Poor Soft Tissue Condition Research Articles

Reorientational arthrodesis of the ankle joint using four screws

Arthrodesis of the ankle has gained wide acceptance as a first-line treatment option for painful posttraumatic osteoarthritis. The technique using four to five lag screws for internal osteosynthesis is a safe and biomechanically stable method to obtain a sound ankle fusion with good to excellent long-term results in the majority of patients. Malalignment hazards are minimized by preservation of the ankle mortise. The meticulous resection of all cartilage and sclerotic bone as well as an atraumatic surgical technique are essential for preventing major complications. The need for revision surgery is minimized by correction of talar malalignment, fusion with the foot in a 90 degrees position and preoperative evaluation of the subtalar joint. In a series of 40 ankle fusions fixed with the lag screw technique, 82.5% good to excellent results were obtained after 5.6 (4.8-7.6) years. No infection, stress fracture or non-union was seen. In cases of osteitis, osteonecrosis, osteoporosis, and poor soft-tissue condition, external fixation techniques are preferred. In the presence of severe loss of bone stock at the distal tibia, stability can be achieved by using a compression nail for tibiotalar fusion without additional subtalar arthrodesis.

Frakturen der proximalen Tibia

Most proximal tibial fractures are high-energy traumata. They often give the impression of open fractures because of poor soft tissue conditions. In spite of modern osteosynthetic implants, the surgical treatment is still a challenge, some of the problems being dislocation of the proximal fragment resulting from opposing muscle forces, a difficult soft issue situation and the danger of malalignment. Such modern implants as anatomically shaped intramedullary nails and fixed-angle plates are increasingly used for fixation. The two methods are characterized by different biomechanical behavior and demand specific operation techniques. This article describes the advantages and disadvantages of each and compares them in the light of the current literature and of the authors’ own observations at follow-up examinations. Finally, recommendations on how to recognize when each is indicated are given.

Fusion of the septic ankle: experience with 15 cases using hybrid external fixation.

In cases of septic joint destruction, an unfavorable situation of soft tissues and chronic osteomyelitis are responsible for high failure rates of ankle fusions. We wanted to evaluate the control of infection and the fusion rate using hybrid external fixators for the fusion of the septic ankle in a prospective study. From 1996 to 1998, 15 arthrodeses were performed using hybrid external fixators. All patients had a combination of bone and soft tissue infections. Fourteen patients suffered from sequelae of posttraumatic osteoarthritis, and one patient suffered from rheumatoid arthritis. In 14 patients, pathogens could be identified; in 87%, Staphylococcus aureus was found. Eight patients had relevant concomitant diseases. The preservation of limbs by solid tibiotalar fusion was achieved in 14 patients (93%). One patient maintained an infected pseudarthrosis. During the 12-month follow-up, three patients had a fistula that persisted, with two patients having a solid arthrodesis. Full weight-bearing was possible for all the patients with a successful fusion. Seventy-five percent of the patients that had not retired at the time of the study regained their fitness for work. The hybrid external fixator presents a successful alternative for those arthrodeses of ankle joints where complications such as bone/joint infections or poor soft tissue conditions occur.

Correction of ankle and hindfoot deformities by supramalleolar osteotomy.

Ankle and hindfoot deformities in 11 patients with a mean age of 15 (range, four to 35) have been gradually corrected by an llizarov external fixator. In all patients, supramalleolar osteotomy was utilized by percutaneous drilling and osteotomy technique. The patients were evaluated clinically by the AOFAS scoring system and radiologically by malorientation and malalignment tests described by Paley. The purpose of the current study is to evaluate the efficacy of supramalleolar osteotomy and correction by an Ilizarov device in treating hindfoot and ankle deformities. The mean external fixation period was five (2.5 to eight) months. The mean interval between the operation and last follow-up examination was 19 (13 to 26) months. The patients improved an average of 30 points after the operation regarding to AOFAS score. A plantigrade foot was achieved in the whole group. Radiologically, no malalignment or malorientation was measured. Equal leg lengths were achieved in all nine patients with one exception. Complications were graded after Paley as minor problems in 11 patients and as obstacles requiring surgical interventions in four patients. Sequelae remained in only one patient. Ankle and hindfoot deformities caused by various etiologies are complicated by poor soft tissue condition and a short foot. A supramalleolar osteotomy and Ilizarov external fixator can safely and effectively correct these deformities.

The use of trans-articular and extra-articular external fixation for management of distal tibial intra-articular fractures

Twenty-nine consecutive cases of distal tibial intra-articular fractures treated by trans-articular or extra-articular external fixation techniques have been reviewed. Eleven cases were treated initially with a trans-articular dynamic axial fixator. Of these seven were converted to an extra-articular SHF, for a combination of poor ankle motion and delayed healing of the metaphyseo-diaphyseal dissociation (MDD). Three of these cases (two patients) required bone grafting for delayed healing of the diaphyseal component of the fracture. Apart from one refracture through the MDD, no major complications were seen. No deep infections and no angular malalignments were noted. There were 11 pin track infections. Subjective assessment using short form-36 (SF-36) questionnaires, however, revealed significant differences compared to a normal population particularly in physical function and pain at a mean follow-up of 21 months. Using Bone’s criteria for assessment of range of motion there were 62% excellent and good results, which dropped to 53% when fractures with a metaphyseo-diaphyseal extension were included. The use of minimally invasive techniques of internal fixation and stabilisation with a Sheffield hybrid frame in the management of distal tibial intra-articular fractures has minimal complications. Trans-articular external fixation is a good primary treatment for badly comminuted articular fractures with poor soft tissue condition. Conversion to extra-articular external fixation is recommended for slower healing fractures allowing ankle movement and early weight-bearing. The presence of a MDD dissociation lengthens the treatment time significantly, adds to the morbidity and affects final outcome.

Osteotomy of the Distal Fibula for Correction of Posttraumatic Malunion

Restoration of anatomic alignment of the lateral malleolus to delay or prevent development of posttraumatic osteoarthritis of the ankle joint. Posttraumatic malunion of the distal fibula with shortening, often combined with external rotation and abduction of the lateral malleolus. Osteoarthritic changes may be absent, mild or moderate. Severe, preexisting osteoarthritis of the ankle. Presence of a remote lateral pilon fracture with articular depression. Poor soft tissue conditions after infection or sympathetic reflex dystrophy. Lateral approach respecting former incisions or wounds, if at all possible. Osteotomy of the fibula (horizontal, oblique or Z-shaped), resection of scar tissue, osteophytes and bony fragments in the fibular notch and freeing of the distal part of the fibula. Correction of any obstacle around the medial malleolus if indicated. Correction of length, rotation and abduction of the lateral malleolus, and fixation with a reconstruction or LC-DC plate. Fixation of the fibula in the fibular notch with two Kirschner wires. After a follow-up of 3.9 years, all eight patients were satisfied. In five of six patients, there was only a slight progression of arthritic changes radiologically already present before osteotomy. Two patients without any arthritic changes before the osteotomy did not develop such changes thereafter. Our results, confirmed by previous reports, indicate that the most important factor determining the final outcome is the presence of degenerative changes at the time of osteotomy. Lengthening of the fibula slowed down or even stopped progression of arthritis.

Ankle and pan-talar arthrodesis with ilizarov composite hybrid fixation: operative technique and review of 21 cases

Summary Ankle and/or pantalar arthrodesis was performed between January 1994 and March 1999 with a composite type of Ilizarov fixation in 21 patients (age 18–82 years). Indications for ankle arthrodesis by composite fixation were: a failed fusion after primary arthrodesis by internal methods (six cases), septic conditions after failed internal fixation of tibia plafond fractures (five cases), primary fracture treatment after talus or tibia plafond fractures (three cases) and primary arthrodesis as a result of poor soft tissue conditions after open surgery (seven cases). In all patients a successful fusion of the affected joint was achieved by composite fixation without a change in the treatment plan. Composite fixation represents a minimal invasive, safe and successful method for arthrodesis of the ankle and subtalar joint. Particularly after failed arthrodesis, difficult post-traumatic conditions, infection, osteoporosis or other soft tissue problem, it seems to be an efficacious tool to prevent amputation in these special cases.

A technique of internal fixation for os calcis fractures

Healing of the fracture in optimal position. Restoration of joint surfaces and function of the subtalar and calcaneocuboid joints. Os calcis fractures of type A2 and B2 of our classification modified after the AO classification published by Muller. Poor skin and soft tissue conditions. Severely comminuted fractures, osteoporosis. Peripheral circular disturbance. Uncooperative or inactive patients. Supine. Tourniquet. Operating table which can be tilted and is radiolucent. General, spinal or epidural anaesthesia. Closed reduction using an external fixator, introduced from the medial side into the calcaneal tuberosity and the first metatarsus. Open reduction of the joint surfaces with the possible use of autogeneous cancellous bone grafts and plate fixation laterally. Posterior plaster slab for the first postoperative days. Elevation of limb. Out of cast physiotherapy of the ankle and subtalar joints starting the first postoperative day. Partial weight bearing of 20 kg using 2 canes is permitted in reliable patients after wound healing. For the other patients partial weight bearing in the plaster slab. Full weight bearing after 8 to 10 weeks depending on radiologic state of consolidation. 37 os calcis fractures were thus treated between 1988 and 1991. Patient age varied between 7 and 74 years, mean age 38.9 years. 12% of the patients suffered of polytrauma. Average time to full weight bearing: 12 weeks. Follow-up of 32 patients after 15 to 64 months, mean 33 months: 24 patients returned to the same occupation, 3 patients retired, 2 patients changed their occupation and 3 are unemployed. Scoring according to the method proposed by Merle d'Aubigne. Fracture types and results are listed in Table 1. The following complications were observed: 6 haematomas needing evacuation. Injury to the dorsal cutaneous nerve in 6 patients, pain at the subtalar joint while walking over uneven ground in 22 patients, 3 patients wear orthopaedic shoes and 12 arch supports. Up to now no subtalar arthrodesis became necessary.

The small pin circular fixator for distal tibial pilon fractures with soft tissue compromise.

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.