1
|
Wunder J, Schirdewahn C, Griger D, Schnabl M, von Rüden C. [Lisfranc injuries]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:665-676. [PMID: 39079994 DOI: 10.1007/s00113-024-01467-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 08/16/2024]
Abstract
Lisfranc injuries are rare but severe injuries of the foot. They range from ligament sprain to complex fracture dislocations. Etiologically, a distinction is made between indirect and direct force and between high-energy and low-energy trauma. Inadequate diagnostics (injuries overlooked or misinterpreted) can lead to painful posttraumatic osteoarthritis, chronic instability and deformity of the foot. A fracture, malalignment and unclear findings in conventional radiological diagnostics necessitate computed tomography imaging including 3D reconstruction. Lisfranc injuries are often associated with accompanying pathologies of the foot that also need to be addressed. Only stable non-displaced fractures can be treated conservatively. Depending on the injury pattern, surgical treatment is performed percutaneously, minimally invasive or open. The prognosis following Lisfranc injury is determined by the severity of damage and the quality of reconstruction.
Collapse
Affiliation(s)
- Johannes Wunder
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Söllnerstr. 16, 92637, Weiden in der Oberpfalz, Deutschland
| | - Christoph Schirdewahn
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Söllnerstr. 16, 92637, Weiden in der Oberpfalz, Deutschland
| | - David Griger
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Söllnerstr. 16, 92637, Weiden in der Oberpfalz, Deutschland
| | - Matthias Schnabl
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Söllnerstr. 16, 92637, Weiden in der Oberpfalz, Deutschland
| | - Christian von Rüden
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Weiden, Söllnerstr. 16, 92637, Weiden in der Oberpfalz, Deutschland.
- Institut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.
| |
Collapse
|
2
|
Pablo Randolino J, Gaitán L, Slullitel G, Gonzalez E, Lopez V. A Novel Uni- and Biplanar External Fixator for Initial and Definitive Complex Foot Trauma. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241265113. [PMID: 39101198 PMCID: PMC11297515 DOI: 10.1177/24730114241265113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Background Evidence concerning the complex foot trauma, especially its definitive management, is scarce. Soft tissue envelope sequalae are the primary parameters that delay or make internal fixation implausible. Stability conferred by external fixators makes them a reasonable initial treatment choice. Although AO or circular fixators can be applied around the foot, this can involve a learning curve and substantial costs, especially for the circular fixator. There is little evidence as to how well external fixators work as a definite method of fixation in patients where progression to internal fixation cannot be made. Methods We prospectively evaluated 10 adult patients with severe and complex foot trauma who were consecutively treated at our clinic. Initial reduction and stabilization were performed with an external fixator that was initially conceived for distal radius fractures, applied during the initial procedure and mantained throughout the treatment. Results Fracture healing was obtained in all 10 cases, and both internal and external column length was restored. One of the patients developed chronic osteomyelitis. At the 1-year follow-up visit, these patients averaged 45.6 points in the physical and 44.8 points on the mental status sections of the 12-Item Short Form Health Survey (SF-12). The Foot Function Index findings for pain, disability, and daily activities limitations were 33.3, 39, and 41.5, respectively, which suggest moderate residual impairment. Conclusion In this relatively small case series of complex foot trauma, we found that the use of simple external fixation as definitive treatment worked reasonably well. Level of Evidence Level III, prospective cohort study.
Collapse
Affiliation(s)
- Juan Pablo Randolino
- Instituto de Ortopedia y Trauma Dr. Jaime Slullitel. Rosario, Santa Fe, Argentina
- Hospital Escuela Eva Perón, Granadero Baigorria, Santa Fe, Argentina
| | - Laura Gaitán
- Hospital Universitario Quirón Salud, Pozuelo de Alarcón, Madrid, España
| | - Gastón Slullitel
- Hospital Escuela Eva Perón, Granadero Baigorria, Santa Fe, Argentina
| | - Emanuel Gonzalez
- Instituto de Ortopedia y Trauma Dr. Jaime Slullitel. Rosario, Santa Fe, Argentina
| | - Valeria Lopez
- Instituto de Ortopedia y Trauma Dr. Jaime Slullitel. Rosario, Santa Fe, Argentina
| |
Collapse
|
3
|
Extremitätentrauma in der Schockraumphase. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
4
|
Godoy-Santos AL, Schepers T. SOFT-TISSUE INJURY TO THE FOOT AND ANKLE: LITERATURE REVIEW AND STAGED MANAGEMENT PROTOCOL. ACTA ORTOPEDICA BRASILEIRA 2019; 27:223-229. [PMID: 32788854 PMCID: PMC7405111 DOI: 10.1590/1413-785220192704221240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Complex trauma of the foot and ankle is characterized by fractures with severe
soft tissue damage associated with neurovascular injury and joint involvement.
These injuries are frequently present in the polytraumatized patient and are a
predictor of unfavorable clinical outcome. In the initial approach to a patient
with complex foot and ankle trauma, the decision between amputation and
reconstruction is crucial. The various existing classification systems are of
limited effectiveness and should serve as tools to assist and support a clinical
decision rather than as determinants of conduct. In the emergency department,
one of two treatment options must be adopted: early complete treatment or staged
treatment. The former consists of definitive fixation and immediate skin
coverage, using either primary closure (suturing) or flaps, and is usually
reserved for less complex cases. Staged treatment is divided into initial and
definitive. The objectives in the first phase are: prevention of the progression
of ischemia, necrosis and infection. The principles of definitive treatment are:
proximal-to-distal bone reconstruction, anatomic foot alignment, fusions in
severe cartilage lesions or gross instabilities, stable internal fixation and
adequate skin coverage. Level of evidence III, Systematic review of
level III studies.
Collapse
|
5
|
Abstract
Posttraumatic hindfoot varus may result from nonoperative treatment or inadequate reduction and fixation of talar and calcaneal fractures. Adequate visualization of the talar neck via bilateral approaches is essential in avoiding malreduction. In cases of medial comminution of the talar neck, lag screws must be avoided and the use of single or double plates should be considered. A Schanz screw introduced into the calcaneal tuberosity is instrumental in realigning shortening, varus, or valgus deformity of the heel. Special attention should be paid to addressing impaction of the medial facet of both the talus and calcaneus to avoid hindfoot varus.
Collapse
Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Akaradech Pitakveerakul
- Department of Orthopaedic Surgery, Sirindhorn Hospital, Bangkok Metropolitan Administration, 20 Onnuch 90, Prawet, Bangkok 10250, Thailand
| |
Collapse
|
6
|
Technical Tip: Talar Neck Fixation Strategy Based on Fracture Variants. Tech Orthop 2018. [DOI: 10.1097/bto.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
7
|
Abstract
Traumatic injury to the subtalar joint occurs during subtalar dislocations, talar and calcaneal fractures, and fracture-dislocations. After closed reduction of subtalar dislocations, peripheral talar or calcaneal fractures need to be ruled out by computed tomography scanning. In fractures and fracture-dislocations of the talus and calcaneus involving the subtalar joint, anatomic reconstruction of joint congruity is essential for functional rehabilitation. Failure to anatomically reduce the subtalar joint potentially leads to chronic instability, subtalar arthritis and posttraumatic hindfoot deformity. Despite adequate management, subtalar arthritis may develop as a result of primary cartilage damage at the time of injury.
Collapse
Affiliation(s)
- Stefan Rammelt
- Foot & Ankle Section, University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Central Military Hospital Prague, U Vojenské nemocnice 1200, Prague 6 169 02, Czech Republic
| | - Kyeong-Hyeon Park
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea
| |
Collapse
|
8
|
|
9
|
Wijers O, Looijen RC, Halm JA, Schepers T. Extra-articular Medial Impression Fracture of the Talus: A Previously Undescribed Injury. Foot Ankle Spec 2018; 11:1938640018788431. [PMID: 30003805 DOI: 10.1177/1938640018788431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Peripheral fractures of the talus are uncommon. Almost all the literature regarding talar fractures consists of central intra-articular fractures, whereas studies about peripheral talar fractures are lacking. The aim of this study is to increase awareness in diagnosing an unusual peripheral extra-articular medial impression fracture of the talus. METHODS This study includes a retrospective case series of patients with an extra-articular medial impression fracture of the talus. Patient characteristics, trauma mechanism, diagnostics, fracture characteristics, and treatment were reported. RESULTS Eight consecutive patients with an extra-articular medial impression fracture of the talus were identified. In 80%, the trauma mechanism was a supination or inversion injury of the ankle and foot. An X-ray was obtained in all patients; in 7 (88%) patients, a computed tomography scan was done, and an additional magnetic resonance imaging was done in 3 (38%) patients. In 4 patients (50%), the correct diagnosis was missed at first presentation. The delay between injury and diagnosis was 0 to 180 days (of 36 days on average). CONCLUSION This is the first case series to describe patients with a peripheral extra-articular medial impression fracture of the talus. Good clinical examination and judicious use of diagnostic imaging are a necessity to find the talar impression fractures in a timely manner, and treatment can be started immediately. LEVELS OF EVIDENCE Level V.
Collapse
Affiliation(s)
- Olivier Wijers
- Trauma Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Rosa C Looijen
- Trauma Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Jens A Halm
- Trauma Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Tim Schepers
- Trauma Unit, Academic Medical Center, Amsterdam, Netherlands
| |
Collapse
|
10
|
Braun BJ, Pelz P, Veith NT, Rollmann M, Klein M, Herath SC, Holstein JH, Pohlemann T. Long-term pathological gait pattern changes after talus fractures — dynamic measurements with a new insole. INTERNATIONAL ORTHOPAEDICS 2018; 42:1075-1082. [DOI: 10.1007/s00264-017-3720-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 12/10/2017] [Indexed: 12/23/2022]
|
11
|
Abstract
Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.
Collapse
Affiliation(s)
- Tim Schepers
- Trauma Unit, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22660, Amsterdam 1100 DD, The Netherlands.
| | - Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Fetscherstrasse 74, Dresden 01307, Germany
| |
Collapse
|
12
|
Aygün Ü, Çalçk Y, Alkan B, Işçk C. Simultaneous Bilateral Fracture Unilateral Dislocation of the Talus. J Am Podiatr Med Assoc 2016; 106:370-374. [PMID: 27762619 DOI: 10.7547/15-102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this study, we present the case of a 42-year-old man with a fracture and dislocation of the left talus neck, and a fracture of the right talus neck due to a fall. This kind of fracture can be considered rare, and thus few cases have been reported. Fracture fixation was provided through cannulated screws on either side. Splints were removed after 6 weeks, and passive/active joint movement exercises were started. The patient was able to walk with partial weightbearing at 2 months and with full weightbearing at 3 months. The magnetic resonance imaging scan at 1 year postoperatively revealed the presence of avascular necrosis on the left, whereas it did not exist on the right. Range of motion in both of the ankles was satisfactory. The patient expressed that he was able to perform daily activities without any difficulty and run for 30 minutes without pain. In this case report, in addition to providing a review of the relevant literature on the subject, we set out to show the importance of rigid fixation and early mobilization in these rare injuries.
Collapse
Affiliation(s)
- Ümit Aygün
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
| | - Yalkçn Çalçk
- Abant İzzet Baysal University, İzzet Baysal Physical Therapy and Rehabilitation Training and Research Hospital, Bolu, Turkey
| | - Barçş Alkan
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
| | - Cengiz Işçk
- Abant İzzet Baysal University, İzzet Baysal Training and Research Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
| |
Collapse
|
13
|
Ahrberg AB, Leimcke B, Tiemann AH, Josten C, Fakler JK. Missed foot fractures in polytrauma patients: a retrospective cohort study. Patient Saf Surg 2014; 8:10. [PMID: 24568599 PMCID: PMC3944986 DOI: 10.1186/1754-9493-8-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/17/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Missed foot fractures are a known problem in the care of the traumatized patient. They do not usually have an influence on the survival, but on the long-term result and the quality of the patient's life. The aim of this study is to find out how many of these fractures are overlooked in a Level I trauma center and what the consequences for the patients are hypothesing that patients with a delayed diagnosis will have worse clinical results. METHODS Forty-seven patients (7.3%) with foot fractures could be identified in 642 polytrauma patients, retrospectively. All patients were divided into two groups: early diagnosed fractures and delayed diagnosed fractures, the latter defined as diagnosed after Secondary Survey. Patients were evaluated according to the Hannover Outcome Score, the Short Form-36 Health Survey, the AOFAS Score and the Hannover Scoring System. The average follow-up was 5 years and 8 months. Reasons for overlooking a foot fracture were analyzed. RESULTS The foot fracture was early diagnosed in 26 (55.3%) patients, but delayed in 21 (44.7%). There were no significant differences in the mean stay in the hospital or in the ICU. The fractures that were most often missed were those of the cuboid or the metarsalia. The highest risk factor for a delayed diagnosis was a fracture already diagnosed on the same foot. In 52.4% of the delayed diagosed fractures, an operative therapy was necessary. There were no significant differences between the two groups in the clinical results. CONCLUSIONS In summary, the results of this study show that foot injuries can be a safety problem for the patient and the examination of the feet in the trauma room has to be a compulsory part of the algorithm. Although the majority of delayed diagnosed foot fractures demonstrated comparable results to the immediately diagnosed fractures, approximately 10% might have benefited from an earlier diagnosis. Even if there were no significant differences in the clinical results, we have to be aware that missing a fracture in the foot can lead to worse results in the complete polytrauma care.
Collapse
Affiliation(s)
- Annette B Ahrberg
- Department of Orthopedics, Traumatology and Plastic Surgery, University of Leipzig, Leipzig, Germany.
| | | | | | | | | |
Collapse
|
14
|
Rammelt S, Olbrich A, Zwipp H. [Hindfoot amputations]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 23:265-79. [PMID: 21922229 DOI: 10.1007/s00064-011-0042-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Obtaining a durable, weight-bearing stump with minimal or no loss of limb length, and stable soft tissue coverage with preservation of the original sensation of the sole of the foot at the heel. INDICATIONS Complex trauma to the foot with devitalized or nonreconstructable forefoot and midfoot, deep bony and soft tissue infection, infected Charcot foot with threatening sepsis, necrosis or gangrene of the forefoot and midfoot with vasculopathy, malignant tumors, certain infections, gigantism of the forefoot. CONTRAINDICATIONS Possible reconstruction of the midfoot and forefoot beyond the midtarsal (Chopart) joint, loss or irreversible destruction of the sole of the foot or the distal tibial metaphysis. SURGICAL TECHNIQUE The skin incision is designed to retain a long plantar flap with a maximum amount of weight-bearing sole 5-7 cm below amputation level and a shorter anterior flap 1-2 cm below amputation level. Exarticulation or bone resection is performed from anterior to posterior, while preserving the posteromedial vessels to supply the heel flap. The Chopart stump is held in a neutral position avoiding equinus with a tibiotalar external fixator and additional tendon balancing with a noninfected posterior tibialis and one of the peronaeal tendons from medial and lateral through the talar head and Achilles tendon lengthening. Alternatively, a Pirogoff stump with minimal limb length loss (about 2 cm) is achieved with minimal resection at the anterior calcaneal process. The calcaneus is rotated 70-80° and fused to the distal end of the tibia with lag screws or an external frame. Alternatively, a Syme stump is covered with the heel skin after resection of the malleoli flush to the tibial plafond. If anterior wound closure cannot be obtained without tension, temporary vacuum-assisted closure and later definitive coverage with skin grafts, local or free flaps is obtained. In cases of deep infection, the amputation is performed as a staged procedure. POSTOPERATIVE MANAGEMENT Nonweight bearing until stable scar formation, early mobilization in a total contact cast. Interim prosthesis after 2-4 weeks, fitting of the definitive prosthesis with special shoewear after 2-3 months. RESULTS Over a 12-year period, 15 Chopart, 7 Pirogoff, and 2 Syme amputations were performed. A total of 15 patients had sustained a complex foot trauma, 9 had a deep infection, among them 7 in a diabetic Charcot foot. In 16 patients, among them all with deep infection, 1-4 planned revisions were performed. In 5 patients (20.8%), the stumps were revised subacutely to a more proximal amputation level. In 2 patients with Chopart amputation, a hindfoot fusion was performed to correct equinus, while 1 Chopart and 1 Pirogoff stump were subjected to resection of a prominent exostosis. Except for 2 patients with Charcot foot, all patients with hindfoot amputation could walk barefoot over short distances.
Collapse
Affiliation(s)
- S Rammelt
- Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Deutschland.
| | | | | |
Collapse
|
15
|
Eberl R, Ruttenstock EM, Singer G, Brader P, Hoellwarth ME. Treatment algorithm for complex injuries of the foot in paediatric patients. Injury 2011; 42:1171-8. [PMID: 22081809 DOI: 10.1016/j.injury.2009.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Complex injuries of the foot in the paediatric population present difficult treatment challenges. While standardised protocols exist for the adult population to achieve an optimal result in the treatment of such injuries, therapy in paediatric patientsmust be managed without a firm treatment algorithm. METHODS Medical records of all patients with a complex trauma of the foot treated at our Department over a period of 13 years were evaluated. A complex trauma of the foot was defined using the scoring system developed by Zwipp et al. (1997).24 Treatment and outcome were analysed. Additionally, our treatment algorithm of complex injuries of the foot in paediatric patients is presented. RESULTS Twenty-nine patients were included in the study (79%m; 21% f, average age 12.1 years, ranging 2–16 years). Traffic accidents were the most common mechanism (n = 14; 48.3%), followed by a fall from a height in five patients (17.2%). Lawnmower injuries were found in another 3 patients (10.3%) and other mechanisms of injury in 7 patients (24.2%). The mean score according to Zwipp et al. (1997)24 was 5.8 points (range 5–8 points). While closed fractures were diagnosed in 20 (69%) patients, 9 patients (31%) presented open fractures. Operative intervention was necessary in 24 patients (82.8%). Fracture stabilisation could be realised using K-wires in 13 cases (54.2%), screws in 3 cases (12.5%) and plate fixation in 1 case (4.2%). Combined techniques including external fixation were applied in another 7 (29.1%) cases. The mean time between injury and latest follow-up examination was 5.7 years (range 13 months to 13 years). The mean functional outcome was 47.6 (29–56) points for the OAFQ, 15.1 (0–69) points for the FFI and 82.3 (59–100) points for the AOFAS Score. DISCUSSION To regard the maxims in treating complex injuries and open fractures in the growing skeleton we developed a simple treatment algorithm for complex foot injuries in order to provide preservation of the soft tissue envelope, avoidance of infection, restoration of the axis and the articular surface. CONCLUSION A complex trauma of the paediatric foot is a rare and challenging injury. Avoidance of infection, preservation of the soft tissue envelope and fracture healing will provide good functional outcome despite the severity of trauma. Long time follow-up is essential to detect complications.
Collapse
Affiliation(s)
- Robert Eberl
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria.
| | | | | | | | | |
Collapse
|
16
|
Roll C, Schirmbeck J, Schreyer A, Müller F, Neumann C, Nerlich M, Kinner B. How reliable are CT scans for the evaluation of calcaneal fractures? Arch Orthop Trauma Surg 2011; 131:1397-403. [PMID: 21544641 DOI: 10.1007/s00402-011-1312-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Indexed: 02/09/2023]
Abstract
INTRODUCTION CT scans are deemed to be the gold standard for the evaluation of calcaneal fractures. However, the reliability of the interpretation has not been studied systematically. PATIENTS AND METHODS In a prospective multicenter study, the CT data set of five different fractures was presented to 57 evaluators. The participating surgeons were asked to assess calcaneal fractures on the basis of a multiple choice questionnaire. The CT scans were validated by the intraoperative findings. The questionnaires were compared to the model solution of three foot and ankle surgeons. The intra- and interrater reliability was calculated. RESULTS The proportion of intraobserver agreement was 82%. Cohen's kappa was κ = 0.748 with P < 0.0001. In total, 61% of the items were answered similarly to the model answer. Only 27% of the evaluators were able to correctly classify the fracture according to Sanders and 63% of the evaluators agreed that surgical procedure was necessary. The more experienced the surgeon, the higher was the interrater agreement. CONCLUSION This is the first study to systematically analyze the reliability of the interpretation of CT scans of calcaneal fractures. This was found to be unsatisfactory. Future studies must show, if specific interventions, e.g., teaching programs or image procession modalities (e.g., 3D reconstructions), are capable of improving the quality of interpretation of CT scans for calcaneal fractures.
Collapse
Affiliation(s)
- Christina Roll
- Department of Trauma and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany.
| | | | | | | | | | | | | |
Collapse
|
17
|
|
18
|
|
19
|
|
20
|
|
21
|
|
22
|
Kobbe P, Lichte P, Pape HC. Complex extremity fractures following high energy injuries: the limited value of existing classifications and a proposal for a treatment-guide. Injury 2009; 40 Suppl 4:S69-74. [PMID: 19895956 DOI: 10.1016/j.injury.2009.10.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Complex extremity fractures have been described as demanding and associated with an increased risk of complications. Since a treatment-guided classification is not currently available, we recommend a new assessment for complex extremity fractures, categorising them into low, moderate and high risk depending on several fracture-related comorbidities. In our experience, the degree of soft-tissue damage and the overall injury severity are the most critical determinants in deciding whether primary definitive fracture stabilisation is possible or should be delayed. Low-risk complex extremity fractures can be managed according to classic fracture principles, whereas these principles may have limited value in moderate-risk complex extremity fractures. High-risk complex extremity fractures in the polytrauma setting require thorough assessment. In selected cases, primary amputation is a life-saving alternative. We present a new treatment guide taking parameters of local injury severity into account.
Collapse
Affiliation(s)
- Philipp Kobbe
- Department of Orthopaedic and Trauma Surgery, University Hospital Aachen, Aachen, Germany
| | | | | |
Collapse
|
23
|
Rammelt S, Zwipp H. Talar neck and body fractures. Injury 2009; 40:120-35. [PMID: 18439608 DOI: 10.1016/j.injury.2008.01.021] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 01/24/2008] [Accepted: 01/28/2008] [Indexed: 02/02/2023]
Abstract
Fractures of the talar neck and body are rare and serious injuries. The vast majority are either intra-articular or lead indirectly to an intra-articular incongruity through a dislocation at the talar neck. Because of the high energy needed to produce talar fractures, they are frequently seen in multiply injured and polytraumatised patients. Open fractures and fracture-dislocations are treated as emergencies. Preoperative planning of definite internal fixation requires CT scanning. To obtain a complete intra-operative overview allowing for anatomical reconstruction of the articular surfaces and the axial deviation bilateral approaches are usually necessary. Internal fixation is achieved with screws or mini-plates supplemented by temporary K-wire transfixation in cases of marked additional ligamentous instability. The clinical outcome after talar neck and body fractures is determined by the severity of the injury and the quality of reduction and internal fixation. The timing of definite internal fixation does not appear to affect the final result. The rates of avascular necrosis (AVN) correlate with the degree of initial dislocation. Only total AVN with collapse of the talar body leads to inferior results with the need for further surgery whilst prolonged immobilisation or offloading of the affected foot is not indicated for partial AVN. Talar malunions and non-unions after inadequate treatment of displaced fractures are debiliating conditions that should be treated by surgical correction. Treatment options include corrective osteotomy by recreating the former fracture with secondary fixation, free or vascularised bone grafting and salvage by realignment and fusion of the affected joint(s).
Collapse
Affiliation(s)
- Stefan Rammelt
- Department of Trauma & Reconstructive Surgery, University Hospital Carl Gustav Carus, Dresden, Germany.
| | | |
Collapse
|
24
|
Tarkin IS, Sop A, Pape HC. High-energy foot and ankle trauma: principles for formulating an individualized care plan. Foot Ankle Clin 2008; 13:705-23. [PMID: 19013404 DOI: 10.1016/j.fcl.2008.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Care of the patient with high-energy foot and ankle trauma requires an individualized care plan. Staged treatment respecting the traumatized soft tissue envelope is often advisable. Wound care is a priority, and the vacuum-assisted closure dressing serves an integral role. Before definitive reconstruction, the surgeon needs to develop a treatment plan designed to match the unique personality of the patient and injury. Amputation is considered a rational treatment option for the patient with severe injury and poor host biology. Despite the most appropriate management, many severe foot and ankle injuries have a guarded prognosis.
Collapse
Affiliation(s)
- Ivan S Tarkin
- University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, 3471 Fifth Avenue, Pittsburgh, PA 15213 412-605-3252, USA.
| | | | | |
Collapse
|
25
|
Roll C, Prantl L, Nerlich M, Kinner B. Osteo-fasciocutaneous parascapular flap transfer for reconstruction of the first ray of the foot. Arch Orthop Trauma Surg 2008; 128:857-63. [PMID: 18297296 DOI: 10.1007/s00402-008-0592-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Severe bone and soft tissue defects of the first metatarsal bone after trauma, tumor resection or osteomyelitis are challenging to treat. Partial amputation of the foot may be the consequence. However, due to its significance for gait, salvage of the first ray should be considered, whenever possible. One option for bone and soft tissue reconstruction, therefore, might be an osteo-fasciocutaneous parascapular flap transfer. METHODS Five patients with bone and soft tissue defects of the first ray of the foot but intact MTP joint were treated with osteo- fasciocutaneous parascapular flap transfer, two after tumor resection, and three after severe bone and soft tissue trauma. Patients were followed for 12-36 months clinically and radiologically. RESULTS All flaps survived. One revision was necessary because of venous thrombosis, which was treated successfully by thrombectomy and patch plastic. All osteosyntheses united and the scapular bone transplant adapted nicely to the new loading conditions. All patients were content with the result and would agree to have the operation again. Two patients were able to stand tiptoe and go jogging, one patient still had limitations of ADLs due to the concomitant injuries. CONCLUSION The osteo- fasciocutaneous flap proved to be very versatile and safe for foot reconstruction due to its favorable vascular anatomy. In all patients (partial), amputation of the foot could be avoided.
Collapse
Affiliation(s)
- C Roll
- Department of Trauma and Reconstructive Surgery, University of Regensburg Medical Center, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany
| | | | | | | |
Collapse
|
26
|
Abstract
The acute and early phase of polytrauma management is decisive for determining and implementing priority-based operative strategy. The patient's general condition and pattern of injury have to be considered. The highest priorities in the acute phase of operative treatment are control of mass bleeding and the release of body cavities (life-saving surgery). In the primary phase of surgical management (day 1 surgery), selected injuries are treated in the order of their urgency. Conceptual damage control surgery is distinguished from early total care. Damage control surgery should be performed only in patients meeting certain instability and risk criteria to avoid additionally burdening their condition.
Collapse
Affiliation(s)
- N P Haas
- Centrum für Muskuloskeletale Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Deutschland.
| | | | | |
Collapse
|
27
|
|