Operative Treatment and Soft Tissue Management of Open Distal Tibial Fractures – Pitfalls and Results

Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I–IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3–5 days. Gustilo II patients needed an average of 1.1 (0–3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0–16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3–28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up.     

Editorial Commentary: Posterior Tibial Slope: The “Unknown Size” of the Knee Joint

The posterior tibial slope (PTS) plays an immensely important role in almost every orthopaedic operation on the knee joint. The PTS is a decisive factor in the reconstruction of a torn anterior or posterior cruciate ligament, in high tibial osteotomy and, of course, in total knee arthroplasty. It is therefore all the more surprising that in current clinical practice relatively little emphasis is placed on the exact measurement of PTS. If the true value is not known, the influence of the same is pure coincidence. In the coronal plane, it is clinically valid practice to determine the hip–knee–ankle angle and thus to be able to determine the mechanical and anatomical axes at the tibia and femur. In the sagittal plane, however, an in-depth analysis is often dispensed with and only a short lateral knee radiograph is used. Different axes are described to determine the PTS. In addition, it is often overlooked that a determination of the PTS on lateral radiographs can only represent an average, since the medial and lateral tibial plateau shows considerable differences purely anatomically. In the future, we should place more emphasis on an analysis of the sagittal plane in the knee joint including PTS at least as profound as the analysis of the frontal plane. Here, radiographs of the entire lateral tibia must be requested to determine the true axis and thus the true PTS.     

The Role of Polymethylmethacrylate Antibiotic–loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections. The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention. A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009. There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years). A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3). All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion. A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (90.4%) and 7 positive for bacterial growth (9.6%). Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively. When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.     

Editorial Commentary: Stump Sparing or Footprint Exposing? Management of the Tibial Remnant During Posterior Cruciate Ligament Reconstruction

Surgical management of an isolated grade III posterior cruciate ligament tear has been enveloped in debate since the first reconstruction technique report was written by Hey Groves in 1919. With the evolution of arthroscopy, party lines have been drawn over tibial inlay versus transtibial techniques, as well as single- versus double-bundle techniques. More subtle controversy exists regarding autograft versus allograft, outside-in versus inside-out drilling, and treatment of the tibial footprint of the posterior cruciate ligament. New remnant-sparing techniques, using a trans-septal posterior portal, may augment biology, maintain better proprioception, and mitigate abrasive wear at the “killer turn.” However, longer-term comparative studies will be necessary to determine the existence of any clinically significant improvement in outcome.     

Treatment of the Aging Face Using the “Round-lifting” Technique

Background: Characteristics of the aging face include not only senescence and flaccidity of the skin, but also sagging of deeper tissues, especially in the fascial and fatty layers. Objective: This study was undertaken to evaluate the different surgical approaches to the aging face, specifically the techniques available for correction of the prominent nasolabial fold, which is a significant sign of facial aging. Methods: Through a total of 7446 cases in more than 40 years of experience in the surgical correction of the aging face, the senior author has emphasized the importance of the repositioning of the skin and the facial soft tissues. After appropriate treatment of the superficial musculoaponeurotic system (SMAS) and the malar fat pad has been completed, adequate placement of the skin flaps is done by rotation, as described in the round-lifting technique, rather than by direct traction. The anatomic basis of this correction is discussed. Results: Traction of the SMAS was found to soften the appearance of the nasolabial fold to varying degrees, but other complementary procedures such as collagen injection or fat grafting often were necessary to achieve a more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varied with each individual and his or her unique aging process. Simple traction of the SMAS did not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results. Again, long-term correction by this technique is related to the aging process, and the final result was deemed superior to treatment of the SMAS alone. Direct excision of the nasolabial fold was performed in patients ranging from 35 to 60 years of age who had extremely prominent folds. In these very select cases, the results were considered satisfactory to both the surgeon and patient, with correction of the fold and acceptable scars. Conclusions: There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely.     

The “Scarf” Osteotomy for the Correction of Hallux Valgus

Objective

Correction of symptomatic valgus deformities.

Indications

A hallux valgus in which the pathologic intermetatarsal angle I–II can be fully corrected by a lateral shift of the metatarsal head not exceeding two thirds of its width.

Contraindications

Hypermobility of the first ray. Osteoporosis. Osteoarthritis of the first metatarsophalangeal joint.

Surgical Technique

Medial longitudinal incision extending from the first metatarsophalangeal joint to the midportion of the metatarsal. Tenotomy of the abductor hallucis longus tendon, and lateral longitudinal incision of the metatarsophalangeal joint capsule to allow complete repositioning of the metatarsal head over the sesamoid bones. Z-shaped osteotomy in the mediolateral plane of the distal two thirds of the first metatarsal. Lateral shift of the distal fragment to reduce the intermetatarsal angle to a physiologic one. A pathologic distal metatarsal articular angle can be corrected simultaneously by rotating the distal fragment medially. Medial metatarsophalangeal capsulorrhaphy.

Results

Between October 1995 and July 1998, 73 Scarf osteotomies were performed in 57 patients and followed up clinically and radiologically for an average of 23 (12–45) months. The average intermetatarsal angle I–II was reduced from 12° to 6° and the first metatarsophalangeal angle from 27° to 11°. Patient’s satisfaction assessed in a visual 0–10 analog scale (10 points representing complete satisfaction) reached a mean value of 9.2 points. Three patients would not undergo the operation again (one bilateral severe undercorrection, one painful osteoarthritis of the first metatarsophalangeal joint, and one overcorrection).     

Outcome of Total Knee Arthroplasty After High Tibial Osteotomy: Does Malalignment Jeopardize the Results when Using a Posterior-Stabilized Arthroplasty?

Background

The controversy regarding the outcome of total knee arthroplasties after high tibial osteotomy may relate to malalignment secondary to overcorrection after high tibial osteotomy (HTO) [1, 2] and to the type of arthroplasty itself (posterior-stabilized arthroplasty or posterior cruciate ligament-retaining prosthesis).

Questions/Purpose

We asked two questions: (1) Would a posterior-stabilized arthroplasty provide sufficient constrain and improve pain and function in patients with severe malalignment due to a previous HTO? (2) Will malalignment of the previous HTO jeopardize the long-term results of a total knee reconstruction with a posterior-stabilized implant?

Patients and Methods

We retrospectively reviewed 25 posterior-stabilized TKAs in 25 patients with severe valgus deformity after HTO (ranging from 10° to 20° of valgus) and compared the results with a series of matched 25 posterior-stabilized TKAs in 25 patients with normocorrection after HTO ranging from 5° of valgus to 5° of varus. Clinical, operative, and radiographic data were reviewed. Minimum follow-up was 10 years after the arthroplasty (average, 15 years; range, 10–20 years).

Results

All the knees had standard posterior-stabilized total knee arthroplasty implants. Patients with an overcorrected HTO were more likely to require a soft tissue release to balance the knee. However, Average Knee Society and Function Score improved, respectively, from 48 to 85 and from 50 to 90 points in the severely overcorrected group, versus, respectively, 50 to 89 and 52 to 97 in the normocorrected group, but the range of mobility was superior for patients with normal alignment. Fifteen-year survivorship after the arthroplasty comparison showed no significant difference between the two groups (one revision in each group).

Conclusions

Patients with an overcorrected HTO are more likely to require a soft tissue release to balance the knee. However, both groups show improvements in function and pain. With a posterior-stabilized arthroplasty, the degree of deformity has no impact on the longevity of the TKA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9344-x) contains supplementary material, which is available to authorized users.     

Hyperthermic Isolated Perfusion With Low-Dose Tumor Necrosis Factor α and Doxorubicin for the Treatment of Limb-Threatening Soft Tissue Sarcomas

Background Tumor necrosis factor (TNF)-–based hyperthermic isolated limb perfusion (HILP) is one of the most active available approaches for locally advanced soft tissue sarcomas (STS) of the limbs. The aim of this study was to investigate the anticancer activity of a novel drug regimen including doxorubicin (DXR) and low-dose TNF-.Methods HILP with low-dose TNF- (1 mg) and DXR (8.5 mg/L of limb volume) was given to 21 patients with limb-threatening STS: 14 had primary and 7 had recurrent STS, most of which were high grade (grade 1, n = 3; grade 2, n = 6; grade 3, n = 12). Resection of the tumor remnant was performed 6 to 8 weeks after HILP. TNF- concentrations in plasma and perfusate were measured throughout perfusion.Results A major tumor response was observed at histology and clinical evaluation in 90% and 62% of patients, respectively. After a median follow-up of 30 months, limb salvage and local disease control were achieved in 71% and 81% of cases, respectively. Fourteen patients had moderate regional toxicity, which was resolved in all cases. One patient had severe limb toxicity, which did not require amputation. Systemic side effects were minimal, and there were no postoperative deaths. The perfusate/plasma area under the curve ratio for TNF- was 56.Conclusions HILP with low-dose TNF- and DXR seems to be an active neoadjuvant drug regimen against limb-threatening STS. This therapeutic approach can achieve high limb-sparing surgery rates with acceptable local and negligible systemic toxicity.     

“One-Stop Hybrid Procedure” in the Treatment of Vascular Injury of Lower Extremity

As a new surgical technique, “one-stop hybrid procedure” is rarely applied in trauma patients. This paper aims to explore its role in vascular injury of the lower extremity. Vascular intervention combined with open surgery was performed to treat three cases of vessel injuries of the lower extremity in our hybrid operating room. One patient with stab injury to the left femoral vein was treated by temporary artery blocking after excluding arterial injury by angiography, followed by blocking surgery and debridement and repair of the injured vein. The other two patients with drug addiction history, who were found to have pricking injuries to the femoral artery combined with local infection, were successfully treated by endovascular techniques and open debridement. One-stop hybrid procedure in treating vascular injury patients could simplify the operation procedure, reduce operative risk, and achieve good curative effect.     

Anterior Cruciate Ligament Reconstruction Using Achilles Tendon Allograft: an Assessment of Outcome for Patients Age 30?Years and Older

Achilles allografts have become popular for anterior cruciate ligament (ACL) reconstructions in older patients. Primary ACL reconstructions using Achilles tendon allografts in patients age 30 years and older are successful in restoring the knee to “normal” or “near normal.” During a three-year period, the two senior authors performed 65 primary ACL reconstructions using Achilles tendon allografts in patients aged 30 years and older. Our exclusion criteria were periarticular fracture, ipsilateral/contralateral knee ligament injury, and previous or concomitant osteotomy or cartilage restoration procedure. Each patient was evaluated via physical examination, functional and arthrometric testing, and radiographic and subjective outcome. Knees were considered normal, near normal, or abnormal based on the International Knee Documentation Committee (IKDC) system. Forty-three patients were examined at an average of 33 months (minimum, 24 months) postoperatively. At the time of ACL reconstruction, 35% had normal articular cartilage in all three compartments and 70% had meniscal tears. No re-ruptures occurred. While 24% had mean maximal translation differences less than or equal to 3 mm, none had side-to-side differences greater than 5 mm. Postoperative IKDC, Activities of Daily Living, and Activity Rating Scale scores averaged 88, 94, and 7.7, respectively. Despite the overall favorable outcomes, 29% had worsened radiographic grades at follow-up. Using an Achilles allograft for ACL reconstruction in patients older than 30 years, we restored over 90% of knees to normal or near normal while limiting postoperative complications. Poor subjective results may be related less to instability and more to pain, which may result from progressive arthritis.     

Editorial Commentary: A Posterior Tibial Tubercle Relative to the Trochlear Groove Is Associated With Increased Risk of Patellofemoral Arthritis: The Sagittal Tibial Tubercle–Trochlear Groove Distance

Arthritis of the patellofemoral compartment affects up to 24% of women and 11% of men over the age of 55 years who have symptomatic osteoarthritis of the knee. Patellofemoral cartilage lesions have been associated with several different geometric measures of patellar alignment, including the tibial tubercle–trochlear groove (TTTG) distance, trochlear sulcus angle, trochlear depth, and patellar height. Recently, there has been interest in the sagittal TTTG distance, which measures the position of the tibial tubercle with respect to the trochlear groove. This measurement is now being used in patients presenting with patellofemoral pain and/or cartilage pathology and may help guide surgical decision making as we gain more data on how changing the tibial tubercle alignment relative to the patellofemoral joint can improve outcomes. For now, there are not enough data to support isolated anteriorization tibial tubercle osteotomy in patients with patellofemoral chondral wear based on the sagittal TTTG distance. However, as we better understand geometric measures as risk factors for patellofemoral arthritis, realignment at a young age might be recommended as a preventative measure against end-stage osteoarthritis.     

Interposition Ankle Arthroplasty Using Achilles Tendon Allograft (“The AAA Procedure”): A Case Report

Surgical treatment options for end-stage osteoarthritis of the ankle joint typically consist of debridement, distraction arthroplasty, osteochondral allograft transfer system, arthrodesis, or total ankle arthroplasty. Interposition arthroplasty is an additional surgical treatment that may delay or eliminate the need for ankle arthrodesis. We report the use of a free Achilles tendon allograft as interposition arthroplasty for treatment of end-stage ankle osteoarthritis, the Achilles Ankle Arthroplasty or “AAA” procedure. The clinical presentation and course of treatment are described, as well as the surgical technique. This case showed that interposition arthroplasty with tendon allograft is an effective treatment for end-stage ankle arthritis.