Tag Archives: Trauma

Management of an open crush fracture to the foot from a lawnmower injury: A case report

Posted on December 31, 2020 | Comments Off on Management of an open crush fracture to the foot from a lawnmower injury: A case report

by Rosario Saccomanno, DPM1*, Matthew S. Kalmar, DPM1

The Foot and Ankle Online Journal 13 (4): 14

A 50-year-old male who reported to the emergency department (ED) with an open fracture to his right great toe sustained from a lawnmower injury is presented. The patient underwent emergent overnight podiatric surgery for treatment of the traumatic crush injury. Removal of all non-viable skin, soft tissue, and bone was performed intra-operatively which ultimately resulted in a partial right hallux amputation with primary closure. This case report aims to highlight the accepted treatment protocols set forth in the management of pedal open crush injuries. Open fractures are true podiatric emergencies and delay in treatment places the patient at increased risk for poorer prognosis.

Keywords: open fracture, trauma, crush, partial amputation

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0014

1 – Huntington Hospital at Northwell Health, Huntington, N.Y.
* – Corresponding author: saccoross@gmail.com

A pedal fracture is considered “open” when broken bone is immediately exposed to the atmosphere [1]. The mechanism of injury causing such injury is typically that of high velocity, crush-type trauma powerful enough to penetrate the layers of the integumentary system to cause said fracture. These injuries are true podiatric emergencies that are often accompanied by severe bone comminution and/or complex soft tissue degloving and may be constituted in polytrauma cases where primary, secondary, and tertiary surveys of the patient are imperative [2]. The essential goals in the management of open fractures revolve around prevention of infection, establishment of bony union, and restoration of function [1,3]. Treatment calls for non-excisional and/or excisional debridement, tetanus and antibiotic prophylaxis, and fracture stabilization, all of which have a synergistic role in attempting to prevent sepsis, minimize disability, and promote limb salvage [4].

Wound lavage acts as a form of non-excisional mechanical debridement to eradicate foreign debris from the wound site and to dilute the concentration of bacteria to a burden less than that of 105 in attempt to prevent infection [5]. Irrigation may be performed with low- or high-pressure modalities. Irrigation may be in the form of 0.9% sterile saline solution or agents such as povidone-iodine, chlorhexidine, and/or hydrogen peroxide which introduce antisepsis to the wound site [6,7]. Excisional debridement goes hand-in-hand with irrigation to further mechanically remove foreign material and nonviable tissue from the wound site [1]. Removal of devitalized tissue prepares the wound site for healthy tissue demarcation which will allow for wound closure to occur in the absence of bacterial bioburden [4].

Open fractures are particularly vulnerable to deep wound polymicrobial infection. Empiric antibiotic selection should be based on wound size, extent of soft tissue injury, and type of environment in which the injury was sustained [1,4]. Gustilo and Anderson devised a classification system with 3 types of open fractures which serves as a guide for recommended antibiotic coverage [8]. Type I open fractures are less than 1 cm in wound diameter with a simple fracture pattern and adequate soft tissue coverage. Type II open fractures have a wound diameter between 1 and 5 cm(s) with moderate soft tissue disruption yet intact periosteal and soft tissue coverage. Type III open fractures have extensive wound diameters greater than 5 cm(s) with comminution, extensive soft tissue damage, or traumatic amputation and can be further subdivided into those injuries with adequate soft tissue coverage (Type III-A), inadequate soft tissue coverage (Type III-B), or arterial compromise (Type III-C) [4,8].

Appropriate tetanus prophylaxis is imperative in cases of open fractures due to their inherently high risk of infection by Clostridium tetani, an obligate spore-forming anaerobe commonly found in farm environments that produces tetanospasmin. This is an exotoxin that causes spastic paralysis of voluntary muscles and can lead to fatal cases of respiratory arrest [1]. The Centers for Disease Control and Prevention (CDC) set forth recommendations in tetanus prophylaxis for wound management [9]. For those individuals sustaining an injury in a contaminated environment, both Tetanus-Diphtheria-Pertussis (TdaP) or Tetanus toxoid (Td) and Tetanus Immunoglobulin (TIG) are warranted for patients with an unknown vaccination history, those with fewer than 3 doses of Tetanus Toxoid (TT), or in cases where it has been more than 5 years since the patient’s last dose of TT. For clean, minor wounds, TdaP or Td are indicated if the patient has an unknown vaccination history or has received less than 3 doses of TT. TdaP or Td is recommended for those patients who have had 3 or more doses of TT if more than 10 years has elapsed since receiving the last dose of TT [9].

Regarding fracture stabilization, reduction followed by immobilization may be necessary to perform in the acute ED setting for open crush injuries. In the operative setting, external fixators are often employed to hold fractured fragments out to anatomic longitudinal length while not interfering with open wound management in cases of contaminated or infected open fractures. Fixation using either open or percutaneous Kirschner (K) Wires are often employed to achieve internal splintage of fracture fragments [4]. It is recommended that the implementation of internal hardware such as that of plates and/or screws is reserved for use once the open fracture site is deemed clean and the site can be primarily closed, which may need to occur in a staged-procedure fashion [1].

Case Report

In the late evening of August 23, 2018, a 50-year-old male with a past medical history significant for alcoholism presented to the ED after his right foot was run over by a commercial lawnmower during farm and landscaping work earlier that afternoon. The patient reported 6 hours from the time of injury to presentation to the hospital. The patient reported wearing steel-toe boots during the incident and reported that he continued to work through his shift after sustaining the injury. The patient denied any trauma to the left foot or any constitutional symptoms upon presentation to the ED.

After thorough primary and secondary examinations were performed, a focused lower extremity physical examination noted a diffusely edematous and ecchymotic right foot with palpable peripheral pulses and soft and non-tender compartments. Delayed capillary refill time to the right first digit with absent protective and light touch sensation were noted. A traumatically amputated distal tuft of the right hallux revealed a Gustilo-Anderson Type III-A open fracture immediately exposing segmental comminution to the distal aspect of the distal phalanx along with gravel debris and active bleeding to the site. The right hallucal nail plate was found to be loose with subungual hematoma encompassing 100% of the underlying nail bed. The patient was unable to passively move the right first toe when prompted.

The nature, severity, and time sensitivity of the patient’s injury called for immediate bedside management of his open crush fracture in the ED setting. Cefazolin, ciprofloxacin, and penicillin G potassium were administered and the patient was started on intravenous fluids. The patient was given an intramuscular (IM) dose of 0.5 mL TdaP for tetanus prophylaxis as he admitted it had been more than 10 years since his last tetanus booster. The open fracture was copiously irrigated using a total of 9 liters of 0.9% sterile saline solution. A right hallux anesthetic block was then administered. An excisional debridement of nonviable tissue as well as a total hallucal nail avulsion to evacuate subungual hematoma and to assess the true extent of the injury were performed (Figure 1). X-ray confirmed comminution of the distal phalanx with surrounding soft tissue swelling (Figure 2). The right hallux was immobilized by means of a basket-weave splint for fracture stabilization and the right foot was dressed with a bulky, compressive dressing. The patient was given pain medication for pain control.

Figure 1 Preoperative image demonstrating open fracture of the right foot with traumatic amputation of the hallucal distal tuft.

Figure 2 Plain dorsoplantar, oblique, and lateral radiographs of the foot revealing a comminuted fracture of the hallucal distal phalanx with surrounding soft tissue swelling.

At this time, the patient was prepped for emergency surgery and was instructed for his subsequent admission. The patient was booked for removal of nonviable skin, soft tissue, and bone from the right foot and instructed on the possible need for a staged procedure. The patient consented to the proposed operation and medical clearance was granted. The patient underwent the emergent operation overnight under monitored anesthesia care with local anesthetic.

Figure 3 Postoperative plain dorsoplantar, oblique, and lateral radiographs of the foot illustrating salvage of the proximal 1/3 base of the distal phalanx resulting in a partial hallux amputation.

Degloved, nonviable skin and soft tissue of the right hallux was excisionally debrided and all comminuted fragmentation of the exposed distal phalanx was excised and passed off for pathological analysis. The proximal 1/3 base of the hallucal distal phalanx was found to be viable and was salvaged intra-operatively (Figure 3). The surgical site was irrigated with 9 liters of 0.9% sterile saline solution. The remaining base of the distal phalanx was rasped to remove sharp edges and bone wax was applied over its surface. Primary closure was achieved using a flap from the plantar hallucal skin and soft tissue which ultimately resulted in a partial hallux amputation.

Surgical pathology revealed findings of hemorrhage and reactive changes without any evidence of bone or soft tissue infection. The patient was continued on IV antibiotics until the date of hospital discharge when he was transitioned to a 10-day course of cephalexin per the infectious disease specialist. The patient healed uneventfully on the outpatient basis with appropriate return to normal shoewear.

Discussion

In this case report, a farm injury caused by a commercial lawn mower resulted in an open fracture of the right hallux that required emergent overnight surgery. Immediate bedside irrigation was initiated using an initial 9 liters of 0.9% sterile saline solution to remove gross debris and bacterial contamination followed by another 9 liters of the same solution used in the operating room. Anglen identified volume, pressure, and pulsation as three variables as part of a proposed irrigation protocol utilized for the treatment of open fractures, with his recommendation calling for 3 liters of irrigation used for Type I open fractures, 6 liters for Type II open fractures, and 9 liters for Type III open fractures [6]. Though antiseptic agents have been purported to have bactericidal properties, they have been reported to cause cytotoxicity, impaired osteoblast function, delayed wound healing, and chondrocyte damage; hence, 0.9% sterile saline solution is considered the standard of choice irrigant in cases of open fractures [1]. Regarding the pressure variable in the irrigation protocol, Anglen and colleagues in another study observed a 100-fold decrease in slime-producing Staphylococcus bacterial count in wounds treated with pulsatile lavage as compared with bulb irrigation when the same solutions and volumes were used in both delivery systems [7]. Anglen reported that even though pulsation may in theory remove surface debris by means of tissue elasticity, there is no established recommendation due to limited studies on this irrigation variable [6].

Another important consideration in the management of open fractures is timing from onset of injury to debridement. The American College of Surgeons Committee on Trauma (ACS-COT) deems debridement within 6 hours from time of injury to be the standard of care as a time lapse greater than this can result in 1 g of tissue inoculated with a single bacterium to duplicate 105 bacteria to convert a contaminated wound to an infected wound [4,5,10]. More recent clinical data in the literature lacks support of this postulation and concludes that early debridement is not an independent predictor of decreased risk of infection [11]. In this case, non-excisional and excisional debridement were performed at bedside within 6 hours from the onset of the patient’s injury and shortly thereafter in the operative setting, which allowed for primary wound closure via a plantar hallucal skin and soft tissue flap.

Tetanus and antibiotic prophylaxis were initiated in this case due to the severity of the patient’s open fracture as well as the farm environment where it occurred. The patient was given an IM dose of TdaP per the ED physician as more than 10 years had elapsed since the patient’s last tetanus booster. The rate of bone and/or soft tissue infection following an open fracture is purported to be 3-25% with the most common pathogens being that of natural skin flora, namely coagulase-positive Staphylococcus aureus [1,8]. For the patient’s Gustilo-Anderson Type III-A open fracture, the ED physician administered cefazolin, ciprofloxacin, and penicillin G potassium per recommendation of the podiatry service which provided appropriate gram-positive, gram-negative, and anaerobic coverage. With Type III-A open fractures occurring in a farm environment, penicillin G potassium is warranted for Clostridium spore coverage [1].In a study of 1104 open fractures, Patzakis and Wilkins reported that early administration of antibiotics, deemed within 3 hours of onset of injury, was the single most important factor in reducing rate of infection (4.7% compared with 7.4% for those that received antibiotics after 3 hours from time of injury) [12]. Following surgical debridement and primary closure, it is recommended that antibiotics are continued for an additional 24 to 48 hours in the post-operative period [1]. In this case, bone and soft tissue of the right hallux that was passed off for pathological analysis came back negative for evidence of infection. The infectious disease specialist continued the patient on cefazolin in the immediate post-operative period and discharged him with a 10-day course of cephalexin due to the open and contaminated nature of the wound upon initial patient presentation.

The emergent nature of the patient’s open fracture ultimately resulted in a partial hallux amputation. Due to the extensive amount of comminution to the distal aspect of the distal phalanx bone, these fragments could not be apposed in an improved position with internal or external fixation and were therefore deemed non-salvageable and excised altogether. Rasping of the salvaged 1/3 base of the hallucal distal phalanx and implementation of bone wax were used to smoothen osseous contour and deter spicule regrowth, respectively. Primary closure via use of a plantar hallucal skin and soft tissue flap was achieved as the site was deemed clean as a result of timely irrigation and debridement from onset of injury.

Conclusion

This article highlights a case of an open fracture to the great toe which resulted in a partial hallux amputation and outlines the accepted management of such traumatic injuries through a review of literature. Open fractures are true podiatric emergencies that can pose life-threatening changes to patients and their well-being. Traumatic great toe amputations may lead to functional and psychological disability as well as decreased propulsive effort during the push-off phase of the gait cycle. Prognosis is highly dependent on both timing of patient presentation to seek medical attention as well as on prompt rendering of medical care by the practitioner. If treatment is delayed, the patient risks suffering from a greater likelihood of morbidity and poorer prognosis. By increasing the knowledge and awareness of these debilitating injuries and their treatment protocols, the patient will be best served and the practitioner will be best guided in the overall aim to prevent infection, minimize disability, and promote limb salvage.

References

  1. Sexton SE: Open fractures of the foot and ankle. Clin Podiatr Med Surg. 2014 Oct;31(4):461-86.
  2. Biffl W, Harrington D, Cioffi W: Implementation of a tertiary trauma survey decreases missed injuries. J of Trauma: Injury, Infection, and Critical Care 2003 Jan;54(1):38-43.
  3. Weitz-Marshall AD, Bosse MJ: Timing of closure of open fractures. J Amer Acad Ortho Surgeons Nov-Dec 2002;10(6):379-84.
  4. McGlamry ED: “Open Fractures,” in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Vol 2, edited by JT Southerland, p 1499, Philadelphia, Lippincott Williams & Wilkins, 2013.
  5. Bowler PG: The 10(5) bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy Wound Manage. 2003 Jan;49(1):44-53.
  6. Anglen JO: Wound irrigation in musculoskeletal injury. J Amer Acad Ortho Surgeons Jul-Aug 2001;9(4):219-26.
  7. Anglen JO, Apostoles S, Christensen G, et al: The efficacy of various irrigation solutions in removing slime-producing Staphylococcus. J Ortho Trauma 1994 Oct;8(5):390-6.
  8. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone and Joint Surg. 1976 Jun;58(4):453-8.
  9. Centers for Disease Control and Prevention: Tetanus – for clinicians. Available at: (https://www.cdc.gov/tetanus/clinicians.html). Accessed February 16, 2020.
  10. American College of Surgeons: Resources for optimal care of the injured patient 2014/resources repository. Available at: (https://www.facs.org/quality-programs/trauma/tqp/center-programs/vrc/resources). Accessed February 15, 2020.
  11. Pollak AN: Timing of débridement of open fractures. J Amer Acad Ortho Surgeons 2006;14(10 Spec No.):S48-51.
  12. Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin Ortho and Rel Research 1989 Jun;(243):36-40.

 

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Ankle arthrodiastasis in conjunction with treatment for acute ankle trauma

Posted on September 30, 2020 | Comments Off on Ankle arthrodiastasis in conjunction with treatment for acute ankle trauma

by Nunzio Misseri, DPM¹; Hayley Iosue, DPM¹; Elizabeth Sanders, DPM¹; Amber Morra, DPM¹; Mark Mendeszoon, DPM2,3

The Foot and Ankle Online Journal 13 (3): 3

Arthrodiastasis has been described as an alternative joint sparing procedure for more advanced stages of arthritis. The use of joint distraction has been gaining popularity in foot and ankle surgery, especially with regards to post-traumatic ankle arthritis. Less is known about the effects of arthrodiastasis in cases of acute ankle trauma. This case series presents four cases of intra-articular ankle trauma that were treated with arthrodiastasis using external fixation along with reduction with/without internal fixation. The external fixators were kept on for at least 6 weeks with follow-up of at least 1-2 years for each case. These cases represent high impact injuries that were destined for post-traumatic arthritis that would eventually result in a joint destructive procedure. The results were promising in all cases, by at least delaying the need for a joint fusion or replacement in one case and foregoing the need for such procedures in the other 3 cases within our follow-up period.

Keywords: Arthrodiastasis, ankle, diastasis, arthritis, trauma, post traumatic, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0003

1 – University Hospitals Regional Hospitals, Surgical Fellow
2 – University Hospitals Regional Hospitals, Fellowship Director; faculty
3 – Precision Orthopaedic Specialities Inc.

The incidence of people with post-traumatic arthritis accounts for nearly 12% of those with symptomatic lower extremity arthritis [1]. Among those with ankle joint osteoarthritis, previous trauma is the most common etiology ranging from 20% to 78% incidence [2-4]. These patients usually end up with joint destructive procedures such as joint fusion or replacement.

Arthrodiastasis is an innovative treatment for ankle arthritis to enhance ankle joint range of motion, diminish pain, and potentially delay or forego ankle joint destructive procedures. Arthrodiastasis of the ankle has been described as an alternative and/or adjunctive salvage procedure for arthritis in patients not amenable to ankle joint replacement or arthrodesis [5]. The procedure is not technically demanding for the surgeon and, long-term, can cost less than arthrodesis or arthroplasty.

Various theories exist to explain how arthrodiastasis has a positive effect on joints. A theory by Gavril Ilizarov suggests applying tension to tissues with distraction increases micro-vascularity to articular cartilage, therefore assisting in cartilage repair [6]. This tension creates a hypervascular state which increases synthesis of nutrients, proteoglycans and in turn helps stimulate chondrocyte formation [6].

Lafeber described a theory in which joint unloading with resulting fluctuations in intra-articular pressure from joint distraction along with concomitant weight bearing, the activity of chondrocytes increases which creates proteoglycans that have the ability to repair articular cartilage and stimulate pluripotent mesenchymal cells to differentiate into articular cartilage [7,8]. This concept of mechanical offloading with continuing pressure changes was shown to increase proteoglycan synthesis by 50% in osteoarthritis knee condyles undergoing arthrodiastasis [7,9]. This process also decreases the inhibition of proteoglycan synthesis by mononuclear inflammatory cells, decreases production of catabolic cytokines and provides increased nutrition delivery to chondrocytes [7].

Both theories predicate the notion that osteoarthritic ankle cartilage is capable of regeneration. Arthrodiastasis has been used over the years with chronic osteoarthritis of the ankle with good results. A review by Dr. Rodriguez-Merchan published in 2017 looked at 14 articles that included patients with end stage osteoarthritis undergoing ankle joint distraction. A total of 249 patients were included in this review with follow up ranging from 1-12 years. Overall 73-91% of patients had good results within their follow up and 6.2-44% of patients ended up with either a joint fusion or replacement [10]. This review serves as a good foundation on the results of ankle joint arthrodiastasis in chronic cases of osteoarthritis, however little is known on its effects during its application in acute trauma. We present a series of acute ankle trauma in which we employ external fixation for arthrodiastasis. In these cases studies, each patient suffered from an intra articular ankle fracture. In the acute setting, the fractures were reduced and an external fixator was applied. Ankle joint diastasis of 5-10mm was applied to the ankle joint utilizing the external fixator. The external fixators were left in place for six to eight weeks.

Case 1

A 30 year-old male sustained an open bimalleolar fracture while operating his horse-drawn lawn mower. Upon presentation to the emergency department, he was evaluated and subsequently taken to the operating room for wound washout, flap closure, application of a delta frame for stability with percutaneous kirschner wire fixation to the medial malleolus. Once the soft tissue envelope was stable nine days later, open reduction and internal fixation was performed. The same delta frame remained intact and the ankle joint was distracted in an attempt to preclude ankle arthritic changes. The frame remained in place for six weeks allowing for ankle joint arthrodiastasis during this time. The patient was seen in the office 1.5 years after surgery and was clinically doing well. He is ambulating without orthoses and able to perform his daily activities without issues. Radiographic images revealed a healed fracture with the ankle mortise in good alignment, without signs of degenerative arthritis.

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Figure 1 Open bimalleolar fracture of a 21-year-old Amish male sustained while operating a horse-drawn lawn mower. Case 1.

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Figure 2 Post-operative radiographs status-post wound washout and closure, open bimalleolar fracture reduction, percutaneous fixation, application of delta frame. Status-post bimalleolar fracture open reduction and internal fixation, syndesmotic repair, and re-application of delta frame to obtain arthrodiastasis at the ankle joint.

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Figure 3 Six weeks status-post bimalleolar fracture open reduction and internal fixation, postoperative day 0 of delta frame removal.

Case 2

A 56-year-old female presented after a motor vehicle accident where she sustained a right closed comminuted talar fracture. Radiographs and a CT scan revealed a Hawkins type IV talus fracture. She was subsequently taken to the operating room after full evaluation in the emergency department. Closed reduction was attempted with a calcaneal pin but was not possible. Therefore, a lateral sinus tarsi approach incision was made from the tip of the fibula extending dorsally over the 4th metatarsal to expose the talus. The talus was reduced and fixed percutaneously with Kirschner wires and a delta frame was applied.

Eleven days later, after the soft tissue envelope improved, she was taken back to the operating room for subtalar and talonavicular joint arthrodesis in an attempt to maintain blood supply to the talus. The deltoid ligament was repaired and a modified Brostrom augmentation was performed. A ring external fixator was placed to achieve stability as well as arthrodiastasis at the ankle joint. The external fixator was removed two months postoperatively. Minor medial ankle arthritis was noted on postoperative radiographic images which worsened over the years. Two years postoperatively the patient is contemplating joint destructive procedures.

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Figure 4 Radiographs and CAT scan of a Hawkins type IV severely comminuted talus fracture. Case 2.

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Figure 5 Intraoperative findings of a severely comminuted talus fracture. Postoperative clinical photos and radiographs of open reduction and external fixation of a comminuted talus fracture, stabilization with percutaneous Kirschner wires and circular external fixator.

Case 3

A 34-year-old male patient was admitted from an outside hospital two days after a trauma where a car he was repairing fell on his left lower limb. He was noted to have a closed dislocated fracture of the left talus, Hawkins type III, and displaced medial malleolus fracture. Closed reduction and splinting was performed at the previous hospital. After full evaluation at our facility, open reduction of the talus and closed reduction of the medial malleolus was performed followed by the application of a ring external fixator. After adequate reduction, approximately a half centimeter of distraction of the ankle joint was produced. This frame was left in place for four months. Following frame removal, the patient continued physical and functional treatment aimed at strengthening the tibial and foot muscles and was encouraged to increase range of motion of the ankle. The patient was able to return to his normal daily activities and return to work. At his two year follow-up he has not needed to go on to further joint destructive procedures and continues to be able to perform his activities of daily living without issue.

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Figure 6 Radiographs on admission. Case 3.

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Figure 7 Radiographs following Ilizarov frame application and during treatment.

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Figure 8 Radiographs following Ilizarov frame removal 80 days status-post reduction and external fixation of talus fracture.

Case 4

A 15-year-old male patient who presented with chief complaint of right foot and ankle injury sustained after a fall while riding a BMX bike. The patient did have a history of a previous talus fracture 3 years prior to this presentation which was treated non-surgically. Radiographic images revealed a Hawkins type III talar neck fracture which was confirmed and evaluated on CT scan. The patient underwent open reduction with internal fixation of the talus fracture with two cannulated screws from posterior to anterior and application of an external fixation with approximately 6-mm of joint distraction.

The external fixator was removed after 6 weeks and the patient was gradually transitioned from a walking boot and into well-supportive sneakers while undergoing physical therapy. He was able to return to his daily activities, sports and BMX bike. The patient was seen in the office 1.5 years after surgery without any clinical or radiographic signs of post traumatic arthritis.

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Figure 9 Preoperative radiographs and CT scan images; post operative radiographs pre and post removal of external fixation.

Discussion

Acute ankle arthrodiastasis with concomitant ankle fracture, open reduction with internal and/or external fixation, should be considered in an attempt to preclude post-traumatic ankle arthritis. This becomes more crucial in cases of intra-articular ankle trauma, where the rate of post-traumatic arthritis increases. With arthrodiastasis, the changes in hydrostatic pressure provide an environment for chondrocyte repair and regeneration thus decreasing the chances for post-traumatic arthritis and the potential need for a joint fusion or replacement. The combination of mechanical offloading along with the microangiogenesis that is produced with increased tension to the soft tissue structures have shown to aid this process of repair.

Vito, et al., distracted 65 arthritic ankles using the Ilizarov frame for 6 weeks with distraction of 5-10 mm [11]. The patients had marked reduction in pain at 12 months for all patients except two: those two went on to arthrodesis. Valburg, et al., reported an average of two years pain relief following three months of arthrodiastasis with an Ilizarov frame [12]. Ploegmakers, et al., assessed the use of arthrodiastasis in 22 patients and reported 73% of the patients had significant improvement at seven years [13]. Although these series were not in the acute setting, one can assess the benefit these series showed with arthrodiastasis of the ankle joint.

This case series showcased four different cases of intra-articular ankle trauma where ankle diastasis was employed as part of the fixation in the acute setting. Successful outcomes were noted in three patients thus far at one to two years of follow up. One of the patients will require a joint fusion or replacement after 2 years. With the widening list of indications for arthrodiastasis, we believe there are benefits of using joint distraction in acute intra-articular trauma to either forgo or delay post-traumatic arthritis. This review serves as a foundation to pursue further indications for arthrodiastasis, however it does have limitations. The sample size is small at this time due to lack of extended follow-up. The follow-up time period listed for these four cases is 1-2 years. The results may prove to be different in the future with extended follow-up, however ankle joint diastasis remains a viable option in patients with intra-articular trauma to possibly reduce or delay the need for arthrodesis in the future

References

  1. Thomas AC, Hubbard-Turner J, Wikstrum EA, Palmieri-Smith RM. Epidemiology of Posttraumatic Arthritis. Journal of Athletic Training. 2017;52(6):491-496.
  2. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. 2006;20(10):739–744.
  3. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-46.13.
  4. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009; 467(7):1800-1806.
  5. Labovitz, J. The Role of Arthrodiastasis in Salvaging Arthritic Ankle. Foot & Ankle Specialist. 2010; 3(4):201-204.
  6. Ilizarov GA. Transosseous Osteosynthesis. Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue, Chapter 11, Non-operative Correction of Foot Deformities. 547-581. Springer-Verlag, Heidelberg, 1992.
  7. Lafeber FP, Intema F, van Roermund PM, et al. Unloading joints to treat osteoarthritis, including joint distraction. Curr Opin Rheum. 2006. 18:519 – 525.
  8. Vito G, et al. Point-Counterpoint: Is Arthrodiastasis A Viable Option For Ankle Arthrosis. Podiatry Today. 2008;21(10).
  9. Kluesner AJ, Wukich DK. Ankle Arthrodiastasis. Clin Podiatr Med Surg. 2009 Apr;26(2):227-44.
  10. Rodriguez-Merchan EC. Joint Distraction in Advanced Osteoarthritis of the Ankle. Arch Bone Jt Surg. 2017;5(4):208-212.
  11. Vito G, Pacheco F, Southerland C, Rodriguez E, Thompson S. A New Solution for the Arthritic Ankle. Podiatry Today. 2005. 18(12):36-43.
  12. Van Valburg AA, van Roermund PM, Marijnissen AC, van Melkebeek J, Lammens J, Verbout AJ, Lafeber FP, Bijlsma JW. Joint distraction in treatment of osteoarthritis: a two-year follow-up of the ankle. Osteoarthritis Cartilage. 1999 Sep;7(5):474-9.
  13. Ploegmakers JJ, et al. Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Osteoarthritis Cartilage. 2005;13(7):582-588

 

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Rare, non-displaced, sagittal plane fractures of the navicular body: A report of two cases

Posted on September 30, 2020 | Comments Off on Rare, non-displaced, sagittal plane fractures of the navicular body: A report of two cases

by Rachelle Randall, DPM1*, Lawrence M. Fallat, DPM, FACFAS2

The Foot and Ankle Online Journal 13 (3): 2

Cases of non-displaced, sagittal plane fractures of the navicular are most commonly seen as stress fractures. Previous literature suggests that the mechanism of injury of most high impact falls have shown significant dislocation of the navicular counterparts or comminution to other structures of the foot. We present two rare cases of high impact injury creating sagittal plane fractures through the navicular body without any dislocation of the navicular or trauma to any surrounding structures. Two patients had similar high impact falls and mechanisms of injury leading to mirrored navicular fracture patterns. Surgical correction was performed in both patients. At three months postoperative both patients were clinically pain free in normal shoe gear, and radiographically healed. At one year postoperative both patients had maintained correction and had returned to full activity prior to injury, pain free. Both of these cases resulted from falls with a longitudinal compression force and an axial loading mechanism, generating these non-displaced, sagittal, navicular body fractures. Due to the avascularity of the body of the navicular and age of the patients, surgical correction of the fracture site was performed to help prevent non-union, avascular necrosis, displacement and future arthritic changes. Both patients had favorable surgical outcomes. There is a need to denote this mechanism of injury and corresponding fracture pattern within the current literature.

Keywords: bone, fall, foot, mechanism, midfoot, stress, trauma

ISSN 1941-6806
doi: 10.3827/faoj.2020.1303.0002

1 – Resident, Postgraduate Year 2 – Beaumont Health Wayne, Podiatric Foot and Ankle Surgical Residency, Beaumont Hospital Wayne, Wayne, MI 48184, USA
2 – Director – Beaumont Health Wayne, Podiatric Foot and Ankle Surgical Residency, Beaumont Hospital Wayne, Wayne, MI 48184, USA
* – Corresponding author: rachellelrandall@gmail.com

Isolated fractures of the navicular bone are rare [1]. The navicular plays an essential role in the medial longitudinal arch and the stability of the midfoot structure as the keystone [2]. Loss of the height or alignment of the keystone can result in loss of 90% or greater of complex hindfoot motion [3]. Classification systems have been derived for fractures of the navicular and corresponding midfoot. Sangeorzan, et al., [4] classified displaced, intra-articular fractures of the tarsal navicular, while Watson-Jones [5] classified multiple navicular fracture patterns including the stress fracture. Though there have been classifications of fracture patterns, the discussion of the mechanism of action and injury is rarely researched and cited. Main and Jowett [6] were the first authors to describe multiple potential mechanisms of action of the navicular fracture. Rymaszewski and Robb [1] in 1976, proposed one revisional mechanism in a later case report and finally, Rockett and Brage [7] in 1997 assessed navicular fractures on Computerized Tomography reviewing five different fracture patterns and proposed another potential mechanism of injury not previously discussed in the literature.

Figure 1 Preoperative radiograph of right foot in Patient 1.

Main and Jowett is still the most cited and well recognized classification system of navicular fracture mechanisms. This classification system was based solely on assessment of radiographic appearance of midtarsal fractures. It was developed by considering the direction of the fracture, the disruption of joints and malalignment of the foot. As stated by Main et al. tarsal navicular body fractures result from axial loading forces that occur frequently when falling from a height. The longitudinal compression forces on the talus lead to compression of the navicular into the cuneiforms, and the navicular to absorb the shock of impact [6].

We present two cases of high impact injury causing sagittal plane fractures through the navicular body, without dislocation of the navicular or surrounding structures.

Figure 2 Eight weeks postoperative radiograph of right foot in Patient 1.

Our case report reveals fracture patterns that appear consistent with stress fractures [8] while the mechanism of action correlates to dislocated, comminuted, corresponding fracture patterns. This mechanism of injury and corresponding fracture pattern has yet to be recognized in the current literature or described in any classification system.

Case Report 1

A 17-year-old male, with no significant past medical history, was treated from 08/2017 to 06/2019. He first presented to the emergency department after a bike riding accident. The patient reported he was 10-15 feet in the air doing a bike trick when he fell and landed directly on his right foot. He stated that he landed with his foot being pointed downward (plantarflexed) and landing on the ball of his foot. The patient admitted to continuing to ride his bike for 20 minutes after initial injury until the pain became too severe. On physical exam the patient had midfoot edema but no ecchymosis or visible deformity present.

Plain radiographs were taken revealing a non-displaced, fracture in the sagittal plane through the body of the navicular. No comminution or dislocation was noted (Figure 1). The patient had surgery three weeks from the initial injury date. He was placed on the operating table in the supine position with an ankle tourniquet inflated. After IV sedation and local anesthesia, the fracture site was reduced percutaneously with a point-to-point clamp and a guide wire was placed across the fracture site from medial to lateral. Guide wire alignment and fracture reduction were then assessed with fluoroscopy imaging intra-operatively. Next, a small stab incision was made on the medial aspect of the navicular and a single 4.0 mm cannulated, cancellous, partially threaded screw was placed across the fracture site. The skin was closed with 3-0 nylon suture.

The patient was placed in a CAM boot to remain non-weight bearing with use of crutches. The sutures were removed at four weeks and the patient was permitted partial weight-bearing in a CAM boot at this time. He was seen again at eight weeks with zero out of ten pain. The radiographs revealed bony callus with cortical healing across the fracture site (Figure 2). The patient was advised to continue use of the CAM boot for two more weeks and then transition into normal shoe gear. The patient started his wrestling season at ten weeks post-operatively, and he was pain free. The patient was seen at three months postoperatively and had been ambulating in supportive shoe gear without pain and participating in wrestling and snow-boarding. The patient was evaluated again 12 months from initial surgery date and remained actively participating in sports and daily activities pain free.

Case Report 2

The second patient was a 26-year-old female, with no significant past medical history, treated from 10/2017 to 05/2019. She presented to our office after being referred from an orthopedic surgeon one week after her initial injury. The patient stated that she fell down a flight of stairs and landed on the ball of her left foot. On physical exam she had no apparent deformity, but localized edema at the midfoot. Plain radiographs showed a complete, non-displaced, sagittal plane fracture through the body of the navicular (Figure 3).

Surgery was performed one week after the initial injury date. She was placed on the operating table in the supine position with an ankle tourniquet inflated. After IV sedation and local anesthesia, the fracture site was reduced percutaneously and stabilized with a point-to-point clamp. Two guide wires were placed from medial to lateral, percutaneously, crossing the fracture site. A small stab incision was then made medially and two 4.0 mm cannulated, partially threaded screws were placed across the fracture site. Fluoroscopy imaging was performed intra-operatively confirming reduction of the fracture site and alignment of the screws. The skin was closed with 3-0 nylon.

The patient was placed in a CAM boot to remain non-weight bearing with use of crutches. Sutures were removed at four weeks postoperatively and the patient was permitted to partial weight-bear in CAM boot at this time. The patient was seen at eight weeks with two out of ten pain. The radiographs revealed bony callus and healing across the fracture site (Figure 4). She was advised to slowly transition out of the CAM boot over the following two weeks. The patient was evaluated again at three months postoperatively and she was playing with her kids pain free at this time. The patient was seen again at 12 months postoperatively and she continued to remain asymptomatic and ambulating in normal shoe gear and full activity.

Figure 3 Preoperative radiograph of left foot in Patient 2.

Discussion

These isolated fracture patterns with associated mechanisms of action are rarely cited in literature. Cases of non-displaced, sagittal plane fractures are most commonly seen as stress fractures. Most high impact falls have shown significant dislocation of the navicular counterparts or surrounding structures [9]. Although both cases resulted from high energy falls with longitudinal compression and an axial loading mechanism, they exhibited non-displaced, sagittal, navicular body fractures, without dislocation or comminution. This fracture pattern and corresponding mechanism of injury does not fit into any previously cited case.

Figure 4 Eight weeks postoperative radiograph of left foot in Patient 2.

Main and Jowett [6] go into great detail when discussing mechanism, classification and treatment of midtarsal joint injuries. They divided the midtarsal injuries into five major categories when assessing mechanism and fracture pattern. The two navicular injuries presented do not fit into any current classification of mechanism of injury and corresponding fracture pattern. The study by Rocket and Brage [7] most closely correlates to our findings. In their 4th patient, the radiograph revealed what appeared to be a non-comminuted, sagittal plane fracture through the body of the navicular. After computed tomography was performed they found a corresponding large plantar fragment suggestive of comminution. It is also important to note the patient had multiple calcaneal fractures from the corresponding injury as well. As Sangeorzan, et al., classified all of their fracture patterns as displaced fractures of the navicular, our fractures only revealed a sagittal plane fracture without dislocation or comminution [4]. The majority of high impact navicular fractures are associated with either dislocation of navicular components or multiple bone injuries of the foot.

Isolated fractures through the body of the navicular lack significant blood flow [10] and frequently require internal fixation to ensure higher healing probabilities. Due to the avascularity of the body of the navicular [3] and young age of patients, it was appropriate to have surgical correction of the fracture site to help prevent non-union, avascular necrosis and future displacement or arthritic changes. Due to the lack of dislocation and ease of fracture site approximation, the ability to reduce and fixate these fractures percutaneously was both imperative and beneficial. Both patients having suffered high impact falls with minor osseous injury, had excellent surgical outcomes.

We propose the concept that there is potentially another mechanism of injury with corresponding fracture patterns, not previously cited in literature. The foot is accepting forces in an axial loading mechanism while the navicular is able to completely absorb the forces of the impact due to the talus and corresponding cuneiforms compressing at equal energies. These cases resulted from longitudinal compressive forces through the foot without any dislocation and allowing solely the navicular bone to absorb their impact.

References

  1. Rymaszewski, L. A., & Robb, J. E. Mechanism of fracture-dislocation of the navicular: brief report. The Journal of bone and joint surgery. British volume, 70(3), 492-492, 1988.
  2. Nyska, M., Margulies, J. Y., Barbarawi, M., Mutchler, W., Dekel, S., & Segal, D. Fractures of the body of the tarsal navicular bone: case reports and literature review. The Journal of trauma, 29(10), 1448-145, 1989.
  3. Buckley R, Sands A, AO Surgery Reference, https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/midfoot/
  4. Sangeorzan, B. J., Benirschke, S. K., Mosca, V. E. A., Mayo, K. A., & Hansen, J. S. Displaced intra-articular fractures of the tarsal navicular. The Journal of bone and joint surgery. American volume, 71(10), 1504-1510, 1989.
  5. Watson-Jones, Reginald. Fractures and Joint Injuries. Baltimore, The Williams and Wilkins Co. Ed. 4, Vol. II, p. 900, 1955.
  6. Main, B. J., & Jowett, R. L. Injuries of the midtarsal joint. The Journal of bone and joint surgery. British volume, 57(1), 89-97, 1975.
  7. Rockett, M. S., & Brage, M. E. Navicular body fractures: computerized tomography findings and mechanism of injury. The Journal of foot and ankle surgery, 36(3), 185-191, 1997.
  8. Mallee, W. H., Weel, H., van Dijk, C. N., van Tulder, M. W., Kerkhoffs, G. M., & Lin, C. W. C. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med, 49(6), 370-376, 2015.
  9. Mathesul, A. A., Sonawane, D. V., & Chouhan, V. K. Isolated tarsal navicular fracture dislocation: a case report. Foot & ankle specialist, 5(3), 185-187, 2012.
  10. Torg, J. S., Pavlov, H., Cooley, L. H., Bryant, M. H., Arnoczky, S. P., Bergfeld, J., & Hunter, L. Y. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. JBJS, 64(5), 700-712, 1982.

 

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Talectomy (astragalectomy) and tibiocalcaneal arthrodesis following traumatic talus fracture-dislocation

Posted on June 30, 2019 | Comments Off on Talectomy (astragalectomy) and tibiocalcaneal arthrodesis following traumatic talus fracture-dislocation

The Foot and Ankle Online Journal 12 (2): 4

by Dr Alison Zander, MBBCh, BSc (hons), MSc (PHNutr)1, Mr Anirudh Gadgil, MBBS, M.S. (Orth), FRCS (Ed), FRCS (Trauma & Ortho)2, Derek Protheroe, BSc(Hons), MSc, PgDip3*

Talus fractures occur rarely but are often associated with complications and functional limitations. Urgent reduction of associated dislocations is recommended with open-reduction and internal fixation of displaced fractures when adjacent soft tissue injury permits [1]. However, it is important to remember that there is a high incidence of long term complications, along with a significant impact on activities of daily living and quality of life.  This case report describes the successful treatment of a severely comminuted talar fracture dislocation with primary talectomy and tibio-calcaneal arthrodesis. A reminder that in selected cases that the talectomy (astragalectomy) may be a viable alternative.

Keywords: talus, comminuted, tibiocalcaneal arthrodesis, fusion, talectomy, astragalectomy, trauma, avascular-necrosis, AVN

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0004

1 – Foundation Doctor, Cardiff and Vale University Health Board, University Hospital of Wales, Heath Park, Cardiff
2 – Consultant Orthopaedic Surgeon, Cardiff and Vale University Health Board, University Hospital of Wales, Heath Park, Cardiff
3 – Advanced Podiatry Practitioner, Prince Philip Hospital, Bryngwyn Mawr, Llanelli, Wales, SA14 8QF
* – Corresponding author: Derek.Protheroe@wales.nhs.uk

Talus fractures account for less than 1% of all fractures, they may be caused by high-energy trauma, and any other form of forced dorsiflexion injury to the ankle and foot [1]. Talar fractures may be classified anatomically as head, neck, body, lateral or posterior processes, displaced or non-displaced. A range of classifications have been established such as the original Hawkins, then modified by Canale & Kelly and then the Sneppe classification [2]. These sub-classifications help to guide treatment options[3]. Non-displaced fractures may be treated conservatively with a non-weight-bearing short-leg cast, whereas displaced fractures require open-reduction and internal fixation. Reconstruction after a talus fracture poses the greater surgical challenge if restoration of the articular surfaces is precluded secondary to comminution [4]. The talus is the second largest of the tarsal bones, with more than half of its surface being covered with articular cartilage, with no muscular attachments[1]. Therefore, the vascular supply of the talus is well-known to be tenuous, therefore predisposing the talus to significant ischemic injury after fractures [5]. Risk of post-traumatic avascular necrosis (AVN) increases with the magnitude of injury [6]. Extensive intraosseous anastomoses are present throughout the talus and are responsible for its survival during severe injuries. At least one of the three main anastomoses preserved may potentially allow adequate circulation via anastomotic channels [1].

Using the Hawkins’s classification system; 0-13% for grade I, 20-50% for grade II, 83-100% for grade III, and 100% for grade IV fracture dislocations result in AVN [1,6]. 

Clinical experience of talar fracture assessment and management is limited by their infrequent incidence, which is further exacerbated by the numerous sub-classifications of fracture, as previously alluded to. Case reports, although regarded as level V evidence can aid and develop an understanding of the risks and benefits of treatment options to achieve optimal patient outcomes [7].  Clinicians should maintain a high index of suspicion for AVN, which can only be diagnosed radiographically six to eight weeks following injury [8].  Furthermore, the potential for long term issues, such as hind-foot arthrosis and further revisionary surgery must be considered, alongside risks of repeated anesthetics for multiple procedures after complications. Approximately 25% of talus dislocations treated with internal reduction require additional surgery, including secondary arthrodesis [9].

Operative treatment measures for this area may be broadly split into two categories; joint sparing procedures – such as protected weight bearing, patella loading splints and bone graft or joint sacrifice procedures – such as talectomy and arthrodesis. Total talectomy and tibiocalcaneal arthrodesis may be viewed as a salvage procedure in this case report due to the case of severe comminuted fracture, where it may be impossible to anatomically reduce the talus and allow for adequate stable fixation. 

A literature search was performed using the keywords ‘talectomy’, ‘astragalectomy’, ‘fracture’, ‘tibiocalcaneal arthrodesis’ and Boolean search terms. Ovid SP databases (including embase & medline) was used with no exclusion dates to allow for a search of all historical literature. It appears that there was only one other reference in 1955 to such a procedure following a traumatic fracture to the talus body [10]. Historically, this case involved a Royal Navy soldier, where following a dislocated fracture a primary talectomy and tibiocalcaneal arthrodesis was performed.

Figure 1 Preoperative radiographs lateral and AP views.

Case Report

A sixty eight-year-old lady with no significant past medical history presented to Accident and Emergency.  She had been a seat-belted, front-seat passenger of a car that suffered a high-speed head-on road traffic collision.  She sustained a grade I (Gustilo-Anderson) open, comminuted fracture dislocation of the talus (Figure 1) with puncture wounds on the lateral aspect of the talus.  The foot was neurovascularly intact initially. The ankle was manipulated and back-slab applied. Apart from body ache and multiple minor abrasions and bruises there were no other injuries.  Whilst she was waiting on the ward to have a CT scan performed she developed increasing pain in foot, numbness of toes and sluggish capillary refill in the toes, which were not relieved even after removing the plaster slab.  She was counselled that she would need to be rushed to the operating room to attempt to reestablish circulation to her foot with a plan to open reduce the fracture and stabilize it. She was also made aware of the possibility of having to excise the fragments if it was not possible to operatively stabilize the fracture.

Procedure

Under spinal anaesthesia, antibiotic cover and usual sterile draping, the lateral puncture wounds were thoroughly debrided and lavaged with saline.  The fracture was exposed using an anterior approach between tibialis anterior and extensor hallucis longus, carefully protecting the neuro-vascular bundle throughout the procedure.  The displaced fracture fragments of the talus, the medial malleolus and the medial hematoma all appeared to have caused pressure on the posterior tibial neurovascular bundle. 

Figure 2 One year follow-up radiographs.

This was relieved after opening the fracture and the toes regained their color.  Intra-operatively, it became apparent that the fracture could not be anatomically reduced and fixated adequately due to the severe degree of comminution, and lack of any soft tissue attachments to the majority of the fragments. Hence, the original plan of anatomical reduction and internal fixation of the fracture was abandoned.  All loose fragments were excised, which involved removing all of the posterior process and body of the talus. Using the cancellous bone from the excised fragments as autogenous graft, the calcaneal and tibial articular surfaces were fused using three 7.5 mm cannulated AO screws (Figure 2). A small lateral malleolar avulsion fragment was excised.  The medial malleolus fragment was reduced and fixed with a cancellous 4mm AO screw (Figure 2). Post-operatively, the foot was observed to be well-vascularised. The lateral wounds were allowed to heal with regular dressings and a plaster of Paris splint was applied.  

Postoperative care protocol

Postoperatively, the patient received intravenous antibiotics for 24 hours, limb elevation for 48 hours and prophylactic anticoagulation for six weeks. Mobilization started with physiotherapy, consisting of non-weight bearing for six weeks, partial-weight bearing in air cast boot for two weeks and then allowed to fully-weight bear with an air cast boot.  The patient was advised to stop using the air cast boot at three months. The wounds healed well and there were no other complications.  

Outcomes

Due to the urgency of care required and history of trauma it was not deemed appropriate to use any form of patient reported outcome measure at the time of incident. However, the patient was reviewed frequently for eight weeks until the wounds healed. Then, accordingly, when she was allowed to weight bear, again at six months, one year and two years post-injury.  At six months, the patient had no pain or tenderness, with some dorsiflexion and plantar flexion possible at the mid-tarsal level. One-year follow-up showed that the tibio-calcaneal fusion was solid via plain x-ray (Figure 2). Final follow up at two years, she had a 2 cm shortening of her right leg measured in a weight bearing manner (measured blocks) and appropriate footwear adaptations were incorporated on the right side.  She is very happy with the outcome, has no pain and is fully mobile and weight bearing without support. 

Discussion

Talus fractures occur rarely and are commonly associated with complications and functional limitations [11].  The main complication being osteonecrosis, Vallier et al reviewed 100 talus fractures and reported osteonecrosis with collapse (31%), ankle arthritis (18%), subtalar arthritis (15%). Operative intervention was complicated by superficial (3.3%) and deep infection (5%), wound dehiscence (3.3%), delayed union (1.7%) and non-union (3.3%) [11]. Restoration of the axial alignment has been recommended to ensure optimisation of ankle and hindfoot function. It has been reported that tibiotalar and subtalar ranges of motion are reduced by up to 50% and arthrosis occurs in roughly 50% of fractures classified as Hawkins type III and IV [4]. The original paper proposing Hawkins classification even stated that comminuted fractures or those involving the body of the talus, were believed to be more problematic injuries and outside the scope of his original article [12].

A range of classifications for talus fractures exist, the most famous being the original Hawkins classification [2]. 

Historically, cases of talus injuries date as far back to as 1608. Interestingly, a term was coined known as ‘aviator’s astragalus’ due to its high frequency of injury in aircraft accidents [12]. The first case of talectomy for compound fracture was reported in 1609 by Hildanus  [13]. The patient had jumped over a ditch and turned his ankle on landing, causing the talus to dislocate completely out of the skin.  The talus was removed completely, following which the man was seen walking without apparent discomfort. In 1931, Whitman reported use of astragalectomy in correction of a calcaneus deformity of the foot [14]. Although these accounts are reported anecdotally, they demonstrate that the procedures used then are used in a similar fashion to case descriptions today. Talectomy has been used as a salvage procedure in correction of pathological deformity in conditions like  Charcot-Marie-Tooth, neglected idiopathic clubfoot, neurogenic clubfoot, cerebral palsy, gunshot wound, hemiplegia secondary to head trauma, Volkmann ischaemic contracture, poliomyelitis, arthrogryposis, myelomeningocele, and Charcot arthropathy  [15-18]. Talectomy has been used for patients with osteomyelitis or osteonecrosis of the talus [19,20]. We found only one study which reported 4 cases of total talectomy for Hawkins Type III fractures dislocations of talus in 1993 [21].  However, tibiocalcaneal arthrodesis was formally not carried out in the patients in this series.

Detenbeck and Kelley (1969) reported dire results following total dislocation of the talus in nine cases, of which seven were open [22]. Eight of the nine developed sepsis; seven required secondary talectomy, five with tibio-calcaneal fusion. This report highlights the serious consequences of this kind of injury. Their recommendations were to apply a more aggressive approach to initial treatment using talectomy and some form of tibio-calcaneal arthrodesis as the primary treatment for fracture-dislocation of the talus.  

Predominantly, cases of tibio-calcaneal (TC) arthrodesis are described for treatment of post-traumatic AVN of the talus or for treatment of rheumatoid arthritis [23-25]. Authors have reported TC arthrodesis of nine ankles in eight patients; seven were for post-traumatic talar AVN and one for rheumatoid arthritis [25]. Fixation was achieved using 6.5 or 7mm cannulated screws or multiple staples, with autologous cancellous bone graft.  Fusion was achieved in all patients between 12 and 40 weeks with a 2cm leg length discrepancy. Complications included local infection, malunion, wound dehiscence, prominent fibula and two patients required supplemental external fixation.  

In 1972, Reckling reported early TC fusion after displaced talus fractures in eight feet; Steinmann pins were used to achieve fixation without the use of bone grafting [26].  No wound complications were reported and bone union was achieved within 17 weeks. 

The main draw-back of TC fusion is the shortening of 2 to 3 cm that is produced in the limb.  It is also possible that secondary arthrosis of other joints of the foot may occur over time after TC fusion.

Using the technique of tibio-calcaneal fusion there is a potential to increase the calcaneal pitch angle. Intra-operatively, the surgeon must be careful to keep this in mind and achieve a well-aligned position of the foot. 7.5 mm cannulated AO screws were utilised providing stable compression across the fusion surfaces and encouraged rapid fusion of the inferior tibial surface to calcaneal articular surface.  There are other modes of fixation discussed within the literature such as intramedullary nail, pre-contoured plates or an external fixator. This would depend not only the surgeon’s experience and preference but in this case the setting (trauma) and clinical scenario due to the compromised blood supply.

Dennison et al treated six patients who had previous failed surgery and suffered post-traumatic AVN of the talus [27]. The necrotic body of the talus was excised and TC fusion achieved using an Ilizarov frame, combined with corticotomy and a lengthening procedure.   Patients were aged between 27 and 67 years. Shortening was corrected in four patients, and bony fusion achieved in all. Four out of six patients reported good or excellent results. 

Thomas and Daniels in 2003 reported using talonavicular and subtalar arthrodesis as a primary fusion to treat a three week old Hawkins type IV traumatic comminuted neck of talus fracture in a 29-year-old man [28]. Their case had similarities to ours, in that open reduction internal fixation had been planned, however, this was not possible anatomically due to the degree of comminution.  The patient underwent 16 months of follow-up and despite successful fusion without avascular necrosis, he was unable to return to his job as a roofer. 

Hantira et al reported treating a comminuted open fracture of the body of the talus on the same day of injury by tibio-talar fusion using the Blair technique [29].  Küntscher nails and cancellous screws remained in situ while the graft healed and they were removed at four and eight weeks post-surgery, respectively.  The patient started active and assisted foot exercises 14 weeks following surgery, with partial-weight bearing on crutches 20 weeks after the injury.  Fusion was complete at 10 months after injury and the patient was reportedly almost pain free.

Conclusion

The severity of talus fractures has increased over the last 3 decades due to modern safety equipment resulting in higher survival rates from serious accidents [2]. Due to recent advances in surgical and fixation techniques, the tendency is to reduce the talar fractures as anatomically as possible and stabilize them with screws.  

It is worthwhile considering the option of a talectomy in conjunction with a primary tibiocalcaneal arthrodesis. although cases of talus fractures with comminuted dislocations are rare. In this particular case study, to attempt to perform an open reduction and internal fixation procedure may have increased the potential risk and complications associated with these procedures, mainly AVN, traumatic hind foot arthrosis both potentially requiring further surgery. Ultimately, increasing the potential for a high rate of long-term complications and a significant impact on activities of daily living and quality of life after such treatment [30].

In summary, surgeons should be flexible in their approach in regards to consideration of treatment options in order to maximise patient outcomes.  This case highlights that the procedure choice of a primary talectomy and tibio-calcaneal arthrodesis is a viable treatment option for traumatic dislocated comminuted talar fractures, which intra-operatively was unable to be anatomically reduced and fixated.

Funding declaration: None  

Conflict of interest declaration: None

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  28. Thomas RH, Daniels TR. Primary fusion as salvage following talar neck fracture: a case report. Foot Ankle Int. 2003 Apr; 24(4):368-71. 
  29. Hantira H, Al Sayed H, Barghash I. Primary ankle fusion using Blair technique for severely comminuted fracture of the talus. Med Princ Pract. 2003 Jan-Mar; 12(1):47-50E
  30. Stake IK, Madesan JE, Hvaal K, Johnsen E. Surgically treated talar fractures. A retrospective study of 50 patients. Foot and Ankle Surg. 2016; 22:85-9.

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Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

Posted on September 30, 2018 | Comments Off on Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

by Amanda Kamery DPM1*, Craig Clifford DPM MHA FACFAS FACFAOM2

The Foot and Ankle Online Journal 11 (3): 1

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients.

Keywords: ankle fracture, trauma, geriatric, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2018.1103.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Residency Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author: akamery@kent.edu

Geriatric patients are at an increased risk for sustaining ankle fractures due to increased fall rate and decreased bone density. Surgical repair for such injuries is often complex, due to the standard large incision and relatively bulky fixation which is necessary in the geriatric patient due to their generally poor bone stock [1]. This traditional form of fixation carries a complication rate of up to 30% [2]. Additionally, wound healing complications and hardware irritation is more common in this population due to a poor soft tissue envelope, with wound infection rates ranging from 26-40% [3]. Commonly, subsequent surgeries are necessary to remove hardware or to perform wound debridements [4]. As it is well documented that surgical morbidity increases in this population, it is important to utilize techniques and fixation methods that limit subsequent encounters. In this case report, we present intramedullary fixation for distal fibular fractures as a viable option for the geriatric population.

Case  Report

The patient is a 94-year-old male who presented 5 days after a fall with a Weber B, slightly comminuted, left distal fibular fracture (Figure 1a). Due to the unstable nature and slight displacement of the fracture, surgical intervention with an intramedullary fibular rod was chosen. Intra-operatively under general anesthesia, excellent anatomic reduction was noted after placement of the rod and one syndesmotic screw (Figure 1b).

At 2 weeks postoperatively, the posterior splint and skin staples were removed. The patient transitioned to protected heel touch weight-bearing for 4 weeks. He resumed regular activity and normal shoe wear at 6 weeks postoperatively. There were no wound healing complications or hardware irritation noted throughout the postoperative course. At 12 months follow up, patient reported no ankle pain or limitations in activities of daily living (Figures 2a-b).

 

Figure 1 AP ankle radiograph showing Weber B fracture with slight comminution and displacement (a). Two weeks postoperative AP radiograph showing excellent anatomic reduction with fibular rod and syndesmotic screw (b).

 

Figure 2 Twelve months post operative AP (a) and lateral (b) radiographs showing excellent bony consolidation of fracture fragments and adequate anatomic reduction.

Discussion

Treatment of distal fibular fractures in geriatric patients have an increased risk for postoperative complications which can lead to wound healing issues and subsequent surgeries. It is important to utilize techniques and fixation methods that limit subsequent encounters in order to decrease surgical morbidity in this cohort. The intramedullary fibular rod is an excellent alternative to traditional ORIF in the geriatric population. Our case example demonstrates an ideal patient for this technique, including successful anatomic realignment and uneventful postoperative course.

References

  1. Mitchell JJ, Bailey JR, Bozzio AE, Fader RR, Mauffrey C. Fixation of distal fibula fractures: an update. Foot Ankle Int. 2014;35(12):1367-1375.
  2. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502)
  3. Höiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642-648.
  4. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop 2007;31:817–821.

 

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Lateral Subtalar Dislocation of the Foot: A case report

Posted on November 1, 2011 | Comments Off on Lateral Subtalar Dislocation of the Foot: A case report

by Dr. M.R.Jayaprakash 1, Dr.Vijaykumar Kulumbi 2, Dr.Ashok Sampagar 3, Dr.Chetan Umarani 4

The Foot and Ankle Online Journal 4 (11): 1

Subtalar dislocation, also known as peritalar dislocation, refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. Subtalar dislocation can occur medially or laterally with resulting deformity. Medial dislocations comprise up to 85% of subtalar dislocations whilst lateral subtalar dislocations are less frequent and in 15% to 20% of dislocations. Closed reduction and immobilization remains the treatment of choice. The tibialis posterior, talar head impaction, and entrapment of the joint capsule may cause difficulty in closed reduction of lateral dislocations; hence open reduction may be necessary. This case report presents an unsuccessful closed reduction of a lateral subtalar dislocation which required an open reduction technique using wire stabilization.

Key words: Subtalar dislocation, talus, trauma, closed reduction, open reduction.

Accepted: October, 2011
Published: November, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0411.0001

Subtalar dislocation is a rare rearfoot injury, it disturbs the normal anatomy and function between the talus, calcaneus and navicular bone. [1,2,3,7,10] The talocal-caneal and talonavicular joints can be dislocated simultane¬ously, without a fracture of the neck of the talus .This has also been referred to as a peritalar or subastragalar dislocation. [4]

Although some dislocations may completely reduce or even partially reduce on its own, there are basically two types of subtalar dislocation reported in the literature. In lateral subtalar dislocation, the head of talus is found medially and the rest of the foot is dislocated laterally. In medial subtalar dislocation, the head of the talus is found laterally and the rest of the foot is dislocated medially. [4,6]

However, in a lateral subtalar dislocation, the talus can remain fixed while the remaining structures of the foot are dislocated laterally along the talus. It is important to check the stability and congruity of the talus in the ankle mortise with any subtalar dislocation.

Subtalar dislocations present with an impressive amount of deformity. Medial dislocation has been referred to as an “acquired clubfoot”, while the lateral injury is described as an “acquired flatfoot”. [6,7] Lateral dislocations are particularly prone to poor results, due to the frequency of open injuries and associated fractures4. We report a case of lateral subtalar dislocation in 35 year-old man in whom closed reduction was unsuccessful hence open reduction was performed.

Case Report

A 35 year-old man, who sustained a high energy trauma while travelling on a two-wheeler. He was then hit by an oncoming tractor. He presented to Bapuji Hospital. The foot was diffusely swollen with a laceration over the medial border of the foot. The skin was distorted and markedly tented over the prominent head of the talus which was felt medially. The posterior tibial artery was not palpable due to severe swelling and the dorsalis pedis artery was palpable. Radiographs showed that the foot along with calcaneum had moved laterally off the talus. (Figs. 1A, 1B and 1C)

  

Figures 1A, 1B and 1C Radiographs showing talonavicular dislocation. (A and B).  Initial radiograph showing lateral subtalar dislocation without signs of fracture.  The talus is displaced along the ankle mortise. (C)

Initially a closed reduction was attempted and this was unsuccessful. The patient was then prepared for surgery for open reduction and stabilization. A medial incision was performed extending the lacerated wound. The posterior tibial tendon was identified. The displaced talus was relocated into the joint after further dissection and reduction. The posterior tibial tendon was retracted and the talus was levered into the position and reduction was achieved. Reduction was confirmed using a computer assisted radio monitor (c- arm). (Fig. 2A and 2B) A thick Kirschner wire was inserted from the calcaneum into the talus to hold the reduction. A below knee splint was applied after placing sterile dressing on the operative site. The splint was then replaced with a windowed cast to inspect the incision daily.The operative reduction was successful. (Fig. 3A and 3B)

 

Figures 2A and 2B  Intraoperative radiographic scans showing insertion of Kirschner wire through the calcaneum.

 

Figures 3A and 3B Intraoperative photographs showing correction of deformity after the reduction of dislocation.

Discussion

Dislocation of the talus can occur in conjunction with major talus fractures. [5] However, dislocations can also occur with no associated bony injury or with relatively minimal appearing fractures. [3,4] Subtalar dislocation, also known as peritalar dislocation refers to the simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. [4,6]

First described by Judcy and Dufaurets [7] in 1811, clinical reviews of subtalar dislocations are relatively infrequent and generally limited to small numbers of patients. Subtalar dislocation can occur in any direction. Significant deformity is always present. Up to 85% of dislocations are medial. [5,7] The calcaneus, with the rest of the foot is displaced medially while the talar head is prominent in the dorsolateral aspect of the foot. The navicular is medial and sometimes dorsal to the talar head and neck. Lateral dislocation occurs less often about 10-15%. [6,7,10]

In a lateral peritalar dislocation, the calcaneus and navicular is displaced lateral to the talus and the talar head is prominent medially. [4,10] Rarely, a subtalar dislocation is reported to occur in a direct anterior or posterior direction, [2,7] but these are usually associated with medial or lateral displacement as well.

Between 10% and 40% of subtalar dislocations are open. [13] Open injuries tend to occur more commonly with the lateral subtalar dislocation pattern and probably as the result of a more violent injury. Long term follow-up demonstrated very poor results with open subtalar dislocations. [13]

The majority of subtalar dislocations can be reduced in a closed manner in the emergency department with the use of local anesthesia and procedural sedation. Early reduction is essential to prevent loss of skin due to pressure necrosis from the underlying dislocation. [4]
In approximately 10% of medial subtalar dislocations and 15% to 20% of lateral dislocations, closed reduction cannot be achieved. [11,12] Soft tissue interposition and bony blocks have been identified as factors preventing closed reduction. [11] With medial dislocations, the talar head can become trapped by the capsule of the talonavicular joint, the extensor retinaculum or the extensor tendons, or the extensor digitorum brevis muscle. [11,12] With a lateral dislocation, the posterior tibial tendon may become when firmly entrapped and present as a barrier to closed and even open reduction. [7,12]

In 1954, Leitner [12] initially proposed a mechanism by which the flexor retinaculum is disrupted, allowing the tendon to drape over the talar head and preventing reduction. In 1982 DeLee, et al., [4] in their case series three of the four lateral disloca¬tions required open reduction. Of these three, the posterior tibial tendon was the obstructing agent in two and a fracture of the head of the talus prevented closed reduction in one.

In our case presentation, the patient had sustained high energy trauma. Initially a closed reduction was attempted, but was unsuccessful. In the open reduction, we identified the tibialis posterior tendon as obstructing the reduction. Open reduction with Kirschner wire or Steinman pin reduction is shown to successfully reduce a lateral subtalar dislocation in this case report.

References

1.Brunet P, Dubrana F, Burgand A, Nen De Le, Lefebre C. Subtalar dislocation: review of ten cases at mean ten-year follow-up. JBJS 2004 86B (Supp 1):57.
2. Lyrtzis CH, Papadopoulos A, Fotiadis E, Ntovas TH, Petridis P, Koimtzis M. Isolated medial subtalar dislocations -conservative treatment. EEXOT 2009: 195-198
3 Capelli RM, Galamnini V, Crespi L. Subtalar anterolateral dislocations: case report and literature review. J Orthop Traumatol 2002 3:181-183.
4. DeLee JC, Curtis R .Subtalar dislocations of the foot. JBJS 1982 64A: 433-437.
5. Monson ST, Ryan JR. Subtalar dislocation. JBJS 1981 63A: 1156-1158,
6. J. Terrence Jose Jerome, Mathew Varghese, Balu Sankaran, K. Thirumagal. Lateral subtalar dislocation of the foot: A case report. The Foot & Ankle Journal, 2008 1 (12): 2.
7. Sanders DW. Fractures of the talus. In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood and Green’s Fractures in Adults. Vol 1. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2249-2292, 2006.
8. Plewes LW, McKelvey KG. Subtalar dislocation. JBJS 1944 26A: 585-588.
9. Smith H. Subastragalar dislocation: a report of seven cases. JBJS 1937 19A: 373-380
10. Joel Horning,John DiPreta .Subtalar Dislocation. Orthopedics 2009; 32:904
11. Mulroy, R. D.: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. JBJS 1955 37A: 859-863.
12. Leitner, L., Baldo: Obstacles to reduction in subtalar dislocations. JBJS 1954 36A: 299-306.
13. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations: long-term results. JBJS 1995 77A: 1075 -1079

Address correspondence to: Dr.M.R.Jayaprakash Ramakrishna, 43, PJ extension, 2nd main, 7th cross, Davanagere, Karnataka India 577002 . Phone (Mobile) – +919448667305, (Clinic) – 08192-253609, Email- umaranicm@gmail.com, ashok.samp@gmail.com

1  Professor and Unit Head,Department of Orthopaedics, JJM Medical College,Davangere, India 577004.
2  Professor of Department of Orthopaedics. JJM Medical College, Davangere, India 577004.
3  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.
4  Resident in Orthopaedics. JJM Medical College. Davangere, India 577004.

© The Foot and Ankle Online Journal, 2011

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Incorporating Platelet Rich Plasma and Platelet Poor Plasma into Open Reduction Internal Fixation of Closed Calcaneus Fractures to Reduce Wound Complication: A Case Study

Posted on November 1, 2009 | Comments Off on Incorporating Platelet Rich Plasma and Platelet Poor Plasma into Open Reduction Internal Fixation of Closed Calcaneus Fractures to Reduce Wound Complication: A Case Study

by Travis A. Motley, DPM, FACFAS1 , John Randolph Clements, DPM, FACFAS2 ,
J. Kalieb Pourciau, DPM3

The Foot and Ankle Online Journal 2 (11): 1

Background: Calcaneal fractures are high energy injuries. There is some debate with the advantages and disadvantages of treating calcaneal fractures with open reduction and internal fixation based on surgical complication rates.
Methods: We describe the management of 12 patients who presented to our emergency department with 14 closed intra-articular calcaneal fractures (7 Sanders Class III fractures, 7 Sanders class IV fractures). These 14 fractures were treated with open reduction and internal fixation. We describe a technique using platelet rich plasma and platelet poor plasma in the closing of the soft tissues after open reduction of calcaneal fractures.
Results: While complications with open reduction of calcaneal fractures include poor wound healing and infection and can range between 26 and 60 percent, we observed no complications in our small series.
Discussion: Wound complications are the most common and potentially threatening consequence of open reduction and internal fixation of calcaneal fractures. The purpose of this case study is to offer the addition of platelet rich plasma (PRP) and platelet poor plasma (PPP) in the treatment of these complicated injuries. The study also attributes the low complication rate to application of pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach and “hands off” retraction. As well as low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting. Our series matched that of previous studies without a single wound complication.

Key Words: Trauma, calcaneal fractures, Algower-Donati suture technique, platelet rich plasma (PRP), platelet poor plasma (PPP).

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0001

The calcaneus is the most commonly fractured tarsal bone constituting 60% of all major tarsal injuries, but only 2% of all fractures of the body. [1] Calcaneus fractures are high energy injuries [2] and most commonly occur with a fall from a height. [1]

A study by Lance, et al.,[3] has recorded calcaneal fractures from falls ranging three to fifty feet with an average of 14 feet. There is debate over the appropriate treatment for closed calcaneal fractures. The majority of this debate deals with complication rates and functional outcomes of conservative versus surgical management.

Complications of open reduction internal fixation (ORIF) include, but are not limited to, wound complications (dehiscence, hematoma, erythema, cellulitis, and infection), thromboembolism (deep venous thrombosis and pulmonary embolus), malreduction, compartment syndrome, nerve conditions (entrapment, numbness, reflex sympathetic dystrophy), osteomyelitis, and shoewear modifications. Subsequent operations may be required such as fasciotomy, secondary arthrodesis, peroneal nerve neurolysis, hardware removal, exostectomy, and irrigation and debridements for deep surgical site infections. [4,5] Several predisposing factors contribute to wound complications. Furthermore, the Sanders classification [6] can be predictive of complication rates. A previous study reported Sanders Class II calcaneal fractures have an overall complication rate of 27%, Class III fractures are 26%, and Class IV fractures are 60%. [4] The overall complication rate with ORIF of all closed calcaneal fractures is between 0% and 25% with wound complications being between 0% and 16%. [4,5]

Soft tissue and bone healing are mediated by a cascade of intra- and extracellular events. These events are regulated by signaling proteins and specific healing stages. Wound healing has three overlapping stages: inflammation, proliferation, and remodeling. Inflammation is the initial response to tissue injury. The main goal of the inflammatory phase is to provide rapid hemostasis and begin the sequence of events that leads to regeneration of tissue. During the proliferative phase, the damaged, necrotic tissue that is being removed via phagocytosis starts to be replaced with living tissue that is specific to the local tissue environment. During remodeling, the newly generated tissue reshapes and reorganizes to more closely resemble the original tissue. [7]

Platelets play a prominent role as one of the first responders during the acute inflammatory phase. In response to tissue damage, platelets are activated resulting in the formation of a platelet plug and blood clot for hemostasis. The alpha granules of activated platelets contain numerous proteins that influence wound healing. These include platelet derived growth factor, transforming growth factor, insulin-like growth factor, and Factor V, among others. In the presence of calcium, Factor V binds to activated factor X to produce prothrombin activator which converts prothrombin to thrombin. Thrombin then converts fibrinogen to fibrin which binds to platelet surface receptors. This activates another series of factors which are involved in activating factor X via the intrinsic pathway. [7] These proteins from platelet degranulation are partly responsible for cellular chemotaxis, proliferation, and differentiation. This includes removal of tissue debris, angiogenesis, establishing the extracellular matrix, and regeneration of the appropriate type of tissue.

Platelet rich plasma (PRP) is, by definition, a volume of the plasma fraction of autologous blood having a platelet concentration above baseline. [8] Therefore, PRP has the full complement of clotting factors and higher concentration of platelets. The portion of plasma that remains deficient in platelets is known as platelet poor plasma (PPP). PPP has clinical roles as fibrin sealant for hemostasis. Platelet concentrations in PRP range from 2 – 8.5 times that of normal plasma. [7]

Methods

Each patient enrolled in our study was stabilized by one of the three authors in our emergency department. The optimal time for operation was determined by soft tissue indicators: absence of fracture blisters, positive skin wrinkle test, and restoration of elastic properties within the area of incision. Preoperatively, all patients received one gram of Cephalexin, or one gram of Vancomycin if patient had an allergy to penicillin, intravenously 30 minutes prior to the procedure.

Patients were placed in a lateral decubitus position depending on the operative side. A pneumatic thigh cuff was used for hemostasis. The operative foot was supported with a Seattle pillow. The operative leg was then prepped and draped using aseptic technique. The leg was elevated and exsanguinated and the tourniquet was then inflated. A surgical marking pen was then used to draw an L-shaped lateral extensile incision over the lateral aspect of the calcaneus as to maximally preserve the blood supply to the lateral subperiosteal flap as described by Borelli. [9] The horizontal arm was 2 cm superior to the plantar fat pad, the vertical arm of this incision was 1 cm anterior to the Achilles tendon. Each arm of the “L” measured approximately 8 cm in length. The incisions were initially made to the level of the bone. The subperiosteal flap, including the peroneal tendons and the sural nerve, was elevated from the lateral wall of the calcaneus superiorly and retracted with Kirschner wires in the fibula, talus, and cuboid. (Fig. 1) This allowed visualization of the lateral calcaneal body, the calcaneocubiod joint and the subtalar joint.

Figure 1 Extensile lateral approach with Kirschner wires retracting full-thickness skin flap.

After reduction of the articular surfaces, calcaneal body and the lateral calcaneal wall, a low profile titanium perimeter plate and screws (ACE-Depuy®, Warsaw, Indiana) was utilized for fixation.

The wound was copiously irrigated with normalized saline using bulb syringe. A 4-mm flat Jackson-Pratt facial drain was then placed exiting dorsally and sutured into place. Next, PRP derived from the Gravitational Platelet Separation System (GPS® III, Biomet®, Inc., Warsaw, Indiana) was then applied to any body defects and the operative field. The wound was then carefully closed in layers using 2-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) for deep tissue, 3-0 Vicryl (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) subcutaneously, and 4-0 Ethilon (Ethicon®, Johnson & Johnson, Inc., Somerville, New Jersey) to reapproximate the skin using the horizontal Allgower – Donati suture technique. [10] (Fig. 2)

Figure 2 Closed extensile lateral approach with Allgower-Donati suture technique. Drain exit site is beyond region of the elevated flap.

Platelet poor plasma from the GPS® III system was then applied above the incision. The wound was bandaged with sterile gauze, kling, and a bulky Curity™ Lakeside™ cotton roll (The Kendall Company, Boston, Massachusetts) compressive posterior splint. The tourniquet was deflated and there were typical hyperemic responses to all the digits. Patients were admitted for postoperative pain management. Drain output was recorded until it produced 30 cc or less in 24 hours. Then, the drain was removed. All patients received one gram of Cephalexin every eight hours or one gram of Vancomycin every 12 hours post operatively until discharged.

Patients were discharged home when their pain was managed appropriately with oral medication. Utilizing this technique, none of our patients had wound complications. Each patient healed the surgical site without incident.

Results

We report on open treatment of 14 calcaneal fractures from 12 patients. Thirteen of the fourteen were sole ORIF of intra-articular calcaneal fractures. One of the fourteen had a primary subtalar joint arthrodesis in addition to reduction of the calcaneus. This patient was included in the study because the surgical approach and timing resembled the other patient who received ORIF. Eleven patients were male, one was female. One patient sustained bilateral injury, and received bilateral repair. Ten of our patients had no pertinent past medical history. One male had a past medical history of transient ischemic attacks, hypertension, and hypothyroidism. One female had a history of numerous psychiatric disorders. Fifty percent (6 of 12) of our patients had social histories significant for tobacco use. There were seven right and seven left calcaneal fractures. Average follow up time period was 11.4 months (range 7-18 months). Average patient age was 35.25 (range from 21 – 69). There were no wound complications in our series utilizing our technique.

Discussion

Calcaneal fractures are high energy injuries with reported complications after ORIF of 0 – 25%.4,5 There is still debate regarding ORIF compared conservative treatment of closed calcaneal fractures based on these complications. In a prospective randomized trial comparing open reduction and internal fixation with non-operative treatment, Howard, et al., [4] reported complication rates of 25% in ORIF of 226 intra-articular calcaneus fractures.

This was then subcategorized into 16% wound complications, 5.8% malpositions of fixation, 1.2% thromboembolisms, 1.6% compartment syndromes, and 0.4% deep infections. All surgeons used the lateral extensile approach in their study.

According to a literature review done by Benirschke and Kramer5, serious infections (those requiring more than oral antibiotic therapy) after ORIF of closed calcaneus fractures range from 0% to 20%. They site three studies that claim 0% complication rates [11-13] and one study with a 20% complication rate. [14] The authors questioned the utility of these findings citing small sample sizes, short follow up times, multiple surgeons, and multiple approaches as concerns. To address those issues they reported on 341 closed calcaneal fractures treated by the senior author (Bernischke) with ORIF via an extensile lateral approach and a two layer closure. He reported only 1.8% of his subjects required further intervention. These finding were comparable to the largest study in their literature review which reported three deep infections in 114 fractures for a rate of 2.6%. [15] Benirschke cited non-compliance as the primary factor of his complications although smoking and predisposing medical conditions also contributed. Other authors have also found smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications, and consideration should be given to nonsurgical management. [16]

As previously concluded by Pietzrak and Eppley [7], platelets direct wound healing. They appear almost immediately at the site of soft tissue injury and create a local environment conducive to tissue generation by secretion of proteins from their alpha granules. Basic science supports the hypothesis of enhancing healing by the placement of a supraphysiologic concentration of autologous platelets at the site of soft tissue injury.

So far, PRP has been applied to the following areas of medicine: cardiopulmonary bypass, mandibular bone augmentation for dental implants, diabetic foot ulcers, periodontal, lumbar spine fusion, and cutaneous ulcers, bone grafting, and cardiovascular surgery with documented success. [17-24]

Wound complications are the most common and potentially threatening consequence of ORIF of calcaneal fractures. There have been previous papers describing techniques to help lower this complication. Our series matched that of previous studies without a single wound complication. While our series is limited to 14 fractures, several important points can be made. Most series of high energy injuries refer to several factors that can influence complication rates: energy of the injury, surgeon experience, soft tissue handling, medical history, patient compliance, social habits, and nutritional status. It can be said with some certainty that constant experience with calcaneal fractures leads to a decreased complication rate. Although the purpose of this case study is to offer the addition of PRP and PPP to the treatment of these complicated injuries, we believe that our low complication rate is multifactorial. This includes pre-operative bulky Jones type splinting, appropriate surgical timing, pre-operative intravenous antibiotic administration, extensile lateral subperiosteal approach, “hands off” retraction, low profile hardware, drain placement, layered closure with Algower-Donati suture technique, surgeon experience and appropriate post-operative bulky splinting.

References

1. Ruch JA, Taylor GC: Calcaneal Fractures. In Comprehensive Textbook of Foot Surgery 2nd Edition, p1543, edited by ED McGlamry, AS Banks, MS Downey, Williams & Wilkins, Baltimore, 1992.
2. DiGiovanni CW, Benirschke SK, Hansen ST: Foot Injuries. In Skeletal Trauma 3rd Edition, pp 2406 – 2417, edited by BD Browner, JB Jupiter, AM Levine, PG Trafton. WB Saunders, Philadelphia, 2003.
3. Lance EM, Carey EJ: Fractures of the os calcis: a followup study. J Trauma 4: 15 – 56, 1964.
4. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R: Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 17(4): 241 –249, 2003.
5. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 18(1): 1 – 6, 2004.
6. Sanders R, Fortin P, DiPasquale T, Walling A: Operative treatment in 120 displaced intraarticular calcaneus fractures. Results Using a Prognostic Computed Tomographic Scan Classification. Clin Orthop Rel Res 290: 87 – 95, 1993.
7. Pietrzak WS, Eppley BL: Platelet rich plasma: biology and new technology. J Craniofacial Surgery 16 (6): 1043 – 1054, 2005.
8. Marx RE: Platelet rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 10: 225 – 228, 2001.
9. Borrelli J Jr., Lashgari C: Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma 13 (2): 73 – 77, 1999.
10. White RR, Babikian GM: Tibial shaft. In AO principles of fracture management pp 525 – 526, edited by TP Ruedi, WM Murphy, Thieme, New York, 2000.
11. Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM, Lin SY: Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus. J Trauma 52: 946 – 950: 2002.
12. Raymakers JT, Dekkers GH, Brink PR: Results after operative treatment of intra-articular calcaneal fractures with a minimum follow up of 2 years. Injury 29: 593 – 599, 1998.
13. Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH: Outcome of foot injuries in multiple injured patients. Orthop Clin North Am. 32:193 – 204, 2001.
14. Assous M, Bharma MS: Should os calcis fractures in smokers be fixed? A review of 40 patients. Injury 32: 631 – 632, 2001.
15. Naovaratanophas P, Thepchatri A: The long term results of internal fixation of displaced intra-articular calcaneal fractures. J Med Assoc Thai 84: 36 – 44, 2001.
16. Early JS, Starr AJ, Folk JW: Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma 13(5): 369 – 372, 1999.
17. Del Rossi AJ, Cernaianu AC, Vertrees RA, Wacker CJ, Fuller ST, Cilley Jr JH, Baldino WA: Platelet-rich plasma reduces postoperative blood loss after cardiopulmonary bypass. J Thorac Cardiovasc Surg 100: 281 – 286, 1990.
18. Marx RE: Platelet concentrate: a strategy for accelerating and improving bone regeneration. In Bone Engineering, pp 447-453, edited by JE Davies, University of Toronto, Toronto, 2000.
19. Margolis DJ, Kantor J, Santanna J: Effectiveness of platelet releasate for the treatment of diabetic neuropathic foot ulcers. Diabetes Care 24 (3): 483 – 488, 2001.
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21. Hee HT, Majd ME, Holt RT, Myers L: Do autologous growth factors enhance transforaminal lumbar interbody fusion? Eur Spine J 12: 400 – 407, 2003.
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24. Englert SJ, Estep TH, Ellis-Stoll CC: Autologous Platelet Gel Applications During Cardiovascular Surgery: Effect on Wound Healing. JECT 37: 148 – 152, 2005.

Address correspondence to: Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com

1  Travis Motley, DPM, MS, FACFAS, John Peter Smith Hospital, 1500 South Main Street, Department of Orthopaedics, Fort Worth, TX 76104. tmotley@jpshealth.com
2  J. R. Clements, DPM, FACFAS, The Carilion Clinic,Department of Orthopaedics, Three Riverside Place, Roanoke, VA 24014. jrclements@carilion.com
3  J. Kalieb Pourciau, DPM, Acadian Medical Center, 3521 Hwy 190 East, Suite U, Eunice, LA 70535. kpourciau@gmail.com

© The Foot and Ankle Online Journal, 2009

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