction of the SI joint is performed using either an anterior exposure with the patient positioned supine, or via posterior surgical exposure in the prone position.

• The SI joint is an unusual articulation composed of iliac and sacral articular pads surrounded by strong ligaments. • The fifth lumbar nerve root is located on the sacral ala just medial to the anterior SI joint. • For reliable and safe iliosacral screw insertions, the upper sacral osteology (including sacral dysmorphism) must be identified and quantified on the preoperative imaging. • Hip flexion during the anterior surgical exposure for ORIF relaxes the iliopsoas muscle, eases retraction, and improves exposure of the anterior joint surface. • Aggressive medial retraction and/or clamp application along the lateral sacral ala during the anterior ORIF risks injury of the fifth lumbar nerve root. • Wound complications are more common when the posterior exposure is selected for ORIF. • Iliosacral screws can be safely inserted with the patient properly positioned either supine or prone. 

POSITIONING PEARLS

• The folded blanket is adjusted in thickness to elevate the pelvis from the OR table sufficiently to allow iliosacral screw insertion. • The surgeon must ensure that the eyes are free of pressure, the genitals are positioned appropriately, and that all bony prominences are well padded when the patient is positioned prone. • Prior to draping, use the C-arm to ensure that the patient is well positioned so that all appropriate images can be easily obtained.

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• When the supine position is selected, a folded operating room (OR) blanket is used to elevate the patient and pelvis from the OR table so the iliosacral screws can be inserted easily. • Skeletal traction is used as a reduction aid when necessary. • Positioning the patient supine allows surgical access to both the anterior pelvic ring and the anterior SI joint. • Prone positioning is more difficult in patients with anterior external fixation devices. •  The prone position denies the anesthesiologist easy access to the airway, and the surgeon must ensure that there is no pressure on the eyes during the surgery. • The upper extremities are positioned so they do not obstruct either pelvic imaging or iliosacral screw insertion. 

PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

PORTALS/EXPOSURES • The anterior SI joint is accessed using the lateral surgical interval of the ilioinguinal exposure. Hip flexion relaxes the iliopsoas muscle for easier retraction and improved visualization. • Because of the SI joint’s unusual osteology, the posterior surgical exposure only reveals the caudal articular facet, whereas the anterior articular reduction is assessed by palpation. • The iliosacral screw’s starting point and directional aim are planned preoperatively using the pelvic CT scan and then determined intraoperatively using inlet, outlet, and true lateral sacral fluoroscopic imaging.  PORTALS/EXPOSURES PEARLS

• A comprehensive preoperative plan includes the details of patient positioning, reduction maneuvers, clamp application, and iliosacral screw insertion. • The pelvic CT scan identifies and quantifies the parameters for the planned osseus fixation pathways. • To optimize screw accuracy, the three-dimensional (3D) surface rendered pelvic CT models are correlated with the intraoperative fluoroscopy views. PITFALLS

• SI joint malreduction decreases the area available for the iliosacral screw within the osseus fixation pathway. • Reduction clamps or the screws used to attach them to the bone should be positioned so that they do not obstruct the iliosacral screw insertion. PORTALS/EXPOSURES EQUIPMENT

• A poor quality C-arm unit will not produce sufficient images for safe screw insertion. • A radiology technician who does not pay attention to the intraoperative imaging details will add unnecessary radiation exposure, time, and cost to the operation. For numerous reasons, an attentive and skilled radiology technician is a critical part of the procedure.

CONTROVERSIES

• When prone posterior ORIF is selected, the reduction clamp is applied to the anterior sacral ala through the greater sciatic notch based on digital palpation of the anterior SI joint alone. This “blind” clamp application remains quite controversial and is not advocated. • The prone posterior surgical exposure remains controversial because it has been associated with higher wound complication rates.

PROCEDURE Step 1 • In patients with an incomplete SI joint injury, accurate reduction of the anterior pelvic ring injury (symphysis pubis, pubic ramus, combination injury) often will indirectly reduce the SI joint. In these patients, iliosacral screws are inserted to stabilize the SI joint injury and support the overall fixation construct. Some evidence indicates that iliosacral screw fixation of incomplete SI joint injury decreases the rate of failure of anterior fixation. If compression is needed to complete the SI joint indirect reduction, an initial iliosacral lag screw is inserted. • In patients with complete SI joint injuries, the anterior pelvic reduction may aid in the SI joint reduction. In these patients with residual SI joint uniform distraction after anterior pelvic reduction, an iliosacral lag screw is used to complete the reduction. Additional screws provide improved support for the SI joint. Multiple iliosacral screws inserted at multiple posterior pelvic levels have lower failure rates. • Open reduction is selected for those injuries when closed reduction fails. The clamp is applied so that it does not injure the fifth lumbar nerve root and does not obstruct the iliosacral screw fixation. 

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PITFALLS

• If the folded blanket is too thick, the pelvis will be overly elevated from the OR table causing un unstable patient position. • Once the patient is positioned and before draping, the necessary intraoperative fluoroscopy images should be obtained. Any positioning changes should be made prior to draping. • The surgical draping should be inclusive of all necessary exposures and implants. • Urethral meatal necrosis can result when the urinary catheter is poorly positioned. Similarly, the patient’s scrotum should not be crushed between his thighs during surgery. • Femoral vein and/or artery catheters and suprapubic catheters should be prepared and draped into the sterile field when necessary rather than removed. POSITIONING EQUIPMENT

• The C-arm is located on the opposite side from the surgeon. • The C-arm unit tilts and positioning are adjusted after the patient is positioned and prior to draping. The x-ray technician should mark the floor and C-arm machine so the necessary intraoperative images remain consistent throughout the operation. CONTROVERSIES

• Some surgeons prefer prone patient positioning for the ease of access to the posterior pelvic ring during iliosacral screw insertion. • Supine positioning allows the surgeon to access the anterior pelvic ring without compromising surgical access to the SI joint. • Insufficient imaging may result from poor patient positioning, morbid obesity, osteoporosis, residual bladder or bowel contrast agents, excessive flatus, among others. PEARLS

• Accurate reduction of the anterior pelvic injury will often result in an excellent indirect reduction of the SI joint. • In ORIF, the clamp must be properly located in order to provide uniform compression across the SI joint during the iliosacral screw fixation. PITFALLS

• The reduction clamp should not obstruct the optimal iliosacral screw pathway. • Poor positioning of the reduction clamp usually results in a poor reduction. INSTRUMENTATION/IMPLANTATION

• The optimal location for the iliosacral screw is best planned preoperatively using the CT scan. • For patients with a symmetric upper sacrum and a unilateral SI joint injury, the uninjured side is used for preoperative iliosacral screw planning.

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PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

CONTROVERSIES

• Controversy persists on the value of accurate anterior pelvic reduction prior to posterior.

Step 2 • The caudal anterior pathway of the sacral alar ellipsoid is selected because it is the most reliable initial iliosacral screw site. • Using inlet and outlet posterior pelvic imaging, a narrow diameter smooth Kirschner wire (K-wire) is used to identify the optimal skin insertion site and ideal directional aim. The wire is then inserted approximately 1 cm through the lateral iliac cortical bone. • The skin incision is then made and the cannulated drill is applied over the K-wire and oscillated into the lateral iliac bone. • The caudal-anterior location allows the drill to be advanced safely until the drill tip is located 2 to 3 mL lateral to the visible S1 nerve root tunnel, best seen on the outlet image. • The true lateral image is then obtained by superimposing the greater sciatic notches and iliac cortical densities. • The true lateral image is used to confirm the accurate location of the drill tip within the safe osseous fixation pathway. The drill tip should be located caudal to the sacral ala-iliac cortical density, posterior to the anterior cortical limit of the vertebral body, cranial to the S1 tunnel, and well anterior to the spinal canal. 

PEARLS PEARLS

• Using the cannulated drill to prepare the pathway first instead of completely inserting the guide pin allows a more precise pathway preparation. Thinner diameter guide pins often become misdirected, resulting in a poorly located screw. • The posterior iliac tangential image demonstrates the washer as it contacts the bone surface. The washer is used to decrease the chance of unwanted screw intrusion through the lateral iliac cortical bone surface.

• The intraoperative pelvic inlet image is optimized by superimposing the upper and second sacral vertebral bodies. • The mid-sagittal image on the injury pelvic CT scan demonstrates the ideal inlet tilt for each patient. • The intraoperative outlet tilt is best achieved when the cranial edge of the symphysis pubis is superimposed on the second sacral vertebral body. That tilt reveals the S1 nerve root tunnel anterior foramen. • For morbidly obese patients, the injury CT scan lateral scout image alerts the surgeon to potential intraoperative lateral fluoroscopic imaging difficulties. If the sacrum is not distinct on the CT scout lateral image, then the intraoperative lateral will be similarly obstructed by the soft tissues.

PITFALLS

PITFALLS

• If the cannulated drill exits the anterior vertebral body, the guide pin can inadvertently advance and injure the local neurovascular structures. • If the washer intrudes through the lateral iliac cortical bone, the iliosacral screw stability is compromised.

• Accepting a poorly located skin starting site will result in either an unacceptable lateral iliac bone insertion site or improper directional aim. • In morbidly obese patients, standard cannulated screw system guide pins, measuring devices, and screw drivers may be of insufficient length. Special longer instrumentation is available and should be utilized.

INSTRUMENTATION/IMPLANTATION

• Oblique iliosacral screws are more perpendicular to the SI joint surfaces than trans-sacral screws. • The oblique iliosacral lag screw compresses residual SI joint distraction. • Oblique iliosacral screws usually spare the majority of the SI joint articular surfaces, whereas transsacral screws penetrate the articular surfaces.

CONTROVERSIES

• Trans-sacral screws are controversial because they penetrate the uninjured SI joint and are riskier than oblique screws because they traverse the alar areas on both sides. • Trans-sacral screws result in better biomechanical construct strength, although it is unclear if this results in superior clinical outcomes.

CONTROVERSIES

• Controversy remains regarding the optimal iliosacral screw number, orientation, and length. • Some surgeons use only the lateral sacral image for iliosacral screw insertion. This is controversial because it limits the surgeon to just one style of iliosacral screw use.

Step 3 • Depending on the planned pathway, the drill is either advanced into the vertebral body or across the contralateral ala and SI joint, exiting the lateral iliac cortical bone. • If an oblique iliosacral screw is planned, the drill should not penetrate the anterior vertebral body cortical bone. • The guide pin for the cannulated screw system is then inserted into the drilled pathway, and the depth is assessed using a measuring device or guide pin of the same length. • The iliosacral screw and washer are inserted over the guide pin. • The C-arm is used at frequent intervals during screw insertion to ensure that the guide pin is not being inadvertently advanced. • At terminal tightening, the C-arm beam is oriented tangentially relative to the screw insertion site at the posterior lateral iliac cortical bone. The screw is tightened to approximate the washer against the lateral iliac cortical bone surface without intrusion. 

PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

Step 4 • Adding additional iliosacral screws improves stability and is performed whenever possible. • If the initial oblique screw is inserted in the caudal-anterior portion of the upper sacral safe osseus fixation pathway, the subsequent screw should be located slightly posterior and cranial to the initial screw in order to be properly contained. • If the initial screw has provided sufficient compression, the subsequent screw can be a fully threaded screw to maintain the reduction. 

Step 5 • The overall fixation construct is strengthened when both the unstable SI joint and the anterior pelvic injured are stabilized and reduced. • For more extensive injuries (e.g., “jumper’s fractures”), lumbopelvic fixation is added to augment the posterior pelvic stability. • Posterior trans-iliac screw and plating fixation techniques also have been described to supplement the iliosacral screw fixation. 

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PEARLS

• Safe and reliable iliosacral screw insertion occurs when the screw pathway is well planned, the osteology and its intraoperative imaging are completely understood, and the intraoperative imaging is high quality and consistent. PITFALLS

• Locating the initial screw in the middle area of the osseus fixation pathway improves the safety for that screw, but that location then adds risk to subsequent screw placement. CONTROVERSIES

• Using multiple screws (and/or trans-sacral screws) at multiple levels to further stabilize the SI joint injury remains controversial. No study has identified how much fixation is required to predictably provide durable stability until complete healing.

PEARLS

• The lumbopelvic supplemental fixation procedure is performed with the patient positioned prone after the SI joint injury has been reduced and stabilized. • Iliosacral screws are inserted before the lumbopelvic iliac bolts are placed. The LPF iliac bolts can be positioned to accommodate the iliosacral screws.

PITFALLS

• Failure to recognize, reduce, and stabilize the associated unstable anterior pelvic ring traumatic injury can result in posterior fixation failure. • Applying LPF or other implants prior to iliosacral insertion can obstruct the iliosacral screw’s optimal pathway.

INSTRUMENTATION/IMPLANTATION

• Malleable reconstruction plates and medullary ramus screws are used commonly to provide anterior pelvic fixation. • Safe iliosacral screws have a limited bone pathway, especially when trans-sacral screws are used. • LPF iliac bolts can be adjusted in position to avoid the iliosacral screws.

CONTROVERSIES

• Controversy remains concerning the number of iliosacral screws necessary to provide sufficient fixation

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Rehabilitation is guided by a licensed physical therapist whenever possible. • The patients use crutches or other assistive devices to unload the injured SI joint during gait. Protected weight bearing on the injured side is continued for 4 to 8 weeks after operation, depending on the injury and fixation details.

PITFALLS

• The fixation construct should be enhanced (i.e., more screws, more levels, trans-sacral screws) at surgery if patient noncompliance is anticipated prior to surgery.

CONTROVERSIES

• Noncompliant patients who exhibit early unprotected weight bearing have an increased risk of fixation failure.

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PROCEDURE 65  Sacroiliac Joint Injuries: Iliosacral Screws

EVIDENCE Lucas JF, Routt Jr ML, Eastman JG. A useful preoperative planning technique for transiliactranssacral screws. J Orthop Trauma. 2017;31(1):e25–e31. This article is a well-illustrated technique guide describing “state-of-the-art” planning for the insertion of trans-iliac and trans-sacral screws. Simonian PT, Routt Jr ML, Harrington RM, Mayo KA, Tencer AF. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instability and fixation. Clin Orthop Relat Res. 1994;309:245–256. A biomechanical study using seven cadaveric pelvii showed that plate fixation of the symphysis pubis alone reduced symphysis pubis motion, but not sacroiliac motion. Use of sacroiliac fixation alone without a symphysis pubis plate did not affect symphysis pubis motion. Both single iliosacral screws and plates produced equivalent decreases in sacroiliac joint motion. Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O’Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma. 1999;13(2):107–113. This paper describes the early results of 38 patients treated with iliosacral screw fixation for injuries of the SI joint. Nearly 44% of patients had some loss of reduction on final follow-up radiographs (malunion). It was recommended that iliosacral screw fixation be protected by anterior ring fixation. Carlson DA, Scheid DK, Maar DC, Baele JR, Kaehr DM. Safe placement of S1 and S2 iliosacral screws: the “vestibule” concept. J Orthop Trauma. 2000;14(4):264–269. This study attempted to determine the optimal starting points for placement of S1 and S2 iliosacral screws using normal subject study evaluating helical CT scans of 30 normal pelvic rings. Finding was that the transversely placed (horizontal) iliosacral screw was the least safe of the screws tested. The safest lateral ilium starting point for our entire population was at the posterior sacral body sagittally and at the inferior S1 foramen coronally. S2 iliosacral screws had less cross-sectional area for placement than S1 screws. Placement of the S2 screw slightly to the S1 foraminal side of the S2 vertebral body increased the safety of placement. Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma. 2004;18(3): 138–143. Anterior symphyseal plating for the vertically unstable hemipelvis significantly increases the stability of the fixation construct and restores the normal response of the hemipelvis to axial loading. A significant benefit to supplementary iliosacral screws, in addition to a properly placed S1 iliosacral screw, was not shown.

PROCEDURE 66

Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation (Crescent Fracture) Jeff Yach INDICATIONS

TREATMENT OPTIONS

• Displaced and/or unstable fractures of the ilium extending into the sacroiliac joint

EXAMINATION/IMAGING • Initial resuscitation of the patient should be conducted as per Advance Trauma Life Support guidelines because these injuries are often associated with high-energy trauma (usually lateral compression) with or without multiple injuries. • A detailed distal neurovascular examination is crucial to identify potential deficits. • The L5 nerve root and sciatic nerve are particularly at risk with fracture-dislocations. Fig. 66.1 shows a fracture-dislocation of the right ilium with medial displacement and L5 nerve root injury. • Inspection of the soft-tissue envelope must be done to identify areas of concern that may influence choice of surgical approach, timing, and management. • Initial imaging includes an anteroposterior (AP) radiograph of the pelvis as well as inlet and outlet views. The AP pelvis radiograph in Fig. 66.2 shows a transarticular (crescent) fracture of the left ilium. • Computed tomography (CT) scanning with or without three-dimensional reconstructions is mandatory in understanding fracture pattern and in preoperative planning. The CT scan in Fig. 66.3 demonstrates comminution and extension into the sacroiliac (SI) joint. • Day et al. proposed a functional classification system for crescent fractures. Type I fractures involve less than one-third of the joint. Type II fractures involved between one-third and two-thirds of the joint. Type III involve more than two-thirds of the joint. 

FIG. 66.1 

• Displaced, unstable iliac fractures are generally treated definitively with open reduction and internal fixation once the patient’s physiologic status permits. • Fixation may be either extraarticular or transarticular. • Initial temporizing measures may include pelvic binders, external fixation, and/or traction.

FIG. 66.2 

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PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

FIG. 66.3 

SURGICAL ANATOMY • Intraarticular iliac fracture • An intraarticular iliac fracture extends into the SI joint. It usually represents a lateral compression injury with rotational instability. Some fractures will be vertically unstable as well, as seen in Fig. 66.2. • The posterior superior iliac spine (PSIS) remains firmly attached to the sacrum via the strong posterior iliosacral ligaments. Fig. 66.4 shows a transarticular fracture of the ilium with displacement of the anterior portion of the ilium and SI joint (A). The posterior fragment (B) generally remains well fixed and stable owing to the strong posterior iliosacral ligaments. • The remainder of the ilium and inferior portion of the SI joint are displaced.

A B

FIG. 66.4 

PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

• Structures at risk • Pelvic nerves (Fig. 66.5) • The L5 nerve root travels over the ala of the sacrum anteriorly, approximately 2.5 cm medial to the SI joint. • The sciatic nerve, as well as the gluteal neurovascular bundles, exit the pelvis via the sciatic notch. • Pelvic musculature (Fig. 66.6) • The gluteus medius and maximus attach to the outer table of the ilium, and a portion of the gluteus maximus attaches to the midline. • The erector spinae attaches to the posterior iliac crest and the medial sacral crest. 

L5 nerve root

SI joint Sciatic notch

Sciatic nerve and gluteal neurovascular bundles

FIG. 66.5 

Erector spinae muscles

Ilium

Gluteus muscles

FIG. 66.6 

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PEARLS

• The lateral position allows additional anterior access to assist in the reduction of fracture dislocations and keeps the patient’s body weight off the displaced fragment.

PITFALLS

• Ensure that adequate fluoroscopic visualization can be obtained, particularly if iliosacral screw fixation is selected. • Iliac fracture lines that extend more anteriorly (Day Type I) will require greater dissection of the gluteals and may be better accessed anteriorly, such as through the lateral window of an ilioinguinal approach. • Patients with severe soft-tissue injuries may have an internal degloving injury posteriorly that will increase the risk of wound complications, and this may alter the timing and/or approach for surgery.

PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

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CONTROVERSIES

POSITIONING

• Proponents of the anterior approach suggest it provides direct visualization of the SI joint for accurate reduction. However, the intraarticular portion of the fracture line may not be directly visualized and plating options are more limited.

• Place the patient on a radiolucent table to allow intraoperative fluoroscopy. • The patient may be positioned supine, prone, or lateral depending on the preferred approach for reduction and instrumentation. • The prone or lateral (Fig. 66.7) position allows the posterior approach to the fracture site with direct access to the fracture line for reduction and instrumentation. 

FIG. 66.7 

PORTALS/EXPOSURES

PEARLS

• The posterior portion of the fracture line is directly visualized and, additionally, the SI reduction can be checked by fluoroscopy and finger palpation inferiorly, through the sciatic notch. • Difficult reductions can sometimes be achieved by using a blunt elevator (carefully inserted) as a “shoehorn” to translate the anterior fragment far enough anterior to clear the posterior fragment and slide into position.

• Make a vertical or curvilinear incision (Fig. 66.8A) over the PSIS and develop a fullthickness flap from skin to periosteum (Fig. 66.8B). • Detach the gluteal musculature from the posterior iliac crest. • Inferiorly, the extension of the gluteus maximus to the midline is identified and released and reflected laterally. • Expose the outer table of the ilium subperiosteally in order to visualize the posterior fragment and fracture line (Fig. 66.9). • Dissection can be carried inferiorly so that a finger can be placed into the sciatic notch to palpate the anterior portion of the SI joint. • Dissection can be carried anteriorly to expose the anterior fragment for subsequent reduction and fixation. 

Posterior superior iliac spine

Full thickness flap

A

B FIG. 66.8 

PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

Fracture line

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Posterior fragment

FIG. 66.9 

PROCEDURE Step 1 • The posterior fragment generally remains stable, secured by the strong posterior sacroiliac ligamentous complex. • The anterior fragment can be controlled with the help of reduction clamps, joysticks, and manual traction. • The anterior fragment is mobilized and reduced to the posterior fragment and sacrum (Fig. 66.10). Reduction can be aided with the use of traction, a spiked ball pusher, and reduction forceps. • Once the fracture is reduced, it can be provisionally clamped or pinned in place. 

FIG. 66.10 

Step 2 • A template is used to help contour a pelvic reconstruction plate along the iliac crest. •  The plate is then secured, and compression can be applied if there is no comminution. • If required, a second plate can be applied inferiorly along the sciatic buttress. Fig. 66.11 shows two pelvic reconstruction plates in place, one along the iliac crest and one inferiorly along the sciatic buttress. 

PEARLS

• Plates should be applied along the margins of the ilium where the bone is thicker and they are out of the way of interfragmentary screws.

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PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

PITFALLS

• Insertion of interfragmentary screws prior to plate application can often lead to malreduction as the screws are tightened owing to the typical oblique orientation of the fracture line relative to the long axis of the screws. PEARLS

• Fluoroscopy can be useful to optimize implant position, particularly iliac and obturator oblique views. • Placing a finger on the margin of the sciatic notch while drilling can help to direct the drill correctly and avoid injury to the neurovascular structures. PITFALLS

• Although cannulated iliosacral screws can be used for fractures with small posterior fragments (Day Type III), care should be taken with type II fractures to ensure the screw placement is not too close to the fracture line. This may result in fracture line extension and loss of purchase.

FIG. 66.11 

Step 3 • Intertable screws (inserted between the inner and outer cortices of the ilium) are placed from posterior to anterior, directed from the PSIS toward the anterior inferior iliac spine (AIIS). • Typically a larger diameter screw, such as a 6.5-mm partially threaded cancellous screw, is used. • In comminuted fractures, a fully threaded screw can be selected. • Two or three parallel screws are placed under fluoroscopic guidance (Fig. 66.12A). • Fluoroscopic guidance with iliac (Fig. 66.12B) and obturator (Fig. 66.12C) oblique views is helpful to ensure proper screw zplacement. •  Fig. 66.12D shows final fixation. 

PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

A

B

C

D

833

FIG. 66.12 

Step 4

CONTROVERSIES

• Additional fixation of concomitant anterior pelvic ring injuries is dictated by fracture pattern, stability of fixation, patient factors, and surgeon preference. 

• Both transarticular and extraarticular fixation techniques are described, and the optimal method is usually dictated by the size of the posterior fragment and location of the fracture line.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The wound is closed in layers over a drain. • Antibiotic prophylaxis is given for 24 hours. • Thromboembolic prophylaxis is also recommended, usually for 4 weeks. • The patient is permitted touch-down weight bearing for 6 to 12 weeks and advanced as healing permits.

CONTROVERSIES

• No definitive evidence exists to determine the required duration of thromboembolic prophylaxis postoperatively. However, 4 weeks seems reasonable based on anecdotal experience and the increased risk of thromboembolic events in patients with pelvic fractures.

834

PROCEDURE 66  Open Reduction and Internal Fixation of Intraarticular Iliac Fracture-Subluxation

EVIDENCE Borelli Jr J, Koval KJ, Helfet DL. The crescent fracture: a posterior fracture dislocation of the sacroiliac joint. J Orthop Trauma. 1996;10:165–170. The authors present a retrospective analysis of the efficacy of posterior extraarticular fixation of crescent fractures in 22 patients. The results showed uneventful healing with no loss of fixation and a low incidence of complications. Calafi LA, Routt Jr ML. Posterior ililac crescent fracture-dislocation: what morphological variations are amenable to iliosacral screw fixation? Injury. 2013;44:194–198. The authors present a retrospective review of 100 patients with crescent fractures. Percutaneous iliosacral screw fixation was utilized in 60% of patients. Not all fractures could be appropriately clas­ sified using the Day classification and it was suggested that the classification system be expanded. Day AC, Kinmount C, Bircher MD, et al. Crescent fracture-dislocation of the sacroiliac joint: a functional classification. J Bone Joint Surg [Br]. 2007;89:651–658. The authors examined the management of 16 crescent fractures, divided into three subgroups based on the size of the posterior fragment. Good results were reported for all groups, which highlight the importance of the fracture line location when selecting transarticular or extraarticular fixation. Starr AJ, Walter JC, Harris RW, et al. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacroiliac joint (OTA Types 61-B2.2 and 6.1-B2.3, or Young-Burgess “lateral compression type II” pelvic fractures). J Orthop Trauma. 2002;16:116–123. The authors present a retrospective review of attempted closed reduction and percutaneous stabi­lization, reporting reasonable results if an appropriate reduction could be achieved. The technique may have a role in selected cases, especially in cases where there is believed to be an increased risk of wound complications.

PROCEDURE 67

Open Reduction and Internal Fixation of Sacral Fractures Richard J. Jenkinson and Jeff Yach INDICATIONS

INDICATION PITFALLS

• Displaced sacral fractures associated with pelvic ring instability • Displaced sacral fractures with or without neurologic deficit • Nondisplaced sacral fractures associated with an unstable fracture pattern to prevent secondary displacement • Displaced or nondisplaced fractures associated with pain and limiting mobility, in order to allow mobilization and improving pain control 

EXAMINATION/IMAGING • Displaced sacral fractures often occur in the setting of multiply injured patients; therefore, a thorough assessment based on Advanced Trauma Life Support (ATLS) principles is indicated. • Examination of the pelvic ring for open injuries, including the rectum and vagina, is mandatory. • Neurologic assessment of lumbosacral nerve roots is required. • Initial imaging consists of an anteroposterior (AP) pelvis radiograph. Fig. 67.1 shows a vertically unstable pelvic ring injury with a displaced sacral fracture. • Inlet and outlet pelvic radiographs are helpful for understanding the associated pelvic ring injury. • Computed tomography scanning of the pelvic ring and sacrum is essential for understanding the injury pattern and to assess the anatomic variation in the patient’s upper sacral anatomy. Fig. 67.2 shows an axial image of the patient in Fig. 67.1. 

• Posterior pelvic exposure and fixation is associated with potential soft-tissue and neurologic complications. • Soft-tissue risks of surgical exposure make nonoperative or percutaneous techniques preferable in many situations.

INDICATION CONTROVERSIES

• The role of foraminal decompression in sacral fractures is unclear given that many patients improve without decompression.

TREATMENT OPTIONS

• Closed or percutaneous reduction • Posterior approach and open reduction • Iliosacral screws • Posterior plating • Spinopelvic fixation

FIG. 67.2 

FIG. 67.1 

835

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

836

SURGICAL ANATOMY • The bony sacrum consists of five fused sacral segments and the coccyx (Fig. 67.3). • Transitional variations commonly exist with partially fused L5 vertebra or a transitional S1 with some S1-S2 disk space present. This may limit safe corridors for fixation. • The upper three sacral vertebrae articulate with the ilium via the sacroiliac joint. • The posterior sacroiliac ligaments are much stronger than the anterior sacroiliac ligaments. • The sacrospinous and sacrotuberous ligaments help provide stability to the pelvic ring. • The neural elements (Fig. 67.4) travel in the spinal canal and branch off bilaterally through the sacral foramina (S1-S4). • The L5 nerve root travels along the anterior surface of the S1-sacral ala approximately 2 cm medial to the sacroiliac joint. • The highly vascular presacral plexus and proximity of the rectum make midline ­anterior exposure to the sacrum unsafe for trauma indications. • Muscular anatomy includes the attachments of the paraspinal muscles and gluteus maximus along the posterior iliac crest and to the medial sacral crest.  L5 nerve root

Paraspinal muscles Sacroiliac joint

Sacrospinous ligament

Sacrum

Sacroiliac joint

Sacrotuberous ligament

Coccyx

FIG. 67.4 

FIG. 67.3 

POSITIONING PEARLS

POSITIONING

• Transverse bolsters may place pressure on the anterior superior iliac spines that may hinder reduction. • Vertical chest bolsters (see Fig. 67.5) help to minimize pressure on the anterior iliac spines by allowing them to be suspended free of direct bolstering.

• Prone positioning on a radiolucent table is required to allow fluoroscopic assessment of reduction and hardware placement (Fig. 67.5). • The leg on the displaced side is usually draped free to allow intraoperative longitudinal traction. • Care should be taken to avoid resting bolsters directly on the anterior superior iliac spines as this will make reduction maneuvers more challenging. 

POSITIONING PITFALLS

• Prone positioning is associated with several complications owing to pressure injury. • Care needs to be taken to ensure a comfortable position of limbs and eyes with appropriate bolsters and padding.

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

837

POSITIONING EQUIPMENT

FIG. 67.5 

EXPOSURES

• Soft gel bolsters • Radiolucent operating table

EXPOSURE PEARLS

• Soft-tissue status should be carefully assessed when considering open approaches to the sacrum. • Unilateral fractures are usually approached with a paraspinal incision (Fig. 67.6). A second incision on the lateral side of the opposite posterior superior iliac spine may be required if a spanning posterior plate is considered. • Bilateral fractures and those where a decompression is planned are approached through a midline posterior skin incision (see Fig. 67.6) • Paraspinal muscles should be elevated carefully off of the underlying sacrum. 

Paraspinal approach

L4

Midline approach

L5

• Preservation of the gluteus maximus aponeurosis should be done by sharply dissecting it off of the underlying paraspinal muscle fascia.

EXPOSURE PITFALLS

• Internal degloving injuries will significantly increase the risk of wound complications and may require separate debridement or the selection of an alternate approach/percutaneous treatment. • The gluteus maximus aponeurosis should be preserved because it attaches to the midline of the sacrum. Transecting this aspect of the muscle increases wound complications. • Detaching the paraspinal muscles and reflecting the cephalad increases wound complications.

EXPOSURE CONTROVERSIES

• Necessity and timing of sacral nerve root decompression are unclear based on limited and retrospective literature and clinical improvement with or without surgical decompression.

FIG. 67.6 

PROCEDURE Step 1: Reduction • The fracture is exposed and cleaned; loose fragments can be removed. • Fig. 67.7 shows exposure of a right-sided sacral fracture with a periosteal elevator in the fracture. • The reduction maneuver will depend on the particular fracture. • The components of the displacement will include vertical (cranial) displacement, horizontal distraction, and flexion/extension rotation of the hemipelvis.

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

838

STEP 1 PEARLS

• The fracture line can be gently distracted using a laminar spreader. • Schantz pins in the PSIS can be used as joysticks to achieve reduction (Fig. 67.8B). • A femoral distractor can be anchored in the PSIS bilaterally and provide distraction. • Mini-fragment plates can be used to hold the sacral fracture reduction while more robust fixation is applied.

• These components of the displacement are reduced using a combination of traction, joysticks, and reduction clamps. • Skeletal or manual traction can be placed through the leg of the injured side if draped into the surgical field. • A common clamp placement is a large fragment pointed reduction forceps placed with one point on the posterior superior iliac spines (PSIS) and the other on the medial sacral ridge (Fig. 67.8A). 

STEP 1 PITFALLS

• Too much anterior pressure from bolsters on the anterior iliac spines may make reduction challenging by imparting a posterior force vector onto the pelvis.

Fracture line FIG. 67.7 

A

B FIG. 67.8 

Step 2: Iliosacral Screw Insertion • Iliosacral screw fixation is biomechanically strong and used for most sacral fractures. • Despite the open exposure required for reduction, iliosacral screw insertion is a primarily fluoroscopic procedure. • Perfect inlet and outlet fluoroscopic images are required. • The inlet view should show the anterior cortex of S1 overlaid with the anterior cortex of the S2 body (Fig. 67.9A). • The outlet view will show the sacral foramina in their maximum dimension. This usually occurs when the pubic tubercles overly the body of S2 (Fig. 67.9 B).

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

839

B

A

C FIG. 67.9 

• A true lateral view can be used to ensure that the guide pin does not breach the anterior cortex of the sacral ala or posteriorly into the spinal canal (Fig. 67.9 C). • The guide pin for a cannulated screw should be inserted perpendicular to the f­ racture. • S1 and S2 are both usually available for iliosacral screw fixation (Fig. 67.10). • S3 is distal to the ilium and is not a fixation opportunity in most patients. • The guide pin can be stopped in the sacral body (conventional iliosacral screw) or continued across into the contralateral ilium (trans-iliac-trans-sacral screw) (Fig. 67.11). • A trans-iliac-trans-sacral screw is biomechanically superior; however, care must be taken to ensure that a safe screw trajectory exists to avoid injury to the contralateral L5 nerve root.  STEP 2 PITFALLS

• Care must be taken to ensure understanding of the upper sacral morphology because sacral dysmorphism will alter the safe zones for screw fixation. • The L5 nerve root is at particular risk of injury where it courses anterior to the sacral ala of S1 (see Fig. 67.4). • If the sacral fracture is not reduced anatomically then the safe corridor for screw fixation is much narrower, increasing the risk of neurologic injury owing to screw penetration.

STEP 2 PEARLS

• Inlet and outlet views of the pelvis are inverted and may be disorienting when one is accustomed to placing screws from the supine position. • A regular and experienced x-ray technologist can greatly increase the successful workflow for these challenging procedures. • In the presence of significant sacral dysmorphism, the S2 corridor usually is larger and represents a good trans-iliac-trans-sacral screw fixation opportunity (Fig. 67.11).

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

840

STEP 2 CONTROVERSIES

• Fully threaded screws will limit the chance of over-compression of the fracture and potential neurologic injury; however, lack of fracture compression may increase the risk of nonunion.

A

B

C FIG. 67.10 

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

A

841

B

C FIG. 67.11 

Step 3: Supplemental Fixation Posterior Plate or Lumbopelvic Fixation • Iliosacral screws are often sufficient, but sacral dysmorphism and fracture characteristics may limit the stability provided by these implants. • A posterior tension band plate is an option to provide further rotational stability in the flexion/extension plane when there is insufficient fixation from iliosacral screws (Fig. 67.11). • A 3.5-mm or 4.5-mm reconstruction plate can be used. • One side is prebent to match the outer ilium of the injured side. • The plate is passed from the injured side out through a small counter-incision made on the lateral aspect of the contralateral posterior superior iliac spine. • The plate sits on the inferior surface of the iliac spines to avoid unacceptable softtissue prominence. • The plate is affixed to the outer surface of the ilium on the injured side first. • The plate is bent in situ on the uninjured side and affixed with appropriate screws. • When high chance of vertical displacement exists or a concomitant lower lumbar spine fracture exists then lumbopelvic fixation may be considered. • A pedicle screw is placed in the pedicle of L5 (Fig. 67.12) under fluoroscopic guidance. • A second screw is placed in the ilium, starting at the PSIS and directed toward the anterior inferior iliac spine (Fig. 67.13). • A rod is templated, contoured, and locked into position (Fig. 67.14). • Final construct is shown in Fig. 67.15. 

STEP 3 PEARLS

• Use of a large diameter polyaxial screw in the ilium can maximize purchase and minimize hardware prominence. • Hardware is often removed at 6 to 9 months as a fusion is not routinely performed.

STEP 3 PITFALLS

• Exposure required for supplemental fixation may lead to soft-tissue problems and postoperative infection. • Hardware prominence of posterior plates and lumbopelvic fixation can be problematic and lead to further wound problems. • Lumbopelvic fixation can be a powerful tool to obtain reduction; however, iatrogenic nerve injury is possible with overzealous manipulation.

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

842

A

B

C FIG. 67.12 

A

B FIG. 67.13 

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

L5 screw Connecting rod Iliac screw

FIG. 67.14 

A

B FIG. 67.15 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The wound is closed in layers. • A wound drain or incisional vacuum-assisted closure should be considered. • Antibiotic prophylaxis for 24 hours • Thromboembolic prophylaxis is required and should be individualized based on patient factors and institutional protocols. • Patients are touch weight bearing on the affected side for 6 to 12 weeks. • Patients with bilateral fractures are allowed pivot transfers from bed to chair for 6 to 12 weeks. • Some degree of long-term dysfunction is expected. • Achieving an anatomic reduction and maintaining this until fracture healing should maximize the potential for recovery.

843

844

PROCEDURE 67  Open Reduction and Internal Fixation of Sacral Fractures

EVIDENCE Bellabarba C, Schildauer TA, Vaccaro AR, Chapman JR. Complications associated with surgical sta­ bilization of high-grade sacral fracture dislocations with spino-pelvic instability. Spine. 2006;31(suppl 11):S80–S88. This retrospective study of 19 consecutive patients reported the complications of treatment with decompression and rigid lumbopelvic fixation. Fracture reduction was maintained in all patients, but asymptomatic rod breakage occurred in 31% and wound complications in 26%. Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock S. Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma. 2006;20(suppl):S30–S36. This retrospective review of 62 patients showed a significantly higher incidence of fixation failure for isolated iliosacral screws in the vertical sacral fracture group compared with the group with sacroiliac dislocations and fracture dislocations (12.5% vs. 0%). Routt Jr MLC, Simonian PT. Closed reduction and percutaneous skeletal fixation of sacral fractures. Clin Orthop Relat Res. 1996;329:121–128. The technique of reduction and percutaneous stabilization of sacral fractures was reported as an alternative to open technique when a closed reduction was feasible, citing decreased wound complications. Schildauer TA, Bellabarba C, Nork SE, Barei DP, Routt Jr MLC, Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spinopelvic dissociation. J Orthop Trauma. 2006;20:447–457. This retrospective review of 18 patients with 1-year follow-up demonstrated full or partial neurologic recovery in 15 patients (83%). All 18 patients healed without loss of reduction.

PROCEDURE 68

Anterior Approaches to the Acetabulum David Stephen INDICATIONS Operative indications for acetabular fractures include: • Loss of articular congruence between the femoral head and acetabulum • Greater than 2 mm of displacement of the articular surface • Posterior wall fragment that involves more than 20% of the articular surface (controversial—see chapter on posterior acetabulum) • Any fracture that involves the superior articular surface • The indications for an anterior approach include the following fracture patterns: • Anterior wall or column • Anterior column/wall plus posterior hemi-transverse • Associated both-column • Some transverse or T-shaped fractures that have significant displacement of the anterior column moiety Fig. 68.1A (Case 1) shows an anteroposterior (AP) radiograph of a 49-year-old male who fell off a ladder and presented complaining of right hip and pelvic pain. Fig. 68.1B outlines the fracture line extending from the iliac wing that enters the hip joint and exits the obturator foramen (black arrow). The numbers indicate that the 6 lines of Letournel are intact except for some minor displacement of the iliopectineal line (6—anterior column). The iliac (Fig. 68.1C) and obturator (Fig. 68.1D) oblique (Judet) views confirm anterior column involvement with a small fracture suspected in the area of the posterior wall (large arrow). Fig. 68.1E demonstrates the volume-rendered images (based on computed tomography [CT] scan) that can be a substitute for plain radiographs. The quality of the volume-rendered images parallels the quality of the initial CT scan (cut thickness) and software. Figs. 68.1F to 68.1I show the axial, 2D (coronal and sagittal), and 3D CT scans that confirm the diagnosis of anterior column fracture with some comminution in the ilium as well as the pelvic brim and a small, almost extraarticular fragment of the posterior wall (blue arrow on axial and 3D). The arrow is also in the area that, if there were a fracture line extending from the greater sciatic notch along the path of the arrow anterior toward the posterior wall fragment and into the joint, would make this injury an associated both-column acetabular fracture. This is because there would be no articular surface remaining in contact with the cranial pelvis. However, if there were a separate fracture line below the superior arrow (thin arrow) such that a portion of the joint would remain attached to the cranial pelvis, this pattern would become an anterior plus posterior hemi-transverse fracture. Fig. 68.2 (Case 2)—AP (Fig. 68.2A) and oblique views (Fig. 68.2B)—shows a low anterior column fracture with suspected posterior-superior impaction of the joint surface (arrow) and quadrilateral surface involvement. This is a typical insufficiency fracture pattern, which is also characteristic of an anterior plus posterior hemi-transverse type (the posterior column fracture is usually undisplaced). In this case, the fracture exits into the obturator foramen and, thus, is an anterior column (not a wall) fracture. Fig. 68.2C is an axial CT scan: impaction is noted on the posterior superior articular surface (blue arrow). The darker arrow points to possible extension into the posterior column that would make this injury an anterior plus posterior hemi-transverse pattern. Fig. 68.2D contains coronal 2D reconstruction views, confirming impaction (arrow). Fig. 68.2E contains sagittal 2D reconstructions showing impaction (arrow). Fig. 68.2F is a 3D reformat showing displacement and comminution of the quadrilateral surface. Fig. 68.3 (Case 3) consists of AP and oblique views of an anterior wall fracture, with partial anterior subluxation of the femoral head. This injury pattern can be associated with an anterior hip dislocation. This patient fell down the stairs. Fig. 68.3B: Oblique

INDICATIONS PITFALLS

• The keys to treatment include: • Complete understanding of the radiographic investigations, which allows determination of fracture characteristics • The use of patient factors and radiographic fracture characteristics to determine the need for surgery and make an appropriate choice of operative approach • Selection of methods to achieve and maintain anatomic reduction, which has been shown to correlate to the optimal outcome • The goal of acetabular surgery is to surgically expose, reduce, and stabilize a particular injury pattern through a single nonextensile approach. Failure to understand the injury completely may lead to the surgeon selecting the wrong approach. • The term “secondary congruence” refers to articular congruence but the acetabulum is not in the anatomic position. This is rare but is most commonly seen in the associated bothcolumn pattern, in which the acetabulum is medialized (and often proximal) in comparison with the uninjured side. INDICATIONS CONTROVERSIES

• The ilioinguinal or anterior intrapelvic (AIP) approach should not be used in isolation in cases of anterior column/wall involvement plus sciatic buttress comminution, segmental or significantly displaced posterior column fractures, extended or large posterior wall fractures, and/or those injuries that are more than 3 weeks old (or when early callus is seen). • For these cases, either a combined anterior and posterior approach, a specialized posterior approach (posterior approach with a trochanteric “flip” osteotomy), or an extensile approach (extended iliofemoral) should be used (see chapter on posterior acetabulum). • Cases of true “secondary congruence” can be considered for nonoperative management, especially in patients who have significant operative risk factors. Examination and Imaging • A detailed clinical examination is completed to assess neurovascular status and the overall condition of the patient. • The examination of the affected hip will be limited by pain, but it is important to rule out an associated dislocation as well as to determine the status of the soft tissues (Scolaro et al., 2016). Continued

845

846

PROCEDURE 68  Anterior Approaches to the Acetabulum

INDICATIONS CONTROVERSIES­—cont’d

• Radiographic evaluation starts with an AP radiograph followed by oblique views (Judet views) to visualize the anterior and posterior components of the acetabulum and pelvis. If the patient is hemodynamically and medically stable, a CT scan is completed that will provide further information regarding the injury pattern. Volume-rendered oblique images, 2D and 3D reformats, can be obtained with the appropriate software.

views confirm the anterior wall fracture, with suspected involvement of the anterior and cranial aspect of the posterior wall. The iliac oblique view demonstrates anterior dislocation of the femoral head. Fig. 68.3C: Axial CT confirms a comminuted anterior wall acetabular fracture, with a small fracture of the cranial (anterior) posterior wall. Fig. 68.3D: 3D reformat demonstrating the anterior wall fracture and comminuted fracture fragments extending to the area of the anterior-inferior iliac spine. Fig. 68.4 (Case 4) consists of AP and oblique views (A–C) of an associated bothcolumn fracture. The “spur sign” is not seen on the obturator oblique view but should

C

A

5

3 1

6

2 4

B

D

E FIG. 68.1 

PROCEDURE 68  Anterior Approaches to the Acetabulum

F

G FIG. 68.1, CONT’D 

847

848

PROCEDURE 68  Anterior Approaches to the Acetabulum

H

I FIG. 68.1, CONT’D 

PROCEDURE 68  Anterior Approaches to the Acetabulum

A

B

C FIG. 68.2 

849

850

PROCEDURE 68  Anterior Approaches to the Acetabulum

D

F

E FIG. 68.2, CONT’D 

TREATMENT OPTIONS

The three most common anterior approaches used to facilitate open reduction and internal fixation include: • the ilioinguinal approach (in some cases with modifications and extensions) • the AIP approach (also referred to as the “modified Stoppa approach”), often combined with the lateral window of the ilioinguinal approach • the iliofemoral (Smith-Petersen) approach

be in the area of the lateral aspect of the ilium (arrow). The CT scans—axial, 2D, and 3D (D–G)—confirm the diagnosis of an associated both-column fracture with a large posterior wall fragment. Note that the anterior column fracture is incomplete, meaning that it does not exit the iliac crest (best seen on the 3D scan). This explains why there is no spur sign, as there has not been medialization of the anterior column fragment to “uncover” the intact posterior ilium (see Fig. 68.5 for spur sign on obturator oblique view from a different case). In this case, the posterior wall does not require a buttress plate (as in an isolated fracture or when associated with a transverse or T-shaped pattern), as the femoral head displaces with the anterior fragment. However, if the fragment is large, a screw inserted from inside the ilium or a plate inserted through dissection on the outer aspect of the ilium may be required. 

PROCEDURE 68  Anterior Approaches to the Acetabulum

SURGICAL ANATOMY Ilioinguinal approach • The ilioinguinal approach was conceived and developed by Letournel to address the problem of incomplete access to the acetabulum. • Previous incisions (iliofemoral) provided limited access to the medial pelvic ring as well as the quadrilateral surface and posterior column. • The ilioinguinal approach allows access to the entire anterior pelvis, from the pubic symphysis to the sacroiliac joint, as well as limited access to the quadrilateral plate and posterior column. •  The essence of the “classic” ilioinguinal approach is the development of three ­windows:

A

B FIG. 68.3 

851

PROCEDURE 68  Anterior Approaches to the Acetabulum

852

C

D FIG. 68.3, CONT’D 

PROCEDURE 68  Anterior Approaches to the Acetabulum

A

B

C

D

FIG. 68.4 

853

854

PROCEDURE 68  Anterior Approaches to the Acetabulum

E

F

G FIG. 68.4, CONT’D 

PROCEDURE 68  Anterior Approaches to the Acetabulum

855

FIG. 68.5 



• The first, or lateral, window allows exposure of the iliac fossa, the pelvic brim, and the sacroiliac joint. • The second, or middle, window allows exposure of the quadrilateral surface, a portion of the posterior column, and the iliopectineal (iliopubic) eminence. • The third, or medial, window allows exposure of the superior pubic ramus, the symphysis pubis, and the retropubic space (Fig. 68.6). 

POSITIONING PEARLS

Anterior Intrapelvic Approach (Modified Stoppa Approach)

• The benefit of the fracture table is that, in most cases, the femoral head can be repositioned under the acetabular dome using longitudinal, with or without lateral, traction. • The benefit of the radiolucent table is that the leg is prepped into the field and is free, allowing more use of the lateral window by means of increased hip flexion.

• The foundation of this approach is an extension of the approach to the symphysis pubis performed through a Pfannensteil or vertical midline incision (Fig. 68.7). • The intrapelvic portion of the exposure provides direct access to the pelvic brim, quadrilateral surface, and a portion of the posterior column (Fig. 68.8). • This exposure facilitates clamp placement and buttress plate application on the quadrilateral surface. • To facilitate access to the anterior column, the first (lateral) window of the ilioinguinal approach is used. • Iliofemoral approach • The iliofemoral approach is a modification of the Smith-Petersen approach (Fig. 68.9). • This may be the preferred anterior approach when a rare simultaneous posterior and anterior approach is desired. • Exposure of and access to the anterior column are possible to the area of the iliopectineal eminence by flexing and adducting the hip. • In addition, (similar to the ilioinguinal approach) dissection on the outer aspect of the ilium provides access to the lateral aspect of the anterior column and cranial posterior wall fractures (see Case 4). 

POSITIONING • For the anterior approaches, the patient is positioned supine with a small bump under the buttock and shoulder on the operative side. • The patient can be positioned on the fracture table with the operative leg in traction or on a radiolucent table with the leg free. • The exception is the AIP approach (modified Stoppa approach) in which the patient is positioned supine on a radiolucent table with the opposite bumped up slightly. This is based on the rationale that the approach is used to provide increased visualization of the quadrilateral surface and posterior column from the midline—essentially, an extension of the Pfannensteil approach for the symphysis pubis. 

POSITIONING PITFALLS

• A wide area is prepped into the field to allow access for the chosen approach. • For the AIP approach, some surgeons advocate a bump under the contralateral buttock. Although this may improve visualization of the quadrilateral surface, it can cause a medial force on the femoral head, making it difficult to manipulate and reduce the fracture fragments.11 POSITIONING EQUIPMENT

• The patient can be positioned on a fracture table (or radiolucent table with the operative leg in traction) or on a radiolucent table with the leg free. POSITIONING CONTROVERSIES

• The decision regarding positioning becomes surgeon preference, philosophy, and the fracture pattern and number of assistants available to provide intraoperative traction (if and when required). • If simultaneous anterior and posterior exposure is planned, the patient is positioned in the so-called “floppy lateral position,” usually on a beanbag.24 It should be stressed that this is a very rare situation and often this positioning will compromise the ability of the surgeon to operate through each approach. More often, a sequential approach is undertaken—either during one operation or a later date.

856

PROCEDURE 68  Anterior Approaches to the Acetabulum

Lateral abdominal muscles Iliac fossa

Iliopsoas Iliopubic eminence External iliac artery vein in sheath Superior pubic ramus Spermatic cord FIG. 68.6 

A

B FIG. 68.7 

PORTALS/EXPOSURES Ilioinguinal Approach Step 1 • The landmarks for the incision include the iliac crest, anterior superior iliac spine (ASIS), and the symphysis pubis. • The proximal incision follows along the course of the iliac crest toward the ASIS and curves along the area of the inguinal ligament to just proximal to the symphysis ­pubis.

PROCEDURE 68  Anterior Approaches to the Acetabulum

FIG. 68.8 

Sartorius Tensor fascia latae

A

B FIG. 68.9 

• The incision is made off the subcutaneous prominence of the iliac crest. • In most cases, the lateral window is developed first with release of the insertion of the abdominal muscles from the iliac crest and the iliacus/iliopsoas from the iliac fossa, continuing cranial and posterior to the sacroiliac joint, and anterior and medial to the pelvic brim. • There is a consistent large nutrient artery in the ilium located approximately 1.5 cm anterior and lateral to the sacroiliac joint that must be controlled with bone wax and/ or cautery to prevent significant blood loss. • The deep dissection, as it is taken distally along the crest, should be stopped 2 cm proximal to the ASIS, as there can be variations in the course of the lateral cutaneous nerve of the thigh in this region. • Further exposure of the anterior column is achieved by medial to lateral elevation of the iliopsoas off the iliac fossa and the anterior column to the iliopectineal eminence. • Medial dissection over the brim and along the quadrilateral plate is limited by the iliopectineal fascia, which separates the false from the true pelvis. • This first lateral window is then packed with sponges. • Next, the skin incision continues medially to a point approximately 1 cm above the symphysis. • Once through the subcutaneous tissue, the spermatic cord—or round ligament (with the ilioinguinal and genital branch of the genitofemoral nerves) at the external inguinal ring—is identified and protected with a Penrose drain. • Then, the external oblique fascia is split above (3–5 cm), but preferably not into, the ring to a point just cranial to the ASIS.

857

858

PROCEDURE 68  Anterior Approaches to the Acetabulum

• Retracting the external oblique fascia distally, the contents of the canal are identified (spermatic cord/round ligament and nerves). • The inguinal ligament and the distal condensation of the conjoint tendon of the internal oblique and transversus abdominis muscles are then identified and divided, leaving a distal cuff (2 mm) to allow reconstruction at the time of closure. 

Step 2 • Development of the middle window proceeds with careful dissection of the iliopectineal fascia between the psoas with the femoral nerve (in the substance of the psoas) laterally and the external iliac vessels medially. • A consistent perforating vessel from the external iliac vessels pierces the fascia, which must be ligated or cauterized. • The dissection is carried vertically down to the superior pubic ramus in the region of the iliopectineal eminence. • A Penrose drain is placed under the psoas to create a bundle consisting of the psoas and the lateral femoral cutaneous and femoral nerves. • Further proximal release of the fascia under the psoas will allow entry into the true pelvis and exposure of the pelvic brim and quadrilateral plate. • A blunt Hohmann retractor, placed in the middle window, improves visualization of the quadrilateral plate. Prolonged retraction in this area must be avoided to prevent occlusion and clot formation in the external iliac vessels and injury to the obturator nerve and vessels. 

Step 3 • The medial window is classically established by dissection medial to the external iliac vessels but lateral to the rectus abdominis. • Care is taken to leave as much tissue as possible around the vessels to protect the lymphatics. • The pubic ramus is exposed and the space of Retzius is entered in the region of the bladder. • Dissection is carried behind the vessels in a subperiosteal fashion to allow a Penrose drain to be passed and create a third bundle. • Visualization deep to the vessels is important to ensure that there is no retropubic vascular anastomosis (corona mortis) between the internal and external iliac vessels. If present, the vessels should be ligated. These vessels can also represent the origin of the obturator artery from the external iliac system or the inferior epigastric artery. 

Step 4 • The approach is now completed and three “bundles” are created: (1) the iliopsoas with the lateral cutaneous nerve of the thigh and femoral nerve; (2) the external iliac vessels; and (3) the spermatic cord with the ilioinguinal and genital branch of the genitofemoral nerves. • The first (lateral) window allows visualization of the iliac crest, iliac fossa, sacroiliac joint, and anterior column to approximately the iliopectineal eminence, facilitated by medial retraction of the iliopsoas and hip flexion (Fig. 68.10). • The second (middle) window allows visualization of the anterior column and pelvic brim and a portion of the quadrilateral plate. It also allows access to the quadrilateral plate and posterior column, facilitated by lateral retraction of the iliopsoas and femoral nerve and medial retraction of the external iliac vessels (Fig. 68.11). • The third (“classic”—medial) window allows visualization of the superior pubic ramus and space of Retzius, facilitated by lateral retraction of the external iliac vessels and lymphatics (Fig. 68.12). 

PROCEDURE 68  Anterior Approaches to the Acetabulum

Iliopsoas muscle Sacroiliac joint

Iliac fossa Penrose drain around iliopsoas, femoral nerve and lateral femoral cutaneous nerve Penrose drain around femoral vessels Penrose drain around spermatic cord FIG. 68.10 

Pelvic brim

Penrose drain around iliopsoas, femoral nerve and lateral femoral cutaneous nerve

Iliopectineal fascia released down to iliopectineal eminence Femoral vessels protected by their overlying internal iliac muscle Penrose drain around femoral vessels Penrose drain around spermatic cord FIG. 68.11 

Step 5 • During closure, precise and stable reconstruction of the inguinal ligament and the floor of the inguinal canal, as well as reattachment of the abdominal musculature to the ilium, are important to prevent complication of hernias and/or wound dehiscence. • Drains are used at the discretion of the surgeon.  PORTALS/EXPOSURES PEARLS

Ilioinguinal • This approach is essentially extraarticular, although with anterior column and quadrilateral plate fracture displacement, the hip joint can be visualized through the middle window. • Care must be taken laterally, as the lateral femoral cutaneous nerve lies immediately beneath the inguinal ligament, running within 1 to 2 cm of the ASIS in most cases. Often, the nerve is avulsed during exposure and reduction of the fracture due to medial retraction of the nerve and iliopsoas. Tension on the nerve can often be reduced by dissection proximally in the abdominal musculature and distally as it perforates the inguinal ligament. • Flexion of the hip (if the radiolucent table is used) will facilitate exposure of the ilium, sacroiliac joint, and anterior column.

859

860

PROCEDURE 68  Anterior Approaches to the Acetabulum

PORTALS/EXPOSURES PITFALLS

Ilioinguinal • During dissection between the psoas muscle (together with the femoral nerve, which lies in the substance of the psoas) and the external iliac vessels, aggressive retraction can damage these structures. • There is often a perforating vessel through the iliopectineal fascia that must be ligated or cauterized. • Structures at risk include the lateral femoral cutaneous nerve of the thigh, which most frequently lies within 1 cm of the medial aspect of the ASIS. However, variations exist, including lateral (proximal) to the ASIS. This nerve is usually found deep to the inguinal ligament and is most often cut during deep dissection (immediately beneath the inguinal ligament) just medial to the ASIS. • Deep to the external iliac vessels, in the retropubic area, are vessels that are often referred to as the “corona mortis.” This is a retropubic anastomosis between the external and internal (via the obturator artery/vein) iliac vessels and is variable in caliber and occurrence (Fig. 68.13). Thus, care must be taken when dissecting in this area. One study noted retropubic anastomoses in 37% of their ilioinguinal approaches, with 43% of the dissections noted to have multiple vessels along the superior pubic ramus. Two cadaveric studies noted arterial anastomoses in 34% and 43%, venous anastomoses in 70% and 59%, and combined arterial and venous anastomoses in 20% and 27%, respectively. It was also found in these two studies that 84% and 79% of the cadavers had at least one vessel that was a minimum of 2 mm in diameter. • As the dissection is carried deep in this area along the quadrilateral surface and the posterior column, the obturator vessels and nerve are visualized and need to be protected. In the cranial aspect in the lateral window, the L5 nerve lies within 2 to 3 cm of the sacroiliac joint. • The ilioinguinal approach does not provide complete access to the posterior column; thus, it requires indirect reduction maneuvers to reduce any displacement in this area.

PORTALS/EXPOSURES EQUIPMENT

Ilioinguinal • Usually, half-inch Penrose drains are used to identify and protect the structures that create the 3 bundles. • Deep retractors will be required to facilitate exposure of the anterior column flexion.

PORTALS/EXPOSURES ­CONTROVERSIES

Alternate Exposures • Many surgeons perform a modification of the “classic” medial window, in which the dissection of the medial window is performed medial to the ipsilateral head of the rectus, as described for the AIP approach. • This translates to the skin incision being continued past the midline, and the dissection is carried out between the heads of the rectus abdominis muscle (as done in a Pfannensteil approach). • The deep dissection follows deep to the rectus in a lateral direction along the superior pubic rami to expose the retropubic space and quadrilateral surface as well as a portion of the medial aspect of the posterior column.

Anterior Intrapelvic Approach Step 1 • The incision starts as described for a Pfannensteil incision, with a transverse incision approximately 2 cm superior to the symphysis pubis (see Fig. 68.7). • The alternative is a midline incision beginning below the umbilicus extending down to the symphysis pubis (see Fig. 68.7, dotted line) • In the deep dissection, the midline is identified by the convergence of the fascia over the rectus abdominis muscle, which is then split vertically between the two muscle bellies with care taken to remain extraperitoneal in the proximal portion (Fig. 68.14). • In the distal portion, the symphysis pubis is identified. • The rectus is next elevated off the superior pubic ramus, but the distal insertion on the anterior aspect of the symphysis is left intact. • Care is taken to identify any anastomoses between the external iliac and/or the inferior epigastric vessels and the obturator vessels (corona mortis; see Fig. 68.13).

PROCEDURE 68  Anterior Approaches to the Acetabulum

• Further dissection is carried out to expose the pelvic brim, in which a retractor can be placed onto the anterior column to facilitate exposure. • Care must be taken to visualize and protect the obturator vessels and nerve running along the quadrilateral surface (see Fig. 68.13). • Further cranial and posterior dissection will allow visualization of the quadrilateral surface and posterior column posterior toward the sacroiliac joint (Fig. 68.15). 

Penrose drain around iliopsoas, femoral nerve and lateral femoral cutaneous nerve

Penrose drain around femoral vessels Bladder and space of Retzius Penrose drain around spermatic cord Pubis

Symphysis pubis

Pubic tubercle and cut end of rectus muscle FIG. 68.12 

FIG. 68.14 

FIG. 68.13 

FIG. 68.15 

861

862

PROCEDURE 68  Anterior Approaches to the Acetabulum

Step 2 • If required, the first (lateral) window of the ilioinguinal approach is used for increased anterior column visualization. • Dissection medial to the sacroiliac joint allows exposure of the lateral sacral ala for retractor placement.  PORTALS/EXPOSURES PEARLS

Anterior Intrapelvic • For the AIP approach, the primary surgeon will spend significant time operating on the side of the patient opposite to the fracture. • To facilitate access to the anterior column, only the first (lateral) window of the ilioinguinal approach is used. • Therefore, the external iliac vessels and the femoral and ilioinguinal nerves are (theoretically) at lower risk with this approach compared with the ilioinguinal approach.

PORTALS/EXPOSURES PITFALLS

Anterior Intrapelvic • The obturator vessels and nerve, as well as the lumbosacral trunk, are at increased risk during the development of the intrapelvic component of the approach via either an extended Pfannensteil or vertical midline approach. • In the posterior portion of the approach, a common obstacle to exposure is branches from the iliolumbar artery, which must be ligated.

Iliofemoral Step 1 • The skin incision is made off the subcutaneous prominence of the iliac crest either 1 cm medial or lateral and directed slightly medially along the presumed course of the inguinal ligament (see Fig. 68.9). • The anterior column is exposed by elevation of the iliopsoas from the iliac fossa. • Further exposure posterior allows exposure of the sacroiliac joint. • Flexion of the hip joint provides medial access to the region of the iliopectineal eminence. • If hip joint access is desired, then the incision can be brought distally in the region of the sartorius. The interval between the sartorius and tensor fascia latae is then developed (Fig. 68.16). 

Step 2 • Deep dissection identifies the straight and reflected heads of the rectus in the region of the anterior inferior iliac spine (AIIS). • Care is taken to identify and ligate (if required) the ascending branches of the lateral femoral circumflex artery deep to the fascia over the rectus femoris in the distal extent of the incision. • Improved access to the hip joint can be achieved by release of the reflected heads alone or together with the straight heads, which are tagged for repair at the end of the procedure (Fig. 68.17). • The iliocapsularis muscle must be dissected from lateral to medial off the capsule. 

PROCEDURE 68  Anterior Approaches to the Acetabulum

863

Iliopectineal bursa Tensor fasciae latae Gluteus medius Gluteus minimus

Ilium

Sartorius

Anterior joint capsule Rectus femoris

Anterior aspect of hip joint capsule

Tensor fasciae latae

FIG. 68.16 

FIG. 68.17 

PORTALS/EXPOSURES PEARLS

Iliofemoral • To improve exposure of the medial aspect of the anterior column, dissection of a portion of the external oblique fascia as well as the inguinal ligament from the ASIS can be performed. • Another option to improve medial access to the anterior column and distal access to the hip joint is an osteotomy of the ASIS (rectangular portion of bone—2–3 cm in length and 1–2 cm in height). • This ASIS osteotomy is predrilled for reattachment with screw(s) and allows retraction of the sartorius, abdominal wall muscles (external oblique), and inguinal ligament medially. • It is usually fixed back with 2.7- or 3.5-mm screws. • If access medial to the iliopectineal eminence is desired, then the ilioinguinal or AIP approaches are indicated.

PORTALS/EXPOSURES PITFALLS

Iliofemoral • Structures at risk are similar to those for the ilioinguinal approach and include the following. • The lateral femoral cutaneous nerve of the thigh is at risk. • Aggressive medial retraction of the psoas can damage the femoral nerve and/or the external iliac vessels. • Posteriorly, the L5 nerve lies within 1 to 3 cm of the sacroiliac joint. • With distal dissection in the upper thigh, there can be further damage to the lateral cutaneous nerve of the thigh and to the ascending branch of the lateral circumflex femoral artery. • The disadvantage of this approach is that entire access to the anterior column is limited medially, such that screws inserted into plates applied through this approach must be directed medially away from the iliopectineal eminence to avoid violation of the hip joint.

864

PROCEDURE 68  Anterior Approaches to the Acetabulum

PORTALS/EXPOSURES CONTROVERSIES

Alternate Exposures Hueter Approach • The Hueter approach has gained popularity for anterior total hip arthroplasty and can be used instead of the iliofemoral approach for approaches to the anterior pelvis and hip joint. (Hueter 1882) • The skin incision is more vertical beginning just distal and slightly posterior to the ASIS, running over the tensor fascia latae muscle belly, and extends distal for approximately 12 to 15 cm. • The fascia over the tensor fascia latae (TFL) is incised, and the interval between the sartorius and the TFL is developed (see Fig. 68.16). • With the rectus femoris retracted medially, care must be taken to identify the lateral circumflex vessels that cross the intermuscular interval just distal to the intertrochanteric line. These vessels are cauterized or controlled with a ligature. • The deep dissection identifies the hip capsule and the straight (AIIS) and reflected (superior margin of the acetabulum) heads of the rectus femoris. • This approach is useful for fractures of the anterior wall and/or avulsions of the AIIS, and/or capsule– labrum pathology.

PORTALS/EXPOSURES CONTROVERSIES

Alternate Exposures • In rare situations, such as fracture patterns that require additional exposure intraoperatively, variations or combinations of the approaches described earlier can be used. • For example, the iliofemoral approach may be combined with the ilioinguinal approach, with a distal vertical extension of the ilioinguinal approach. • A modification of the ilioinguinal approach involves making the incision more distal to the ASIS in the region of the AIIS, as described by Kloen et al. • Weber and Mast described another modification of the ilioinguinal approach that incorporates the posterior approach to the sacroiliac joint.This may be indicated in associated both-column fractures that extend into the sciatic buttress or sacroiliac joint. • Finally, Keel et al. described a new approach to the anterior pelvis, referred to as the “pararectus approach,” which is performed through a vertical incision and is developed with an interval lateral to the rectus abdominis muscle.9

PROCEDURE • Reduction of the fracture should proceed according to a preoperative plan developed with a thorough understanding of the injury pattern. • This understanding guides selection of the approach, techniques required to achieve reduction, and fixation required to stabilize the fracture. • For all approaches, intravenous preoperative antibiotics are given and a Foley catheter is inserted preoperatively to decompress the bladder. 

CASE 1: ANTERIOR COLUMN Reduction • In contrast to most articular fractures, reduction of the anterior column proceeds from peripheral toward the joint. • The exception would be in a case with impaction of the joint, which often requires elevation prior to reduction of the fracture (see Case 2). • For fracture patterns that involve the anterior column (including anterior column plus posterior hemi-transverse and associated both-column fractures), the reduction sequence begins with reduction and provisional fixation of the peripheral fragments— usually, the iliac wing (Fig. 68.18).

PROCEDURE 68  Anterior Approaches to the Acetabulum

A

B

C

D FIG. 68.18 

865

866

PROCEDURE 68  Anterior Approaches to the Acetabulum

PEARLS

• To reduce the anterior column, use a combination of pointed reduction forceps (on the surface of the iliac crest), Farabeuf (onto the iliac crest for derotation of the anterior column), and large pelvic forceps (often termed “queen and king tongs”) for correction of the medialization of the anterior column (see Fig. 68.18). • Schanz pins inserted into the iliac crest and/ or the AIIS are used to facilitate reduction (Fig. 68.19). • Using a 2-screw technique, a medium pelvic reduction clamp (“Jungbluth”) or Farabeuf can be used to reduce an anterior column fracture at the iliac crest that is very posterior (Fig. 68.20).

• In some cases, the anterior column component will have a segmental fragment (wedge shaped) between the intact ilium and the major anterior column fragment that will be reduced and fixed first to either the larger fragment or the intact ilium (see Fig. 68.18).  PITFALLS

• Even slight imperfections along extraarticular fracture lines and/or fragments can produce a malreduction of the articular surface. • Image intensification is used to ensure accurate screw trajectory and that the fixation remains extraarticular. • If it is anticipated that posterior column screws will be inserted from the anterior column plate, accurate position of the plate—slightly lateral to the edge of the pelvic brim—will facilitate insertion of long screws into the area of the ischium. If the plate is too close to the brim, the screws will exit to cranial to the fracture line either medially in the area of the quadrilateral surface or laterally in the area of the posterior column.

INSTRUMENTATION/IMPLANTATION

• Following reduction of the anterior column, fixation is accomplished using multiple 3.5-mm lag screws, with configuration based on fracture pattern. • The usual location starts with one screw peripherally along the iliac crest (which takes the place of the pointed reduction forceps), often starting at the ASIS for lower anterior column fractures, but can start on the crest for more posterior (or segmental) fractures (Fig. 68.21). • A second screw can be placed from the area of the AIIS directed posteriorly into the sciatic buttress. A third screw can be placed in an area just lateral to the projected position of the plate along the brim from the anterior column fragment directed posterior and cranial into the intact ilium (see Fig. 68.21). • In most cases, a 12- to 14-hole, 3.5-mm reconstruction plate is contoured along the pelvic brim from a position just lateral to the caudal area of the sacroiliac joint to the superior pubic rami (Fig. 68.22). • The accurate placement of the plate requires utilization of the three (or fourth) windows of the ilioinguinal approach. • The plate is initially secured proximally with a 3.5-mm screw (see Fig. 68.22) and distally with a screw and/or a Kirschner wire (K-wire).

CONTROVERSIES

• In some cases, for a single large anterior column fragment, multiple lag screws alone will provide adequate stability (Fig. 68.23). • Postoperative radiographs • One-year follow-up radiographs for Case 1 show fixation, including screws through the plate into the posterior column (Fig. 68.24—Case 1). This is also the usual fixation montage for an associated bothcolumn fracture, although a second long screw into the posterior column is desirable for stable fixation.

FIG. 68.19 

PROCEDURE 68  Anterior Approaches to the Acetabulum

A

C

B FIG. 68.20 

867

PROCEDURE 68  Anterior Approaches to the Acetabulum

868

FIG. 68.21 

FIG. 68.22 

A

B Screw direction FIG. 68.23 

PROCEDURE 68  Anterior Approaches to the Acetabulum

869

FIG. 68.24 

CASE 2: ANTERIOR COLUMN PLUS POSTERIOR HEMI-TRANSVERSE Reduction • For an anterior column plus posterior hemi-transverse fracture pattern, the reduction and fixation sequence is similar to the anterior column pattern, but there may be a segmental portion of the anterior wall and/or column that may require reduction and provisional stabilization with K-wires prior to definitive fixation with lag screws. 

PITFALLS

• Image intensification is used to ensure accurate screw trajectory, especially in the case of support for the elevated impacted fragment (Fig. 68.26). • In cases of low anterior column or wall fractures, insertion of independent lag screws will not be possible, as the trajectory will be intraarticular. In these cases, accurate plate contouring is key to buttress the fragments.

INSTRUMENTATION/IMPLANTATION

• Subchondral screws are inserted to maintain the elevation, most often through the anterior column plate (Fig. 68.27). • A medial plate along the quadrilateral surface can be added to act as a buttress to prevent medialization of the femoral head (see Fig. 68.27).

PEARLS

• There is often medialization of the quadrilateral surface that requires the placement of the asymmetric clamp from the outer aspect of the interspinous area to the quadrilateral surface (with a spiked disc to reduce perforation of the spiked ball tip (Fig. 68.25). • In this case, there is impaction of the joint surface that must be elevated prior to reduction of the anterior column and quadrilateral surface (Fig. 68.26).

870

PROCEDURE 68  Anterior Approaches to the Acetabulum

CONTROVERSIES

• In cases of low anterior column or wall patterns with or without quadrilateral surface involvement, some surgeons are now using the AIP approach alone to expose, reduce, and stabilize the injury pattern. • Newer plates have been used by some surgeons that are designed to be inserted through the AIP approach and are a montage of an anterior column and quadrilateral surface plate. • Postoperative radiographs • The 6-month follow-up radiographs for Case 2 show the anterior column and the smaller 4-hole quadrilateral surface plate (seen on the intraoperative images) providing a buttress to the quadrilateral surface (Fig. 68.28).

A

B FIG. 68.25 

FIG. 68.26 

PROCEDURE 68  Anterior Approaches to the Acetabulum

FIG. 68.27 

FIG. 68.28 

871

872

PROCEDURE 68  Anterior Approaches to the Acetabulum

PEARLS

• There is often disruption of the anterior hip capsule, labrum, or tendons (rectus femoris) that require repair—usually with suture anchors (see suture anchor in Fig. 68.29). • Intraoperative fluoroscopy is important to ensure that screws are extra-articular.

CASE 3: ANTERIOR WALL Reduction • Following exposure (usually by means of an iliofemoral approach), reduction for an anterior wall pattern is undertaken with a combination of large and small reduction forceps, and temporary stabilization with multiple small-caliber K-wires. • Intraoperative fluoroscopy allows confirmation of reduction. 

FIG. 68.29 

PROCEDURE 68  Anterior Approaches to the Acetabulum

873

PITFALLS

• The screws can be very close to the joint and detailed intraoperative fluoroscopy (or arthrotomy) must be completed to ensure extra-articular fixation. • In some cases, a postoperative CT scan will be completed to confirm extraarticular hardware.

INSTRUMENTATION/IMPLANTATION

• Fixation is completed with implants of appropriate size for the fragments, but usually mini-fragment caliber, such as 2.0-, 2.4-, and/or 2.7-mm plates and screws. • Depending on the number of fragments, multiple plates will be required.

CONTROVERSIES

• Rarely, small intraarticular fragments may need to be excised if stable fixation cannot be achieved. • Postoperative radiographs • Follow-up radiographs of Case 3 at 1 year show maintenance of reduction (see Fig. 68.29).

CASE 4: ASSOCIATED BOTH-COLUMN FRACTURE Reduction • For an associated both-column fracture, medialization and external rotation of the anterior column fragment in relation to the intact posterior ilium (which produces the so-called “spur sign”) must be reduced. • The reduction and fixation sequence is completed in a similar manner to the anterior column pattern. • The posterior column (including any medialization of the quadrilateral surface) is reduced with a combination of pelvic forceps, including the asymmetric clamp, the angled clamp, or a pointed large fragment forceps (see Fig. 68.25). • In some cases, the posterior column needs to be reduced in an upward (anterior) direction. In these cases, a collinear clamp can be used, working through the lateral (first) and middle (second) windows, or the modified medial window (i.e., as per the AIP approach; Fig. 68.30). 

PEARLS

• In cases of osteopenia, a screw can be inserted through the plate in the middle window (medial to the iliopectineal eminence) into the posterior column (ischium) in a corridor between the hip joint and the obturator foramen. This screw must be placed with fluoroscopy, using an “obturator-outlet” projection (Fig. 68.31). PITFALLS

• Image intensification is required to ensure that fixation is extraarticular (the posterior column screws). • Incomplete reduction of the posterior column will necessitate an additional approach—either during the same anesthetic or another day. If this is the case, fixation must be kept out of the area of the posterior column. INSTRUMENTATION/IMPLANTATION

• Fixation of the posterior column is accomplished by insertion of two to three 3.5-mm screws inserted through the reconstruction plate (Fig. 68.32). • The posterior column screws that end in the ischium can be over 100 mm in length. • Finally, 3.5-mm screws are inserted into the medial aspect of the plate in the region of the superior pubic rami through the medial (third) window to complete the fixation montage. CONTROVERSIES

FIG. 68.30 

Postoperative Reduction • Follow-up radiographs of Case 4 show a concentric hip joint and maintenance of reduction. There is some prominence of bone seen medial to the plate on the AP radiograph related to medialization of comminuted fragments along the superior pubic rami (Fig. 68.33).

874

PROCEDURE 68  Anterior Approaches to the Acetabulum

FIG. 68.32 

FIG. 68.31 

FIG. 68.33 

PROCEDURE 68  Anterior Approaches to the Acetabulum

ADDITIONAL STEPS • If there is concern regarding the soft tissues, any wounds, and/or incision closure, then a specialized postoperative dressing—“negative pressure wound care”—can be used. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative management includes a short course of antibiotics (usually 24 hours). • In cases in which dissection is carried onto the lateral side of the ilium, resulting in potential damage to the abductor musculature, heterotopic ossification (HO) prophylaxis is considered. • Follow-up is by surgeon preference but is usually at 6, 12, 26, and 52 (sometimes 104) weeks postoperatively. • Supervised rehabilitation is used at the discretion of the health care team.

POSTOP PEARLS

• The patient is kept on toe-touch weight bearing on the operative side for approximately 3 months.

POSTOP PITFALLS

• There is a very high rate of injury to the lateral cutaneous nerve of the thigh (approaching 100%) with anterior approaches to the acetabulum—specifically, the ilioinguinal and iliofemoral approaches. • Patients should be counseled preoperatively as to this occurrence of postoperative numbness in the anterolateral thigh, which tends to be painless and reduce in distribution over a period of 12 months postoperatively. • For the AIP approach, there is a significant incidence of obturator nerve injury; disability postoperatively is minimal.

Postop Evaluation • Outcomes following treatment of acetabular fractures can be evaluated clinically and radiographically. • Clinical outcomes can be evaluated using surgeon-graded scoring systems, such as the Merle d’Aubigné and Postel (1954) functional score, or patient-graded systems, such as the Short Form-36. • The Merle d’Aubigné and Postel scale assesses pain, gait, and hip range of motion, with each having a score ranging from 1 to 6. • The sum of these three scores produces an overall score. • Clinical results are rated as excellent (score of 18), very good (score of 17), good (15–16), fair (13–14), or poor ( 2 mm) • Articular impaction • Interposed fragments with nonconcentric joint reduction • Irreducible fracture dislocation • Fragment size greater than 50% of posterior wall (Calkins, 1998; Moed et al., 2009) 

EXAMINATION AND IMAGING • Adequate preoperative resuscitation by general and orthopedic surgical teams (critical care involvement as necessary) • Detailed neurovascular physical examination of the affected extremity • Sciatic nerve function • Skin integrity about proposed surgical incision • Anteroposterior (AP) pelvis, obturator oblique, iliac oblique radiograph (Figs. 71.4–71.6) • Computed tomography (CT) scans with 3D reconstruction (Figs. 71.7 and 71.8) • Placement of skeletal traction as necessary

Ilioischial line Posterior column

A

B FIG. 71.4

A

B FIG. 71.5

A

B FIG. 71.6

Anterior lip

PROCEDURE 71  Posterior Wall Acetabular Fracture

904

Posterior superior iliac spine

Gluteus medius (cut)

Gluteus maximus (cut)

Posterior inferior iliac spine

Piriformis

Gluteus minimus

Superior gemellus

Greater sciatic notch

Obturator internus

Lesser sciatic notch

Quadratus femoris Gluteus maximus (cut)

Inferior gemellus

Greater trochanter

Vastus lateralis

A

B FIG. 71.7

Superior gluteal nerve

Inferior gluteal nerve Sciatic nerve

FIG. 71.8

• Evaluation of additional fracture patterns • EUA with live fluoroscopy (see Figs. 71.1–71.3) 

SURGICAL ANATOMY • Bony anatomy (see Fig. 71.9) • Greater trochanter (GT) • Posterior superior iliac spine (PSIS) • Greater sciatic notch • Ischial spine • Lesser sciatic notch • Muscular anatomy (see Fig. 71.10) • Gluteus maximus • Gluteus medius • Gluteus minimus • Piriformis • Superior gemellus • Obturator internus • Inferior gemellus • Quadratus femoris (see Fig. 13 from page 784 1st edition) • Neurovascular anatomy • Inferior gluteal neurovascular bundle

PROCEDURE 71  Posterior Wall Acetabular Fracture

Posterior wall

Posterior column

Posterior wall/ posterior column

Transverse/ posterior wall

Anterior wall

Anterior column

T-shaped

Anterior with posterior hemitransverse

A

Transverse

B

905

Both columns

FIG. 71.9

POSITIONING PEARLS

FIG. 71.10



• Superior gluteal neurovascular bundle (see Fig. 71.10) • Sciatic nerve • Medial femoral circumflex artery 

POSITIONING • Prone with skeletal traction • Radiolucent traction table with pelvic arc (Fig. 71.11) • Lateral • Radiolucent Jackson flat-top with deflatable beanbag or bolsters (Figs. 71.11– 71.12) 

• Prone positioning • Allows use of skeletal traction with continuous knee flexion and hip extension to decrease tension on sciatic nerve and aid in intraoperative fracture reduction • Can be used with skeletal traction or with a femoral distractor • Easier use of fluoroscopy, drape, and approach from opposite side of the table • Lateral positioning • Preferred for patients with significant facial, pulmonary, or abdominal injuries • Allows for circumferential access of ipsilateral hip • Place beanbag holder below pubic symphysis if anterior surgical access is needed. • Placement of towel roll between proximal thighs can facilitate hip joint distraction.

906

PROCEDURE 71  Posterior Wall Acetabular Fracture

Gluteus maximus (split)

Inferior gluteal nerve

Piriformis Tip of greater trochanter

Sciatic nerve

FIG. 71.11

FIG. 71.12

POSITIONING PITFALLS

• Prone positioning • Cannot be used for surgical hip dislocation • Pad upper extremities well to prevent ulnar nerve or brachial plexus injuries. • Lateral positioning • Difficult to maintain constant joint subluxation through manual traction • Fluoroscopy can be more challenging. • Femoral head/weight of leg displaces posterior wall fracture pattern. • Increased difficulty in plate tensioning versus prone.

Piriformis

Sciatic nerve Quadratus femoris

Tip of greater trochanter

POSITIONING EQUIPMENT

• Prone • Radiolucent traction table with perineal post, pelvic arc • Femoral traction pin • Foot attachment allowing knee flexion and hip extension • Alternatively a padded Mayo stand and femoral distractor can be used in place of traction bed to maintain similar positioning • Lateral • Radiolucent Jackson flat-top • Beanbag holder or hip rests • Padded Mayo stand • ± Femoral distractor

Medial circumflex femoral artery

FIG. 71.13

EXPOSURES • Kocher-Langenbeck (Fig. 71.13–71.16) • Modified Gibson • Surgical hip dislocation  EXPOSURES PEARLS

POSITIONING CONTROVERSIES

• Prone versus lateral positioning • Duration of use of femoral traction with use of perineal post • Neuromonitoring of operative extremity

• Clear identification of piriformis tendon, conjoined tendon (superior gemellus, obturator internus, inferior gemellus) is the most important portion of the surgery, as these structures will allow the surgeon to protect the sciatic nerve and maintain proper intraoperative orientation. • The operating surgeon should identify bone and soft-tissue damage resulting from injury and incorporate into the surgical approach if at all possible. • If significant soft-tissue damage is present, identification of the sciatic nerve at the level of the quadratus femoris has the least anatomic variability. • Periodically release the pressure of the conjoined tendon when retracting the sciatic nerve or relax retractors placed in the greater or lesser sciatic notches. • Preserve soft-tissue attachments to fracture fragments. • The modified Gibson approach can be used for simple fracture patterns with decreased damage to gluteus maximus.

PROCEDURE 71  Posterior Wall Acetabular Fracture

Piriformis

Gluteus Obturator Greater medius retracted internus trochanter Quadratus

Gluteus medius retracted

907

Gluteus Greater Gemelli and minimus trochanter obturator internus

B

A Superior gluteal Inferior gluteal Sciatic artery and nerve artery and nerve nerve

Superior and inferior gemellus

Piriformis Greater Superior Sciatic Quadratus gluteal bundle retracted sciatic notch nerve

Gluteus minimus

Gluteus medius retracted Greater sciatic notch Lesser sciatic notch

Piriformis retracted

Quadratus

Greater trochanter

Sciatic nerve

C Obturator internus and gemelli retracted FIG. 71.14 

EXPOSURES PITFALLS

FIG. 71.15  EXPOSURES EQUIPMENT

• Basic orthopedic instrument set • Self-retaining retractors (Charnley, Wheatlander, cerebellar, Miskimon) • Pelvic retractors, including Hohmann (blunt and sharp), Deaver, Mehrding, and deep pelvic retractors • Cobb elevators, curettes, freer, dental pick, bone hook, ball spike pushers, pituitary rongeur • Kirschner wires (K-wires), oscillating power driver, 2.5-mm drill bits (short and long) • Pointed reduction clamps, single and double straight reduction clamps; pelvic clamps, offset and angled clamps • Spring plates: one to three holes (manufactured or custom by cutting and bending one-third tubular plate) • Pelvic reconstruction plate set with anatomic acetabular plates, posterior column plates, 2.7- and 3.5mm cortical screws, 4.0 cancellous screws of depths 8 to 120 mm, small fragment set

• Detachment of piriformis and conjoined tendons < 1.5 cm from insertion, or dissection into the quadratus femoris can compromise the ascending branch of the medial femoral circumflex artery. This can lead to femoral head osteonecrosis. • Failure to identify and protect the sciatic nerve throughout the case can lead to iatrogenic damage and poor functional outcomes. • Placement of the incision too posteriorly will limit access to the superior acetabulum and place the sciatic nerve at increased risk of injury. • Failure to appropriately visualize the joint with traction can result in retained intraarticular fragments.

PROCEDURE 71  Posterior Wall Acetabular Fracture

908

A

B

C

D FIG. 71.16 

EXPOSURES CONTROVERSIES

• Kocher-Langenbeck versus Gibson approach for extended superior/posterior wall fracture patterns • Labral repair versus débridement in cases of concomitant labral injuries • Surgical timing/approach in patients with concomitant Morel-Lavallee lesions STEP 1 PEARLS

• Palpation of bony landmarks and careful placement of incision can minimize extra exposure, dissection, blood loss, and operative time. • Partial release the gluteus maximus insertion on the femur to increase the surgical exposure distally, but beware of the first perforating branch in the muscle insertion. • Placement of a stitch at the apex of the gluteus maximus fascial split limits additional fascial dissection and facilitates easier identification of the tissue plane and subsequent closure. STEP 1 PITFALLS

• Division of multiple perforating branches of the inferior gluteal neurovascular bundle can lead to partial gluteus maximus denervation, weakness, and gait abnormalities. • Multiplanar dissection increases difficulty of wound closure and creates additional surgical trauma, dead space, and seroma formation.

PROCEDURE Step 1 • Surgical timeout, verification of antibiotic administration • Mark palpable bony landmarks, including GT, vastus ridge, PSIS, femoral shaft. • Sterile prep and drape using iodine adhesive. • Mark out curvilinear incision centering over GT, in line with femoral shaft distally and curving two-thirds of the way toward the PSIS, apex anterior (Fig. 71.13). • Incise skin sharply and obtain hemostasis with electrocautery. • Identify gluteus maximus fascia and iliotibial (IT) band overlying the GT. • Palpate and divide the GT into thirds and incise the IT band at the level of the GT at the junction of the middle and posterior thirds. Carry distally in line with the femoral shaft to the level of the gluteus maximus insertion (Fig. 17.14) • Incise the gluteus maximus fascia in line with the incision, then bluntly divide muscle fibers in the avascular plane to the level of the first perforating neurovascular bundle (inferior gluteal). 

Step 2 • Identify and remove the GT bursa with cautery. • Identify the gluteus medius, piriformis, conjoined tendons. Release the piriformis tendon 1.5 cm from its insertion and tag; repeat with the conjoined tendon to protect the medial femoral circumflex artery. • Retract the piriformis tendon to expose the sciatic nerve; retract the conjoined tendon to protect the sciatic nerve (see Fig. 17.16). • Identify the greater and lesser sciatic notches. 

Step 3 • Identify posterior wall fracture fragment(s) with subperiosteal dissection of the gluteus minimus and medius origins as necessary.

PROCEDURE 71  Posterior Wall Acetabular Fracture

STEP 1 INSTRUMENTATION

• 15-blade scalpel • Bovie monopolar cautery • Self-retaining retractors STEP 2 PEARLS

• Completely expose and identify the short external rotators before proceeding deeper with dissection. • Intimate knowledge of the entire course of the medial femoral circumflex artery is critical to prevent ligation, which can jeopardize femoral head vascularity (Seeley et al., 2016). • The piriformis originates from the greater sciatic notch; the conjoined tendons originate from the lesser sciatic notch. • Use frequent relaxation on conjoined and piriformis tendons/tagging stitches retracting sciatic nerve. STEP 2 PITFALLS

• Beware of the variable sciatic nerve anatomy exiting the greater sciatic notch with respect to the piriformis and conjoined tendons. • Do not dissect deep to the quadratus or posterior/superior femoral neck to protect the medial femoral circumflex artery. • The superior gluteal artery and vein exit the greater sciatic notch and can cause life-threatening bleeding if injured, especially if they retract inside the pelvis. Great care must be taken with any dissection/traction in the notch to avoid this. STEP 2 INSTRUMENTATION/IMPLANTATION

• #2 PDS tagging suture • Self-retaining retractors • Blunt Hohmann retractors STEP 2 CONTROVERSIES

• Simultaneous placement of Hohmann retractors into greater and lesser sciatic notches • Identify the labrum, capsule, and soft-tissue components of injury; inspect the posterior column for nondisplaced fractures. • Use skeletal traction to allow for joint subluxation, inspection of the femoral head and acetabular articular surfaces; perform evaluation for intraarticular debris. • Gently manipulate fracture fragments when able to work through fracture and retain soft-tissue attachments to fracture fragments. • Evacuate hematoma, debride fracture callus, and prepare fracture surfaces with pituitary tongues, curettes, freer, irrigation. • Mobilize fracture fragment(s); use small threaded K-wires for joystick control as needed. • Identify and address marginal impaction of acetabulum. • Release traction as needed to assist in contouring the acetabular surface to the intact femoral head as template. • Fill and impact the bone defect with the appropriate bone graft/substitute. • Reduce the wall fracture with ball spike pushers and provisionally fix with K-wires. • Verify reduction directly and with fluoroscopy. • AP hip, obturator oblique, iliac oblique views • Inlet and outlet iliac oblique views 

STEP 3 PEARLS

• A universal distractor can be applied across the hip to facilitate joint distraction for improved visualization and debris removal. Pins are placed into the intact ilium lateral to the sciatic notch and the femur proximal to the lesser trochanter (Calafi and Routt, 2010). • Meticulously prepare the fracture site and remove the callous before reduction. • An incongruent retroacetabular surface reduction means that the articular surface is likely malreduced. • Place K-wires in locations that will not block definitive fixation. • Use 2-mm K-wires for provisional fixation, then replace with lag screw fixation using 2.7-mm screws owing to the same core diameter.

909

910

PROCEDURE 71  Posterior Wall Acetabular Fracture

STEP 3 PITFALLS

• Removing soft-tissue attachments of fracture fragments jeopardizes vascularity. • Articular malreduction can be caused by graft placement, interposed soft-tissue, or bony fragments. STEP 3 INSTRUMENTATION/IMPLANTATION

• Blunt and sharp Hohmann retractor • Small curettes, freer, pituitary ronguer, dental pick • Curved and straight tined pointed reduction clamps, ball spike pushers • K-wires, power driver • Skeletal traction, fluoroscopy STEP 3 CONTROVERSIES

• Autograft, allograft, and other graft substitutes (e.g., calcium phosphate) are frequently used to fill bony defects in the setting of marginal impaction. Risks and benefits for each should be known and use should be patient specific. • This is limited data on bioabsorbable fixation methods.

Step 4 • Identify location for reconstruction buttress plate(s) appropriate for the fracture pattern. • Lag larger fracture fragments when able, ensuring extraarticular screw placement. • Place spring plate(s) to secure smaller fragments. • Repair versus débride labrum if needed. • Use template and slightly undercontour plate as necessary. • Provisionally fix buttress plate. • Verify position directly and fluoroscopically to ensure that the plate sits at the edge of the wall fracture and does not impinge on the labrum. • Begin fixation by using a 2.5-mm drill and placement of a 3.5-mm screw of appropriate length into the intact ischium. • The second point of plate fixation is an additional 3.5-mm screw into one of the two proximal holes engaging the intact ilium. • Definitively apply a reconstruction plate with additional proximal and distal 3.5-mm cortical screws of appropriate depth, lagging fracture fragments through a buttress plate when able. • Ensure that hardware placement is extraarticular. • Ensure the fracture reduction is adequate.  STEP 4 PEARLS

• Owing to the concave nature of the joint, if a screw is extraarticular on one tangential view, it is extraarticular on all other nontangential views (Fig. 71.17). • Spring plates can be used to provide provisional fixation of fracture fragments. • Place spring plates before buttress plates. • Screw heads for 2.7-mm cortical lag screws do not inhibit placement of a buttress plate. • If this is a concern, larger screw heads can be countersunk. • Use of oscillating drill mode, reverse mode, smaller drill bits, and malleted drill bits can be used to avoid intraarticular hardware placement. • Placement of the buttress plate at the edge of the wall fragment maximizes the biomechanical advantage of this fixation modality. • Re-dose antibiotics at 4 hours or >1000 mL estimated blood loss.

STEP 4 PITFALLS

• Do not allow the tines of a spring plate to enter the joint; ensure that screw fixation is extraarticular. • Intercalated screws should be used judiciously, as they can deflect additional screws intraarticularly. • Failure to obtain tangential imaging after hardware placement risks intraarticular hardware.

PROCEDURE 71  Posterior Wall Acetabular Fracture

STEP 4 INSTRUMENTATION/IMPLANTATION

• K-wires, power driver • Spring and acetabular 3.5-mm buttress plates • 2.7- and 3.5-mm cortical screws

STEP 4 CONTROVERSIES

• Routine use of multiple buttress plates provides better biomechanics fixation at the cost of increased exposure and surgical time.

A

B

C FIG. 71.17

911

912

PROCEDURE 71  Posterior Wall Acetabular Fracture

Step 5 • Thorough irrigation of the entire operative site • Débridement of devitalized muscle, especially the gluteus minimus and medius, to reduce heterotopic ossification risk • Ensure hemostasis • Closure of short external rotators in layers with #1 PDS suture • Deep drain placement • Closure of IT band and gluteal fascia with interrupted #1 PDS suture • Multiple interrupted layers of buried #2-0 monocryl to close dead space and reduce seroma formation • Skin closure with interrupted #2-0 nylon or staples • Cover with standard dressing  STEP 5 PEARLS

• Repair of the short external rotators should be done while protecting the medial femoral circumflex artery. • Attention to detail when closing can prevent many wound complications. • Morbidly obese patients require several interrupted deep layers of absorbable suture. • Begin closure at corners of incisions initially to ensure tight fascial closure and prevent wound drainage proximally. STEP 5 PITFALLS

• Use care when placing drains to avoid further tissue injury and do not sew in place with deep suture. STEP 5 INSTRUMENTATION/IMPLANTATION

• Absorbable suture (PDS, monocryl) • Nonabsorbable suture (nylon, proline) • Staples • Drains STEP 5 CONTROVERSIES

• Routine use of drains deep and superficial to the IT band/ luteal fascia • Timing of drain removal if used • Use of incisional wound vacuum-assisted closure devices: current evidence is contradictory on their utility POSTOPERATIVE PEARLS

• Toe-touch weight bearing has less joint reactive force across the hip than non–weight bearing. POSTOPERATIVE PITFALLS

• Inadequate follow-up time frame, 87% of patients at 15-year follow-up (Mitsionis et al., 2012). • 80% of patients had good to excellent clinical and radiographic outcomes at 5-year follow-up (Moed et al., 2002). • Inferior results are more common in patients with increased age, increased body mass index, concomitant femoral head and/or neck fracture, marginal impaction, intraarticular comminution, irreducible dislocations, nonanatomic reduction.

PROCEDURE 71  Posterior Wall Acetabular Fracture

B

A

FIG. 71.18 

A

B

C FIG. 71.19 

913

PROCEDURE 71  Posterior Wall Acetabular Fracture

914

A

B FIG. 71.20 

FIG. 71.21 

A

B FIG. 71.22 

PROCEDURE 71  Posterior Wall Acetabular Fracture

A

B FIG. 71.23 

B

A FIG. 71.24 

A

B FIG. 71.25 

915

916

PROCEDURE 71  Posterior Wall Acetabular Fracture

FIG. 71.26 

EVIDENCE Calafi LA, Routt MLC. Direct hip joint distraction during acetabular fracture surgery using the AO universal manipulator. J Trauma. 2010;68:481–484. A technique paper describing how the universal manipulator can be used to augment joint visualization in difficult cases. Though only used in 18% of the senior author’s Kocher-Langenbeck approaches, in each instance, debris was removed from the joint. It may decrease the incidence of pudendal nerve palsies, as the perineal post is not in use. Calkins MS, Zych G, Latta L, et al. Computed tomography evaluation of stability in posterior fracture dislocation of the hip. Clin Orthop Relat Res. 1998;227:152–163. An often-cited article that is one of the first attempts at using posterior wall acetabular fracture size to determine hip stability using a CT-based system. Firoozabadi R, Spitler C, Tornetta P, et al. Determining stability in posterior wall acetabular fractures. J Orthop Trauma. 2015;29:465–469. A retrospective review of 138 posterior wall acetabular fractures that underwent EUA. The ones deemed unstable had an exit point closer to the acetabular dome than those defined as stable. Even a wall fragment less than 20% can prove unstable on EUA. Grimshaw CS, Moed BR. Outcomes of posterior wall fractures of the acetabulum treated nonoperatively after diagnostic screening with dynamic stress examination under anesthesia. J Bone Joint Surg [Am]. 2010;92:2792–2800. A retrospective review of 18 patients treated nonoperatively after EUA determined stability of their posterior wall acetabular fracture. All patients had functional and most had radiographic assessments confirming good to excellent outcomes at 2-year follow-up. McNamara AR, Boudreau JA, Moed BR. Nonoperative treatment of posterior wall acetabular fractures after dynamic stress examination under anesthesia: revisited. J Orthop Trauma. 2015;29:359–364. A retrospective case series reporting the short-term (30 months) outcomes of patients treated nonoperatively after posterior wall acetabular fracture deemed stable by EUA. The authors report excellent radiographic results similar to uninjured population reference values. Mitsionis GI, Lykissas MG, Beris AE. Surgical management of posterior hip dislocations associated with posterior wall acetabular fracture: a study with a minimum follow-up of 15 years. J Orthop Trauma. 2012;26:460–465. A retrospective review of long-term results for ORIF of posterior wall acetabular fractures. Though the results are limited by poor follow-up, the authors report > 87% good to excellent clinical and radiographic follow-up at 18.5 years. Anatomic ORIF was found to be an important predictor of long-term outcomes. Moed BR, Ajibade DA, Isreal H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma. 2009;23:7–15. A retrospective review of 33 patients undergoing EUA with comparisons to the Moed, Calkins, and Keith methods for determining posterior wall acetabular fracture stability. They find the Moed method most predictive of stability, though fractures between 20% and 50% may remain a gray area that contains both stable and unstable patients during EUA.

PROCEDURE 71  Posterior Wall Acetabular Fracture Moed BR, Wilson Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg [Am]. 2002;84:752–758. A retrospective review of 100 patients who underwent ORIF for posterior wall acetabular fracture. Positive outcomes were correlated with anatomic reduction, though even an anatomic reduction could yield a poor result. Negative outcomes were correlated with comminution, delay in hip relocation > 12 hours, osteonecrosis, and age > 55 years. Reagan JM, Moed BR. Can computed tomography predict hip stability in posterior wall acetabular fractures? Clin Orthop Relat Res. 2011;469:2035–2041. An investigation to validate the Moed method for predicting posterior wall acetabular fracture stability based on fragment size. Although not always specific, it was sensitive 90% of the time and can reliably predict clinical stability in wall fractures involving > 50%, though EUA remains the gold standard for determining fracture stability. Sagi HC, Jordan CJ, Barei DP, et al. Indomethacin prophylaxis for heterotopic ossification after acetabular fracture surgery increases the risk for nonunion of the posterior wall. J Orthop Trauma. 2014;28:377–383. A prospective randomized control trial detailing the administration of indomethacin as prophylaxis for heterotopic ossification formation after posterior wall acetabular fracture ORIF. A 6-week course increased the rate of nonunion and did not have a therapeutic effect to decrease heterotopic bone formation, though treatment for 1 week may be of benefit. Seeley MA, Georgiadis AG, Sankar WN. Hip vascularity: a review of the anatomy and clinical implications. J Am Acad Orthop Surg. 2016;24:515–526. A detailed review article describing the anatomic course of the medial femoral circumflex artery and its branches. It outlines the various contributions to the femoral head blood supply from infancy to adulthood.

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PROCEDURE 72

Cervical Spine: Anterior and Posterior Stabilization Rudolf Reindl

INDICATIONS PITFALLS

INDICATIONS

• Before embarking on a stabilization technique, the spine should be well aligned and the facet joints reduced. If a closed reduction maneuver is ineffective or deemed to be unsafe, an open reduction will be required first.

• Acute fractures and dislocations that result in acute cervical spine (C-spine) instability require early stabilization to prevent acute or gradual displacement that can cause spinal cord compression. • Traumatic lesions resulting in progressive deformity of the cervical spine despite appropriate conservative measures may require surgical stabilization. 

INDICATIONS CONTROVERSIES

• A detailed neurologic examination is imperative, as it may influence the timing and character of the surgical treatment. • Anteroposterior (AP) and lateral, Swimmer view • While computed tomography (CT) with reconstruction has replaced the standard views in some Level 1 trauma centers, they remain the standard radiologic tests for the diagnosis of significant C-spine pathology. For optimal views to the C7/T1 level, traction should be applied to the upper extremities. • Despite adequate traction, the T1-T4 levels usually cannot be visualized with the standard lateral view. The Swimmer view will demonstrate severe pathology in this zone (Fig. 72.1). • CT scan: The CT scan is paramount in preoperative planning and should be used in all surgical cases. The scan should include the entire C-spine, and caudally to T4.

EXAMINATION AND IMAGING • While the posterior approach offers the most predictable method of achieving a satisfactory reduction and the strongest biomechanical construct, the anterior approach allows for easier patient positioning and less extensive soft-tissue dissection. Disc material and retropulsed bony fragments will require an anterior approach.

TREATMENT OPTIONS

• Nonoperative treatment is acceptable in mostly osseous injuries and in the pediatric population provided that good alignment is obtained and maintained. This may range from the application of a soft collar to the installation of a halo vest. The failure rate of these modalities is higher in mostly ligamentous and soft-tissue injuries. In the obese patient, bracing is less effective, and the elderly may not tolerate bracing well.

FIG. 72.1 

918

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

FIG. 72.2 

• Magnetic resonance imaging (MRI) scan: The MRI scan is used for evaluation of discs and ligaments. In the unconscious or sedated patient, it may be the only test that reveals significant soft-tissue disruption. Additionally, the spinal cord may show evidence of injury not appreciated by other modalities. Most patients should undergo a preoperative MRI unless the delay in obtaining this test is detrimental to the patient’s outcome or if there are specific contraindications to MRI (Fig. 72.2). 

SURGICAL ANATOMY • Anterior approach • Carotid sheath—artery, vagus nerve • Strap muscles • Superior and inferior thyroid arteries • Recurrent laryngeal nerve • Sympathetic chain • Vertebral arteries • Spinal cord • Posterior approach • Posterior mid-line • Between Para-cervical muscles 

919

920

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization Anterior approach

Strap muscles

Pretrachea fascia Longus capitis & longus coli muscles Carotid sheath Common carotid artery Jugular vein Vagus nerve Cervical ganglion of sympathetic chain

A

Sternocleidomastoid muscle Vertebral artery Paracervical muscles Posterior approach FIG. 72.3  Transverse cut at the mid-cervical level showing intervals of the anterior and posterior approaches.

B FIG. 72.4  A, Supine position for the anterior approach. B, Prone position for the posterior approach.

POSITIONING PEARLS

• Ensure satisfactory fluoroscopic visualization of the affected levels preoperatively. • Slightly oblique views may be necessary to view the lower levels if the shoulders obscure the view. • AP fluoroscopy may be useful for C7 and T1 pedicle screw placement. • Taping suggestions • Prepare the skin with a transparent film dressing spray (OPsite spray) to improve adhesion of tape. • Use surgical foam tape (3M Micropore tape) to prevent excessive arm traction.

POSITIONING • Anterior approach (Fig. 72.4A) • Supine positioning on radiolucent table • Slight extension if spine is reduced • Mayfield headrest • Gardner-Wells traction • Arms at side with slight traction • Expose iliac crest optional • Posterior approach (Fig. 72.4B) • Prone position on radiolucent table • Slight extension if spine is reduced • Mayfield headrest, Mayfield tongs or halo ring • Traction optional • Arms at side with slight axial traction • Expose iliac crest optional 

POSITIONING PITFALLS

• Excessive traction on head • Once the spine is reduced, traction is optional; it serves to stabilize the head during the operative procedure and to counteract traction on the arms. In most cases, 5 to 10 pounds is satisfactory. Fixing the spine in a distracted position may lead to late instability and hardware failure. • Excessive traction on the arms • Prolonged excessive traction on the arms may lead to brachial plexus injuries. • Pressure on the eyes • Care needs to be taken to prevent any pressure on the eyes, especially in the prone position. Cases of blindness have been reported with this type of positioning. Mayfield head tongs or a halo ring allow for stable positioning without any pressure on the eyes in the prone position.

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

921

POSITIONING EQUIPMENT

• Gardner-Wells tongs • Mayfield head tongs • Mayfield headrest • Halo ring • Radiolucent table • Foam tape

Thyroid gland

Larynx and trachea

Paraspinal muscles dissected

Esophagus

Interspinalis cervicis muscles

Chin Neck

A

Vertebrae and discs Platysma Superior thyroid covered by anterior vessel Carotid sheath longitudinal ligament

B

C6

Lamina

Facet joints

FIG. 72.5  Anterior (A) and Posterior (B) approaches to the cervical spine.

Chin

A

Curette

Neck

B

Kerrison rongeur

FIG. 72.6  A, Anterior discectomy is performed after resection of the anterior longitudinal ligament at the injured level. B, Partial resection of the inferior facet may be required to achieve reduction of a dislocated segment after a posterior approach.

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PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

PORTALS/EXPOSURES PITFALLS

• Anterior approach • Frequently palpate the carotid artery to be certain that the plane of dissection remains medial to the sheath. • Always ligate sectioned arteries to avoid postoperative arterial hematomas that can lead to airway obstruction. • Do not dissect the longus colli muscle more than 2 cm from the midline to avoid injury to the sympathetic chain lying just anterior to the lateral border of the muscle. • Palpate or visualize the carotid pulse proximal to the retractors to ensure adequate circulation, especially in the elderly population. • Avoid excessive retraction for approaches in the lower cervical spine as the recurrent laryngeal nerve crosses from the carotid sheath medially under the subclavian artery on the right side and is therefore at risk. • Posterior approach • Keep the dissection in the midline to avoid bleeding from the venous plexus, located in the paraspinal muscles. • Beware of lamina fractures that may allow inadvertent penetration to the spinal cord during muscle dissection. Use electrocautery prudently in such cases. PORTALS/EXPOSURES EQUIPMENT

• Anterior approach • Various retractor systems are available. Surgeon’s preference dictates their use. • Radiolucent retractors allow for easy fluoroscopic visualization of the hardware. • Posterior approach • Angled cerebellar retractors allow for effective retraction of the paraspinal muscles.

PORTALS/EXPOSURES • Anterior approach (Smith and Robinson, 1958) (Fig. 72.5A) • A line is drawn along the anterior margin of the sternocleidomastoid muscle that is readily palpable. It extends from the lateral aspect of the jugular notch to the ipsilateral ear lobe. • A 5-cm incision can follow this line. Alternatively, a transverse incision can be made. Two-thirds of the transverse incision should be medial to the line drawn along the sternocleidomastoid muscle. The incision should be centered over the affected level. • The underlying platysma is split along the direction of its fibers. • Identify the interval between the sternocleidomastoid muscle and the strap muscles medially and bluntly dissect this interval, keeping the carotid sheath with its contents lateral at all times. • The omohyoid muscle traverses this interval at the level of the 5th and 6th cervical vertebrae. This muscle can be retracted medially above and laterally below these levels. In rare cases, the muscle is transsected to obtain adequate access. • At C4 and C7, the superior and inferior thyroid arteries, respectively, may need to be retracted or ligated. The superior and middle thyroid veins are encountered at variable locations and may also need to be sectioned. • Retract the thyroid gland, strap muscles, trachea/larynx, hyoid bone, and esophagus medially and the carotid sheath laterally. • The midline of the spine can now be visualized. The longus colli muscles are dissected off the anterior aspect of the spine for adequate visualization of the discs and vertebral bodies. • Posterior approach (Fig. 72.5B) • A line is drawn in the midline along the posterior spinous processes of the cervical spine. • A 10-cm incision is made in this line centered over the affected level. • The paraspinal muscles are dissected from the lamina and retracted laterally to visualize the lateral aspect of the facet joints. • If a laminectomy is not required for the purpose of spinal cord decompression, the interspinalis cervicis muscles may be left intact.  PORTALS/EXPOSURES CONTROVERSIES

• For low cervical approaches, theoretically, a left-sided approach reduces the risk of a recurrent laryngeal nerve injury, as the nerve passes to the midline more caudally, under the arch of the aorta, than on the right side.

PROCEDURE Step 1 Preparation and Decompression Anterior Approach (Fig. 72.6A) • The anterior longitudinal ligament is excised and the annulus of the damaged disc is detached from the endplate above and below. • Using a pituitary rongeur, the anterior annulus and most of the disc is removed. • Removal of the anterior inferior lip of the upper vertebral segment may be required to achieve a level upper endplate. • The remainder of the disc is removed using a small curette. All soft tissue must be removed from both endplates but care must be taken not to damage the endplates as they prevent subsidence of the cage or graft to be placed later. • If decompression of the spinal cord is not required, proceed to step 2. • To achieve a complete decompression, some distraction of the spine may be required. • The posterior longitudinal ligament is usually disrupted in these injuries; thus, care must be taken not to place inadvertent pressure on the spinal cord.

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

923

• Once the dura is visualized, a small Kerrison rongeur can be used to remove the annulus or osteophyte above or below the affected disc. • If a corpectomy is required for the purpose of decompression, perform a complete discectomy above and below the injured vertebra as outlined earlier, followed by removal of the fractured segment all the way posteriorly until the dura is visualized. 

Posterior Approach (Fig. 72.6B) • To achieve a reduction of the facet joints, it is frequently necessary to remove the superior facet of the inferior segment. A Kerrison rongeur is used for this purpose. This allows the upper segment to slide posteriorly into the correct position without the use of excessive force. • A laminectomy may be required if fragments of the posterior elements are impinging on the dural contents or if a dural leak needs to be repaired. This is most effectively achieved using a Kerrison rongeur or a high-speed burr. 

Step 2

STEP 1 PEARLS

Anterior: • Remove the discs above and below the fractured vertebra first, as they are avascular and give a good indication of the anterior border of the spinal canal. Removal of the vertebra can lead to obstructive bleeding.

STEP 1 PITFALLS

Anterior • Avoid dissecting lateral to the oncovertebral joints. The vertebral artery lies just lateral to this anatomic structure. • The epidural veins are located laterally and are usually injured during extensive foraminotomies. In most fractures, foraminotomies are not essential. Bleeding can be avoided by not entering this area.  Posterior • Excessive removal or facet joints may make satisfactory purchase within the lateral masses difficult. Resect only as much bone as is necessary.

STEP 1 INSTRUMENTATION/IMPLANTATION

Anterior • Use a Kaspar retractor to achieve the desired amount of distraction of the vertebral segments if skeletal traction is insufficient. • A high-speed burr may be used effectively to remove sclerotic bone.

Place the Graft/Spacer Anterior • A tricortical graft may be harvested from the iliac crest. A 5-cm incision is made over the iliac crest, 10 cm posterior to the anterior superior iliac spine (ASIS). Expose the iliac crest in a subperiosteal fashion. A microsagittal saw is then used to harvest the appropriate thickness of graft. • Allograft and plastic and metal spacers have become more popular, as they avoid the complications associated with the donor site with only a slight increase in risk for nonunion. Select the appropriate spacer. • Insert the graft or spacer into the disc space and release all traction. 

STEP 2 PEARLS

Anterior • Use a paper ruler cut at 2 cm to measure the gap to be filled with the graft or spacer. The spacer is almost always less than 10 mm.  Posterior • To achieve a solid fusion, decorticate the facets and scrape the joint cartilage with a small angled curette.

Posterior

STEP 2 PITFALLS

• Autograft can be harvested from the posterior superior iliac spine (PSIS). This can be achieved through a 5-cm incision directly over the PSIS. Curettes and gauges are used to harvest the bone. • Usually, sufficient bone is harvested from the posterior elements during the decompression. Therefore, the harvesting of autograft is not usually required. 

Anterior • In the severely or circumferentially disrupted spine, overdistraction is a common mistake. It destabilizes the facet joints and leads to a weaker construct.

924

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

STEP 2 INSTRUMENTATION/IMPLANTATION

Anterior • Autograft, allograft, titanium, porous metal, polyetheretherketone (PEEK) cages  Posterior • Autograft, allograft, graft substitute

STEP 2 CONTROVERSIES

• The choice of spacer should be made based on patient anatomy and need. While the use of autograft may yield the highest fusion rates, it exposes the patient to donor site morbidity (Silber et al., 2003). • Anterior plating across the spacer is recommended in most cases.

STEP 3 PEARLS

Anterior • If the plate appears as a single radio-opaque line on a perfect lateral fluoroscopic view, it is likely to be in the midline on the AP view. If unsure, use an AP view as a guide.  Posterior • A Penfield retractor may be inserted into the facet joint on each side. When these overlay each other fluoroscopically, the lateral view is perfect and can be used as an accurate guide for screw placement.

STEP 3 INSTRUMENTATION/ IMPLANTATION

Anterior • Locked plates • Dynamic stabilization plates 

Step 3 Instrumentation of the Spine Anterior •  Stabilization of the reduced spine is important in achieving a successful fusion across the injured segment(s). This is achieved with an anterior plating construct. • The plate length is measured and placed on the anterior aspect of the spine. • Use fluoroscopy to check the appropriate length and position. • Fix the plate to the vertebral bodies above and below. The upper and lower screws should be parallel or divergent (Fig. 72.8). 

Posterior • Screws or hooks are used to stabilize the posterior cervical spine. The choice of implant depends on the nature of the injury and surgeon familiarity with the instrumentation. • Lateral mass screws are placed through a starting point in the supero-medial quadrant of the inferior facet aiming approximately 20° laterally and superiorly, parallel to the facet joint surface (Do Koh et al., 2001). 

Posterior • Rods and locked screws

FIG. 72.7 

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

Step 4 Direct Odontoid Screw Fixation for Odontoid Fractures

925

STEP 4 PEARLS

• Odontoid fractures can lead to C1-C2 instability (Fig. 72.8). • Stability can be reestablished in select cases by achieving a direct repair of the fracture (Fig. 72.9A–B). • Standard anterior approach: Smith-Robinson at the C6 level • Blunt dissection to spine with retropharyngeal dissection proximally to the anterior C2 vertebra • Retractors allow view of the inferior border of C2 (Fig. 72.10). • Screw insertion under biplanar fluoroscopy (Fig. 72.11) 

• Neck extension allows for easier screw trajectory, but it may also displace the fracture. • The Mayfield head holder allows for anterior head translation with extension at the C1-C2 junction. • The C2-C3 disc may need to be entered anteriorly to allow for a safe screw trajectory.

STEP 4 PITFALLS

• Beware of comminuted fractures or reverse oblique fracture lines. Compression may lead to shortening. • Individual anatomy may preclude odontoid screw fixation. • Severe thoracic kyphosis • Barrel chest • Obesity • Poor bone quality with resultant poor screw purchase • Fractures extending into the C2 anterior body

STEP 4 INSTRUMENTATION/ IMPLANTATION

• Titanium 4.0-mm cannulated or solid partially threaded screws or lag screw technique with fully threaded screws for simple fracture patterns. • Fully threaded screws can be used to fix some comminuted fractures.

STEP 4 CONTROVERSIES

• One versus two screws

FIG. 72.8 

A

B FIG. 72.9A–B 

926

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

FIG. 72.10 

STEP 5 PEARLS

• Evaluate the trajectory of the screws after positioning of the patient on the lateral fluoroscopic view. The entry points for the screws may well be at the upper thoracic spine, especially for the transarticular fixation. • Special long drill bits and guidewires are required for the transarticular procedure. • Slight reverse Trendelenburg positioning of the patient and avoiding abdominal compression in the prone position will diminish venous pressure and intraoperative blood loss during the approach. • If the C2 anatomy is unfavorable for pedicle or transarticular fixaton, do not hesitate to go to C3 (Fig. 72.15B–C).

FIG. 72.11 

Step 5 Posterior C1-C2 Fixation for Instability • Posterior transarticular C1-C2 fusion (Magerl, 1987) (Fig. 72.12) • Posterior C1-C2 fusion using lateral mass screws (Fig. 72.13) • Standard posterior approach up to the occipito-cervical junction • Careful dissection of the lateral masses and facet joints • Preserve the posterior primary ramus of C2 and the greater occipital nerve during the lateral dissection behind the facet joints. • Palpate the medial edge of the C2 lamina and pars to delineate the spinal canal all the way anteriorly to the edge of the facet joint. • Detailed knowledge of the individual anatomy is essential in allowing safe placement of transarticular and lateral mass screws (Fig. 72.14A–B and Fig. 72.15A–C). • Supplemental sublaminar wiring and grafting will improve the fusion rate. 

STEP 5 PITFALLS

• Anatomic variants, especially the course of the vertebral artery • Never dissect superior to the C1 lamina to avoid injury to the vertebral arteries. • An extensive venous plexus is found inferior to the C1 lamina, posterior to the C1 facet. Disruption of these veins during the C1 screw insertion can lead to significant blood loss.

STEP 5 INSTRUMENTATION/ IMPLANTATION

• Various screw types are used depending on the fracture configuration. • Cannulated or solid titanium screws, fully and partially threaded, are available. They are used per surgeon’s preference.

Interfacet fusion site

Laminar interposition graft

STEP 5 CONTROVERSIES

• Motion sparing odontoid fixation versus C1-C2 fusion • Transarticular versus lateral mass C1-C2 fusion

FIG. 72.12 

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

FIG. 72.13 

A

B FIG. 72.14A–B 

927

928

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

Direct insertion (Goel, 1994) C2 root and venous problem

Translaminar (Tan, 2003) C1 root, lamina breakage

Notching (Lee and Riew, 2006) Ideal method?

2 mm 19 mm

A

L/M mid point, 1–2 mm above articular surface

19 mm lateral, 2 mm superior

L/m mid point (lower end)

15° medial

0° medial

10° medial

15° cephalad

5° cephalad

5–10° cephalad

B

C FIG. 72.15A–C 

PROCEDURE 72  Cervical Spine: Anterior and Posterior Stabilization

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The cervical spine may need a 6-week period of immobilization using a brace or soft collar. In good-quality bone this may not be required, as the stability afforded by modern instrumentation is often sufficient. • Physiotherapy of the cervical spine is started at 6 to 8 weeks postoperatively for single-level, stable constructs but it may be restricted for up to 3 months in poorquality bone.

EVIDENCE Do Koh Y, Lim TH, Won You J, et al. A biomechanical comparison of modern anterior and posterior plate fixation of the cervical spine. Spine. 2001;26:15–21. This is a biomechanical study of 10 cadaveric specimens that were instrumented. The posterior fixation seems more stable than the anterior. (Level III evidence.) Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine. 2003;28(2):134–139. This is a retrospective study of 187 patients on donor site morbidity after anterior iliac crest autograft. The patients were investigated with a mailed questionnaire. A large percentage of patients report chronic donor site pain after anterior iliac crest bone graft donation, even when only a single-level anterior cervical discectomy and fusion procedure is performed. (Level IV evidence [retrospective cohort].) Smith GW, Robinson RA. The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg [Am]. 1958;40:607–624. This is a study focusing on the anatomy of the anterior cervical spine approach. It describes the technique of anterior cervical discectomy and fusion. (Level IV evidence [case series].)

929

PROCEDURE 73

Thoracolumbar Spine Injuries Henry Ahn and Kayee Tung

PITFALLS

• Osteoporosis (caution) • Significant medical comorbities (caution) • Life-threatening injuries (caution)

CONTROVERSIES

• Kyphotic deformity greater than 30°

TREATMENT OPTIONS

• Basic principles for fracture management are (1) early decompression plus or minus reduction, (2) stabilization, and (3) early mobilization. • Surgical approaches are anterior, posterior, or combined, depending on the injury morphology, the integrity of the posterior ligamentous complex, and the patient’s neurologic status (intact vs. incomplete vs. complete). • Some fracture patterns may be approached differently by different surgeons. • Significant lung injury may preclude an anterior thoracic approach. • The posterior approach technique and the anterolateral approach technique are discussed separately later. • Methylprednisolone is a treatment option, but it is not mandatory for blunt spinal cord trauma in many spine centers. Potential adverse events are related to high-dose steroids, including higher incidence of early infections. • Multimodal neuromonitoring during surgery maybe an option at some centers.

INDICATIONS • Neurologic compromise • Instability of the posterior ligamentous complex, including fracture-dislocations/subluxations, unstable burst fractures, and flexion-distraction injuries • Ankylosing spondylitis fractures 

EXAMINATION/IMAGING • Advanced Trauma Life Support protocols should be followed, including complete primary and secondary survey and anterior superior iliac spine (ASIA) assessment and detailed documentation of preoperative neurologic status. • Life-threatening injuries need stabilization. • Plain supine radiographs are obtained in anteroposterior (AP) and lateral views, including areas outside of the primary injury site to rule out noncontiguous fractures (can occur in 20% of patients with thoracolumbar and lumbar fractures). • Computed tomography (CT) scans with axial images and sagittal/coronal reconstructions are obtained for assessment of bony morphology and canal encroachment by bony fragments. • CT visualizes the cervicothoracic region, which is difficult to assess with radiographs. CT scans also assess levels above and below the injury to see if there are additional fractures and to assess pedicle diameters/trajectories for screw insertion. • In Case 1, preoperative axial (Fig. 73.1A) and sagittal (Fig. 73.1B) CT scans show disruption of the posterior ligamentous complex through the facet joint. • In Case 2, a preoperative CT scan shows a burst fracture of L2 with retropulsion of the posterior vertebral body wall; however, the posterior ligamentous complex is intact (Fig. 73.2). This patient had symptomatic cauda equina compression.

A

B FIG. 73.1 

930

PROCEDURE 73  Thoracolumbar Spine Injuries

• In Case 3, a preoperative CT scan shows a severe burst fracture with retropulsion of the posterior wall and disruption of the posterior ligamentous complex (Fig. 73.3). • Magnetic resonance imaging (MRI) is done in selected patients to assess the spinal cord for signal change and neural element compression by soft-tissue structures, such as traumatic disk herniations and epidural hematomas, and evidence of disruption of the posterior ligamentous complex. • In Fig 73.4A, a sagittal CT reconstruction shows a thoracic fracture-dislocation with perched facets. • A sagittal T2-weighted MRI of the same patient (Fig. 73.4B) shows significant spinal cord edema and contusion at the level of the bony injury extending proximally. Clinically, this patient’s sensory level matched the bony injury level. 

FIG. 73.3  FIG. 73.2 

A

B FIG. 73.4 

931

PROCEDURE 73  Thoracolumbar Spine Injuries

932

SURGICAL ANATOMY

PEARLS

• Posterior approach • Pad all bony prominences, including the chest, arms, pelvis, knees, feet, and the malleoli between the ankles, with gel padding. • A Jackson table provides a radiolucent frame for imaging and fluoroscopic navigation. • A Jackson table also allows a protuberant abdomen to hang freely. This minimizes intraabdominal pressure, reducing blood loss from venous bleeding during spinal decompression. This also minimizes changes in pulmonary compliance, making ventilation easier in an obese individual in the prone position. • Anterolateral approach • It is important to maintain the posterior cortex of the vertebrae in a direct vertical alignment while decompressing and placing screws anteriorly to avoid neural injury. PITFALLS

• Heavier weighted individuals can develop complications related to prone positioning after prolonged surgery, such as meralgia paresthetica, despite adequate padding. • Patients with polytrauma can have multiple lines, such as endotracheal tubes, arterial lines, central lines, chest tubes, nasogastric tubes, and catheters, that need to be coordinated during a logroll or rotation with the Jackson table.

Posterior Approach • Surgeons performing instrumentation should be familiar and comfortable with pedicle screw insertion landmarks, as well as pedicle screw trajectories and diameters, which vary from T1 down to S1. •  Fig. 73.5 shows changing pedicle diameters in terms of transverse width (Fig. 73.5A) and sagittal width (Fig. 73.5B). In the thoracic spine, the transverse width of the pedicles is smaller than 9 mm, with the narrowest at T5. In the lumbar spine, the narrowest transverse width occurs at L1. •  Fig. 73.6 shows the varying transverse angles of the pedicles from T1 to L5. In terms of transverse angles, the greatest degree of medialization occurs at T1 and L5, with angles of 27° and 30°, and the least occurs at the thoracolumbar junction at T12. • The spinal cord is at risk from medial pedicle screw breaches. •  Fig. 73.7 shows a right-sided medial breach by a thoracic pedicle screw as seen on CT scan. Mild breaches such as this one have no impact on the patient’s clinical outcome. Inferior pedicle breaches can lead to nerve root injuries. • Perforation of the anterior vertebral body may lead to vascular complications, including aortic perforation. • Vascular perforations can present acutely or in a delayed fashion owing to the pulsatile nature of the vessel next to a metal tip. • The thoracic spinal canal is narrowed, with decreased space for the cord, and there is a watershed zone for the blood supply. Both factors can lead to spinal cord injury with less canal intrusion than in other regions of the spinal column. 

20 15 10 5 0 L5 L4 L3 L2 L1 T T T T9 T8 T7 T6 T5 T4 T3 T2 T1 12 11 10

A

Spinal level

Sagittal width (mm)

20 18 16

40 35 30 25 20 15 10 5 0 -5 -10 -15 L5 L4 L3 L2 L1 T T T T9 T8 T7 T6 T5 T4 T3 T2 T1 12 11 10

14

Spinal level

12

FIG. 73.6 

10 8 6 L5 L4 L3 L2 L1 T T T T9 T8 T7 T6 T5 T4 T3 T2 T1 12 11 10

B

Transverse angle (deg)

Transverse width (mm)

25

Spinal level FIG. 73.5 

PROCEDURE 73  Thoracolumbar Spine Injuries

933

FIG. 73.7 

Anterolateral Approach • Vital structures vary, depending on whether the level being approached is thoracic, thoracolumbar, or lumbar. • In the thoracic or the thoracoabdominal approach, the neurovascular bundle under the rib is at risk during initial rib resection and during closure from stitches. • With a thoracic anterolateral approach, structures at risk include but are not limited to the aorta, lung, heart, nerve roots in the foramen, and segmental vessels, including the artery of Adamkewitz. • With a thoracoabdominal and lumbar anterolateral approach, structures at risk include the diaphragm (can be taken down with a 1.5-cm cuff), aorta, lung, ureter, sympathetic chain, visceral organs, genitofemoral nerve on the body of the psoas, and retroperitoneal structures such as the kidneys. 

POSITIONING Posterior Approach • The posterior approach is done with the patient in the prone position. • A multiple-person logroll of the patient into the prone position is an option. • For incomplete spinal cord injuries with an unstable thoracic or thoracolumbar spine fracture, a Jackson table utilizing 360° rotation provides safer rotation into the prone position than manual logrolling with assistants (Fig. 73.8A). • For high thoracic fractures, Mayfield pins attached to the Jackson table (Fig. 73.8B), rather than a foam cushion or pad, can minimize external pressure on the eyeballs, which can be a factor in the development of blindness following spine surgery. 

EQUIPMENT

• Posterior approach • A Jackson table provides a radiolucent frame that also allows for 360° rotation, making positioning safer. • Insertion of Mayfield pins attached to the Jackson table with a Mayfield adaptor eliminates external pressure on the eyes from downward pressure during cannulation of high thoracic pedicles. • Anterolateral approach • Beanbag • Radiolucent table that can flex

PROCEDURE 73  Thoracolumbar Spine Injuries

934

A

B FIG. 73.8 

Anterolateral Approach • Lateral decubitus positioning with the left side up is used for most lumbar retroperitoneal, thoracoabdominal, and thoracotomy approaches to the spine (Fig. 73.9). • Left side up, over a beanbag, on a radiolucent operating table is used for injuries at the level of T5 and below. • Above T5, right side up may provide better exposure away from the aortic arch. • The patient is positioned over the break in the table so flexion of the table will permit lateral flexion. • For lumbar retroperitoneal approaches, the lumbar spine should be placed directly over a break in the table, which is then flexed down to increase the opening between the ribs and the pelvis. However, this break in the table should be straightened out prior to reconstructing the vertebral body; otherwise the cage will be placed in an angled position relative to the end plates. • A roll is placed under the axilla and the upper arm is placed in a position over a pillow or armboard. • The hips and knees are padded and flexed. •  The beanbag should not come higher than the umbilicus anteriorly and the spinous processes posteriorly. 

FIG. 73.9  Modified from Lee Y-P, Templin C, Eismont F, Garfin S. Thoracic and upper lumbar spine injuries. In Browner B, Jupiter J, Levine A, Trafton P, eds. Skeletal Trauma. Philadelphia: Saunders, 2002, 957, 961.

Portals/Exposures • A decision needs to be made whether the injury will be treated from the posterior aspect only, anterior aspect only, or both. • Reasons for selecting a particular approach depend on bony fracture morphology, neurologic status, and integrity of the posterior ligamentous complex. • There are variations in practice patterns for the surgical approach from surgeon to surgeon.

PROCEDURE 73  Thoracolumbar Spine Injuries

• The posterior-only approach can be performed in patients with disruption of the posterior ligamentous complex who are intact neurologically or if neurologically complete. • Reasons for an anterolateral approach are (1) to restore anterior column biomechanical support and (2) a need for decompression. • The anterolateral approach can be done as the primary means of decompression and stabilization without a posterior approach if the posterior ligamentous complex is intact. • If the spine is not stabilized adequately after use of the anterolateral approach (i.e., the posterior ligamentous complex is disrupted, such as in a severe burst fracture, or the bone quality is poor), a posterior approach may then be needed to supplement fixation and to restore stability to the posterior ligaments. • An anterolateral approach may also be done as a secondary operation, after the posterior approach, to restore anterior column support and improve decompression (i.e., in the setting of a translational fracture). • In situations in which the patient has disruption of the posterior ligamentous complex and is neurologically incomplete, a combined anterior and posterior approach may be required. This can occur in severe burst fractures, flexion-distraction injuries through the ligaments, and translational injuries. • If anterior access is not feasible in these cases, such as with comorbidities or additional injuries, or instrumentation access is not feasible anteriorly (L5, L4, T1, T2), posterolateral decompression and posterior stabilization may be an alternative. • If both front and back approaches are required for a translational injury in a patient with a neurologically incomplete spinal cord injury, the posterior approach should be performed first to reduce the translation and then decompress the canal posteriorly. The anterior approach should then be performed to remove any additional or residual compressive fragments if needed. Although decompression is the priority, realignment of the translation will relieve neurologic compression indirectly by realigning the spinal canal. • In contrast, in a severe burst fracture, in which the patient is neurologically incomplete and the posterior ligamentous complex is not intact, the anterior approach should be done first to decompress the spinal canal with reconstruction of the vertebral body, followed by posterior instrumentation to reestablish the posterior ligamentous complex stability. 

Posterior Approach • The skin incision is centered over the traumatic injury. • Muscle is elevated off the lamina and out laterally toward the transverse processes of the thoracic and/or lumbar spine. • The spine is exposed with adequate levels above and below the fracture. • Confirmation of levels is done using clinical findings in the operative field and documentation using radiographs or fluoroscopy. • The surgeon must ensure that landmarks for pedicle screw insertion are adequately exposed. Fig. 73.10 shows a wide exposure with visible landmarks of the transverse process, facet, and pars. 

FIG. 73.10 

935

PEARLS

• Posterior approach • With significant posterior element injury, such as in a fracture-dislocation, there will be considerable amounts of clinical “bogginess,” a “step,” or a gap. The subcutaneous tissue will appear reddened from hemorrhage into the tissues and fascia may already be torn open from the trauma with dissection done in the zone of trauma. • Use cautery and bipolar to minimize blood loss and a cell saver to recycle blood products. • It is safer to expose above and below the injury site and then complete dissection toward the injured level if the lamina is split. • Anterolateral approach • On a preoperative chest radiograph, draw a line perpendicular to the spinal axis from the level of the injury until it intersects a rib. This is the rib that needs to be resected during exposure. • Just before rib resection, a radiograph may be taken with a metallic marker on the rib.

936

PROCEDURE 73  Thoracolumbar Spine Injuries

PITFALLS

• Potentially more bleeding occurs during exposure for a fracture case than for an elective spine case. • During exposure, landmarks may be altered and care must be taken not to inadvertently dissect into the spinal canal and spinal cord if the interlaminar spaces are widened or vertebral bodies are translated. • If the level approached is lumbar, an oblique incision is made from the midaxillary line to the umbilicus for L3-L4, at the middle to upper third of the way between the umbilicus and pubic symphysis for L4-L5, and midway between the umbilicus and pubic symphysis for L5-S1. • The external oblique is parallel to the oblique skin incision. The internal oblique is 90° perpendicular to this direction. The transversalis abdominus muscle is horizontal, and the transversalis fascia is underneath. • The peritoneum and retroperitoneal fat are swept away ventrally away from the spine. • Dissection is carried out down to the psoas. • Care is taken to avoid injury to the sympathetic trunk lying on the medial aspect, the lumbar plexus, and the genitofemoral nerve on the surface. The ureter can be identified with peristaltic movement and usually moves with the peritoneum as it is reflected anteriorly. • A localizing radiograph should be obtained. • Segmental vessels are found in the valleys, and should be ligated as close to the aorta as possible, away from the foramen. • Retractors from the Synframe can be utilized to improve exposure. • The psoas is taken laterally in the lumbar and thoracolumbar regions.

Anterolateral Approach • The incision varies depending on the level approached for both the lumbar and thoracic spine (see Fig. 73.9). • If the level approached is thoracic or thoracolumbar, an incision is made over the rib one to two levels proximal to the level of the spinal injury (e.g., the 10th rib is resected for a T12 fracture). • The rib is exposed and dissected free of the underlying neurovascular bundle. • The rib is then resected from its anterior tip to the costotransverse joint using rib cutters. The ends can then be sealed with bone wax for hemostasis. The rib is saved for future bone grafting. • Fig. 73.11 shows a lateral approach to the thoracoabdominal spine from the left side, and the 10th rib excised with the external oblique, internal oblique, and transverse abdominal muscle. The neurovascular bundle is present underneath the excised rib, and under that is the diaphragm and a portion of the pleural tissue. • The pleura is then incised, without injuring the lung. • At the thoracolumbar level, the diaphragm is identified, and the peritoneum is mobilized away with blunt dissection. • The diaphragm can be released from the lateral wall and, posteriorly, the medial and lateral arcuate ligaments and the left crus of the diaphragm are detached, leaving a 1.5-cm cuff for repair. • Fig. 73.12 shows the diaphragm excised 2.5 cm from the peripheral attachment to the chest wall and blunt dissection of the retroperitoneal fat from the diaphragm. Stitches are inserted to mark the diaphragm for repair at the end. 

Transverse abdominus

External oblique

Excised 10th rib

INSTRUMENTATION

• Anterolateral approach • A retractor system, such as the Synframe from Synthes, can help optimize exposure and lighting. • A cell saver may minimize the need for transfusion.

Diaphragm with pleura

Neurovascular bundle

11th rib

CONTROVERSIES

• Minimally invasive fixation options are becoming more popular, but their roles may be limited to spine fractures that have not translated significantly or do not have severe deformity.

Internal oblique

FIG. 73.11 

PROCEDURE 73  Thoracolumbar Spine Injuries Retroperitoneal fat

Diaphragm

Peritoneum

Aorta Psoas major Left crus released Pleura 11th rib

937

PEARLS

• Ensure that landmarks for pedicle screws are well exposed, including the facet joint, transverse process, and pars. • Review the CT spine preoperatively to understand the pedicle trajectories and diameters, and preoperatively to template approximate screw lengths. • Pedicle screws that are too long on the lefthand side may need to be revised if near the aorta. Rarely is a pedicle screw revised for being too short. • Thoracic pedicle screws may need to be placed using an “in-out-in” technique, especially in areas that may be too narrow to accommodate a screw. • If a screw can be put easily into L1 or T5 based on pedicle diameter, usually the rest of the spine can accommodate pedicle screws as the transverse diameters are larger than these two levels.

Diaphragm

FIG. 73.12 

PROCEDURE: POSTERIOR APPROACH Step 1 • Insert pedicle screws using a pedicle screw set. •  Fig. 73.13 shows the USS Fracture Module with Schantz screws. These screws can be utilized as joysticks to manipulate the spine. The USS Fracture Module can also be utilized to apply distraction to the posterior spine and then apply lordosis independently while having the distraction locked in to aid in reduction of burst fractures through indirect ligamentotaxis. • An intraoperative three-dimensional frameless stereotactic navigation unit with proper registration, utilizing techniques, such as surface matching, may help aid in pedicle screw placement. Fig. 73.14 shows the Stryker Navigation unit (Fig. 73.14A) with three-dimensional frameless stereotactic capabilities (Fig. 73.14B). • Depending on injury pattern, long-segment instrumentation (three above and below) may be needed, such as in fracture-dislocations, or short-segment instrumentation (single level above and below) may be needed, such as in ligamentous Chance fractures or some burst fractures. 

FIG. 73.13 

PITFALLS

• Pedicle diameters vary; pedicle screw diameters should reflect these changes. • The narrowest pedicles are at L1 and the region of T4, T5, and T6. • Bulky retractors may prevent adequate medialization at lower lumbar levels and lead to laterally placed screws.

INSTRUMENTATION/IMPLANTATION

• A pedicle screw set with the ability to translate the spine in multiple planes, such as the USS Fracture Module or the USS II Dual Opening Set, makes fracture reduction easier.

938

PROCEDURE 73  Thoracolumbar Spine Injuries

PEARLS

• Utilize a microscope. This aids in lighting and magnification, and allows the surgeon to operate without having to flex the neck, which occurs when using loupes and a headlamp. • Avitene rolled in Surgicel (i.e., “small empanadas”) can aid in hemostasis along with products such as gel foam and neuropatties. • Utilize a reverse Epstein curette to get under the dural sac and push fragments away from the neural elements. • Utilize ultrasound to assess the decompression in both the sagittal and axial planes. • Maintain mean arterial blood pressures above 90 mm Hg to maintain adequate spinal cord perfusion during surgery to minimize secondary spinal cord injury. This can be done through appropriate fluid administration, administration of vasopressors, and transfusion of blood products, if needed. • Always finish putting in screws prior to decompression. This minimizes bleeding with an open canal and prevents the possibility of inadvertent plunging into an open canal. • Save bone from the decompression for the fusion.

A

PITFALLS

• Thoracic nerve roots are relatively small and can be easily cut during a wide thoracic decompression. • Dural tears may be present when decompressing burst fractures with lamina fractures that entrap the dural sac during recoil of the lamina. • During induction, mean arterial pressures may drop, adding secondary injury to a spinal cord injury.

B FIG. 73.14 

Step 2 INSTRUMENTATION/IMPLANTATION

• Microscope • Wide range of Cloward retractors and curettes for decompression

CONTROVERSIES

• Multimodal neuromonitoring may be available at larger trauma centers and can be used for incomplete spinal cord–injured patients.

• The spinal canal is decompressed from the posterior approach. • This may involve a laminectomy and, in burst fractures, resection/burring down of the pedicle to gain access to the retropulsed posterior vertebral body wall. •  Fig. 73.15 shows the technique of posterolateral decompression with exposure of the spine (Fig. 73.15A), followed by exposure of the dura mater at the level of the pedicle (Fig. 73.15B). • A burr can be used to create an empty hole in the pedicle into the posterior vertebral body, and bone fragments of the medial wall of the pedicle can be removed with a pituitary (Fig. 73.15C). • A reverse Epstein curette can then be carefully placed under the dural sac, and the retropulsed bone fragments can be pushed anteriorly away from the neural elements into the vertebral body (Fig. 73.15D). This can be done unilaterally or bilaterally (Fig. 73.15E). • Some injuries may require an initial posterior decompression to allow for direct visualization of the spinal cord during the reduction maneuver. In fracture-dislocations, the reduction of the translational component can indirectly provide significant canal decompression. 

PROCEDURE 73  Thoracolumbar Spine Injuries

A

939

B

C

D

E

FIG. 73.15  Modified from Lee Y-P, Templin C, Eismont F, Garfin S. Thoracic and upper lumbar spine injuries. In Browner B, Jupiter J, Levine A, Trafton P, eds. Skeletal Trauma. Philadelphia: Saunders, 2002, 957, 961. PEARLS

Step 3 • The deformity is reduced and rods are placed with final tightening of nuts/caps, as shown for the short-segment fixation in Case 1 (Fig. 73.16A). • Crosslinks are applied above and below the injury (Fig. 73.16B). • The wound is thoroughly irrigated with several liters of saline. • Bone graft is applied for fusion. • Watertight closure of the fascia, subcutaneous layer, and skin is done. 

• Deformity reduction in a burst fracture is done via ligamentotaxis. • For burst fractures, the USS Fracture Module allows for application of distraction to stretch the posterior longitudinal ligament (which is inherently a kyphogenic maneuver), followed by an independent reduction of the angular deformity through lordosis. • For fracture-dislocations, systems such as the USS II Dual Opening System allow for powerful coronal and sagittal plane correction. The sticks on the screws also allow for direct manipulation of the spine to reduce virtually any degree of translation. • By undercontouring the rod, the spine can be brought to the rod for deformity reduction. • Avoid crosslinks directly on the site of injury because this prevents the placement of adequate bone graft and causes MRI artifact on follow-up axial imaging.

940

PROCEDURE 73  Thoracolumbar Spine Injuries

PITFALLS

• Osteoporosis may lead to difficulty in fracture reduction owing to hardware pullout.

PITFALLS

• The aorta lies anteriorly. Be cautious and avoid anterior dissection.

A

B FIG. 73.16 

PROCEDURE: ANTEROLATERAL APPROACH PEARLS

• CT scans should be reviewed to assess the key bony pieces that need removal for the decompression.

PITFALLS

• Attempting quick removal of bone fragments off the dura may lead to a dural tear; it is better to perform a gentle blunt dissection of the dura off the bone and then remove it. • Blood loss is an issue, especially with fresh burst fractures.

INSTRUMENTATION/IMPLANTATION

• A cell saver and Floseal can help reduce the need for transfusions. • For patients requiring larger amounts of blood, recombinant factor VII can help reestablish clotting profiles quickly, improving visualization.

PEARLS

• A tilted anterior vertebral body implant may lead to worse tilting and implant failure when the patient is upright. PITFALLS

• If the bed is not straightened prior to cage insertion, the cage will be tilted.

Step 1: Staple/Screw Insertion and Diskectomies • Once the level is identified and confirmed clinically and by radiographs, staples/ screws are inserted prior to decompression. • Staples are utilized on the lateral aspect of the vertebral body, which helps anchor the screws. • Posteriorly, the screws are directed parallel to or slightly away from the cord. • Anteriorly, the screws are directed slightly dorsally to get longer lengths. • All screws should be bicortical. • Screw lengths should be preoperatively templated. • Once screws are in, diskectomies can be performed. • Diskectomy of the disks proximal and distal to the fracture is performed. • Disks are the “hills.” • Cartilage is denuded from endplates for fusion. 

Step 2: Decompression • The pedicle of the fractured level is identified; this will provide entry into the spinal canal and serve as a marker where the canal is situated. • Using a large rongeur, remove large bone fragments (which should be saved for fusion). A microscope allows for better lighting and magnification. • Once space is created in the ventral aspect of the spinal level, posterior decompression can begin. • The pedicle can be resected with careful attention to the nerve root. In a burst fracture, the retropulsed bone fragments are situated at the level of the pedicles, as in the patients in Case 2 (see Fig. 73.2) and Case 3 (see Fig. 73.3). • The posterior wall of the vertebral body below the pedicle can be pushed anteriorly with a reverse Epstein curette, away from the neural elements. • Retropulsed bone fragments can then be removed with a Cloward and a Penfield 4 retractor, dissecting between the bone and dural sac under a microscope. • Bone can also be removed with a high-speed burr.

PROCEDURE 73  Thoracolumbar Spine Injuries

• The bed can be rotated along to the patient’s left, with the microscope, to get a better view of the contralateral right side. • Decompression should go from pedicle to pedicle. • The contralateral vertebral body wall should be retained. Going through the contralateral wall may lead to disruption of the right segmental artery. 

Step 3: Vertebral Body Reconstruction and Fusion • Prior to the availability of cages, allograft was used for reconstruction. • The patient in Case 3 was treated with reconstruction with allograft bone packed with autogenous bone graft from a corpectomy. • The patient was then placed prone and posterior pedicle screws were inserted to stabilize the posterior ligamentous complex. Fig. 73.17 shows a postoperative AP radiograph (Fig. 73.17A) and sagittal CT scan (Fig. 73.17B). • Nonexpandable or expandable cages are currently preferred for reconstruction. • A distractor is inserted between the anterior screw heads. • Callipers are utilized to measure defect length. • An appropriate-size cage is chosen. • Most modern systems will have modular components in terms of cage diameters and angles on the cage end caps, and even have expandable cages. The Stryker VLIFT cage (Fig. 73.18A) has a continuously variable length in comparison to other cages, which can be expanded only in finite increments. • Modern nonexpandable cages will also have easy methods of cutting the cages to appropriate lengths, in direct contrast to older methods such as the Harms cage. End caps should be chosen to appropriately restore lordosis. • The center of the cage is packed with bone graft (Fig. 73.18B). • The bed should be straightened prior to cage insertion. • The cage is then inserted parallel to the spinal axis and placed as far right or central as possible. • If expandable, the cage is expanded to fill the defect. It is easy to directly visualize placement in the sagittal plane. However, the coronal placement cannot be seen and radiography is ideal to ensure proper placement. It is easy to tilt the cage.

A

B FIG. 73.17 

941

INSTRUMENTATION/IMPLANTATION

• Expandable cages and modular nonexpandable cages are available. Allografts can also be utilized, but they require measuring and appropriately cutting the graft.

942

PROCEDURE 73  Thoracolumbar Spine Injuries

A

B FIG. 73.18 

PEARLS

• Proper postoperative wound management is critical. Incisions extending toward the lumbar and lumbosacral region may be susceptible to fecal bacteria contamination if the patient is nursed in diapers. Daily cleansing with dressing changes and sealing the dressings with OpSite is necessary, especially for patients with impaired bowel/bladder function.

CONTROVERSIES

• Bone stimulators, such as magnetic bone stimulators and ultrasound stimulators, may improve time to bony union and fusion rates. However, this is controversial.

• The cage should not overstuff the defect because it may then migrate when the patient is upright or may subside through the end plates. • Distraction is then removed. • Anterior and posterior rods are inserted in slight compression and blocking caps put on. • The anterior and posterior rods are crosslinked. • The patient in Case 2 was treated with reconstruction with an expandable Stryker VLIFT Cage with anterior Xia screws and staples. No posterior approach was needed. Fig. 73.19 shows decompression of the canal on lateral (Fig. 73.19A) and AP (Fig. 73.19B) radiographs and an axial CT scan (Fig. 73.19C). • If a thoracic or thoracoabdominal approach was used, a chest tube should be inserted. • Careful closure of structures, such as diaphragm and muscle layers, must be done to prevent hernias. 

PROCEDURE 73  Thoracolumbar Spine Injuries

A

B

C FIG. 73.19 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Mean arterial blood pressures must be maintained above 90 mm Hg in patients with spinal cord injuries for 48 hours after surgery to maintain adequate cord perfusion because an injured spinal cord cannot autoregulate adequate blood flow. • Frequent regular spinal cord assessments are necessary. • CT scans should be obtained to assess extent of decompression and reduction of fracture, and to assess pedicle screws for breaches. • Low-molecular-weight heparin is given to prevent deep venous thrombosis in patients with spinal cord injuries after postoperative bleeding is stabilized. In the immediate postoperative period when bleeding is an issue, especially into the epidural space, the patient can be started on pneumatic sequential compressive devices. • Aggressive management is needed postoperatively to prevent pressure sore formation, including frequent and regular position changes (every 2 hours), air mattresses, physiotherapy to maintain range of motion of joints, padding of heels, and frequent checks of areas at risk of pressure sore formation.

943

944

PROCEDURE 73  Thoracolumbar Spine Injuries

• Appropriate analgesics should be provided, including medications for neuropathic pain if needed. This may be best provided through a dedicated acute pain service. • Patients should be nicotine free (i.e., no smoking, no nicotine patches, or no nicotine gum) while fusion is taking place. Also, nonsteroidal antiinflammatory drugs and bisphosphonates should be avoided while fusion is taking place. • Once medically stable, patients who have spinal cord injuries should be transferred to a rehabilitation center focused on spinal cord rehabilitation. • Patients with cord injuries above T5 are at risk of autonomic dysreflexia acutely in the first month and chronically.

EVIDENCE Agarwal N, Heary RF, Agarwal P. Adjacent-segment disease after thoracic pedicle screw fixation. J Neurosurg Spine. 2018;28(3):280–286. This long-term radiographic evaluation revealed the use of pedicle screws for thoracic fixation in 122 patients to be an effective stabilization modality with fusion in 94% of patients. Adjacent segment disease was rare (one case at a mean follow-up of 50 months) and seemed to be less of a problem in the relatively immobile thoracic spine compared with the more mobile cervical and lumbar spines. Gunnarsson T, Krassioukov AV, Sarjeant R, Fehlings MJ. Real-time continuous intraoperative electromyographic and somatosensory evoked potential recordings in spinal surgery: correlation of clinical and electrophysiologic findings in a prospective, consecutive series of 213 cases. Spine. 2004;29:677–684. Grade-B recommendation based on a retrospective cohort for the use of combined multimodal electromyographic recordings and somatosensory evoked potentials for predicting neurologic injury during thoracolumbar spine surgery. Joaquim AF, Patel AA, Schroeder GD, Vaccaro AR. A simplified treatment algorithm for treating thoracic and lumbar spine trauma. J Spinal Cord Med. 2018;7:1–11. This paper provides a modern view of the treatment of thoracolumbar spine fractures based in their morphology, associated neurologic deficits, and patient characteristics. Kato S, Murray JC, Kwon BK, Schroeder GD, Vaccaro AR, Fehlings MG. Does surgical intervention or timing of surgery have an effect on neurological recovery in the setting of a thoracolumbar burst fracture? J Orthop Trauma. 2017;31(suppl 4):S38–S43. This review states that, although operative management is generally recommended for thoracolumbar fracture with significant neurologic deficits, the evidence is weak, and nonoperative management is a valid option. With regard to timing of operative management, high-quality studies comparing early and delayed intervention are lacking. Sayer FT, Kronvall E, Nilsson OG. Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature. Spine J. 2006;6:335–343. Grade-A recommendation that there is insufficient evidence to support the use of methylprednisolone as a standard treatment in acute spinal cord injury. Urquhart JC, Alrehaili OA, Fisher CG, et al. Treatment of thoracolumbar burst fractures: extended follow-up of a randomized clinical trial comparing orthosis versus no orthosis. J Neurosurg Spine. 2017;27(1):42–47. This randomized controlled trial failed to show any benefit of orthosis use following the nonoperative treatment of thoracolumbar burst fractures. Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. 1997;87:239–246. Grade-B recommendation based on prospectively applied resuscitation principles to maintain mean arterial blood flow above 85 mm Hg in patients with spinal cord injuries. Surgery was performed in selected cases. Early and aggressive management of acute spinal cord injury optimized the potential for neurologic recovery.

PROCEDURE 74

Treatment of Open Fractures Adrian Z. Kurz and Brad Petrisor INDICATIONS

CONTROVERSIES

• Management of open fractures is indicated with any Gustilo and Anderson open fracture grade 1 to 3. There are many different open fracture classifications; however, the most commonly used is Gustilo and Anderson described in 1976 based on wound characteristics after the initial debridement (Table 74.1).

• Antibiotic choice • Timing of surgery • Wound irrigation techniques and additives • Stabilization techniques • Adjunctive therapies • Open wound management

TABLE 74.1    Gustilo and Anderson Classification for Open Fractures

Type

Description

I

Wound less than 1 cm, clean

II

Wound greater than 1 cm, without extensive soft tissue damage, flaps, or avulsions; moderate contamination

III

Severe soft-tissue injury with high level of contamination

IIIA

Soft-tissue coverage of bone adequate

IIIB

Bone coverage poor; usually requires further procedures for soft-tissue coverage; severe contamination

IIIC

Associated with a vascular injury requiring repair

Examination/Imaging The tibia is the most common site for open fracture (up to 50% of all open fractures), followed by the forearm, ankle, distal femur, and femoral shaft. • Emergency management • Immediate emergency department management includes Advanced Trauma Life Support protocol to identify life-threatening injuries. The open fracture is then managed. Basic open fracture management includes immediate intravenous antibiotic administration. Provide tetanus prophylaxis, depending on immunization history (Table 74.2). • The limb should then be examined. Documentation of neurovascular status is crucial. Any concerns for vascular injury will prompt further investigation usually with a computed tomography (CT) angiogram as they are readily available in trauma centers. • The wound should then be examined. Gross debris should be removed with the aid of irrigation at the bedside. A moist sterile dressing is then applied and the limb is reduced to achieve as close to anatomic alignment as possible, and is subsequently splinted (Fig. 74.1). A neurovascular status post reduction should be documented. • A full musculoskeletal examination is carried out to identify concomitant injuries. • Standard orthogonal view radiographs of the affected limb(s) are then obtained to plan operative stabilization of the injury (Fig. 74.2). Include imaging of the joint above and below. • If vascular status was a concern, a CT angiogram is a useful adjunct to identify any vessel injuries that may prompt involvement of the vascular surgical team. • If the fracture has significant articular comminution then a CT scan with 3D reconstruction may be useful, depending on the surgical plan. However, a CT scan after external fixation is, in fact, more beneficial to preoperative planning for the final construct. 

PEARLS

• Ideally, the patient should be positioned only once to allow for both irrigation and debridement of the wound and the stabilization procedures. • Set up a separate sterile table to carry out the irrigation and debridement procedure, particularly when there is a great deal of contamination of the wound. This way, any contaminated instruments will not be used for the stabilization procedure. Consider redraping the limb and changing surgical gloves and gown once the initial debridement has been completed.

945

946

PROCEDURE 74  Treatment of Open Fractures

TABLE 74.2    Suggested Tetanus Protocol*

Tetanus Immunization History

Tetanus Prone?

Suggested Prophylaxis

Unknown or series < 3

Yes

Toxoid and immunoglobulin

Unknown or series < 3

No

Toxoid

Fully immunized, booster > 5 yr ago

Either

Toxoid

Fully immunized, booster < 5 yr ago

Either

Nil

Tetanus-prone wounds include those more than 6 hours old, more than 1 cm deep, devitalized tissue, or grossly contaminated.

FIG. 74.1 

FIG. 74.2 

PROCEDURE 74  Treatment of Open Fractures

SURGICAL ANATOMY

EQUIPMENT

• As open fractures can occur anywhere in the body, the orthopedic trauma surgeon must be knowledgeable in the surgical anatomy of all areas of the appendicular skeleton. • Because the soft tissue usually has more damage than initially anticipated, identification of anatomic structures can be more challenging than in virgin tissue. Protection of neurovascular structures is critical. • Open fractures should be graded according to the Gustilo and Anderson classification after initial debridement: • Type I fractures (Fig. 74.3) • Type II fractures (Fig. 74.4) • Type III fractures (Fig. 74.5) 

A

B FIG. 74.3 

A

947

B FIG. 74.4 

• The surgeon needs to plan for use of a fracture table or radiolucent table, as required. Any fluoroscopy equipment needs to be arranged appropriately in the room before the start of the procedure.

948

PROCEDURE 74  Treatment of Open Fractures

A

B FIG. 74.5 

PITFALLS

• During debridement and exploration, be careful not to devascularize any bony fragments that may be supported only by a small amount of soft tissue. • Remove all cortical bony fragments that have been skeletonized with no soft-tissue attachment. These may become a nidus for infection if not completely removed. Consider keeping articular fragments because without them the joint cannot be reconstructed. CONTROVERSIES

• Timing of surgical treatment • Historically, based on two studies, there was a trend to perform the initial debridement within 6 hours after the injury to decrease infection rate. • However, more recent studies, including randomized data, have not shown any significant difference in infection rates when comparing early debridement (within 6 hours) to later debridement (after 6 hours). One recent trial however does suggest that for each hour of delay, there is a 3% increased risk of deep infection. Ideally, the patient should be brought to the operating room as soon as possible without unnecessary delay. • Ultimately, the use of systemic antibiotics, adequacy of debridement, and soft-tissue coverage may be more important variables.

POSITIONING • Positioning of the patient will depend on the location of the open fracture. Polytrauma patients may need to be positioned to accommodate multiple fractures. This must be taken into consideration. Furthermore, the limb should be draped to ensure adequate exposure in the event that the wound must be extended or vascular access is anticipated. Most patients can be positioned supine. • The use of a fracture table or radiolucent table may be required, particularly when treating long-bone fractures in the lower extremity. • Fluoroscopy is usually an adjuvant that can be useful in open fracture management. Positioning of the fluoroscopy machine in the appropriate area to facilitate ease of room flow, space for the surgical team, and easy viewing of the screen is important. The fluoroscopy machine should be brought into the room once the sterile tables are in position for surgery. Set the fluoroscopy up prior to the start of the initial surgical incision. 

PROCEDURE Step 1: Debridement • The limb should be pre-scrubbed with a 2% chlorhexidine scrub brush or similar alternative. Remove gross debris in the open wound as well as the debris on the intact skin (Fig. 74.6). The leg is then prepared with iodine and draped to allow for extension of the open wound and vascular access if necessary. • Consider the use of a separate sterile table which becomes the dirty table throughout the debridement. This is so the surgical equipment used for the debridement does not cross-contaminate the sterile table used for the fixation. Consider redraping as well as regowning and gloving once the debridement is complete. • Debridement begins with extension of the open wound proximally and distally until healthy tissue is visualized (Fig. 74.7). Attempt to make the extension of the wound in line with the planned surgical incision for the final construct. Only the minimum skin required for thorough debridement should be excised as primary closure of the wound is the best scenario (Fig. 74.8A). However, all devitalized skin edges must be sharply excised to leave a clean bleeding skin edge.

PROCEDURE 74  Treatment of Open Fractures

• Next, inspect the soft tissues. Look for gross debris and remove this using a rongeur. Look for the four Cs of muscle health (contractility, color, consistency, and capacity to bleed). Remove devitalized muscle and soft tissue carefully but completely (Fig. 74.8B). Deliver the bone ends through the wound and use a curette and rongeur to debride the bone ends until they are clean (Fig. 74.9). • When performing the debridement, avoid distally based flaps and leave the smallest skin flaps whenever possible. Avoid and protect neurovascular structures. The surgeon must be aware of the local surgical anatomy. 

A

CONTROVERSIES

• Recent results from the fluid lavage of open fracture wounds (FLOW) trial suggest that saline is the solution of choice to irrigate open wounds. However, the volume of saline irrigation solution to be used is controversial. Use enough solution to appropriately flush out all foreign debris and devitalized tissue. • In regard to fluid pressure, assess the amount of contamination of the wound to help guide the decision process. The FLOW trial showed no difference in very low (gravity flow), low, and high pressures for irrigation in open fractures. • In cases with lower levels of gross contamination and earlier access to the operating room, the surgeon may consider using lower pressure irrigation methods. • However, if there is a delay to the operating room with a higher level of gross contamination, one may consider using a higher pressure system to more effectively remove debris.

FIG. 74.7 

FIG. 74.6 

B FIG. 74.8 

949

PROCEDURE 74  Treatment of Open Fractures

950

PITFALLS

• Many hospitals do not carry prefabricated antibiotic beads. Be prepared to make antibiotic beads using cement with the addition of antibiotic powder. Ensure the hospital pharmacy carries the appropriate doses of heat-stable antibiotic powder that may be required. FIG. 74.9 

PEARLS

• Antibiotic beads are simple to make intraoperatively. Use standard bone cement (PMMA) and add a heat-stable antibiotic powder of choice. Mix gently to allow heterogeneity of the solution to increase antibiotic elution properties. Allow the mixture to become doughy. Roll up the cement into small beads to increase surface area. Use a suture wire or a nonabsorbable, monofilament suture with a straight needle to thread each bead sequentially onto the suture by piercing the doughy bead with the straight needle. Thread as many beads as desired. Cut needle off, tie each end, and allow to harden to become an antibiotic bead chain. CONTROVERSIES

• The antibiotic regimen and duration of therapy are controversial. Most authors recommend 1 to 3 days of antibiotic therapy initially and after each subsequent operative procedure.

A

Step 2: Wound Irrigation • Many surgeons will use 3 L of solution for type 1 and 6 L for type 2 or 3, graded according to the Gustilo and Anderson classification. However, no evidence supports these recommendations, with the overall recommendation being to use enough for the wound to be clean of all contaminating debris and tissue. • There are a variety of irrigation pressure options. Very low pressure (1–2 psi; by gravity or bulb syringe), low pressure (5–10 psi; low pressure setting on a pulsed irrigator), and high-pressure irrigation systems (>20 psi; high-pressure setting on a pulsed irrigator). The FLOW trial did not find any differences among the irrigation pressure options and thus the decision can be left to surgeon’s choice based on clinical acumen and availability of high-pressure flow systems (Fig. 74.10). • Very low-pressure lavage (by gravity or bulbed syringe) may effectively remove contaminants with less bone damage but may be less effective after a significant (>24 h) surgical delay (Fig. 74.11). • Additives • The FLOW trial has shown superiority with normal saline as the standard solution of choice for irrigation of open wounds. • It is controversial whether additives, such as antibiotics or antiseptics, provide any useful benefit. Furthermore, there is a cost associated with additives. 

B FIG. 74.10 

PROCEDURE 74  Treatment of Open Fractures

A

B FIG. 74.11 

Step 3: Antibiotic Treatment • To reduce infection rate, the standard of care is time to antibiotics less than 3 hours after the initial injury. • Preoperative or intraoperative wound cultures are not accurate in determining infection risk or the infecting organism. Therefore, wound cultures should not be obtained at the initial debridement or in the emergency department. • For Gustilo and Anderson grade 1 and 2 open fractures, a first-generation cephalosporin, such as cefazolin, is widely available and a sound choice. • For Gustilo and Anderson grade 3 injuries, or soiled grade 2 injuries, the addition of an aminoglycoside, such as Gentamycin or tobramycin, is recommended. • For open fractures associated with gross contamination, such as farm injuries, coverage for anaerobic bacteria is warranted and the recommendation is the addition of penicillin. Other choices include metronidazole. • Local antibiotics • The use of local antibiotics (i.e., antibiotic beads, antibiotic powder) can generate high local doses of antibiotics with low systemic concentrations. • There is a trend to use vancomycin powder in open fractures if primary closure is obtainable. However, no evidence currently supports this practice. • Local insertion of antibiotic beads promotes elution of the antibiotic locally and may be a useful adjunct to systemic antibiotics in open fractures (Fig. 74.12). • The antibiotic beads can be either those made intraoperatively or the available premanufactured antibiotic beads. • Make the beads intraoperatively and insert the antibiotic bead chain (Fig. 74.13) into the wound (Fig. 74.14A and 74.14B). • The chain should be placed in the wound and the wound sealed with OpSite to allow any hematoma to collect underneath with the antibiotics (Figs. 74.14C and Fig. 74.15). 

FIG. 74.12 

951

952

PROCEDURE 74  Treatment of Open Fractures

FIG. 74.13 

A

B

C FIG. 74.14 

PROCEDURE 74  Treatment of Open Fractures

FIG. 74.15 

Step 4A: Wound Coverage • Early wound coverage is now the best practice for open fractures because it reduces infection rates, decreases reoperations, and decreases time to union (Fig. 74.16). This can be accomplished through many methods; however, the optimal way to approach this difficult problem is to use the most appropriate and effective method, regardless of complexity. This is known as the reconstructive elevator (going straight to the best available option), rather than reconstructive ladder (a stepwise approach) that has been used in the past. • If early primary wound closure can be obtained, this is the recommended approach. Primary closure needs to be free of tension. An over-tensioned primary closure probably indicates that the wound needs alternative coverage options. • After the initial debridement the surgeon must grade the wound (Gustilo and Anderson classification) and anticipate the need for soft-tissue coverage. If primary wound closure cannot be obtained, options for coverage depend on the location of the wound and the type of fracture. Expedient referral to a plastic surgery service is paramount to attempt early coverage attempting to decrease subsequent infection and to increase union rates (Fig. 74.17). • If the wound cannot be closed primarily, options include negative pressure wound therapy (NPWT) with subsequent skin graft, NPWT to bridge and allow delayed local or free flaps, acute local flaps, acute free flaps, and acute bone shortening with subsequent lengthening to allow sutured closure. • Benefits of NPWT are that it promotes blood flow, promotes granulation tissue, removes edema, and decreases bacterial burden (Fig. 74.18). • Contraindications to NPWT would be to place the dressing over a neurovascular bundle or recent vascular anastomosis. Furthermore, active bleeding or a wound anticipated to have high fluid output would be a contraindication to NPWT. 

FIG. 74.16 

953

954

PROCEDURE 74  Treatment of Open Fractures

FIG. 74.17 

FIG. 74.18 

Step 4B: Surgical Stabilization • A stable fracture is of paramount importance in the operative treatment of open fractures. Whenever possible, definitive stabilization should be done at the time of the initial procedure. Primary internal fixation is warranted if the wound has been debrided effectively, the initial wound contamination was low, and there is adequate soft-tissue coverage allowing primary closure. •  This will help restore limb alignment, minimize further soft-tissue damage, reduce edema and pain, improve blood flow, and decrease further bacterial spread. • Types of definitive fixation, which are many, are dependent on the surgeon. Upper extremity fractures and periarticular fractures may be best treated with plate fixation, whereas diaphyseal lower extremity fractures are routinely amenable to intramedullary nail fixation. • Temporary external fixation with subsequent second surgery for definitive open reduction and internal fixation may be necessary in cases with significant bone or soft-tissue loss or other cases that require rapid stabilization, such as vascular injury requiring repair or a patient who is or may be becoming unstable (Fig. 74.19). External fixation may allow for a second look debridement and wound management planning with the plastic surgery service. 

PROCEDURE 74  Treatment of Open Fractures

A

B

C FIG. 74.19 

Step 5: Wound Closure • Nosocomial organisms are the most frequent cause of infections, and therefore there is a trend toward earlier closure of open wounds. Immediate closure does not seem to increase infection rates compared with delayed closure. Some studies even suggest that early closure will decrease infection rates. • If immediate closure is not feasible, then NPWT should be initiated to bridge for flap coverage or to eventually cover with skin grafting, as discussed above. However, if there is concern about significant initial contamination, the wound should be left open, covered with a sterile dressing, and a plan made for a future debridement procedure within 48 hours. If primary closure is unobtainable after the second look debridement, plastic surgery consult is initiated and options for early wound coverage are sought. • Closure of wounds treated with antibiotic beads, as for the patient in Fig. 74.12, can be done after sufficient local healing and removal of the beads (Fig. 74.20). 

FIG. 74.20 

955

956

PROCEDURE 74  Treatment of Open Fractures

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Appropriate wound care dressings are used until the soft tissues have sufficiently healed. Dressing changes need to be performed under sterile conditions and may be best monitored and done by the surgeon. • Signs of infection are best treated surgically with adjuvant antibiotic therapy. • Infection rates by fracture type are as follows: •  Type I: 0%–2% • Type II: 2%–5% • Type IIIA: 5%–10% • Type IIIB: 10%–50% • Type IIIC: 25%–50% • Splints may be used to allow severe soft-tissue swelling to settle down. However, depending on fracture stability, early range of motion of all joints should be initiated as soon as possible. • Weight bearing is permitted through the limb at the discretion of the surgeon. A stable construct should allow early weight bearing. • A schedule of postoperative visits with radiographs identifies the quality and quantity of fracture healing and helps dictate further management. The surgeon must be prepared to perform a secondary procedure, if necessary, to stimulate healing if no progress has been observed.

EVIDENCE Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. J Bone Joint Surg [Am]. 2005;87:1415–1421. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9:219–226. Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532–535. Study Group BESTT, Govender S, Csimma C, et al. Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures. J Bone Joint Surg [Am]. 2002;84:2123–2134. Bhandari M, Adili A, Schemitsch EH. The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone. J Bone Joint Surg [Am]. 2001;83:412–419. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Treatment of open fractures of the shaft of the tibia: a systemic overview and meta-analysis. J Bone Joint Surg [Br]. 2001;83:62–68. Chang Y, Kennedy SA, Bhandari M, et al. Effects of antibiotic prophylaxis in patients with open fracture of the extremities: a systematic review of randomized controlled trials. JBJS Rev. 2015;3(6). pii: 01874474-201503060-00002. https://doi.org/10.2106/JBJS.RVW.N.00088. Charalambous CP, Siddique I, Zenios M, et al. Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union. Injury. 2005;36:656–661. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg [Br]. 2007;89:580–585. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg. 2001;108:1184–1191. Investigators FLOW, Bhandari M, Jeray KJ, et al. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373(27):2629–2641. https://doi.org/10.1056/NEJMoa1508502. Giannoudis PV, Papakostidis C, Roberts C. A review of the management of open fractures of the tibia and femur. J Bone Joint Surg [Br]. 2006;88:281–289. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–458. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742–746. Harley BJ, Beaupre LA, Jones CA, et al. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma. 2002;16:484–490. Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clin Orthop Relat Res. 2005;439:27–31. Hull PD, Johnson SC, Stephen DJ, et al. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. J Bone Joint Surg Am. 2014;96-B(3):379–384. https://doi.org/10.1302/0301-620X.96B3.32380. Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339: 71–75.

PROCEDURE 74  Treatment of Open Fractures Moehring HD, Gravel C, Chapman MW, et al. Comparison of antibiotic beads and intravenous antibiotics in open fractures. Clin Orthop Relat Res. 2000;372:254–261. Okike K, Bhattacharyya T. Current Concepts Review: trends in the management of open fractures. J Bone Joint Surg [Am]. 2006;88:2739–2748. Ostermann PA, Seligson D, Henry SL. Local antibiotic therapy for severe open fractures: a review of 1085 consecutive cases. J Bone Joint Surg [Br]. 1995;77:93–97. Petrisor B, Jeray K, Schemitsch E, et al. FLOW Investigators. Fluid lavage in patients with open fracture wounds (FLOW): an international survey of 984 surgeons. BMC Musculoskelet Disord. 2008;9:7. https://doi.org/10.1186/1471-2474-9-7. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendations. J Trauma. 2005;58(5):1082–1088. Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94(12):1057–1064. Skaggs DL, Friend L, Alman B, et al. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg [Am]. 2005;87:8–12. Swiontkowski MF, Aro HT, Donell S, et al. Recombinant human bone morphogenetic protein-2 in open tibial fractures. J Bone Joint Surg [Am]. 2006;88:1258–1265. Wood T, Sameem M, Avram R, et al. A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage. J Trauma Acute Care Surg. 2012;72(4):1078–1085. https://doi.org/10.1097/TA.0b013e31823fb06b.

957

PROCEDURE 75

Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion G. Yves Laflamme and Jonah Hébert-Davies

PITFALLS

• Many fractures classified as Vancouver type B1 (well-fixed stem) are in reality type B2 fractures with a loose stem that were not recognized (Lindahl et al., 2006). Caution should be exercised before fixing a B1 type fracture involving the cement mantle of a polished cemented femoral stem. • A high failure rate has also been reported for stable femoral stems in varus. Even if the stem is solid, a revision of the femoral stem rather than fixation is preferred. CONTROVERSIES

• With a cemented femoral stem, violation of the cement mantle with unicortical locking screws may induce crack propagation that could lead to loosening of the femoral stem (Fulkerson et al., 2006).

INDICATIONS • Periprosthetic fractures of the femur associated with well-fixed total hip arthroplasty • Vancouver type B1 fractures around the tip of the femoral stem • Vancouver type C fractures distal to the tip of the stem (Brady et al., 2000)

Examination/Imaging • Preoperative assessment should include range of motion of the hip and knee, softtissue (previous incisions) evaluation, neurovascular status, and leg lengths. • Adequate radiographs are needed to identify the extent of the fracture, stability of the prosthesis, and the quality of the bone. • The standard radiographs include a low anteroposterior (AP) pelvis radiograph, a frog-leg or cross-table lateral of the affected hip, and AP and lateral views of the entire femur, including the knee. • Fig. 75.1 shows AP pelvis (Fig. 75.1A) and AP (Fig. 75.1B) lateral (Fig. 75.1C) femur radiographs of a periprosthetic fracture in a 102-year-old female patient with a wellfixed Moore’s prosthesis. • If acetabular osteolysis is seen or suspected, then Judet films should be obtained, with a computed tomography scan to assess the extent of bony deficiency. • Preoperative templating is necessary to determine plate length, plate contouring, and approximate screw lengths. 

A

B FIG. 75.1 

958

C

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

959

TREATMENT OPTIONS

• Most displaced fractures are treated operatively except in patients at very high risk. Nonoperative treatment may be appropriate for stable and nondisplaced fractures. • As the proximal fragment has always been a problem, many types of fixation devices have been used. Two strut allografts or a combination of one strut and one plate are biomechanically proven to be the strongest constructs (Wilson et al., 2005). • The Dall-Miles plate and cables system alone is insufficient for the treatment of periprosthetic femoral fractures (Tsiridis et al., 2003). A combination of screws and cables is essential in the proximal femur.

SURGICAL ANATOMY

PEARLS

• The lateral approach is a quick and easy approach that involves splitting of the vastus lateralis muscle. • There is no internervous plane or intermuscular plane. • The quadriceps receives its nerve supply (femoral nerve) high in the thigh, so splitting the muscle distally does not denervate it (Fig. 75.2). • Numerous perforating branches of the profunda femoris artery traverse the vastus lateralis muscle and can be damaged during the approach. • At the level of the knee, the lateral superior genicular artery is at risk and may need to be coagulated (Fig. 75.3). 

Gluteus medius Gluteus maximus Tensor fascia lata

Iliotibial tract Vastus lateralis

FIG. 75.2 

• Fluoroscopic visualization of the entire femur in both AP and lateral views must be verified prior to patient draping.

PITFALLS

• Care must be taken during rotational alignment of the limb because the bump will cause the hip to be in an externally rotated position. An inflatable/deflatable bump can solve this problem (see Fig. 75.4B).

960

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined Superficial epigastric artery Deep circumflex iliac artery Deep circumflex iliac artery Profunda femoris artery

Abdominal aorta

Inferior epigastric artery External pudendal artery

Lateral circumflex femoral artery

Obturator artery Medial circumflex femoral artery

Perforating arteries

Superficial branch Superior gluteal artery

Common iliac artery External iliac artery Internal iliac artery

Deep branch superior ramus Deep branch inferior ramus

Inferior gluteal artery Medial circumflex femoral artery Profunda femoris artery Femoral artery

Muscular branch

Transverse branch of lateral circumflex femoral artery Perforating branches

Femoral artery Descending branch

Superior lateral genicular branch Inferior lateral genicular branch

Popliteal artery Descending genicular artery Articular branch Superior medial genicular artery

Hiatus in adductor magnus Popliteal artery Superior medial genicular branch

Saphenous branch Inferior medial genicular branch

Inferior medial genicular artery

Superior lateral genicular artery Inferior lateral genicular artery

B

A FIG. 75.3 

POSITIONING • The patient is placed in a supine position on a radiolucent table (Fig. 75.4A). • A small bump or a beanbag should be used under the ipsilateral hip (Fig. 75.4B). • The entire leg and lateral hip region should be prepared and draped to allow proximal extension of the surgical exposure. • Obtain gross metaphyseal alignment using manual traction or skeletal traction. • Position a fluoroscopy C-arm on the contralateral side and place the monitor on the same side near the foot of the table.

Alternative Positioning • The lateral decubitus position, affected side up, on a radiolucent table, is the preferred positioning when the stability of the femoral implant is uncertain. Extension of the incision proximally allows access to the hip joint to test or revise the implants. Additionally, with extensive incisions, gravity will facilitate the retraction of the vastus for optimal visualization. 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

A

961

B FIG. 75.4 

PORTALS/EXPOSURES

PEARLS

• Begin with the small, distal, longitudinal incision (5 cm) over the lateral femoral condyle (distal window) (Fig. 75.5A). • For distal extension, it may be necessary to incise the anterior fibers of the iliotibial tract and then carry down through the capsule and synovium. • Take care to identify the superior lateral genicular artery and to avoid damage to the lateral meniscus (Fig. 75.5B). • A second incision (5 cm) at the tip of the plate is a straight lateral proximal thigh incision (proximal window) (Fig. 75.6A). 

• Confirm the position of the incision with fluoroscopy in order to minimize the length of the incision. • Exposure is limited to the region necessary to apply and secure the plate. PITFALLS

• Preservation of the blood supply of the femur is critical. Medial dissection is avoided, and the linea aspera should not be stripped of its soft-tissue attachments. • The dissection is carried down to the iliotibial fascia, which is then incised parallel to its fibers. • A lateral vastus split or peel off the posterior fascia with meticulous deep soft-tissue dissection in line with its fibers is carried out with care to clamp and cauterize the perforators (Fig. 75.6B).

Superior lateral geniculate artery

Lateral meniscus

B

A FIG. 75.5 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

962

First perforating artery

Vastus lateralis

Distal incision

Proximal incision

A

B FIG. 75.6 

PEARLS

• Before insertion, attach two or more locking screw guides to the distal holes to facilitate their assembly and to manipulate as a handle. • Contour the plate to accommodate the proximal metaphyseal flare and the trochanteric anatomy. PITFALLS

• For correct coronal alignment, the guidewire must be parallel to the joint in the AP view when using the Synthes condylar plate. This specific plate sometimes must be placed off the bone anteriorly to avoid external malrotation. • Whenever possible, the muscle is left undisturbed in the region of the fracture and the plate is placed extraperiosteally deep to the muscle. • Direct access to the fracture may be required to remove incarcerated muscle (spiral fracture type), to help reduction, and to insert screws. In these cases, make a stab wound incision at the level of the fracture to allow access.

A

PROCEDURE: RETROGRADE PLATE INSERTION Step 1: Plate Insertion and Positioning • Insert a locking plate between the muscle and the periosteum, keeping the proximal end of the plate against the femur from distal to proximal in a retrograde fashion (Fig. 75.7A). • Position the distal femur locking plate by matching the contour of the plate to the lateral portion of the femur (Fig. 75.7B). • Pass a guidewire through the central screw hole in the distal portion of the plate and into the condyles such that it is parallel to the trochlear notch in the axial plane and parallel to the distal tips of the condyles in the AP plane. This Kirschner wire (K-wire) can be redirected if necessary until it is parallel to the knee joint (Fig. 75.8A). • Obtained and confirm sagittal alignment with a lateral radiograph. The position of the plate is referenced to Blumensaat’s line and the subchondral margin of the trochlear groove (Fig. 75.8B and C). • After readjusting the plate position, place a second guidewire to prevent rotation of the plate for provisional fixation (Fig. 75.9). 

B FIG. 75.7 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

A

B

Blumensaat’s line

C FIG. 75.8 

FIG. 75.9 

963

964

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

INSTRUMENTATION/IMPLANTATION

• A distal femur locking plate (4.5 mm) with or without a targeting radiolucent device. A long plate is needed that extends proximally enough to allow screws to be placed into the trochanter for optimal purchase in the proximal fragment.

ANTEGRADE PLATE INSERTION • For periprosthetic femur fractures with a short proximal fragment, a proximal femur locking plate (4.5 mm) is preferred (Fig. 75.10). This anatomically contoured plate allows better purchase in the trochanter. Antegrade insertion is done thru the proximal window rather than the distal window. Follow the same fixation principles as the retrograde technique.

FIG. 75.10  PEARLS

• Adjustment of the plate contour may be required to optimize coronal alignment. • Remember that the plate is used as a reduction tool to realign the femur in varus/ valgus. Never accept even the slightest amount of varus when fixing the femur. PITFALLS

• Locking screws do not influence fracture reduction. Therefore, the reduction must be achieved before placement of locking screws.

Step 2: Indirect Fracture Reduction • Insert a cannulated nonlocking screw over the guidewire to compress the plate to the lateral femoral condyle. • With the 4.5-mm LCP condylar plate, it is advantageous to start with the central 7.3-mm conical screw (Fig. 75.11A). A better fit is achieved at the level of the knee to minimize iliotibial band irritation. • A second 4.5-mm cortical screw is added to the distal segment to completely approximate the plate on the lateral cortex of the distal femur (Fig. 75.11B and C). • The plate applied to the lateral aspect of the femur extraperiosteally is provisionally centered and secured to the proximal femur in the region of the stem with standard nonlocking screws, pulling devices, provisional fixation pins, cables, or reduction clamps. Tightening of these devices will create compression of plate to the bone, achieving indirect reduction with manual manipulation of the limb (Fig. 75.12A). • At the level of the trochanter, screws can be oriented anterior or posterior to the femoral stem for better purchase (Fig. 75.12B). • At least one cerclage cable is recommended at the level of the femoral stem to maximize frictional forces at the plate-bone interface to prevent pullout. • Positioning pins are available to maintain the location of the cable on the plate relative to the plate hole (Fig. 75.12C). • Select the appropriate cable passer that will allow passage of the instrument around the femur without causing significant damage to soft tissues (Fig. 75.13). • Optional technique: A lag screw can be used to create interfragmentary compression at the fracture site with a long spiral fracture type (Fig. 75.14). • Once a satisfactory reduction is confirmed by fluoroscopy, definitively secure the plate to the femur with locking screws. 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

A

B

C FIG. 75.11 

965

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

966

A

B

C FIG. 75.12 

FIG. 75.13 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

967

FIG. 75.14 

Step 3: Definitive Plate Fixation • Next definitively fix the distal segment with locking screws in the distal femoral condyles. • Usually, a minimum of four locking screws are used in osteopenic bone. • Conical screws, such as the central 7.3-mm screw, should be replaced with locking screws after reduction is complete (Fig. 75.15A). • In the proximal region of the intramedullary implant, insert and tighten cables and standard screws prior to inserting the unicortical locking screws. • Bicortical screws can be inserted in the trochanter and at the level of the tip of the femoral stem. • Locking screws are most effective when they are placed closest to and farthest from the fracture (Fig. 75.15B). • Depending on fracture configuration, it may be possible to achieve bicortical fixation at the level of the tip of the stem in order to enhance torsional stability (Fig. 75.15C). • Take postoperative radiographs of the proximal (Fig. 75.16A) and distal (Fig. 75.16B) femur to confirm placement of plate and screws. • Close surgical wounds (Fig. 75.17). 

PEARLS

• Supplementing the proximal construct with a minimum of one cable or one standard nonlocking screw is essential to prevent pullout of the unicortical locking screws. • Plate bridging and indirect reduction techniques are use to minimize disruption of the soft-tissue envelope surrounding the fracture site (Erhardt et al., 2007). PITFALLS

• Avoid use of short plates; longer plates, spanning the entire femur, allow for an increase in working distance without compromising construct strength. • Malreduction rates of 6% to 20% have been reported with internal fixator systems (e.g., the Less Invasive Stabilization System (L.I.S.S)) in which reduction is independent of plate contour (Ricci et al., 2005). INSTRUMENTATION/IMPLANTATION

• Locking plates that are designed to accommodate nonlocking and locking screws are preferred. These plates are used in a “hybrid” mode as both a reduction aid and fixed-angle devices (Ricci et al., 2005).

A

B

C FIG. 75.15 

A

B FIG. 75.16 

FIG. 75.17 

PROCEDURE 75  Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients are kept from weight bearing on the affected side for 6 weeks postoperatively or until callus formation, at which time partial weight bearing can be initiated. • Physiotherapy is started on the first postoperative day with knee exercises, including active (closed chain) and passive range of motion.

EVIDENCE Brady OH, Garbuz DS, Masri BA, et al. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty. 2000;15:59–62. This study showed that this classification is reliable and valid. Validity analysis revealed an observed agreement kappa value of 0.78, indicating substantial agreement. Erhardt JB, Grob K, Roderer G, et al. Treatment of periprosthetic femur fractures with the non-­contact bridging plate: a new angular stable implant. Arch Orthop Trauma Surg. 2008;128:406–416. This prospective cohort study showed promising results in 24 patients with hybrid fixation. (Level IV evidence.) Fulkerson E, Koval K, Preston CF, et al. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locking and conventional cable plates. J Orthop Trauma. 2006;20:89–93. This laboratory study using eight pairs of embalmed femurs concluded that locking plates are stiffer than the Ogden construct (plate with cables). However, in loads-to-failure testing, only the locked plating constructs exhibited catastrophic failure. Lindahl H, Malchau H, Oden A, et al. Risk factors for failure after treatment of a periprosthetic fractured femur. J Bone J Surg [Br]. 2006;88:26–30. This observational study that included 1049 fractures from the Swedish Register found that Vancouver type B1 had a significantly higher failure rate (P = .0001). The difficulty in separating type B1 from type B2 fractures suggested that the prosthesis should be considered as loose until proven otherwise, and an exploration of the joint was recommended to test the stability. (Level IV evidence.) Ricci WM, Bolhofner BR, Loftus T, et al. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg [Am]. 2005;87:2240–2245. This study supported the use of indirect open reduction and internal fixation with a single extraperiosteal lateral plate, without the use of allograft struts, for the treatment of a femoral shaft fracture about a stable intramedullary implant. (Level IV evidence [case series].) Tsiridis E, Haddad FS, Gie GA. Dall-Miles plates for periprosthetic femoral fractures: a critical review of 16 cases. Injury. 2003;34:107–110. This study concluded that the Dall-Miles plate and cable system alone is insufficient for the treatment for periprosthetic femoral fractures. (Level IV evidence [case series].) Wilson D, Frei H, Masri BA, et al. A biomechanical study comparing cortical onlay allografts struts plates in the treatment of periprosthetic femoral fractures. Clin Biomech. 2005;20:70–76. This cadaveric study was designed to determine the effect of cable plate, strut allograft, and combined plate–strut allograft fixations of Vancouver type B1 fractures.

969

CONTROVERSIES

• Fixation principles should be modified according to fracture configuration. For transverse and short oblique fracture types, reduced rigidity of the plate construct may be beneficial to promote enhanced callus formation avoiding delayed or nonunion and failure. PEARLS

• Strengthening exercises are initiated on evidence of progressive fracture healing. PITFALLS

• Thromboprophylaxis, including mechanical and/or pharmacologic agents, is essential for all patients.

PROCEDURE 76

Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation) for the Treatment of Vancouver B1 Periprosthetic Femur Fractures Ian Whatley and Aaron Nauth INDICATIONS PITFALLS

• Failure to recognize loosening of the femoral component (i.e., misdiagnosis of a Vancouver B2 as a Vancouver B1) • Failure to recognize/rule out periprosthetic infection INDICATIONS CONTROVERSIES

• The need for surgery in displaced periprosthetic fractures of the proximal femur is well agreed upon • There is also general consensus that fractures around well fixed stems (Vancouver B1) should be treated with fracture fixation without prosthesis revision • There is substantial controversy (and a lack of evidence) regarding the ideal method of fracture fixation • The controversy is mainly focused on the use of isolated lateral locked plating versus the combination of cable plating and an anterior cortical allograft strut (90-90 fixation) • The biomechanical evidence supports 90-90 fixation with cable plating and an anterior cortical allograft strut as the biomechanically superior construct

INDICATIONS • Displaced periprosthetic fractures of the proximal femur around or just distal to a wellfixed total hip arthroplasty stem (Vancouver B1 periprosthetic hip fractures; Fig. 76.1) 

EXAMINATION AND IMAGING • Information regarding the mechanism of injury and level of energy involved should be obtained. • Detailed information regarding the preinjury function of the total hip arthroplasty should be obtained, including any history of: • prodromal thigh pain (which could indicate preexisting loosening of the femoral stem, an atypical femur fracture associated with bisphosphonate use, or infection) • fevers/chills, wound erythema/drainage, previous antibiotic treatment (infection) • any instability or dislocation of the prosthesis (poly wear, component malposition, or infection) • Physical examination should include assessing for gross deformity, limb length, signs of infection at the previous incision, open wounds, and neurovascular injury. • Anteroposterior (AP; Fig. 76.2A–B) and lateral views of the affected femur and an AP pelvis • Assess location of fracture, degree of displacement, and quality of bone stock.

AG

AL

B1

B2

B3

C

FIG. 76.1  The Vancouver classification of periprosthetic fractures of the femur about a total hip arthroplasty. (Used with permission from Nauth A, Stevenson I, Smith MD, and Schemitsch EH. (2016). Fixation of Periprosthetic Fractures About/Below Total Hip Arthroplasty. In P. Tornetta and S. W. Weisel (Eds), Operative Techniques in Orthopaedic Trauma Surgery (2nd Ed) (pp. 416-426). Philidelphia, PA: Wolters Kluwer.)

970

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

A

D

C

B

E

F

FIG. 76.2  Radiographs of the right femur of an 82-year old female patient with a Vancouver type B1 periprosthetic fracture at the tip of a well-fixed stem that had been functioning well prior to a fall (A and B). Postoperative radiographs showing fixation of the fracture with a lateral distal femoral locking plate combined with an anterior allograft strut (90–90 fixation) and cables (C–F). White arrows demonstrate lag screw fixation across the spiral type fracture. (Modified with permission from Nauth A, Stevenson I, Smith, MD, and Schemitsch EH. (2016). Fixation of Periprosthetic Fractures About/Below Total Hip Arthroplasty. In P. Tornetta and S. W. Weisel (Eds), Operative Techniques in Orthopaedic Trauma Surgery (2nd Ed) (pp. 416-426). Philidelphia, PA: Wolters Kluwer.)

• Careful attention should be paid to plain film radiographs to assess for any evidence of component loosening. • Whenever possible, preinjury radiographs of the prosthesis should be obtained to allow for comparison with current films and assessment for any change in femoral component position (e.g., stem subsidence; Fig. 76.3) • Definite signs of loosening include change in component position (e.g., stem subsidence), stem or cement mantle fracture, progressive periprosthetic or cement mantle lucency (76.3 D-G).

971

972

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

B

A

D

E

C

F

G

FIG. 76.3  (A–C) Vancouver type B2 periprosthetic fracture in a 75-year-old male. Comparison with preinjury radiographs (A) shows noticeable subsidence and change of prosthesis position confirming loosening (B). Revision to a long-stemmed prosthesis combined with fracture fixation was performed (C).(Used with permission from Nauth A, Stevenson I, Smith MD, and Schemitsch EH. (2016). Fixation of Periprosthetic Fractures About/Below Total Hip Arthroplasty. In P. Tornetta and S. W. Weisel (Eds), Operative Techniques in Orthopaedic Trauma Surgery (2nd Ed) (pp. 416-426). Philidelphia, PA: Wolters Kluwer.) (D–G) Radiographs of a 91-year-old male patient with a Vancouver type B2 periprosthetic femur fracture 1 year following total hip arthroplasty. Comparison with immediate postoperative radiographs (D) shows definite signs of loosening including progressive radiolucency of the cement–bone interface, subsidence of the implant, fracture of the cement mantle (white arrow), and debonding of the cement mantle around the implant (red arrow). The patient reported a 3-month history of prodromal thigh pain and his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated significantly. The total hip arthroplasty was presumed to be both loose and infected, and revision to an antibiotic cement spacer combined with fixation of the fracture was performed (G) after infection was confirmed intraoperatively. (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

TREATMENT OPTIONS

• Cable plate/compression plate with anterior cortical strut allograft (90-90 technique) • Isolated lateral locked plating • Isolated lateral cable/compression plating • Cortical strut allograft alone • Stem revision and fracture fixation

• Probable signs of loosening include greater than 2 mm of periprosthetic or cement mantle lucency, bead shedding, endosteal scalloping, and endosteal bone bridging at the tip of the stem. • Occasionally, the use of a preoperative computed tomography (CT) scan with metal subtraction can be helpful in evaluating the fracture and looking for any subtle signs of radiographic loosening of the femoral component. • Careful attention should be paid to femoral component positioning, as varus malpositioning of the femoral component has been associated with a significant rate of fixation failure and, occasionally, a well-fixed femoral component may require revision if it is in substantial varus. 

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

973

POSITIONING PEARLS

A

• It is critical to use a bump or beanbag to adequately elevate the fractured limb in the supine position. • Surgical prepping should allow access to the entire previous surgical incision in case prosthesis revision is required. • The lateral decubitus position should be used if the need for revision of the femoral component is a substantial possibility (suspicion for a Vancouver B2 fracture).

POSITIONING PITFALLS

• The supine position is not ideal if the femoral component is found to be loose and requires revision arthroplasty.

B FIG. 76.4  Intraoperative photographs showing patient positioning in the supine position with a beanbag used to elevate the operative hip and positioning of the C-arm on the patients contralateral side (A and B). (Used with permission from Nauth A, Stevenson I, Smith MD, and Schemitsch EH. (2016). Fixation of Periprosthetic Fractures About/Below Total Hip Arthroplasty. In P. Tornetta and S. W. Weisel (Eds), Operative Techniques in Orthopaedic Trauma Surgery (2nd Ed) (pp. 416-426). Philidelphia, PA: Wolters Kluwer.)

POSITIONING EQUIPMENT

• For the supine position, the C-arm should be placed on the contralateral side to the fracture to allow for intraoperative fluoroscopy. • For the lateral decubitus position, the C-arm is placed on the contralateral side to the fracture and brought into the over-the-top position to allow for intraoperative fluoroscopy. • Radiolucent table

SURGICAL ANATOMY • Tensor fascia lata • Fascia lata • Gluteus medius • Vastus lateralis • Perforating arteries 

POSITIONING • The patient is placed in the supine position on a radiolucent table (Fig. 76.4A–B). • A beanbag or bump is placed under the ipsilateral side to elevate the fractured limb. • Alternatively, the patient can be positioned in the lateral decubitus position with the affected side facing up. 

PORTALS/EXPOSURES • A lateral skin incision is made extending from the previous total hip arthroplasty incision toward the knee (Fig. 76.5). • The fascia lata is split in line with the skin incision. • The vastus lateralis is elevated from the femur along its posterior fibers and retracted anteriorly (Fig. 76.6). • The perforating vessels are identified and coagulated to achieve hemostasis. • The lateral and anterior aspects of the femur are exposed from the level of the greater trochanter to the metaphyseal flare. • Care should be taken to preserve the soft tissues and vascular supply to the femur by avoiding substantial dissection along the posterior and medial aspects of the femur.

PORTALS/EXPOSURES PEARLS

• Ensure adequate exposure from the greater trochanter to the metaphyseal flare of the knee. • Adequate exposure to ensure the safe passage of cables around the femur and avoid the entrapment of neurovascular structures is required (posteriorly, this requires some dissection of the structures inserting on the linea aspera).

PORTALS/EXPOSURES PITFALLS

• Minimize soft-tissue stripping along the posterior and medial aspects of the femur.

Procedure Step 1: Assessment of Implant Stability and Fracture Reduction

PORTALS/EXPOSURES EQUIPMENT

• If concern regarding the stability of the implant exists, the bone-implant interface should be assessed at the fracture site for any evidence of implant loosening.

• Hohmann retractors • Bennet retractor

974

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

PORTALS/EXPOSURES CONTROVERSIES

• Proponents of isolated lateral locked plating argue that less soft-tissue stripping is required for that technique (when compared to cable plate and allograft strut fixation), allowing for better preservation of fracture biology. However, the advantages of that approach remain unproven. Numerous biomechanical (Zdero et al, Demos et al) and retrospective studies (Buttaro et al, Dehghan et al, Haddad et al, Lindahl et al) have evaluated the risk factors for fixation failure in patients with Vancouver B1 periprosthetic fractures and advocated for 90-90 fixation.

FIG. 76.5  Intraoperative photograph of the left femur demonstrating the incision for a lateral approach to the femur (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

• If this assessment confirms loosening or is inconclusive, the incision should be extended proximally and a dislocation of the prosthesis should be performed with formal assessment of the femoral component for stability. • If the implant is loose, treatment should be converted to revision with a long-stemmed femoral component combined with fixation of the fracture. • Once stability is confirmed, a direct reduction of the fracture is performed (Fig. 76.7).  STEP 1 PEARLS

• If there is any concern for loosening of the femoral component, it is critical that intraoperative assessment of implant stability is carried out. • Corten et al. (2009) found that 20% of B type fractures that were thought to be associated with a stable femoral component were, in fact, found to be loose at the time of surgery. • The literature has consistently shown that the treatment of a periprosthetic fracture of the femur around a loose stem (Vancouver B2) without revision to a long-stemmed component that bypasses the fracture leads to high rates of failure (Lindahl et al., 2006).

Step 2: Plate Application • A plate of appropriate length is chosen. The plate should span from the distal femur to just below the greater trochanter (Fig. 76.2C–F, Fig. 76.8, and Fig. 76.9). • Contouring of the plate may be required depending on the type of plate selected. • Provisional fixation is secured with screws placed both proximal and distal to the fracture site (Fig. 76.10). • If the fracture is amenable to absolute stability, anatomic reduction and compression should be achieved either using the compression holes in the plate, the AO articulated tensioner, or lag screw or cerclage fixation around spiral fractures (see Fig. 76.2C–F). • Intraoperative fluoroscopy is used to ensure satisfactory reduction and position of the plate. 

STEP 1 PITFALLS

• It is important to adhere to general fracture principles when reducing and stabilizing the fracture (i.e., absolute stability with anatomic reduction and compression for transverse or simple spiral fractures versus bridge plating and relative stability techniques for more comminuted fractures). • It is critical to avoid varus malreduction, particularly if the femoral component has been implanted in varus (occasionally, this requires intentional valgus reduction of the fracture or revision of a well-fixed femoral component if the varus malposition is severe). STEP 1 INSTRUMENTATION/ IMPLANTATION

• Large AO reduction forceps

FIG. 76.6  Intraoperative photograph of the left femur demonstrating longitudinal splitting of the fascia lata with elevation of the vastus lateralis to allow dissection along its posterior border and subsequent exposure of the femur (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

FIG. 76.7  Intraoperative photograph of the left femur demonstrating direct reduction of the fracture using two reduction forceps (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

Prosthesis stem

Cerclage cable Allograft strut Allograft strut

Vancouver type B1 fracture (behind allograft)

Lateral cable plate Lateral cable plate

Anterior view

Lateral view

FIG. 76.8  Illustration depicting the construct of a lateral cable plate and anterior allograft strut (90–90 fixation) used for fixation of a Vancouver type B1 fracture. (Used with permission from Nauth A, Stevenson I, Smith MD, and Schemitsch EH. (2016). Fixation of Periprosthetic Fractures About/Below Total Hip Arthroplasty. In P. Tornetta and S. W. Weisel (Eds), Operative Techniques in Orthopaedic Trauma Surgery (2nd Ed) (pp. 416-426). Philidelphia, PA: Wolters Kluwer.)

975

976

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

STEP 2 PEARLS

• Ensure adequate overlap of plate and femoral stem to avoid mechanical failure. • Ideally, the plate should span the entire femur. • New-generation lateral femoral plates (Fig. 76.9D–G) are precontoured to accommodate the anterior bow of the femur and provide the option of locking screw fixation, which can be advantageous, particularly in the proximal femur. STEP 2 PITFALLS

• Insufficient overlap of plate and allograft with the femoral stem will lead to mechanical failure (Fig. 76.11). STEP 2 INSTRUMENTATION/IMPLANTATION

• Lateral femoral plates (AO large-fragment plates, cable plates, or precontoured locking plates)

A

D

B

E

F

C

G

FIG. 76.9  Radiographs of the right femur of a 78-year-old female patient with a Vancouver type B1 periprosthetic fracture at the tip of a well-fixed stem that had been functioning well prior to a fall (A–C). Six month postoperative radiographs showing fixation of the fracture with a periprosthetic lateral femoral locking plate combined with an anterior allograft strut (90–90 fixation) and cables (D–F).

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

977

FIG. 76.10  Intraoperative fluoroscopy pictures demonstrating provisional reduction and plate fixation of a Vancouver B1 fracture. Note that the entire femur is spanned with the plate from just below the greater trochanter to the distal femur. (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

A

B

C

D

FIG. 76.11  Radiographs of a 41-year-old female juvenile rheumatoid arthritis patient with a Vancouver type B1 periprosthetic fracture that was fixed with lateral locked plating and fibular strut allograft (A, B). Radiographs show that insufficient overlap of the femoral component was obtained with the plate/strut and predictable failure occurred (C, D). (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

978

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

STEP 3 PEARLS

• Using the anterior cortex from a femoral allograft provides a graft with a preexisting anterior femoral bow, making contouring easier. • Using a distal femoral allograft provides ample supply of cancellous allograft if this is desired. • The minimum length of the allograft is typically 25 to 30 cm. • Beveling of the allograft distally helps to avoid irritation of the quadriceps (see Figs. 76.8 and 76.2).

Step 3: Allograft Preparation • Preparation of allograft can be initiated once the approach has been completed and stability of the implant has been confirmed. • A strut allograft is created from the femur, tibia, or humerus using an oscillating saw and burr (Fig. 76.12). • The length of the allograft should be such that there is adequate overlap with the prosthesis and that two cerclage wires can be passed both proximal and distal to the fracture site. • Correct contouring of the strut allograft is confirmed by provisional placement along the anterior cortex of the femur (Fig. 76.13). 

STEP 3 PITFALLS

• Ending the allograft at the same level as the plate distally can lead to stress risers, thus should be avoided. • Ensuring adequate overlap of the allograft with the native femoral component proximally is critical to avoid failure (see Fig. 76.11).

STEP 3 INSTRUMENTATION/ IMPLANTATION

• Oscillating saw • Burr • Allograft

FIG. 76.12 Intraoperative photograph demonstrating preparation of the allograft strut from a distal femoral allograft (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

A

B FIG. 76.13  Intraoperative photograph demonstrating final allograft strut preparation and sizing. (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

Step 4: Allograft Placement and Cable Passage • Pass cables around the femur using the cable passer (Fig. 76.14). • A minimum of two cables proximal and two cables distal to the fracture site should be used. • The strut allograft is placed along the anterior cortex of the femur after the cables have been passed. • Cables are tightened, secured, and trimmed in a sequential fashion (Fig. 76.15). 

979

STEP 4 PEARLS

• Passing the cables prior to final placement of the strut allograft (but after contouring and appropriate fit has been confirmed) makes cable passage easier.

STEP 4 PITFALLS

• It is critical that care is exercised when passing the cables around the femur (particularly medially and posteriorly) to avoid injury or entrapment of neurovascular structures.

STEP 4 INSTRUMENTATION/ IMPLANTATION

• Cable passer • Cables or wires • Tensioning device and crimper (if cables are used).

FIG. 76.14  Intraoperative photograph demonstrating the technique for safe cable passage around the allograft strut and lateral plate (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

FIG. 76.15  Intraoperative photograph demonstrating the final allograft strut and cable plate construct (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

Step 5: Final Proximal and Distal Screw Placement • Nonlocking bicortical screws or locking unicortical screws are placed proximally around the femoral stem (Fig. 76.16). • Nonlocking or locking screws are placed at the distal aspect of the construct (see Fig. 76.16). Spaced fixation with 50% or less screw fill should be used distally to avoid an overly rigid construct. • Intraoperative fluoroscopy is used to confirmed satisfactory reduction of the fracture as well as the satisfactory placement of screws, cables, and the strut allograft (see Fig. 76.16). 

STEP 5 PEARLS

• Proximal fixation is best achieved with a combination of cables and screws (the use of at least one to two proximal screws is necessary to achieve rotational control). STEP 5 PITFALLS

• Overly rigid fixation and lack of adherence to fracture principles leads to predictable failure.

980

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

FIG. 76.16  Intraoperative fluoroscopy pictures demonstrating the final construct of a lateral plate and anterior allograft strut (90-90 fixation) for a Vancouver B1 fracture. In this case a non-locking 4.5 mm plate was used in combination with a cortical strut from a distal femoral allograft (Reproduced with permission from Nauth A, Henry P, Schemitsch EH. Periprosthetic fractures of the femur after total hip arthroplasty: cable plate and allograft strut fixation of Vancouver B1 fractures. In: Sarwark JF, ed. Knowledge Online Journal. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2014.)

Additional Steps Step 6: Cancellous Allograft Placement and Closure

STEP 6 INSTRUMENTATION/ IMPLANTATION

• Cancellous allograft

• The wound is generously irrigated. • Cancellous allograft from the distal femoral allograft can be placed at the fracture site and the strut allograft-femur interface. • Closure is completed respecting original tissue planes. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative weight bearing should be as tolerated (ideally) or 50% partial weight bearing depending on intraoperative stability and fixation. • Activity as tolerated for both the hip and knee is allowed.

POSTOP PEARLS

• The literature has demonstrated similar morbidity and mortality to the hip fracture population in these patients with a 1-year mortality rate of 11% (Bhattacharyya et al., 2007). • As such, these patients benefit from the same principles of care that are applied to hip fracture patients, including early surgery, immediate mobilization and weight bearing, and multidisciplinary care with geriatrics or medicine.

PROCEDURE 76  Cable Plating Combined with Cortical Strut Allograft (90-90 Fixation)

EVIDENCE Bhattacharyya T, Chang D, Meigs JB, Estok 2nd DM, Malchau H. Mortality after periprosthetic fracture of the femur. J Bone Joint Surg [Am]. 2007;89(12):2658–2662. Buttaro MA, Farfalli G, Paredes Nunez M, Comba F, Piccaluga F. Locking compression plate fixation of Vancouver type-B1 periprosthetic femoral fractures. J Bone Joint Surg [Am]. 2007;89(9):1964–1969. This retrospective series evaluated the surgical treatment of 14 Vancouver B1 fractures. Nine patients received isolated lateral locking plate fixation and 5 patients received lateral locking plate fixation combined with cables and cortical strut fixation. The failure rate was 56% (5/9 patients) with isolated locked plating versus 20% (1/5) when locked plating was combined with a cortical strut and cables. Corten K, Vanrykel F, Bellemans J, Frederix PR, Simon JP, Broos PL. An algorithm for the surgical treatment of periprosthetic fractures of the femur around a well-fixed femoral component. J Bone Joint Surg [Br]. 2009;91(11):1424–1430. In this prospective study, the authors evaluated 45 Vancouver B1 fractures (the implant was deemed stable on the basis of preoperative imaging) undergoing fracture fixation with a standardized protocol of dislocation of the prosthesis and a formal evaluation of femoral component stability. They reported that 20% of the implants were unstable at the time of surgery. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch EH. Surgical fixation of Vancouver Type B1 periprosthetic femur fractures: a systematic review. J Orthop Trauma. 2014;28(12):721–727. In this systematic review of the literature, 333 patients with Vancouver type B1 periprosthetic fractures were evaluated for treatment outcomes with different modes of treatment. When compared with other modes of treatment, isolated locking plate fixation had a significantly higher rate of nonunion (3% vs. 9%, P = 0.02) and a trend toward a higher rate of hardware failure (2% vs. 7%, P = 0.07). Demos HA, Briones MS, White PH, Hogan KA, Barfield WR. A biomechanical comparison of periprosthetic femoral fracture fixation in normal and osteoporotic cadaveric bone. J Arthroplasty. 2012;27(5):783–788. This biomechanical study found that the use of a combination of plates and screws provided optimal proximal fixation when evaluating constructs for Vancouver type B1 periprosthetic fractures. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002;84-A(6):945–950. In this retrospective multicenter series, the authors evaluated 40 patients with Vancouver type B1 periprosthetic fractures of the femur. All patients were treated with either cortical onlay strut allografts alone (19 patients) or plate fixation combined with one or two cortical struts (21 patients). The union rate in their series was 98%. Lindahl H, Garellick G, Regner H, Herberts P, Malchau H. Three hundred and twenty-one periprosthetic femoral fractures. J Bone Joint Surg [Am]. 2006;88(6):1215–1222. In this retrospective series of 1049 periprosthetic fractures of the femur (Vancouver B1 and B2) from the Swedish National Hip Arthroplasty Registry, the authors evaluated the risk factors for treatment failure requiring reoperation. The best predictor of treatment failure in Vancouver B1 fractures was use of a single plate. In addition, failure to perform revision of the femoral prosthesis in the setting of a Vancouver B2 fracture was a significant predictor of failure. Zdero R, Walker R, Waddell JP, et al. Biomechanical evaluation of periprosthetic femoral fracture fixation. J Bone Joint Surg [Am]. 2008;90(5):1068–1077. This biomechanical study compared a variety of fixation constructs for the fixation of Vancouver type B1 periprosthetic fractures of the femur. The authors found that the combination of a cable plate and anterior allograft cortical strut (90-90 fixation) provided the best biomechanical stability.

981

PROCEDURE 77

Periprosthetic Distal Femur Fractures: IM Nailing/Plating Samuel E. Young and James L. Howard INDICATIONS PITFALLS

• In cases where fractures extend distal to the anterior flange of the prosthesis, there is a possibility that revision total knee arthroplasty would be more appropriate than internal fixation. • In cases with significant distal metaphyseal bone loss and comminution or previous distal femoral malunion, distal femoral replacement should be considered.

INDICATIONS The majority of periprosthetic fractures of the distal femur are amenable to internal fixation. • A prerequisite for considering treatment of a distal femoral periprosthetic fracture with an intramedullary (IM) nail or locking plate is that the patient must have a wellfixed implant. • Rorabeck and Taylor (1999) developed the first commonly used classification that incorporated fracture location and integrity of the prosthesis (Table 77.1). Subsequent classifications and treatment schemes have expanded the evaluation of fracture location with preoperative planning. • Fracture pattern (proximity to prosthesis, comminution, orientation), patient bone quality and residual bone stock, and features of retained implants, all need to be considered when choosing between IM nail and locking plate fixation.  TABLE   Lewis and Rorabeck Classification of Supracondylar Periprosthetic 77.1  Fractures Proximal to Total Knee Arthroplasty Type I

Undisplaced fracture; prosthesis intact

Type II

Displaced fracture; prosthesis intact

Type III

Displaced or undisplaced fracture; prosthesis loose or failing (i.e., significant instability or polyethylene wear)

EXAMINATION/IMAGING

TREATMENT OPTIONS

• For most periprosthetic distal femur fractures, both intramedullary nail and plate fixation are reasonable options. • Retrograde intramedullary nails are used more commonly than antegrade nails as antegrade nails would fail to achieve adequate distal fixation in most periprosthetic fracture types. • Advantages and disadvantages of intramedullary nails and plates for periprosthetic femoral fractures are listed in Table 77.2. 982

• History should include a thorough assessment of the circumstances surrounding the injury. Symptoms that may indicate a concurrent acute medical concern, such as chest pain, dizziness, or shortness of breath, should be identified and investigated accordingly. • Patient comorbid conditions, especially diabetes and smoking, should be noted. • A history of the current prosthesis, including a history of infection or stiffness in the knee, should be sought. • Focus physical examination on the quality of the soft tissues (including obesity), placement of previous surgical scars, and assessment of neurovascular function. Range of motion and stability assessment of the joint is usually difficult in the setting of fracture. • Radiographic evaluation consists of anteroposterior (AP) and lateral images of the knee (Fig. 77.1). If possible, obtain old radiographs and compare them to assess for subtle signs of loosening and prefracture anomalies in position (component coronal and sagittal plane alignment, presence of femoral notching). Full-length films of the femur are required to identify any abnormalities in proximal femoral morphology or presence of proximal hardware. • Occasionally a computed tomography (CT) scan of the knee can be obtained to assess fracture characteristics. However, these images can be difficult to interpret owing to the image artifact created with the prosthesis in the field of view. • Obtain the previous operative report(s) and implant information to confirm the prosthesis type and size as this could dictate the treatment option chosen. 

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

A

B FIG. 77.1 

TABLE   Advantages and Disadvantages of IM Nail vs Plate Fixation of Distal 77.2  Femoral Periprosthetic Fractures

IM Nails

Lateral Locking Plates

Advantages

Advantages

Load-sharing device that can allow early loading through length stable constructs

Diversity of load-bearing constructs achieving absolute or relative stability

Less soft-tissue trauma compared with open plating techniques

Ability to use indirect reduction techniques with the plate

Use of previous midline incision

Allows fixation around preexisting implants More fixation options for distal fracture patterns

Disadvantages

Disadvantages

Isolated to use with CR and some PS components

Greater soft-tissue exposure with open plating techniques (less of a concern with minimally invasive techniques)

Ipsilateral proximal implants or hardware preclude use of intramedullary (IM) nails

Often restricted weight bearing for 6–12 weeks

Achieving adequate fixation for fractures distal to the anterior flange may be difficult

Possibility of screw pullout and coronal plane malalignment

Possibility of valgus and extension deformities Separate incision often required CR, Cruciate Retaining; PS, Posterior Stabilized.

SURGICAL ANATOMY • Specific to the prosthesis, the surgeon should note extent of the cement mantle (if present), presence of the stem, and whether the design is cruciate retaining or sacrificing. In the latter scenario, the “box” of the prosthesis can prohibit the insertion of a retrograde nail. Thompson et al. (2014) have published an extensive list of contemporary Total Knee Arthroplasty (TKA) measurements and compatibility for IM nailing.

983

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

984

• When considering the fracture, the focus of the assessment is often on the distal fragment as this is where obtaining fixation can prove difficult. These fractures tend to occur at the region of the femoral flange and extension is a common deformity. Bone quality is often poor secondary to osteopenia, comminution, and stress shielding. Bony defects can be easily underappreciated and only become clear when the fracture is reduced to length. Examine for medial comminution, as this is poorly controlled with a lateral locking plate and higher failure rates have been reported. Some authors have advocated for nailing in this scenario to prevent late varus collapse. Nails require a certain volume of distal bone be present in order to achieve interlocking screw fixation. Classically, 4 cm of intact bone was required, but newer nails have distal options and locking cross bolts for enhanced rigidity and this may expand the indications. Failure to recognize insufficient bone stock distally can result in inadequate fixation in the distal fragment and loss of reduction (Fig. 77.2). 

RT.

RT.

A

B [H]

[A]

C

[H]

[P]

[F]

[L]

D FIG. 77.2 

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

Intramedullary Nails POSITIONING • Position the patient supine for the procedure. • The limb is free draped to allow maximal intraoperative flexibility. • The knee is flexed to facilitate access to the intercondylar notch. • Use a radiolucent operating room table to allow fluoroscopic imaging of the entire femur in the AP and lateral planes • The choice of anesthesia may be dependent on other comorbid conditions; however, muscle relaxation can be of benefit particularly if there has been a delay getting to surgery with a shortened fracture. • Intravenous antibiotics with skin organism coverage should be administered in all cases. Cefazolin is the routine in our institution; however, other agents may be required, depending on local organism profiles or patient factors. Take care with surgical antiseptic preparation. 

PROCEDURE Step 1

985

POSITIONING PEARLS

• Being able to access the contralateral limb can be beneficial for comparison of limb rotation. POSITIONING EQUIPMENT

• In order to relax the gastrocnemius muscles and facilitate access to the intercondylar notch, towels/drapes can be placed under the leg at the level of the fracture to relax the gastrocnemius muscle. A radiolucent triangle also works well for this purpose. PORTALS/EXPOSURES

• The surgical incision generally incorporates the mid portion of the old TKA incision. • Deep exposure is achieved via a medial parapatellar arthrotomy. PORTALS/EXPOSURES PEARLS

• Reduction must be carried out as a first step through closed or mini-open methods prior to placing a nail. Gentle traction in flexion combined with a varus or valgus force as directed by intraoperative imaging is often helpful. 

• Often a larger skin incision is required than using retrograde nails through native knees.

Step 2

• Failure to make an appropriate sized incision can result in too tight of a working area. This can lead to the reamers or nail damaging the patella or the prosthesis, or result in the nail being driven into poor position by the tension of the extensor mechanism.

• Identify the notch of the prosthesis. Take care to minimize trauma to the posterior cruciate ligament origin (in cruciate retaining knees) along the medial femoral condyle, but synovium and debris can be cleared to ensure an adequate view. • The guidewire for the nail can now be placed. Carefully check the position under fluoroscopy in both views as standard landmarks are often distorted. Part of the femoral component posterior trochlea may need to be burred away to allow passage of the nail in certain nail designs/component positions. 

Step 3 • Once a satisfactory start point is achieved, the femur can be opened with an entry reamer. • A guidewire can be advanced across the fracture and into the proximal segment. • Femoral canal reaming is completed. 

Step 4 • The femoral nail length can be measured and an appropriate length/diameter nail is impacted into place. • Once the nail has been impacted into position, distal locking should occur. These screws are placed percutaneously using the targeting arm compatible with the nail (Fig. 77.3). • Proximal locking should then be performed using mini-open techniques dissecting down to bone (Fig. 77.4). 

PORTALS/EXPOSURES PITFALLS

STEP 1 PEARLS

• Temporary pinning with K-wires can be helpful, provided they do not interfere with passage of the nail. STEP 1 PITFALLS

• Retrograde intramedullary nailing of a periprosthetic fracture allows minimal reduction through the implants. Therefore, obtaining reduction prior to reaming and placement of the nail is important. • Repeated forceful closed manipulations can further damage bone fragments or soft tissues in proximity to the fracture. STEP 2 PEARLS

• Be aware of the type of prosthesis in situ to ensure compatibility with a retrograde nailing technique for periprosthetic fracture. Previous literature has references available for review on this topic. STEP 2 PITFALLS

• The start point for a retrograde nail is dictated by the location and geometry of the femoral component. Compared with a standard start point in a native knee, the start point is relatively more posterior and lateral secondary to the presence of the femoral component. As a result, fractures may demonstrate a valgus and extension deformity with IM nailing.

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

986

RT 158.3 SEC

A

B FIG. 77.3 

A

B FIG. 77.4 

STEP 3 PEARLS

• Over-reaming is typically by 1 mm but can be up to 2 mm, depending on the degree of engagement in the diaphysis. STEP 3 PITFALLS

• Because short supracondylar nails have demonstrated high failure rates, the nails should engage the diaphysis to ensure added stability.

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

A

987

B FIG. 77.5 

Locked Plating

STEP 4 PEARLS

POSITIONING • The patient can be positioned supine or lateral for the procedure. • Free-drape the limb to allow maximal intraoperative flexibility. • A radiolucent operating room table is used to allow fluoroscopic imaging of the entire femur in the AP and lateral planes. • Anesthesia choice and preoperative antibiotic use is similar to what was described earlier for IM nails. • The knee is flexed 30 to 40 degrees over towels/drapes to relax the gastronemius muscle and remove that deforming force. • In-line axial traction will help facilitate reduction. 

• Locking bolts require bicortical fixation for maximal construct strength. • Maximal number of screws in the distal segment should be used. • Proximally, AP locking screws are preferable as they lead to less weakening of the subtrochanteric area. STEP 4 PITFALLS

• Most available nails have multiple options for screw trajectories in the distal segment. These screws are at various tangents and the surgeon should be aware of these to minimize risk of neurovascular injury. • With proximal locking, be aware that the branches of the femoral nerve and vessel cross anteriorly. The safest position for proximal locking is above the lesser trochanter, but this is not always practical. • Owing to the lateral and posterior start point commonly required in retrograde nails through a total knee replacement, the fractures may demonstrate a valgus and extension deformity postoperatively (Fig. 77.5A and B). POSITIONING PEARLS

• A skeletal traction pin can be placed in the proximal tibia and hooked up to traction/weight to provide constant reduction force (Fig. 77.6). POSITIONING EQUIPMENT

• A radiolucent ramp or pillows can be used with the patient in the supine position to facilitate biplanar imaging of the fracture. FIG. 77.6 

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

988

PORTALS/EXPOSURES PEARLS

PORTALS/EXPOSURES

• The surgeon should decide in advance if attempting to obtain rigid fixation (minimal comminution, long spikes for lag screws) or relative stability with bridge plating (comminuted fractures and poor quality bone). The latter is the more common scenario. Surgical approach varies with technique. Rigid fixation will often require a more extensive approach. • Surgical incisions need to be large enough to admit the plate with associated jig or locking towers.

• A lateral skin incision is landmarked using fluoroscopy. • Incision length varies dependent on patient anatomy, but should be centered over the lateral epicondyle curving distally toward Gerdy’s tubercle. • The iliotibial band is incised in line with the skin. • An elevating device, such as a Bristow, is used to open the submuscular plane on the lateral side of the femur. 

PORTALS/EXPOSURES PITFALLS

• Based on preoperative plan or intraoperative decision, place an appropriate length plate submuscularly and check with an image intensifier. • Most of these plates are designed to sit slightly anterior on the lateral flare of the femur and this should be anticipated. 

• Excessive retraction on the iliotibial (IT) band can close down the operative field. STEP 1 PEARLS

• It is important to remember that anatomic reduction is not the aim of this procedure in most cases. The surgeon should be attempting to correct coronal, sagittal, and rotational plane alignment of the distal prosthetic segment relative to the femoral shaft.

PROCEDURE Step 1

Step 2A • There are two basic options for the sequence of securing the plate to the femur. The first is obtain reduction and temporarily hold it (by closed or open means). • Once adequate reduction is achieved, secure the plate to the femur provisionally with pins/wires in the proximal and distal segments. (Fig. 77.7 and Fig. 77.8) • Then secure the plate using a combination of locking and nonlocking screws. • Nonlocking screws or threaded pins attached to a targeting guide can be used to reduce the fracture in the coronal plane (Fig. 77.9). • Once adequate alignment is achieved, place locking screws on both sides of the fracture (Fig. 77.10). • Secure fixation in the distal fragment is critical to success and multiple locking screws are often used in this segment. • Most plates have multiple screw options distally and the plate should be positioned to achieve maximal screw purchase. • Proximally cables may be required in the setting of preexisting hardware. 

LEFT

A

LEFT

B FIG. 77.7 

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

LEFT LEFT

A

B FIG. 77.8 

LEFT

LEFT

A

B FIG. 77.9 

989

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

990

LEFT

LEFT

A

B FIG. 77.10 

STEP 2A PEARLS

• Be careful about placement of the screw closest to the fracture because this will define working length and construct stiffness. • Remember the anatomy of the distal femur is roughly trapezoidal, narrower anteriorly. It is easy to penetrate the medial cortex if judging length on a true AP fluoroscopy image. A 30-degree rotation view can help better define screw length. • Similarly, very posterior screws may penetrate the notch and place posterior neurovascular structures at risk. • Be mindful of tactile feedback when drilling and use the depth gauge as a “feeler” tool to ensure bone is encountered on all sides of the proposed screw.

STEP 2A PITFALLS

• If the reduction cannot be achieved through closed, or limited open means, this technique can require more dissection to achieve reduction.

STEP 2B PITFALLS

• This technique requires exceptional care in flexion/extension placement of the plate distally as any error could result in either a malreduction or the plate being forced off the shaft proximally in the anterior or posterior direction.

Step 2B • The second option secures the plate distally with locking screws initially despite not having the fracture completely reduced. The plate can then be used as a reduction tool to guide the final reduction. • Fixation techniques with locking screws, nonlocking screws, and cables follow the principles outlined in step 2A above. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients should receive 24 hours of postoperative antibiotics following surgery. • Venous thromboembolic prophylaxis should be administered postoperatively. • Surgeons may consider a postoperative x-ray study to assess overall alignment as intraoperative fluoroscopy can be misleading. • The decision on weight-bearing status is based on the construct choice and bone quality. As many of these fractures are comminuted with poor bone quality, in many cases patients are treated non–weight bearing for 6 weeks. If at this point fracture callus is visible and minimal tenderness is present, 50% weight bearing is allowed. Range of motion can be initiated when the soft tissues are settled, with most reported series allowing range from 2 to 6 weeks. • Medical complications are common and the involvement of an internist or physician may be beneficial. • Surgical complications following treatment of periprosthetic fractures with IM nails and locked plates include infections, nonunions, malunions, and need for reoperation. Current literature comparing IM nail fixation with locked plating can be difficult to interpret owing to the lack of standardization of surgical approach, reduction techniques, and screw placement combined with lack of quantification of the complexity of fractures and available distal bone stock. Some studies comparing IM nailing and locked plating show no difference in time to union and similar complication rates (Gondalia et al., 2014; Kiluçoğlu et al., 2013; Matlovich et al., 2017). Others have reported a trend toward a higher nonunion rate in patients treated with locked plating, although the small sample sizes did not allow for statistical significance (Aldrian et al., 2013; Meneghini et al., 2014). Other literature has also explored the importance of fracture location when considering outcomes. Struebel et al. (2010) found similar failure rates with very distal fractures compared with proximal fractures when using locked plates. However, recent literature has highlighted that caution should be exercised when managing fractures that extend below the flange of the prosthesis with intramedullary nails, with higher nonunion rates and need for reoperation in patients with low fractures.

PROCEDURE 77  Periprosthetic Distal Femur Fractures: IM Nailing/Plating

• Ristevski et al. (2014) completed a systematic review of the literature in 2014 and found superior rates of union when comparing locked and conventional plating techniques. However, no significant difference in rates of union were identified when comparing locked plating and intramedullary nails. Malunion rates were higher in the IM nail group. This may be because of the difficulty in obtaining the correct starting point owing to the femoral component of the arthroplasty, combined with difficulty filling the wide metaphyseal flare and limited fixation options for fractures distal to the anterior flange of the femoral component.

EVIDENCE Aldrian S, Schuster R, Haas N, et al. Fixation of supracondylar femoral fractures following total knee arthroplasty: is there any difference comparing angular stable plate fixation versus rigid interlocking nail fixation? Arch Orthop Trauma Surg. 2013;133(7):921–927. Retrospective study of clinical and radiographic records of 86 patients (48 patients underwent lateral plate fixation by an angular stable plate system (LISS), 38 patients were stabilized by a rigid interlocking nail device). Functional outcome and individual satisfaction of the patients was similar between the two groups. With regards to fracture healing and treatment-related complications, intramedullary nail fixation showed slight advantages. Gondalia V, Choi DH, Lee SC, et al. Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrogradeinserted supracondylar nail. J Orthop Traumatol. 2014;15(3):201–207. Retrospective study included 42 cases of periprosthetic supracondylar femoral fractures proximal to posterior stabilized total knee arthroplasty. Clinical results were similar when comparing the femoral plating and retrograde-inserted supracondylar nail groups Fixation method and fracture type did not cause an increase in the complication rate. Kiluçoğlu OI, Akgül T, Sağlam Y, et al. Comparison of locked plating and intramedullary nailing for periprosthetic supracondylar femur fractures after knee arthroplasty. Acta Orthop Belg. 2013;79(4):417–421. Retrospective review of 16 cases of periprosthetic fractures treated with either IM Nailing or Locked plating. At mean follow up of 4.3 years, sagittal and coronal plane measurements were similar and with favorable clinical results in both groups Matlovich NF, Lanting BA, Vasarhelyi EM, et al. Outcomes of surgical management of supracondylar periprosthetic femur fractures. J Arthroplasty. 2017;32(1):189–192. The outcomes of locked plating and intramedullary (IM) nail fixation were evaluated retrospectively in 57 patients based on fracture location, being above or at/below the total knee arthroplasty (TKA) flange. The use of both technique for supracondylar periprosthetic fractures provided comparable clinical outcomes. However, caution is recommended in using IM nails for fractures below the flange since limited fixation may increase the risk of nonunion. Meneghini RM, Keyes BJ, Reddy KK, et al. Modern retrograde intramedullary nails versus periarticular locked plates for supracondylar femur fractures after total knee arthroplasty. J Arthroplasty. 2014;29(7):1478–1481. Retrospective review of 91 consecutive periposthetic fractures. Twenty nine were treated with retrograde IM nail and 66 were treated with periarticular locked plates. There were 2 (9%) nonunions in the IM nail group and 12 non-unions/delayed-unions (19%) in the locked plate group. Ristevski B, Nauth A, Williams DS, et al. Systematic review of the treatment of periprosthetic distal femur fractures. J Orthop Trauma. 2014;28(5):307–312. A systematic review comparing nonoperative and operative treatments for the management of periprosthetic distal femur fractures adjacent to total knee arthroplasties. Superior rates of union were seen when comparing locked and conventional plating techniques. However, no significant difference in rates of union were identified when comparing locked plating and intramedullary nails. Malunion rates were higher in the IM nail group. Rorabeck CH, Taylor JW. Classification of periprosthetic fractures complicating total knee arthroplasty. Orthop Clin North Am. 1999;30(2):209–214. Streubel PN, Gardner MJ, Morshed S, et al. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joint Surg Br. 2010;92(4):527–534. A retrospective multicentre study on lateral locked plating of periprosthetic supracondylar femoral fractures evaluating the results according to extension of the fracture distal with the proximal flange of the femoral component. Twenty-eight patients with proximal fractures were compared to 33 with fractures distal to the proximal border of the component. The distal fractures were successfully managed with locked plating with similar results to the more proximal fractures. Thompson SM, Lindisfarne EAO, Bradley N, et al. Periprosthetic supracondylar femoral fractures above a total knee replacement: compatibility guide for fixation with a retrograde intramedullary nail. J Arthroplasty. 2014;29(8):1639–1641.

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PROCEDURE 78

Acetabular Fractures: Acute Total Hip Arthroplasty (THA) Theodore T. Manson and Aaron J. Johnson INTRODUCTION AND INDICATIONS

TREATMENT OPTIONS WITH IMAGING

• Nonoperative treatment with late THA for symptomatic posttraumatic arthritis • ORIF • Acute THA without ORIF • Acute ORIF with THA

• Elderly patients who are healthy enough to undergo surgical treatment • Isolated posterior or anterior wall fractures may be treated with total hip arthroplasty (THA) alone through an anterior approach. • Anterior column comminution or anterior inferior iliac spine (AIIS) disruption may be treated with ORIF plus THA from an anterior approach. • Displaced posterior column fracture lines should be treated through a posterior Kocher-Langenbeck approach. • Fractures of the acetabulum represent a wide variety of injury patterns. In young patients who meet operative criteria, open reduction and internal fixation (ORIF) is the preferred treatment. In older patients ORIF can be technically challenging and has a high incidence of posttraumatic arthritis. Furthermore, THA after failed acetabular ORIF has inferior outcomes to primary THA for osteoarthritis. Some authors have consequently argued THA may be the preferred treatment in the acute setting after acetabular fracture for certain patients and fracture patterns. This chapter discusses the various approaches that can be used to perform acute THA with or without concomitant ORIF, when to utilize each approach, and the postoperative regimen after accomplishing this procedure. • Once the decision has been made to treat the acute acetabular fracture with THA, there are three methodologic approaches to performing this. The first is acute THA alone. The second is ORIF with concomitant THA through an anterior approach. And the third is ORIF with concomitant THA through a posterior Kocher-Langenbeck approach. Each has its advantages, disadvantages, and specific indications. • For all approaches, we always obtain calibrated marker ball pelvic films preoperatively. Based on these images, templating should be performed to determine acetabular and femoral component size, and level of femoral neck cut relative to the lesser trochanter from the uninjured hip. 

Acute THA Alone • In certain patients who have an isolated posterior or anterior wall acetabular fracture, acute THA alone without ORIF is feasible provided certain conditions are met (Fig. 78.1). For THA to be effective in this setting without ORIF, it is critical that the patient have intact subchondral bone attached to the ischium as well as the AIIS (Fig. 78.2A) for adequate cup stability (Fig. 78.2B). • In this setting, the principles of jumbo cup reconstruction are typically used, allowing the cup to be wedged between the AIIS and ischium and the posterior wall fragment to be ignored. Although the AIIS is typically intact for posterior wall fractures, the ischium must be scrutinized for adequate bone stock. Computed tomography (CT) scans can be useful to evaluate for this (Fig. 78.3). 

ORIF and THA Through an Anterior Approach • For patients who do not have intact subchondral bone attached to the AIIS, it is necessary to perform ORIF in order to achieve enough bony stability to obtain a press fit between the AIIS and the ischium. Therefore, in patients who have fracture lines that disrupt the subchondral bone of the AIIS, an anterior-based approach is helpful in this setting because it allows the anterior fracture lines to be directly addressed and stabilized. Once the AIIS is stabilized, acetabular preparation and 992

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.1  With permission from R Adams Cowley Shock Trauma Center.

AIIS

Ischium

A

AIIS

Ischium

B FIG. 78.2  With permission from R Adams Cowley Shock Trauma Center.

993

994

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.3  With permission from R Adams Cowley Shock Trauma Center.

FIG. 78.4  With permission from R Adams Cowley Shock Trauma Center.

acetabular component placement can safely be performed. Protrusio can also be adequately addressed through this approach, provided that there is not significant displacement of any posterior column fracture lines. Should additional fixation be needed to address quadrilateral surface fracture lines (Fig. 78.4), this approach also allows for a separate incision to be made concomitantly to address this with fixation through an anterior intrapelvic (Stoppa) approach. (Please see Chapter 68 for a detailed discussion of the anterior intrapelvic [Stoppa] approach.) However, we find that this is rarely needed. 

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.5  With permission from R Adams Cowley Shock Trauma Center.

ORIF and THA Through a Posterior Approach • The third approach for ORIF and acute THA is to approach the hip posteriorly. This is typically reserved for patients who have fracture lines with displacement of the posterior column, such as posterior column, transverse, or T-type fractures. Although nearly any acetabular fracture could be treated with ORIF and THA through a posterior approach, the major concern is a theoretical increased risk of dislocation postoperatively. However, we have not seen this as a problem with this technique. The main fracture pattern where this approach is contraindicated is in patients who have any protrusio or medial dislocation of the femoral head that disrupts the AIIS. If there is disruption and comminution of the subchondral bone attached to the AIIS, we prefer the Levine approach over the posterior approach. Furthermore, patients who have side-impact trauma and compromised soft tissue laterally may be better served with an anterior approach. 

POSITIONING, EXPOSURES, AND SURGICAL ANATOMY Acute THA Alone • An anterior approach, such as direct anterior, Watson-Jones, or Hardinge, should be used for this procedure based on surgeon comfort and preference. Typically in these injury patterns, some of the short external rotators may be torn; however, the obturator externus and quadratus femoris attachments to the posterior greater trochanter usually remain intact. Any approach to THA in this setting should emphasize the importance of these stabilizers of the THA and focus on keeping them intact. Therefore, performing any of the anterior approaches would exploit this benefit. • Positioning should be performed in an appropriate manner for the chosen approach, either supine or lateral. At our center, we prefer supine positioning when possible with both legs prepared and draped free into the surgical field. This also allows for direct comparison of leg length at the conclusion of the case (Fig. 78.5). Our preferred technique is a direct anterior approach to the hip. 

ORIF and THA Through an Anterior Approach • The approach we recommend for this procedure is the Levine modification of the anterior Smith-Peterson interval. Levine described this modification in 1943 to allow for intrapelvic extension to treat central acetabular fractures with protrusio. More

995

996

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.6  With permission from R Adams Cowley Shock Trauma Center.

FIG. 78.7  With permission from R Adams Cowley Shock Trauma Center.

recently, Beaule and Matta described the use of this approach for concomitant ORIF and THA. In addition to providing adequate access to the anterior fracture lines, the patient is supine for this approach, which facilitates anesthesia access to the patient’s chest, arms, and airway throughout the entirety of the case. • Although Beaule and Matta described the approach performed on a traction table, we prefer to use a flat-top Jackson table. At our center, a standard OR bed is typically used for the direct anterior approach to THA. However, most beds will not allow for intraoperative visualization of the iliac oblique imaging, and we modify the setup to be performed on a radiolucent table. The patient’s torso and pelvis are elevated on folded blankets to allow for hip extension during femoral preparation (Fig. 78.6). Both legs are always draped into the field, as well as the area above the pubic symphysis in the event an anterior intrapelvic (Stoppa) approach is required (Fig. 78.7). • A curvilinear incision is then made approximately three fingerbreadths lateral to the anterior superior iliac spine (ASIS) that extends proximally along the iliac crest, and distally about 7 cm in the direction of the tensor fascia lata muscle fibers (Fig. 78.8). • Distally the interval is similar to that for the direct anterior approach. Superficially, the fascia of the tensor fascia lata is incised in its midline in order to protect the lateral femoral cutaneous nerve (Fig. 78.9). Then the ascending branch of the lateral femoral circumflex artery is identified and cauterized. A capsulotomy is performed to expose the femoral head and neck. The acetabular fixation can be performed with or without the femoral head in place. If the femoral head is to be removed at this time, we now make an in situ neck cut at the level that was determined on the preoperative template. • Once the hip is exposed, the dissection continues proximally toward the iliac spine. The inguinal ligament is typically released subperiosteally from its insertion and tagged with ethibond suture to facilitate repair at the end of the case (Fig. 78.10).

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

Head ASIS

Foot

FIG. 78.8  With permission from R Adams Cowley Shock Trauma Center.

Iliac Crest HEAD

ASIS

TFL

FIG. 78.9  With permission from R Adams Cowley Shock Trauma Center.

HEAD

ASIS

Inguinal Ligament

FIG. 78.10  With permission from R Adams Cowley Shock Trauma Center.

An ASIS osteotomy can also be performed, which allows for bony repair at the end of the case. • The iliacus muscle is then elevated off the inner table. The hip is flexed to relieve tension of the neurovascular structures and retractors can now be safely placed into the true pelvis. Should more exposure of the anterior column be required, an osteotomy of the AIIS can also be performed in order to release the direct insertion of rectus femoris (Fig. 78.11). This is rarely necessary. 

997

998

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

Iliac Fossa Patient’s Head

ASIS

Femoral Head FIG. 78.11  With permission from R Adams Cowley Shock Trauma Center.

ORIF and THA Through a Posterior Approach • The Kocher-Langenbeck approach is typically used for this procedure. The patient should be in the lateral decubitus position on a flat radiolucent table. We prefer to use hip positioners, such as those used in primary total hip arthroplasty. However, it is necessary to check imaging preoperatively to ensure that the positioners do not obscure the oblique pelvic imaging, especially the iliac oblique. The details of this surgical approach and dissection can be found elsewhere, in Chapter 69. The gluteus maximus sling is always taken down and the hip is extended with a flexed knee during the procedure. Both of the maneuvers are performed to decrease pressure on the sciatic nerve throughout the case. 

PROCEDURE Acute THA Alone

PEARLS

• Obtain preoperative marker ball films and template as you would a total hip arthroplasty. • Plan to use a multihole revision type acetabular component. • Resected femoral head can be used for morselized cancellous bone graft. • Place multiple screws in the ileum, ischium, above and below the equator of the acetabular cup. • Advantages to supine positioning on a flat top table is the ability to directly assess leg lengths intraoperatively. ACUTE THA ALONE: INSTRUMENTATION/IMPLANTATION

• Anterior hip retractors • Standard instrumentation for preparation of total hip arthroplasty

• After approaching the hip through one of the anterior approaches, we typically proceed with acetabular preparation first. Using a reamer that is 6 mm less than the templated acetabular component size, the cup is medialized to the floor of the cotyloid fossa. We then sequentially ream in the orientation of the final acetabular component until we reach 1 mm under the final component size. This is done to obtain an appropriate press-fit on the cup. • The acetabular component is typically a porous-coated multihole revision-style cup, in order to allow for multiple screws placed wherever there is adequate bone stock. We again verify that the AIIS and ischial bone is intact and stable prior to cup insertion. The resected femoral head is morselized and reamed into any remaining acetabular defects with a reamer that is 2 mm smaller than the final cup size, with the reamer on reverse. • Once the cup is impacted and stable, between three and five screws are placed. Several are typically placed into the ileum, ischium, and cotyloid fossa in order to prevent failure of the cup in abduction (Fig. 78.12). • Following acetabular implantation, proceed with femoral component preparation and leg length comparison as you would for a typical total hip arthroplasty. With the final implants in place and the patient positioned supine, the heels and maleoli can be directly compared in order to assess leg length when placed directly in line with the pubic symphysis. The implants can also be assessed for range of motion, impingement, and dislocation risk in deep flexion, and internal and external rotation. Radiographic evaluation of leg length can also be performed by the overlay method described by Matta. 

ORIF and THA Through an Anterior Approach • The goal of this procedure differs from standard acetabular ORIF. We are less concerned with anatomic reduction and more concerned with pelvic stabilization

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.12  With permission from R Adams Cowley Shock Trauma Center.

in order to obtain stable purchase for a THA cup between the subchondral bone of the AIIS anteriorly and ischium posteriorly. • A 3.5-mm reconstruction plate is usually sufficient to definitively fix the fragments, with long screws parallel to the quadrilateral surface that traverse just medial to the cotyloid fossa (Fig. 78.13). • It is also possible to obtain posterior column fixation through this approach if the posterior fracture lines are not significantly displaced. Long 3.5-mm or 7.3-mm screws can be used to obtain fixation of the posterior column fragment by traversing from the iliac fossa to the posterior column (Fig. 78.14). • Once the pelvis has been sufficiently stabilized, attention is then turned to the acetabulum in preparation for cup placement. Acetabular reaming is started at 7 mm less than the templated acetabular component. The first reamer is used to medialize to the base of the cotyloid fossa, then sequential reaming is performed in the orientation of final cup placement in 2-mm increments. The final reamer should be 1 mm less than the final cup size to allow for a 1-mm press fit. • Similar to the procedure for acute THA alone, the femoral head may be morselized for bone graft. This should be used to fill any bony defects prior to cup placement. After placing adequate graft in the defects, a reamer should be used on reverse that is 2 mm less than the cup size. • Once the acetabulum is prepared, a multihole revision-style highly porous cup is implanted. Again, three to five screws are placed into the ilium, ischium, and medially if necessary. We find it necessary to place screws above and below the equator of the acetabular component in order to avoid abduction failure of the acetabular component prior to bony ingrowth. • The femur is then exposed for preparation of the femoral canal. The leg must be hyperextended in order to gain access for broaching. In general, this is not as difficult as in a direct anterior THA for osteoarthritis owing to the lack of capsular

999

1000

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.13  With permission from R Adams Cowley Shock Trauma Center.

contractures, stiffness, or osteophytes. To elevate the femur, the ischiofemoral ligament must be released from the “saddle” area of the proximal femur, which is where the femoral neck joins the greater trochanter. The femur is then prepared in the standard fashion as one would for a THA.

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.14  With permission from R Adams Cowley Shock Trauma Center.

• After canal preparation, the components are trialed and leg lengths can be directly compared as described above because both legs are prepared into the operative field. • After implantation of the final components, the hip capsule is typically closed. We typically close the capsule to the undersurface of the gluteus medius tendon. This is performed with #5 ethibond sutures. The inguinal ligament is repaired with a

1001

1002

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

Foot

Head

Troch

Hip Cobra in Lesser Notch ORIF AND THA THROUGH AN ANTERIOR APPROACH: PEARLS

• Distally the intervals and approach are the same as the direct anterior approach to the hip. • To gain exposure to the pelvis and anterior column, the inguinal ligament is taken down subperiosteally. • The ASIS can be osteotomized to take down the direct insertion of the femoris rectus muscle and increase exposure to the anterior column. • Hip flexion can help limit tension on the neurovascular structures and can facilitate bony reduction. • Nondisplaced posterior column fractures can be stabilized through this approach with long 3.5-mm or 7.3-mm screws.

Capsule

FIG. 78.15  With permission from R Adams Cowley Shock Trauma Center.

subperiosteal ethibond suture and, if an ASIS osteotomy was performed, this is repaired with a 3.5-mm lag screw. • Layered closure is then performed. Drains are always placed; one is usually placed in the iliac fossa and another under the tensor fascia lata. 

ORIF and THA Through a Posterior Approach • The general principles for fixation through a posterior approach are similar to those just described for an anterior approach. The pelvis should be stabilized to obtain stable cup fixation, as opposed to obtaining anatomic reduction of the acetabulum. • After proceeding with a posterior approach to the hip, the main decision to perform ORIF and THA through this approach is whether the femoral head should be left in place while the pelvis is stabilized. We will describe both techniques here. 

ORIF With the Femoral Head in Place ORIF AND THA THROUGH AN ANTERIOR APPROACH: INSTRUMENTATION/IMPLANTATION

• Anterior hip retractors • 3.5-mm pelvis reconstruction plates • Long 3.5-mm and 7.3-mm screws for posterior column fixation • Standard THA preparation instrumentation • The resected femoral head should be reserved for morselized bone graft • Multihole highly porous revision style cup

• If the femoral head is to be left in place, the external rotators are taken down independent of the capsule and tagged for future repair. The acetabular fracture is then stabilized with posterior column plates, as needed. These should be placed directly over the hip capsule proximally (Fig. 78.15). This will serve to anchor the acetabular side of the capsule in place for future hip stability. • By leaving the femoral head reduced during this aspect of the procedure, it allows for a higher likelihood that a hemispheric acetabulum may be recreated. We typically use 3.5-mm pelvic reconstruction plates to obtain fixation (Fig. 78.16). • After fixation, a capsulotomy is performed and the hip is dislocated. The femoral neck cut is made based on the preoperative template. 

ORIF With the Femoral Head Resected • An alternative to the above technique is to take down the external rotators and capsule as one continuous sleeve, dislocating the hip and making the neck cut prior to stabilizing the pelvis. The advantage of this technique is that it may remove the medially directed force off the acetabulum, which may facilitate reduction in certain fracture patterns. Transverse and T-type fractures may be particularly difficult to reduce with the femoral head left in place. The disadvantage of this technique is the possibility of creating an elliptical rather than circular acetabular vault. Reconstruction plates are used in a similar fashion now as if the head were still in place. 

Total Hip Arthroplasty • After the pelvis is stabilized, THA is then performed. The femur is prepared first using standard femoral broaching techniques. • The acetabulum is then prepared and a C-shaped retractor is typically placed to retract the femur anteriorly in order to gain visualization of the acetabulum for prepa-

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

A

1003

B FIG. 78.16  With permission from R Adams Cowley Shock Trauma Center.

ration. Should the femur be difficult to retract, the reflected head of rectus femoris muscle can be released off its insertion. • The capsule should be tagged, and this tag stitch can be effectively used as a retractor by pulling posteriorly. Acetabular preparation is then performed in a similar fashion as that described in the previous section; bone graft is used to fill defects, as needed (Fig. 78.17), and the final component is impacted with multiple screws both above and below the equator of the cup to provide additional stability (Fig. 78.18). • Following this, trial components are inserted, stability is tested, and the compound version is assessed. We typically aim for a compound version of around 40°. The hip should also be stable in a position of flexion and deep adduction. The preoperative template should be checked for lesser-trochanter-to-center of the head distance. This should be measured now to verify that the leg length has been recreated to match the contralateral side. • If the hip is stable and the leg lengths appear equal based on the above measurements, then the final components can be implanted at this time. Fluoroscopic images including AP and Judet views of the hip should be obtained prior to closure to ensure that acetabular cup screws are in safe positions. • For the closure, the capsule and short external rotators are repaired using #5 ethibond sutures. Although these could be repaired through bone tunnels, we prefer to repair them to the posterior edge of the gluteus medius tendon (Fig. 78.19). The gluteal sling is repaired with 0–polydioxanone (PDS) suture. The fascia lata is then closed over an 1/8” drain that is placed to suction. 

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients who undergo acute THA alone are kept 50% weight bearing for 6 weeks. After that time, they are allowed to progress to weight bearing as tolerated. • In our practice, these patients do not have displaced columnar injuries so prolonged non–weight bearing is not utilized. • For those who undergo ORIF with THA, they are touchdown weight-bearing for three months, regardless of whether an anterior or posterior approach is used. Patients who have a posterior approach performed are placed in an abduction pillow postoperatively, but we have not found it necessary to fit patients with any abduction

ORIF AND THA THROUGH A POSTERIOR APPROACH: PEARLS

• When performing THA + ORIF for displaced fractures of the posterior column, it is best to use a posterior approach. • The pelvis can be stabilized with the femoral head in place or after it is resected. For fractures, such as T-type or transverse patterns, it may be more useful to resect the femoral head prior to ORIF. • Hip extension and knee flexion while working on the posterior column can help limit iatrogenic sciatic nerve injury. • Care must be taken not to create an oblong acetabulum if the femoral head is resected prior to ORIF. • Retain the resected femoral head for use as bone graft. • Use a multihole, highly porous revision style cup. • The external rotators and capsule should be repaired to the gluteus medius tendon for added stability.

ORIF AND THA THROUGH A POSTERIOR APPROACH: INSTRUMENTATION/IMPLANTATION

• C-shaped hip retractor • 3.5-mm pelvis reconstruction plates • Standard THA preparation instrumentation • The resected femoral head should be reserved for morselized bone graft. • Multihole, highly porous revision style cup

1004

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

FIG. 78.17  With permission from R Adams Cowley Shock Trauma Center.

FIG. 78.18  With permission from R Adams Cowley Shock Trauma Center.

braces. They are taught typical posterior hip precautions once they are able to participate with physical therapy. • After 3 months, patients are instructed to gradually relinquish their assistive devices to bear full weight on the injured side. Depending on the bone quality and type of fixation achieved, it may be possible to advance their weight bearing earlier. However, in our center we have not done so to date. • Outcomes of this procedure are typically better than delayed THA after acetabular ORIF but may not be as good as those of THA performed for primary osteoarthritis. There also may be a difference in patient expectations in this cohort. We have also noted that patients can be broadly categorized into those who undergo low-energy fragility-type fractures. They tend to be lower demand patients. Those in the high-energy cohort may be higher demand patients who have different expectations following surgery.

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA)

Foot

Head Troch

FIG. 78.19  With permission from R Adams Cowley Shock Trauma Center.

• Complications surrounding ORIF and THA for acetabular fractures are a typical combination of those that would be expected for either of these procedures. Heterotopic ossification, dislocation, symptomatic pulmonary embolism or deep vein thrombosis, periprosthetic infection, and aseptic loosening of the arthroplasty components are all possible complications. • Heterotopic ossification is a common complication following acetabular surgery. In a meta-analysis from 2013 that assessed outcomes of acute THA for displaced acetabular fractures, the authors reported a 38% incidence of heterotopic ossification. • Dislocation rates for THA and ORIF after acetabular fractures are higher than they are for primary total hip arthroplasty. Incidence varies between 2% and 4%. We try to perform the procedure through an anterior approach whenever possible in order to keep the remaining posterior structures intact for added stability. When we do have to perform the procedure through a posterior approach, we carefully scrutinize component position, compound version, and a dynamic repair of the capsule and external rotators to the gluteus medius tendon to maximize stability. • No good data are available regarding the specific incidence of venous thromboembolic (VTE) after acute ORIF and THA for acetabular fractures owing to the relatively low incidence of each. However, at our center, we typically follow the guidelines based on the arthroplasty literature, and patients all receive enteric-coated aspirin for 6 weeks postoperatively for VTE prophylaxis unless they have a previous history of deep venous thrombosis or pulmonary embolism. • As with any arthroplasty procedure, periprosthetic infection can be a devastating complication. Although no large series specifically address this complication, the incidence in the few reports in the literature is low, ranging between 1% and 5%. This is still higher than infection rates after primary THA. Surgeons should keep in mind that this is a technically challenging procedure and efforts should be made to emphasize speed rather than anatomic reduction. We feel that decreased operative time is critical in reducing the risk of infection.

EVIDENCE Beaule PE, Griffin DB, Matta JM. The Levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture. J Orthop Trauma. 2004;18:623–629. This is a technique paper that describes a modern Levine approach to performing acute THA and ORIF for acetabular fractures. The authors describe the use of the fracture table to position the patient supine for the approach. They also report on a small series of two patients with successful outcomes after employing this approach. Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures in an older population. J Orthop Trauma. 2010;24:637–644. The authors present a series of 97 elderly patients who had acetabular fractures that were treated with a variety of techniques. They had 58 patients who underwent ORIF, 26 who had ORIF with delayed THA, and 9 who underwent acute THA with concomitant ORIF. They retrospectively review their results and present a treatment algorithm based on injury mechanism, comorbidities, fracture characteristics, and other risk factors.

1005

1006

PROCEDURE 78  Acetabular Fractures: Acute Total Hip Arthroplasty (THA) Chemaly O, Hebert-Davies J, Rouleau DM, Benoit B, Laflamme GY. Heterotopic ossification following total hip replacement for acetabular fractures. J Bone Joint Surg [Br]. 2013;95-B:95–100. This paper reports the incidence of heterotopic ossification (HO) after total hip arthroplasty, with or without ORIF for acetabular fractures. They evaluate the incidence between early and late THA, as well as other post-operative complications. The overall incidence of HO in the early THA cohort was 12/19 (63%), and 3/20 for the late THA cohort (15%). Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am. 1997;28:435–446. This is a review paper that discusses the various options for using THA in the surgical treatment of acetabular fractures and the advantages and disadvantages of early versus late THA. Kreder HJ, Rozen N, Borkhoff CM, et al. Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall. J Bone Joint Surg [Br]. 2006;88:776–782. Kreder et al. reported on 128 patients who had surgical treatment of acetabular fractures. They evaluate risk factors, including patient risk factors, age, fracture characteristics, and reduction quality that put patients at risk for later total hip arthroplasty. Of the 16 patients (12.5%) who ultimately underwent THA, they determined that patients who had posterior wall fractures with marginal impaction or comminution in patients 50 years or older were at higher risk of requiring THA than patients younger than 50 years old. Levine MA. A treatment of central fractures of the acetabulum. J Bone Joint Surg. 1943;XXV:5. This is a case report by Levine in 1943 describing an anterior approach to treating an acetabular fracture. This was a novel treatment at the time, when they describe most approaches to acetabular fractures utilizing traction and turnbuckle casts. Matta JM. The goal of acetabular fracture surgery. J Orthop Trauma. 1996;10:586. Letter to the editor by Joel Matta urging practitioners that it is “too early to give up” on acetabular fracture fixation, and that the goal of the acetabular surgeon is “to preserve the skeletal parts and restore them to as functional a condition as possible,” rather than merely prepare the pelvis for reconstruction by the total joint surgeon. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999;7:128–141. Review article from 1999 discussing techniques for reconstructing the acetabulum in geriatric patients. The authors present therapeutic options and indications for each, including conservative options, minimally invasive fixation in situ, conventional ORIF, and total hip arthroplasty. Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop. 2003:173–186. This is a retrospective study of 424 acetabular fractures to determine which of the following risk factors correlated with clinical outcomes: initial displacement, fracture pattern, delay to surgery, quality of reduction, patient age, and patient weight. They found that patients who had extensive impaction, articular damage, preexisting arthrosis, advanced age, osteopenia, and associated femoral head and neck fractures were associated with poor reduction and poor functional outcomes. Sheth D, Cafri G, Inacio MC, Paxton EW, Namba RS. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop. 2015;473:3401–3408. This is a large registry study of the Kaiser Permanent Total Joint Registry that evaluated 42,438 primary THAs, which showed that the anterolateral and direct lateral approaches had a lower relative risk of dislocation compared to the posterior approach. Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg [Am]. 1998;80:1295–1305. This is a report of 63 patients who had delayed THA after ORIF for acetabular fracture. The 10-year Kaplan-Meier survivorship for the THA was 78%, which is higher than other reported survivorship for primary THA. They found that patients who were less than 50 years old, had weight greater than 80 kg, or who had large cavitary defects at the time of conversion THA were at increased risk of component loosening.

PROCEDURE 79

Total Hip Replacement for Intertrochanteric Hip Fractures Hans J. Kreder and G. Yves Laflamme INDICATIONS

PITFALLS

• A  ll indications should be considered relative because the decision to perform total joint replacement surgery for intertrochanteric hip fractures is uncommon and remains highly controversial (1,2). • Patient factor prerequisites: • No major cardiovascular comorbidity • A patient who is at least community ambulatory • Relative injury-related indications (in the presence of an intertrochanteric or subtrochanteric fracture) (5): • Preexisting symptomatic hip joint arthritis • Complex proximal femoral fracture through osteopenic bone (fixation likely to result in significant malunion, including shortening, weakness, and decreased function in a community ambulator) • Pathologic fracture • Nonunion or significant malunion with weakness and functional loss after previous fixation attempts.

Examination/Imaging • C  areful templating is mandatory to avoid hip instability and leg length inequality. It is better to template the intact side as the fracture significantly distorts the radiographic landmarks on the injured side. The following plain radiographic films are required for this purpose: • Anteroposterior (AP) pelvis radiograph centered low to show both hip joints and the affected and intact proximal femurs, as in the AP pelvis radiograph in Fig. 79.1, showing a complex osteopenic proximal femur fracture. • Lateral radiograph of the affected hip • Consider full-length femur AP and lateral views to include the knee. On these views, one should:

• R eplacement is a more extensive surgical procedure than fracture fixation and may not be appropriate in the following situations: • Bedridden individuals or wheelchair users • Patients with major cardiovascular comorbidity or other surgical risk factors • Patients with pathologic fractures and life expectancy less than 6 weeks (not expected to survive past the early recovery phase following replacement surgery)

CONTROVERSIES

• T otal joint replacement for intertrochanteric hip fractures remains a controversial treatment option at this time. The lack of good-quality information regarding the following issues hinders the resolution of this controversy: • What is the relative mortality and morbidity of total joint replacement versus fracture fixation? • How do various degrees of proximal femoral malunion affect patient pain and function? • Does immediate total hip replacement result in a better outcome than salvage after failed fixation attempts? • What type of replacement should be performed: cemented versus uncemented; unipolar, bipolar; or total hip replacement?

TREATMENT OPTIONS

• Fracture fixation • Intramedullary • Extramedullary • With or without bone augmentation— cement or bone substitute • Replacement (implants and fixation) • Femoral and acetabular side • Bipolar • Unipolar • Short or long femoral stem • Cemented or uncemented femoral stem • Trochanteric fixation: claw device attached to femoral component, short claw secured with cables, or long claw/plate secured with cables and screws

FIG. 79.1 

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PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

FIG. 79.2  PEARLS

• D  rape the affected leg free from just above the iliac crest, with the entire leg covered with a “leg stocking” up to approximately 10 cm below the groin. • An adhesive drape folded in half (adhesive side out), placed into the groin and joined by a second adhesive drape from the top (lateral) side of the leg, allows complete isolation of the groin.

PITFALLS

• B e aware of beanbag use for holding a large patient in the lateral decubitus position as patient orientation relative to the floor may shift during limb manipulation, leading to malorientation of the acetabular component. Secure patient positioning is preferred, especially in large patients. • Frail elderly patients may have stiff shoulders and elbows. Take great care to avoid injury during lateral positioning. All dependent extremities must be carefully padded. The upper arm may be supported by a pillow or lateral arm rest. A flannel sheet placed between the legs provides padding, but is thin enough to allow palpation of the opposite limb for intraoperative leg length determination. • The deep dissection depends on the precise nature of the fracture. The principles are as follows: • The surgeon should spend some time analyzing the bone fragments and soft-tissue attachments before detaching soft tissues. Identify the gluteus medius and palpate the gluteus minimus tendon from anteriorly deep to the abductors. Note the relationship of muscle disruption to the trochanteric fragments; if possible, areas of muscle disruption are worked through (using a transtrochanteric approach, but without dividing the posterior soft-tissue attachments from the trochanter).

• Note the presence of deformity or hardware. • Pay particular attention to the femoral bow if a long-stemmed implant is considered. • Look for additional lesions if dealing with a pathologic fracture (Fig. 79.2). • Pathologic fractures demand a complete local and systemic workup to detect other lesions locally or in other body regions, and to stage the disease overall (prognosis and systemic treatment requirements). 

SURGICAL ANATOMY • •

Bone (Fig. 79.3) • Greater trochanter • Lesser trochanter • Medial calcar Muscles (Fig. 79.4) • Gluteus medius • Vastus lateralis • Iliopsoas tendon • Effects of deforming forces (Fig. 79.5) 

Greater trochanter Medial calcar Lesser trochanter

FIG. 79.3 

PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

Gluteus medius

Piriformis insertion

Iliopsoas

Vastus lateralis

FIG. 79.4 

1009

• U sually the injury has already detached the greater trochanter partially or completely from the intertrochanteric region or the subtrochanteric region. As much soft tissue as possible should be left attached and the trochanteric fragment retracted posteriorly and superiorly (Fig. 79.9). • If necessary, detach the anterior portion of the gluteus medius in a fashion similar to a routine total hip replacement via a modified Hardinge approach (see below). • Elevate the anterior portion of the gluteus medius and vastus lateralis along with the gluteus minimus tendon off the joint capsule. • Identify the cleavage point proximally by palpating the small notch in the greater trochanter or by palpating the most anterior aspect of the femoral neck beneath the abductor muscle from anteriorly. • Split the gluteus along its fibers proximally for up to 2 cm. • Distally elevate the tissues using electrocautery just anterior to a palpable prominence on the anterolateral aspect of the greater trochanter to approximately 1 cm into the first muscle fibers of the vastus lateralis. PEARLS

• S plitting the gluteus medius along its fibers is important to avoid undue muscle injury. Note that the fibers may be horizontal because the proximal femur is displaced superiorly. PITFALLS

A

B FIG. 79.5 

POSITIONING • • • •

 egular operating room table R Lateral decubitus position (must be held securely to avoid cup malposition) (Fig. 79.6). Bottom knee padded under peroneal nerve Padding between legs 

• B e careful to initiate the split of the iliotibial band distally in the midpoint (from posterior to anterior) or even slightly anterior to the midpoint to avoid entering the gluteus maximus insertion. • Elevating the rectus muscle fibers off the joint capsule is relatively safe superiorly and anteriorly. Take care to avoid injury to vessels located inferiorly. A Cobb elevator can be used to isolate the capsule in this area before completing the capsulotomy or capsulectomy. • Place a small, sharp Hohmann retractor along the neck of the femur over the brim of the pelvis just below the anterior inferior iliac spine. This helps to initiate the dissection between the hip joint capsule and the overlying rectus femoris muscle fibers. • Then use a sharp pair of capsulotomy scissors or a scalpel blade to elevate the rectus off the joint capsule. A second small sharp Hohmann retractor can be inserted into the iliac wing just above the hip joint using a mallet. • The capsular exposure can then be completed under direct visualization. • A capsulotomy or capsulectomy may now be performed. • A capsulectomy, if performed, should be initiated from anteriorly and as far inferiorly as can be safely visualized (bleeding is often encountered inferiorly). • The blade is drawn superiorly around the femoral head and posteriorly under the abductor muscles. Posterior retraction of the Continued

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PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

FIG. 79.6 

PITFALLS—cont’d



abductor muscles and abduction of the leg allow for safe posterior capsular incision. • The blade is then drawn along the femoral neck and turned 180 degrees to come from above distally along the femoral neck insertion of the capsule. The resulting upside-down U-shaped flap of capsule is detached distally, taking care to avoid dividing any vessels in the adjacent soft tissues (Fig. 79.10).

PORTALS/EXPOSURES • A  modified Hardinge or lateral approach is described. • An oblique incision is made from 2 to 5 cm above the posterior margin of the greater trochanter distally for approximately 8 to 10 cm (Fig. 79.7). The incision can be enlarged proximally and distally, if needed, depending on the size of the patient. • The iliotibial band is split from distal to proximal, extending into the interval between the tensor fascia lata and the gluteus maximus or into the lateral aspect of the gluteus maximus (Fig. 79.8). 

CONTROVERSIES

• A lternative approaches include the posterior approach and anterior approach. • Historically, the posterior approach was associated with a higher dislocation rate. However, less-invasive posterior approaches with capsular repair may have dislocation rates similar to other approaches. • Historically, the anterolateral approaches have been associated with a higher risk of injury to the innervation of the gluteus medius (the superior gluteal nerve). However, less-invasive anterolateral approaches do not jeopardize the innervation. • A capsulotomy is made by first adjusting the anterior Hohmann retractor to a position along the middle of the femoral neck and over the brim of the pelvis. A scalpel blade is then drawn from this retractor along the femoral neck. Superior and inferior flaps are then created resulting in an upside-down T-shaped capsulotomy (Fig. 79.11). • The limbs of the T are created by placing the scalpel inside the capsule and detaching the capsule from inside out along its insertion on the femoral neck superiorly and inferiorly. • Posterior retraction of the abductor muscles and abduction of the leg allow for safe superior capsular incision. Take care to avoid injury to the abductor muscles. • Extract the femoral head using a “corkscrew” threaded into the femoral head. • If total hip replacement is being performed, now expose the acetabulum using four small Hohmann retractors placed around the acetabulum to retract the muscles and capsule (if present).

FIG. 79.7 

FIG. 79.8 

PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

1011

PEARLS

FIG. 79.9 

• F or pathologic fractures of the proximal femur, a cemented component is recommended because radiation and chemotherapy may prevent bone ingrowth. • A stable calcar platform that allows immediate weight bearing must be created. In rare cases where the fracture extends well below the lesser trochanter, a proximal femur replacement prosthesis or strut allograft would be required to replace the missing calcar with metal or to support the compromised host bone with allograft (although implants up to 70 mm of calcar replacement are commercially readily available and should suffice in all but the most extreme cases). Alternatively, the implant may be cemented into position. • Similar to the revision situation, stability of the hip joint is enhanced by selecting a large femoral head and a liner with a lip that can be positioned superolaterally.

PITFALLS

U-shaped capsulectomy FIG. 79.10 

T capsulotomy FIG. 79.11 

• D  uring trial reduction with the greater trochanter not yet repaired, take care to avoid excessive leg lengthening to achieve a sense of stability. The hip will not be stable until the trochanter is repaired. The shuck test is not useful in this situation. Assess stability with the hip placed under axial load. • A large internal diameter liner with a lip placed superolaterally is recommended to minimize the risk of dislocation. • Femoral preparation requires careful attention to detail to ensure that correct length and femoral component anteversion is achieved. • If the fracture involves the lesser trochanter, it is sometimes still possible to use that as a landmark by reducing and temporarily clamping or cabling it into place. The greater trochanter can sometimes also be used as a landmark in this way. • Calcar replacement stems are usually required to create a calcar platform that can bear the patient’s body weight immediately (Fig. 79.12). This may require a low cut in host bone and a long metal calcar replacement stem. • Once the final femoral implant is correctly positioned in the femoral canal, undertake a trial reduction to assess leg length and stability. • Leg length is based partly on the preoperative template and also on the intraoperative comparison with the opposite leg. • With the knees together, the operated leg should be a few millimeters shorter than the opposite leg to account for the relative leg adduction. • With the operated leg abducted to neutral abduction, the two legs should seem the same length, but it may be difficult to ensure that the knees and ankles are in the same position.

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PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

FIG. 79.12  CONTROVERSIES

• Cemented versus uncemented implants (3,4) • Cemented implants achieve immediate stable fixation and allow for antibiotic addition to the cement. However, cement pressurization can cause pulmonary shunting, especially in elderly frail patients. Cement between the shaft and trochanteric fragments may prevent trochanteric union. Cement integrity fails over time, possibly accelerated by falls and other injuries, leading to failure and the need for revision. • Uncemented implants are associated with less pulmonary compromise and, once ingrown, failure is limited to interface wear. Implants must be chosen carefully to allow immediate weight bearing in the elderly population to minimize the complications associated with immobility. FIG. 79.13 

INSTRUMENTATION/IMPLANTATION

• R evision hip implant sets must be available. Rarely, primary hip implants can be used. • Two large pointed reduction forceps should be available to use for reapproximating the lesser and greater trochanter (needed to gauge implant position). • Wires or cables are rarely needed for this step to recreate an intact femoral tube before femoral preparation. • Strut allograft is rarely required for creating a stable calcar platform. If used, it should be cabled into position at the level of the calcar over the compromised host bone. If possible, it is usually preferable to make a lower cut in host bone and to use a longer calcar replacement metal implant. • When assessing stability, consider the normal contribution of the intact greater trochanter to stability. • Assess stability by axially loading the hip (to recreate the effect of the intact greater trochanter) and then assessing rotation, flexion, and adduction. • The “shuck test” is useless before trochantic fixation is completed; rotation must be judged in the absence of landmarks relative to knee position (Fig. 79.13). Broach handle is positioned relative to knee (positioned perpendicular to the floor).

PROCEDURE Step 1 • If a total hip replacement is chosen (as opposed to a bipolar implant), undertake acetabular preparation first. • Prepare the acetabulum in standard fashion and insert the acetabular component. Even in osteoporotic bone, an uncemented acetabular component (with screws if needed) provides excellent results. 

Step 2 • R  estoration of hip abductor function through trochanteric reattachment is essential for hip stability and normal gait. The reconstruction should allow immediate weight bearing. • A long trochanteric claw/plate construct is preferred. • If possible, screw fixation should be obtained distal to the tip of the implant. However, with long-stemmed implants this may not be possible, in which case multiple cables are combined with unicortical screws. • Use of a short plate with the proximal wire above the lesser trochanter may result in plate failure (Fig. 79.14). Replacement with a long plate makes the claw/plate construct more secure (Fig. 79.15). • First slide the plate underneath the vastus lateralis muscle (see Video 79.1). • Impact the claw into the greater trochanteric fragment.

PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

• H  old the trochanteric fragment in the claw by passing a wire around the greater trochanter and the claw. Some implants have specially designed grooves or holes in the claw and the plate to facilitate wire placement without slippage, but careful wire placement should enable any device to be used. • Hip abduction facilitates approximation of the greater trochanter against the remaining femoral shaft. A large pointed reduction forceps may help in this process as well. 

FIG. 79.14 

1013

PEARLS

• H  ip abduction facilitates bone-to-bone contact between the greater trochanter and the femoral shaft, which is essential if a fibrous union or nonunion is to be avoided. • Cables (as opposed to wires) should be used to achieve secure plate fixation for a long enough period to allow the trochanteric fracture to unite. • If possible, pass a screw through the plate below the femoral prosthesis. Fluoroscopy is not required for this step if care is taken to measure out the length of the prosthesis relative to a bone landmark before implant insertion. • Most cable instrument sets include cable passers of two or more diameters. Chose the smallest diameter passer that can be placed around the femur. This facilitates passage directly on bone, thus avoiding injury to neurovascular structures. • With the trochanteric fragment held in correct position, first secure the plate proximally with an oblique cable from below the lesser trochanter to the upper portion of the plate/claw. • Distally the plate is secured with a screw if possible or multiple cables. A minimum of four cables along the femoral shaft should be used. • Some revision hip systems allow placement of sutures through metal flanges that may be useful in attaining additional trochanteric fixation. • Once the trochanteric fixation is complete, close the wound in layers, as per routine total hip replacement. • Drains are not used. INSTRUMENTATION/IMPLANTATION

• L ong claw/plate construct, preferably one that allows cables to be secured to the plate • Cable passing system and bone cables

PITFALLS

A

B FIG. 79.15 

• F ailure to achieve contact between the greater trochanter and the femoral shaft prevents bone union. • Failure to pass a cable around the trochanteric fragment to secure it to the claw can result in trochanteric escape from underneath the claw, leading to nonunion and loss of abductor function. • Avoid stripping muscle from the femoral shaft. Cables can be passed with limited exposure underneath the muscle. When selecting a space for cable passing, it is important to carefully expose the site from behind and to identify any perforating vessels that might be encountered. It is often possible to work around these vessels without ligating them. However, blind cable passage may lacerate a vessel, resulting in hemorrhage that may be difficult to control after the cable is passed. • Take care to avoid injury to the sciatic nerve, which is vulnerable during the passage of both the proximal cable just below the lesser trochanter and all cables along the femoral shaft distally. • Rarely, arterial injury can occur owing to passage of a cable, especially in the most distal part of the femoral shaft.

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PROCEDURE 79  Total Hip Replacement for Intertrochanteric Hip Fractures

PEARLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

• E lderly patients should be allowed immediate weight bearing, as tolerated. The repair must be secure enough to permit this activity.

• Postoperative care • Immediate weight bearing is permitted as tolerated. • The patient should avoid abductor strengthening exercises for 6 weeks.

PITFALLS

EVIDENCE

• F ailure to allow weight bearing, as tolerated, leads to prolonged hospitalization and a higher risk of multiple complications related to immobility. CONTROVERSIES

• T rochanteric fixation that allows immediate weight bearing is desirable. • Cables alone, short or long claws, and direct suture to implants are possible. There are no comparative studies. Long claws with distal fixation provide sufficient stability for immediate weight bearing. • Some advocate locking implants. No comparative studies exist to compare locked and nonlocking implants in this setting. However, locked implants have been successfully used in the setting of periprosthetic fractures. • Implementation of so-called hip precautions is at the discretion of the surgeon and should follow the usual revision protocol. • Venous thromboprophylaxis should follow the institution’s routine protocol for revision total hip replacement patients. • Potential complications • Immediate postoperative footdrop could be caused by a cable having been placed around the sciatic nerve. The patient should be returned to the operating room for exploration immediately. • Rarely, arterial injury resulting from cable passage may manifest as an ischemic foot in the immediate postoperative period. Urgent vascular consultation, angiography (to determine the site of injury), and urgent surgical exploration and vascular repair are required in this situation. • Other complications are similar to those that might occur after routine revision total hip replacement.

Berend KR, Hanna J, Smith TM, et al. Acute hip arthroplasty for the treatment of intertrochanteric fractures in the elderly. J Surg Orthop Adv. 2005;14:185–189. Parker MJ, Handoll HHG. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2006;(2):CD000086. Pieringer H, Labek G, Auersperg V, et al. Cementless total hip arthroplasty in patients older than 80 years of age. J Bone Joint Surg [Br]. 2003;85:641–645. Pitto RP, Blunk J, Kößler M. Transesophageal echocardiography and clinical features of fat embolism during cemented total hip arthroplasty: a randomized study in patients with a femoral neck fracture. Arch Orthop Trauma Surg. 2000;120:53–58. Waddell JP, Morton J, Schemitsch EH. The role of total hip replacement in intertrochanteric fractures of the femur. Clin Orthop Relat Res. 2004;429:49–53.

PROCEDURE 80

Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA) Jesse Wolfstadt, Mansour Abolghasemian, and David Backstein INDICATIONS • Acute total knee arthroplasty (TKA) for fractures around the knee in elderly patients has been proposed as an alternative to open reduction and internal fixation (ORIF), which is associated with a high failure rate in elderly, osteoporotic patients. • Internal fixation of fractures around the knee in the elderly is associated with a high rate of failure (up to 79%) and associated mortality. Even successful fixation is usually associated with a significant decline in function and independence. • There are no high-quality randomized studies comparing acute TKA with internal fixation of fractures around the knee in the elderly. • Strong evidence suggests better outcomes with acute TKA compared with secondary TKA after previous internal fixation. • Potential advantages of acute TKA are earlier weight bearing, quicker recovery and rehabilitation, and lower reoperation rates. • Specific indications include: • Significant preexisting knee arthritis, including both degenerative and inflammatory arthritis. • Bicondylar distal femur fractures in severely osteoporotic patients. • Elderly patients unable to comply with the weight-bearing restrictions typically associated with ORIF. • The patient should have had acceptable baseline mobility, cognition, independence, and medical optimization. 

INDICATIONS PITFALLS

• Acute TKA should not be considered the standard of care for comminuted, intraarticular fractures around the knee in the elderly, particularly in the absence of preexisting arthritis. • Significant soft-tissue compromise, open fractures, or concomitant infections such as urinary tract infections or pneumonia are contraindications for acute TKA.

INDICATIONS CONTROVERSIES

• Some authors prefer primary internal fixation for all proximal tibial fractures irrespective of bone quality.

EXAMINATION AND IMAGING • Anteroposterior and lateral radiographs of the knee (Fig. 80.1A–B) in addition to radiographs of the ipsilateral hip and ankle joints. The entire length of the femur and tibia/fibula should be visualized. • A computed tomography (CT) scan of the knee is helpful if there is a plan to stabilize fracture fragments with internal fixation in addition to the planned acute TKA. 

TREATMENT OPTIONS

• ORIF can be used for extraarticular or simple intraarticular distal femoral fractures and for most proximal tibia fractures. • Internal fixation of proximal tibia fractures can aid in the overall stability of the TKA construct.

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PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

A

B FIG. 80.1A–B 

SURGICAL ANATOMY • Extensor mechanism includes the quadriceps tendon proximally, patella, patellar tendon, and its attachment distally to the tibial tubercle (Fig. 80.2). • Medial and lateral collateral ligaments are sacrificed when using a distal femoral endoprosthesis. • Osseous structures of the distal femur and proximal tibia. 

Quadriceps muscle

Quadriceps tendon Patella (kneecap)

Femur (thighbone) Patellar tendon

Articular cartilage Collateral ligament

Tibial tubercle Tibia (shinbone) FIG. 80.2 

PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

POSITIONING

1017

POSITIONING PEARLS

• The patient is positioned supine on a regular operating room table. • A bump can be positioned underneath the ipsilateral hip to provide slight internal rotation and aid in exposure. • A tourniquet is placed high on the thigh, ensuring that it does not impede on the planned surgical incision. A sterile tourniquet should be used if an extensile exposure is anticipated. • A sizable sterile bolster should be available to provide moderate flexion of the knee and support to its bony elements, especially during open reduction of the fracture. • A foot holder is used to stabilize the knee in flexion during femoral and tibial preparation. 

• Ensure that the tourniquet is placed high enough on the thigh to avoid infringing on the extensile exposure. Consider using a sterile tourniquet.

POSITIONING PITFALLS

• Extreme care should be taken during prepping and draping the knee and during the procedure to avoid hyperextension and subsequent injury to the popliteal neurovascular bundle.

POSITIONING EQUIPMENT

• We use an Alvardo knee holder (Fig. 80.3); however, any device to stabilize the knee in flexion is suitable.

POSITIONING CONTROVERSIES

• Ensure that the table has been returned to flat and parallel to the floor following any positioning maneuvers used for administration of a spinal anesthetic.

FIG. 80.3 

PORTALS/EXPOSURES • A medial parapatellar approach is used. • A midline skin incision is centered over the patella, extending from 5 cm proximal to the superior pole of the patella to the tibial tuberosity. The entire length of the incision is usually approximately 15 cm but may vary depending on the level of the fracture. • Sharp dissection continues through the subcutaneous tissue, elevating full-thickness subcutaneous medial and lateral skin flaps. • The medial parapatellar arthrotomy is marked out. Proximally, a 5-mm cuff of medial tendon should be preserved along the medial margin of the vastus medialis. • The arthrotomy is carried distally, curving gently around the medial aspect of the patella, and continued distally parallel to the patellar tendon approximately 5 mm medial to the tibial tubercle. • A medial periosteal sleeve, including the deep fibers of the medial collateral ligament (MCL) and medial capsule, is elevated from the tibia to aid in exposure. This permits deep flexion and greater exposure of the proximal tibia if needed. • The fat pad is excised as necessary to aid in mobilization of the patella and exposure of the proximal tibia. • The anterior cruciate ligament (ACL) is transected to improve exposure of the proximal tibia.

PORTALS/EXPOSURES PEARLS

• Careful attention should be paid to the patellar tendon to avoid iatrogenic injury. The patella should be gently dislocated or everted. • Hohmann retractors should be carefully placed medially and laterally to protect the collateral ligaments from iatrogenic injury. • Meticulous dissection of the distal femur fracture helps to protect the popliteal neurovascular bundle and will minimize the risk of devitalizing the bone fragments if the distal femur is to be preserved. • Careful attention should be paid to avoid hyperextension of the distal femur or perforation of the posterior capsule, as this can injure the popliteal neurovascular structures. • It is helpful to use the native distal femur to mark the femoral rotation outside of the area of resection for later reference in the setting of a distal femur fracture.

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PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

PORTALS/EXPOSURES PITFALLS

• Forceful traction on the patellar tendon can cause an injury to the extensor mechanism or an avulsion of the tibial tuberosity. • Preexisting stiffness secondary to arthritis may make it difficult to gain adequate exposure. The knee should be flexed very carefully. Extensile exposures, including longer skin incisions, rectus snip, or subperiosteal peel should be used judiciously.

STEP 1 PEARLS

• The most important technical decision is whether to resect or preserve the distal femur. • Even when the distal femur can be reduced and retained, use of a hinge-type TKA should be considered, as collateral ligament integrity is likely compromised by the fracture. If the surgical plan involves resection of the distal femur, a distal femoral replacement prosthesis should be used. • Care should be taken to avoid blocking the femoral canal from reaming with provisional or definite fixation devices.

STEP 1 PITFALLS

• Incorrect estimation of the length or rotation of the segmental femoral prosthesis will result in improper kinetics and kinematics of the prosthetic knee and severe functional deficit. • Appropriate soft-tissue tension and avoidance of hyperextension must be accomplished by recreating appropriate femoral length.

STEP 1 INSTRUMENTATION/ IMPLANTATION

• Hohmann retractors • Reduction clamps • K-wires • Periarticular plates • Large- and small-fragment screws • Revision TKA equipment with all levels of constraint, including hinge and distal femoral replacement

STEP 1 CONTROVERSIES

• Attempts to reconstruct the distal femoral bone adequately followed by standard revision TKA implants versus distal femoral replacement

• The patella is dislocated laterally and the knee is flexed to expose the distal femur. Alternatively, the patella may be everted. • The distal femur should be exposed subperiosteally. Perforating vessels should be cauterized or tied off. Collateral ligaments should be carefully explored and their competency ensured to determine the necessary level of prosthesis constraint. • Fracture hematoma is evacuated and the fracture site is copiously irrigated with normal saline. • Reduction and fixation of the fracture may be possible through the exposure provided by the medial parapatellar approach. In the case of metaphyseal or large condylar fractures of the tibia or femur, however, an extra medial or lateral subvastus (for the femur) or subperiosteal (for the tibia) approach may be needed through the same incision. 

PROCEDURE Step 1: Preparation of the Distal Femur • Preservation of the distal femur with TKA components ± ORIF • The displaced fracture fragments are reduced using pelvic bone clamps and temporary fracture reduction is maintained with Kirschner wire (K-wire) fixation. Occasionally, definite fixation of the fracture using cerclage wires, lag screws, or plating may be necessary. • A drill bit is used to open the distal femur. • A guidewire is inserted into the femoral canal to confirm that there is no perforation of the canal proximally. • The distal femur cut is performed using an intramedullary femoral cutting guide. • The femoral canal is reamed to an appropriate fit for an intramedullary stem that bypasses the fracture site. • The anterior and posterior condylar cuts and chamfer cuts are made while the reduction is temporarily maintained with pelvic bone clamps and K-wire fixation. • The K-wires can be exchanged for definitive internal fixation devices (large-fragment lag screws or plate/screw constructs) to maintain fracture reduction. • Resection of the distal femur with use of distal femur endoprosthesis • The distal femur fracture is temporarily reduced to estimate the femoral rotation and length. • The femoral rotation is marked on the anterior aspect of the femoral shaft parallel to the Whiteside line and perpendicular to the transepicondylar axis. • Preliminary unpublished data suggest that the plane of posterior femoral cortex could be a reliable reference for proper rotation of a distal femur endoprosthesis. • The distal femur is excised, preferably on block, to limit damage to surrounding soft tissue and neurovascular structures. • The excised distal femur segment is measured to approximate the length of the distal femoral endoprosthesis required. • The distal femur cut is freshened using a reciprocating saw. Use adequate irrigation during sawing to prevent overheating and necrosis of the bone surfaces. • A guidewire is inserted into the femoral canal to confirm that there is no perforation of the canal proximally. • The femoral canal is then prepared with reamers to achieve a stable fit in the isthmus. • The distal femur cut can then be freshened with a planer. 

PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

Step 2: Preparation of the Proximal Tibia • The proximal tibia is exposed to identify a tibial fracture. • Pelvic bone clamps are used to obtain a reduction of the fracture and temporary reduction is maintained with K-wire fixation. • The tibial canal is opened with a drill bit. • A guidewire is inserted into the tibial canal to confirm that there is no perforation of the canal distally. • The tibial canal is reamed to an appropriate fit for an intramedullary stem that bypasses the fracture site by about 5 cm. • Bone loss is reconstituted using porous metal cones or allograft bone. Use of autograft from the distal femur is also possible to restore bone stock. • The proximal tibia cut is performed using an intramedullary tibial cutting guide. • Trial tibial base plates are used to assess the size and rotation of the tibial component. Generally, use of a straight stem is preferable.  STEP 2 PEARLS

• Large fracture fragments may be fixed with internal fixation if appropriate. • An intramedullary alignment guide may be preferable, particularly if the proximal tibial surface is severely distorted by fracture. • Any condylar fracture of the proximal tibia should be addressed with a stemmed implant. • Contained defects, such as those found in pure depression-type tibial plateau fractures (Schatzker III), can be managed with bone grafting or porous metal cones. • Uncontained defects greater than 5 mm should be managed with tibial augments or porous metaphyseal cones and a stemmed implant.

STEP 2 PITFALLS

• Careful attention must be paid to the tibial tubercle, as detachment of the patellar tendon is a catastrophic complication. • Fractures involving the tibial tubercle are a relative contraindication to acute TKA owing to the high risk of nonunion. It may be preferable to allow the tubercle to heal and perform TKA on a delayed schedule.

STEP 2 INSTRUMENTATION/IMPLANTATION

• Hohmann retractors • Reduction clamps • K-wires • Periarticular plates • Large- and small-fragment screws • Revision TKA equipment with all levels of constraint

Step 3: Assemble Provisional Components and Perform Trial Reduction • Trial tibial and femoral implants are assembled and inserted, along with a trial polyethylene liner. • The knee is taken through a full range of motion (ROM). Stability is assessed in full extension, 30° of flexion, and 90° of flexion. • The thickness and degree of constraint of the polyethylene liner can be changed to achieve adequate stability and ensure that the knee does not hyperextend. • The decision to resurface or debride the patella is based on surgeon preference. • The ROM, stability, and patellar tracking are carefully inspected, with care taken to ensure that the knee does not hyperextend and there is not excessive tension on the posterior soft tissues. • Soft-tissue releases are rarely necessary to adequately balance the knee. Care must be taken to avoid creating a situation of gross instability. 

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PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

STEP 3 PEARLS

• The femoral and tibial provisional component should be evaluated for appropriate rotation and marked using electrocautery or a sterile marker. • A porous metal cone can be added to the femoral or tibial stem to achieve appropriate length and rotational stability. • When planning for a distal femoral endoprosthesis, use patellar tracking as the final determinant of appropriate component rotation and use the extension gap for ensuring correct restoration of length. STEP 3 PITFALLS

• Failure to test the patellar tracking and extension gap may result in major malrotation of the components or displacement of the joint line. STEP 3 CONTROVERSIES

• Determining the appropriate level of constraint is challenging. The general principle of using the lowest necessary constraint to minimize the forces transferred to the bone and fracture sites may be modified for elderly, lower-demand patients. • A hinged prosthesis is necessary if the MCL is compromised. The lateral collateral ligament (LCL) may be compensated for by lateral structures such as the popliteus and iliotibial band. The need for a hinge should be determined on a case-by-case basis. However, some authors recommend a condylar constrained-type prosthesis for isolated MCL or LCL compromise and others recommend a hinge prosthesis even for isolated MCL deficiency.

STEP 4 PEARLS

• Pay close attention to the rotation of the femoral and tibial components, as they are cemented into position. • Recreate appropriate joint height to avoid hyperextension.

STEP 4 PITFALLS

• Prevent heat necrosis of the distal femur and proximal tibia with copious irrigation during cementing and the use of a low-speed planer/ saw during bone preparation.

STEP 4 INSTRUMENTATION/ IMPLANTATION

• Instruments recommended by the manufacturer

STEP 5 PEARLS

• Positioning the knee in slight flexion will aid in aligning the medial and lateral retinacular flaps and ease the closure process. • Irrigating the wound with diluted povidone iodine solution may decrease the infection risk. STEP 5 CONTROVERSIES

• Using a suction drain is controversial. We do not routinely use drains owing to the lack of evidence to support their use in revision TKA.

Step 4: Implanting Definitive Components • The definitive implants are opened and assembled on the back table based on the instructions of the manufacturer. • The distal femur and proximal tibia are copiously irrigated with normal saline via pulsed lavage. • Cement restrictor plugs are inserted into the femoral and tibial canals if a cemented stem is planned for implantation. • Antibiotic-impregnated cement is recommended for these high-risk cases. • The femoral and tibial components are covered with cement and the definitive implants are inserted. We prefer a noncemented stem whenever possible to avoid interposition of cement at the fracture sites and to facilitate component removal should a revision become necessary. • A trial polyethylene liner is inserted and the knee is held in full extension until the cement has fully cured. • Patellar tracking is then checked and the stability and ROM are reassessed. • Excess cement is removed with a small osteotome and mallet. • At this point, the trial polyethylene liner can be removed and the definitive liner is inserted. The post-and-hinge mechanism is assembled and secured into place if using a hinged prosthesis. • The knee is evaluated one final time, paying close attention to ROM, stability, patellar tracking, and soft-tissue balancing. 

Step 5: Closure • Meticulous hemostasis is achieved. • The wound is copiously irrigated with pulsed irrigation. • The subcutaneous tissue, synovium, and posterior capsule are infiltrated with bupivacaine hydrochloride, and tranexamic acid is injected into the joint space if not contraindicated. • The wound is closed in layers, starting with heavy absorbable (#2 Vicryl) for the medial parapatellar arthrotomy. • The subcutaneous tissue is closed with a combination of #1 and 2-0 absorbable suture (Vicryl). • The skin is closed with staples or sutures. • The wound is dried and sterilely dressed. • The tourniquet is lowered. 

PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative AP and lateral radiographs (Fig. 80.4A–B) • Weight-bearing regimen is dictated by the rigidity of fixation. Full weight bearing as tolerated is the goal for most patients. • A knee immobilizer should be used in the early postoperative period for the patient’s comfort, although this should be removed regularly for physiotherapy. • Physiotherapy is started immediately and continued as an outpatient, focusing on knee ROM and patient mobility. Isometric quadriceps strengthening exercises are started immediately. • Appropriate venous thromboembolism prophylaxis is required. • Based on available evidence, antibiotics are administered intravenously for 24 hours postoperatively. • Discharge on POD #3-5

A

B FIG. 80.4A–B 

1021

POSTOP PEARLS

• Each patient should be considered individually. • Early ambulation is critical to maximize function and decrease mortality. POSTOP PITFALLS

• Delayed ambulation owing to lack of construct rigidity invites complications. POSTOP CONTROVERSIES

• The amount of safe weight bearing is controversial. Most authors, however, advocate early weight bearing for patients treated with distal femur endoprostheses.

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PROCEDURE 80  Fractures Around the Knee: Acute Total Knee Arthroplasty (TKA)

EVIDENCE Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. J Bone Joint Surg [Br]. 2006;88-B. 1065–1070. This paper showed low revision rates for selected elderly patients who underwent a cemented, constrained TKA to treat distal femoral fractures. Bell KM, Johnstone AJ, Court-Brown CM, Hughes SP. Primary knee arthroplasty for distal femoral fractures in elderly patients. J Bone Joint Surg [Br]. 1992;74-B. 400–402. This retrospective case series showed excellent results for elderly, low-demand patients treated with primary TKA for AO type C and some type A distal femur fractures. Bettin CC, Weinlein JC, Toy PC, Heck RK. Distal femoral replacement for acute distal femoral fractures in elderly patients. J Orthop Trauma. 2016;30:503–509. This retrospective case series demonstrated that cemented distal femoral replacements are a viable option for comminuted, intra-articular, osteoporotic distal femoral fractures, with most patients returning to preoperative function. Bohm ER, Tufescu TV, Marsh JP. The operative management of osteoporotic fractures of the knee: to fix or replace? J Bone Joint Surg [Br]. 2012;94-B. 1160–1169. Acute TKA for femoral fracture can be considered for patients with preexisting arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or when a single definitive procedure is ideal. Boureaua F, Benada K, Putmana S, Dereudrea G, Kerna G, Chantelota C. Does primary total knee arthroplasty for acute knee joint fracture maintain autonomy in the elderly? A retrospective study of 21 cases. Orthop Traumatol Surg Res. 2015;101:947–951. Retrospective study showing that total knee replacement is a viable alternative to fracture fixation in osteoporotic, elderly patients. Choi NY, Sohn JM, Cho SG, Kim SC, In Y. Primary total knee arthroplasty for simple distal femoral fractures in elderly patients with knee osteoarthritis. Knee Surg Relat Res. 2013;25:141–146. Retrospective case series of eight patients treated with combined primary TKA and internal fixation for distal femoral fractures. Malviya M, Reed MR, Partington PF. Acute primary total knee arthroplasty for peri-articular knee fractures in patients over 65 years of age. Injury. 2011;42:1361–1387. This case series of 26 patients shows good clinical results and overall knee alignment for elderly patients with osteoporotic distal femoral fractures. Nau T, Pflegerl E, Erhart J, Vecsei V. Primary total knee arthroplasty for periarticular fractures. J Arthroplasty. 2003;18:968–971. This small case series concluded that immediate weight bearing and satisfactory functional outcomes can be achieved with primary TKA for periarticular fractures of the knee. Parratte S, Bonnevialle P, Pietu G, et al. Primary total knee arthroplasty in the management of epiphyseal fracture around the knee. Orthop Traumatol Surg Res. 2011;97S:S87–S94. This retrospective cohort study suggests that primary TKA is a reasonable option for complex fractures in previously independent elderly patients suffering from knee OA. Rosen AL, Strauss E. Primary total knee arthroplasty for complex distal femur fractures in elderly patients. Clin Orthop. 2004;425:101–105. This small retrospective study shows that primary total knee arthroplasty for complex distal femoral fractures avoids fracture healing issues, facilitates early mobilization, and allows immediate weight bearing.

PROCEDURE 81

Nonunion Matthew Menon Indications

INDICATIONS PITFALLS

• Nonunion indicates that fracture healing has ceased prior to obtaining continuity of the bone fragments. • Delayed union indicates that fracture healing is proceeding slower than expected for a particular fracture. Expected time for healing is specific to each fracture, patient, and treatment. • The surgeon needs to make an informed judgment about the expected healing time for each fracture and plan surgical intervention accordingly. 

• In all cases of suspected nonunion, rule out infection with clinical examination and laboratory tests. • Prior to diagnosing a fracture as a nonunion, obtain serial clinical examination and radiographs over a certain period of time indicating that no progression of healing is occurring.

Examination/Imaging

INDICATIONS CONTROVERSIES

• Standard serial radiographs are indicated as dictated by the specific fracture type. In the authors’ practice radiographs are followed for 3 months to document a lack of bone growth (Fig. 81.1). • Computed tomography (CT) scans can further determine whether there is any continuity between two fracture fragments when radiographs are unclear. • Magnetic resonance imaging (MRI) can be used to confirm bony healing. However, it has little use in fractures treated with metal hardware owing to scatter and artifact. • Failure of hardware with displacement, by definition, indicates a failure of fracture healing (Fig. 81.2). • In a HYPERTROPHIC nonunion, there is progressive callus formation on radiographs indicating adequate biological mechanisms are present for bone healing, yet there is inadequate stability at the fracture site for bone healing to complete (Fig. 81.3). • In an ATROPHIC nonunion, there is no progression of callus formation on radiographs indicating that there is inadequate biological potential for bone healing to occur (Fig. 81.4). • OLIGOTROPHIC nonunion demonstrates features of both hypertrophic and atrophic nonunion. This implies that each nonunion lies on a spectrum of potential fracture healing. 

A

B

• Deciding how long a fracture should take to heal • Determining whether a fracture site is infected

C FIG. 81.1 

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PROCEDURE 81  Nonunion

TREATMENT OPTIONS

• Delayed unions can be treated with careful observation. Judgment is necessary to ensure healing occurs prior to fixation failure. If fixation failure is a concern, then consider surgical treatment. • Optimization of the patient’s medical conditions should be performed. Referral to an internal medicine specialist for treatment of cardiovascular and endocrine disorders is appropriate. • Provide counseling to assist with smoking cessation, moderation of alcohol intake, and optimization of the patient’s nutrition needs. • Any potentially correctable factors inhibiting union (i.e., vitamin D deficiency, smoking, hypothyroidism) should be identified and corrected prior to surgical intervention. • Low-intensity pulsed ultrasound is available to augment fracture healing; however, its efficacy has not been shown in the most current studies. • Surgical treatment for nonunion consists of debridement of the nonunion site, revision fixation, and bone grafting. The details of revision fixation and bone grafting are determined by the specifics of the fracture and the patient. Hypertrophic nonunions require enhanced construct stability with revision fixation. Atrophic nonunions require optimized construct stability as well as enhancement of the biological environment for healing such as debridement and bone grafting.

FIG. 81.3 

FIG. 81.2 

FIG. 81.4 

SURGICAL ANATOMY POSITIONING PEARLS

• In lower extremity nonunion, it is best to drape the entire limb, including the ipsilateral iliac crest, in most cases. • The ipsilateral femoral shaft can be reamed through an incision proximal to the greater trochanter in this position as well. • In upper extremity nonunion, a separate draping field for iliac crest exposure is usually performed.

• The important anatomy will be determined by the specifics of the fracture to be addressed. The surgeon should be familiar with the relevant anatomy around the area to be approached. It should be noted that nonunion surgery is often a revision procedure. Thus, neurovascular structures may be in nonanatomic locations (e.g., the ulnar nerve), embedded in scar tissue, and may not be as compliant as expected during exposure and retraction. Nerve injury rates are higher with revision fracture surgery in general. • Common sites for autogenous bone graft harvest include the iliac crest and the intramedullary femoral shaft. • The lateral femoral cutaneous nerve is at risk with exposure of the iliac crest. The nerve crosses the iliac crest usually within 2 cm of the anterior superior iliac spine. Dissection in this area should be performed with caution. • The surgical anatomy for harvesting the intramedullary femoral shaft is the same as reaming for the insertion of an intramedullary femoral nail. 

POSITIONING POSITIONING PITFALLS

• Failure to allow adequate draping for extensile exposures will limit your intraoperative options for debridement and fixation.

• Positioning is determined by the specific fracture to be addressed. • Take into account that nonunion surgery often requires a more extensile exposure than initial fracture surgery. Positioning should take this into account. • Bone graft harvest is performed through a separate incision, in most cases. Positioning should take into account that access to the iliac crest or femoral shaft may be required. • The supine, prone, and lateral positions all allow access to the iliac crest. The supine and lateral positions allow access for reaming of the femoral intramedullary canal. 

PROCEDURE 81  Nonunion

PROCEDURE

STEP 1 PEARLS

Step 1: Exchange Nailing of Tibial Nonunion • A 25-year-old athlete sustained a high-energy closed tibia fracture following a motor­ cycle collision. Persistent pain and serial radiographs 9 months after intramedullary (IM) nailing indicated an atrophic nonunion (Fig. 81.5). • Exchange nailing of the tibia is indicated for aseptic nonunion of the tibia without significant bone loss or length deficit. • Exchange tibial nailing with IM reaming was performed. The procedure provided enhanced stability through the use of a larger diameter IM nail, stimulation of the extra medullary blood supply through reaming of the intramedullary canal, and local bone graft from the reamings (Fig. 81.6). 

A

B FIG. 81.5 

A

1025

B FIG. 81.6 

• Blood flow to the extramedullary surface of the bone is enhanced by intramedullary reaming, thus improving the local biological environment for bone healing. • Gross stability of the limb is usually adequate with tibal nonunion to allow the procedure to be done “free” without the need for further reduction or traction devices.

PROCEDURE 81  Nonunion

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Step 2: Augmentation Plating of Femoral Shaft Nonunion

STEP 1 PITFALLS

• Remove all interlocking screws prior to nail removal: newer designs may have screws in multiple planes. Catastrophic fracture of the bone has been experienced when trying to remove a locked nail. • Extramedullary debridement should not be done in conjunction with intramedullary reaming to avoid completely devascularizing a segment of bone

A

B FIG. 81.7 

STEP 1 INSTRUMENTATION/ IMPLANTATION

• As large a diameter nail as possible should be used to optimize the stability at the fracture site. Typically, this is 2 mm larger than the previous nail. • Usually, there will be sufficient rotational stability in the tibial nonunion that interlocking screws can be avoided. Dynamic locking (screws in the short segment) is another option. STEP 2 PEARLS

• Nonunion of the femoral shaft following IM nailing is most often oligotrophic. • Augmentation plating with bone grafting provides both the required stability for healing and the viable bone cells needed for the healing process. • Removing the IM nail is unnecessary. Further disruption of the intramedullary blood supply by removing the femoral nail should be avoided.

• The right femur fracture in a 40-year-old laborer is 1 year from retrograde intramedullary fixation. The fracture has developed a hypertrophic nonunion, indicating that the biological process needed for healing is present yet there is inadequate stability at the fracture site (Fig. 81.7). • In situ augmentation plating is indicated for nonunion of the femur following treatment with an intramedullary nail. • A lateral approach to the femur was performed. In situ augmentation plating with a 4.5-mm Limited Contact Dynamic Compression (LCDC) plate was performed to provide neutralization of the forces at the fracture nonunion site. The fracture is healed 3 months after adequate stability was provided (Fig. 81.8). 

A

B FIG. 81.8 

Step 3: Revision ORIF and Bonegrafting Subtrochanteric Nonunion • A 57-year-old male sustained a left subtrochanteric fracture of the femur that was treated with cephalomedullary nailing. An atrophic nonunion was diagnosed 15 months after the injury (Fig. 81.9). • The cephalomedullary nail was removed. The lateral proximal femur is exposed through an extensile approach. The nonunion site is exposed. Scar tissue in the fracture site where healed bone should be is noted (Fig. 81.10). • Scar tissue is debrided from the fracture site to expose healthy vascularized bone on each side of the nonunion (Fig. 81.11). • Rigid fixation with a 95-degree blade plate is performed following detailed preoperative planning. An interfragmentary screw is placed through the plate to achieve compression at the fracture site (Fig. 81.12). • Fresh cancellous autograft was harvested from the ipsilateral iliac crest (Fig. 81.13). • The debrided nonunion tissue appears avascular and void of bony tissue compared with the harvested cancellous bone graft (Fig. 81.13). • The cancellous bone graft is packed into the nonunion site (Fig. 81.13). • Radiographic healing is progressing 3 months following revision plating and bone grafting (Fig. 81.14). 

PROCEDURE 81  Nonunion

1027

STEP 2 PITFALLS

• Performing an extramedullary debridement, bone grafting, and plating procedure should not be combined with removing or replacing the intramedullary nail because this risks further insult to both the extramedullary and intramedullary blood supply. • On occasion, the nail will need to be removed to correct deformity (e.g., varus deformity with a proximal femoral nail). STEP 2 INSTRUMENTATION/ IMPLANTATION

A

B FIG. 81.9 

• A broad 4.5-mm plate is used for fixation. • The fixation construct should span a large distance proximal and distal to the nonunion site to maximize the neutralization ability of the plate. • Cortical screws are placed either anterior or posterior to the plate, and may be transcortical. A combination of screws is often needed. STEP 2 CONTROVERSIES

• Exchange nailing of femoral nonunion has a poor success rate when compared with that for tibial nonunion. There is, however, a very low morbidity associated with exchange nailing of the femur. Exchange nailing of the femur should be used sparingly in patients who would benefit from a low–morbidity procedure with the understanding that the success rate is low compared with augmentation plating. STEP 3 PEARLS

FIG. 81.10 

FIG. 81.11 

• Detailed preoperative planning is an essential component of revision fixation with a 95-degree blade plate. Templating should be performed prior to commencing the procedure. • Subtrochanteric nonunions that have failed intramedullary fixation should be treated with an absolutely stable construct such as a 95-degree blade plate to provide adequate stability. • Intraoperative tissue samples (five, both bone and soft-tissue) should be sent for culture and sensitivity to rule out colonization/infection of the nonunion site and to guide treatment should postoperative infection occur. • Perioperative antibiotic prophylaxis is given prior to surgery in all cases where infection is not suspected preoperatively. Preoperative antibiotics can be held in cases where infection is suspected to increase yield rates from the cultures. Additionally, holding cultures for 10 to 14 days may help identify lowervirulence organisms such as Propionibacterium acnes or Staphylococcus epidermidis.

PROCEDURE 81  Nonunion

1028

A

B

C FIG. 81.12 

STEP 3 PITFALLS

• Treatment of atrophic nonunions should address both the stability of the fracture (revision rigid fixation) as well as the biology (debridement and bone grafting). Failure to address both components is likely to lead to further failure. • Failure of appropriate preoperative planning can lead to inadequate implant stability. • Adequate debridement of the nonunion site must be performed to expose healthy bone ends with good healing potential.

A

B

C FIG. 81.13  STEP 3 CONTROVERSIES

A

B FIG. 81.14 

• Several sources of autogenous bone graft are available. The most commonly used are the iliac crest and the femoral shaft—harvested through an intramedullary reaming technique. The femoral shaft potentially supplies a larger amount of bone; however, the biological equivalence of the graft material has not been conclusively established and the iliac crest remains the current gold standard. • Frozen allograft can provide a large volume of cancellous bone, however it is devoid of bone cells and has no osteogenic potential. • Bone graft substitutes are commercially available. They have a role in filling some bone defects, yet they have no osteogenic potential that autograft has. • Bone morphogenic proteins (BMPs) 2 and 7 have been used to stimulate bone healing. There has been some success using BMP 7 to treat nonunion. This product is in limited supply for clinical use at the current time.

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PROCEDURE 81  Nonunion

POSTOPERATIVE PEARLS

• Addressing the patient’s nutrition requirements can greatly enhance the results of nonunion surgery. • Smoking cessation is ideal, yet difficult to achieve. Counseling can be provided to at least minimize smoking during the healing period. There is often enough time to optimize conditions before surgical intervention. • If present, endocrine disorders should be addressed by an internal medicine specialist. Ideally, this should be done prior to commencing nonunion surgery and should continue in the postoperative period. POSTOPERATIVE CONTROVERSIES

• Opinions regarding the duration of perioperative antibiotic prophylaxis vary. Some surgeons limit antibiotic exposure to preoperative only to minimize the risk of favoring resistant organisms. Other surgeons will maintain postoperative antibiotics until 5-day negative intraoperative cultures are confirmed. • The use of nonsteroidal antiinflammatory drugs (NSAIDs) in the setting of fracture healing is controversial. Some laboratory evidence indicates that NSAIDs may impair fracture healing. Thus, many surgeons avoid the use of NSAIDs in fracture and nonunion surgery.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Routine postoperative care includes analgesia, thromboprophylaxis, and mobilization. • Smoking cessation is difficult to achieve, particularly when the patient is undergoing an acutely stressful event such as a fracture. Counseling can help to minimize smoking. • Weight bearing is routinely allowed following tibial exchange nailing. • Weight bearing is limited to toe-touch if an absolute stability construct is being used, such as a plating technique of the lower extremity. Weight bearing is limited until signs of bony healing are observed.

EVIDENCE Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral nonunions after intramedullary nailing. J Orthop Trauma. 2001;15(4):254–263. The authors report on a consecutive series of 23 patients who underwent indirect reduction and plating of femoral nonunion after intramedullary nailing: 21 healed and the remaining 2 healed within 16 weeks of revision plating. Busse JW, Bhandari M, Einhorn TA, et al. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (LIPUS): randomized clinical trial. BMJ. 2016;355:1–7. This randomized, blinded, sham-controlled trial evaluated the effect of low-intensity pulsed ultrasound (LIPUS) in the treatment of 501 surgically treated tibia fractures from 43 participating North American centers. LIPUS was not shown to speed radiographic healing or improve functional recovery. Court-Brown CM, Keating JF, Christie J, et al. Exchange intramedullary nailing. Its use in aseptic nonunion. J Bone Joint Surg. 1995;77-B:407–411. Thirty-three cases of exchange nailing for aseptic nonunion of the tibia were reviewed. Exchange nailing was successful in all cases without significant bone loss. The risk of postoperative infection (12.1%) was substantially higher than that reported for primary tibial nailing (1.6%). Dawson J, Kiner D, Gardner II W, et al. The Reamer-Irrigator-Aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014;28(10):584–590. This prospective randomized trial comparing the results of Reamer-Irrigator-Aspirator (RIA) acquired autograft versus autogenous iliac crest bone graft (ICBG) in the treatment of nonunions and segmental bone defects. Total of 133 patients were included. The authors conclude that RIA has a similar efficacy to ICBG with lower harvest site morbidity. RIA provided a larger volume of graft than ICBG. Garrison K, Donell S, Ryder J, et al. Clinical effectiveness and cost-effectiveness of bone morphogenetic proteins in the non-healing of fractures and spinal fusion: a systematic review. Health Technol Assess. 2007;11(30):1–149. This systematic review of studies was performed to assess the clinical and cost effectiveness of bone morphogenetic proteins (BMPs) for the healing of fractures and spinal fusion. Studied were 8 randomized trials of BMP for tibial fractures, 1 randomized trial of BMP for scaphoid nonunion, and 12 randomized trials of BMP for spinal fusion. The review concludes that BMP is equivalent to autogenous bone grafting for scaphoid nonunion and in acute tibial shaft fractures and may be more effective than bone graft alone for single level spinal fusion. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg. 2000;82-B(5):655–658. This retrospective case-control study compared 32 patients with nonunion of the femoral diaphysis with 67 comparable patients with healed fractures. The use of NSAIDs was associated with an increased risk of nonunion and delayed union.

PROCEDURE 82

Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting Steven Borland and David Stephen INDICATIONS

INDICATIONS PITFALLS

• The reamer irrigator aspirator (RIA) system was introduced primarily as an adjunct to reaming long bones prior to intramedullary nailing but has provided a new means of harvesting autologous bone graft (3). • This procedure is indicated for the treatment of bone defects with or without a history of infection (2). • Several papers have shown that the quantity of graft acquired using the RIA is greater than anterior iliac crest graft and at least equivalent to the volume from the posterior iliac crest (3,6,8). • Basic science studies suggest that the graft acquired using the RIA is of higher quality with better osteoconductive and osteogenic potential (5,10). • Reduced morbidity has been reported in the use of RIA for bone graft harvesting (7).

• The smallest diameter RIA reamer head is 12 mm, which limits this technique—in most individuals—to the femur as the site of harvest. • The presence of a hip or knee arthroplasty, or other implanted metalwork in the femur must be checked. • In most cases, preexisting implants will be a contraindication to harvesting from this site, although an antegrade procedure is still possible if the patient has a nonstemmed total knee replacement.

EXAMINATION/IMAGING

INDICATIONS CONTROVERSIES

• Perform a detailed clinical and radiographic examination of the femur (or tibia) used for the graft harvest. • Calibrated radiographic imaging of the femur in both the anteroposterior (AP) and lateral plane will identify any femoral deformity, which may impede the procedure. • Note the diameter of the isthmus, as the smallest diameter RIA reamer head is 12 mm, which limits this technique to the femur as the site of harvest. 

TREATMENT OPTIONS • Historically, following iliac crest bone graft harvest, significant morbidity has been reported in terms of postoperative pain at the harvest site, as well as variable volumes from the donor site, although recent publications suggest a lower incidence of postoperative pain (9). • When dealing with smaller defects, surgeons may wish to rely on iliac crest graft owing to the added expense of the RIA system. 

SURGICAL ANATOMY • For antegrade RIA: The gluteus medius muscle runs from the gluteus medius pillar on the ilium to the greater trochanter. A soft-tissue protector can be used to minimize injury, but often a portion of the tendon can be injured. The inferior branch of the superior gluteal nerve may be at risk as it lies close to the path between the skin incision and trochanter. 

POSITIONING • The patient is supine on a radiolucent table, with a bump raising the buttock and shoulder to 20 to 30 degrees—similar to that used for antegrade femoral nailing on a radiolucent table. • Fluoroscopy is used throughout and the surgeon should check images are attainable prior to preparing the patient. 

• In some situations, especially very large bone defects, (>8–10 cm) it may be surgeon preference to perform bone transport procedures, or free fibular grafts. • The upper age limit for RIA bone graft harvest is unknown (3,8). POSITIONING PEARLS

• Shifting the torso to the opposite side and adducting the leg will facilitate access to the antegrade entry point. • Preoperative planning is important to decide if the harvest site and recipient site can be positioned and prepared correctly at the same time without creating difficulty in either procedure. For example, if graft is to be taken from a femur for an ipsilateral tibia, this may be possible, but graft taken from one femur for the contralateral femur may provide logistical problems. It is often easier to harvest the graft, then reposition and reprepare the patient, as needed. • If the contralateral lower limb is the donor site, then supine (with bump that can be removed) positioning will facilitate access to both limbs. POSITIONING PITFALLS

• The area of draping must be proximal—at the inferior costal (rib) margin to allow satisfactory access to the proximal femur in the case of antegrade femoral RIA harvesting (Fig. 82.1).

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PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting

POSITIONING EQUIPMENT

asis

• If the lateral position is chosen, posts or a “bean” bag will facilitate patient stability. POSITIONING CONTROVERSIES

• A lateral position can also be utilized according to surgeon preference. • The choice of whether to perform an antegrade or retrograde procedure is surgeon preference, which has an impact on the position of the patient; usually the patient is not bumped for a retrograde procedure. FIG. 82.1 

PORTALS/EXPOSURES

STEP 1 PEARLS

• The surgeon must ensure a stable, infectionfree, soft-tissue environment; the PMMA spacer is usually performed at the time of softtissue coverage. Fig. 82.2 shows soft-tissue flap coverage with insertion of cement into the defect.

• For antegrade RIA, make a 2- to 3-cm skin incision superior and posterior to the palpable edge of the greater trochanter. Determine the exact site by the patient’s anatomy and body habitus, but on average 5 to 7 cm superior and just posterior to a line parallel to the prominence of the greater trochanter. • Sharply dissect the skin, fat, and fascia toward the greater trochanter. • A trochanteric or piriformis start point can be used, with a starting guidewire passed into the start point. • Confirm the correct placement of the starting wire in both AP and lateral planes on fluoroscopy, and advance the guidewire into the femur.  PORTALS/EXPOSURES PEARLS

STEP 1 PITFALLS

• It is important to ensure the PMMA cement spans the defect and covers the edges of the bone to create an optimal membrane for the bone graft. Fig 82.3 is a postoperative radiograph of PMMA inserted into a defect following debridement of devitalized bone.

• The accurate placement of the guidewire in the central aspect of the intramedullary canal is key to avoiding eccentric reaming and possible fracture of the bone following RIA harvest. PORTALS/EXPOSURES PITFALLS

• The presence of severe stiffness of the hip may make an antegrade procedure difficult. • If a retrograde procedure is planned, note range of knee motion. PORTALS/EXPOSURES EQUIPMENT

STEP 1 INSTRUMENTATION/ IMPLANTATION

• At the time of preoperative planning for RIA bone graft, assess the donor site for evidence of active or suspected infection—bloodwork for inflammatory markers (CBC, ESR, C-reactive protein). In some cases radionucleotide studies are obtained (bone/gallium or indium scans). Fig. 82.4 shows the site at the time of RIA bone graft insertion. STEP 1 CONTROVERSIES

• The optimal interval between initial insertion of the cement spacer and RIA bone graft is unknown, although the basic science research from Masquelet would suggest 4 weeks as the optimal time for biologic activity of the membrane (6). • In some cases of open fractures or when a soft-tissue procedure (flap and/or skin graft) has been required, a slightly longer period of time (6–8 weeks) is required to allow maturation of the soft tissues and reduction in the inflammatory response.

• A starting reamer can be passed along the guidewire to open the proximal femoral canal, but it does not need to go too far so as to maintain proximal femoral bone stock. • A long ball-tipped guidewire can then be passed down the femoral canal to the level of the knee. PORTALS/EXPOSURES CONTROVERSIES

• Large patient body habitus adds difficulty for the antegrade starting point, such that a retrograde harvest or a lateral position for antegrade harvest is contemplated.

PROCEDURE Step 1: Bone Graft Recipient Site Preparation • In the acute setting, bone defects are filled with PMMA bone cement (with antibiotics added into the cement at the discretion of the surgeon, but usually used with a history of infection). This is known as the Masquelet technique, which was originally developed for bone loss in the upper limb but has shown good results in lower limb defects (6). 

PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting

A

B

C FIG. 82.2 

A

B FIG. 82.4 

FIG. 82.3 

STEP 2: RIA HARVESTING

• Construction of the RIA device as per manufacturer’s instructions (Fig. 82.5). • Take an AP view at the isthmus and use a measuring device to identify the diameter of the isthmus. Fig. 82.6 shows an intraoperative measurement of the canal diameter. • The manufacturer’s recommendation is to use a reamer 1.5 mm larger than the isthmus diameter (3). • Ensure that the RIA is properly connected to both irrigation and suction. • Pass the tip of the RIA into the femur prior to starting the reamer to avoid unwanted reaming to the lateral part of the greater trochanter. • Pass the RIA down the femur. Keep the reamer constantly moving with push-pull motions to avoid clogging and keep it on constantly throughout the harvesting procedure. Fig. 82.7 shows the RIA reamer in the femoral canal. Continued

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PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting

Efficient cutting Reamer head 12.0-16.5 mm

Drive shaft within tube assembly (360, 520 mm)

Irrigation

Portals to collect reamings

Aspiration

A

B FIG. 82.5 

FIG. 82.7 

FIG. 82.6 

FIG. 82.8  STEP 2: RIA HARVESTING—cont’d

• The RIA device will remove excess fluid from the collection device via suction, and then the harvested graft can be removed from the collection device using the plunger provided in the set. Fig. 82.8 shows bone graft that was harvested. • If very large volume of graft is needed, the ball tipped guide wire can be bent and directed into each femoral condyle in turn, maximizing the graft harvested from the distal femur. Fig. 82.9 shows the RIA reamer head in a femoral condyle. 

PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting

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STEP 2 INSTRUMENTATION/ IMPLANTATION

• The harvested bone graft can be combined with additional graft autologous, allograft, or substitute to increase volume. • A commercially available “mesh” made of suture material (vicryl:pga) can be used to cover the graft to prevent efflux from the defect, although the “membrane” should prevent such an occurrence. Fig. 82.10 shows mesh around the bone graft in the donor site.

STEP 2 CONTROVERSIES

• The addition of antibiotics to the bone graft is surgeon preference.

PEARLS FIG. 82.9 

• The approach for retrograde RIA bone graft harvest is performed in the same manner as for a retrograde femoral nail. • Positioning is supine on a radiolucent table. • The use of a radiolucent triangle or bump allows flexion of the knee giving better access to the entry point. • Fluoroscopy is used throughout and images should be checked prior to preparing. • If the contralateral tibia is to be grafted, both limbs can be prepared and draped simultaneously using twin isolation drapes, saving operative time.

PITFALLS

• The accurate placement of the guidewire is important to prevent eccentric reaming and postoperative fracture.

INSTRUMENTATION/IMPLANTATION

FIG. 82.10 

STEP 2 PITFALLS

• Efforts should be made to avoid eccentric reaming, which can lead to femoral fracture. • Using a push-pull motion rather than a constant pressure will help to avoid clogging of the system because occasionally small cortical fragments can block the system. • Once assembled, the RIA cannot be easily disassembled and is single use; therefore, correct selection of reamer size and its correct use to avoid clogging or deformation of the plastic parts are essential. • When the graft is removed from the collector, take care to maintain sterility, especially if the patient is to be repositioned. • If the reamer is not advancing, the most likely reason is that the reamer head is too large and should be reduced by 0.5 mm. • Take care regarding volumes of irrigation, as high volumes, with slow progression of the reamer, can lead to significant blood loss (4). • The construction of the RIA device can be complicated for the occasional user and less experienced theatre staff.

• Make a midline incision from the distal pole of the patella to the proximal tibia. • Split the patellar tendon in the midline using a single sharp cut. • Controversies: alternatively a medial parapatellar approach can be used and the patella retracted laterally. This avoids division of the tendon but may impede the initial guidewire. • The entry point is centrally in the notch on the AP view and just anterior to Blumensaat’s line on the lateral view. The guidewire should be directed along the axis of the femur. • As with the antegrade procedure, use a reamer to open the entry point and pass a balltipped guidewire up to the proximal femur. • Once the long guidewire is in place, the procedure of using the RIA device is identical to an antegrade procedure.

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PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting

Additional Steps: Retrograde Femoral RIA Bone Graft Harvest  POSTOPERATIVE CONTROVERSIES

• Recent studies have shown that by 3 months, the intramedullary canal has started to remodel, and by about 12 to 18 months the formation of bone in the medullary canal offers the option of repeat reaming, should further bone graft be required at a later date (1).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative care will be directed to the recipient site. • The patient can commence weight bearing as tolerated on the harvest leg immediately after surgery, but the surgeon may choose to alter this if the recipient site is the ipsilateral limb. • Follow-up radiographs are obtained to assess the incorporation of the bone graft (Figs. 82.11 and 82.12).

FIG. 82.12 

FIG. 82.11 

EVIDENCE Conway JD, Shabtai L, Specht SC, Herzenberg JE. Sequential harvesting of bone graft from the intramedullary canal of the femur. Orthopedics. 2014;37(9):e796–e803. The authors detail their experience of repeat harvesting using RIA. They found that compatible graft volumes were available at repeat reaming at an average of 9 months. Cox G, Jones E, McGonagle D, Giannoudis PV. Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop. 2011;35(7):951–956. This systematic review details that RIA is a reliable method of harvesting high volumes of bone graft and that high union rates are reported when using this graft. The technique appears to be safe with low morbidity rates. Dawson J, Kiner D, Gardner 2nd W, Swafford R, Nowotarski PJ. The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014;28(10):584–590. A multicenter randomized controlled trial comparing RIA with iliac crest bone graft. Findings show similar union rates with less harvest site pain. RIA also yields a greater volume of graft compared with anterior crest graft, although yields from the posterior crest are similar. Donders JC, Baumann HM, Stevens MF, Kloen P. Hemorrhagic-induced cardiovascular complications during reamer-irrigator-aspirator-assisted femoral nonunion treatment. J Orthop Trauma. 2016;30(9):e294–e298. This paper discusses cardiac complication caused by rapid massive blood loss that can occur if the system is used incorrectly. Kuehlfluck P, Moghaddam A, Helbig L, et al. RIA fractions contain mesenchymal stroma cells with high osteogenic potency. Injury. 2015;46(suppl 8):S23–S32. This study compared the osteogenic potential of cells from RIA harvesting with bone marrow cells and adipose cells and showed the high osteogenic potential of RIA cells compatible with that in bone marrow.

PROCEDURE 82  Use of the Reamer Irrigator Aspirator (RIA) for Bone Graft Harvesting Mauffrey C, Hake ME, Chadayammuri V, et al. Reconstruction of long bone infections using the induced membrane technique: tips and tricks. J Orthop Trauma. 2016;30(6):e188–193. A technical discussion of the Masquelet technique and the use of RIA harvested graft during the second stage. Qvick LM, Ritter CA, Mutty CE, et al. Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series. Injury. 2013;44(10):1263–1269. Analysis of 204 RIA cases and a discussion of complications. A low complication rate of 1.9% was recorded with three femoral fractures that were treated with intramedullary nailing. Sagi HC, Young ML, Gerstenfeld L, et al. Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient. J Bone Joint Surg Am. 2012;94(23):2128–2135. A comparison of the histologic and molecular profiles of bone grafts from RIA and from iliac crest of the same patient. Both grafts had a similar profile for genes acting in early stages of bone repair. Shin SR, Tornetta 3rd P. Donor site morbidity after anterior iliac bone graft harvesting. J Orthop Trauma. 2016;30(6):340–343. A review of morbidity following iliac crest harvesting, suggesting that morbidity is lower than previously thought, with little long-term pain or functional limitations. Uppal HS, Peterson BE, Misfeldt ML, et al. The viability of cells obtained using the reamer-irrigatoraspirator system and in bone graft from the iliac crest. Bone Joint J. 2013;95-B(9):1269–1274. This study shows in vitro that cells harvested from iliac crest and with RIA have similar viability and osteogenic potential, again suggesting RIA to be a viable alternative to ICBG.

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PROCEDURE 83

Malunion Jean Lamontagne and Martin Lesieur

INDICATIONS

• Coronal plane deformity (varus or valgus malunion) • Sagittal plane deformity (flexion or extension malunion) • Malrotation • Lower limb length discrepancy INDICATIONS PITFALLS

• Knee stiffness • Infection • Unrecognized nonunion INDICATIONS CONTROVERSIES

• Prevention of post-traumatic arthrosis • Cosmesis in isolation as an indication

Malunion is defined as any fracture that heals in a nonanatomic position, which results in unacceptable function or cosmesis. Even with modern implants such as condylar locked plate and appropriate trauma training, the incidence of malunion for distal femoral fracture is still significantly high. In a recent prospective randomized study comparing locked plating and retrograde nailing for distal femoral fracture, the incidence of malalignment greater than 5 degrees was 32% for locked plating in patients treated in a Level 1 Trauma Center by fellowship trained surgeons ( Tornetta et al., 2014). An intraarticular malunion can lead to joint subluxation, joint stiffness, and posttraumatic arthrosis. Diaphyseal and metaphyseal malunion can affect the lower limb alignment. This can lead to asymmetric joint loading and possibly accelerated joint wear (Puno et al., 1991). Patient age and expectations and location and magnitude of the deformity should be all considered in making decision for a corrective osteotomy. Preoperative planning is critical to treat malunions. The deformity should be evaluated with a complete physical examination of the entire lower limb as well as appropriate radiographic examination that should include a full-length anteroposterior (AP) and lateral (LAT) of the lower limb in order to define the anatomic and mechanical axis. Understanding the deformity in the coronal and sagittal planes as well as recognizing the presence of translation, shortening, and malrotation is mandatory. Defining the center of rotation of angulation (CORA) (Paley, 2002) is the first step while planning a corrective osteotomy. When the deformity is located in the diaphysis of the femur or tibia, the anatomic axis of the proximal segment and the distal segment are easily drawn and their intersection is defined as the CORA. When the deformity is juxtaarticular, the reference should then be the joint line orientation (see Fig. 83.2). The next step is to decide the type and location of the osteotomy in order to obtain the desired alignment and correction. Complex diaphyseal malunions can be corrected with the clamshell osteotomy and fixed with intramedullary nails (Russell et al., 2009). Juxtaarticular malunions can be corrected with wedge, dome, or oblique osteotomy and they are usually fixed with plates and screws. Severe deformities are more amenable to progressive correction with a circular external fixator frame. The ultimate goals in dealing with malunions are to obtain the correction of the deformity, stable fixation to allow early motion, while minimizing complications such as infection, nonunion, and joint stiffness. In this particular case, the oblique osteotomy was chosen to achieve adequate correction of a valgus femoral malunion with associated shortening. This osteotomy provides the surgeon with the ability to correct both deformities with a single cut and to achieve rigid interfragmentary fixation through the same exposure without the need for structural bone grafting. If a malrotation be present as well, it could be corrected with the same technique with careful orientation of the cut (Sangeorzan et al., 1989).

PROCEDURE Step 1: Deformity Correction for Valgus Malunion of Distal Femoral Fracture  Examination/ Imaging

TREATMENT OPTIONS

• Long oblique osteotomy • Closing wedge osteotomy • Opening wedge osteotomy • Dome osteotomy • Corticotomy and progressive correction with circular external fixator frame 1038

•  Physical examination (joints range of motion [ROM], previous scars, alignment, shortening, leg rotation) • Careful measurement of leg length (from Anterior Superior Iliac Spine (ASIS) to medial malleolus) • AP-l femur x-rays (Fig. 83.1) • 3 feet standing lower extremity x-rays (Fig. 83.2) • Computed tomography (CT) scan for malrotation assessment and consolidation 

PROCEDURE 83  Malunion

A

B FIG. 83.1  A-B shows a distal femur valgus malunion G

101 101

79.0

79.0

2M

CORA

3M

4

FIG. 83.2  3 feet Standing Radiograph

SURGICAL ANATOMY • Distal femur lateral “Swashbuckler approach” (Fig. 83.3A) taking into consideration the previous skin incision • Lateral superior genicular artery identified and ligated • Lateral collateral ligament identification and protection (Fig. 83.3B) • Perforating vessels identified and ligated (Fig. 83.3C) 

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PROCEDURE 83  Malunion

A

B

C FIG. 83.3  A Skin incision B Origin of lateral collateral ligament C Perforating vessels and lateral superior genicular artery POSITIONING PEARLS

• Bump under distal femur (Fig. 83.5) • Consider bump under ipsilateral buttock to facilitate access to the proximal femur

POSITIONING • Patient supine on radiolucent table (Fig. 83.4) • Consider bilateral draping for comparison of angle and length • Fluoroscopy from the opposite side of the table 

POSITIONING EQUIPMENT

• Radiolucent table • Radiolucent knee support POSITIONING CONTROVERSIES

• Lateral decubitus may help with exposure but makes alignment assessment very difficult.

FIG. 83.4  Positionning on a radiolucent table

FIG. 83.5  Bump under knee joint

PROCEDURE 83  Malunion

Portals/Exposures

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PORTALS/EXPOSURES PEARLS

• Classic Swashbuckler lateral approach to the femur (Fig. 83.3) • Through fascia lata and between vastus lateralis and lateral intermuscular septum 

PROCEDURE Step 1: Distal Femoral Lateral “Swashbuckler” Approach • Make a skin incision long enough for previous implant removal/planned fixation. • Make a fascia lata incision; elevate the vastus lateralis from the intermuscular septum. • Ligate perforating vessels and the lateral superior genicular artery. • Incise capsule distally to visualize articular margin (see Fig. 83.3) 

Step 2: Previous Implant Removal

• Maintain periosteum integrity as much as possible. • Plan proximal exposure for articulated tension device application. • Consider concomitant arthroscopic/open arthrofibrosis release and/or quadricepsplasty in associated joint (knee) stiffness. PORTALS/EXPOSURES PITFALLS

• Avoid aggressive medial dissection. • Avoid extensive periosteum stripping. STEP 1 PEARLS

• Remove distal femoral locked plate through the same surgical approach. • Remove antegrade or retrograde femoral nails through a separate incision. • Previous sugery report can be useful to identify nail type. • Remove all hardware with minimal bone loss. • Resect bony prominence/exuberant callus to facilitate implant positioning. 

• Keep muscle dissection as minimal as possible. • Preserve bone blood supply. • Release adjacent joint stiffness to improve function and decrease stress on fixation.

Step 3: Location of the Osteotomy Site

STEP 1 PITFALLS

• Identify center of rotation angle (CORA) from available landmarks (see Fig. 83.2). • Assess adequate plane of osteotomy based on preoperative planning (Fig. 83.6). 

• Previous incision around the knee (anterior skin incision from previous surgery or open fracture) • Avoid lateral collateral ligament injury or release distally. STEP 1 INSTRUMENTATION/ IMPLANTATION

• Self-retaining retractors, Hohman retractors

STEP 1 CONTROVERSIES

• Using percutaneous approach proximally for screw fixation

STEP 2 PEARLS

FIG. 83.6  Oblique femoral osteotomy

Step 4: Correction of Valgus Deformity and Shortening • Obtain proper limb axis and length using the femoral distractor or articulated tension device (Fig. 83.7). • Use temporary fixation with clamps or Kirschner wires (K-wires) (Fig. 83.8). • Apply a long anatomically contoured distal femoral locked plate. • Apply a central fixed angled wire first to confirm parallelism with the joint line. • Use a proximal conventional cortical screw fixation or pulling devise (“whirley bird”) to reduce bone to the plate and secure proper length. • Assess alignment and length with temporary fixation. 

• Carefully start removing each screw by hand to avoid stripping. • Be prepared for stripped/broken hardware.

STEP 2 PITFALLS

• Bone ingrowth over plate • Locking screws fused to plate • Screw heads stripping • Heterotopic ossification over nail insertion site

STEP 2 INSTRUMENTATION/ IMPLANTATION

• Femoral nail removal kit if nail was used for fracture fixation • Multiple screwdrivers for plate removal • Broken screw removal set • Metal burrs available • Osteotomes

PROCEDURE 83  Malunion

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A FIG. 83.7  A Distal femoral plate with tension device applied

B FIG. 83.7  B Distraction with large femoral distractor

STEP 3 PEARLS

• Blood supply preservation • Use the “no-angulation view” technique for osteotomy plane determination (2). • Identify landmarks from preoperative planning. • Fluoroscopy can be useful to confirm center of rotation angle (CORA). • Measure twice, cut once. • Angulation of the osteotomy mainly depends on CORA location and the amount of shortening. • Longer obliquity (30 degrees) will preserve bone contact after deformity correction and length restoration. • Greater bone contact will allow more predicable bone healing. • Osteotomy with oscillating saw completed with sharp osteotomes STEP 3 PITFALLS

• Avoid thermal necrosis during osteotomy by water-cooling the saw with irrigation. • Be aware of short oblique cut (steeper than 45 degrees) leaving little contact surface after length correction. STEP 3 INSTRUMENTATION/ IMPLANTATION

• Sharp osteotomes • Oscillating saw STEP 3 CONTROVERSIES

• Osteotomy performed with oscillating saw versus osteotome STEP 4 PEARLS

• Alignment comparison with contralateral limb • Plain x-rays of the entire femur in order to measure the alignment STEP 4 PITFALLS

• Over or under correction • Bone lengthening is the most challenging deformity to correct properly (6).

FIG. 83.8  Compression with Weber Clamp

PROCEDURE 83  Malunion

Step 5: Osteotomy Fixation • Lag screw fixation (Fig. 83.9) • Neutralization with locked condylar plate (Fig. 83.10) 

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STEP 4 INSTRUMENTATION/ IMPLANTATION

• Anatomically contoured locked distal femoral condylar plate • Femoral distractor • Articulated tension device • Reduction clamps • Fluoroscopy STEP 5 PEARLS

• Use central fixed-angle distal screw parallel to joint line (Fig. 83.11). • Provisional or definitive fixation is obtained proximal to the osteotomy. • Once proper correction is obtained, apply lag screws across the long oblique osteotomy to provide compression (absolute stability). • Complete distal and proximal fixation with multiple locked screws. • Remove femoral distractor or articulated tension devise and clamps. • Bone graft or substitutes may be applied, if necessary. STEP 5 PITFALLS

• Improper use or placement of locked condylar plate inducing iatrogenic deformity

FIG. 83.9  Lag screw across the oblique osteotomy

STEP 5 INSTRUMENTATION/ IMPLANTATION

• Anatomically contoured locked distal femoral condylar plate • Percutaneous guide, if needed STEP 5 CONTROVERSIES

• Addition of bone graft or substitutes

2M

3M

4

G

FIG. 83.10  Final 3 feet Standing radiograph

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PROCEDURE 83  Malunion

POSTOPERATIVE PEARLS

• Early mobilization • Toe-touch weight bearing • Intraoperative culture should be made, allowing proper treatment of indolent infection. POSTOPERATIVE PITFALLS

• Infection • Nonunion • Soft-tissue deficit/inability to perform primary closure after correction POSTOPERATIVE CONTROVERSIES

• Aggressive physiotherapy

FIG. 83.11  Central K-wire parallel to joint line

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Thromboprophylaxis • No routine postoperative antibiotics recommended

EVIDENCE Paley D. Principles of Deformity Correction. 1st ed. New York: Springer-Verlag Berlin Heidelberg; 2002. This is a comprehensive textbook on the analysis, planning, and treatment of lower limb deformities. It offers detailed information on deformities and malalignment, radiographic assessment, mechanical and anatomic axis planning, osteotomies, and hardware considerations. Probe RA. Lower extremity angular malunion: evaluation and surgical correction. J Am Acad Orthop Surg. 2003;11:302–311. This review explains the key principle in dealing with lower extremity malunion, including preopera­ tive planning, method of correction and rationale behind each of them as well as literature review of those different options. Puno RM, Vaughan JJ, Stetten ML, et al. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma. 1991;5:247–254. This is a retrospective case series of 27 patients with uneventfully healed tibial shaft fracture with normal joint function prior to injury with an average follow-up of 8.2 years. Ankle and knee were evaluated both functionally and radiographically. A significant correlation was found between ankle malalignment (worse for varus) and ankle score, but no correlation with knee malalignment. Russell GV, Graves ML, Archdeacon MT, et al. The clamshell osteotomy: a new technique to correct complex diaphyseal malunions. J Bone Joint Surg Am. 2009;91(2):314–324. This is a prospective series of ten patients with complex diaphyseal malunion (tibial or femoral) treated with the clamshell osteotomy technique. The authors describe the surgical technique and result of their correction technique. All osteotomies healed within 6 months. Sangeorzan BJ, Sangeorzan BP, Hansen Jr ST, et al. Mathematically directed single-cut osteotomy for correction of tibial malunion. J Orthop Trauma. 1989;4:267–275. A four-case series of patients with rotational and angular malunion of the tibia treated with a single oblique osteotomy correcting both deformations. The authors explain the calculation and preoperative planning leading to an appropriately oriented cut for the correction. Tornetta III P, Egol KA, Ertl JP, et al. Locked plating vs retrograde nailing for distal femur fractures: a multicenter randomized trial. Presented at AAOS. 2014. This prospective randomized controlled trial of 126 patients was presented at the 2014 AAOS meeting evaluating radiographic, functional, and physical outcomes of distal femoral fracture treated with a retrograde nail versus a locked plate. The authors found a malalignment rate of more than 5 degrees in 22% of the nails and 32% of the plates, with 87% of the plates malalignment being valgus. They also reported a distal femur flexion of more than 5 degrees in 16% of the plates and 12% of the nails.

PROCEDURE 84

Surgical Fixation of Chest Wall Injuries Niloofar Dehghan INDICATIONS • Flail chest with: • Paradoxical chest wall motion or • Fracture displacement • Multiple displaced rib fractures (without a flail segment) causing: • Chest wall deformity or loss of thoracic volume • Rib fractures impaling internal organs (e.g., lung, liver) • Prolonged pain and disability, unable to wean off mechanical ventilation  PEARLS

• Flail chest is defined as ≥ 3 consecutive rib fractures, fractured in ≥ 2 locations, creating a flail segment. A flail segment can also be created by ≥ 3 bilateral consecutive rib fractures or ≥ 3 rib fractures associated with a sternal fracture or costochondral dissociation (Fig. 84.1) • Flail chest injuries are rarely present in isolation and are commonly present in polytraumatized patients (with injury severity score > 16). • Patients with flail chest injuries have a high rate of mortality (16%) and morbidity, such as pneumonia, tracheostomy, sepsis, need for mechanical ventilation, and admission to the intensive care unit (ICU).

CONTRAINDICATIONS

• Not all rib fractures require fixation: • Undisplaced rib fractures with a stable chest wall do not require fixation. • “Floating ribs” (11 and 12) do not contribute to chest wall stability and rarely require fixation. • Ribs 1 and 2 are difficult to access surgically; thus, in general, surgical fixation is not performed on them. • Very posterior rib fractures (adjacent to the costovertebral joints) are not amendable to plate fixation owing to their location and lack of an adequate medial fragment (see Fig. 84.3). • Severe concurrent head injury (injury severity score ≥ 4) • These patients require long-term mechanical ventilation for their head injury, have significantly higher risk of morbidity and mortality, and may not benefit from chest wall fixation. • The presence of severe pulmonary contusion (including alveolar hemorrhage) • Patients present with acute respiratory distress syndrome (ARDS), with significant radiographic evidence of pulmonary contusion, or extensive contusion involving the majority of lung parenchyma on computed tomography (CT) scan • Surgical fixation after a prolonged period postinjury (> 5 days) owing to increased risk of pneumonia and sepsis • Patients medically unfit for surgery (hemodynamic instability, acidosis, coagulopathy)

INDICATIONS CONTROVERSIES

• The presence of pulmonary contusion is controversial. The majority of patients with flail chest/ multiple rib fractures have some evidence of pulmonary contusion on chest CT. Surgical fixation of patients with significant pulmonary contusion involving the majority of lung parenchyma and ARDS is a contraindication. However, surgical treatment of patients with some evidence of mild to moderate pulmonary contusion may be beneficial. • There is controversy regarding surgical fixation of multiple rib fractures in patients without respiratory distress or pain/disability and fixation of rib fracture nonunion or painful malunion.

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PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

A

Flail Chest

B FIG. 84.1  A, Diagram depicting the injury pattern in flail chest, with ≥ 3 consecutive rib fractures, fractured in ≥ 2 locations. (From Black JM, Hawks JA. Medical-surgical nursing, 8th ed. St. Louis, MO: Saunders; 2009.) B, Chest computed tomography scan demonstrating multiple anterolateral rib fractures (stars) and costochondral dissociation (arrows) creating a flail segment.

EXAMINATION AND IMAGING TREATMENT OPTIONS

• Treatment in trauma bay/emergency department—patients in respiratory distress require urgent treatment: • Needle thoracostomy for tension pneumothorax followed by chest tube placement • Chest tube insertion for presence of significant hemothorax/pneumothorax • Mechanical ventilation may be required if the patient is unable to maintain ventilation/ oxygenation. • Nonoperative treatment of chest wall injuries: • Mechanical ventilation as needed (in patients with respiratory distress) • Pulmonary toilet to clear secretions: suctioning, chest physiotherapy, incentive spirometry • Adequate pain management: intercostal nerve blocks, epidural catheters, patientcontrolled analgesia (PCA) • Surgical fixation of the chest wall: • The patient receives optimal nonoperative treatment listed earlier as well as surgical fixation of the chest wall

• Physical examination • Assess for respiratory distress (e.g., tachypnea, small and shallow breaths, low oxygen saturation). • Be mindful of the possibility of pneumothorax or tension pneumothorax contributing to respiratory compromise. • Look for paradoxical chest wall motion indicating a flail segment. • The presence of subcutaneous emphysema in the setting of trauma is generally indicative of rib fractures with pneumothorax. • Presence of blunt force to the chest wall, such as a “seat belt sign” or contusion, may suggest the presence of rib fractures. • Imaging • A plain chest radiograph can demonstrate the presence of rib fractures as well as pneumothorax and/or hemothorax (Fig. 84.2) • A chest CT scan is the best tool for identifying fractures (on bone window) as well as intrathoracic injuries (pneumothorax, hemothorax, pulmonary contusion, etc., on lung window; Fig. 84.3). • Three-dimensional reconstruction of chest CT scan is very helpful in identifying the location of rib fractures and amount of displacement, and assists in surgical planning (Fig. 84.4) 

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

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TREATMENT OPTIONS—cont’d TRAUMA AP SUPINE

FIG. 84.2  Preoperative image demonstrating multiple rib fractures (arrows).

Rib 4

Rib 6

• The goal of surgery is to reduce and fix rib fractures to stabilize the chest wall, prevent paradoxical motion, and improve pulmonary mechanics. • Not every fracture needs to be fixed surgically. In general, fixation of the displaced fractures can yield adequate stability without the need for fixation of the undisplaced fractures. (With flail chest, fractures at one location are often displaced, while fractures at the second location remain undisplaced/hinged.) • Surgical fixation can be performed with use of plates and screws to obtain anatomic fixation. Intramedullary fixation remains controversial owing to decreased mechanical stability and risk of hardware migration. • Precontoured rib-specific plates with locking screws can be used for surgical fixation. If these are unavailable, 3.5 pelvic reconstruction plates (with or without locking screw capability) can be used, which may require contouring intraoperatively.

Rib 5

Rib 7

Rib 8 FIG. 84.3  Segmental rib fractures involving ribs 4 to 8: with displaced posterolateral fractures (stars) and undisplaced posterior fracture adjacent to the vertebra (arrow). Displaced posterior fractures adjacent to the vertebra are not amenable to plate fixation owing to the anatomic location. Note the associated scapula fracture, subcutaneous emphysema.

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

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TREATMENT OPTIONS PEARLS

• The goal of surgical fixation of rib/sternal fractures is to stabilize the chest wall to decrease the time on mechanical ventilation, time in the ICU, and to lower the rate of related complications such as pneumonia, sepsis, and tracheostomy.

FIG. 84.4  Three-dimensional reconstruction of chest computed tomography scan can aid with evaluation of rib fracture location and displacement.

SURGICAL ANATOMY • The bony thorax is composed of 12 pairs of ribs. Anteriorly, the bony ribs are connected to costal cartilage (costochondral joints). The ribs are connected to the sternum anteriorly (sternocostal junction) and to the vertebra posteriorly (costovertebral junction) (Fig. 84.5). • Ribs 1 to 7 are directly connected to the sternum, while ribs 8 to 10 are indirectly connected, via the 7th rib. Ribs 11 and 12 are floating ribs and connected only posteriorly to the vertebra. • The neurovascular bundles travel along the inferior aspect of each rib. Although these bundles are typically disrupted in displaced rib fractures, further injury should be avoided by dissecting over the superior border of ribs.

1

C7 T1 T2

Acromion process

2

Manubrium

5

Gladiolus Xiphoid

6 11 T11 12 T12

8 9

1

3 4 5

Scapula

4

7

2

Coracoid process

3

Ribs

Clavicle

6 7

Sternum (3 parts)

Costal cartilage

L1

Costo-chondral junction

L2

Floating ribs

8

C7 T1 T2 T3 T4 T5 T6 T7 T8 T9

9

T10

10 11 12

T11 T12 L1 L2

10

Anterior view

Anterior view

FIG. 84.5  Chest wall anatomy.

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

1049

• The normal motion of the chest wall is affected in the setting of a flail chest, causing paradoxical motion of the flail segment (Fig. 84.6). • The lung parenchyma can be injured in blunt trauma, causing hemorrhage and contusion of the alveoli (pulmonary contusion). 

Inspiration

Fail Chest Fail Chest

Expiration

© Alila Medical Media - WWW.AlilaMedicalMedia.com FIG. 84.6  Flail chest and paradoxical chest wall motion. (From Black JM, Hawks JA. Medical-surgical nursing, 8th ed. St. Louis, MO: Saunders; 2009.)

POSITIONING • Positioning will depend on the injured area of the chest wall that requires repair. • In general, three approaches are used: thoracotomy, posterior, and anterior. 

EXPOSURES • Thoracotomy approach (Fig. 84.7) • The thoracotomy approach is the preferred approach for anterolateral or posterolateral rib fractures. It is an extensile approach, created anteriorly or posteriorly depending on the location of the rib fractures. • The patient is placed in the lateral decubitus position.

A

POSITIONING PEARLS

• Removal of the chest tube preoperatively can cause a tension pneumothorax in the setting of positive pressure ventilation. If the patient has a chest tube in place preoperatively, ensure that this is prepared and draped into the operating field. An Opsite can be used to cover the insertion site if it appears contaminated. Once access into the pleural cavity is made, the chest tube can be removed (if desired), to be replaced at the conclusion of the procedure.

B

FIG. 84.7  Thoracotomy approach. A, Lateral decubitus position with the arm draped on a padded Mayo stand to allow for traction of the arm and scapula. The dashed line marks the border of the latissimus dorsi muscle. The solid line marks the thoracotomy incision for the approach to the anterolateral ribs. B, Subcutaneous dissection exposing the serratus anterior muscle underneath. (Images courtesy Dr. Aaron Nauth.)

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PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

C

D

E

F

G

H

I

J

FIG. 84.7, cont’d C, The latissimus dorsi muscle is retracted, exposing the long thoracic nerve at the lateral border of the serratus anterior muscle (the snaps are pointing to the location of the nerve). D, Creating the first muscle-split window in the serratus anterior. E, Enlarging the muscle split. F, Exposing the anterolateral ribs underneath. G, Two ribs exposed through the first window. H, Palpating fractures superior to the first split to identify location of the second muscle-split window. I, The second muscle split window created. J, The second window enlarged, exposing ribs underneath. (Images courtesy Dr. Aaron Nauth.)

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

• Free drape the ipsilateral arm and place it on a sterile padded Mayo stand. This will allow intraoperative traction of the arm to aid retraction of the scapula away from the underlying ribs (see Fig. 84.7A). • A standard thoracotomy incision (curvilinear) is made, centered over the fractured ribs. • Dissection is made through subcutaneous tissues and fascia. Identify and retract the latissimus dorsi muscle posteriorly and serratus anterior muscle anteriorly. • Be mindful and protect the long thoracic nerve, located along the lateral border of the serratus anterior, as well as the thoracodorsal nerve at the lower border of the latissimus dorsi muscle. • The serratus anterior muscles are split in line, creating a window, and exposing the fractured ribs underneath. In general, two to three ribs can be fixed through each window. Another muscle-splitting window can be created cranially/caudally to gain exposure to additional rib fractures. • To gain access to more posterior rib fractures, deep dissection is carried out between the latissimus dorsi caudally, trapezius superomedially, and border of scapula superolaterally. Muscle-splitting windows can be created in the latissimus dorsi muscle to aid with exposure of more posterior rib fractures. • Posterior approach (Fig. 84.8) • This approach is best used for multiple posterior rib fractures. It is not an extensile approach laterally and provides access to the portion of ribs adjacent to the spine only. • A longitudinal incision is made over the fractured ribs, parallel to the spinous processes. • Dissection is carried out through soft tissue and fascia. Identify the erector spinae muscle in this interval between the latissimus muscle inferiorly, trapezius superiorly, and border of the scapula laterally (triangle of auscultation). • The erector spinae muscle is reflected laterally, exposing the fractured ribs underneath. • Anterior approach • This approach is used for anterior chest wall fractures and/or dislocations, including anterior rib fractures, costochondral disruptions, sternocostal junction injuries, and sternal fractures. • The patient is placed supine on the operating room table. • If surgical extension laterally is considered, then the ipsilateral arm can be free draped to allow limb abduction and access to the chest wall. • Depending on the nature and location of the injury, a midline “sternotomy” incision can be made or a more transverse thoracotomy incision that can be extended more laterally. • Muscle dissection occurs in the midline (sternotomy incision) or as per a thoracotomy approach (detailed earlier). 

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EXPOSURES PEARLS

• The incision is made over the center of the fractured ribs, as per preoperative assessment. Clinically, the ribs should be palpated and counted to ensure that the incision is placed over the appropriate level. Use of landmarks such as the xiphoid and tip of scapula can help with identification of the appropriate level. • The use of a double-lumen endotracheal tube, or deflation of the ipsilateral lung, has not been routinely required for rib fracture fixation in our experience.

EXPOSURES PITFALLS

• Surgeons should ensure appropriate training and expertise before attempting surgical fixation of rib fractures. In the case of unfamiliarity with the approach or technique, ensure that you have the assistance of another orthopedic surgeon with expertise or a general surgeon/thoracic surgeon familiar with the local anatomy. • Be mindful and protect the long thoracic nerve, located along the lateral border of the serratus anterior. Injury to this nerve can cause deinnervation of the serratus anterior muscle and lead to a “winged scapula.”

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PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

 

A

B

c

D

E

F

G FIG. 84.8  Posterior approach. A, Longitudinal posterior incision centered over posterior rib fractures. B, Exposing the trapezius muscle superiorly (star), latissimus inferiorly (triangle), lateral border of scapula laterally (arrow). C and D, The trapezius is retracted superiorly. E, The scapula and latissimus dorsi muscle are retracted, exposing the erector spinae muscle underneath. F, The erector spinae is reflected, exposing the posterior ribs. G, The posterior rib fractures are exposed. (Images courtesy Dr. Aaron Nauth.)

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

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PROCEDURE Step 1 • Identify the most displaced rib fracture (commonly in the area with the most softtissue disruption). In general, displaced rib fractures are associated with disruption of the pulmonary pleural from the original trauma. • Once access to the pleural cavity is made, remove the original chest tube to decrease the risk of infection. A new sterile chest tube will be placed at the end of the procedure. • Irrigate and suction the retained hemothorax, which has been accumulated from the initial trauma. This can be done with the use of a mini rib spreader and pool suction. This helps lower the risk of infection (Fig. 84.9). • At this time, a general or thoracic surgeon can perform any other intrathoracic procedure(s) required (i.e., lung resection or repair). 

A

B

FIG. 84.9  A, A mini rib spreader is used to open the intercostal space and gain exposure to the pleural cavity. B, The pleural cavity is irrigated and cleared of retained hemothorax. (Images courtesy Dr. Aaron Nauth.)

Step 2

STEP 2 PEARLS

• Reduce the displaced rib fractures through the created muscle-splitting window (usually two to three ribs). This can be done with the use of reduction clamps to bring the overriding fracture ends together. In the setting of a simple fracture with no comminution, once the ribs are reduced, they commonly remain stable without the use of reduction clamps to “hold” the reduction (Fig. 84.10). • Plate fixation of rib fractures is relatively straightforward, performed with the use of plates and bicortical screws. Simple fractures can be reduced and fixed anatomically, with three screws on either side of the fracture. Comminuted fractures require bridge fixation and use of longer plates. • Reduce and fix the ribs visible through the created window. Another muscle-splitting window can be created to fix the remaining ribs (see Fig. 84.7). • In the case of costochondral dislocation, plate fixation is not recommended. The dislocated rib can be fixed to the cartilage with use of transosseous sutures (Fig. 84.11). • Not every fracture needs to be fixed. The goal is to fix as many ribs needed to obtain a stable chest wall segment (this usually involves fixing most displaced rib fractures; Figs. 84.12, 84.13) 

• The aim is bicortical screw fixation, but ensure that the screws are not too long. This can be done by the use of instruments (or finger palpation) to feel the undersurface of the rib to assess for protruding screws. • Plate fixation can be performed with precontoured rib-specific plates. If these are unavailable, curved or straight 3.5 pelvic reconstruction plates can be used, which may require contouring. • Cortical screws can be used in young patients, while cancellous screws can be used in osteoporotic bone. Some plates have locking screw capability, which may be beneficial in osteoporotic bone. • In the setting of flail chest injuries, most ribs are fractured at two locations. However, rarely are both fractures displaced sufficiently to require fixation. If both fractures require fixation, this can be addressed with a single long plate (if the fractures are reasonably close). However, if the fractures are far apart, each can be fixed with a separate plate. Alternatively, in this setting, an intramedullary fixation device may be used.

STEP 2 PITFALLS

• Ensure fixation of each rib fracture to its corresponding fragment. In the setting of multiple fractures with severe chest wall distortion, it is possible to fix a rib to the wrong level above/below. When in doubt, assess and reduce all rib fractures prior to surgical fixation. Intraoperative radiographs may also be useful in this setting. • Avoid surgical fixation with Kirschner wires, as they have a risk of wire migration into adjacent soft tissues and vital structures. Rib-specific intramedullary devices may be useful in certain settings (displaced segmental fractures with a wide intramedullary canal) but, in general, plate fixation is preferred.

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

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A

B

C FIG. 84.10  A, The displaced rib fractures are exposed. B, The rib fractures are reduced. C, The fractures are fixed with plates applied to each rib. (Images courtesy Dr. Aaron Nauth.)

A

B

FIG. 84.11  A, Rib fracture associated with costochondral dislocation. The fracture has been fixed with a plate; however, there is remaining instability from the costochondral dissociation. B, Intraosseous sutures are used to fix the costochondral dissociation. (Images courtesy Dr. Aaron Nauth.)

A

B

FIG. 84.12  A, Multiple rib fractures with instability of the chest wall. B, Chest wall stability has been achieved after surgical fixation. (Images courtesy Dr. Aaron Nauth.)

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

A

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B

C FIG. 84.13  A, Multiple right-sided anterolateral rib fractures (stars). B and C, Postoperative radiographs demonstrating surgical fixation of ribs 4 to 7 with plates and screws.

Step 3 • At the end of the procedure, a new sterile large-bore chest tube (32F or 36F) is placed, under direct visualization. The chest tube should be directed posteriorly toward the apex and ideally not in direct contact with the hardware. • The chest tube should be placed through a separate new incision, caudally and away from the surgical incision. Ensure that the chest tube is appropriately sutured and secured to prevent dislodgment (Fig. 84.14). • Following plate fixation and insertion of the chest tube, closure of the muscle split and interval is performed with interrupted absorbable sutures. 

STEP 3 PEARLS

• A chest tube should always be placed at the end of the procedure to prevent pneumothorax and hemothorax (Fig. 84.15).

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PROCEDURE 84  Surgical Fixation of Chest Wall Injuries

FIG. 84.14  The preoperative chest tube has been removed (arrow). A new chest tube has been placed away from the surgical incision caudally and secured with sutures.

FIG. 84.15  Intraoperative radiograph demonstrating a tension pneumothorax following open reduction and internal fixation of multiple rib fractures and scapula fracture. A chest tube was promptly inserted to relieve the pneumothorax. All patients with surgical fixation of a flail chest injury should have a chest tube placed prior to closure of the thoracic cavity.

POSTOPERATIVE CARE POSTOP PEARLS

• Most patients with flail chest injuries are admitted to the ICU. A multidisciplinary approach and collaboration with intensivist colleagues from the ICU, respiratory therapy, and trauma/general/thoracic surgery are required for their care.

• Chest tube management: • The chest tube should be set to negative pressure postoperatively to allow for lung expansion. Once the lung has re-expanded, there should be no air leak (bubbles) in the underwater seal of the collecting system. Once the lung has re-expanded, the chest tube can be placed to underwater seal. • Ensure that the patient receives appropriate postoperative antibiotics until the chest tube is removed. Antibiotic prophylaxis following chest tube insertion can help prevent postoperative emphysema and pneumonia.

PROCEDURE 84  Surgical Fixation of Chest Wall Injuries



• Examine the amount and type of chest tube output (blood, fluid, pus) daily. • The chest tube can be removed once the lung has re-expanded and the daily rate of chest tube output is < 100 cc. • Other postoperative recommendations are intensive spirometry, pulmonary toilet (to clear secretions), chest physiotherapy, and adequate pain management (intercostal nerve blocks, epidural catheters, PCA). 

EXPECTED OUTCOMES • Prior studies indicate that surgical fixation chest wall injuries in patients with a flail chest can decrease the length of time on mechanical ventilation and time spent in the ICU. • Surgical fixation has also been shown to lower the risk of pneumonia, chronic pain, time off work, and long-term respiratory dysfunction. • Further studies in this area are warranted to assess the benefits of surgical fixation compared with current modern nonoperative treatment strategies and assess the benefits in subgroups such as nonintubated patients and patients with pulmonary contusion.

EVIDENCE Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the national trauma data bank. J Trauma Acute Care Surg. 2014;76(2):462–468. A study of patients with flail chest injuries from the National Trauma Data Bank focusing on outcomes and current treatment strategies. The study demonstrates high rates of morbidity and mortality in patients with a flail chest diagnosis and significantly worse outcomes in patients with concurrent severe head injuries. Less than 1% of patients with a flail chest are treated with surgical fixation, while less than 8% receive epidural catheters for pain management. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4:583–587. A small randomized controlled trial of patients with flail chest, 20 treated with surgical fixation, and 20 nonoperatively. Surgical fixation was performed with stainless steel and Kirschner wires. Surgically treated patients had a shorter time on mechanical ventilation, time in the ICU, and hospital stay. They also had a lower rate of pneumonia and lower chest wall deformity as well as improved pulmonary function. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, outcome. J Bone Joint Surg [Am]. 2011;93:97–110. A review article examining the indications for surgical fixation as well as surgical techniques and outcomes. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216(5):924–932. A small randomized controlled trial of 46 patients with flail chest who were also on mechanical ventilation: 23 treated with chest wall fixation (with absorbable plates) and 23 nonoperatively. Surgically treated patients had a shorter time in the ICU and a lower rate of tracheostomy. McKee MD, Schemitsch EH. Injuries to the Chest Wall–Diagnosis and Management. Switzerland: Springer; 2015. A comprehensive textbook on chest wall injuries, focusing on flail chest injuries. There are dedicated chapters discussing the pathophysiology of flail chest injuries as well as current treatments, indications for surgical fixation and surgical approaches, outcomes, and complications. Nirula R, Diaz Jr JJ, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009;33:14–22. A review article detailing the indications for surgical fixation of rib fractures as well as surgical techniques. Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013;216(2):302–311. A meta analysis of 11 studies with a total of 753 patients with flail chest injuries, comparing outcomes between surgical fixation and nonoperative management. The study demonstrates improved outcomes with surgical fixation, including shorter time on mechanical ventilation; shorter time in the ICU; and lower rates of mortality, pneumonia, sepsis, tracheostomy, and chest wall deformity. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52:727–732. A small randomized controlled trial of patients with flail ches, who were all on mechanical ventilation: 18 treated with chest wall fixation (with Judet struts) and 19 nonoperatively. Surgically treated patients had shorter time on mechanical ventilation; shorter time in the ICU; lower rates of pneumonia and tracheostomy; higher percentage forced vital capacity; and higher return to full-time employment.

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POSTOP CONTROVERSIES

• The timing of chest tube removal and need for daily chest radiographs in patients with a chest tube is variable, based on a number of factors. It is best to follow the protocol set at each institution regarding chest tube management.

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PROCEDURE 84  Surgical Fixation of Chest Wall Injuries Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion. J Am Coll Surg. 1998;187:130–138. A retrospective study of patients with flail chest injury, assessing the effect of pulmonary contusion. The study concluded that patients without pulmonary contusion benefit from surgical fixation. However, those with pulmonary contusion did not benefit from surgery.

PROCEDURE 85

Optimizing Perioperative Fracture Care Dominique M. Rouleau, Marie-Ève Rouleau, and G. Yves Laflamme • This chapter describes several perioperative principles and techniques that are of importance in the care of injured patients. The goal of this chapter is to synthesize relevant information, enabling the orthopedic surgeon to provide the best global care for his or her patient based on actual literature. • The subjects selected are Advanced Trauma Life Support, initial care of the injured limb, thromboprophylaxis, antibiotic prophylaxis, psychological reaction to injury, and secondary prevention.

ADVANCED TRAUMA LIFE SUPPORT* Indications • Any patient who sustains a moderate- to high-energy injury must be evaluated with the Advanced Trauma Life Support (ATLS) protocol. • Other indications for ATLS evaluation include the following: • Pelvic fracture • Femur fracture • Decreased level of consciousness or intoxication • Multiple injuries 

Examination/Imaging • The principle of the “golden hour” is now part of standard care in every health center from the small rural health center to the level I trauma center. • ATLS evaluation is done according to the following steps • A—Airway (with cervical spine protection) • B—Breathing • C—Circulation: includes stopping bleeding • D—Disability: neurologic status • E—Exposure (undress)/Environment (temperature control) 

PROCEDURE Step 1: Airway • Airways are evaluated first in the “primary survey.” • In the primary survey, physicians must evaluate and treat the patient following the ABCDE sequence (see Examination/Imaging above). • Injuries must be addressed and treated following logical steps according to vital signs and injury mechanisms. • To assess the airway, the physician must examine the mouth for any foreign body and signs of burns or smoke inhalation. • A patient who can speak and has a Glasgow score over 8 (see Step 4) is not likely to have airway obstruction. 

Step 2: Breathing • Breathing is the second step of the ATLS sequence. • Oxygenation (normal: > 95% saturation) and breathing rhythm (normal: 15–20 breaths/ min) out of normal range are red flags for deficient air entry and/or hypoxemia. • Ventilation requires proper function of chest wall muscles, diaphragm, and lungs.  * Portions of this section are adapted from American College of Surgeons. Advanced Trauma Life Support for Doctors—Student Course Manual, ed 7. Chicago: American College of Surgeons, 2004.

PITFALLS

• A patient being young does not mean he can compensate for significant blood loss and maintain normal vital signs. • An older patient may be unable to increase heartbeat secondary to cardiac medication. • An intoxicated patient can be misleading secondary to an absence of pain sensation and a poor injury history. • The orthopedic surgeon must not undertake care of unstable traumatized patients alone. Teamwork is more efficient and must be prioritized when possible. Physicians from emergency medicine, intensive care, anesthesiology, and general surgery are most often involved in ATLS. PEARLS

• When possible, a complete trauma team must be available on patient arrival. • In the case of an unstable or severely traumatized patient, three supportive care measures must be instituted immediately upon arrival • Supplemental oxygen • Two large-gauge intravenous access lines • Monitoring (cardiac rhythm, pulse oximetry, blood pressure) • A complete blood test and blood typing must be done. Complete vital signs must be taken. • Chin lift or jaw thrust maneuvers can help keep the airway open. • Definitive airway management by orotracheal intubation or cricothyroidotomy must be done by the appropriate caregiver while maintaining the cervical spine in the neutral position by manual immobilization. PITFALLS

• Posterior sternoclavicular dislocation can be involved in airway obstruction. This rare condition can be identified by palpation of the sternoclavicular joint during tracheal and neck examination. Closed reduction with traction using a towel clamp can be undertaken in extreme situations with the collaboration of a thoracic surgeon. Posterior dislocations have associated intrathoracic injuries in 30% of the cases. The mortality in this subset of patients is reported to be 12.5% and such associated conditions must be ruled out before attempting reduction. PEARLS

• Inspection, palpation, and auscultation must be done to identify tension pneumothorax, flail chest, massive hemothorax, open pneumothorax, tracheal or bronchial rupture, or diaphragmatic rupture. Modification of ventilation and chest drainage must be done, when necessary. 1059

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PEARLS

• The orthopedic surgeon must be particularly attentive to external bleeding of the extremities, unstable pelvis fractures, and femoral fractures. PITFALLS

• Direct manual pressure is the safest way to stop external bleeding. Hemostatic clamps can damage neurologic structures when used in a suboptimal setting in the emergency room. Use them only if absolutely necessary. • A pneumatic tourniquet may be applied temporarily to control limb bleeding, but must not be used indefinitely when the extremity is salvageable because the tourniquet can cause irreversible limb ischemia. INSTRUMENTATION/IMPLANTATION

• Specialized pelvic belts must be available in multiple sizes in trauma centers. • Long-bone fractures can be stabilized by longitudinal skin traction and a well-padded splint. • External bleeding must be controlled by direct manual pressure. PEARLS

• This evaluation is not possible after sedation and intubation. When possible, a quick neurologic assessment can be done before the use of sedation. PITFALLS

• The physician must remember that patients with spine or head injury can develop neurogenic shock. Typically bradycardia and low blood pressure are associated with that kind of shock. PEARLS

• Hypothermia is a frequent consequence of trauma; therefore, room temperature in the trauma suite must be adjusted according to patient need. PITFALLS

• The contraindication to urinary catheterization is a suspected urethral injury. • If the cribriform plate is fractured, a gastric tube must be inserted orally to prevent intracranial passage.

FIG. 85.1 

Step 3: Circulation • Circulation and hemorrhage control represent the next step. • Increased heart rate, decreased blood pressure, pale skin color, and a decrease of the level of consciousness are all signs of impaired circulation. • Immediate volume repletion must be initiated with 2 L of crystalloid. Units of blood, and colloid and coagulation products (platelets and plasma) must be ready for use in patients with shock unresponsive to crystalloid resuscitation. • A systematic review of possible bleeding causes includes external blood loss, thoracic bleeding, abdominal bleeding, pelvic bleeding, and internal hemorrhagic bleeding around a long-bone fracture. • Immediate closed reduction and immobilization of a fracture decreases bleeding, decreases pain, and slows the inflammatory reaction. • A pelvic fracture can be reduced and immobilized by a pelvic binding sheet or commercially available binder around the greater trochanter (Fig. 85.1). 

Step 4: Disability (Neurologic Status) • Evaluation for neurologic disability must be done at the end of the primary survey using pupillary size and reaction, lateralizing signs, and level of spinal cord injury. • The Glasgow Coma Scale score is used to quantify the level of consciousness. Three responses are tested, and the scores for each are totaled. • Eye opening Spontaneous: 4 To speech: 3 To pain: 2 None: 1 • Best motor response Obeys commands: 6 Localizes pain: 5 Normal flexion (withdrawal): 4 Abnormal flexion (decorticate): 3 Extension (decerebrate): 2 None (flaccid): 1 • Verbal response Oriented: 5 Confused conversation: 4 Inappropriate words: 3 Incomprehensible sounds: 2 None: 1 

PROCEDURE 85  Optimizing Perioperative Fracture Care

Step 5: Exposure/Environment • Finally, patients must be completely undressed to complete the assessment. • Control of the patient’s body temperature should be obtained. • At this point, an electrocardiogram can be obtained, and urinary and gastric catheterization can be done. 

Step 6: Secondary Survey and Transfer Decision • Before undertaking the secondary survey, results of blood tests and arterial blood gases must be verified. • Judicious radiologic and abdominal tests must be requested. • In the situation of an unstable patient, anteroposterior radiographs of the chest and pelvis can provide important information. Lateral cervical spine radiographs can also be obtained at this time. 

LOGROLLING MOBILIZATION TECHNIQUE Indications • Every patient at risk of spinal injury must be mobilized using the logrolling technique. • This technique must be used during every patient mobilization until complete spinal evaluation is normal. 

Positioning • A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs. The technique of mobilization is important to minimize spinal movement. • Three persons are needed. • One person stabilizes the head and neck. This person must lead every step in patient mobilization. • Two others stand together on the side of the patient that is the least injured. • The second person, standing at trunk level, places one hand on the shoulder furthest from him or her and the other hand on the greater trochanter. • The third person who is at pelvic level places one hand at the T12 level and the other hand at thigh level. • All movements are done in a coordinated way to keep the patient’s spine as straight as possible. 

PROCEDURE Step 1: Positioning • The person holding the patient’s head must ensure that the team is well positioned to do the logrolling. • Fig. 85.2A shows the logrolling starting position. • Note that a rigid cervical collar must be used in a trauma patient. 

Step 2: Logrolling • The person holding the patient’s head coordinates logrolling of the patient onto his or her less injured side (Fig. 85.2B). 

Step 3: Posterior Examination • The patient’s back, buttocks, and posterior aspect of the legs are examined while he or she is stabilized on the less injured side. 

Step 4: Repositioning • The person holding the patient’s head coordinates logrolling of the patient back to the supine position. • The person responsible for head and neck immobilization must give a clear order to ensure a coordinated movement of the mobilization team to roll the patient back to the supine position: “On my count, we will roll back the patient on his back at 3, slowly: . . . 1, . . . 2, . . . 3, . . . turn.” 

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PEARLS

• Initial treatment of life-threatening injuries or limb salvage can be undertaken before transfer in agreement with the consultant trauma center. • All fractures must be stabilized in a splint or traction before transfer. • Transfer of patients with pelvic fractures must be done with a stabilization device. PITFALLS

• A normal or inadequate radiograph does not exclude spinal injury. When in doubt, the entire spine must be protected at all times. • The orthopedic team must ensure that the patient does not have any limb-threatening injuries. These injuries are easy to miss in a polytrauma patient or unconscious patient. • Nondisplaced fractures or isolated dislocations can also be neglected. Liberal use of radiography, vascular Doppler examinations, and compartment pressure monitoring must be done if any doubt arises during physical examination or because of injury mechanism. • Abdominal ultrasonography and diagnostic peritoneal lavage are useful tools when used by an experienced physician. • After the primary survey, the physician in charge often has sufficient information to determine whether transfer to a trauma center is needed. Criteria for transfer are • Glasgow score under 13 • Systolic blood pressure under 90 mm Hg • Respiratory rate under 10 or over 29 breaths/min • Flail chest • Multiple long-bone fractures • Amputation • Penetrating trauma to head, neck, torso, or extremity proximal to elbow or knee • Open or depressed skull fracture • Limb paralysis • Unstable pelvic fracture • Major burns • Significant mechanism of injury • Significant preexisting comorbidity • Pediatric patients • After completion of the primary survey and the resuscitation phase, a second survey can begin. This is done only when the patient is stable and has normal vital signs. • Each part of the body must be examined from head to toe. • A past medical history and a history of the mechanism of injury must be obtained at this point. The AMPLE mnemonic is used to obtain a complete history • A—Allergies • M—Medications • P—Past illnesses/Pregnancy • L—Last meal • E—Events/Environment related to the injury • The role of the orthopedic surgeon in the secondary survey is to identify all significant musculoskeletal injuries, guided by injury mechanism and energy level. Continued

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PITFALLS—cont’d

• The first step is to look for deformity, redness, edema, wounds, or any sign of blunt trauma. Every part of the body must be examined. • A careful mobilization must be done “en bloc” to examine the back, buttocks, and posterior aspect of the legs (see Logrolling Mobilization Technique). • Pelvic and femoral fracture identification is important because either can lead to significant blood loss. • The orthopedic surgeon must also check carefully for signs of any limb-threatening injuries. • Vascular injury •  Decreased or absent pulse • Cold limb •  Pale or white limb •  Slow capillary refill •  Significant bleeding from an open wound • Compartment syndrome •  Tense edema •  Positive stretch test •  Severe pain •  Paresthesia •  Paresis • Open fracture •  Open wound •  Anal or vaginal bleeding (pelvic fracture)

PITFALLS

• Logrolling a patient with an unstable pelvis fracture can increase blood loss and cause a decrease of blood pressure. An intravenous fluid bolus must be given before logrolling in these patients. • The logrolling side must be chosen with respect to the patient’s injury. The side with more injuries must be kept up. • The appropriate analgesia must also be given to prevent excessive pain during mobilization.

A

INITIAL CARE OF THE INJURED LIMB • This topic is straightforward. Adequate reduction and immobilization, sufficient pain management, and providing walking aids are three primary things to do. • However, a study undertaken at our center revealed alarming rates of low-level care quality by referring first-line physicians or referring orthopedic surgeons. In our study, 166 patients referred to the fracture clinic for a limb injury were evaluated during a 4-month period. • Of patients, 30% who needed immobilization for a fracture had not received it after seeing the first referral doctor. • At the time of the orthopedic evaluation, 50% of patients felt pain of 5/10 or more, and 30% of patients did not receive any analgesic medication and stated that they needed it. Of patients, 21% who received pain medication stated that it was insufficient to allow them to sleep or rest peacefully. The group of patients with unacceptable analgesia had a significantly higher level of pain (6/10) compared with 4/10 on average for patients with adequate analgesia (P < 0.05). • Of patients, 32% who needed a walking aid did not receive any prescription for it. These patients had a significantly higher level of pain (6/10) when compared with patients with appropriate walking aid prescriptions (4/10) (P < 0.05). 

Limb Immobilization • Initial care for limbs that have sustained fracture or dislocation includes the following • Good immobilization must be performed after proper realignment or reduction and a neurovascular evaluation. • Splints are recommended for initial management because they accommodate the initial swelling.

Step 1 • A good splint must immobilize proximal and distal joints of the fractured bone or proximal and distal bone segments of an unstable joint. The splint must be made of three layers. • The first layer of a splint is the padding (Fig. 85.3A). 

Step 2 • The second layer is made of the stabilization material. • A regular plaster of Paris cast slab (Fig. 85.3B) or fiberglass can be used. 

Step 3 • The last layer is necessary to hold the splint in place. • Elastic (Fig. 85.3C) or nonelastic bandages can be used in a loose fashion. 

B FIG. 85.2  Logrolling

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A

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B

C FIG. 85.3 

IMMOBILIZATION OF OTHER INJURIES • Shoulder injuries cannot be immobilized by a standard splint. A sling and an abduction pillow are two examples of useful techniques for shoulder trauma. • Pelvic and femoral fractures have specific needs. Skin traction and pelvic belts are used to stabilize these injuries. • Immobilization of a spine injury cannot be accomplished by a splint. • A semi-rigid collar can be applied for cervical spine fractures. • Initial immobilization of dorsal and lumbar spine injuries can be achieved by bed rest. 

PAIN MANAGEMENT • Pain management is the second important part of initial limb injury care. • Every patient with an orthopedic injury must have pain evaluation and management.

Protocol • We recommend a progressive analgesia protocol. • Step 1: Immobilization, rest, walking aids, ice • Step 2: Acetaminophen 650 mg to 1 g four times daily as needed taken orally • Step 3: Antiinflammatory drugs if there is no medical risk factor • Naprosyn 250 mg every 12 hours as needed taken orally • Step 4: Nonnarcotic analgesics • Tramadol/acetaminophen 1 to 2 tablets every 4 hours as needed taken orally

PEARLS

• Verbal and visual contact among the three persons responsible for patient mobilization is essential. PEARLS

• The person responsible for head and neck immobilization must give a clear order to ensure a coordinated movement of the mobilization team: “On my count, we will turn the patient on his right side at 3, slowly: . . . 1, . . . 2, . . . 3, . . . turn.” PEARLS

• A fourth person must be available to examine the patient’s back, to remove all foreign bodies, or to change drapes. PITFALLS

• Although application of a splint is important, signs of vascular impairment, infection, or compartment syndrome can be hidden by a splint. • Frequent assessment of soft tissue under the splint must be done.

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TREATMENT OPTIONS

• Traction can also be used for lower limb injuries. PEARLS

• All open wounds must first be cleaned and covered by a sterile dressing. • Cotton roll is an easy-to-use padding to protect the skin from pressure points. PITFALLS

• Extra layers must be applied on bony eminences such as the ankle, malleoli, and olecranon. PEARLS

• Coverage of 50% of the limb circumference is usually sufficient to create stability. Posterior and dorsal sides are normally used. PITFALLS

• Modeling of the hard material is very important to prevent pressure points and ensure sufficient stability. • More than 12 layers of plaster can increase the temperature inside the cast and cause burns. • Use of water over 24°C can increase the temperature inside the splint and cause burns. PEARLS

• Neurovascular examination must be repeated after any splint application. • Repeat radiologic evaluation may also be necessary. • Classic use of an elastic bandage requires application from distal to proximal.

PITFALLS

• A bandage that is too tight can cause neurovascular injury. • Use of fiberglass over a regular plaster of Paris slab can increase temperature inside the splint and cause burns. • Resting the limb on a pillow during the drying is associated with dangerous temperature at the skin level. PEARLS

• Regular checks for the development of compartment syndrome must be done. • The use of special mattresses to prevent pressure points is essential. • Mobilization of a patient with a spinal injury must be done by “en bloc” mobilization (see Logrolling Mobilization Technique).

• Step 5: Narcotics (for moderate pain) • Codeine 30 to 60 mg subcutaneously every 4 hours as needed • Oxycodone/acetaminophen 1 to 2 tablets every 4 hours as needed taken orally • Step 6: Narcotics (for severe pain) • Morphine 0.2 mg/kg orally every 3 hours as needed; 5 to 10 mg/dose for an adult (max. 20 mg/dose) • Morphine 0.1 mg/kg subcutaneously every 3 hours as needed; 2 to 5 mg/dose for an adult (max. 10 mg/dose) • Dilaudid 0.04 mg/kg orally every 3 hours as needed; 1 to 2 mg/dose for an adult (max. 4 mg/dose) • Dilaudid 0.015 mg/kg subcutaneously every 3 hours as needed; 0.5 to 1 mg/dose for an adult (max. 2 mg/dose) 

Walking Aids • Finally, initial care of an injured limb must include the prescription of an appropriate walking aid in the presence of a lower limb injury. • Walking aids vary depending on patient status and ability. • A cane is appropriate when partial weight bearing is safe. • Crutches require good balance and strong upper limbs and are recommended for younger patients. Adjustment of crutches is critical for effective mobilization. • With the patient in a standing position, the crutch length is adjusted to obtain 5 cm of clearance under the axilla (Fig. 85.4). • The crutch handle must be adjusted to create 30° of flexion at the elbow. • Older patients need more stability, which can be provided by a walker or a wheelchair. 

THROMBOPROPHYLAXIS AND FRACTURE • Preventing venous thromboembolism is of first importance in the treatment of an orthopedic trauma patient. • Patients with hip fractures or proximal femur fractures have a 46% to 60% chance of suffering a deep venous thrombosis (DVT) and a 3% to 11% chance of having a pulmonary embolism. • These numbers increase in the presence of pelvic fractures or spine fractures with neurologic deficit. 

IDENTIFIED RISK FACTORS FOR THROMBOSIS IN ORTHOPEDIC TRAUMA PATIENTS • Age over 60 years • Presence of cancer • Prior venous thrombosis • Molecular hypercoagulability (genetic disorder) • Major trauma • Obesity • Surgery lasting 2 hours or more • Bed rest for more than 72 hours 

CURRENT RECOMMENDATIONS • For thromboprophylaxis in patients with fractures of the pelvis, hip, or proximal ­femur, the use of low-molecular-weight heparin (LMWH) is recommended (Grade 1) for at least 10 days and up to 28 days after the intervention. • There is no clear advantage to LMWH for patients with isolated lower limb injuries below the knee. • Patients suffering from spinal fractures are more at risk of DVT in the presence of a neurologic deficit, anterior surgical approach, and associated cancer. • In patients other than those with fractures from the pelvis to knee or polytrauma patients, the orthopedic surgeon must use his or her own judgment to identify patients with higher DVT risk in the absence of clear evidence in the literature to guide the decision.

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5 cm

30˚

FIG. 85.4 

• Again, the benefits of LMWH must always be balanced by the bleeding risk, especially with trauma patients. 

ANTIBIOTIC PROPHYLAXIS AND TETANUS PREVENTION • Infection after fixation of a fracture is a serious complication. • Despite modern aseptic surgical suites and the use of antibiotics, the incidence of infection is still significant. According to a comprehensive study on 2195 patients, the incidence of infection after treating closed fractures is approximately 2%.

Current Recommendations • In the literature, there is no Level I evidence-based article to provide information on the optimal regimen of antibiotics to give patients undergoing surgery for a fracture. • Systematic reviews and some recommendations from experts: • A metaanalysis on hip fracture surgery concluded that the use of intravenous (IV) prophylactic antibiotics reduces the risk of postoperative infection. The same study showed no advantage to multiple doses of postoperative antibiotics compared with only one dose (Grade A). •  A review done by Schmidt and Swiontkowski (2000) recommended a first-­ generation IV cephalosporin for 24 hours following the fixation of a closed fracture (Grade B). • According to a well-conducted systematic review, all patients with open fracture should receive IV antibiotics as soon as possible (Grade A). The ideal regimen of antibiotics most favorable to patients is not known. • Experts recommend a first-generation cephalosporin until 24 hours after the skin is closed in an open fracture (Grade B). • Gentamycin adjusted to weight and renal clearance must be given for Gustilo III fractures (Grade C). • We recommend that the clinical evaluation of the wound dictate the length of time for IV antibiotics for Gustilo III fractures (Grade C). • Penicillin must be given for injuries sustained on a farm or very contaminated injuries. 

PSYCHOLOGICAL REACTION TO INJURY • The orthopedic surgeon treating injured patients also must address the patients’ emotional reactions.

PITFALLS

• The choice of appropriate medication and dosage must be made after considering the risks of drug interactions, comorbidities, medication allergy, age, weight, and presence of head injury. • High doses of narcotics can only be given under adequate medical observation. • Pain out of proportion to the injury can be a sign of compartment syndrome, neurologic injury, vascular compromise, or aggressive infection.

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• Sometimes it is clear that the emotional reaction is out of the normal range. It is important to identify these patients because psychological pathologies can interfere with patient collaboration in regimens of treatment and result in poor outcomes. • Cardiac surgery literature has shown an increased hospitalization length for patients with posttraumatic stress disorder.

Posttraumatic Stress Disorder • Posttraumatic stress disorder (PTSD) is a significant psycho-emotional state following an overwhelming traumatic event. • The typical symptoms are: • Flashbacks • Nightmares intrusive in nature • Sense of numbness and emotional blunting • Detachment from others • Unresponsiveness • Fear and avoidance of reminders of the trauma • Hyperarousal and hypervigilance • These symptoms must be present for at least 1 month and they must have a significant impact on the patient’s functional status to be diagnosed as PTSD. If the symptoms have been present for less than 1 month and are still having a significant impact on the patient’s functional status, the patient has acute stress disorder. • The prevalence of PTSD is high. • A study done on a cohort of 400 children recovering from a minor orthopedic injury showed that 33% had PTSD. • A similar study done on 580 adults showed a prevalence of PTSD of 51%. These authors devised a key statement to identify patients at risk for PTSD: “The emotional problems caused by the injury have been more difficult than the physical problems.” In patients who responded “yes” to that statement, the study showed a 78% chance of having PTSD.

Risk Factors for PTSD • Presence of concomitant head injury • Hospitalization • Social isolation and the loss of a significant person during the trauma 

The Orthopedic Surgeon’s Responsibility • The orthopedic surgeon must guide the patient suffering from PTSD to the appropriate professional. • A systematic review of various psychological therapies has shown that early cognitive behavioral therapy is efficient in decreasing the length and severity of psychological effects following trauma. • When doing research on outcome after fracture treatment, most studies now use standardized questionnaires on patient perception of functions and limitations. It is important to know that patients with PTSD have a biased emotional attention and recall more negative events. 

SECONDARY PREVENTION • When the surgeon sees an injured patient, it is already too late to prevent the traumatic event. However, the literature shows that several interventions are possible in order to prevent future fractures or accidents. This is known as secondary prevention. • Secondary prevention interrupts, prevents, or minimizes the progression of a disease or disorder at an early stage. • The orthopedic surgeon can be a key agent of prevention in sports and motor vehicle accidents, situations of intimate partner violence (IPV), and osteoporosis.

PROCEDURE 85  Optimizing Perioperative Fracture Care

Prevention of Sport- and Accident-Related Injury

PEARLS

• The literature lists some important risk factors for injury recidivism. The orthopedic surgeon must be aware of these risk factors. • When a risk factor is noted, the patient must be oriented toward the proper resources. 

• It has been shown that social service intervention is effective in decreasing risk behavior and risk of injury recidivism.

Risk Factors for Recidivism of Injury • Illegal drug or alcohol use • Some studies have shown that an alcohol consumption problem was present in 48% of patients admitted to a level I trauma center. • Presence of psychiatric or mental illness • Being engaged in illegal activities • Being homeless 

Modalities That Can Decrease the Risk of Injury • A recent Cochrane Database review underlined the efficacy of helmet use for cyclists to decrease head injury. • Use of wrist protectors when snowboarding has shown a significant reduction in wrist fractures. • Use of postinjury proprioceptive training decreases the risk of recurrent injury following an ankle sprain. 

INTIMATE PARTNER VIOLENCE (IPV) • IPV is an important issue in female health. • IPV is the most common cause of nonfatal injury to a woman in the United States. • Of women, 4 of 10 have been victims of violence. • Of all murdered females in the United States, 30% were killed by a husband or a boyfriend. • Half the mothers who reported that their children had been assaulted were also ­victims of IPV. • The most frequent injuries caused by assault were to the head and neck. This type of injury was reported by 40% of women. • The second most frequent type of injury, reported by 28% of women, affected the musculoskeletal system.

Risk Factors for a Woman to be a Victim of IPV • Young age • Lower social status • Pregnancy • Short-term relationship • Drug or alcohol abuse 

Red Flags of IPV • Head injury • Multiple injuries • Injury history does not match known pathomechanics of fracture or injury. • Different healing stages for lesions and delayed presentation 

Recommendations • The orthopedic surgeon can use the following questions to open discussion: “Did someone you know do this to you?” or “Do you feel safe at home?” • We must be ready to inform women about available services. • We must support the woman in making a statement to the police. Social workers and community service organizations can be of great help. • Hospitalization, in extreme cases, can be indicated to protect our patients. 

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OSTEOPOROSIS • “Fragility fractures,” which result from low-trauma events, such as a fall from a standing height, affect one-half of women and one-third of men over 50 years of age. • The risk of having a fracture for females over 50 years of age is almost 1 in 2, and the risk for males is 1 in 3. • According to Osteoporosis Canada, 1.4 million Canadians suffer from osteoporosis.

Definitions and Assessment • Osteoporosis has been defined by the World Health Organization as a bone mineral density of more than 2.5 standard deviations below the young adult mean. • Osteopenia has been defined as a bone mineral density of between 1 and 2.5 ­standard deviations below the young adult mean. • The American Academy of Orthopaedic Surgeons has issued recommendations regarding fragility fractures. • Consider the likelihood that osteoporosis is a predisposing factor when a patient has a fragility fracture. • Advise patients with fragility fractures that an osteoporosis evaluation may lead to treatment that can reduce their risk of future fractures. • Initiate an investigation of whether osteoporosis is an underlying cause in patients with fragility fractures. The orthopedic surgeon may conduct this evaluation or may refer the patient to another medical provider. • Establish partnerships within the medical and nursing community that facilitate the evaluation and treatment of patients with fragility fractures. • Urge hospitals and office practices to establish clinical pathways that ensure that optimal care is provided for patients with fragility fractures. 

Treatment Recommendations Medications • Calcium and vitamin D supplements should be given to all women over 50 years of age and to every person who has had a fragility fracture. • The recommended dose of calcium is up to 1500 mg/day, with calcium citrate showing the better rate of absorption. • Vitamin D dosage must be 800 to 1000 units/day. • A bisphosphonate should be considered in every person with osteoporosis or with osteopenia and a fragility fracture. • Bisphosphonates have been shown to decrease the risk of fragility fractures by 50%. • Bisphosphonates have potential complications (atypical femoral fractures) and a drug “holiday” should be considered with long-term use. • Besides medications, other modalities have shown promising results in decreasing fragility fractures. • Weight-bearing exercises increased bone density in a randomized study. • Training programs and home care prevention programs have been shown to decrease the number of falls in women over 73 years of age.

EVIDENCE Advanced Trauma Life Support American College of Surgeons. Advanced Trauma Life Support for Doctors—Student Course Manual. 7th ed. Chicago: American College of Surgeons; 2004. Carmont MR. The Advanced Trauma Life Support course: a history of its development and review of related literature. Postgrad Med J. 2005;81:87–91. This review article noted that studies have shown significant loss of overall knowledge of ATLS after 4 years, justifying regular recertification. The principle of the “first golden hour” is now part of standard care in every health center from the small rural health center to the level I trauma center. The mnemonic “ABCDE” is the basis of the ATLS sequential evaluation and intervention (Grade B recommendation).

PROCEDURE 85  Optimizing Perioperative Fracture Care Kuzak N, Ishkanian A, Abu-Laban RB. Posterior sternoclavicular joint dislocation: case report and discussion. Can J Emerg Med. 2006;8:355–357. This article reviewed the literature on posterior sternoclavicular dislocation and reported 30% of associated thoracic injuries and 12.5% risk of mortality in that subgroup (Level IV evidence). Shakiba H, Dinesh S, Anne MK. Advanced trauma life support training for hospital staff. Cochrane Database Syst Rev. 2004;3:CD004173. This 2003 Cochrane review evaluated the efficiency of ATLS training in order to improve knowledge. The reviewers concluded: “There is no clear evidence that ATLS training (or similar) impacts on the outcome for victims of trauma, although there is some evidence that educational initiatives improve knowledge of what to do in emergency situations. Further, there is no evidence that trauma management systems incorporating ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using rigorous research designs.” (Grade B recommendation; Level II evidence). Styner JK. The birth of Advanced Trauma Life Support (ATLS). Surgeon. 2006;4:163–165. The ATLS movement was initiated following an orthopaedic surgeon’s personal tragedy in 1976. The children of Dr. J. K. Styner received suboptimal care in a regional health care center after a plane accident. Back then, the absence of a clear treatment algorithm resulted in disorganized care. The American College of Surgeons Committee on Trauma has worked to establish guidelines for optimal care of the trauma patient. Advanced Trauma Life Support regroups the fundamental principles of patient care following injury. van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Clinical impact of Advanced Trauma Life Support. Am J Emerg Med. 2004;22:522. This study showed a significant decrease in mortality after the institution of ATLS in two teaching hospitals. We recommend that all orthopedic surgeons follow an ATLS protocol because they are part of a multidisciplinary trauma team (Grade B recommendation; Level II evidence [cohort study]).

Limb Immobilization Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg [Am]. 2007;89:2369–2377. The authors studied risk factors for thermal injury with cast application techniques. The use of more than 12-ply plaster, the use of dip water at a temperature over 24°C, and resting the limb on a pillow during cast drying were associated with dangerous temperatures at the skin level. Rouleau DM, Feldman DE, Parent S. Delay to orthopaedic consultation for isolated limb injury: crosssectional survey in a level 1 trauma centre. Can Fam Physician. 2009;55:1006–1007. This cohort study describes mechanisms for referral to orthopedic surgery for isolated limb injuries in a public health care system and to identify factors affecting access. This was a prospective study of 166 consecutive adults (mean age 48 years) referred to orthopedic surgery for isolated limb injuries during a 4-month period (Level II evidence). Payne R, Kinmont JC, Moalypour SM. Initial management of closed fracture-dislocations of the ankle. Ann R Coll Surg Engl. 2004;86:177–181. Immobilization quality or presence is rarely reported in the literature. These authors reported the absence of immobilization in two cases of ankle fracture-dislocation, resulting in re-dislocation, out of a cohort of 23 patients seen by primary care physicians (Level IV evidence).

Thromboprophylaxis and Fracture Bagaria V, Modi N, Panghate A, Vaidya S. Incidence and risk factors for a development of a venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study. Postgrad Med J. 2006;82:136–139. Grade-B recommendation on identification of risk factors that can modify the decision for prophylaxis prescription (Level II evidence). Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338–400. This systematic review is the most recent and extensive source of information available.

Antibiotic Prophylaxis and Tetanus Prevention Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet. 1996;347:1133– 1137. Grade-A recommendation for the use of ceftriaxone compared with placebo in the prevention of infection for the surgical treatment of closed fracture (Level I evidence). Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2000;2:CD000244. This study found evidence supporting the use of antibiotics, although no specific antibiotic could be recommended. The authors concluded: “Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomized trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large and may not be feasible.” (Level I evidence).

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PROCEDURE 85  Optimizing Perioperative Fracture Care Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;1:CD003764. This systematic review identified the need to give IV antibiotics for open fracture. The best regimen of IV antibiotic could not be identified (Grade A recommendation). Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am]. 1990;72:299–304. This article described the Gustilo open fracture classification (Level IV evidence). Okike K, Bhattacharyya T. Trends in the management of open fractures: a critical analysis. J Bone Joint Surgery [Am]. 2006;88:2739–2748. An excellent critical review recommending different treatment modalities for open fractures. A Grade-A recommendation is made about the use of systemic antibiotic therapy. The type of antibiotic was recommended according to their institution’s current practice (Grade B recommendation). Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of fractures. J Am Assoc Orthop Surg. 2000;8:285–291. This review article supported the use of IV antibiotics to prevent infection in the surgical treatment of fracture. The type of antibiotic was recommended according to their institution’s current practice (Grade B recommendation; Level IV evidence). Southwell-Keely JP. Antibiotic prophylaxis in hip fracture surgery: a meta-analysis. Clin Orthop. 2004;419:179–184. This metaanalysis supported the use of IV antibiotics in the treatment of hip fracture surgery. One dose seemed no different than multiple doses, but the quality of the reviewed articles was low according to the authors of the metaanalysis. Grade B recommendation was made for one dose of antibiotic (Level I evidence).

Psychological Reaction to Injury Ehlers A, Clark DM, Hackmann A, et al. A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Arch Gen Psychiatry. 2003;60:1024–1032. This article supported the efficacy of psychological support for PTSD. The authors concluded: “Cognitive therapy is an effective intervention for recent-onset PTSD. A self-help booklet was not effective. The combination of an elevated initial symptom score and failure to improve with selfmonitoring was effective in identifying a group of patients with early PTSD symptoms who were unlikely to recover without intervention.” (Grade A recommendation; Level I evidence.) Levi RB, Drotar D, Yeates KO, Taylor HG. Posttraumatic stress symptoms in children following orthopaedic or traumatic brain injury. J Clin Child Psychol. 1999;28:232–243. This study showed a high incidence of PTSD in association with head injury (No recommendation; Level II evidence). Moore K, Thompson D. Posttraumatic stress disorder in the orthopaedic patient (continuing education credit). Orthop Nurs. 1989;8(1):11–19. This paper provided a definition of PTSD (No recommendation; Level IV evidence). Oxlad M, Stubberfield J, Stuklis R, Edwards J, Wade TD. Psychological risk factors for increased post-operative length of hospital stay following coronary artery bypass graft surgery. J Behav Med. 2006;29:179–190. This case series of 119 patients following cardiac surgery showed that psychological response can increase hospitalization length when all other medical factors were controlled (No recommendation; Level II evidence). Sanders MB, Starr AJ, Frawley WH, McNulty MJ, Niacaris TR. Posttraumatic stress symptoms in children recovering from minor orthopaedic injury and treatment. J Orthop Trauma. 2005;19:623–628. This study showed a high incidence of PTSD in children (No recommendation; Level II evidence). Starr AJ, Smith WR, Frawley WH, et al. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg [Am]. 2004;86:1115–1121. This study showed a high incidence of PTSD after orthopaedic trauma (No recommendation; Level II evidence). Sutherland AG, Alexander DA, Hutchison JD. The mind does matter: psychological and physical recovery after musculoskeletal trauma. J Trauma. 2006;61:1408–1414. This study showed a strong correlation of PTSD with impaired functional outcome after musculoskeletal trauma stresses (No recommendation; Level II evidence). Vythilingam M, Blair KS, McCaffrey D, et al. Biased emotional attention in post-traumatic stress disorder: A help as well as a hindrance? Psychol Med. 2007;37:1445–1455. This study showed that patients with PTSD had a biased memory in favor of negative events (No recommendation; Level II evidence).

Secondary Prevention: Prevention of Injury Caufeild J, Singhal A, Moulton R, Brenneman F, Redelmeier D, Baker AJ. Trauma recidivism in a large urban Canadian population. J Trauma. 2004;57:872–876. A retrospective study of 13,057 trauma patients showed a 0.38% recidivism rate. Risk factors were identified and they are mentioned in the present chapter. The study used a database covering 1976 to 1999 in two level 1 trauma centers of Toronto (No recommendation; Level II evidence [descriptive study]).

PROCEDURE 85  Optimizing Perioperative Fracture Care Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–480. Grade-A recommendation in favor of alcohol interventions in trauma patients. The authors concluded: “Alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counselling for alcohol problems should be routine.” (Level I evidence.) Machold W, Kwasny O, Eisenhardt P, et al. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: a prospective randomized trial. J Trauma. 2002;52:517–520. In this study, nine severe wrist injuries were sustained in the unprotected control group and only one in the protected group. The authors recommended the use of a wrist protector, particularly for novices participating in snowboarding. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev. 2007;(2):CD005401. Grade-A recommendation for bicycle helmet legislation. The authors concluded: “Bicycle helmet legislation appears to be effective in increasing helmet use and decreasing head injury rates in the populations for which it is implemented. However, there are very few high quality evaluative studies that measure these outcomes, and none that reported data on a possible decline in bicycle use.” (Level I evidence.) Mohammadi F. Comparison of 3 preventive methods to reduce the recurrence of ankle inversion sprains in male soccer players. Am J Sports Med. 2007;35:922–926. Proprioceptive training, compared with no intervention, was an effective strategy to reduce the rate of ankle sprains among male soccer players who suffered ankle sprain (Grade A recommendation; Level I evidence). Rønning R, Rønning I, Gerner T, Engebretsen L. The efficacy of wrist protectors in preventing snowboarding injuries. Am J Sports Med. 2001;29:581–585. This randomized study of 5029 snowboarders reported 8 wrist injuries in the braced group and 29 in the control group. Beginners were a high-risk group. Orthopedic surgeons should recommend the use of wrist protectors (Grade A recommendation; Level I evidence). Toschlog EA, Sagraves SG, Bard MR, et al. Rural trauma recidivism: a different disease. Arch Surg. 2007;142:77–81. This cohort study underlined the role of substance abuse in trauma recidivism. Grade-D recommendation in favor of intervention in drug and alcohol abuse (Level II evidence). Wan JJ, Morabito DJ, Khaw L, Knudson MM, Dicker RA. Mental illness as an independent risk factor for unintentional injury and injury recidivism. J Trauma. 2006;61:1299–1304. This retrospective study done on a database covering 2003–2004 in a level 1 trauma center evaluates 1709 cases of patients with unintentional injury. Of them, 20% also had a psychological illness. They found 20% of recidivism on consultation for injury in the group. The subgroup of patients with mental pathology showed 42% risk of recidivism compared with 10% in the psychologically healthy group (Level II evidence [descriptive study]).

Secondary Prevention: Intimate Partner Violence Bhandari M, Dosanjh S, Tornetta 3rd P, Matthews D, for the Violence against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma. 2006;61:1473–1479. This cohort study included 263 women consulting in a community service for domestic abuse. From the most frequent form of abuse, physical violence was reported by 43% of participants. A total of 144 injuries were reported in the group of women. The second most frequent type was related to the musculoskeletal system in 28%, after head and neck injuries. Risk factors for physical violence were younger age, short-term relation, and other forms of abuse and substance dependency. Women presenting with concomitant head and orthopedic injury must be questioned about domestic violence (Level II evidence [descriptive study]). Kyriacou DN, Anglin D, Taliaferro E, et al. Risk factors for injury to women from domestic violence against women. N Engl J Med. 1999;341:1892–1898. This case-control study included 256 intestinally injured women and 659 control subjects. Control subjects were women consulting in the emergency department for other reasons. Injuries were 434 contusions, 89 lacerations, and 41 fractures and dislocations. Partner’s risk factors for being violent were substance abuse, working difficulties, less than high school degree, and being former partners (Level III evidence). Plichta SB, Falik M. Prevalence of violence and its implications for women’s health. Women’s Health Issues. 2001;11:244–258. This study is an American national survey on 1840 women. It excluded 19 women who did not respond to questionnaires. The survey asked about abuse in their lifetime and findings were that 44% of women experienced abuse in their life. According to the authors, this translates into a national estimate of 36,000,000 women who experience violence as a child or as an adult. The prevalence of domestic violence is 34.6% (Level III evidence). Zillmer DA. Domestic violence: the role of the orthopaedic surgeon in identification and treatment. J Am Acad Orthop Surg. 2000;8:91–96. This article is a review of the importance of the problem of domestic violence in the United States. Also, it gives advice to help orthopedic surgeons to identify and help women at risk (Level IV evidence).

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Secondary Prevention: Osteoporosis Bouxsein ML, Kaufman J, Tosi L, Cummings S, Lane J, Johnell O. Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture. J Am Acad Orthop Surg. 2004;12:385–395. This review article reports the importance of osteoporosis as a health problem and gives American orthopedic surgeons guidelines to identify and treat patients affected by this pathology (Level IV evidence). Brown JP, Josse RG. for the Scientific Advisory Council of the Osteoporosis Society of Canada. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(suppl 10):S1–S34. This article on Canadian clinical practice guidelines describes the ideal practice in relation with osteoporosis following the recommendation of the Osteoporosis Society of Canada (Level IV evidence). Englund U, Littbrand H, Sondell A, Pettersson U, Bucht G. A 1-year combined weight-bearing training program is beneficial for bone mineral density and neuromuscular function in older women. Osteoporosis Int. 2005;16:1117–1123. This randomized study of 48 women evaluates the impact of a structured program with exercise session to improve bone density and strength. Forty subjects completed the session. Bone density improved by almost 10% in the treatment group (Level I evidence). Suzuki T, Kim H, Yoshida H, Ishizaki T. Randomized controlled trial of exercise intervention for the prevention of falls in community-dwelling elderly Japanese women. J Bone Miner Metab. 2004;22:602–611. This randomized study of 52 women over 73 years of age reports a significant decrease of falls in the group attending exercise courses after 8 months (14% vs. 41%) and after 20 months (14% vs. 55%) (Level I evidence).