Manage high-energy intra-articular tibial fractures.

Decide when to perform operative fixation of clavicle fractures.

Employ plating in managing traumatic proximal tibial fractures.

Avoid infection in shoulder arthroplasty.

Perform Prosthesis with Antibiotic-Loaded Acrylic Cement (PROSTALAC) insertion for infected shoulder arthroplasties.

High-energy Intra-articular Distal Tibial Fractures
Michael S. Sirkin, MD, Associate Professor and Vice Chair, Department of Orthopaedics, University of Medicine & Dentistry of New Jersey—New Jersey Medical School; Chief Medical Informatics Officer and President, Medical Staff, University Hospital; and Chief, Orthopaedic Trauma Service, North Jersey Orthopedic Institute, Newark

Radiography: ankle films centered on joint; computed tomography (CT)—guide to fracture fragments; helps plan surgery; obtain after temporary external fixation

Soft tissue management: primary issue and focus of protocol; poor timing leads to poor outcome; soft tissue must be ready for surgery

Staged protocols: average time to definitive surgery 12 to 14 days in speaker’s series; in Cole and Paterson’s series, ≈3 wk; includes 2 stages

Early stage: fix fibula with transarticular external fixation; allows soft tissue stabilization; stage 1 goals—restoration of skeletal length and alignment; spanning joint and allowing soft tissues to stabilize; distraction across ankle joint

Procedural points: incision posterior and posterolateral; ensure anatomic reduction of fibula

Temporizing fixation: spans joint and allows soft tissue stabilization; maintains length and alignment (not articular congruity); “portable traction”; enables treatment of soft tissues; steps—put pins in tibia and calcaneus; distract fracture (overdistract somewhat); check length and alignment; check bony landmarks; after fixator applied, obtain CT as guide for fracture fragments

Wait for soft tissue stabilization: resolution of edema; appearance of wrinkles; epithelization of fracture blisters; wait ≤3 wk

Late stage: definitive articular reconstruction; remove fixator; stage 2 goals—avoiding complications; anatomic restoration of joint; stable fixation to allow motion; anatomic healing and alignment

Identify major fragments: anterolateral (Chaput); medial malleolus; posterior

Comminution locations: between anterolateral and posterolateral; shoulder or axilla of medial malleolus; central (posterior fragment)

Surgical approach: anterolateral used in procedure; dictated by location of fixation, eg, medial approach for medial plate or anterolateral for anterolateral plate

Compression failure: of fibula; needs lateral buttress; anterolateral plate prevents valgus collapse

Anterolateral approach: incision in line with fourth metatarsal; centered on ankle; exposure onto talar neck distally; preserve superficial peroneal nerve; preserve anterior tibiofibular ligaments; transverse arthrotomy; more proximally, medial to anterior compartment

General fixation strategy: posterolateral fragment first; posteromedial to posterolateral; reduce central impaction; reduce anterolateral fragment; provisional wire fixation; lag screw fixation; fix articular block to diaphysis

Tension failure: medial displacement; needs medial buttress to prevent varus; for Chaput fragment, may need small anterolateral approach

Medial approach: full skin incision over anterior compartment (lateral to tibial crest); toward navicular tubercle; parallel to path of tibialis anterior tendon; excise extensor retinaculum; anteromedial capsulotomy; ensure joint stability; slide plate percutaneously and place screws

Intact fibula: may be lower-energy injury; axial failure possible—talus impacted into tibia; significant articular impaction and comminution

Surgical procedure: open reduction at joint surface; place plate under skin and muscle; place screws percutaneously; enables anatomic reduction with minimal incisions

Postoperative protocol: cast until sutures out; controlled ankle motion (CAM) walker until able to keep foot in neutral; delay weight-bearing for 8 to 12 wk

Outcomes: patients perceive improvement for ≥2.5 yr; ankle scores improve with time; radiographic evidence of arthritis increases with time; negative long-term impact on function—recreation limited (27 of 31 patients unable to run); 50% of patients change jobs; ≤50% fail to return to work

Management of Clavicle Fractures: When to Operate
Jon J. P. Warner, MD, Professor, Department of Orthopaedics, Harvard Medical School, and Chief, Harvard Shoulder Service, Massachusetts General Hospital, Boston

Incidence: 44% of shoulder girdle fractures; ≈5% of all fractures

Anatomy: S-shaped bone; thinnest at middle third (more often fractured); articulation between axial skeleton and appendicular skeleton; sternoclavicular and acromioclavicular joints often involved in fracture; entire length subcutaneous, protecting neuromuscular structures (risk for injury during fixation); rotation critical for abduction power and overhead use of extremity

Midshaft clavicle fracture: deforming forces include weight of arm and pectoralis major muscle (upward) and sternocleidomastoid muscle (downward)

Mechanism of injury: sports and motor vehicle accidents; simple falls

Associated injuries: pulmonary, brachial plexus, spleen, and rib fractures

Classification

Group I: middle third (most fractures)

Group II: distal third (≈15%)

Group III: medial third (<5%)

Presentation: deformity, with scapular internal rotation; shoulder shortened; possible abrasions and ecchymosis

Radiology: Zanca view (15° cephalic tilt) for contour of clavicle; anteroposterior (AP) view of glenohumeral joint

Nonoperative management: results in literature; 132-patient series—34 patients (25.8%) dissatisfied; 208-patient series—46% experienced sequelae; 7% nonunion; 9% pain at rest; 29% pain during activity; 27% cosmetic defects; predictors include no bony contact, comminution, and older patient; 52 patients with completely displaced fractures— 15% incidence of nonunion; with shortening >20 mm, incidence of nonunion 100%; in 31%, results unsatisfactory

Operative treatment: absolute indications—open fracture; skin compromised; neurovascular injury; complete displacement; >2 cm shortening; comminution

Intramedullary fixation: indications include no comminution, single butterfly fragment, and minimal soft tissue dissection; disadvantages include pin migration

Speaker’s approach: involves dedicated “beach-chair” position, fluoroscopy (allowing control of procedure without moving C-arm in and out of field), small incision over clavicle in line with skin creases, and drilling out lateral clavicle through fracture

Postoperative management: immobilization usually unnecessary; sling ≤7 days; return to full activities of daily living (ADLs) as soon as possible

Plate fixation: many plates available; advantages—compression; better rotational control; disadvantages— cosmetic; prominent hardware; frequent need to remove plate

Clavicle malunion: results of fixation in Canadian study—132 patients; faster time to union; lower malunion rate; fewer symptomatic nonunions; functional loss same whether treatment acute or delayed

Lateral fracture: if coroclavicular ligaments lateral to fracture, weight of arm distracts segments of fracture, leading to nonunion (rate ≤30%); fixation (relatively easy) avoids problem

Proximal Tibial Fractures: Submuscular Plating
Thomas F. Higgins, MD, Assistant Professor, Department of Orthopaedics, University of Utah School of Medicine, and Orthopaedic Trauma, University of Utah Orthopaedic Center, Salt Lake City

Introduction: surgery through small incisions underlying issue

First priority: properly aligning good joint on tibia with shaft (percutaneous plating indicated)

Bicondylar fractures: those involving both aspects of articular surface pose challenge; in case example discussed, attempting fixation from one side leaves metaphysis in some varus; addressing intra-articular injury from lateral side alone leaves femur displaced from tibia (rapidly leading to arthritic unstable joint in 19-yr-old female patient)

Caution indicated: reducing articular component highest priority; posterormedial fragment—in speaker’s series of 111 bicondylar plateau fractures, 66% had posteromedial fragment; cannot address percutaneously or from lateral side; medial metaphysis with highly comminuted cortex—offers no support; varus alignment—difficult to assess with fluoroscopy; whether flexed or extended—check lateral view; critical

Results in literature: Cole and Krieger series—77 high-energy fractures; 28% open; 2 loss of fixation; 2 deep infection; 2 nonunion; 10% malalignment (extension most likely); Ritchie series—37 of 38 achieved union and had satisfactory alignment (but speaker notes 13% malaligned); Standard series—34 fractures; 30% open; no deep infection; 1 flexion malunion; 1 valgus malunion

Key Points: ensure axial alignment; taking plain x-ray intraoperatively (requires ≥15 min) avoids malalignment (occurs in 10% to 15% of cases); obtain weight-bearing x-rays at follow-up to evaluate surgeon’s operative techniques

Infections in Shoulder Arthroplasty: Detection and Management
Dr. Warner

Rate of infection: Mayo Clinic— primary arthroplasty, 18 of 2279 cases (0.4%); revision, 3.6%; reverse prosthesis— 0% to 6%; speaker’s experience—of 400 primary cases, 2% incidence of infection; after changes in management, 200 cases without infection; in reverse prosthesis, rate ≈1%

How to avoid: patient selection considerations—risk factors; infection already present (eg, after previous surgery)

Speaker’s approach: preoperative preparation—washing shoulder; prepping arm; surgeon washing in operating room (OR); using best antiseptic (speaker recommends 2% chlorhexidine gluconate and 70% isopropyl alcohol [ChloraPrep]); occlusive dressing; laminar airflow; limiting traffic in OR; operating quickly; frequent irrigation; frequent glove changing; never touching implant without changing gloves; using antibiotics in cement (speaker uses Polycose G cement)

Diagnosis: case example—patient 67 yr of age; presents several months after surgery; dull aching pain; stiffness (unable to raise arm); weakness; no fever, chills, or malaise; no erythema or warmth; axillary nerve sensation intact; weak belly-press sign; ask about—drainage; dental work; x-ray—early radiolucent lines (indicates infection, until proven otherwise); other studies—CT arthrography; serum culture (Propionibacter acnes common)

Classification: proposed by Mayo Clinic group; type 1—positive cultures at revision; type 2—acute infection ≤30 days after surgery; type 3—acute hematogenous infection; type 4—chronic infection

Treatment options: antibiotic suppression; debridement and retention; 1- or 2-stage exchange; Prosthesis with Antibiotic-Loaded Acrylic Cement (PROSTALAC) insertion; resection arthroplasty

Factors in selection: acute or chronic infection; nature of organism (whether virulence high or low; with P acnes, speaker never retained prosthesis); well-fixed or loose; medical comorbidities; status of deltoid and rotator cuff

Antibiotic suppression: in knee, successful in only 24% of cases; reported results—successful in 2 in 5 shoulders

PROSTALAC insertion: results (from case example)—flexion improved; good rotation (patient able to put hand on top of head); active external rotation; at 4 yr (no pain; patient able to perform ADLs; subjective shoulder value 70%)

Speaker’s approach: builds PROSTALAC himself (although commercial device available); exposes prosthesis; extracts stem; employs special 44-mm mold; bends limited contact dynamic compression (LCDC) plate to neck-shaft angle (120°-130°); puts plate into antibiotic cement and creates facsimile prosthesis; rotational stability essential; results—≈8 patients “feel fine” after several years

Other results: 1- and 2-stage reimplantation—Constant scores 33 and 48; no recurrent infection; reverse prosthesis—21 patients, mean follow-up 43 mo (no recurrent infection; mean flexion 74°); resection arthroplasty—indicated in reverse prosthesis failure; relieves pain; function poor