Orthopaedic Trauma Surgery: Volume 2: Lower Extremity Fractures and Dislocation [1st ed. 2023] 981160214X, 9789811602146

Table of contents :
Foreword
Preface
Contents
Contributors
1: Hip Dislocations and Femoral Head Fractures
1.1 Basic Theory and Concepts
1.1.1 Overview
1.1.2 Applied Anatomy
1.1.3 Mechanism of Injury
1.1.4 Classification of Femoral Head Fractures and Hip Dislocations
1.1.5 Assessment of Hip Dislocations and Femoral Head Fractures
1.1.5.1 Clinical Assessment
1.1.5.2 Imaging Assessment
1.2 Surgical Treatment
1.2.1 Closed Reduction Technique for Hip Dislocations
1.2.2 Indications and Purposes of Surgical Treatment
1.2.2.1 Indications
1.2.2.2 Purposes of Surgery
1.2.3 Surgical Techniques
1.2.3.1 Open Reduction and Internal Fixation for Femoral Head Fractures (The Smith-Petersen Approach)
1.2.3.2 Open Reduction and Internal Fixation for Femoral Head Fracture (The Kocher–Langenbeck Approach)
1.2.4 Surgical Complications and Preventive Measures
References
2: Fractures of the Femoral Neck
2.1 Basic Theory and Concepts
2.1.1 Overview
2.1.2 Applied Anatomy
2.1.3 Mechanism of Injury
2.1.4 Classification of Femoral Neck Fractures
2.1.5 Assessment of Femoral Neck Fractures
2.1.5.1 Clinical Assessment
2.1.5.2 Imaging Assessment
2.2 Surgical Treatment
2.2.1 Surgical Indications and Purpose
2.2.1.1 Surgical Indications
2.2.1.2 Timing for Surgery
2.2.1.3 Purposes of Surgery
2.2.2 Surgical Techniques
2.2.2.1 Closed/Open Reduction and Internal Fixation for Femoral Neck Fractures
2.2.2.2 Hip Arthroplasty (The Posterolateral Approach)
2.2.3 Prevention and Treatment of Postoperative Complications of Fractures
References
3: Intertrochanteric Fractures of the Femur
3.1 Basic Theory and Concepts
3.1.1 Overview
3.1.2 Applied Anatomy
3.1.3 Mechanism of Injury
3.1.4 Classification of Intertrochanteric Femoral Fractures
3.1.5 Assessment of Intertrochanteric Femoral Fractures
3.1.5.1 Clinical Assessment
3.1.5.2 Imaging Assessment
3.1.5.3 Evaluation of the Intertrochanteric Femoral Fracture Stability
3.1.5.4 Evaluation of Special Types of Fractures and Potentially Unstable Fractures (Fig. 3.8)
3.2 Treatment of Intertrochanteric Femoral Fractures
3.2.1 Conservative Treatments
3.2.2 Surgical Treatment
3.2.2.1 Basic Principles of Surgical Treatment
3.2.2.2 Selection of Surgical Treatment Methods
3.2.2.3 Surgical Techniques
3.2.2.4 Prevention and Treatment of Surgical Complications
References
4: Subtrochanteric Femoral Fractures
4.1 Basic Theory and Concepts
4.1.1 Overview
4.1.2 Functional Anatomy
4.1.3 Mechanism of Injury and Fracture Classification
4.1.4 Assessment of Subtrochanteric Femoral Fractures
4.1.4.1 Clinical Assessment
4.1.4.2 Imaging Assessment
4.2 Surgical Treatment of Subtrochanteric Femoral Fractures
4.2.1 Surgical Indications
4.2.2 Surgical Options and Principles of Surgical Treatment
4.2.3 Surgical Techniques
4.2.3.1 Closed Reduction and Intramedullary Nail Fixation for Subtrochanteric Femoral Fractures
4.2.3.2 Open Reduction and Plate-Screw Fixation for Subtrochanteric Femoral Fractures
4.2.3.3 Experiences and Lessons
4.2.4 Surgical Complications and Their Prevention and Treatment
References
5: Femoral Shaft Fractures
5.1 Basic Theory and Concepts
5.1.1 Overview
5.1.2 Applied Anatomy
5.1.3 Mechanism of Injury
5.1.4 Classification of Femoral Shaft Fractures
5.1.5 Assessment of Femoral Shaft Fractures
5.1.5.1 Clinical Assessment and Surgical Treatment
5.1.5.2 Imaging Assessment
5.2 Surgical Treatment
5.2.1 Surgical Indications
5.2.2 Femoral Shaft Fractures and Surgical Treatment (Roberts et al. 2005)
5.2.3 Selection of Final Internal Fixation Approaches
5.2.4 Surgical Techniques
5.2.4.1 Internal Fixation with Antegrade Intramedullary Nailing
5.2.4.2 Retrograde Intramedullary Nailing for Internal Fixation
5.2.4.3 Open Reduction and Internal Fixation of Femoral Shaft Fractures (The Lateral Approach)
5.2.5 Postoperative Complications and Their Prevention and Treatment Strategies
References
6: Distal Femoral Fractures
6.1 Basic Theory and Concepts
6.1.1 Overview
6.1.2 Applied Anatomy
6.1.3 Mechanism of Injury (Collinge 2010)
6.1.4 Classification of Distal Femoral Fractures
6.1.5 Assessment of Distal Femoral Fractures
6.1.5.1 Clinical Assessment
6.1.5.2 Imaging Assessment
6.2 Surgical Treatment
6.2.1 Surgical Indications and Purposes
6.2.2 Surgical Techniques
6.2.2.1 Open Reduction and Internal Fixation of Distal Femoral Fractures
Experience and Lessons
6.2.2.2 Retrograde Intramedullary Nailing for Proximal Femoral Fractures
6.2.3 Surgical Complications and Their Prevention and Treatment
References
7: Patellar Fractures
7.1 Basic Theory and Concepts
7.1.1 Overview
7.1.2 Applied Anatomy
7.1.3 Mechanism of Injury (Bedi and Karunakar 2010)
7.1.4 Classification
7.1.5 Assessment of Patellar Fractures
7.1.5.1 Clinical Assessment (Bedi and Karunakar 2010)
7.1.5.2 Imaging Assessment
7.2 Surgical Treatment
7.2.1 Surgical Indications
7.2.2 Surgical Techniques
7.2.2.1 Open Reduction and Tension Band Internal Fixation for Patellar Fractures
Body Position and Preoperative Preparation
Operative Incision According to the Preoperative Incision Marks by Surface Projection
Surgical Procedures
Postoperative Management
Experience and Lessons
7.2.2.2 Partial Patellectomy
Surgical Techniques
Experience and Lessons
7.2.2.3 Total Patellectomy
Surgical Techniques
Experience and Lessons
7.2.3 Prevention of and Treatment Measures for Surgical Complications
References
8: Tibial Plateau Fractures
8.1 Basic Theory and Concepts
8.1.1 Overview
8.1.2 Applied Anatomy
8.1.3 Mechanism of Injury
8.1.4 Classification of Tibial Plateau Fractures
8.1.5 Assessment of Tibial Plateau Fractures (Chan et al. 1997)
8.1.5.1 Clinical Assessment
8.1.5.2 Imaging Assessment (Dias et al. 1987; Liow et al. 1999; Macarini et al. 2004)
8.2 Surgical Treatment
8.2.1 Surgical Indications
8.2.2 Surgical Timing and Treatment Principles
8.2.3 Selection of Surgical Strategies
8.2.4 Surgical Technique
8.2.4.1 Temporary Fixation with an External Fixator Across the Knee for Tibial Plateau Fractures (Cole et al. 2009)
8.2.4.2 Closed Reduction and External Fixation with a Hybrid Fixator for Tibial Plateau Fractures (Babis et al. 2011; Kumar and Whittle 2000)
8.2.4.3 Open Reduction and Internal Fixation for Tibial Plateau Fractures (Endayan et al. 1996)
Body Position and Preoperative Preparation
Operative Incision According to the Preoperative Incision Marks by Surface Projection
Fracture Reduction and Fixation
Incision Closure
Postoperative Management
Experience and Lessons
8.2.5 Postoperative Complications and Their Prevention and Treatment Strategies
References
9: Tibial Shaft Fractures
9.1 Basic Theory and Concepts
9.1.1 Overview
9.1.2 Applied Anatomy
9.1.3 Mechanism of Injury
9.1.4 Assessment of Tibial Shaft Fractures
9.1.4.1 Clinical Assessment
9.1.4.2 Imaging Assessment
9.1.5 Classification of Tibial Shaft Fractures
9.2 Surgical Treatment
9.2.1 Surgical Indications
9.2.2 Timing of Surgery
9.2.3 Selection of Surgical Strategies
9.2.3.1 Initial Soft Tissue Treatment Technique for Tibial Shaft Open Fractures
Application of Antibiotics
Debridement and Wound Irrigation
Wound Treatment (Fig. 9.7)
9.2.3.2 Lower-Leg Fasciotomy for Compartment Decompression
Body Position and Preoperative Preparation
Operative Incision According to the Preoperative Incision Marks by Surface Projection
Surgical Techniques
Postoperative Management
9.2.3.3 Unilateral External Fixation of Tibial Shaft Fractures with a Fixator Frame
Body Position and Preoperative Preparation
Surgical Technique
Experience and Techniques
9.2.3.4 Intramedullary Nail Fixation
Body Position and Preoperative Preparation
Operative Incision According to the Preoperative Incision Marks by Surface Projection, Surgical Approach, and Intramedullary Nail Entry Point
Surgical Techniques
Experience and Lessons
9.2.3.5 Plate-Screw Fixation
Body Position and Preoperative Preparation
Operative Incision According to the Preoperative Incision Marks by Surface Projection (Fig. 9.28)
Surgical Technique
Postoperative Management
Experience and Lessons
9.2.4 Surgical Complications and Their Prevention and Treatment
References
10: Ankle Fractures
10.1 Basic Theory and Concepts
10.1.1 Overview
10.1.2 Applied Anatomy
10.1.3 Mechanisms of Injury
10.1.4 Classification of Ankle Fractures
10.1.5 Assessment of Ankle Fractures
10.1.5.1 Clinical Assessment
10.1.5.2 Imaging Assessment
10.2 Surgical Treatment
10.2.1 Surgical Indications and Purposes
10.2.2 Surgical Techniques
10.2.2.1 Choices of Surgical Approaches
10.2.2.2 Body Position and Preoperative Preparation
10.2.2.3 Operative Incision According to the Preoperative Incision Marks by Surface Projection and Surgical Approaches
10.2.2.4 Reduction and Fixation of Ankle Fractures
10.2.2.5 Postoperative Management
10.2.2.6 Experiences and Lessons
10.2.3 Surgical Complications and Their Prevention and Treatment
References
11: Pilon Fractures
11.1 Basic Theory and Concepts
11.1.1 Overview
11.1.2 Applied Anatomy
11.1.3 Mechanism of Injury in Pilon Fractures
11.1.4 Classification of Pilon Fractures
11.1.5 Preoperative Assessment
11.1.5.1 Clinical Assessment
11.1.5.2 Imaging and Other Auxiliary Examinations
11.2 Surgical Treatment for Pilon Fractures
11.2.1 Surgical Indications
11.2.2 Strategies for Staged Surgical Treatment
11.2.3 Surgical Techniques
11.2.3.1 Limited Open Reduction and Trans-ankle External Fixation Frame for Pilon Fractures
11.2.3.2 Open Reduction and Internal Fixation for Pilon Fractures
11.2.4 Surgical Complications and Their Prevention and Treatment
References
12: Calcaneus Fractures
12.1 Basic Theory and Concepts
12.1.1 Overview
12.1.2 Applied Anatomy
12.1.3 Mechanisms of Injury
12.1.4 Fracture Classification
12.1.4.1 Extra-articular Fractures
12.1.4.2 Intra-articular Fractures
12.1.5 Assessment of Calcaneus Fractures
12.1.5.1 Clinical Assessment
12.1.5.2 Radiographic Evaluation
12.2 Surgical Treatment
12.2.1 Surgical Indications (Dhillon et al. 2011)
12.2.2 Surgical Procedures
12.2.2.1 The Lateral Approach for Open Reduction and Internal Fixation for Intra-articular Fractures of the Calcaneus
Body Position and Preoperative Preparation
Operative Incision According to the Projection on the Body Surface
The Surgical Approach (Fig. 12.18)
Fracture Reduction and Fixation
Incision Closure
Postoperative Management
Experience and Lessons
12.2.2.2 Closed Reduction and Internal Fixation Technique for Tongue-Type Calcaneus Fractures via the Minimally Invasive Approach
Fracture Reduction and Fixation
12.2.3 Surgical Complications and Their Prevention and Treatment Strategies
References
13: Talus Fractures
13.1 Basic Theory and Concepts
13.1.1 Overview
13.1.2 Applied Anatomy
13.1.3 Mechanism of Injury in Talus Fractures
13.1.4 Classification of Talus Fractures
13.1.5 Preoperative Assessment
13.1.5.1 Clinical Assessment
13.1.5.2 Imaging and Other Auxiliary Examinations
13.2 Surgical Treatment for Talus Fractures
13.2.1 Surgical Indications
13.2.2 Timing for Surgery
13.2.3 Surgical Techniques
13.2.3.1 Open Reduction and Internal Fixation for Talus Fractures
Body Position and Preoperative Preparation
Surgical Incision and Approaches
Sequence and Techniques for Fracture and Dislocation Reduction
13.2.3.2 Closed Reduction and Percutaneous Internal Fixation (Abdelgaid and Ezzat 2012)
Indications
Body Position and Preoperative Preparation
Reduction of Talus Fractures
Fixation of the Talus Fracture
Postoperative Management
13.2.3.3 Advantages and Disadvantages of Various Fixation Methods
13.2.4 Surgical Complications and Their Prevention and Treatment
13.2.4.1 Soft Tissue Complications
13.2.4.2 Nonhealing of Fractures
13.2.4.3 Malhealing of Fractures
13.2.4.4 Osteonecrosis
13.2.4.5 Post-traumatic Arthritis
References
14: Achilles Tendon Rupture
14.1 Basic Theory and Concepts
14.1.1 Overview
14.1.2 Applied Anatomy
14.1.3 Mechanism of Injury of Achilles Tendon Rupture
14.1.4 Classification of Achilles Tendon Injuries
14.1.5 Assessments of Achilles Tendon Rupture
14.1.5.1 Clinical Assessment
14.1.5.2 Radiographic Evaluation
14.2 Surgical Treatment
14.2.1 Principles of Treatment
14.2.2 Open Suture Repair for Acute Achilles Tendon Rupture Using the Krackow Locking Stitch Technique
14.2.3 Percutaneous Minimally Invasive Suture for Repairing Acute Achilles Tendon Rupture
14.2.3.1 Development and Design of the Channel-Assisted Minimally Invasive Achilles Tendon Suture Repair Technique
14.2.3.2 The CAMIR Procedures for Acute Achilles Tendon Rupture
14.2.4 Abraham’s V-Y Lengthening Repair of Subacute Achilles Tendon Rupture
14.2.5 The Lindholm Repair Method for an Old Achilles Tendon Rupture (Fig. 14.11)
14.2.6 Experience and Lessons
References

Citation preview

Peifu Tang Hua Chen Editors

Orthopaedic Trauma Surgery Volume 2: Lower Extremity Fractures and Dislocation

123

Orthopaedic Trauma Surgery

Peifu Tang • Hua Chen Editors

Orthopaedic Trauma Surgery Volume 2: Lower Extremity Fractures and Dislocation

Editors Peifu Tang Department of Orthopaedics Chinese PLA General Hospital Beijing, China

Hua Chen Department of Orthopaedics Chinese PLA General Hospital Beijing, China

ISBN 978-981-16-0214-6    ISBN 978-981-16-0215-3 (eBook) https://doi.org/10.1007/978-981-16-0215-3 Jointly published with Military Science Publishing House The print edition is not for sale in China (Mainland). Customers from China (Mainland) please order the print book from: Military Science Publishing House. © Military Science Publishing House 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

In the last 50 years, the methodology of treating fractures has undergone a series of changes. The Association for the Study of Internal Fixation (AO), shortly after its establishment in 1980, proposed the treatment principle emphasizing mechanical stability and focusing on anatomical reduction, rigid internal fixation, surrounding soft tissue protection, and early functional exercise. Gradually, this concept evolved into one emphasizing a biological internal fixation that better protects the blood supply of bone and soft tissues at the fracture site. The change has prompted the invention of new types of implants, including locking compression plates and interlocking intramedullary nails, and the development of new technologies, including minimally invasive plate osteosynthesis. These advances, in combination with high-quality intraoperative imaging technologies, such as X-ray and CT, have raised fracture care to a new level. The Chinese PLA General Hospital is a top-tier comprehensive hospital. Its Department of Orthopaedics has been established in 1953. In 1977, the Orthopaedic Trauma Center was formed. It has obtained prominent medical and scientific achievements in the field of orthopaedic trauma treatment. Great thanks to the contributions of our respected seniors, such as Prof. Shibi Lu, Prof. Shengxiu Zhu, Prof. Boxun Zhang, and Prof. Yan Wang. Prof. Peifu Tang, as the editor-in-chief of this book, chairman of the department of orthopaedic surgery, director of the Orthopaedic Trauma Group of the Orthopaedics Division of the Chinese Medical Association, has been a good friend of mine for many years. Under his leadership, the Department of Orthopaedic Trauma of the Chinese PLA General Hospital has made brilliant achievements in clinical and scientific research. I am delighted to see that the books have summarized years of experience at the 301 Orthopaedic Hospital of the Chinese PLA General Hospital in fracture care in a book, which will surely benefit the development of orthopaedic trauma care in China. The following distinguishing features of this book stand out to me. First, this book is a valuable guide for clinicians. By introducing the conceptual evolution of internal fracture fixation approaches in recent years, the book increases the awareness and willingness of readers to utilize new technologies. Considering that orthopaedic trauma medicine covers a wide range of injuries with diverse mechanisms and complex conditions, the book emphasizes the importance of treatment timing and individualized optimal treatment strategies in clinical decision-making and presents practicable approaches for reference. Second, the book has a well-organized, easy-to-read structure with concise, bulleted text, full-colour illustrations, and intraoperative photographs. Each chapter follows a similar format, starting with applied anatomy and then combining it with the biomechanics and functional characteristics of the fractured body part to describe the anatomical structure and clinical issues such as injury mechanisms, treatments, and healing. This unique format is an attractive feature of the book. In addition, the book maintains a focus on clear, step-by-step depictions and descriptions of surgical procedures for each surgical technique, consistent with the working habits of clinicians. Another feature of the book is the combination of illustrations/photographs and text. On many occasions, intraoperative photographs, schematic diagram(s), and intraoperative X-ray or CT images are jointly used. The schematic diagrams help readers understand the mechanisms underlying the surgical approach and fracture reduction and v

vi

Foreword

­ xation, the intraoperative photographs supply readers with an intuitive visual impression of fi the intraoperative scene, and the intraoperative radiographs and CT images offer a reference for reduction and fixation. Third, this book provides tips and cautions based on the experience obtained over the years by the Department of Orthopaedic Trauma of the Chinese PLA General Hospital. In the sections introducing the surgical procedures in particular, the experience and lessons, which have not been easy to explain clearly in previous books, are unreservedly presented in detail through illustrations and text, which offers a surgeon’s-eye view of the relevant scenarios and helps readers grasp the “gold content” of the book. I have known Professor Peifu Tang for more than 15 years. He is a rising star in the young generation of orthopaedic traumatologists in China. With his intelligence and diligence, he has become a good model for the young generation of orthopaedic trauma surgeons. Hard work will certainly yield fruitful results. I sincerely applaud the publication of this book, and hope that Prof. Peifu Tang will continue to publish more work on orthopaedic trauma. The Third Hospital of Hebei Medical University Shijiazhuang, Hebei, China

Ying-ze Zhang

Preface

In recent years, with the economic growth and subsequent rapid development of construction and transportation industry, the incidence of orthopaedic trauma has shown a prominent increasing trend. Moreover, with the advancement of medicine, the expectations of patients regarding treatment outcomes have also increased. Surgery is an important treatment method for orthopaedic trauma, which is attracting an increasing amount of attention. In response to these trends, the Department of Orthopaedics of the Chinese PLA General Hospital was established in 1953, upgraded to a Grade one Orthopaedic Trauma Center in 1977. The Department has been developed along the path initiated by a group of well-known researchers, including Prof. Jingyun Chen, Prof. Zhikang Wu, Academician Shibi Lu, Prof. Shengxiu Zhu, Prof. Boxun Zhang, Prof. Jifang Wang, and Prof. Yan Wang. They emphasize clinical and scientific research and have earned five first-class and two second-class awards of the National Science and Technology Progress Award. This book, Orthopaedic Trauma Surgery, is a summary of our valuable experience in fracture treatment gained over the previous 60 years. We systematically searched for relevant information in China and other countries and compiled case reports and imaging data from the Department of Orthopaedics of the PLA General Hospital accumulated over the years, writing this book, which has three volumes and 29 chapters that, respectively, introduce upper extremity fractures and dislocations, lower extremity fractures and dislocations, axial skeleton fractures, and nonunion. The book adopts the principle of guiding surgery by anatomy, fixation by biomechanics, and clinical procedures by functional recovery. In each chapter, the applied anatomy of the fracture site is first introduced. This section confers prominence to the relationship between the anatomical structure and surgery and emphasizes the structure that must be protected and repaired during surgery. In addition, the biomechanical characteristics of the fracture site are described, so that the appropriate fixation method can be selected according to the characteristics of the mechanical environment. In most chapters on periarticular fractures, the book also describes in detail how the joints fulfil their function, which is often the core of clinical decision-­making, with the hope that the reader can understand the how and the why. The book adopts the outline-style format instead of the traditional paragraph-by-paragraph discussion to supply readers with the extracted essence in a more succinct manner, which improves the logical flow and concision and thereby improves the readability of the book. In addition, using more than 3000 illustrations and photos, many of which were obtained from our clinical practice, the book discusses injury mechanisms and the classification and assessment of extremity and axial skeleton fractures, with a focus on typical and new surgical methods developed in recent years. These illustrations and photos provide the reader with a good reference for learning surgical techniques and skills. Hopefully, this design will make the book useful for orthopaedic surgeons at all levels in China. Many professors and associate professors with rich clinical experience in the Department of Orthopaedic Trauma of the PLA General Hospital have contributed to this book. We would like to thank Dr. Zhe Zhao for his painstaking efforts in the preparation of this book. He has contributed a tremendous amount of work in the structural design, content compilation, case selection, and figure design. Thanks are extended to Dr. Hua Chen for his work in the structural vii

viii

Preface

design of this book, which laid the foundation for this book. We also thank Professor Boxun Zhang and Professor Yutian Liang for their meticulous review of the manuscript. During the preparation of this book, we have done our best to keep abreast of the latest surgical advances in fracture treatment and striven to deliver accurate and informative content. However, due to the rapid development of new concepts and instruments for the treatment of orthopaedic trauma, time and knowledge source limitations, inevitably there might be deficiencies in this book, and we welcome the reader to point them out and help us to improve the content of the book. Beijing, China

Peifu Tang

Contents

1 H  ip Dislocations and Femoral Head Fractures�������������������������������������������������������   1 Zhe Zhao, Zhuo Zhang, and Yan Wu 2 F  ractures of the Femoral Neck ���������������������������������������������������������������������������������  25 Zhe Zhao, Zhuo Zhang, Jianheng Liu, and Jia Li 3 I ntertrochanteric Fractures of the Femur ���������������������������������������������������������������  63 Peifu Tang, Zhe Zhao, Zhuo Zhang, and Jianheng Liu 4 S  ubtrochanteric Femoral Fractures������������������������������������������������������������������������� 113 Zhe Zhao, Hao Guo, and Shaobo Nie 5 F  emoral Shaft Fractures�������������������������������������������������������������������������������������������� 145 Zhe Zhao, Zhuo Zhang, Jiantao Li, and Wei Zhang 6 D  istal Femoral Fractures������������������������������������������������������������������������������������������� 177 Zhe Zhao, Zhuo Zhang, and Ming Li 7 Patellar Fractures������������������������������������������������������������������������������������������������������� 215 Zhe Zhao, Lei Geng, and Lin Qi 8 T  ibial Plateau Fractures��������������������������������������������������������������������������������������������� 237 Zhe Zhao, Zhuo Zhang, and Hao Guo 9 T  ibial Shaft Fractures������������������������������������������������������������������������������������������������� 285 Zhe Zhao and Jiantao Li 10 Ankle Fractures����������������������������������������������������������������������������������������������������������� 325 Zhe Zhao, Zhuo Zhang, and Jiaqi Li 11 Pilon Fractures ����������������������������������������������������������������������������������������������������������� 369 Zhe Zhao and Bin Shi 12 Calcaneus Fractures��������������������������������������������������������������������������������������������������� 397 Zhe Zhao and Jiantao Li 13 Talus Fractures����������������������������������������������������������������������������������������������������������� 433 Zhuo Zhang and Hao Guo 14 Achilles Tendon Rupture ������������������������������������������������������������������������������������������� 449 Hua Chen, Peifu Tang, and Hongzhe Qi

ix

Contributors

Hua Chen  Chinese PLA General Hospital, Beijing, China Lei Geng, MD  Chinese PLA General Hospital, Beijing, China Hao Guo, MD  Chinese PLA General Hospital, Beijing, China Jia Li, MD  Chinese PLA General Hospital, Beijing, China Jiantao Li, MD  Chinese PLA General Hospital, Beijing, China Jiaqi Li, MD  Chinese PLA General Hospital, Beijing, China Ming Li, MD  Chinese PLA General Hospital, Beijing, China Jianheng Liu, MD  Chinese PLA General Hospital, Beijing, China Shaobo Nie, MD  Chinese PLA General Hospital, Beijing, China Hongzhe Qi, MD  PLA Strategic Support Force Characteristic Medical Center, Beijing, China Lin Qi, MD  Chinese PLA General Hospital, Beijing, China Bin Shi, MD  Chinese PLA General Hospital, Beijing, China Peifu Tang  Chinese PLA General Hospital, Beijing, China Yan Wu, MD  Chinese PLA General Hospital, Beijing, China Wei Zhang, MD  Chinese PLA General Hospital, Beijing, China Zhuo Zhang  Chinese PLA General Hospital, Beijing, China Zhe Zhao  Beijing Tsinghua Changgung Hospital, Beijing, China

xi

1

Hip Dislocations and Femoral Head Fractures Zhe Zhao, Zhuo Zhang, and Yan Wu

1.1 Basic Theory and Concepts 1.1.1 Overview • Femoral head fractures account for 0.19% of all bone fractures in adults and 1.5% of femoral fractures (Droll et al. 2007). • Femoral head fractures are intracapsular fractures and have a high incidence of complications, including arthritis, ischemic necrosis, nerve injury, and heterotopic ossification. • Hip dislocation is mostly caused by a highly violent force; therefore, it is necessary to carefully examine the possibility of any concomitant injuries elsewhere at the time of hip dislocation (Kelly and Yarbrough 3rd 1971). • Posterior dislocations constitute 90% of hip dislocations, with anterior dislocations constituting 10% (DeLee 1996).

1.1.2 Applied Anatomy • The structures stabilizing the hip joint: –– Osseous structures stabilizing the hip joint (Fig. 1.1): The hip joint is a ball-and-socket structure. Compared with the shallower joint, which achieves a higher movement range at the expense of stability, the hip joint has a significantly higher stability. In addition, the negative pressure in the articular cavity, acting via a similar mechanism to the Magdeburg hemispheres, strengthens the stability of the hip joint. Acetabulum: The acetabular cavity has a hemispheric shape facing laterally, anteriorly, and downward. Through the downward-facing surface, the top half of the acetabulum covers the upper part of Z. Zhao (*) Beijing Tsinghua Changgung Hospital, Beijing, China Z. Zhang · Y. Wu Chinese PLA General Hospital, Beijing, China

the femoral head, allowing the transmission of body weight between the two. There is a deeper depression at the center of the acetabular cavity, known as the acetabular fossa, where the acetabulum does not directly contact the femoral head. Cartilage, acetabular labrum, and transverse ligament: The inner surface of the acetabulum is covered with crescent-shaped cartilage. The labrum along the acetabular rim deepens the acetabular cavity and makes it deeper than a hemispherical shape, thus improving the stability of the joint. The lower articular cartilage is disrupted by the acetabular notch and instead connected by the acetabular transverse ligament. Femoral head: The femoral head is shaped as an approximate 2/3 sphere, and except for the fovea capitis femoris, its surface is covered with cartilage that varies in thickness. Its head part, which bears the highest force load, is covered with the thickest cartilage, while the peripheral area bears a relatively small load and is covered with thinner cartilage. –– Ligaments surrounding the hip joint (Fig. 1.2): There are strong ligamentous supports for both the anterior and posterior hip joint. The fovea capitis femoris is connected to the acetabular fossa by the round ligament. Iliofemoral ligament: Located in front of the hip joint, the iliofemoral ligament starts from the lower anterior inferior iliac spine (AIIS) and ends in the intertrochanteric line. It has a fan shape with a thick edge and a thin middle part. Pubofemoral ligament: Located underneath the hip joint, the pubofemoral ligament starts from the anteromedial iliac protuberance and ends in the lesser trochanter. Ischiofemoral ligament: The ischiofemoral ligament starts from the posterior margin of the acetabulum, runs superolaterally across the posterior

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0215-3_1

1

2

Z. Zhao et al.

Fig. 1.1 (a) Coronal cross-section view of the hip: the acetabular cavity is hemisphere-shaped and faces downward, with cartilaginous tissue covering its inner surface and the labrum along its rim increasing its depth. (b) Lateral view of the acetabulum: the crescent-­ shaped cartilage is disrupted by the acetabular notch and instead connected by the acetabular transverse ligament at its lower part. The round ligament of the femoral head (severed) is located in the acetabular fossa

a

a

b

b

c

Fig. 1.2 (a) Front view of the hip joint: the iliofemoral ligament and pubofemoral ligament are visible in this view. (b) Rear view of the hip joint: the ischiofemoral ligament is visible in this view. (c) These ligaments lose tension when the hip flexes, placing the hip in an unstable position

femoral neck, and ends on the inner surface of the greater trochanter. A change during the evolution of bipedalism from quadrupedalism in human beings is observed in curling and loose ligaments around the hip joint when the hip joint flexes and tight wrapping of the femoral neck when the hip joint extends. Thus, the hip joint is unstable when it is in flexion. Therefore, when sitting with one leg across the top of another leg, i.e., the hip joint is in flexion and adduction, an

external force applied along the axis of the femur could easily cause posterior dislocation of the hip joint. Round ligament: The round ligament plays a relatively insignificant role in stabilizing the hip joint, but it contains the round ligament artery that plays a certain role in the blood supply to the femoral head. Owing to the existence of this ligament, the hip dislocation may be accompanied with avulsion ­ fracture at the fovea capitis femoris of the hip joint.

1  Hip Dislocations and Femoral Head Fractures

–– Muscles stabilizing the hip joint (Fig. 1.3): The pelvis-trochanter muscles, including the gluteal, piriform, internal and external obturator muscles, start from the pelvis and end at the greater and lesser trochanters, running approximately parallel to the femoral neck. The contraction force vector of these muscles points to the acetabulum and fixes the femoral head inside the acetabulum, providing a critical mechanism for hip stabilization. The adductor muscle group: The contraction force of the adductor muscle group along the longitudinal axis of the femur adducts the hip joint and could easily cause a posterior and superior dislocation of the hip joint. • Weight-bearing area and load transmission of the femoral head (Fig. 1.4): –– When the body is in the upright position, the axes of the acetabulum and femoral neck do not overlap because the former is deviated forward, downward, and laterally, and the latter is deviated forward, upward, and medially. At this position, the anterolateral surface of the femoral head is not covered by the acetabulum; therefore, the anterior approach is a better choice for Fig. 1.3 (a) Rear view of the hip joint: the contraction force vector of the pelvis-trochanter muscle group points to the acetabulum, providing a critical mechanism for hip stabilization. (b) The contraction force vector of the adductor muscle group is along the longitudinal axis of the femur, and it could easily cause a superior dislocation of the hip joint when the hip is in the adduction position

a

3

exposing the femoral head in the treatment of femoral head fractures. When the hip joint is flexed at 90°, the axes of the acetabulum and femoral neck overlap perfectly, and the acetabulum and the femoral head overlap the most, which is a vestige remaining in the evolution of upright human walking. –– Fractures of the upper and medial femoral head, the weight-bearing area, require open reduction and internal fixation to restore the alignment and stability of the joint. –– In the upright position, in addition to the body weight transferred to the femoral shaft through compression and tensile trabeculae (this process is detailed in the related section on femoral neck fractures), the force loaded on the hip joint is mostly from the powerful contractions of its surrounding muscles, as evidenced by research data showing that the force born by the hip joint is approximately six times the body weight during normal walking and up to two times the body weight when a patient lies on the hospital bed and urinates into a bedpan. Hence, special attention should be paid to the force loaded on the hip joint of patients during rehabilitation. b

4

Z. Zhao et al.

a

b

Fig. 1.4 (a) Anatomic structure of the acetabulum and the femoral head: the blue area denotes the areas covered with the thickest cartilage in the acetabulum and the femoral head, which is the weight-bearing area of the femoral head. (b) The acetabulum faces laterally, anteriorly, and down-

ward, while the axis of the femoral neck is deviated forward, upward, and laterally. When the body is in the upright position, the acetabulum and the femoral head do not share the same axis; therefore, a portion of the surface of the femoral head is not covered by the acetabulum

Fig. 1.5  Front and rear views of the blood-supplying system to the femoral head and neck

• The blood supply of the femoral head (Fig.  1.5): The blood supply to the femoral head may be partially disrupted due to dislocations or fractures. As the dislocation continues, the degree of blood supply disruption is gradually aggravated over time, often resulting in complications such as femoral head necrosis after reduction and

internal fixation (Wertheimer and Lopes 1971; Tornetta and Mostafavi 1997). –– Medial femoral circumflex artery: Its branch, the lateral ascending cervical artery, is the most important blood-supplying vessel to the femoral head and, in

1  Hip Dislocations and Femoral Head Fractures

particular, to the weight-bearing area. Therefore, damage to this artery will cause later femoral head necrosis. –– Lateral femoral circumflex artery: Its branch, in a joint capsule ending at the upper femoral neck, supplies blood to the non-weight-bearing area of the femoral head. –– The round ligament artery plays a certain role in the blood supply to the femoral head in childhood, and it is mostly occluded or degenerated with aging.

1.1.3 Mechanism of Injury • Mechanism of hip dislocation: Hip dislocations are mostly caused by a highly violent force indirectly striking the hip joint. The direction of hip dislocation is significantly related to the body position at the time of injury (Upadhyay et al. 1983; Dudkiewicz et al. 2000; Letournel 1986; Letournel and Judet 1981). –– Posterior dislocation: The most common injury scenario is that of a vehicle passenger sitting with knee and hip flexed and adducted (i.e., cross-legged) encountering a sudden brake force that strikes the knees. –– Anterior dislocation: The most common injury scenario is that of a motorcyclist sitting with hip flexed, externally rotated, and abducted encountering a sudden brake that causes extreme thigh abduction. –– Posterior hip dislocation combined with fractures of the femoral head and acetabulum: The occurrence of this fracture is largely related to the body position at the time

5

of injury. Larger angles of hip and knee joint flexion and internal rotation more likely result in simple posterior dislocations. When a posterior dislocation occurs with the hip partially flexed and internally rotated, it is often accompanied by a posterior wall fracture of the acetabulum or a shear fracture of the femoral head (Fig.  1.6) (DeLee et al. 1980; Epstein et al. 1985).

1.1.4 Classification of Femoral Head Fractures and Hip Dislocations • Thompson–Epstein classification of hip dislocations (Paus 1951; Stewart and Milford 1954; Thompson 1972): –– Type I: Simple dislocation with or without a small fracture fragment; –– Type II: Dislocation combined with a single large posterior wall fracture fragment of the acetabulum; –– Type III: Dislocation combined with comminuted posterior wall fracture of the acetabulum with or without a larger fracture block; –– Type IV: Dislocation combined with fracture of the acetabular roof; and –– Type V: Dislocation combined with fracture of the femoral head. • Pipkin classification of femoral head fractures (Fig. 1.7): Pipkin further divided Epstein Type V of hip dislocations into four types (Hougaard and Thomsen 1988; Kim et al. 2007): –– Type I: Hip dislocation with fracture of the femoral head inferior to the fovea capitis femoris; –– Type II: Hip dislocation with fracture of the femoral head superior to the fovea capitis femoris; –– Type III: Type I or Type II injury combined with a fracture of the femoral neck; and. –– Type IV: Type I or Type II injury combined with a fracture of the acetabular rim.

1.1.5 Assessment of Hip Dislocations and Femoral Head Fractures

Fig. 1.6  Under a violent force along the longitudinal axis of the femur, larger angles of hip flexion and internal rotation more likely result in simple posterior dislocations. When a posterior dislocation occurs with the hip partially flexed and internally rotated, it is often accompanied by a posterior wall fracture of the acetabulum or a shear fracture of the femoral head

1.1.5.1 Clinical Assessment • Patients with posterior dislocation typically show the lower extremities in a position with hip flexion, adduction, and internal rotation. • Patients with anterior dislocation typically present a position of the lower extremities with hip external rotation, flexion, and abduction.

6

a

Z. Zhao et al.

b

c

d

Fig. 1.7  Pipkin classification of femoral head fractures. (a) Type I: Hip dislocation with fracture of the femoral head inferior to the fovea capitis femoris. (b) Type II: Hip dislocation with fracture of the femoral head

superior to the fovea capitis femoris. (c) Type III: Type I or II injury combined with a fracture of the femoral neck. (d) Type IV: Type I or II injury combined with a fracture of the acetabular rim

• Because hip dislocations are mostly caused by indirect highly violent force, it is necessary to rule out the possibility of organ injury in the body, especially the head, chest cavity, and abdominal cavity. • In addition to the acetabulum and the femoral head, the possibility of injury elsewhere in the motor system should be evaluated, including injury of the femoral neck, femoral shaft, knee ligaments, patella, and spine (Tabuenca and Truan 2000; Fina and Kelly 1970). • The sciatic nerve is damaged in 8–19% of posterior hip dislocations (Bromberg and Weiss 1977; Epstein 1980), and it may also be damaged during closed reduction; therefore, it is necessary to carefully evaluate sciatic nerve injury before and after reduction.

of hip dislocations or femoral neck fractures (Fig. 1.8). The greater trochanter horizontal line (the Skinner’s line) is the horizontal line passing through the apex of the greater trochanter, which passes through or slightly below the fovea capitis femoris in the anteroposterior view of the hip joint. This line can be used for the diagnosis of femoral head abnormalities. –– The Judet view of acetabular X-ray: For patients who also have acetabular fractures, the Judet view of the X-ray should be observed before and after reduction. The Judet-oblique view of the ilium: To identify fractures of the posterior wall and posterior column of the acetabulum, the patient lies flat with the body inclining to the affected side by 45°. The Judet-oblique view of the obturator: To observe the continuity of the structure from the symphysis pubis to the anterior inferior iliac spine and the anterior column of the acetabulum, the patient lies flat with the body inclining to the contralateral side by 45° (Fig. 1.9). • CT scan and three-dimensional reconstruction of the hip joint (Figs. 1.10 and 1.11): If possible, all patients with a femoral head fracture should be examined by CT to assess the fracture reduction and clarify whether the articular surface shows a step-like arrangement. CT imaging can clearly display the fracture profile of the femoral head and show intra-articular free bone fragments; therefore, it can be used to further identify femoral neck fractures with a negative X-ray to guide the operative procedure (Stein 1983; Walker and Burton 1982). • MRI is not often used, but it provides some information for blood supply assessments of the femoral head.

1.1.5.2 Imaging Assessment • X-ray: –– Anteroposterior and lateral views of the hip joint are used to observe the joint space and determine the presence of fracture fragments in the joint by comparing radiographs of the left and right sides. In the anteroposterior X-ray view, the finding that the ipsilateral femoral head is larger than the unaffected contralateral femoral head suggests an anterior dislocation, and conversely, a smaller femoral head at the ipsilateral side suggests a posterior dislocation of the femoral head. Shenton’s line, which is a continuous curve linking the lower edge of the femoral neck and the inner edge of the obturator, will lose its integrity when the hip joint is dislocated. The iliac crest-femoral neck line (the Clave line), a smooth curve linking the lateral margin of the iliac crest lateral to the anterior inferior iliac spine and the outer margin of the femoral neck, would lose its integrity and continuity in the case

1  Hip Dislocations and Femoral Head Fractures Fig. 1.8  Case example of right acetabular loosening and dislocation accompanied by a femoral head fracture. (a) Pre-reduction anteroposterior (AP) X-ray and body position of the patient: the right femoral head is smaller than the left, and both Shenton and Clave lines are disrupted. The affected leg was at the position of hip flexion, adduction, and internal rotation. It is worth noting that there was soft tissue injury at the knee area. (b) Post-reduction AP X-ray and body position of the patient: the X-ray confirms the success of reducing the hip joint and restoring its concentrically aligned structure, which allowed the patient to lie in a normal position

a

Fig. 1.9  The Judet view of the acetabulum. (a) The Judet-oblique view of the obturator. (1) Anterior column and (2) posterior column. (b) Oblique view of the ilium: (1) posterior column and (2) anterior column

a

7

b

b

1

1 2

2

8

Z. Zhao et al.

1.2 Surgical Treatment 1.2.1 Closed Reduction Technique for Hip Dislocations

Fig. 1.10  A CT scan image of the hip clearly demonstrates a femoral head fracture with a disrupted articular surface Fig. 1.11 3D-reconstructed CT scan images demonstrating a right femoral head fracture accompanied by a subtrochanteric fracture

• Indications and contraindications for closed reduction of the hip joint: –– Closed reduction is the first option for all patients with hip dislocation, including those accompanied by femoral head and hip joint fractures (Toni et  al. 1985; Hougaard and Thomsen 1987). –– Closed reduction should not be applied in hip dislocation patients accompanied by ipsilateral femoral neck and shaft fractures that make closed reduction inconvenient to operate. • Timing and surgical conditions for closed reduction of hip dislocations: –– Timing of treatment: Closed reduction should be performed as an emergency treatment (Yang and Cornwall 2000). Hip dislocation can cause twisting of the bloodsupplying vessels of the femoral head and neck and damage the vascular endothelium, resulting in vascular

1  Hip Dislocations and Femoral Head Fractures

embolization and further declination of blood supply to the femoral head. Therefore, it is critical to reduce the dislocated hip joint as early as possible to restore the blood supply to the femoral head and neck, thus reducing the risk of femoral head necrosis (Stewart and Milford 1954; Brav 1962). –– The function of the sciatic nerve and the pulsation of the femoral artery should be examined and recorded in detail before and after surgery. –– Surgical condition: Reduction should be conducted in an operation room under general anesthesia or epidural anesthesia; if the condition does not allow, it should be conducted under close monitoring after appropriate sedation and analgesia. • Reduction techniques for posterior dislocations of the hip: Manual reduction should be performed by using the traction force gently and continuously without any violence to avoid iatrogenic fractures. Fluoroscopy can be used to assist technical adjustment for difficult reduction. Dislocation reduction should be completed at one time without repeatedly attempting to avoid further damage. If the closed reduction is unsuccessful, open reduction should be performed. –– Bigelow maneuver (the “question mark” method) (Bigelow 1878): While the patient lies flat on the operation bed with his/her pelvis stabilized firmly by an assistant, the operator holds the ankle of the affected limb with one hand and holds the affected limb with the other arm around the popliteal fossa to apply continuous longitudinal traction to the femur. First, force is applied to cause the affected limb to adduct, internally rotate, and flex to the maximal level, forcing the knee joint to medially and tightly contact the torso. Subsequently, the limb is pulled to abduct and externally rotate the hip joint, directing the femoral head into the acetabulum. Meanwhile, the affected limb is gradually straightened. –– Allis method (Allis 1895): The patient lies on the operation bed, and an operation assistant stabilizes the pelvis of the patient and pushes the base of the thigh from the inside to the outside during traction. With one hand or forearm holding the affected limb around the popliteal fossa of the patient, the operator longitudinally pulls and adducts the femur while the hip and knee are flexed. Meanwhile, with the other hand holding the ankle joint of the affected limb, the operator swings the affected limb from side to side and gently rotates the femur to reduce the dislocated hip joint. –– Stimson technique (Stimson 1889): The patient is placed prone on the operation bed with both lower limbs hanging off the side of the bed, and an assistant stabilizes the pelvis to prevent the patient from falling. While the affected limb flexes to 90°, the operator applies a downward force in combination with the gravity of the lower limb to longitudinally pull the

9

•

•

•

•

femur via one hand above the popliteal fossa. Meanwhile, using the other hand to hold the ankle joint of the affected limb, the operator swings the affected limb from side to side and gently rotates the femur to reduce the dislocated hip joint (Fig. 1.12). Reduction techniques for anterior dislocations of the hip (Fig. 1.13): –– Modified Allis method (Allis 1895): The patient lies supine on the operation bed, and an operation assistant stabilizes the pelvis of the patient and pushes the base of the thigh from the inside to the outside during traction. After longitudinally pulling the affected limb and slightly flexing the hip of the patient, the operator internally rotates and adducts the limb with a gentle force to reduce the dislocated hip. –– Reverse Bigelow maneuver (the reverse “question mark” method) (Bigelow 1878): While the patient lies flat on the operation bed with his/her pelvis stabilized firmly by an assistant, the operator holds the ankle of the affected limb with one hand and holds the affected limb with the other arm around the popliteal fossa to apply a continuous longitudinal traction to the femur. First, the force is applied to cause the affected limb to gradually flex, externally rotate, and abduct, forcing the knee joint to laterally and tightly contact the torso. Subsequently, the limb is pulled to adduct and internally rotate the hip joint, directing the femoral head into the acetabulum. Meanwhile, the affected limb is gradually straightened. Postoperative assessment: X-ray and CT scanning should be performed immediately after completion of the reduction operation to assess the status of the reduced joint and the presence of any accompanying fractures of the femoral head and acetabulum (Fig. 1.14). –– A failure to restore the concentric structure of the acetabulum and the femoral head, i.e., hip subluxation, indicates the existence of femoral head or acetabular fractures, which requires further surgical treatment to restore the stability of the hip joint. –– For well-reduced Pipkin Type I femoral head fractures with an anatomic reduction or fracture displacement 45° of the affected extremity. • The greater trochanter of the affected side is swollen or bruised, the tenderness is obvious at the trochanteric part, and axial percussion can trigger fierce hip pain. • An intertrochanter fracture is often accompanied with fractures of the distal radius, proximal humerus, and ribs, as well as compression fractures of the spine, which should be carefully examined.

68

P. Tang et al.

• Hidden blood loss often exists in patients with intertrochanteric femoral fractures; therefore, hemodynamics and other related parameters should be carefully evaluated and monitored after hospital admission. • Elderly patients often have delayed treatment and reduced dietary intake before and after hospital admission. Therefore, special attention should be paid to biochemical examination and evaluation of the water and electrolyte balance to avoid complications, such as dehydration, electrolyte disorder, and stress ulcer. • Routine preoperative ultrasound examination should be performed to evaluate venous thrombosis of the lower extremity. Anticoagulation therapy with low-molecular-­ weight heparin and factor Xa inhibitors should be used before and after the operation to prevent the formation of deep venous thrombosis of the lower extremity and the occurrence of pulmonary embolism due to thrombus detachment.

3.1.5.2 Imaging Assessment • AP X-ray of the pelvis and lateral X-ray of the hip are routine examinations and generally can confirm the diagnosis of intertrochanteric femoral fractures (Fig. 3.6). • CT scan and 3D reconstruction can be used to further determine the severity and direction of fracture displacement, observing the hidden fracture line and evaluating the possibility of tumor lesions (Fig. 3.7).

a

Fig. 3.6  Intertrochanteric fractures of the femur

b

Fig. 3.7 (a) Cross-sectional CT scan of intertrochanteric fractures of the femur. (b) Coronal CT scan of intertrochanteric fractures of the femur. (c) 3D reconstruction of intertrochanteric fractures of the femur

3  Intertrochanteric Fractures of the Femur

c

Fig. 3.7 (continued)

• MRI can be used to discover hidden intertrochanteric fractures and evaluate the possibility of pathological fractures (e.g., tumor-caused fracture).

3.1.5.3 Evaluation of the Intertrochanteric Femoral Fracture Stability Treatment failure mostly occurs in cases of unstable fractures; therefore, discriminating intertrochanteric fractures with different levels of stability is essential for improving treatment efficacy. Unstable fractures are characterized by the following clinical factors (Elder et al. 2000; Koval et al. 2008): • Severe rotational deformity or shortening of the affected extremity. • Loss of support in the posteromedial side of the femur: A large fracture fragment of the lesser trochanter is visible in radiographic images. • Significant displacement between the femoral head and neck and the femoral shaft: Loss of contact between the femoral head and neck and femoral shaft can be observed in radiographic images. • A reversed trochanteric fracture: The proximal bone fragment is pulled outward and upward by the gluteus medius and gluteus minimus muscles, and the distal femoral shaft is pulled medially by the adductor, generating a strong shear force at the fracture ends; therefore, this fracture is extremely unstable. • Severe osteoporosis: The Singh index is lower than 3.

69

• Comminuted fracture: Comminution and separation of bone fragments are present in radiographic images. The AP view may not always clearly show the comminuted bone, but lateral view can display the remarkably comminuted fracture. In clinical practice, comminuted fractures are often found by intraoperative lateral fluoroscopy.

3.1.5.4 Evaluation of Special Types of Fractures and Potentially Unstable Fractures (Fig. 3.8) • Fractures at the base of the femoral neck: The fracture is located at or near the intertrochanteric line. –– The fracture is located outside the capsule of the hip joint. –– The probability of osteonecrosis of the femoral head is greater than that of other intertrochanteric femoral fractures. –– Rotational displacement often occurs and is difficult to identify; therefore, special attention should be paid to control rotational displacement during the placement of internal fixators. –– Anti-rotation internal fixation devices should be used. • Reversed intertrochanteric femoral fractures: –– The fracture line extends from the medial cortex of the proximal femur to the distal lateral bone cortex. –– There is a large shear force on the broken ends, leading to very poor stability of the fracture. Fixation with dynamic hip screws (DHS) may cause the entire proximal end to move outward, resulting in a failure of internal fixation (Haidukewych et al. 2001). –– Therefore, type A3 fractures are mostly internally fixed using an intramedullary system. For screw-plate internal fixation, dynamic condylar screws (DCS) are the preferred choice (Wright 1947). • Type A1.3 fractures: The fracture line extends to the site below the lesser trochanter, and as a result, the lesser trochanter is included in the proximal femoral fracture fragment (Kregor et al. 2005). –– The pulling force of the iliopsoas muscle causes extreme external rotation and anteromedial displacement of the lesser trochanter. –– The pulling forces of the gluteus medius and gluteus minimus muscles make the distal end of the fracture to move upward and outward, and the adductor pulls the affected extremity to move upward and thus become shortened. –– Fracture reduction is difficult to operate and maintain. The reduction can be completed only if the rotation is well controlled.

P. Tang et al.

70

a

b

c

Fig. 3.8 (a) Basicervical fracture: the fracture is extracapsular and close to the intertrochanteric line, and as a result, it is prone to rotational displacement. (b) Reversed intertrochanteric fractures: the fracture line extends laterally from the medial cortex of the proximal femur up to the lateral cortex. There is a large shear force at the fracture ends, resulting in very low stability of the fracture. (c) Type A1.3 fractures: the fracture line is below the lesser trochanter so that the lesser trochanter is attached to the proximal bone fragment. The pulling force from the iliopsoas muscle causes extreme external rotation and anteromedial displacement of the proximal fragment. Intraoperative correction of rotational dis-

placement is required, and reduction is difficult. (d, e) Potentially unstable fractures: traditional intertrochanteric fractures that have a fracture line along the direction of the trochanteric line can be considered potentially unstable fractures only if a small portion of the greater trochanter is connected to the femoral shaft or the greater trochanter fragment is excessively thin. When using DHS to fix this type of fracture, it is possible that enlarging the holes for dynamic screw insertion causes an iatrogenic fracture. Consequently, the fracture is converted to a type A3 unstable fracture of the reversed intertrochanteric fracture, eventually leading to a failure of internal fixation

3  Intertrochanteric Fractures of the Femur

d

71

e

Fig. 3.8 (continued)

• Potentially unstable fractures: –– Traditional intertrochanteric fractures that have a fracture line along the direction of the trochanteric line can be considered potentially unstable fractures if only a small portion of the greater trochanter is connected to the femoral shaft or the greater trochanter fragment is excessively thin. –– When using DHS to fix this type of fracture, it is possible that enlarging the holes for dynamic screw insertion will cause an iatrogenic fracture. Consequently, the fracture is converted from a type A1–A2.1 stable fracture to a type A1–A2.1 unstable fracture, eventually leading to failure of internal fixation.

3.2 Treatment of Intertrochanteric Femoral Fractures

• Conservative treatment is only suitable for patients who have other serious internal diseases and cannot tolerate anesthesia and surgery. Patients who are unconscious and unable to move on their own, or have lost their mobility before injury, should be treated conservatively. • Patients who can walk before injury but cannot tolerate surgery because of internal diseases should receive traction treatment and wear an anti-rotation device to avoid the occurrence of shortening and external rotation deformity of the affected extremity. After 8–12 weeks of continuous traction, if fracture healing is confirmed by X-ray, the patient can gradually begin weight-bearing walking. • Patients who have lost their ability to walk before injury should be encouraged to participate in outdoor activities in a wheelchair with proper pain control to avoid bedridden-­associated complications as early as possible.

3.2.1 Conservative Treatments

3.2.2 Surgical Treatment

• The mortality rate of patients who receive conservative treatment is significantly higher than that of surgical treatment because the bedridden status not only deteriorates the initially existing internal disease, but it also causes complications such as hypostatic pneumonia, bedsores, and venous thrombosis.

3.2.2.1 Basic Principles of Surgical Treatment • Surgical indications: • Most patients with intertrochanteric fractures are elderly people, and a long-term bedridden status can cause various complications. Therefore, patients who can tolerate surgery should receive surgical treatment.

72

• Surgical purpose: –– To firmly fix the fracture to enable early off-bed activities, avoiding bedridden-associated complications and reducing mortality. –– To restore the normal function of the hip joint and prevent complications such as varus and shortening deformity of the affected extremity. • Timing of surgery: Based on the experience of the 301 Hospital, the timing of surgery can be chosen as follows: –– Once the patient is in a stable condition, surgery should be performed as soon as possible. –– Those who do not have internal disease or only have mild internal disease usually have a relatively low surgical risk and should receive the surgery as soon as possible within 48 h. –– Patients who have serious internal diseases and a relatively high surgical risk should receive internal medical treatment first; once the condition allows, surgery should be performed as soon as possible. –– For a patient who has serious internal diseases and a very high surgical risk or cannot tolerate surgery, surgical treatment is not an option as it may accelerate the death of the patient.

3.2.2.2 Selection of Surgical Treatment Methods • The two most commonly used treatment methods for intertrochanteric femoral fractures are closed reduction plus intramedullary nail fixation and open reduction plus DHS internal fixation. Other surgical methods include artificial femoral head replacement and the use of external fixators (Little et  al. 2008; Ruecker et  al. 2009). • In recent years, intramedullary fixation has become a mainstream internal fixation method. However, there is no medical evidence to prove the absolute superiority of any method (Anglen and Weinstein 2008). –– Closed reduction and intramedullary nail fixation: Advantages: The forces loaded on the fracture and fixators are evenly distributed, and the layout is mechanically more reasonable; the operation can be completed percutaneously with less blood loss. Disadvantages: It is difficult to operate because this approach has a high requirement for fluoroscopic conditions; it is costly, and revision surgery is difficult. –– Open reduction and DHS internal fixation: Advantages: This approach has a low requirement for fluoroscopic conditions and thus is relatively easy to operate; its operating technique is easy to learn; it is inexpensive, and revision surgery is easy. Disadvantages: It is an open operation that will cause a relatively large amount of blood loss; it is unsuitable for reversed intertrochanteric femoral

P. Tang et al.

fractures or fractures extending to the level below the lesser trochanter; it may cause an unstable intertrochanteric fracture to collapse, resulting in shortening of the affected extremity; patients whose fracture does not obtain sufficient medial support cannot begin early weight-bearing exercise. • Evans Type II reversed femoral trochanteric fractures, in which the fracture ends bear a large shear force because the pulling force of the adductor displaces the distal fracture end medially and the pulling forces of the gluteus medius and gluteus minimus muscles result in flexion, external rotation, and abduction displacement of the proximal fracture end, should be considered as a contraindication for the application of DHS; therefore, intramedullary nail fixation or open reduction and DCS internal fixation is more suitable. • In summary, Evans Ia and Ib fractures can be fixed by either intramedullary nails or DHS, Ic and Id fractures are fixed mostly by intramedullary nails, and Evans II can be fixed by either intramedullary nails or DCS (Babst et al. 1993; David et al. 1996).

3.2.2.3 Surgical Techniques DHS fixation for intertrochanteric femoral fractures • Body position, preoperative preparation, and closed reduction: • Body position and preoperative preparation are basically the same as closed reduction and internal fixation for femoral neck fractures. The patient lies on the traction bed, and the affected extremity is pulled and then rotated internally for closed reduction. • Determination of coxa vara and coxa valga by fluoroscopy during surgery: Normally the apex of the greater trochanter and the center of the femoral head should be on the same plane (Fig. 3.9). • The finding that the center of the femoral head is lower than the apex of the greater trochanter suggests coxa vara. • The finding that the center of the femoral head is higher than the vertex of the greater trochanter suggests coxa valga. • The femoral neck-shaft angle is evaluated using that in the X-ray plain film of the unaffected hip as a reference. • Reduction criteria: Reduction quality relies heavily on the surgeon’s skill, and poor reduction is the most important cause for the failure of internal fixation. The criteria for proximal femoral fracture reduction are as follows (Carr 2007; Bucholz and Court-Brown 2010): • The varus does not exceed 5°, and the valgus is no more than 20°. • The reduction requirement for the varus deformity is significantly more rigorous than that for the valgus deformity because a slight valgus can reduce the eccentric

3  Intertrochanteric Fractures of the Femur

a

73

b

c

Fig. 3.9 (a) Normally the tip of the greater trochanter should be at the same level as the center of the femoral head. (b) The finding that the center of the femoral head is below the apex of the greater trochanter

indicates coxa vara. (c) The finding that the center of the femoral head is higher than the apex of the greater trochanter indicates coxa valga

torque, which reduces the shear stress on the internal fixators and decreases the severity of shortening of the affected extremity (Fig. 3.10). The angle formed cannot be larger than 10° in the lateral view. The rotational displacement is difficult to determine. A standard lateral view obtained after adjusting the femoral condyle to a horizontal position under fluoroscopy may display the actual anteversion angle. Operative incision according to the projection on the body surface: The greater trochanter and the longitudinal axis of the femoral shaft are marked as references for the surgical incision. Surgical approach (Fig. 3.11): –– The skin and subcutaneous tissue are cut along the incision according to the projection on the body surface, and the proximal femoral fascia and tensor fasciae latae are cut along the direction of the incision. –– After the fascia of the vastus lateralis muscle is cut open, the muscle is bluntly split. –– Two hooks are placed at the upper and lower femur, and after the vastus lateralis muscle is bluntly split, the perforating vessels of the muscles in the surgical field are severed and ligated. The quality of reduction is evaluated fluoroscopically. If a closed reduction does not achieve satisfactory results, a pointed reduction clamp can be used to assist further reduction. First, the soft tissue intercalated between the

fracture ends is removed, and the traction is adjusted to restore the length of the affected extremity. Next, the affected extremity is rotated, and then the pointed reduction clamp is closed with one leg placed near the lesser trochanter to complete the reduction (Fig. 3.12). • The entry point of the guide wire is determined according to the angle of the steel plate (Fig. 3.13a). –– The apex of the proximal lesser trochanter at the proximal side of the attachment point of the gluteus maximus can be used as a marker to determine the needle entry point for a 135° plate. –– When using a steel plate with a large angle, the needle entry point is shifted distally by 5 mm with every 5° increase in the angle of the sleeve. • A Kirschner wire is inserted into the femoral head from the front to determine its direction. Guided by the lateral view, a guider with an appropriate angle is placed at the entry point at the junction of the anterior and middle thirds of the greater trochanter. Subsequently, guided by the AP view, the position of the guider is adjusted to make the guiding needle parallel to the longitudinal axis of the femoral neck and located at the lower part of the femoral neck. Finally, the needle is drilled into the subchondral bone (Fig. 3.13b, c). • The ideal length of the medullary tunnel and the implanter should be 5  mm shorter than the guide wire. After the desired length is determined, a special drill with a preset drilling depth is used to enlarge the medullary cavity.

• •

•

•

•

74

a

P. Tang et al.

b

c

Fig. 3.10  The effect of reduction quality on the eccentric torque and the length of the affected extremity when using a sliding hip screw to fix an intertrochanteric fracture. (a) Presence of a 10° valgus angle of the fracture compared with the contralateral extremity: D1 denotes the eccentric torque, and H1 is the distance from the apex of the femoral head to the lesser trochanter. (b) Anatomical reduction: D2 denotes the eccentric torque, and H2 is the distance from the top of the femoral head to the lesser trochanter. (c) Presence of a 10° varus angle of the fracture

compared with the contralateral extremity: D3 denotes the eccentric torque, and H3 is the distance from the apex of the femoral head to the lesser trochanter. A comparison of (a), (b), and (c) shows D1 130° in the AP view. If the angle is 130°. (d)

The intramedullary nail is inserted, and its depth is ensured under radiography

3  Intertrochanteric Fractures of the Femur

d

Fig. 3.24 (continued)

pression process is monitored and evaluated by intraoperative fluoroscopy (Fig. 3.26). • The distal locking screw is locked via a guider. The distal locking screw can be locked dynamically for stable intertrochanteric fractures and statically for unstable intertrochanteric fractures (Fig. 3.27). • Placement of the screw cap: This step is unnecessary in most cases because patients with intertrochanteric fractures usually do not need to remove the internal fixators. • After rinsing, incisions are sutured layer-by-layer (Fig. 3.28).

Experience and lessons • Expansion of the medullary cavity must be performed after reduction. • The intertrochanteric fracture should be reduced before intramedullary nail fixation. Attempts to reduce the fracture after placement of the intramedullary nail often fail. • If closed reduction fails, the fracture can be reduced percutaneously or via a limited incision. • The entry point of the intramedullary nail must be accurate so that the screw is inserted from the apex of the greater trochanter. –– Reasons for the lateral deviation of the screw entry point: In addition to incorrect judgment in selecting the entry point, an improper operation can also lead to deviation of the screw entry point. Operations of cortical expansion, medullary cavity expansion, and intra-

85

medullary nailing are often interfered with by soft tissue and surgical drapes, and as a result, the opening on the apex of the greater trochanter may be gradually enlarged and biased to the lateral side, eventually causing the intramedullary nail to become unexpectedly positioned closer to the lateral side. –– Consequences of the lateral deviation of the screw entry point: The insertion of an intramedullary nail via the laterally deviated entry point can lead to the loss of reduction and coxa vara (Fig. 3.29). In addition, the position of the lag screws placed into the femoral head may be too high, increasing the risk of lag screw impingement. –– Measures to avoid misoperation: Radiographic monitoring should be used to ensure the accuracy of the screw entry point, which is on the apex of the greater trochanter in the AP view and at the junction of the middle and anterior thirds in the lateral view. The screw must be inserted in the direction of the femoral medullary cavity. Expansion of the medullary cavity should be performed under protection of the sleeve. The sleeve is pushed toward the torso side to avoid the outward movement of the surgical reamer and the resulting lateral deviation of the canal during the opening and widening of the medullary cavity. • Internal fixators must be appropriately chosen. –– Proximal femoral intramedullary nails or long intramedullary nails: In an unstable intertrochanteric fracture, a long intramedullary nail is a better choice because the intramedullary nail will bear greater stress and because a long screw can distribute the excessive stress more to the femoral shaft and reduce complications caused by the local stress concentration. –– A cephalomedullary nail with either a spiral blade or common threads can be selected. For elderly patients with osteoporosis, a cephalomedullary nail with a spiral blade design is a better option, which is advantageous for both anti-rotation and load-bearing performance. The screw with a spiral blade design can be placed directly without need for a drill hole in advance, thus avoiding drilling-­caused bone loss. In addition, placement of this type of screw into the femoral head and neck can squeeze the surrounding cancellous bone, causing it to become more solid and dense to increase the anchoring force of the screw (Fig. 3.30). However, for young people with good bone quality in the femoral neck, a screw with a spiral blade design is not recommended because its direct entry may cause iatrogenic fracture of the femoral neck. • Separation of the fracture ends should be avoided. –– The reduction operation can easily cause a separation or rotational displacement of the fracture ends of transversal and reversed intertrochanteric fractures.

86

P. Tang et al.

a

c

b

d

Fig. 3.25 (a) The guide wire of the cephalomedullary nail is inserted in the direction of the fixation sleeve. (b) The tip of the guide wire should be 5 mm away from the surface of the subchondral bone, and the length of the actual selected spiral blade should be 10 mm shorter than the measured depth. (c) The direction of the guide wire is ensured under

AP radiography, which should be parallel to and below the longitudinal axis of the femoral neck, and the guide wire is inserted up to the subchondral bone of the femoral head. (d) In the lateral view, the guide wire should be in the middle of the femoral neck without either anterior or posterior deviation

–– If the fracture is fixed with the fracture ends apart, the contact between the ends during weight bearing is insufficient to effectively disperse the stress load; consequently, the stress would be concentrated on the internal fixation device, resulting in complications such as nonunion of bone or fatigue fracture of the internal fixator. –– To avoid the separation of the fracture fragments, operations such as lag screw compression and distal locking should be performed only after the traction of the lower extremity is loosened at the proper time and the contact between the bone fragments is confirmed under fluoroscopy.

• Excessive soft tissue injury should be avoided: The intramedullary nail should be placed via minimally invasive surgery, and the fracture fragments do not need to be anatomically reduced and fixed. Open reduction and intramedullary nail fixation inevitably destroy the biological environment favorable for fracture healing, resulting in complications such as bone nonunion (Fig. 3.31). • Distal locking and tip fracture of the intramedullary nail: The stress can be concentrated on the tip of the internal fixator, causing fracture. The design of an additional two interlocking screws at the tip of an intramedullary nail can increase the stability of the fixator when both are locked; however, this design also results in a relatively greater

3  Intertrochanteric Fractures of the Femur

a

87

b

c

Fig. 3.26 (a) The direction and depth of the cephalomedullary nail are confirmed fluoroscopically; a gap in the spiral blade is visible when the spiral blade is not tightly locked. (b) After the spiral blade is tightly locked, the gap disappears, and the fracture is compressed. (c) An intraoperative compression bolt is screwed into the rear of the cephalomedullary nail. The stop bolt on the sleeve is rotated in the direction opposite

to the compression bolt to enable contact between the rear of the sleeve and the intraoperative compression bolt. Subsequently, intraoperative compression is achieved by further rotating the compression bolt with the sighting arm as a pivot. The compression process is monitored by intraoperative fluoroscopy

P. Tang et al.

88

a

b

c

Fig. 3.27 (a) A distal locking screw is inserted into the hole drilled on the sleeve. (b) Distal static locking. (c) Distal dynamic locking

Fig. 3.28  Postoperative X-rays after intramedullary nail fixation for an intertrochanteric fracture

3  Intertrochanteric Fractures of the Femur

89

a

b

Fig. 3.29  Inappropriate positioning of the nail entry point causes reduction failure. (a) If the nail entry point is deviated posteriorly, intramedullary nailing would cause a forward or backward angulation of the

fracture. (b) If the nail entry point is deviated laterally, intramedullary nailing would cause coxa vara

90

P. Tang et al.

a

b

Fig. 3.30 (a) The implantation of a cephalomedullary nail with regular threads requires the entry hole to be drilled in advance, which causes bone loss. (b) Direct implantation of a cephalomedullary nail with a

spiral blade into the femoral neck causes compression of the surrounding cancellous bone but not bone loss

stress concentration. For some relatively stable fractures, the approach that uses only the proximal interlocking screw but leaves the distal screw hole abandoned can be considered because it reduces the stress concentration (Brumback et al. 1992; Hajek et al. 1993) (Fig. 3.32). • Mechanical design for internal fixation:

ullary fixation, sliding compression is always the core mechanism in fixator design. Axial sliding between the compression screw and the main nail generates a compressive force on the fracture ends and maintains the stability of the fracture. The sliding compression design has experienced the process from single screw to double screw and then back to single screw. Abandonment of the double-­screw design can be attributed to the difficulty associated with achieving simultaneous sliding compression due to the complex mechanical transmission of the proximal femur, which instead causes some complications, such as the “Z”-shaped screw retreat (Werner-Tutschku et al. 2002; Boldin et al. 2003). –– Locking plate: The biggest drawback of locking plate fixation is that it limits the compression of fracture ends. For stable fractures, the use of a locking plate can achieve good fixation; however, for unstable fractures, platescrew fixation should be applied with caution as it would cause complications such as fatigue fracture of steel plates and screws caused by greater stress (Fig. 3.35).

–– Anti-rotation design: Rotational displacement of the femoral head and neck is one of the most important factors responsible for internal fixation failure. –– Internal fixator design and surgical techniques for controlling the rotation of the femoral head and neck have always been the focus of attention of orthopedic surgeons. –– The double-screw and spiral blade designs for fixation of the femoral head and neck are all focused on enhancing anti-rotation performance. A special antirotation design is a goal that continuously drives the development of intramedullary fixation products (Fig. 3.33). –– Design for compression of fracture ends (Fig. 3.34): Dynamic compression can promote bone healing. Regardless of extramedullary fixation or intramed-

91

3  Intertrochanteric Fractures of the Femur

a

b

c d

Fig. 3.31  During open reduction and intramedullary nail fixation surgery for an intertrochanteric fracture of the femur, the wire cerclage of the lesser trochanteric bone fragment damages the soft tissue, which affects fracture healing and eventually causes internal fixation failure. (a) Preoperative AP X-ray. (b) X-ray at postoperative 6  weeks. (c)

X-ray at postoperative 6  months showing a partial collapse of the medial cortex and cephalomedullary nail impingement on the femoral head. (d) X-ray at postoperative 14 months revealing that the tip of the cephalomedullary nail impinges on the femoral head and protrudes into the acetabulum

P. Tang et al.

92 Fig. 3.32  Different locking methods with distal screws. (a) The method utilizing two interlocking screws to lock the distal end may result in a fracture due to concentrated stress. (b) The method utilizing only one proximal interlocking screw for locking while abandoning the distal screw hole can reduce the stress concentration

a

a

b

b

Fig. 3.33  Surgical techniques and designs for controlling femoral head and neck rotation. (a) Placement of a screw on top of the DHS to control the rotation. (b) Implantation of two intramedullary nails into

c

d

the femoral head and neck. (c) The design of the cephalomedullary nail with spiral blades. (d) InterTan double-screw design

93

3  Intertrochanteric Fractures of the Femur

a

b

Fig. 3.34  Design for compression of the fracture ends. (a) The sliding compression design of the dynamic hip screws (DHS), proximal femoral nail antirotation (PFNA), and proximal femur nailing (PFN) sys-

tems. (b) In PFN, it is difficult for the two screws to slide synchronously, resulting in a “Z”-shaped screw retreat

Artificial femoral head replacement for intertrochanteric femoral fractures • Surgical indications: Because intertrochanteric femoral fractures are mostly treated with internal fixation, the application of arthroplasty should be strictly controlled based on the indications (Kim et al. 2005; Stappaerts et al. 1995; Haentjens et al. 1989; Baumgaertner et al. 1995). • Patients with hip joint diseases such as femoral head ischemic necrosis or osteoarthritis before fracture can choose total hip arthroplasty to solve both the fracture and disease simultaneously. • In cases of internal fixation failure, it is difficult to obtain sufficient stability by internal fixation again; thus, joint replacement can be used as a remedy. • In patients with serious osteoporosis, the reliability of internal fixation is questionable, and femoral head replacement can be considered. • Body position and preoperative preparation, incision according to the projection on body surface, and surgical approach: Please see the Sect. 2.2.2.2 “Hip Arthroplasty (The Posterolateral Approach)” in fractures of the femoral neck for details. • Fracture reduction: –– The external rotator muscle group is severed near the base of the femoral neck and turned outward to protect the sciatic nerve. Because the fractured greater trochanter is pulled to move upward and backward by the gluteus medius and gluteus mini-

mus muscles, special attention should be paid to identify the anatomical structures to avoid mistakenly cutting the gluteus medius muscle and causing unnecessary damage. Based on our experience, a bone hook can be placed on the piriform fossa to pull the greater trochanter forward and to the distal end. After reduction of the greater trochanter, the short group of external rotators and the posterior joint capsule are severed. • Treatment before implantation of the prosthesis: –– For a fracture near the base of the femoral neck, the femoral head can be removed directly because only a very small portion of femoral neck is connected. If the femoral neck is connected to the calcar femorale and the fragment containing the calcar femorale is relatively larger, the femoral neck should be amputated at a site 1  mm away from its bottom to retain the calcar femorale. After removal of the femoral head, the retained calcar femorale can be reinserted into the bone defect site to restore the integrity of the calcar femorale during the reconstruction of the proximal femur. –– The acetabulum and the residual round ligament are cleaned up. Attention should be paid to carefully treat significant bleeding from the branches of the obturator artery in the transverse ligament of the acetabulum. –– Reconstruction of the proximal femur: This is a key step in surgery that is very critical for restoring the function of the hip joint.

94

a

P. Tang et al.

b

c

Fig. 3.35  A reverse proximal femoral locking plate is used to fix the greater trochanter fracture. (a) Postoperative X-ray showing an acceptable fracture reduction. (b) X-ray at postoperative 2  years: the hip shows a varus deformity with a non-united fracture; the upper two locking screws are broken and impinge on the femoral head. (c) CT scan and 3D-reconstructed image at postoperative 2  years: the hip has a

varus deformity with a non-united fracture; the locking screws are broken and impinge on the femoral head. (d) The internal fixator is surgically removed, and intramedullary nailing is performed after reduction. (e) X-ray at 1 month after the second surgery showing a blurred fracture line

3  Intertrochanteric Fractures of the Femur

d

95

e

Fig. 3.35 (continued)

The greater trochanter is fixed with a “∞”-shaped steel wire: According to the principle of the tension band, the fracture of the greater trochanter can be fixed with a “∞”-shaped steel wire. In addition, the greater trochanter is cancellous bone that is easy to slice with the wire if the wire is tightened with excessive force. The lesser trochanter is fixed using a wire cerclage method: After the displaced femoral lesser trochanter is reduced, two steel wires are placed above and below the lesser trochanter through a ring-­ shaped steel wire guider. When tightening the steel wire, a medullary broach can be prepositioned in the intramedullary cavity to prevent

narrowing of the medullary cavity during tightening of the steel wires. To avoid sliding of the steel wire, it is sometimes necessary to create grooves at the sites of the steel wires to increase the stability of the steel wires. Alternatively, the wires can be placed through pre-drilled holes on the fragment containing the lesser trochanter for cerclage as shown in Fig.  3.36, in which a hole is drilled through a bone block. Management of the calcar femorale: The calcar femorale reserved from the osteotomy is inserted into the distal bone defect site, and the proximal medullary cavity of the femur is reconstructed by wire cerclage. In some cases, bone cement can be used to reshape

96

P. Tang et al. a

b

c

Fig. 3.36 (a–d) The lesser trochanter is fixed using a wire cerclage method: (a) A hole is drilled in the lesser trochanter fragment via a guider after the fragment is reduced. (b–d) A cerclage wire is passed through the bone hole using a guider. Before tightening the steel wire, a medullary broach is prepositioned in the intramedullary cavity to pre-

d

vent narrowing of the medullary cavity caused by wire tightening (replaced with a prosthesis in the figure). (e) Similarly, a wire is passed through the hole pre-drilled in the greater trochanter through the guider and tightened to fix the greater trochanter in an “∞” pattern

3  Intertrochanteric Fractures of the Femur

e

97

infiltrate into the fracture space and affect bone healing. Minimizing the gap between the fracture ends, which can be achieved by reducing the fracture and tightening the wires as much as possible, can prevent bone cement leakage. In addition, implantation of the prosthesis during the dough period of the bone cement can reduce the infiltration of bone cement. –– Assurance of the proper length of the affected extremity: The implantation depth of prosthesis is difficult to determine due to a lack of reference markers once the calcar femorale is defected in the fracture. If the ­prosthesis is implanted too deep, various complications may occur, including shortening of the extremity and dislocation of the joint; if it is implanted at a position that is too shallow, the extremity may be too long, and reduction is difficult. Before bone cement fixation, the prosthesis can be inserted into the medullary cavity, and the desired insertion depth of the prosthesis can be estimated based on the relationship between the apex of the greater trochanter and the center of the femoral head, i.e., the apex of the prosthesis should be at the same level as the apex of the greater trochanter (Fig. 3.37).

Fig. 3.36 (continued)

the calcar femorale if the comminuted calcar femorale cannot be fixed or is completely missing. –– Determination of the anteversion angle of the femoral prosthesis: In the case in which an intertrochanteric fracture involves the base of the femoral neck or even no calcar femorale can be reserved, there are no anatomical markers for implantation of the femoral prosthesis. Our suggestion for determination of the anteversion angle of the prosthesis is that the hip and knee be flexed by 90° to position the femoral condyle line on the horizontal plane and then the femoral prosthesis be tilted forward by 15° using this plane as a reference. The anteversion can be moderately increased to prevent posterior dislocation of the prosthesis. –– Treatment of bone cement leakage: When bone cement is used to fix the prosthesis, it will inevitably

Experience and skills • Joint replacement for intertrochanteric fractures requires the reduction and wire cerclage fixation of the greater and lesser trochanters. Due to relatively severe surgical trauma and blood loss and long operation time, joint replacement has a higher surgical risk than internal fixation. Therefore, surgical indications for joint replacement should be strictly evaluated, and it is not recommended as a routine treatment method. • Selection of bone cement fixation: For elderly patients with severe osteoporosis, a high bone fragility results in poor mechanical anchoring force between the bone and prosthesis; therefore, biological fixation is unsuitable, which may lead to complications such as prosthesis loosening and sinking, and therefore, bone cement fixation is a better alternative option. • Selection of appropriate prostheses: –– Currently, the selection of prostheses for joint replacement in the treatment of intertrochanteric fractures lacks a unified standard. Some researchers have proposed the use of bioprosthesis and even tumor-type proximal femoral prostheses for intertrochanteric fractures, which are apparently superfluous as they would unnecessarily increase the complexity of the surgery and cause more serious trauma and complications.

P. Tang et al.

98 Fig. 3.37  Case example of a 90-year-old male patient. (a) Preoperative X-ray of an intertrochanteric femoral fracture. (b) Intraoperative photo: a double-strand thick steel wire is placed closely on the proximal femoral cortex for cerclage to fix the greater and lesser trochanters, followed by joint replacement. (c) X-ray at postoperative 3 months

a

c

b

–– In recent years, some special prostheses for intertrochanteric fractures have emerged, which are characterized by additional designs for fixation of the greater and lesser trochanters, with the hope of easing the operation and improving hip function. –– Experience of the 301 Hospital: Traditional bone cement fixation and prosthesis implantation is recommended. The proximal femoral bone is reconstructed by using wire cerclage. The greater and lesser trochanters are fixed by steel wires with the muscle attachment points on the greater and lesser trochanters being preserved, enabling the muscles surrounding the prosthesis to function normally. The combination of steel wire and bone cement fixations can reconstruct a stable hip joint.

3.2.2.4 Prevention and Treatment of Surgical Complications • Lag screw impingement and application of the tip-apex distance (TAD): –– The position of the lag screw in the femoral head is one of the most important factors affecting the stability of the internally fixed intertrochanteric fractures, especially in elderly patients with osteoporosis. Poor fracture reduction, especially in the lateral view, is the major cause for poor positioning of the lag screw. –– Concept of the tip-apex distance (TAD): TAD refers to the sum of the distances between the tip of the lag screw of the apex of the femoral head measured in the AP and lateral X-ray films after magnification correction. As shown in Fig.  3.38, Xap and Xlat refer to the

3  Intertrochanteric Fractures of the Femur

99

a

b

Fig. 3.38 (a) Schematic diagram of the measurement and calculation of TAD. (b) Effect of the internal fixator with different angles on TAD. (c, d) After using a sliding hip screw to fix an intertrochanteric femoral

fracture, TAD 2 mm. –– Anterior process fracture affecting >25% of the articular facet of the calcaneocuboid joint. –– Displaced fracture of the calcaneal tuberosity. –– Open fracture. –– Fractures accompanied by luxation. • Purposes of surgical treatment: –– Restore the integrity of the subtalar joint. –– Restore Bohler’s angle and Gissane’s angle. –– Restore the normal width and height of the calcaneus. –– Maintain normal function of the calcaneocuboid joint. –– Correct the inversion deformity of the fracture. • Evidence-based prognostic predictors (McChesney and Buckley 2012): –– Currently, there is a lack of high-quality data for evidence-­ based analysis regarding whether surgical and nonsurgical treatment for calcaneus fractures have significantly different outcomes in terms of pain and foot functions. Compared with patients without surgical treatment, the patients who are surgically treated can return to work earlier, can use the same shoes as before the injury, and have a lower probability of subtalar arthritis (Ceccarelli et al. 2000). –– Age: Surgical treatment for calcaneus fractures shows more satisfactory outcomes than nonsurgical treatment in adolescent and young adult patients (50  years old) (Buckley et  al. 2002; Tufescu and Buckley 2001).

413

–– Gender: There is evidence to confirm that surgical treatment for calcaneus fractures has more satisfactory outcomes than nonsurgical treatment in female and young male patients (Barla et al. 2004). –– Type of occupation: For patients in physically undemanding occupations, surgical treatment for calcaneus fractures often yields a higher posttreatment function score than nonsurgical treatment. For patients in physically demanding occupations, although the two treatment strategies do not show significant differences in function scores, the patients who receive surgical treatment are able to return to work earlier and have a lower incidence of subtalar arthritis. –– Smoking: Even though smoking does not show a direct correlation with prognosis, it significantly increases the risk of wound complications. –– Bilateral fractures: The prognosis of patients with fractures on both sides does not show any difference between surgical and nonsurgical treatment, and it is worse than that of patients with unilateral fractures regardless of surgical or nonsurgical treatment (Dooley et al. 2004). –– Operation skills of the medical team: As reported in literature, the prognosis of surgically treated calcaneus fractures is correlated to the corresponding operation frequency in the medical organization in which the surgical treatment is given, and patients who are treated in medical organizations where the monthly average number of patients treated for calcaneus fractures is less than one often have a worse prognosis (Poeze et al. 2008).

12.2.2 Surgical Procedures 12.2.2.1 The Lateral Approach for Open Reduction and Internal Fixation for Intra-articular Fractures of the Calcaneus Body Position and Preoperative Preparation • The patient is given general anesthesia, epidural anesthesia, or nerve block anesthesia. • The patient lies in the lateral decubitus position, with the protruding bones protected by a soft cushion beneath, the affected extremity positioned behind, and the healthy extremity positioned forward. • A tourniquet is tied around the base of the thigh on the affected side (Fig. 12.16).

414

a

Fig. 12.16  Body position during open reduction and internal fixation for intra-articular calcaneal fractures via the lateral approach. (a) The patient lies in the lateral decubitus position, with the protruding bones

a

Z. Zhao and J. Li

b

protected by a soft cushion beneath. (b) Projection angle for the axial view of the calcaneus

b

Fig. 12.17 (a) The vertical section of the incision starts from the point 1.5 cm above the tip of the lateral malleolus and in the middle of the line connecting the posterior edge of the fibula and the anterior edge of the Achilles tendon; the horizontal section runs along the boundary between

the skin areas with and without hair at the lateral aspect of the foot and ends at the base of the fifth metatarsal. (b) Schematic diagram of the lateral incision of the calcaneus, which fully exposes the lateral aspect of the calcaneus and avoids damage to the sural nerve

Operative Incision According to the Projection on the Body Surface • Starting from the point 1.5 cm above the tip of the lateral malleolus and in the middle of the line connecting the posterior edge of the fibula and the anterior edge of the Achilles tendon, the incision line is drawn along the fibula until the borderline between the plantar skin and dorsal skin using a marker pen. Afterwards, the line is curved anteriorly and runs up to the base of the fifth metatarsal with its distal end slightly upwards (Fig. 12.17).

protect the blood supply to the skin flap, instead of layer-­ by-­layer dissection, the full-thickness skin and subcutaneous soft tissue are incised up to the calcaneal periosteum. • To flip the skin flap, the soft tissue is separated closely along the lateral surface of the calcaneus; alternatively, the surface periosteum of the calcaneus can be dissociated and flipped along with the skin flap. • The peroneal tendons and the sural nerve are flipped proximally along with the skin flap without exposure. Next, the calcaneofibular and talocalcaneal ligaments are severed beside the calcaneus to expose the lateral wall of the calcaneus.

The Surgical Approach (Fig. 12.18) • The calcaneus is a cancellous bone where the blood supply is abundant and avascular necrosis rarely occurs. To

12  Calcaneus Fractures

a

415

b

c d

e

Fig. 12.18 (a) A full-thickness flap is collected up to the periosteum; the soft tissue flap is dissected along the lateral surface of the calcaneus (i.e., the flap must not be stratified), and the calcaneofibular ligament and the talocalcaneal facet ligament are cut open to expose the subtalar joint. (b) Using the no-touch technique, Kirschner wires are placed into the fibula, talus, and cuboid along the diagonal of the skin flap and then bent to fix the flap. (c) The joint capsule is cut open to expose the sub-

talar joint. (d) A photo taken during the surgery: Without exposure, the peroneus longus and brevis tendons are flipped anteriorly together with the skin flap. (e) A photo taken during the surgery: The skin flap is protected using the non-touch technique, and the calcaneofibular ligament and talocalcaneal ligament are cut open to expose the calcaneus and subtalar joint

416

• Using the no-touch technique, Kirschner wires are placed into the fibula, talus, and cuboid along the diagonal of the skin flap and then bent to fix the flap. Use of retractors for exposure should be avoided because repeated position adjustment and strong pulling of the retractors might further damage the blood-supplying structure of the skin flap. • On the proximal side, an upwards cut is created to open the joint capsule for exposure of the subtalar joint. In addition, the tissue is separated distally to expose the calcaneocuboid joint. Fracture Reduction and Fixation • Reduction of calcaneus fractures is performed from anterior to posterior and from medial to lateral with the sustentaculum tali fragment as a landmark reference. The medial fragment must be reduced before attempting to reduce other fracture fragments. • The first step is flipping open or temporary removal of the lateral wall fragment of the calcaneus for exposure of the calcaneal body and articular facet fragments. Next, after clarifying whether there is a secondary fracture line in the articular facet based on preoperative CT scans, the broken fragments are temporarily removed, and blood coagulation clots and irreducible bone debris are cleaned up. • To restore the height of the calcaneus, the following two methods can be used: –– A bone stripper is inserted into the gap between the calcaneal tuberosity fragment and the sustentaculum tali fragment (the primary fracture line), through which the calcaneal tuberosity fragment is pried downwards and medially to return the calcaneal tuberosity fragment and the sustentaculum tali fragment back to their normal positions. –– Alternatively, a thick Kirschner wire or Schanz screw inserted into the calcaneal tuberosity fragment from lateral to medial can serve as a joystick to pull it downwards and posteriorly for restoration of the length of the calcaneus and correction of the inversion deformity of the calcaneus. • Temporary fixation: After the positions of the calcaneal tuberosity fragment and the sustentaculum tali fragment are restored, two Kirschner wires are inserted into the medial calcaneal tuberosity from inferoposterior to superoanterior to fix the calcaneal tuberosity fragment with the sustentaculum tali fragment. It is important not to place the Kirschner wires at the position that interferes with the subsequent fixation (Fig. 12.19). • Attention to the calcaneal axis: When the patient lies in the lateral decubitus position, the calcaneus tends to invert

Z. Zhao and J. Li

•

•

•

•

due to gravity; therefore, special attention should be paid to the calcaneal axis constantly during reduction and fixation so that the inversion of the calcaneus can be prevented and corrected in a timely manner. Attention to the width of the calcaneus: Reduction status of the medial wall as well as the width of the calcaneus can be observed in the axial view of the calcaneus under fluoroscopy; the increased width of the calcaneus often indicates that the length of the calcaneus has not been restored. Reduction and fixation of posterior subtalar facet fracture: After the posterior wall fracture of the calcaneus is reduced, the facet fracture is then reduced and fixed. –– For a Sanders Type II fracture, a stripper can be used to pry upwards and lift the compressed articular facet; after the normal anatomical relationship between the facet and sustentaculum tali fragments is restored, the fragments are temporarily fixed with Kirschner wires (Fig. 12.20). –– For a fracture of Sanders Type III or higher, fracture reduction is performed from medial to lateral. The fragments are reduced and temporarily fixed with obliquely inserted Kirschner wires layer by layer under direct view. After all fragments are reduced, two Kirschner wires are placed through all facet fragments to complete the entire reduction process. –– If it is too difficult to fix the fragments onto the sustentaculum tali, then the reduced fragment can be temporarily fixed onto the talus using Kirschner wires. –– The reduction status of the posterior facet is confirmed fluoroscopically on Broden’s views. Reduction and fixation of the anterior facet: –– It is important to ensure that Gissane’s angle is restored and the structural relationship among anterior and posterior calcaneus fragments is reconstructed, which is relatively easy if other fragments have been successfully reduced. –– Restoration of Gissane’s angle is confirmed fluoroscopically in the lateral view. Reduction and fixation of the lateral fragment: –– Whether bone grafting is necessary is determined according to the statuses of bone compression and bone defects (see section “Experience and Lessons” for detailed information). –– The lateral fragment is placed above other fragments at the end. Reduction and fixation of the lateral fragment is achieved via compression generated by the calcaneal plate. –– Restoration of the height, length, width, and mechanical axis of the calcaneus should again be confirmed fluoroscopically before final fixation.

12  Calcaneus Fractures

417

a

b

4

3

1

2

3 1

2

5

c 3

4

1

d

2

3

4

1 2 3

5 2

1

Fig. 12.19 (a) Taking the fracture shown in the figure as an example, the reduction sequence is as follows: the positional relationship between the calcaneal tuberosity fragment (2) and the sustentaculum tali fragment (4) is restored first to recover the height of calcaneus, then the articular facet fragment (3) is returned to its normal position, and finally, the lateral wall fragment (1) is reduced. (b) A bone stripper is inserted into the gap between the calcaneal tuberosity fragment and the sustentaculum tali fragment and used for downward prying to restore

3 2

5 1

the height of the calcaneus. (c) A thick Kirschner wire or Schanz screw inserted into the calcaneal tuberosity fragment serves as a joystick to pull the calcaneus and restore its length, as well as to correct the inversion deformity. (d) After the positions of the calcaneal tuberosity fragment and the sustentaculum tali fragment are restored, two Kirschner wires are inserted into the medial calcaneal tuberosity from inferoposterior to superoanterior to fix the calcaneal tuberosity fragment with the sustentaculum tali fragment

418 Fig. 12.20 (a) The articular facet fragments of the subtalar joint are reduced and temporarily fixed with Kirschner wires. (b) For patients with severe articular facet compression fractures and bone defects, bone grafting should be considered to accelerate healing and prevent loss of reduction

Z. Zhao and J. Li

a

• Final fixation of the calcaneus fracture: –– Despite the variable appearance, all types of calcaneal plates share a basically similar concept in design; that is, the screws are placed within the areas containing high-density trabecular bones, and the lateral fragment is fixed through compression. In addition, to prevent iatrogenic increase of the width of the calcaneus, all calcaneal plates have a thin body (Fig. 12.21). –– In recent years, a new type of calcaneus locking plate was developed to fix comminuted fractures or osteoporotic fractures of the calcaneus. –– As discussed in Sect. 12.1.2, an essential point in fragment fixation is that the screws should be placed by all possible means within the areas containing high-­density trabecular bones, including the sustentaculum tali, the subchondral bone of the posterior talocalcaneal joint, the area beneath Gissane’s angle, the anterolateral aspect of the calcaneus, and the subchondral bone of the calcaneocuboid joint. –– Because there are nerves and vessels running through the medial side of the calcaneus, in particular the areas close to the anterior calcaneus and below the subtalar joint, excessively long screws in these areas might damage the tibial nerve and vessels or even the flexor hallucis longus tendon; avoidance requires painstaking palpation on the opposite side with the other hand or fluoroscopic examination to confirm the appropriate length of the screws during hole drilling and screwing (Figs. 12.22, 12.23 and 12.24).

b

Incision Closure • Reduction of the peroneus longus and brevis tendons: –– A calcaneus fracture caused by high-energy violence is likely accompanied by rupture of the peroneal retinaculum, which can cause the peroneal tendon to subluxate and luxate to the anterior fibula. –– Such an injury can be primarily diagnosed through physical and CT examinations and reexamined after fixation of the calcaneus. –– The structure of the distal fibular fossa recovers naturally with anatomical reduction of the lateral wall of the calcaneus, which facilitates reduction of the peroneal tendon. –– Through the vertical section of the L-shaped incision, a tissue separation is created proximally to isolate the peroneus longus and brevis tendons, with special attention to protect the sural nerve and integrity of the skin flap. –– The tendons are reduced into the fibular groove, and the anatomical structure of the retinaculum is repaired with rivets for at least one tendon. • After internal fixation is completed, the Kirschner wires serving as exposure marks should be removed in a timely manner, and a gauze cushion soaked with normal saline is used to fill the wound for compression hemostasis. Subsequently, with attention to the bleeding status, the tourniquet is carefully loosened, followed by thorough hemostasis.

12  Calcaneus Fractures

a

419

b

d

c

e

Fig. 12.21 (a–e) Types of calcaneal plates

420

Z. Zhao and J. Li

a

• Placement of a drainage tube: –– The one end of the drainage tube should be placed below the L-shaped skin flap on the lateral side of the calcaneus to avoid flap floating and necrosis resulting from hydrops. –– The drainage tube exits from the lower leg skin at the site with a relatively plumper layer of muscles and soft tissue. It usually exits from the cut created at the site posterior to the fibula and proximal to the incision, and it is very important not to push the end of the drainage tube out from the tip of the L-shaped incision. –– The drainage tube is connected to a negative-pressure bottle for continuous negative pressure drainage. • After the joint capsule is sutured, the incision is closed by two-layer suturing (Fig. 12.25): –– The subcutaneous tissue is sutured with absorbable suture. Research has shown that the degradation of single-strand absorbable sutures causes a slightly reduced subcutaneous tissue reaction than the multistrand suture (Hollawell 2008). –– The stitches are made from the two ends of the vertical and horizontal sections to the middle in an interrupted fashion, but the they are knotted only after ensuring no tension on the subcutaneous tissue of the turning corner of the L-shaped skin flap by adjusting each stitch. –– To ensure the quality and effectiveness of each stitch, the sutures are knotted sequentially from the two ends to the middle turning corner after the entire incision is stitched. –– Different suturing techniques have been recommended for surface skin, including continuous intradermal suture (Stannard et  al. 2006) or interrupted suture using the improved Donati-Allgöwer vertical mattress suture technique (DeOrio et al. 2010) combined with compression bandaging with gauze. • Application of wound negative-pressure therapy (e.g., VSD) in treating the wound after open reduction and internal fixation of calcaneus fractures (Stannard et  al. 2006; DeCarbo and Hyer 2010): –– When wound dehiscence and marginal flap necrosis occurs after open reduction and internal fixation of calcaneus fractures, VSD can facilitate wound healing. –– The study by Stannard et al. showed that use of VSD as a routine treatment method can accelerate wound healing and solve problems such as hematoma after surgery. –– Wound negative-pressure therapy can remove blood, exudate, and interstitial fluid and clean up inflammatory factors and the source of infection, as well as alleviate pain and swelling. –– For open fractures, wound negative-pressure therapy started immediately after surgery can effectively reduce the risk of wound complications.

b

Fig. 12.22 (a) The screws inserted from the lateral calcaneus below the posterior facet might damage the tibial nerve and vessels or even the tendon of the flexor hallucis longus on the medial side if the screws are too long. (b) As shown in the figure, Albert has divided the calcaneus into four areas: The anterior and superior regions are the most dangerous regions for screw placement, where the medial vessels and nerves might be damaged by screws that are inserted too deep, followed by the lower region, and the inferior region, which is the safest

12  Calcaneus Fractures

a

421

b

c

e

d

g

h

Fig. 12.23  A Sanders Type IIA calcaneus fracture with the collapsed posterior articular facet. (a) A preoperative lateral radiograph: The posterior facet of the calcaneus collapsed, Bohler’s angle was 10°

430

Z. Zhao and J. Li

a

c

b

d

f

Fig. 12.32  Conserved treatment for bilateral calcaneus fractures after inversion malhealing. (a) A bilateral calcaneal lateral radiograph: The height of the calcaneus and Bohler’s angle were acceptable. (b) A bilateral axial radiograph of the calcaneus: Both calcanei showed an inversion deformity, which was more severe on the left side than on the right

e

g

side. (c, d) The 3D reconstructed CT images of the left and right feet: There were inversion deformities on both side of the calcanei. (e–g) AP, lateral, and axial radiographs of the calcaneus after subtalar joint arthrodesis

12  Calcaneus Fractures

• Impingement between the peroneus longus and brevis tendons: –– Loss of active eversion function and pain on the lateral foot indicate impingement, scar formation, or slippage of the peroneal longus and brevis tendons. –– Diagnosis can be made by evaluating the motion function of the subtalar joint and palpating the position of the tendons. –– The causes for these types of complications, including widening of the calcaneus and structural change of the distal fibular fossa, mostly result from anatomical reduction failure of the lateral calcaneus. Therefore, reduction of the lateral calcaneus and restoration of the width of the calcaneus are two foci in surgical treatment. –– Before incision closure, it is important to examine the position of the peroneal tendons and to determine the presence of anterior slippage of the tendons resulting from functional loss of the retinaculum, which might be caused by high-energy factures or damage to the lateral wall of the calcaneus.

References Abidi NA, Dhawan S, Gruen GS, et al. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998;19:856–61. Badillo K, Pacheco JA, Padua SO, et al. Multidetector CT evaluation of calcaneal fractures. Radiographics. 2011;31(1):81–92. Banerjee R, Chao J, Sadeghi C, et al. Fractures of the calcaneal tuberosity treated with suture fixation through bone tunnels. J Orthop Trauma. 2011a;25(11):685–90. Banerjee R, Saltzman C, Anderson RB, et al. Management of calcaneal malunion. J Am Acad Orthop Surg. 2011b;19(1):27–36. Barla J, Buckley R, McCormack R, et al. Displaced intraarticular calcaneal fractures: long-term outcome in women. Foot Ankle Int. 2004;25:853–6. Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Int. 2008;29(8):863–6. Boack DH, Manegold S, Haas NP.  Treatment strategy for talus fractures. Unfallchirurg. 2004;107:499–514. Böhler L. Diagnosis, pathology and treatment of fractures of the os calcis. J Bone Joint Surg. 1931;13:75–89. Borrelli J Jr, Torzilli PA, Grigiene R, et  al. Effect of impact load on articular cartilage: development of an intra-articular fracture model. J Orthop Trauma. 1997;11(5):319–26. Bradford CH, Larsen I.  Sprain-fractures of the anterior lip of the os calcis. N Engl J Med. 1951;244:970–2. Brodén B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol. 1949;31:85–91. Buckley R, Tough S, McCormack R, et  al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84:1733–44. Buddecke DE Jr, Mandracchia VJ.  Calcaneal fractures. Clin Podiatr Med Surg. 1999;16(4):769–91.

431 Car JB.  Calcaneal fractures. In: Archdeacon MT, editor. Prevention and management of common fracture complications. Slack incorporated; 2012. Carr JB, Hamilton JJ, Bear LS.  Experimental intra-articular calcaneal fractures: anatomic basis for a new classification. Foot Ankle. 1989;10:81–7. Cave EF. Fractures of the os calcis. Clin Orthop Relat Res. 1963;30:64–6. Ceccarelli F, Fatdini C, Piras F, et al. Surgical versus non-surgical treatment of calcaneal fractures in children: a long-term results comparative study. Foot Ankle Int. 2000;21:825–32. DeCarbo WT, Hyer CF.  Negative-pressure wound therapy applied to high-risk surgical incisions. J Foot Ankle Surg. 2010;49(3):299–300. DeOrio M, Easley ME. Intra-articular calcaneus fractures. Pfeffer GB, Easley ME, et al. Foot and ankle surgery. Saunders Elsevier, 2010: 570. Dhillon MS, Bali K, Prabhakar S. Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg. 2011;95(3):171–81. Dieterle JO. A case of so-called “open-beak” fracture of the os calcis. J Bone Joint Surg. 1940;22:740. Dooley P, Buckley R, Tough S, et al. Bilateral calcaneal fractures: operative versus nonoperative treatment. Foot Ankle Int. 2004;25:47–52. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395–419. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9:114–27. Gellman M. Fractures of the anterior process of the calcaneus. J Bone Joint Surg Am. 1951;33:382–6. Gissane W. Proceedings of the British Orthopaedic Association. J Bone Joint Surg. 1947;29:254–5. Green W. Fractures of the anterior-superior beak of the os calcis. N Y State J Med. 1956;56:3515–7. Hansen ST Jr. Functional reconstruction of the foot. Philadelphia: Lippincott; 2000. Heckman JD. Fractures and dislocations of the foot. In: Rockwood C, Green D, Buckholtz R, et al., editors. Rockwood and Green’s fractures in adults. Lippincott: Philadelphia; 2000. p. 2325. Heffernan G, Khan F, Awan N, et al. A comparison of outcome scores in os calcis fractures. Ir J Med Sci. 2000;169:127–8. Hollawell S.  Wound closure technique for lateral extensile approach to intra-articular calcaneal fractures. J Am Podiatr Med Assoc. 2008;98(5):422–5. Inokuchi S, Ogawa K, Usami N. Classification of fractures of the talus: clear differentiation between neck and body fractures. Foot Ankle Int. 1996;17:748–50. Inokuchi S, Hashimoto T, Usami N.  Posterior subtalar dislocation. J Trauma. 1997;42:310–3. Isbister JF. Calcaneo-fibular abutment following crush fracture of the calcaneus. J Bone Joint Surg Br. 1974;56(2):274–8. Isherwood I. A radiographic approach to the subtalar joint. J Bone Joint Surg Br. 1961;43:566–74. Jahss MH, Kay B.  An anatomic study of the anterior superior process of the os calcis and its clinical application. Foot Ankle Int. 1983;3:268–81. Koval KJ, Sanders R. The radiologic evaluation of calcaneal fractures. Clin Orthop Relat Res. 1993;290:41–6. Lindsay WRN, Dewar FP.  Fractures of the os calcis. Am J Surg. 1958;95:555–76. Lu J, Ebraheim NA, Skie M, et al. Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study. Foot Ankle Int. 1997;18:351–5. McChesney SJ, Buckley RE. Calcaneus fractures. In: Bhandari M, editor. Evidence-based orthopedics. Blackwell; 2012. p. 574. Miric A, Patterson BM. Pathoanatomy of intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 1998;80:207–12.

432 Mizel MS, Miller RA, Scioli MW.  Orthopaedic knowledge update: foot and ankle. American Academy of Orthopaedic Surgeons: Rosemont, IL; 1998. Morton D.  The human foot: its evolution, physiology and functional disorders. New York: Columbia University Press; 1935. Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res. 1993;290:142–50. Paley D, Hall H.  Intra-articular fractures of the calcaneus: a critical analysis of results and prognostic factors. J Bone Joint Surg Am. 1993;75(3):342–54. Poeze M, Verbruggen J, Brink P. The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load. A systematic review of the literature. J Bone Joint Surg Am. 2008;90:1013–21. Rammelt S, Grass R, Zawadski T, et  al. Foot function after subtalar distraction bone-block arthrodesis: a prospective study. J Bone Joint Surg Br. 2004;86(5):659–68. Rothberg AS.  Avulsion fractures of the os calcis. J Bone Joint Surg. 1939;21:218–20. Rowe CR, Sakellarides H, Freeman P, et al. Fractures of os calcis—a long term follow-up study of one hundred forty-six patients. JAMA. 1963;184:920. Sanders R. Intraarticular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992a;6:252–65. Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992b;6:252–65. Sanders RW, Clare MP. Fractures of the calcaneus. In: Coughlin MJ, Mann RA, Saltzman CL, editors. Surgery of the foot and ankle. 4th ed; 2007.

Z. Zhao and J. Li Sanders RW, Clare MP.  Fractures of the calcaneus. In: Robert WB, James DH, Charles MC, et al., editors. Rockwood and Green’s fractures in adults. 7th ed. Lippincott: Williams & Wilkins; 2010. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993;290:87–95. Sarrafian SK. Anatomy of the foot and ankle. 2nd ed. Philadelphia, PA: JB Lippincott; 1993. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-­ energy trauma. J Trauma. 2006;60(6):1301–6. Stephens HM, Sanders R. Calcaneal malunions: results of a prognostic computed tomography classification system. Foot Ankle Int. 1996;17(7):395–401. Tennent TD, Calder PR, Salisbury RD, et al. The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury. 2001;32(6):491–6. Tornetta P III.  The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma. 1998;12:469–73. Tornetta P III.  Percutaneous treatment of calcaneal fractures. Clin Orthop. 2000;(375):91–6. Tufescu T, Buckley R. Age, gender, work capability, and worker’s compensation in patients with displaced intraarticular calcaneal fractures. J Orthop Trauma. 2001;15:275–9. Warrick CK, Bremner AE.  Fractures of the calcaneum. J Bone Joint Surg Br. 1953;35:33–45.

13

Talus Fractures Zhuo Zhang and Hao Guo

13.1 Basic Theory and Concepts 13.1.1 Overview • Talus fractures are relatively rare, accounting for approximately 0.55% of total body fractures. However, as the second most common foot fracture, they account for 3–5.54% of total foot fractures. More than 80% of talus fractures occur in male patients. Talar neck fractures are most common among talus fractures (Zhang 2016). • Severe talus fractures are high-energy injuries and are often accompanied by other bone and muscle injuries and systemic damages. • In multiple trauma, the diagnosis of foot injury is most often missed (Vallier et  al. 2004a) and should be effectively examined at the time of admission. • If the situation allows, a displaced talus fracture should be treated with emergency joint reduction because fixation of the fractured bone and luxated joint eases the treatment and promotes recovery of the soft tissue injury. • Talus fractures are one of the most complex and difficult to treat ankle fractures. Due to a high incidence rate of complications, especially osteonecrosis, the treatment of talus fractures often fails to achieve satisfactory outcomes.

13.1.2 Applied Anatomy • The talus is composed of the talar head, neck, and body. The tarsal sinus (or sinus tarsi) is located between the talus and calcaneus beneath and divides the talus into three parts, the body at the posterior aspect and head and neck at the anterior aspect (Fig. 13.1). • The talus is the vertex of the longitudinal arch of the foot.

• The upper surface of the body of the talus is articulated with the distal tibia and displays a “wide front and narrow back” and “high lateral side and low medial side” shape. Therefore, the stress is mainly concentrated in its posterior part (Fig. 13.2). • The talar neck and body have an average inclination angle of 24° on both horizontal and sagittal planes (Fig. 13.3) (Sarrafian and Kelikian 2012). • The talus, which is connected to the adjacent bones by the synovium and joint capsule, has no muscle tissue attached to itself. • Approximately 60% of the surface of the talus is covered with cartilage; therefore, it is difficult to receive blood from the perforating vessels. There are a large number of “vascular holes” on the dorsal side of the talar neck and at the attachment points of the ligaments, through which the vessels enter the talus through the attachment points of the fascia and ligaments. Talus fractures and luxation often result in osteonecrosis (Fig. 13.4). • Below the talar neck, the anastomotic branches from the tarsal canal and tarsal sinus form a blood-supply network for the tarsal head. The branches from the dorsal side of the talus and the tarsal sinus jointly supply blood to the talar head (Mulfinger and Trueta 1970). • Talar neck fractures are often accompanied by ruptures of branch arteries in the tarsal sinus or tarsal canal. The increasing displacement of the fracture might break the branches from the dorsalis pedis artery, excluding those arising from the tarsal canal and the tarsal sinus. Therefore, the extent of fracture displacement is directly related to the incidence rate of osteonecrosis. • During percutaneous fixation or anterolateral incision, attention should be paid to avoid damaging the superficial peroneal nerve branch and dorsalis pedis artery passing through the dorsal surface of the foot (Fig. 13.5).

Z. Zhang (*) · H. Guo Chinese PLA General Hospital, Beijing, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 P. Tang, H. Chen (eds.), Orthopaedic Trauma Surgery, https://doi.org/10.1007/978-981-16-0215-3_13

433

Z. Zhang and H. Guo

434 Fig. 13.1  Overview of the talus: (a) Top view. (b) Bottom view. (c) Medial view. (d) Lateral view

a

b

c

d

a

b

Fig. 13.2  The talus and other bony components of the foot, and the longitudinal arch of the foot. (a) Medial plane. (b) Lateral plane Fig. 13.3  Inclination angles of the talar neck and body of the talus. (a) a is the long axis of the talar neck; b is the long axis of the talus body; and c is the inclination angle on the horizontal plane. (b) a is the tangent line of the talar head; b is the perpendicular line of a, representing the direction of the talar neck; c is the extended midline of the trochlea of talus; d is the perpendicular line of c; and e represents the inclination angle on the sagittal plane

a

o

AV 24° MN 10° MX 44°

b

c

d

a

e

c o

b AV 24° MN 5° MX 50°

a b

13  Talus Fractures

a

435

b

d c

e

Fig. 13.4  Vascular supply of the talus. (a) Coronal plane A in g; (b) Coronal plane B in g; (c) Coronal plane C in g; (d) Sagittal plane D in h; (e) Sagittal plane E in h; (f) Sagittal plane F in h; (g) Diagram of the coronal plane; (h) Diagram of the sagittal plane

436

f

Z. Zhang and H. Guo

g

h

Fig. 13.4 (continued)

13.1.3 Mechanism of Injury in Talus Fractures • Talar neck fractures result from highly torsional injuries (Figs. 13.6, 13.7, and 13.8) (Sanders 2023). –– During dorsiflexion, the posterior capsular ligament of the subtalar joint is ruptured, and the subsequent collision between the talar neck and the anterior edge of the distal tibia causes a talar fracture. The fracture line extends from the collision point to the nonarticular facet part in the posterior middle subtalar joint (no-­displaced fracture, type I talar neck fracture). –– Continuous dorsiflexion results in anterior subluxation of the calcaneus and all other bones in the foot including the talar head (subtalar joint luxation, type II talar neck fracture). If the traumatic force has a component force towards the medial side, the foot will be subluxated or luxated towards the medial side; if the compo-

nent force is towards the lateral side, the foot will be luxated towards the lateral side. If the trauma force is lost at this point, the foot will bounce back, and the body of the talus shows a horseshoe-like varus; the fracture line of the talar neck fracture points to the upper surface of the calcaneus (the subtalar joint). –– The continuing dorsiflexion force will further rupture the capsular ligaments of the posterior malleolus, including the posterior tibiotalar ligament and the superficial layer and posterior bundle of the deltoid ligament. The talus slips out posteromedially from the fornix of the ankle joint and rotates along the horizontal and transverse axes, creating a fracture line in the superolateral direction (tibiotalar joint luxation, type III talar neck fracture). The deep layer of the deltoid ligament and the flexor hallucis longus tendon remain intact, which acts as an axis for rotation of the talus.

13  Talus Fractures

a

437

b

Fig. 13.6  The talus collides with the tibia during the process of dorsiflexion

Fig. 13.5  Essential neurovascular anatomy on the talar surface. (a) Superficial anatomy; (b) Deep anatomy

The body of the talus rotates into and is fixed in the gap between the posterior surface of the medial malleolus and the anterior surface of the Achilles tendon, which is difficult to manipulatively reduce. In addition, this displacement is likely complicated

by fractures of the medial malleolus and sustentaculum tali. • Talus fractures can also be caused by low-energy violence: –– The common varus/valgus mechanism in sport injuries may cause fractures of the lateral and posteromedial processes of the talus and subtalar joint luxation. • Talar body fractures are often caused by high-energy violence: –– They are primarily caused by axial force and might be complicated by a talar neck fracture. –– Complications, including fractures of the tibial plafond or the medial and lateral malleoli, are often seen.

438

Z. Zhang and H. Guo

Fig. 13.8  Slipping out of the body of the talus

Fig. 13.7  Dislocation of the subtalar joint

13.1.4 Classification of Talus Fractures • The most commonly used classification system of talar neck fractures is the improved Hawkins classification system (Figs. 13.9, 13.10, 13.11, and 13.12) (Hawkins 1970), which is directly based on necrosis of the talus, the main indicator for treatment efficacy evaluation of talar neck fractures. –– Type I: Non-displaced talar neck fractures, that is, talar neck fractures without joint luxation. Most mildly displaced talar neck fractures are accompanied by rotation of the talar head, causing displacement of the forefoot and midfoot towards the dorsal side relative to the hindfoot. –– Type II: Talar neck fractures associated with subtalar joint subluxation or luxation. The incidence rate of necrosis of the talus reaches 40–50%. –– Type III: Talar neck fractures associated with luxation of the tibiotalar and subtalar joints. The incidence rate of necrosis of the talus is close to 100%. It is often difficult to achieve closed reduction.

–– Type IV: Talar neck fractures associated with dislocations of the tibiotalar joint, subtalar joint, and talonavicular joint. The incidence rate of necrosis of the talus is nearly 100%. Talar neck fractures associated with simple talar head dislocation are also classified as Hawkins type IV fractures. Talus comminuted fractures caused by high-energy violence have an extremely poor prognosis and are difficult to classify using other classification systems; therefore, they are also classified as Hawkins type IV. Although the Hawkins classification is based directly on necrosis of the talus, the severity of comminution of the fractured bone is an important prognostic predictor independent of Hawkins classification. A higher degree of comminution indicates the injury was caused by a higher-energy force, and the prognosis is poorer. –– Sneppen classification of talar body fractures (Sneppen et al. 1977) Type I: Compression fractures (the fracture line passes the cartilage/osteochondral bone). Type II: Shear fractures on the coronal, sagittal, or horizontal plane. Type III: Posterior process fractures of the talus. Type IV: Lateral process fractures of the talus. Type V: Comminuted fractures. –– AO/OTA classification of talus fractures (Fig. 13.13).

13  Talus Fractures Fig. 13.9  Hawkins type I talar neck fracture. (1) Virtual figure. (2) Radiographic image

Fig. 13.10  Hawkins type II talar neck fracture.(1) Virtual figure. (2) Radiographic image

Fig. 13.11  Hawkins type III talar neck fracture (1) Virtual figure. (2) Radiographic image

439

440 Fig. 13.12  Hawkins type IV talar neck fracture. (1) Virtual figure. (2) Radiographic image

Fig. 13.13  AO/OTA classification of talus fractures (1) Skeleton diagram. (2) Detail drawing

Z. Zhang and H. Guo

13  Talus Fractures

Fig. 13.13 (continued)

441

442

Z. Zhang and H. Guo

13.1.5 Preoperative Assessment 13.1.5.1 Clinical Assessment • The trauma history of the patient should be inquired in detail to identify whether the injury is caused by high-­ energy or low-energy violence. • Talus fractures caused by high-energy violence: –– They are often complicated by severe soft tissue damage (Dumber Patil et al. 2014; Marsh et al. 1995; Niazi et al. 1992; Smith et al. 2006). –– Soft tissue injury is common in talus fractures and luxation, although the injury might not penetrate to the skin. –– In some cases of open talus fractures, the talus may be completely separated from the attached soft tissue or even left at the scene of the injury, making subsequent treatment more difficult. –– Examinations for potential vascular and nerve injuries are important. • Soft tissue damage assessment: –– Open injury: The Gustilo-Anderson scoring system (Gustilo and Anderson 1976; Gustilo 1971) is used for assessment, with special attention paid to whether the body of the talus is deficient or completely separated from the surrounding soft tissue. –– Closed injury: The Tscherne scoring system is used for assessment (Oestern and Tscherne 1984). –– The conditions of the affected extremity, such as swelling, distal toe sensations and motion functions, skin integrity, water blisters and necrosis, must be regularly observed and examined. • The accompanying injuries: Talus fractures are often accompanied by injuries of other bones or muscles, as well as systemic trauma (Vallier et al. 2004a). –– The patient is given a systemic assessment, including injury evaluation of the head and organs in the chest, abdominal, and pelvic cavities. –– Further assessment of foot and ankle injuries should be conducted to avoid missing the diagnosis of fractures elsewhere, including ankle fractures and calcaneus fractures. 13.1.5.2 Imaging and Other Auxiliary Examinations 1. Radiographs: (a) AP and lateral foot radiographs are obtained to determine the location, extent of displacement, and severity of comminution of talus fractures.

Fig. 13.14  The foot in the position described by Canale and Kelly for radiography of the talus



(b) Mortise radiography is helpful in evaluating the fractures of the talar body, neck, and processes. (c) Radiography in the view described by Canale and Kelly (Fig. 13.14) (Canale and Kelly Jr 1978): The bottom of the affected foot is placed on the side of the film on the radiolucent table, and the beam is projected at an angle of 75° relative to the horizontal plane, with the foot in the pronation position and the lower leg inwardly rotated. Radiographs obtained in the view described by Canale and Kelly above can demonstrate the medial aspect of the talar neck and determine whether the talar neck is inverted. (d) Radiographs obtained in the oblique position of the foot and axial position of the calcaneus, ankle AP and lateral radiographs, and mortise radiographs can help identify the accompanying fracture displacement. 2. CT scanning is very useful for the assessment of talus fracture displacement. It can provide detailed information regarding the displacement and comminution severity of the fractured talus, which is difficult to obtain in plain radiographs (Fig. 13.15). (a) For talus fractures, 3D CT reconstructed images should be obtained before surgery. 3. Vascular ultrasound or angiography of the affected lower extremity helps evaluate vascular injuries.

13  Talus Fractures

443

• If possible, the reduction and final fixation of displaced talus fractures should be completed as soon as possible, as long as the soft tissue conditions allows, to reduce the risk of talus avascular necrosis. The timing for surgery is mostly 1–3  weeks after injury (Xue et  al. 2014; Mayo 1987; Vallier et al. 2004b).

13.2.3 Surgical Techniques 13.2.3.1 Open Reduction and Internal Fixation for Talus Fractures

Fig. 13.15  A 3D reconstructed CT image of a talus fracture. (Note: the image needs to be added here)

13.2 Surgical Treatment for Talus Fractures 13.2.1 Surgical Indications • The goal of treatment for a talus fracture is to restore the normal function of the ankle and subtalar joint. Therefore, it is necessary to restore the shape of the talus and the evenness of the joint surface (Vallier 2015). • All displaced talus fractures must be reduced and fixed. –– Nonsurgical treatment is limited to non-displaced talar neck fractures with an intact subtalar joint (Hawkins type I fractures), non-displaced talar body or head fractures, and patients who can cannot tolerate surgery due to a poor general condition. • If the condition allows, emergency reduction should be performed for a displaced talus fracture (Vallier et  al. 2004a, 2014; Patel et al. 2005; Xue et al. 2014).

13.2.2 Timing for Surgery • The severity of soft tissue damage and fracture displacement is an important factor determining the necessity for emergency treatment. • Open fractures, displacement, exposure of the talus, and significant osteofascial compartment syndrome or complex trauma of the foot are indications for emergency surgery (Vallier 2015; Vallier et al. 2014; Patel et al. 2005; Xue et al. 2014).

Body Position and Preoperative Preparation • General anesthesia or epidural anesthesia is administered. • The patient lies in a supine position. • An inflatable tourniquet is tied round the proximal end of the affected extremity. • The fluoroscopic device for intraoperative use is set up. • Preparation of external fixation system: The external fixation frame can be used to assist in distracting the joint space and reducing the joints during surgery. After surgery, it can be retained to facilitate recovery of the soft tissue and prevent an excessively high intra-articular pressure. Surgical Incision and Approaches • The medial approach (Fig. 13.16) –– A medial straight incision is created from the tip of the medial malleolus and extended along the axis of the talus. –– The saphenous nerve and great saphenous vein are pulled towards the head side. –– The posterior tibial tendon is retracted towards the plantar side. –– The ankle joint capsule is opened to expose the fracture site. –– The medial approach provides an access to expose the anterior part of the subtalar joint and observe the talonavicular joint. –– To treat a fracture of the talar dome, the incision can be extended proximally, and osteotomy of the medial malleolus can be performed. –– For a single isolated fracture on the medial side of the body of the talus, the ankle joint capsule can be opened via the anteromedial approach, and osteotomy of the medial malleolus is unnecessary. • The lateral approach (Fig. 13.17) –– The lateral oblique incision, approximately 4–5 cm in length, is created from the tip of the lateral malleolus and extended along the direction of the dermatoglyphic pattern.

444

Z. Zhang and H. Guo

Fig. 13.16  The medial approach to the talus. (a) The projection of the incision on the body surface. (b) Exposure of the fracture

a

Fig. 13.17  The lateral approach to the talus. (a) Superficial anatomy. (b) Deeper anatomy

a

–– Attention should be paid to protection of the central dorsal cutaneous nerve, which can be pulled aside after further separation. –– An observation window is created on the head side of the anterior talofibular ligament to visualize the ankle. –– The posterior talus can be observed after separating the space between the anterior talofibular ligament and the calcaneofibular ligament. Sequence and Techniques for Fracture and Dislocation Reduction • Reduction of the luxated joint –– General anesthesia helps relax the gastrocnemius muscle, thereby easing the reduction operation. –– A Steinmann pin placed transversely in the calcaneal tuberosity can be used to control the reduction. –– The operation should be gentle and slow to prevent further damage to the damaged blood supply of the talus. –– A tourniquet is applied only during reduction.

b

b

• Reduction of the fragments • The procedures are as follows: –– Lift the compression area. –– Reduce the dissociated bone fragments. –– Perform the reduction with the posterior facet of the calcaneus as a template for subtalar joint reconstruction. –– Fill the bone defect with cancellous bone. –– Place Kirschner wires for temporary fixation. –– If the fracture is accompanied by a talar head fracture, the fractured talar head should be reduced prior to the above reduction and fixation procedures. • Fracture fixation –– Most talus fractures can be fixed with cancellous bone screws. –– The size of the screw to be used is decided by the size of the fracture fragment (2.7–4.0 mm). –– A talar neck fracture requires at least two to three lag screws for fixation, and the screws should be countersunk in the talar head.

13  Talus Fractures

445

• Postoperative management –– After reduction and fixation of talus fractures, the Steinmann pin of the calcaneal traction system is often used to establish a trans-articular external fixation system. At the early postoperative stage, this fixation system can effectively immobilize the ankle and maintain the ankle position, reduce the pressure in the joint cavity, and avoid further compression on the blood-­supplying vessels of the talus. –– After removal of the external fixators at postoperative 4–6  weeks, functional exercise of the ankle is encouraged.

13.2.3.2 Closed Reduction and Percutaneous Internal Fixation (Abdelgaid and Ezzat 2012) Indications • Talar neck fractures with the body of the talus remaining in the ankle mortise can be treated by closed reduction. • This technique is especially suitable for Hawkins type II talar neck fractures and a portion of the fractures that cannot be surgically treated immediately. • A portion of Hawkins type III fractures can also be treated with closed reduction. Body Position and Preoperative Preparation • General anesthesia or epidural anesthesia is administered. • The patient lies in the supine position, with the knee in the flexion position and the ankle in the plantarflexed position.

• An inflatable tourniquet is applied. • The external fixation devices are prepared. • Preparation for open reduction: There is always a risk that closed reduction might fail; therefore, it is necessary to prepare for open reduction ahead of time. Reduction of Talus Fractures • In patients whose talar body falls out of the ankle mortise and causes an inversion and dorsiflexion of the affected foot, the luxated talar body should be reduced, which can be performed with the assistance of the Steinmann pin of the calcaneal traction system. However, excessive traction can lead to excessive tension of the posterior ankle ligaments, making closed reduction more difficult. In addition, prolonged or overpowered traction may lead to necrosis of the skin (Fig. 13.18). • The peroneus muscle complex is relaxed in the knee flexion and ankle joint plantarflexed position, which eases the reduction of the talar head fragment towards the talar body fragment. • The inversion and eversion are corrected by proper alignment. • Once the reduction is complete, any excessive dorsiflexion may result in loss of reduction. Therefore, the foot should be maintained in the correct position during radiography. Fixation of the Talus Fracture • After successful reduction, percutaneous screws are used to fix the fracture.

a

b

c

d

e

f

Fig. 13.18  Percutaneous screw fixation of a talar neck fracture. (a) Fracture of talus neck. (b) Insert proximal guide needle. (c) Insert the distal guide needle. (d) Insert the distal screw. (e) Insert proximal screw. (f) The screws should be counter sunk in the talar head

446

Z. Zhang and H. Guo

Table 13.1  A comparison of different fixation methods Fixation method

Advantages

Disadvantages

Fixation with screws placed from anterior to posterior

1. The fracture is reduced under direct vision

1. It is difficult to fix the fracture in the direction perpendicular to the fracture line

2. The risk of articular cartilage injury is eliminated 3. Compression screws can be used

2. The fixation strength is lower than the other two fixation methods 3. Improper compression can cause poor alignment, especially yams alignment.

Fixation with screws placed from posterior to anterio.

Direct plate fixation

1. The strength is higher than that of fixation with

1. The fracture is reduced under indirect vision: a prone body position might be required for the operation

screws placed from anterior to posterior 2. The fracture can be easily fixed in the direction perpendicular to the fracture line 3. Less soft tissue injury is caused

2. The posterior talar cartilage is damaged

1. The fixation is robust 2. The comminuted fragments can be well supported

1. The soft tissue is excessively dissected

Postoperative Management • After 6 weeks of external fixation with the external fixation frame retained after surgery or a plaster cast, the patient can begin functional training. • At 8  weeks postoperatively, the patient may engage in limited weight-bearing activities, e fracture healing.

13.2.3.3 Advantages and Disadvantages of Various Fixation Methods See Table 13.1.

13.2.4 Surgical Complications and Their Prevention and Treatment 13.2.4.1 Soft Tissue Complications • The soft tissue complications of talus fractures include skin necrosis, wound healing problems, and infection, among others (Lack et al. 2015). • Fracture dislocations should be treated as early as possible, and the appropriate timing for surgery can effectively reduce the risk of soft tissue complications (Xue et  al. 2014; Mayo 1987; Vallier et al. 2004b). 13.2.4.2 Nonhealing of Fractures • Nonhealing of fractures, which is relatively rare, occurs most frequently in fractures of the talar process. • The incidence rate is 6 cm, and it is impossible to make the two ruptured ends of the Achilles tendon contact each other by plantar flexion of the ankle joint and performing V-Y lengthening of the Achilles tendon.

14.1.5 Assessments of Achilles Tendon Rupture 14.1.5.1 Clinical Assessment • Medical history: It is clearly witnessed that the Achilles tendon has been directly cut or struck by a sharp or

•

•

•

•

blunt instrument, or the patient has experienced a sudden feeling of “being kicked by a foot from behind” after a strenuous movement such as running and jumping. Symptoms: The patients often present with local swelling and pain in the Achilles tendon, weakness in the foot plantar flexion or when pressing the floor with the heel, and difficulties standing and walking. Physical examination: Palpation examination of the Achilles tendon can detect the continuity interruption of the tendon and the depression in the tendon area. The strength of plantar flexion of the foot significantly decreases, the patient cannot raise the heel while standing (positive for the heel-raise test), and the Thompson sign is positive (when the patient kneels at the bedside, plantar flexion of the foot would normally occur when the gastrocnemius muscle is squeezed; otherwise, the absence of foot plantar flexion indicates an Achilles tendon rupture). In general, the diagnosis of Achilles tendon rupture, which can be made based on the patient’s medical history, symptoms, signs, and imaging evidence, is not difficult; however, it is worth noting that the neglect of young inexperienced doctors often causes a missed diagnosis in clinical practice. The reasons for the missed diagnosis are as follows: (1) Open injury is incorrectly considered to be a laceration of the skin and soft tissue without thorough examination. (2) After rupture of the Achilles tendon, plantar flexion of the foot does not completely disappear because the posterior tibia muscle, peroneus longus and brevis, and flexor toe muscle still participate in flexion of the ankle and toes. (3) Some patients can still stand and limp with a ruptured Achilles tendon.

14.1.5.2 Radiographic Evaluation • Radiography shows that the local soft tissue is swollen. • B-ultrasound or magnetic resonance imaging (MRI): These techniques can provide the most reliable radiographic evidence for the diagnosis of Achilles tendon rupture by directly displaying the interruption of continuity of the Achilles tendon (Fig. 14.4).

14  Achilles Tendon Rupture

a

453

b

Fig. 14.4  MRI of the completely ruptured Achilles tendon. (a) T2-weighted image. (b) T1-weighted image

14.2 Surgical Treatment 14.2.1 Principles of Treatment • Whether surgical repair and suture should be used to treat closed complete Achilles tendon ruptures has been controversial. Some researchers believe that the ruptured Achilles tendon can be repaired through scar healing, as long as the ankle is maintained in the plantarflexed position; therefore, conservative treatment is a better choice compared with surgical treatment, which would have the risk of incision infection. Conversely, some researchers insist on surgical treatment because the ruptured Achilles tendon can be precisely sutured together, which greatly recovers the strength of the Achilles tendon during plantar flexion, and the incidence of surgical complications can be largely reduced by optimizing surgical treatment methods. • In 2005, the Journal of Joint & Bone Surgery (JBJS) published a meta-analysis study (Khan et  al. 2005), which involved 12 randomized, controlled clinical studies on the treatment of Achilles tendon rupture and 800 patients. The study used ten independent parameters and indicators for evaluation, and all the data were analyzed by three researchers. The results showed that the Achilles

tendon re-rupture rates were 12.6% in the conservative treatment group and 3.5% in the surgical treatment group, respectively, and the wound infection rates were 4% and 0%, respectively. In addition, the percutaneous minimally invasive suture technique had a re-rupture rate close to that of the surgical treatment group and a lower infection rate of only 2.4%. • Based on our experience in the Department of Orthopaedics of 301 Hospital (Chinese People’s Liberation Army General Hospital), surgical treatment is recommended to young patients for closed Achilles tendon rupture considering their needs for higher levels of physical activities and strength of the Achilles tendon, and conservative treatment is recommended to elderly patients considering their low-level physical activity and relatively poorer health conditions (i.e., systematic chronic diseases, such as diabetes and hypertension). –– Nonsurgical treatment: The affected foot is immobilized and fixed in the plantarflexed position for 8–12 weeks with a special boot, plaster cast, or brace. –– Open and suture repair techniques for Achilles tendon rupture: The recommendations by the Department of Orthopaedics of 301 Hospital are as follows: New rupture: The ruptured ends of the newly ruptured Achilles tendon often have an irregular shape

454

H. Chen et al.

and appear like a horse’s tail with approximately a 3-cm-long contracture shortening of the proximal end. The two ends can contact each other after plantar flexion the ankle and are then sutured together end-to-end using the Krackow method, the Bunnell method, or the improved end-to-end Kessler suture combined with interrupted fine-suture reinforcement stitching (Li et al. 2011). A special instrument has been designed and tested in 301 Hospital for a channel-­assisted minimally invasive suture to repair acute Achilles tendon rupture. We strongly recommend this technique because it effectively avoids damaging the sural nerve, creates a strong mechanical support for the affected ankle, and requires only a short operation time of 15–20  min and a small incision of 1.5–2 cm in length. Subacute injury: Ten days after injury, although the ruptured Achilles tendon does not show severe degeneration and necrosis at the ruptured ends, it often has contracture shortening of 3–6 cm, and the two ends cannot form an end-to-end contact by simply plantar flexion the ankle joint. The Abraham V-Y lengthening method is recommended for suture repair. Chronic injury: After 3 weeks post-injury, contracture shortening of the ruptured tendon often exceeds 6 cm, which should be repaired with sutures using the Lindholm method. In cases in which the Achilles tendon does not regain its strength sufficiently after initial suture repair, the following reinforcement methods can be used: the method proposed by White Krynick, the method proposed by Rugg and Bogoe, the gastrocnemius tendon flap transfer reinforcement method, simple reinforcement of the plantaris muscle, repair with the fibula longus muscle and artificial materials, and fascia lata transplantation. Achilles tendon injuries caused by traffic accidents are often accompanied by defects in the calcaneus

a

and skin, which are difficult to repair by local skin loosening and tension-reducing suture/free skin flap grafting. The methods commonly used to repair Achilles tendon defects are as follows: (1) transposition repair of the tendon with a muscle pedicle; (2) transposition repair using a tissue flap with a vascular pedicle; and (3) transplantation of a free composite-tissue flap with vascular anastomosis.

14.2.2 Open Suture Repair for Acute Achilles Tendon Rupture Using the Krackow Locking Stitch Technique • The patient lies in the prone position under local anesthesia, continuous epidural anesthesia, or sciatic nerve block anesthesia, with an inflatable tourniquet tied around the middle to upper segment of the thigh. –– To avoid wound infection, skin necrosis, and adhesion of the Achilles tendon to the skin, surgical treatment should be administered either before the swelling occurs or after the swelling subsides and the skin wrinkles reappear. • After routine skin disinfection with iodine tincture and alcohol, preparation of the surgical drapes, and placement of the sterile sticker in the surgical area of the affected extremity, exsanguination is achieved using an Esmarch bandage, followed by application of the tourniquet. • A longitudinal incision is created on the medial side of the Achilles tendon (Fig. 14.6). It is 10–15 cm long and 1 cm away from the Achilles tendon to minimize the risk of local irritation of the Achilles tendon caused by rubbing of the shoe after surgery. –– There are three approaches for exposing the Achilles tendon: the posterior median approach, the lateral approach, and the medial approach (Fig.  14.5). The central approach can expose the Achilles tendon satisfactorily, but rubbing of the scar by the shoe often

b

Fig. 14.5  The sural nerve in the foot and ankle. (a) The lateral view of the foot and ankle. (b) The medial view of the foot and ankle

14  Achilles Tendon Rupture

455

causes pain after scar healing of the incision. In addition, the incision is sutured at the point with the highest tension, which affects the healing of the incision and might cause exposure of the Achilles tendon. The lateral approach easily damages the branch of the sural nerve that innervates the heel region, causing sensation loss in the heel skin and eventually denervation and

atrophy of the skin. The medial longitudinal approach of the Achilles tendon is relatively safe, as it has a lower risk of damaging the posterior cutaneous nerve of the lower leg compared with the lateral approach and a lower risk of skin necrosis and incision infection compared with the posterior median approach via a straight incision.

a

b

c

d

e

f

Fig. 14.6  Open repair for acute Achilles tendon rupture using the Krackow locking stitch technique. (a, b) Incise the skin, subcutaneous tissue and deep fascia, protect the deep fascia, and connect it to the subcutaneous tissue (suture the skin and deep fascia with silk and fix it on the peripheral skin). (c) Suture the Achilles tendon rupture ends with nonabsorbable #2 ETHIBOND® Suture (Polyester, Ethicon Inc.) Krackow, and use absorbable 2-0 antibacterial PDS® Plus Suture

(polydioxanone, Ethicon Inc.) for interrupted suturing to strengthen the rupture ends. (d) Suture the peritendinous tissue and completely wrap the Achilles tendon to reduce the postoperative adhesion of the Achilles tendon. (e) After the suturing is completed, knot to close the deep fascia, and put the knots under the skin. (f–h) Use long leg plaster or brace to fix the knee joint at the knee flexion 10° ~ 15°, plantar flexion of the ankle joint 30° position

456

g

H. Chen et al.

h

Fig. 14.6 (continued)

• The skin, subcutaneous tissue, and deep fascia are cut open, and the deep fascia is connected to the subcutaneous tissue by suturing the skin and deep fascia with silk suture and fixing them to the surrounding skin. Thus, no subcutaneous separation is performed, and the Achilles tendon rupture is fully exposed with protection of the peritendinous tissue (Fig. 14.6a, b). –– The deep fascia (epitendineum) is exposed by a sharp cut rather than blunt dissection to avoid damaging the subcutaneous nutrient vascular network and fat liquefaction, thereby reducing the risk of skin necrosis, infection, and adhesion in the incision area. The peritendinous tissue must be protected to avoid damaging the vascular bundle that enters the ventral part of the Achilles tendon. • Suturing: The Ethibond #2 suture is used to suture together the ruptured ends of the Achilles tendon using the Krackow technique, and the 2-0 absorbable suture is used for interrupted reinforcement stitching (Fig. 14.6c). –– The suture knots are buried inside the ruptured ends during reinforcement suture, and the knots are buried

in the subcutaneous tissue during the interrupted suture of the epitendineum, which minimizes knot irritation. –– After repair, the Achilles tendon should regain its strength but should not be over-tensioned, as excessive tension might block the blood supply to the ruptured ends and affect rupture healing. –– The peritendinous tissue is sutured and completely wrapped around the Achilles tendon to reduce postoperative adhesion of the Achilles tendon (Fig. 14.6d). –– After surgery, a plaster cast is used to maintain knee flexion and the plantarflexed position, which reduces the tension at the anastomosed ends. • A negative pressure drainage tube is placed with its beginning part exiting at a higher position and its distal end at the lowest part of the wound. –– Opposite to the negative pressure drainage, when a rubber strip is used for drainage, it exits from the lowest part of the drained area. • The deep fascia must be closed thoroughly. Each stitch is placed in a figure-eight pattern and knotted after all stitches are finished to close the deep fascia, with the suture knots buried in the subcutaneous tissue (Fig. 14.6e).

14  Achilles Tendon Rupture

• After suturing the subcutaneous tissue, the knots are left in the deep place. • The skin is sutured, and complete closure of the incision must be ensured. • Using a long leg plaster cast or brace (Fig.  14.6f), the knee joint is fixed at the 10°–15° flexion position and the ankle is fixed at the 30° plantarflexed position, which creates a zero-tension condition for rupture healing of the Achilles tendon by allowing relaxation of the gastrocnemius muscle and generation of the least tension on the anastomosed ends. • Postoperative rehabilitation treatment –– The postoperative management plan should be made based on the pathophysiological mechanism of healing of the ruptured Achilles tendon. The rehabilitation planning should consider not placing excessive weight on the unhealed tissue but also preventing the negative effect of immobilization and disuse on the healed tissue. 1–4  weeks after surgery (28  days): Both the knee and ankle are immobilized with a long leg plaster cast. The patient can leave bed and engage in an appropriate amount of exercise with a crutch. 5–6 weeks after surgery (2 weeks): Only the ankle is immobilized with a short leg plaster cast, which is made by sawing the long leg plaster cast to the level 3  cm below the fibulae capitulum to allow movement of the knee joint. The cast is temporarily removed to allow warm-water heating and massage of the Achilles tendon area daily. In addition, the patient is encouraged to engage in more ankle dorsiflexion and plantar flexion exercises, such as rolling a bottle with the foot and picking up a towel with the toes while keeping the ankle in the plantarflexed position. 7–14 weeks after surgery (8 weeks): The short leg plaster cast is removed, and the patient can walk with a special walking boot (Fig. 14.6g–h). When walking, a 2.5 to 3-cm-high heel cushion consisting of ten layers of thin sheets is placed between the heel and the sole. During this period, falling or ­sudden pressing on the floor with the heel, which might pull the repaired Achilles tendon, should be avoided. Heel-raise exercises of both feet in a seating position are encouraged. 15–19  weeks (5  weeks) after surgery: The patient can walk with the entire sole of the foot on the ground and initiate ankle joint exercises to fully recover the range of motion of the ankle joint. To improve the strength of the triceps muscle, the initial step is a heel-raise exercise, and then weight-­ bearing exercise of the affected extremity can be gradually increased and eventually changed to single-­leg heel-raise exercises. At this point, the

457

patient with a light workload job can return to work. Nevertheless, falling or sudden pressing on the floor with the heel, which might pull the repaired Achilles tendon, should still be avoided. 20–24 weeks after surgery: The patients shall continue single-leg heel-raise exercises to correct the residual ankle plantar flexion or dorsiflexion deficiencies. In addition, they can start jogging with the entire sole of the foot on the ground to gradually restore the flexibility of the ankle joint and the strength and girth of the triceps. At this point, athletes can begin to participate in a small amount of training, and those engaging in moderate physical work can return to work. >24 weeks after surgery: Athletes can start formal training, and heavy physical labor is allowed for most patients.

14.2.3 Percutaneous Minimally Invasive Suture for Repairing Acute Achilles Tendon Rupture • Comparison of the popular minimally invasive methods for Achilles tendon injury in the world (Table 14.1). • This method was first used and reported by Ma and Griddith et al. in 1977 (Ma and Griffith 1977; Klein et al. 1991), but it has an incidence rate of sural nerve injury up to 13%. Therefore, some doctors have tried to reduce the risk of sural nerve injury by using absorbable sutures or improving the surgical approaches, as well as inventing special suture instruments, such as the Mayo needle (BL059N) and Achillon device for Achilles tendon suturing (French) (Haji et al. 2004; Kakiuchi 1995; Carmont and Maffulli 2008; Maffulli et al. 2011). • The Achillon suturing device (Rippstein et al. 2002; Assal et  al. 2002) for the Achilles tendon, which is the most promising tool, was invented by a Swiss orthopedist and sutures the ruptured tendon in a “box” form. However, we have found in clinical practice that the Achilles tendon is often cut by the suture and that the initial mechanical strength of suturing is questionable. Consistently, recent research has confirmed that this technique cannot provide sufficient initial mechanical strength, which is only 1/10 of the initial strength provided by the Krackow suture technique; therefore, the repaired tendon would require postoperative protection with a plaster cast or brace. In addition, cadaver studies on the surgical operation have also found that the risk of sural nerve injury is extremely high and the incidence rate of suturing nerve injury (e.g., being directly punctured or accidently sutured) reaches 25.6% (Aibinder et al. 2013). The Achillon suturing system was introduced into China in 2007, but it has not been promoted due to its

458

H. Chen et al.

Table 14.1  Comparison of the popular minimally invasive methods for Achilles tendon injury in the world Channel-assisted suture system (CAMIRI)

Achillon suturing apparatus

Mayo needle

Ma & Griddith method

Suture technique

Modified Bunnel method

Box method

Bunnel method

Bunne method

Suturing and sural nerve injury

The needle passes through the channel for suture. The sural nerve is kept outside the channel, which is created through a specially designed trocar

The suture is performed through direct puncture, which has a potential risk of damaging the nerve

The use of a curved needle creates a potential risk of damaging the nerve

The use of a straight needle creates a potential risk of damaging the nerve

Positional relationship between the suturing apparatus and the Achilles tendon

The suturing apparatus moves on the surface of the Achilles tendon and grasps the Achilles tendon for sunning like a “sewing machine”

Relatively immobile

Special suturing guider

A specially designed eccentric or central guider assists in suturing

No

Average suturing time (mins)

15

30

30

40

unreliable performance and high risk of sural nerve injury. Although this technique has been nearly abandoned in clinical practice, its design concept has shed some light on research investigating the percutaneous minimally invasive suture technique of the Achilles tendon.

14.2.3.1 Development and Design of the Channel-Assisted Minimally Invasive Achilles Tendon Suture Repair Technique Due to the concerns over iatrogenic sural nerve injury and mechanical strength of suturing, the research group for minimally invasive Achilles tendon repair began a new exploration in 301 Hospital since 2010. • In 2010, the research group attempted to improve the Bunnell method (one of the most reliable methods for open repair of the Achilles tendon, Fig. 14.7a) and developed a new suturing method (Fig.  14.7b), that is, the oblique stitching was changed to transverse stitching and the suture knots were left outside instead of inside the tendon. The preliminary mechanical study confirmed that this method met the mechanical requirements for repairing the Achilles tendon and showed improved clinical outcomes. • In 2012, on the basis of the modified Bunnell suture method, the channel-assisted minimally invasive Achilles tendon repair (CAMIR) technique was designed and developed, which was nationally patented in 2015. This technique (Fig. 14.8) achieves percutaneous minimally invasive suture of the Achilles tendon and avoids iatrogenic sural nerve injury through five technical innovations.

–– Technical innovation 1: This system enables a relative movement between the suturing apparatus and the Achilles tendon. Normally, the skin, subcutaneous tissue, and deep fascia must be dissected to expose the Achilles tendon. The deep fascia is wrapped around the Achilles tendon and forms a fibrous channel, in which the Achilles tendon moves to participate in plantar flexion and dorsiflexion of the ankle. The skin over the Achilles tendon has a certain mobility. To achieve relative slipping between the suturing apparatus and the Achilles tendon, it is necessary to make a longitudinal incision in the deep fascia. In the present suturing system, a specially designed 30° transverse blade is installed on the side of the end of the core rod, which can be used to make the desired incision after passing through the deep fascia. –– Technical innovation 2: A safe suture channel is created to avoid sural nerve injury. Through a 5-mm sharp skin incision at the planned entry point of the channeling trocar, a pair of hemostatic forceps is inserted to bluntly separate the tissue of the deep fascia, paying special attention to protect the sural nerve. Next, a specially designed trocar core needle is inserted and advanced until it passes through the deep fascia and enters the sheath of the Achilles tendon. Another trocar core needle is placed into the opposite side by repeating the above procedures. Subsequently, the blade on the core needle is positioned parallel to the Achilles tendon, and the suturing apparatus is then pushed up and down repeatedly to generate a 1-cm incision in the deep fascia. Finally, the trocar sleeve is inserted along the core needle to establish a channel for suturing.

14  Achilles Tendon Rupture

a

459

b

Fig. 14.7  The Bunnell suture method. (a) The classic suture method. (b) The modified Bunnell suture method

a

Fig. 14.8  The channel-assisted minimally invasive Achilles tendon repair (CAMIR) system developed by our research group. (a) ProE drawing showing the CAMIR system. (b) Actual photo. (1) A special auxiliary channel passing through the skin, subcutaneous, and Achilles tendon sheath is created for suturing, and the sural nerve is outside the channel. (2) A neutral-position or eccentric-position suturing guider is

b

used to guide the suturing, which prevents crosscutting between the sutures. (3) The specially designed trocar core needle (taper), which has a 30° transverse blade at the side of its tip, cuts the tendon sheath after it penetrates the deep fascia. This allows the movement of the channel (trocar sleeve) together with the suturing apparatus on the Achilles tendon surface and achieves a suturing process similar to a sewing machine

460

H. Chen et al.

–– Technical innovation 3: A transverse needling techthrough the incision is pushed aside with hemostatic nique to prevent crosscutting of sutures. A neutral-­ forceps (Fig.  14.9a). Next, a 1.5-cm-length doubleposition and eccentric-position suturing guider is bladed sharp taper with a trocar sleeve is inserted specially designed to prevent crosscutting between the through the guide hole (Fig.  14.9b). After the fascia transverse sutures and the resultant suture breakage. sheath of the Achilles tendon is bluntly penetrated, the –– Technical innovation 4: The suture inside the Achilles CAMIR apparatus is pushed along the near-far directendon sheath can be pulled out without adding an tion along the Achilles tendon (Fig.  14.9c) so that incision. Uniquely designed inner arms can hold and 1–1.5  cm of the fascia sheath can be cut by the side pull out the suture through an incision in the tendon blade of the sharp taper. Finally, the trocar sleep is sheath. rotated along the sharp taper and advanced into the –– Technical innovation 5: Reconstruction of the ending inner arm of the suturing apparatus to establish the point of the Achilles tendon is achieved using a reconsuture channel (Fig. 14.9d). struction trocar sleeve at the distal site. For a rupture • Needling is performed to pass the suture through the injury close to the ending point of the Achilles tendon, proximal ruptured end of the Achilles tendon via the a channel between the deep fascia and the calcaneus central or eccentric-position guider, which is an essencan be created subcutaneously using the special arm of tial step of the improved Bunnell suture method the suturing system, followed by insertion of a trocar (Fig.  14.9e). Subsequently, the inner arms, along with sleeve through the channel. Next, the suture is placed the suture passing through the proximal ruptured end of through a canal drilled in the calcaneal and pulled out the tendon (Ethibond suture 2-0), are pulled out from the by the suturing apparatus. incision (Fig. 14.9f, g). The same procedure is repeated to pass the suture through the distal ruptured end of the 14.2.3.2 The CAMIR Procedures for Acute Achilles tendon (Fig.  14.9h). After all the sutures are Achilles Tendon Rupture pulled out, they are tightened and knotted to complete • The patient lies in the prone position and undergoes scithe suture fixation of the ruptured Achilles tendon atic nerve/lumbar plexus block anesthesia. A tourniquet is (Fig. 14.9i). tied around the mid-to-upper segment of the thigh. • A 3-0 absorbable Vicryl suture is used for interrupted Exsanguination is performed for the lower extremity, and reinforcement suturing of the ruptured ends of the Achilles the tourniquet pressure is 320  mmHg tendon, followed by suturing of the peritendinous tissue. (1 mmHg = 0.133 kPa). • The incision is closed layer by layer, and then the affected • After successful anesthesia, 1 g of cefmetazole sodium is ankle is wrapped with elastic bandage for compression, intravenously injected to prevent infection. followed by loosening of the tourniquet. • First, the rupture site of the Achilles tendon is identified • Postoperative management and rehabilitation are the by palpation, and a transverse skin incision with a length same as described earlier for the open repair technique. of approximately 1.5 cm is created perpendicular to the Achilles tendon. • The skin, subcutaneous tissue, and the fascial sheath of 14.2.4 Abraham’s V-Y Lengthening Repair the Achilles tendon are cut open to expose the ruptured of Subacute Achilles Tendon Rupture ends of the Achilles tendon. • The proximal end of the ruptured Achilles tendon is held • The patient lies in a prone position, with the tourniquet and pulled out from the incision with a pair of Kocher fortied around the proximal end of the thigh. A straight inciceps. Next, the inner arms of the CAMIR system are sion approximately 15  cm in length is created from the inserted into the fascial sheath to hold the Achilles tendon. site 1 cm medial to the attachment point of the Achilles • A pair of incision forceps is used to make a 5-mm skin tendon to the middle part of the lower leg, with special incision corresponding to the guide hole on the lateral attention paid to protecting the sural nerve and superficial arm on each side, and the sural nerve that may run peroneal nerve.

14  Achilles Tendon Rupture

461

a

b

c

d

e

Fig. 14.9  CAMIR for an acute Achilles tendon rupture. (a) Use hemostatic forceps to push the sural nerve that may run through the incision, and (b) insert the sleeve and 1.5  cm long double-sided sharp cone through the guide hole of the lateral arm, (c) pierce the Achilles tendon fascia sheath bluntly, push CAMIR towards the distal and proximal directions of the Achilles tendon rupture ends, (d) use the side blade at the sharp cone end to cut the fascial sheath for 1.0 ~ 1.5 cm, and screw the sleeve along the sharp cone, so that the sleeve enters the inner arm of the stapler to establish the suturing channel. (e) Pass the needle along

f

the central or eccentric guider to complete the modified Bunnell suture technique grasping the proximal end of the ruptured Achilles tendon, (f, g) pull out the CAMIR inner arm from the incision, and pull out the suture that holds the proximal end of the ruptured Achilles tendon from the incision (No. 2 Ethicon suture). (h) In the same way, use the suture to grasp the distal end of the ruptured Achilles tendon, (i) pull out the suture, tighten the suture, knot, and complete the suturing fixation of the Achilles tendon

462

H. Chen et al.

g

h

i

Fig. 14.9 (continued)

• The Achilles tendon aponeurosis is cut open. After the injury status is carefully examined, the scar tissue at the ruptured ends is completely removed. The shortening of the tendon is measured when the knee is in the 30° flexion position and the ankle is in the 20° plantarflexed position. Abraham’s V-Y lengthening method is used if the shortening is in the range from 3 to 6 cm (Fig. 14.10). • An inverted V-shaped incision is made approximately 1 cm distal to the muscle-tendon junction of the triceps, with the length of each of two incisions forming the V shape at least 1.5 times longer than the tendon defect.

• The tendon sheath is completely cut open and pushed downwards for an end-to-end anastomosis. • The ruptured Achilles tendon is sutured end-to-end with Ethibond #2 suture using the improved Kessler method. No. 2-0 noninvasive absorbable suture is used to suture the inverted V-Y-shaped incision. Finally, the Achilles tendon aponeurosis is repaired, followed by incision closure. • Postoperative management is the same as described earlier for the open repair technique.

14  Achilles Tendon Rupture

463

a

b

c

d

Fig. 14.10  Abraham’s V-Y lengthening repair of a subacute Achilles tendon rupture. (a) Make an inverted “V”-shaped incision about 1 cm distal to the junction of the muscle-tendon of triceps surae. (b) The length of the two incisions that make up the “V”-shaped incision is at least 1.5 times longer than the defect. After opening all the tendon sheath, advance downward to complete the end-to-end anastomosis. (c) Make end-to-end sutur-

14.2.5 The Lindholm Repair Method for an Old Achilles Tendon Rupture (Fig. 14.11)

ing of the Achilles tendon rupture ends with nonabsorbable #2 ETHIBOND® Suture (Polyester, Ethicon Inc.) with modified Kessler technique, and suture the inverted “V-Y”-shaped incision with absorbable 2-0 VICRYL® Plus Control Release Suture (Polyglactin 910, Ethicon Inc.), repair the Achilles tendon membrane and suture the wound. (d) Abraham V-Y advancement and repair of subacute Achilles tendon rupture

• If there is a gap between the ruptured ends due to a large tension after repair, the gastrocnemius tendon flap can be anastomosed directly with the distal ruptured end, followed by reinforcement suture of the proximal ruptured • The patient lies in the prone position. An arc-shaped inciend. If the plantaris tendon remains intact, it can also be sion is created posteriorly from the middle of the lower used for reinforcement. leg to the calcaneus, and the deep fascia is cut along the midline to expose the ruptured ends of the Achilles • The defective gastrocnemius aponeurosis is sutured to close the gap left by downward flipping of the tendon flap. tendon. Finally, the tendon sheath and its surrounding tissue and • After debridement and trimming of the ruptured ends, skin are sutured. mattress suturing with thick silk suture or fine stainless-­ steel wire, or interrupted suturing with fine silk suture, is conducted. • A gastrocnemius muscle aponeurosis and Achilles tendon 14.2.6 Experience and Lessons flap approximately 7–8 cm in length and 1 cm in width is obtained from each side of the proximal end of the rup- Spontaneous Achilles tendon rupture following hormone tured Achilles tendon and flipped towards the distal end. use should be given more attention. The flap is sutured to the distal Achilles tendon with its base connected to the proximal ruptured end of the • Local hormone use may cause inflammation of the small Achilles tendon. Finally, after the edges of the two tendon vessels around the Achilles tendon, increasing the permeflaps are sutured, the two are sutured together and used to ability of vessels and triggering intravascular coagulation. completely cover the rupture site of the Achilles tendon. This affects the blood supply to the surrounding area of

464

H. Chen et al.

a

b

c

d

e

f

Fig. 14.11  The Lindholm repair method for an chronic Achilles tendon rupture. (a) The patient is in prone position, and makes a posterior curved incision from the middle of the calf to the calcaneus. Open the deep fascia in the midline direction to expose the rupture ends of the Achilles tendon. (b) Debridement first, trim the rupture ends, use thick silk or thin stainless steel wire for mattress suture, or use thin silk for interrupted suture. (c) Take a piece of gastrocnemius aponeurosis and Achilles tendon flap with a length of 7 ~ 8 cm and a width of about 1 cm from both sides of the proximal rupture end of Achilles tendon, flip to the distal end, leave the base part at the proximal rupture end of the

Achilles tendon, and suture them to the distal Achilles tendon end. (d) Suture the edges of the tendon strips, and suture the two tendon strips to each other to completely cover the rupture part of the Achilles tendon. (e) When the tension is large and there is a gap, the gastrocnemius tendon flap can be used to have direct anastomosis with the distal end, make reinforcement suturing at the proximal end. If there is a plantar tendon, use this tendon for reinforcement. Suture the defect of the aponeurosis to close the gap left by the tendon flip. (f) Suture the tendon sheath and surrounding tissue and skin

14  Achilles Tendon Rupture

the Achilles tendon and accelerates the degenerative changes in the Achilles tendon, and as a result, the tendon becomes more brittle and less elastic and loses its ability to withstand a high load. Therefore, local hormone use impairs the load-bearing ability of the Achilles tendon and makes it more vulnerable to rupture. • To treat the inflammation around the Achilles tendon, regular physical therapy is the first option, and invasive treatment (local block) should be avoided as much as possible; even with the local block for pain control, the indications and dose of drugs should be strictly controlled, and weight-bearing activities should be avoided after treatment. In patients with local hormone use, surgical treatment and postoperative management require greater attention because the patients have a higher risk of incision complications and exposure of the Achilles tendon, which would prolong the length of their hospital stay and increase their treatment costs.

References Aibinder WR, Patel A, Arnouk J, et al. The rate of sural nerve violation using the Achillon device: a cadaveric study. Foot Ankle Int. 2013;34(6):870–5. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited open repair of Achilles tendon ruptures: a technique with a new

465 instrument and findings of a prospective multicenter study. J Bone Joint Surg Am. 2002;84-A(2):161–70. Carmont MR, Maffulli N.  Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2008;16(2):199–203. Haji A, Sahai A, Symes A, Vyas JK. Percutaneous versus open tendo achillis repair. Foot Ankle Int. 2004;25(4):215–8. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg Br. 1995;77(1):60–3. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202–10. Klein W, Lang DM, Saleh M. The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis. Chir Organi Mov. 1991;76(3):223–8. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med. 1998;25(2):79–100. Li C, Feng X, Li W. Repair of acute avulsion-type Achilles tendon rupture by locking-loop stereoscopic suture. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2011;25(1):47–9. Ma GW, Griffith TG.  Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977;128:247–55. Maffulli N, Waterston SW, Squair J, Reaper J, Douglas AS. Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med. 1999;9(3):157–60. Maffulli N, Longo UG, Maffulli GD, Khanna A, Denaro V.  Achilles tendon ruptures in elite athletes. Foot Ankle Int. 2011;32(1):9–15. Rippstein PF, Jung M, Assal M.  Surgical repair of acute Achilles tendon rupture using a “mini-open” technique. Foot Ankle Clin. 2002;7(3):611–9.