Removal Of Symptomatic Hardware Research Articles

Complications of Tibial Tubercle Surgery

Objectives:Tibial tubercle osteotomy (TTO) is a common procedure that is frequently used in the treatment of recurrent patellar instability and/or patellar chondrosis. Medialization of the tubercle decreases the lateral quadriceps vector of the patella resulting in load shifting away from the lateral patella. Distalization of the tubercle decreases patella height and allows for earlier containment of the patella in the bony walls of the trochlear groove. Anteriorization has been shown to be an effective treatment to unload the inferior lateral patella when chondrosis of the patella is present in this region. Current estimates of this procedure’s complication rates range from 0% to 11%. The purpose of this study was to review the complication rate following TTO performed within an academic sports medicine practice. The hypothesis was that complication rate for TTO is greater than 10% and that the rate of complications with distalization exceeds that of medialization alone.Methods:All patients between May 2009 and May 2015 who underwent a TTO were retrospectively identified. Those with at least 6 months of follow up or a complication within the first 3 months were included for data analysis. Complications were identified and labeled as either major or minor. Major complications were defined as fracture of the tibia, deep infection requiring surgical debridement, nonunion requiring revision fixation, delayed union requiring bone graft, bone stimulation, or screw exchange, arthrofibrosis requiring manipulation under sedation and/or open lysis of adhesions, loss of fixation of the tubercle fragment, and deep vein thrombosis (DVT) whereas minor complications were defined as removal of symptomatic hardware, superficial wound infection, disturbance of cutaneous sensation, and delay in wound healing not requiring surgery.Results:During the study period, 126 TTO were performed. Representing the study cohort are 111 patients, who have at least 6 months of follow up or a complication within 3 months. The mean follow up was 23 months. There were 62 of 126 (49.2%) TTO performed for patellofemoral instability and 23 of 126 (18.2%) for patellofemoral chondral damage. Thirty-eight osteotomies were performed for both instability and cartilage damage (30.2%). Two osteotomies were performed solely for patella alta and one TTO was performed for unspecified reason (2.4%). Of the complications, 28 came following distalization of the tubercle and 4 of these complications represent subsequent tibia fracture. Overall, the complication rate was 28.7 percent; major (17.1%) and minor (11.6%) complication rates are shown in Table 1. Subgroup analysis shows a complication rate of 54% for tubercles that were distalized versus 46% for medialization alone.Conclusion:The rate of total complication for TTO was 28.7%, this is greater than the estimated rate of complication in the current literature. Further, the rate of complications when the tibial tubercle was distalized was greater than when medialized alone suggesting that special considerations be made with this cohort. This high rate of complication is accompanied by a high rate of arthrofibrosis when compared to current literature suggesting the need for preoperative discussion as well as a detailed plan for postoperative rehabilitation to improve motion in patients and decrease the need for subsequent intervention. This study’s findings may redirect patient and physician discussions regarding risks of tibial tubercle osteotomies.Table 1:Complication Frequency Major Complication 17.1% Fracture of Tibia33%Deep Infection0.0%Loss of Fixation1.7%Nonunion0.6%Delayed Union2.8%DVT1.1%Arthrofibrosis requiring surgery8.3% Concomitant Intraarticular Procedures33.3% Concomitant Extraarticular Procedures66.7% Minor Complication 11.6% Removal of Hardware9.4%Superficial Infection1.7%LosstDecrease of Cutaneous Sensation3.9%Wound Dehiscence0.6%

Clinical and Radiological Outcomes of Transfibular Total Ankle Arthroplasty at 2-years Follow-up

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a highly limiting pathology that causes pain and functional limitation with subsequent deterioration of quality of life. With recent advances in surgical instrumentation and techniques, prosthetic replacement of the ankle has proved to be a valid alternative to arthrodesis with comparable outcomes. The purpose of this study was to evaluate clinical and radiological findings in a transfibular total ankle replacement with two years follow-up. Methods: This prospective study included 59 patients who underwent transfibular total ankle arthroplasty from May 2013 to December 2015. The mean age was 51.6 ± 13.4 years. All patients were followed for at least 24 months postoperative with an average follow-up of 42.0 ± 23.5 months. Patients were assessed clinically and radiologically preoperatively and at 6, 12, and 24 months postoperatively. Results: At 24 months, patients demonstrated statistically significant improvement in the American Orthopaedic Foot and Ankle Society score from 33.6 to 88.1 (P<0.01), VAS scale from 79.3 to 14.0 (P<0.01) and SF-12 Physical and Mental Composite Scores from 29.9 and 44.6 to 74.4 and 95.3, respectively (P<0.01). Ankle dorsiflexion and plantarflexion improved from 5.5 and 8.8 degrees to 24.2 and 20.0 degrees, respectively (P<0.01). Radiographically, patients demonstrated neutral alignment of the ankle with a tibio-talar ratio of 34.9 ± 9.2 and hindfoot alignment view angle of 1.2 ± 7.0 degrees. No patient demonstrated any radiographic evidence of tibial or talar lucency at 24 months. Seven patients underwent reoperation for removal of symptomatic hardware; one patient developed a postoperative prosthetic infection requiring placement of an antibiotic spacer. Conclusion: This study demonstrates that transfibular total ankle replacement is a safe and effective option for the patients for ankle arthritis with improvements in patient-reported outcomes, range of motion, and radiological parameters. However, further studies are required to determine the mid- and long-term performance of these implants.

Mid-term outcomes of minimally invasive plate osteosynthesis for fresh and old calcaneal fractures with locked plate

Category: Trauma Introduction/Purpose: Since the mid-1990s, open reduction and internal fixation via an extended L-shaped lateral approach has been considered the gold standard for surgical treatment of displaced intraarticular calcaneal fractures. However, postoperative wound healing complications, including wound infection, skin edge necrosis, wound breakdown, and hematoma, remain a major concern. To minimize the incidence of and offer rigid stabilization of the calcaneal fracture fragments, we have performed minimally invasive plate osteosynthesis (MIPO) with locked plate for fresh and old calcaneal fractures. This study aims to assess the clinical and radiological mid-term outcomes in surgical treatment of the fresh and old calcaneal fractures using a minimally invasive technique and a locking plate to permit early weight bearing. Methods: A total of 29 fractures in 24 patients were found that met our inclusion criteria. 23 foots were fresh calcaneal fractures with an average age of 53.9 years (range, 17-80 years). We defined calcaneal fractures more than 6 weeks old as old calcaneal fracture. 6 foots were old calcaneal fractures with an average age of 43 years (range,35-52 years). Patients with fresh calcaneal fracture had been followed up for an average of 25.8 months (range, from 18-65 months). Patients with old calcaneal fracture had been followed up for an average of 29.4 months (range, from 24-48 months). The mean interval between injury and operation was 8.9 days (3-19 days) in fresh calcaneal fractures and 97 days (43-154 days) in old calcaneal fractures. There were 19 foots Sanders type II fractures, 9 foots Sanders type III and one Sanders type IV. Results: For fresh calcaneal fractures, the mean change in Böhler’s angle and width of the calcaneus from immediately after surgery to final follow-up were 0.5° and 0.7 mm, respectively. For old calcaneal fractures, the mean change in Böhler’s angle and width of the calcaneus from immediately after surgery to final follow-up were 3.4° and 1.7 mm, respectively. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement) in all fractures. One of the 22 foots had a blister. There were no events of osteomyelitis or infection or nonunion. Eight foots had revision surgery for symptomatic hardware removal. At final follow up the average American Foot and Ankle Society Score (AOFAS) were 82.8 for fresh calcaneal fractures and 83.2 for old calcaneal fractures. Conclusion: This study is first report to show that MIPO with locked plate and early weight bearing can be effectively treated for displaced intra-articular calcaneal fractures. Surgical preparation, reduction maneuvers, and fixation techniques can take time to master; however, with experience, all types of calcaneus fractures can be treated with this technique.

Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure.

The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, α angle, greater trochanteric height, and femoral neck length. Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, +19 to -9.4 degrees) (SD, 7.2), α angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5 mm below the center of femoral head (-17.5 to +25 mm), and mean femoral neck length difference measured -7.75 mm (range, -1.8 to -18.6 mm). A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest follow-up. Radiographs showed restoration of the slip angle, α angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. Level III-retrospective review.

Medial Displacement Osteotomy Performed Concurrently with Triple Arthrodesis Improves Pain and Mobility in Patients with Rigid Flatfoot Deformity and Hindfoot Valgus

Category: Hindfoot, Midfoot/Forefoot, Flatfoot Introduction/Purpose: Progression of flatfoot deformity and arthritis affects 6-38% of patients with posterior tibial tendon dysfunction treated with a triple arthrodesis. Current theory suggests that undercorrection of hindfoot valgus places abnormal stresses on the deltoid ligament and tibiotalar joint, contributing to the development of increased valgus tilt of the ankle joint or collapse of the medial arch. No large series to our knowledge has attempted to assess the potential benefit of the prospective correction of hindfoot valgus at the time of the triple fusion. Here we analyze the outcomes of 31 unilateral Stage III or IV rigid flatfoot corrections performed with concurrent medial displacement osteotomies. Methods: In an institutional review board approved retrospective study, a total of 31 feet in 31 patients were operated upon from 1/1/2009 to 1/1/2016 by a single surgeon at a large academic medical center. American Orthopaedic Foot & Ankle Society hindfoot scores and visual analog pain scores (VAS) were obtained prior to surgery and at the final post-operative follow-up where available). Foot and Ankle Ability Measure (FAAM) scores were available for 17 (54.8%) of patients. Patient demographic data, including age, body mass index (BMI), charlson comorbidity score, smoking status, and HbA1c where available were recorded. Additional surgical outcomes of interest included a return to unassisted mobility in a shoe or boot, infection and wound complication rate, 90 day re-admissions and revision/subsequent procedures. Pre-and post-operative data were analyzed using Student’s t-test for continuous variables, and Fisher’s exact test for categorical variables using Graphpad Prism (LaJolla, CA). Results: Patient demographic data is demonstrated in figure 1. Average follow-up was 1.3 ± 1.1 years (range .5 to 6.0 years). Average Pre-operative AOFAS scores available from 23/31 (74.2% of patients) averaged 33.5, with 1-year post-operative scores (8/31, 25.8%) of 76.8 ± 4.6 (p < .0001). VAS scores decreased from 6 ± 2.9 to 2 ± 2.7 (p < .0001). Superficial infections were treated in 3/31 (9.7%) of patients, while wounds developed in 6.5%. Mobility without assistive modality in a shoe or boot was reported by 30/31 (96.8%) patients, with one patient requiring a walker. No 90-day readmissions occurred, no amputations occurred, and a single patient returned to the OR 393 days after admission for symptomatic hardware removal. Conclusion: Here we demonstrate in a large retrospective analysis that performing a medial displacement osteotomy in patients with hindfoot valgus in the setting of rigid flatfoot deformity results in nearly universal remobilization, substantially improved functional outcomes, and significantly decreased pain. Few patients had wound complications or infections, and no revision reconstructions were required. Limitations to this study include inconsistent post-operative reporting, and a lack of long term post-operative outcomes. Further work includes a re-surveying of this patient base for updated patient outcomes, as well as quantitative radiographic analysis.

Is there a clinical benefit of additional tension band wiring in plate fixation of the symphysis?

BackgroundThe purpose of this study was to determine whether additional tension band wiring in the plate for traumatic disruption of symphysis pubis has clinical benefits. Therefore, outcomes and complications were compared between a plate fixation group and a plate with tension band wiring group.MethodsWe retrospectively evaluated 64 consecutive patients who underwent open reduction and internal fixation of the symphysis pubis by using a plate alone (n = 39) or a plate with tension band wiring (n = 25). All the patients were followed up for a minimum of 24 months (mean, 34.4 months; range, 26–39 months). Demographic characteristics, outcomes, movement of the metal works, complications, revision surgery, and Majeed functional score were compared.ResultsSignificant screw pullout was relatively significantly more frequently found in the plate fixation group than in the plate with tension band wiring group (P = 0.009). In terms of the overall rate of all-cause revision surgery, including significant loosening, symptomatic hardware, and patient-requested hardware removal during follow-up period, the plate with tension band wiring group showed a significantly lower rate.ConclusionTension band wiring in combination with a symphyseal plate showed better radiological outcomes, a lower incidence of hardware loosening, and a lower rate of revision surgery than plate fixation alone. This technique would have some potential advantages in terms of avoiding significant movement of plate, symptomatic hardware failure, and revision surgery.

Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes: a retrospective cohort study.

Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise. We retrospectively reviewed the results of fluoroscopy-guided reduction and percutaneous fibular nail fixation for unstable Weber type B or C fractures in 24 adult patients with type 1 or type 2 diabetes. The re-operation rate for wound dehiscence or other indications such as amputation, mortality and functional outcomes was determined. Two patients developed lateral side wound infection, one of whom underwent wound debridement. Three other patients required re-operation for removal of symptomatic hardware. No patient required a below-knee amputation. Six patients died during the study period for unrelated reasons. At a median follow-up of 12 months (7 to 38) the mean Short Form-36 Mental Component Score and Physical Component Score were 53.2 (95% confidence intervals (CI) 48.1 to 58.4) and 39.3 (95% CI 32.1 to 46.4), respectively. The mean Visual Analogue Score for pain was 3.1 (95% 1.4 to 4.9). The mean Ankle Osteoarthritis Scale total score was 32.9 (95% CI 16.0 to 49.7). Fluoroscopy-guided reduction and fibular nail fixation of unstable ankle fractures in patients with diabetes was associated with a low incidence of wound and overall complications, while providing effective surgical fixation. Cite this article: Bone Joint J 2016;98-B:1197-1201.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. Level IV, therapeutic study.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Medial Opening Wedge High Tibial Osteotomy

Objectives:High tibial osteotomy (HTO) has become a well-established treatment for unicompartmental osteoarthritis of the knee. Over the last 30 years, various techniques have been introduced to advance this procedure. The purpose of this study is to review the outcomes of patients who received medial opening wedge HTO over the last ten years (2002-2012) using a modern, low profile, medially based fixation device. In addition, we sought to determine if obese patients had a less favorable outcome than their non-obese counterparts.Methods:Ninety-three patients were identified from a surgical database as having undergone a HTO for medial compartment osteoarthritis of the knee with varus mal-alignment . All procedures were performed by one of two fellowship trained orthopedic surgeons from 2002-2012 utilizing a low profile fixation device and identical surgical technique. Minimum follow-up was one year for inclusion in the study. Outcomes were measured using Lysholm and WOMAC scores. Radiographs were evaluated to determine delayed union or non-union at the osteotomy site and surveillance was undertaken to evaluate post operative complications.Results:93 patients were identified from the database, 63 (70%) were available for follow-up and are included in this analysis. Average follow-up time was 48 months (range 17 to 137). There were 44 males and 19 females. The average age was 45 years old. The average final Lysholm and WOMAC scores were 66.4 (range: 13-100) and 18.6 (range: 0-86) respectively. There was no significant difference in reported Lysholm or WOMAC scores between obese (BMI >30) and non-obese patients (p=.31;p=.69). Complications were as follows: 3 patients required a surgical lysis of adhesions, 2 patients developed an infection, and 1 patient experienced a delayed union. At final follow-up, 18 patients received additional treatment on the affected knee: 11 required removal of symptomatic hardware, 5 received viscosupplementation, 2 underwent a total knee replacement.Conclusion:Low profile, medial based devices used in the setting of HTO is an accepted treatment for unicompartmental osteoarthritis of the knee. At final follow-up, a majority of patients reported positive outcomes and few complications. 18 patients required additional treatment for osteoarthritis. In our analysis, obese patients faired equally as well as their non-obese counterparts, with no significant difference in outcomes scores or complication rate. Survivorship of high tibial osteotomy was excellent in this series, with only 2 patients having undergone total knee replacement at last follow-up.

End-Stage Hindfoot Arthrosis: Outcomes of Tibiocalcaneal Fusion Using Internal and Ilizarov Fixation

End-stage post-traumatic pantalar arthrosis from ankle, pilon, and talus fractures has often been complicated by infection, bone loss, and a soft tissue deficit. Patients can present with neuropathy, diabetes, tobacco use, and previously failed arthrodesis. Fusion in this population has been challenging, with nonunion rates up to 30%, often leading to amputation. We reviewed the results of a standardized protocol that combined simultaneous internal fixation with the Ilizarov technique to achieve fusion in high-risk patients. With institutional review board approval, a retrospective review of the patients treated with simultaneous internal fixation and an Ilizarov frame was undertaken. The records and radiographs allowed identification of the comorbidities and the presence or absence of successful fusion. Complications were acknowledged and treated. Fifteen patients had undergone the procedure. The mean follow-up period was 27.9 (range 9 to 67) months. Thirteen patients (86.67%) had had previous fusion failure. Twelve patients (80%) had developed post-traumatic arthrosis, 5 (33.33%) of whom had open injuries. All patients had 1 comorbidity, and 10 (66.67%) had multiple, including rheumatoid arthritis, diabetes (types 1 and 2), and smoking. Four patients (26.67%) presented with deep infection and bone loss. Union was achieved in 11 (73.33%), with 12 (80%) patients experiencing profound pain relief. Seven patients (46.67%) required symptomatic hardware removal. Three patients (20%) eventually underwent below-the-knee amputation for recalcitrant nonunion. Statistically significant correlations were found between smoking and wound infection and revision and between nonunion and amputation. Our results have indicated that combined internal fixation with Ilizarov application can provide a strong surgical option for the management of end-stage, pantalar arthritis. More studies are needed to compare the cohort outcomes and gait analysis in these patients with those who have chosen below-the-knee amputation.

Limited Sinus Tarsi Approach for Intra-articular Calcaneus Fractures

Operative treatment of calcaneal fractures has a historically high rate of wound complications, so the most optimal operative approach has been a topic of investigation. This study reviews the radiographic and clinical outcomes of the use of the sinus tarsi approach for operative fixation of these fractures with attention to the rate of infection and restoration of angular measurements. The radiographs and charts of 20 patients with 22 calcaneal fractures were reviewed to assess for restoration of angular and linear dimensions of the calcaneus as well as time to radiographic union. Secondary outcome measures included the rate of postoperative infection, osteomyelitis, revision surgeries, and nonunion. We found a statistically significant restoration of Böhler's angle and calcaneal width. Three of the 22 cases had a superficial wound infection. One patient had revision surgery for symptomatic hardware removal. There were no events of osteomyelitis, deep infection, malunion, or nonunion. We found that the sinus tarsi approach yielded similar outcomes to those reported in the literature. Level IV, retrospective case series.

Olecranon Osteotomy Fixation Using a Novel Device

A posterior approach to the elbow utilizing an olecranon osteotomy has been shown to provide excellent visualization of the distal humerus articular surface. However, many bony stabilization and fixation methods for the olecranon osteotomy are usually prominent, frequently symptomatic, and often require a second operation for removal. This paper evaluates the use of an innovative device, the olecranon sled, in fixation of olecranon osteotomies for exposure of intra-articular distal humerus fractures and provides follow-up results. A retrospective review of all patients with intra-articular distal humerus fracture treated through an olecranon osteotomy approach and fixed with an olecranon sled, between September 2008 and December 2011 was conducted. Charts and radiographs were reviewed to determine olecranon union or nonunion, presence of symptomatic hardware, and need for secondary surgery to remove symptomatic olecranon fixation. Fourteen patients were included in the study. Average clinical follow-up was 33.5 weeks (range, 6 to 118 wk). There were no olecranon nonunions. One patient underwent additional surgery for symptomatic hardware removal (7.1%). Two additional procedures were performed; 1 for revision open reduction and internal fixation of distal humerus fracture nonunion (7.1%) and 1 for release of elbow contracture (7.1%). Although follow-up is limited, the use of this device has been associated with excellent rates of olecranon union with a low rate of symptomatic hardware requiring removal.

Prospective Study of the Treatment of Adult Primary Hallux Valgus With Scarf Osteotomy and Soft Tissue Realignment

The scarf osteotomy has been a widely practiced bunion operation, but relatively limited prospective data on its outcomes have been reported. The purpose of this investigation was to prospectively evaluate the clinical and radiographic results of treatment of adult primary hallux valgus using the scarf osteotomy of the first metatarsal with soft tissue realignment. Hallux valgus corrections were performed on 51 patients (53 feet), who were followed for at least 1 year with an average follow-up of 24 months. Mean age at the time of surgery was 59 years, and subjects included 3 male and 48 female patients. Prospective clinical data collected included the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-interphalangeal scale score, the SF-36 scores, and the visual analogue scale (VAS) for pain. Data were collected preoperatively and postoperatively. Prospective radiologic data were also collected including hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and medial sesamoid position (MSP). Clinical data were collected on complications and reoperations. Mean AOFAS hallux-interphalangeal score increased from 52 preoperatively to 88 postoperatively. Mean preoperative and last follow-up SF-36 physical component summary increased from 46 preoperatively to 52 postoperatively, whereas mean VAS pain scores decreased from 5.8 preoperatively to 1.1 postoperatively. All the changes in clinical outcomes were statistically significant, except the Mental Component Summary of the SF-36. Mean preoperative HVA decreased from 29 degrees preoperatively to 10.7 degrees in the initial postoperative period and was maintained at last follow-up at 10.6 degrees. The mean preoperative IMA decreased from 13.6 degrees preoperatively to 5.6 degrees in the initial postoperative period and regressed mildly at last follow-up to 7.8 degrees. The mean preoperative MSP grade of 2.3 decreased to 0.5 in the initial postoperative period and regressed mildly to 0.9 at last follow-up. All radiographic changes were statistically significant. The overall complication rate was 15% (8/53), attributable to 4 feet with symptomatic hardware, 2 feet with hallux varus, and 2 feet with progression of first MTP arthritis. Reoperations were performed in 4 feet (8%) for removal of symptomatic hardware. Scarf osteotomy was a reliable technique for correction of moderate to severe hallux valgus and had low rates of complication or recurrence. Level IV, case series.

Lag Screw Fixation of Medial Malleolar Fractures

Bicortical fully threaded (FT) lag screw fixation (lag by method) is a technique for medial malleolar fixation that may provide advantages to partially threaded (PT) cancellous lag screws (lag by screw design). A direct comparison of the biomechanical properties and the clinical outcomes of these 2 methods of medial malleolar lag screw fixation were undertaken. The null hypotheses were that unicortical PT lag screws and bicortical FT lag screws had similar biomechanical and clinical outcomes. Biomechanics--Human cadaver biomechanical investigation. Clinical-Retrospective cohort series with control. Settings-Level-1 trauma center. One hundred forty-one consecutive patients with closed medial malleolar fractures (OTA 44) treated with lag screw fixation were identified from a prospective orthopaedic trauma database. Thirty-nine were lost to follow-up and 12 were treated with a single screw leaving 46 in the PT group and 46 in the FT group all treated with 2 screws for their medial malleolar fracture. Biomechanics--Human cadavers (n = 3) had bilateral oblique medial malleolar fractures (n = 6) created with an osteotome to simulate a typical medial malleolar fracture amenable to lag screw fixation. Fixation of each side was randomly allocated to either two 4.0-mm PT lag screws (length 45 mm) or two 3.5-mm FT threaded screws [length determined by depth gauge after near cortex overdrilled and far cortex (distal lateral tibia) drilled based on core diameter (2.7 mm)]. Clinical-Either 2 traditional PT (n = 46) or 2 FT screws (n = 46) were used for fixation of medial malleolus fractures. Biomechanics--Peak insertion torque generated during screw insertion. Clinical: Radiographic evidence of screw loosening, clinical non-union, and reoperation. Biomechanics--The FT lag screw group (n = 6 screws) showed an average maximum torque of 14.4 in-lbf (range 8.0-20.1, SD = 4.4) before screw stripping. This was over 3 times greater than that seen with the PT lag screws (n = 6) (average maximum torque generation = 4.0 in-lbf, range 2.5-6.6, SD = 1.4), P < 0.0002. Clinical-Radiographic screw loosening was evident in one of the 46 patients (2%) in the FT cohort and in 11 of the 46 patients (24%) in the PT cohort, P < 0.003. Two of the patients with screw loosening in the PT cohort required reoperation for removal of symptomatic hardware, whereas no patient from the LT screw group required removal. All patients in the LT cohort healed after the index procedure although 2 in the PT cohort had nonunions. Screws placed with the lag by method technique that engaged the distal lateral tibial cortex have superior biomechanical, radiographic, and clinical outcomes compared to traditional PT screws for the fixation of medial malleolar fractures.

ACL Tibial Spine Avulsion: Mid-Term Outcomes and Rehabilitation

Tibial spine fractures are characterized by fractures at the insertion site of the anterior cruciate ligament (ACL) on the tibia and were first classified into 3 types. For displaced (type II/III) fractures, surgical treatment has included fixation with screws, sutures, or wires performed through either open or arthroscopic approaches. Optimal treatment methods remain controversial and are varied by classification type, surgeon preference, and patient age. We retrospectively studied the outcome of 22 surgically treated patients with tibial spine fractures. We analyzed factors such as age, skeletal maturity, fixation device, surgical approach, presence of comminution, loss of reduction, and rehabilitation protocol against the development of arthrofibrosis and clinical and functional outcomes. We found that age older than 18 years was a statistically significant factor for lower outcome scores. Two factors trended toward significance including; those with comminution had lower Tegner scores, and those with early range of motion returned to previous activity level more frequently. Factors found to be insignificant included surgical approach, fixation device, weight bearing, skeletal maturity, postoperative immobilization, and loss of reduction. Those with screw fixation had a higher reoperation rate due to symptomatic hardware removal. Age was the only factor that negatively impacted final functional scores.

Comminuted fractures of the proximal ulna—Preliminary results with an anatomically preshaped locking compression plate (LCP) system

IntroductionThe purpose of this investigation was to review the preliminary results and patients outcome following treatment with an anatomically preshaped LCP in patients with comminuted fractures of the proximal ulna. We hypothesized that this fixation system provides equal or superior results in fracture care when compared with other available plating devices, but results in better patient's comfort due to its low-profile design. Patients and methodsBetween 2007 and 2009, 15 patients with comminuted fractures of the proximal ulna including three posterior Monteggia fractures were managed with the preshaped LCP olecranon plate. The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the shortened Disability of the Arm, Shoulder and Hand (Quick-DASH) score, postoperative range of motion, objective muscle-strengths testing and patient's satisfaction were evaluated. All patients had follow-up radiographs. ResultsFourteen patients were available for evaluation. The mean arc of elbow motion was 129°. The mean MEPI was 97 with good results in two patients and excellent results in 12 patients. The mean Quick-DASH was 13. Thirteen of fourteen patients documented satisfaction with their elbow outcome. There was one patient with symptomatic hardware and one patient complained about deficit of motion. In four patients the hardware was removed including two patients with elective removal. Fourteen fractures healed with ulnohumeral congruity after a mean time to union of 11 weeks. One fracture non-union occurred without mechanical failure or loss of reduction. ConclusionAnatomically preshaped LCP olecranon plating is an effective fixation method for comminuted fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. A low rate of symptomatic hardware removal suggests better patient's compatibility.

Proximal radio-ulnar synostosis and nonunion after olecranon fracture tension-band wiring: A case report

Fractures of the olecranon are the most common type of elbow fracture. Displaced fractures usually require operative treatment with open reduction and internal fixation to allow early motion in order to avoid significant stiffness of the elbow joint. Two parallel Kirschner wires inserted across the fracture into the medullary canal of the proximal ulna combined with a tension band wiring is a recognized and frequently performed method of fixation for noncomminuted fractures. Although isolated closed fractures of the olecranon in adults have a favorable long-term outcome, a few complications with this technique have been reported. The most common complication is migration of the K wires proximally leading to pain and local skin complications, with a high incidence (80%) of reoperation for the removal of symptomatic hardware. Therefore, this method has been modified so that the distal end of the Kirschner wires are inserted through the anterior cortex of the proximal ulna to prevent proximal wire migration postoperatively and to increase the stability of the tension band unit. The authors present a case of a patient with an isolated fracture of the olecranon that developed a proximal radioulnar synostosis and an olecranon nonunion associated with the use of the transcortical tension-band wiring technique. The possible mechanism for the synostosis formation, different from others described previously in accordance with the literature reviewed, will also be discussed herein below.

Is the Use of Arch Bars or Interdental Wire Fixation Necessary for Successful Outcomes in the Open Reduction and Internal Fixation of Mandibular Angle Fractures?

The purpose of this retrospective cohort study was to analyze the complications associated with a series of mandibular angle fractures treated by open reduction and internal fixation and to determine if the method of intraoperative maxillomandibular fixation (MMF) affected patient outcome. The records of 162 consecutive patients with isolated mandibular fractures that were treated by the senior author (R.B.B.) with open reduction and internal fixation were retrospectively reviewed and a number of clinical variables were recorded. Of these, all patients with fractures involving the mandibular angle, alone or in combination with other mandibular fractures, were identified. Only patients in the permanent dentition with angle fractures treated with a single 2.0 mm titanium plate placed at the superior border using standard Champy technique were included in the study. Patients with less than 6 weeks follow-up, concomitant midface fractures, edentulous patients, patients with comminuted fractures or gunshot wounds, and those patients presenting with infected fractures were excluded from the primary study group, which totaled 75 patients with 83 angle fractures. Postoperative complications, including infection, malunion/nonunion, wound dehiscence, osteomyelitis, pain, and the need for secondary operative intervention, were tabulated. For purposes of comparison, patients were divided into 3 groups based upon the type of intraoperative MMF utilized: group 1, Erich arch bars (n = 24); group 2, 24 gauge interdental "Stout" wires (n = 25); and group 3, manual reduction alone (n = 26). Outcome measures were defined as successful bone healing, acceptable occlusion, minor complications, and major complications. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fisher's exact test was used to evaluate whether a complication occurred more frequently in any one particular group. The mean age of the 75 patients included in the study was 28.2 years (M = 63, F = 12) and there were no significant demographic differences between the 3 groups (P = 0.22). All patients eventually achieved successful bony union with an acceptable occlusion. Thirty-two percent of patients in the cohort required a second procedure, usually outpatient removal of loose or symptomatic hardware under local anesthesia or intravenous sedation, but there was no difference in re-operation rate based upon the method of intraoperative fixation (P = .47). Major complications occurred in 2 patients that required secondary operations due to malunion and nonunion (2.7%). Twenty-two minor complications occurred in 16 patients (21.3%) and were evenly distributed amongst the 3 groups (P = .074), including infection (n = 4), wound dehiscence (n = 1), and/or symptomatic hardware (n = 16) that required hardware removal. All of the minor complications were treated in an outpatient setting under local anesthesia or under intravenous sedation. When the complications were pooled together, the Fisher exact test again yielded no difference in complications between the 3 groups (P = .33). The use of Erich arch bars or interdental wire fixation to assist with MMF during the open reduction and internal fixation of noncomminuted mandibular angle fractures treated in Champy fashion is not always necessary for successful outcome.