Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears.

MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Cite this article: Bone Joint J 2014;96-B:1631–6.

Summary

Syndesmotic malreduction or failure to restore fibular length are the leading causes for early reoperation after ankle fracture surgery. Anatomic fracture reduction and congruent ankle mortise can be achieved in the majority of cases following revision surgery.

Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) disruptions are uncommon orthopaedic injuries. They are usually caused by high- or low-velocity knee dislocations. Because knee dislocations might spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee. Both of the cruciate ligaments are usually disrupted, and they are often combined with a third ligamentous disruption (medial collateral ligament or lateral collateral ligament and/or posterior lateral complex). Associated neurovascular, meniscal, and osteochondral injuries are often present and complicate treatment.

Classification Knee dislocations are classified by relating the position of the displaced tibia on the femur; anterior, posterior, medial, lateral, or rotational. Both cruciate ligaments might be disrupted in all these injuries. A rotatory knee dislocation occurs around one of the collateral ligaments (LCL) leading to a combined ACL and PCL injury and a tear of the remaining collateral ligament. Knee dislocations that spontaneously reduce are classified according to the direction of instability. Knee dislocations are classified as acute (< 3 weeks) or chronic (> 3 weeks).

Initial management The vascular status of the limb must be determined quickly. The knee should be reduced immediately through gentle traction-countertraction with the patient under anesthesia. After reduction, repeat vascular examination. If the limb remains ischemic, emergent surgical exploration and revascularisation is required. If the initial vascular examination is normal, postreduction a formal angiogram should be done especially if the patient has a high velocity injury, is polytraumatized or have altered mental status. Compartment syndrome, open injury, and irreducible dislocation are other indications for emergent surgery.

Definitive management Many authors have noted superior results of surgical treatment of bicruciate injuries when compared to nonsurgical treatment. In most cases early ligament surgery (at the second or third week) seems to produce better results compared to late reconstructions. Still the management of knee dislocations remains controversial. Controversies persist regarding surgical timing, technique, graft selection, and rehabilitation. The goal of operative treatment is to retain knee stability, motion, and function.

The most common injury patterns include both cruciate ligaments and either medial collateral ligament (MCL) or lateral collateral ligament (LCL) and/or posterolateral structures. Less commonly both collateral ligaments are disrupted. Our policy has been early (from 7 to 21 days) simultaneous reconstruction of both cruciate ligaments and repairing of grade III LCL and posterolateral structures. Most acute grade III MCL tears are successfully treated with brace treatment when ACL and PCL are reconstructed early.

Most cruciate ligament injuries are midsubstance tears that need to be reconstructed with autografts or allografts. Repairs can be done in cases of bony avulsion of cruciate ligaments or grade III collateral ligament or capsular injuries. Bone-patellar tendon-bone (BPTB) autograft has mainly used in our clinics to reconstruct the ACL. In some cases BTPB allograft or hamstring tendon autografts has been used. For PCL reconstruction, BPTB allograft (11 mm in diameter) or Achilles tendon allograft has been used.

Intrasubstance grade III tears of the LCL can be repaired (in early state) but may need to be augmented with tendon allograft. The LCL and/or the popliteofibular ligament are reconstructed either with an Achilles tendon allograft, hamstring tendon autograft/allograft, tibialis anterior tendon allograft, or the BPTB allograft.

Both cruciate ligaments are reconstructed arthroscopically. The ACL tunnels are placed in the center of its anatomic insertion in tibia and in its isometric or anatomic insertion in femur. A transtibial tunnel technique for PCL reconstruction is used. The PCL tibial tunnel is drilled first under arthroscopic guidance using the PCL guide. The ACL tibial guide is drilled at least 2 cm proximal to the PCL tunnel to ensure that wide enough bone bridge remains between these tunnels. Fluoroscopy is used to ensure the right guidewire placement.

Sequence of bicruciate ligament reconstruction with BPTB grafts

Drill PCL tibial tunnel first, then ACL tibial tunnel

Rehabilitation Our protocol after bicruciate ligament reconstruction with MPTB grafts has been very active. Progressive range of motion is started early after the operation with an unlocked functional brace. If simultaneous suturation of a meniscus tear has been performed, motion is limited to 60° of flexion during the first 4 weeks. Progression from partial to full weight bearing is done over the first 6 weeks. Quadriceps exercises are progressed to open-chain knee extension exercises early as well as closed-chain hamstring exercises. Brace is discontinued after 12 weeks.

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations.

Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.

Withdrawn

Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws.

Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear.

Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant.

Aims: In the present study we evaluated short-term outcome of complex proximal tibial fractures treated with hybrid external þxation. Methods: A retrospective evaluation of 33 tibiae in 31 patients treated with hybrid external þxation; 9 (27.2%) AO type A metaphyseal and 24 (72.8%) type C bicondylar intraarticular proximal tibial fractures. Majority of the fractures (58.1%) were due to high-energy trauma and open fractures constituted 18.2% of all fractures. Percutaneous pinning combined with indirect reduction techniques was used in 14 (42.4%) cases. Mini-open clamp reduction and screw þxation was applied in 12 (36.4%) operations. Open reduction, reconstruction of articular surface, bone-grafting and screw þxation combined with the hybrid frame was used in 7 (21.2%) patients. Results: Uneventful consolidation without complications occurred in 13 (39.4%) patients. The mean time to bony fusion was 18 ± 6.6 weeks. However, in 21.2% of the patients the fracture had not consolidated by 24 weeks. There were 5 (20.8%) primary re-operations due to malreduction of a type C fracture. In addition 3 (33.3%) type A metaphyseal fractures were re-operated upon due to non-union by 24 weeks. Two (6.1%) fractures united in axial malalignment and required an osteotomy. Conclusions: Our þndings suggest that due to high rate of unsatisfactory reductions, hybrid external þxation may not be the method-of-choice in þxation of displaced intra-articular proximal tibial fractures. It may be indicated in þxation of high energy metaphyseal fractures, but includes a signiþcant risk of delayed consolidation.

Aims: Meniscus repair has become the procedure of choice for the treatment of meniscal tears whenever possible. However, problems with healing of the repaired meniscus do exist. We have assessed both clinically and with MRI the outcome of meniscal ruptures treated with bioabsorbable arrows. Methods: 74 consecutive patients with 80 longitudinal vertical meniscal tears were treated using polylactide meniscus arrows (Bionx Implants Ltd, Tampere, Finland) during a three year period. Half of the patients had an old meniscal tear (> 6 weeks). The average length of the follow-up was 25 months (range, 6–56 months). The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI. Results: 56 out of 80 meniscal ruptures (70%) healed clinically. However, in 7 of these asymptomatic patients the MRI showed partial healing. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (82%) than in the isolated tears (62%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (43% healing rate). Conclusions: Bioabsorbable arrows offer a good alternative for the treatment of meniscal ruptures, but special attention should be payed on the reliability of the þxation. In long and unstable tears we suggest combined þxation techniques to be used; arrows for the þxation of the posterior horn and inside-out sutures for the corpus area.

Aims: To evaluate the outcome after early angiographic embolization in pelvic ring injuries associated with massive bleeding. Methods: We evaluated prospectively 32 consecutive patients. Special attention was paid to the þndings in angiography, the reliability of embolization, and the þnal result (survive or death). The causes of deaths were evaluated as well as the parameters correlating to this. Results: Angiography showed an isolated arterial injury in 16 (50%) and multiple arterial injuries also in 16 patients (50%). 9 patients had bilateral bleeding. Internal iliac artery and/or its main branches was the source of bleeding in 27 (85%), external iliac artery or its main branches in 2 (6%), and branches of both internal and external iliac arteries in 3 patients (9%).

The embolization was successful in all cases. 11 patients (34%) died. The early deaths (< 24h) were the result of massive bleeding in 4 out of 5 patients. One died to cardiac failure. Six late deaths were the result of MODS. All the died patients had more than one bleeding artery, and 6 had bilateral bleeding. The non-survivors had more severe injuries (mean ISS 51) and were older (mean age 50,2 yrs) than the survivors (mean ISS 41; mean age 43,9 yrs). Conclusions: Angiographic embolization is an effective and life saving procedure. It should be considered in hypotensive patients with unstable pelvic ring injuries who remain haemodynamically unstable following adequate resuscitation with component therapy and external þxation.

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries.

The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor.

External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.