Arthroscopically assisted percutaneous fixation and bone grafting of a glenoid fossa fracture nonunion

Arthroscopy is commonly used for evaluating intra-articular fracture patterns and assessing postfixation reduction; however, the use of arthroscopy for the definitive treatment of articular fracture nonunion has not been reported. This article describes a case of symptomatic glenoid fossa fracture nonunion that was successfully treated with arthroscopically assisted percutaneous screw fixation and bone grafting.A 48-year-old laborer sustained a glenoid fossa fracture following a fall from a height. An initial period of nonoperative management was attempted; however, the patient reported continued shoulder pain during his rehabilitation course. Imaging 5 months after injury showed no osseous union at the fracture. Using an arthroscopically assisted technique, percutaneous fixation and bone grafting of the nonunion with cancellous allograft was performed. Postoperatively, the patient progressed through a structured therapy program, and his pain improved. A computed tomography scan 4 months postoperatively showed osseous union at the fracture site.To the authors' knowledge, this is the first report in the literature of definitive arthroscopically assisted bone grafting and percutaneous fixation of a diarthrodial joint nonunion. Advantages of arthroscopic fixation of glenoid fossa fracture nonunion include avoiding potential axillary nerve injury and preserving the native subscapularis insertion, which may be important if subsequent procedures require access to the anterior access to the joint.     

Scaphoid AARIF: Arthroscopically assisted reduction and internal fixation of scaphoid fractures

The unstable scaphoid fracture can be treated by a variety of different methods, including open reduction and internal fixation (ORIF), percutaneous fixation with either K wires or cannulated screws, and arthroscopically assisted reduction and internal fixation (AARIF) with various cannulated screw systems. The drawbacks of ORIF include extensive soft tissue dissection, disruption of the nondominant volar blood supply, division of the radioscaphocapitate and radioscapholunate ligaments and volar capsule, and prolonged rehabilitation. Percutaneous fixation avoids these drawbacks yet relies on fluoroscopic guidance alone to assure accurate reduction of the scaphoid fracture fragments and optimal positioning of the implant in the apex of the proximal pole. Plain radiography and fluoroscopy are limited in their ability to provide detailed visualization of the oddly oriented scaphoid, and this limits the accuracy of the percutaneous technique. AARIF avoids the limitations of ORIF yet allows direct visualization of the scaphoid fracture site and assures accurate reduction of the fragments before and during definitive arthroscopically assisted internal fixation. AARIF also assists in accurate targeting of the proximal pole apex, or ″sweet spot,” in addition to allowing detection of concurrent pathology in the radiocarpal or midcarpal joints. This article outlines 3 of the currently available techniques for scaphoid AARIF. Copyright © 2001 by the American Society for Surgery of the Hand     

Advancements in percutaneous fixation for foot and ankle trauma

Operative fixation of foot and ankle trauma can be challenging. Often times, the soft tissue envelope can have extensive damage as a result of the fracture. In these cases, percutaneous fixation may be used. Percutaneous fixation can benefit both soft tissue and osseous healing when used correctly. Many techniques have been described in the literature that may help to preserve blood supply, minimize soft tissue dissection, and restore a functional limb. This article reviews general guidelines for fracture and soft tissue management, osseous healing of fractures, and how certain techniques influence fracture healing. It also illustrates certain techniques for specific fracture reduction.     

Four-part fracture dislocation of the proximal humerus: an arthroscopic approach

The 4-part fracture dislocation of the proximal humerus remains an unsolved problem in young patients. The majority of 4-part fracture dislocations are best managed by humeral head replacement, although open reduction and internal fixation in young patients with good bone quality may be considered. Better results are obtained associated with limited exposure, careful soft tissue dissection, and stable fixation. We present an unpublished technique of reduction with arthroscopic assistance and percutaneous stabilization, which preserves the soft tissue around the fragments, avoiding the deltopectoral approach.     

Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation.

BACKGROUND: There is no consensus that an arthroscopically guided operation can improve the anatomical and functional results of treatment of intra-articular fractures of the distal aspect of the radius. The purpose of the present prospective study was to determine the usefulness of arthroscopically assisted reduction of displaced intra-articular fractures of the distal aspect of the radius by comparing the results of that procedure with those of conventional open reduction and internal fixation. METHODS: Thirty-four fractures were treated with arthroscopically guided reduction with use of one volar and two dorsal arthroscopic portals. The fractures were pinned, and external fixation was used with or without autogenous bone graft. Intraoperative fluoroscopy was not used. Forty-eight fractures were treated with conventional open reduction and internal fixation with a plate and screws or with pinning, with or without external fixation. The average duration of follow-up for all fractures was thirty-one months. RESULTS: The scores for overall outcome, assessed with use of the system of Gartland and Werley and that of Green and O'Brien as modified by Cooney et al., demonstrated that the group that had had an arthroscopically assisted procedure had better outcomes than the group that had had conventional open reduction and internal fixation. The group that had had an arthroscopically assisted procedure also had significantly better ranges of flexion-extension and radial-ulnar deviation of the wrist and grip strength (p<0.05). We detected an association between the maximum step and gap displacement and evidence of osteoarthritis of the radiocarpal joint (p<0.001), but we did not find a significant association, with the numbers available, between the scores for osteoarthritis, graded according to the scale of Knirk and Jupiter, and the scores for overall outcome, assessed with the scale of Gartland and Werley and the modified system of Green and O'Brien, in either group (p = 0.376). The radiographic results showed that the patients who had had an arthroscopically assisted procedure had better reduction of volar tilt, ulnar variance, and articular (gap) displacement than did those who had been managed with conventional open reduction and internal fixation (p<0.05 for each comparison). CONCLUSIONS: An arthroscopically guided operation achieved an accurate reduction of intra-articular fractures of the distal aspect of the radius. Minimum capsular and adjacent soft-tissue scarring reduced postoperative contracture, which improved the overall functional results. We recommend arthroscopically guided reduction and internal fixation not only for young adults but for all patients who are less than seventy years old and have an intra-articular fracture of the distal part of the radius with more than one millimeter of displacement on plain radiographs.     

Management of lateral humeral condylar fracture in children

Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy.     

Posterior approach for arthroscopic reduction and antegrade fixation of avulsion fracture of the posterior cruciate ligament from the tibia with cannulated screw and washer

Avulsion fracture of the posterior cruciate ligament (PCL) is a rare condition, and arthroscopically assisted reattachment of the surgical fixation of the fragment is not always an easy task. Only a few reports describe techniques for arthroscopic fixation of avulsion of the PCL.We report on a case treated arthroscopically with reduction and antegrade fixation of an avulsion fracture of the tibial attachment of the PCL with a cannulated screw and washer through an additional posterolateral portal. Postoperative morbidity was reduced, and rehabilitation was accelerated. Fixation with a cannulated screw and washer is technically simple and allows for stable fixation and immediate postoperative mobilization and pain-limited weight-bearing, even in cases of a comminuted fragment. The safe zone for an additional posterolateral portal and the technique for placing instruments and a guidewire to avoid neurovascular structures is defined.     

Endoscopic bone grafting for management of nonunion of the tuberosity avulsion fracture of the fifth metatarsal

The most common fracture of the proximal fifth metatarsal is the tuberosity avulsion fracture. Most of the time, the fracture is relatively undisplaced and it can be treated conservatively with a hard-soled shoe or walking cast. For painful intra-articular nonunion, internal fixation with or without bone graft is the treatment of choice. We describe an endoscopic approach to treat nonunions of the tuberosity avulsion fracture. Under endoscopic guidance, the nonunion site can be debrided thoroughly and bone grafted without the need of extensive soft tissue dissection. Moreover, the condition of the fifth metatarsal cuboid articulation can be assessed and intra-articular pathology can be dealed with arthroscopically. Finally, the desired position of the screw can be guided by the arthroscopic aiming device.     

Arthroscopic-assisted fixation of Hoffa fracture: A case report and description of technique

Medial condyle Hoffa fractures are intra articular injuries, which require prompt anatomical reduction and internal fixation. Arthroscopy-guided fixation of these fractures has also been advocated; the advantages include avoidance of soft tissue dissection, fast recovery and mobilization. We describe a case of a 28-year-old male patient presenting with a 10-day-old medial condylar Hoffa fracture. Skin condition prevented from conventional open reduction and internal fixation; hence, taking note of the urgency of fixation of an intraarticular fracture, arthroscopic-assisted minimally invasive approach was performed with good outcome.     

Salvage of open tibial fracture with segmental loss of tibial nerve: case report and review of the literature.

We report a case history, treatment, and follow-up of an open comminuted distal tibial fracture with significant soft tissue loss and segmental loss of the tibial nerve and posterior tibial artery. This constellation of injuries with an insensate plantar foot has often been an indication for amputation. In this instance, a functional distal extremity was salvaged with the use of Ilizarov fixation, delayed primary tibial nerve cable grafting, and staged soft tissue coverage. Clinical follow-up and review of the literature on the techniques used are offered for consideration.     

Retrograde interlocking intramedullary nailing under arthroscopy for supracondylar femoral fracture

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Osteosynthesis of a triplane fracture under arthroscopic control in a bilateral case

There are various types of ankle triplane fractures; they may be lateral and medial with two, three or four fragments. Some are described as extra-articular. We describe an exceptional bilateral case occurring after a trampoline accident of a displaced articular and an extra-articular fracture. The extra-articular fracture was treated by closed reduction and percutaneous fixation under fluoroscopic control. For the displaced articular fracture, an arthroscopically assisted reduction and percutaneous fixation was performed. The degree of rotation of the antero-lateral fragment of the articular triplane fracture, during percutaneous screw fixation, was not visible under image intensifier but could be corrected under arthroscopic control. Several portals can be made to enhance articular fracture reduction. This surgical procedure offers reliability and safety to the reduction and the synthesis of this articular fracture. It allows surgery to be less invasive in young patients, while decreasing the risk of malunion and poor long-term clinical results.     

Hoffa fracture in a 14-year-old

Coronal shear fractures of the femoral condyle (ie, Hoffa fracture) are an uncommon clinical entity typically seen in adults after higher-energy trauma. Historically poor outcomes have been reported in the literature with nonoperative treatment of these fractures. Conversely, open reduction and internal fixation of these fractures has been shown to produce good long-term clinical results in adults. These fractures appear to be even more uncommon in skeletally immature patients, with only 3 case reports documented in the literature to date. Two of the 3 cases presented as a symptomatic nonunion after initial nonoperative treatment. Herein we present a case report of a Hoffa fracture of the lateral femoral condyle in a 14-year-old boy after a wrestling injury. The fracture was treated with diagnostic arthroscopy followed by conversion to an arthrotomy for open reduction and internal fixation. Rigid fixation of the fracture was obtained with 4 headless compression screws. Twelve months postoperatively, the fracture was radiographically healed and the patient was pain free with restoration of full knee motion and return to sporting activity. The Hoffa fracture is a unique and relatively uncommon clinical entity that has a different personality than other intra-articular fractures of the knee in both adults and children. Instability of the fracture fragment can lead to a higher likelihood of nonunion with persistent pain and disability. These fractures should be treated with open reduction and internal fixation to achieve anatomic reduction with stable fixation and preservation of the blood supply to achieve early, active mobilization. We believe this optimizes the chance for good long-term functional results.     

Hip Arthroscopic Reduction and Fixation for Adolescent Acetabular Posterior Wall Fracture: A Case Report

BackgroundPosterior wall fracture is the most common type of acetabular fracture, the traditional open reduction and fixation through the Kocher–Langenbeck approach required a large incision and extensive muscle and soft tissue dissection, resulting in more blood loss, more complications and delayed recovery after the operation. Hip arthroscopy has been widely used in clinical practice but rarely reported in acetabular fractures.Case PresentationWe present the case of a 14‐year‐old boy with acetabular posterior wall fracture who was treated with hip arthroscopy reduction and fixation using anchors. He began to walk with partial weight‐bearing assisted by double crutches, and returned to school with crutches at 3 days after surgery. Although hip arthroscopy is technically more demanding, it’s an optimal choice for selected patients of acetabular fracture with the advantages of less invasive and faster postoperative recovery.     

Conjoint bicondylar Hoffa fracture in a child: a rare variant treated by minimally invasive approach

A case of conjoint Hoffa-type fracture in a child is presented. Hoffa fracture, i.e., coronal slice fracture of the condyles of the femur, is rare in adults and even rarer in the pediatric population. To date, no case of conjoint bicondylar Hoffa fracture has been reported in the literature. The presented case was successfully treated by arthroscopically assisted internal fixation.     

A Modified Technique of Arthroscopically Assisted AC Joint Reconstruction and Preliminary Results

Surgical treatment of high-grade acromioclavicular (AC) joint separations has become analogous to ligament reconstructions elsewhere in the body with the goal being restoration of the native anatomy. Circumferential access to the base of the coracoid is essential to reconstruct the coracoclavicular ligament complex. Using some of the traditional open approaches, this access requires detaching the deltoid insertion and performing extensive soft tissue dissection. Also, poor visualization risks injury to nearby neurovascular structures. An arthroscopically assisted reconstruction offers the advantage of less soft tissue dissection and superior visualization to the base of the coracoid. We have developed a unique arthroscopically assisted technique that uses a subacromial approach to pass suture material and a tendon graft around the coracoid to reconstruct the coracoclavicular ligament complex. We describe our technique and preliminary results in 10 patients who have undergone coracoclavicular ligament reconstruction for high-grade AC separation. All patients improved subjectively with regard to pain and function at a minimum followup of 3 months (mean, 5 months; range, 3-18 months). This arthroscopically assisted technique has the potential to allow for safe and at least in the short term reliable restoration of the coracoclavicular ligament complex and provides an alternative technique to treat AC joint separations.     

严重Pilon骨折的手术治疗

目的探讨严重Pilon骨折的手术治疗的方法及其临床效果。方法自2006年8月至2011年8月共收治严重Pilon骨折患者189例,获得随访的76例患者中,骨折按AO／OTA分类,均为C型,其中C1型19例,C2型35例,C3型22例。合并腓骨骨折75例。开放性骨折9例,软组织损伤程度按Gustilo分型,9例均I型。开放性骨折急诊行清创缝合及跟骨牵引后等待延期手术。闭合性骨折人院后均行跟骨牵引后延期手术。延期手术均在踝部肿胀消退后进行,伤后至手术时间5～14d,平均7．2d。65例行骨折切开复位内侧钢板螺钉内固定术,其中11例加用前或后侧小钢板固定,21例加用螺钉固定。11例采用骨折有限切开固定加超关节外固定架固定。有腓骨骨折者先行腓骨内固定术。61例取自体髂骨植骨。结果76例患者获得随访,随访时间10～54个月,平均27个月,术后骨折复位情况影像学评估结果（Burwell—Chamley标准）：解剖复位33例,复位一般41例,复位差2例。骨折全部愈合,愈合时间12周-73周,平均17．6周,其中骨折延迟愈合9例。皮肤创面浅表坏死7例,浅表感染6例,深部感染2例。发生踝关节创伤性关节炎18例,按美国骨科协会足踝外科分会（AOFAS）评分标准：评分为47～95分,平均82．7分。结论根据骨折类型和软组织损伤程度,对严重Pilon骨折采用手术治疗,通过合理的固定及早期功能锻炼,能取得满意的疗效,有效减少并发症的发生。     

Arthroscopic reduction and internal fixation of a displaced intraarticular lateral femoral condyle fracture of the knee

Anatomic reduction, typically obtained by direct visualization through an arthrotomy and internal fixation (open reduction and internal fixation), is the traditional treatment method for displaced intraarticular condylar fractures of the distal femur. We present a case report describing an alternative treatment method, namely, arthroscopic reduction and internal fixation, of a displaced, malrotated intraarticular lateral femoral condyle fracture of the knee. The potential benefits of decreased blood loss, shortened operative time, excellent intraarticular visualization, decreased soft tissue dissection, and shortened postoperative recovery are outlined.     

Arthroscopically Assisted Transfibular Talar Dome Fixation With a Headless Screw

We describe an articular talar dome fracture treated with the use of an arthroscopically assisted placement of a transfibular Acutrak screw (Accumed, Hillsboro, OR). This minimally invasive technique can be used to avoid the large incision used in the traditional open reduction and internal fixation of these fractures. Accurate reduction and stable fixation of fractures of the articular surface of the talus is a must, and this technique allows this while avoiding the morbidity of the open approach.