JOINT CONTRACTURES AFTER INTRA-ARTICULAR FRACTURE SURGERY: WHERE ARE WE NOW?
Post-traumatic joint contracture is a significant problem that impacts the outcome of intra-articular fracture surgery. It can affect any joint, but is most commonly found in the elbow, knee, and hip. Contractures can be classified as either intrinsic (eg, intra-articular adhesion, articular malalignment, and loss of articular cartilage) or extrinsic (eg, capsular and ligamentous contracture, heterotopic ossification (HO), extra-articular malunion, and skin contracture). There is a multitude of etiologies and associations with post-traumatic joint contractures, including open fractures, burns, spinal cord injury, prolonged immobilization, and patient compliance. Structural changes in the joint capsule after trauma can contribute significantly to contracture. These changes include thickening of the capsule (with increases in collagen types I, III, and V), increased collagen cross-linking, and disorganized fiber orientation.1 Increased migration of lymphocytic cells leads to a profibrotic environment with increases in tumor necrosis factor-α (TNF-α), transforming growth factor-β1 (TGF-β1), fibronectin ED-A, and matrix metalloproteinases (MMP-1,2,9,13,15). The key cell involved is the myofibroblast. Myofibroblasts are specialized fibroblasts that are characterized by their well-developed contractile apparatus that links intracellular stress fibers to the extracellular matrix (ECM). Their activation and proliferation depends on mechanical stresses and growth factor signaling. The ability of these cells to sustain contractile forces in tissue over time and synthesize new ECM can lead to a positive feedback loop of generated tension and deposition of ECM that alters the tension and mechanical properties of native tissues.2 Myofibroblasts have been shown to be elevated in pathologic fibrotic conditions and have been demonstrated to be elevated in the joint capsule tissue in contractures in both humans and animals.1 In addition, their numbers have been inversely related to range of motion of the affected joint.3
Treatment and Outcomes of Specific Joints
The treatment of elbow contractures is generally directed at obtaining a 100-degree motion arc of the joint. Nonoperative treatment is typically attempted for less than 6 months and involves splinting in either a static progressive or dynamic fashion. Operative intervention is considered when nonoperative means have been exhausted. Arthroscopic contracture release is technically challenging but can be useful for simple, intrinsic contractures. It is generally contraindicated in the face of previous nerve transposition, severe contracture, or extrinsic causes. However, a prospective study on arthroscopic lysis for extrinsic joint contracture on 54 patients demonstrated significant improvements with a final arc of motion of 124 ± 22.7 degrees at 2-year follow-up.4 Open treatment allows for mobilization and identification of nerves, removal of hardware and excision of heterotopic bone, as well as the treatment of more complex contractures. Prospective studies on open elbow contracture release have demonstrated significant gains in range of motion arc (42–52 degrees), with 1 study demonstrating that 88/103 of patients ultimately achieved a flexion/extension arc greater than 100 degrees.5
Extension contractures of the knee are typically caused by posterior impingement, anterior adhesions, soft-tissue retractions, or patella baja, whereas flexion contractures are typically caused by anterior impingement, contracture of the posterior joint capsule, gastrocnemius, and/or anterior cruciate ligament/posterior cruciate ligament. Operative treatments for knee contracture include arthroscopic release for flexion with/without extension contracture, open quadriceps release for extra-articular extension contracture, tibial tubercle osteotomy for extension contracture with patella baja, and posterior capsule release for flexion contracture. Although studies of both arthroscopic and open contracture release by quadricepsplasty have demonstrated good results with significant improvement in range of motion, comparisons of the 2 have shown arthroscopic arthrolysis to have better results and better postoperative final joint range of motion (105 ± 18 degrees vs. 91 ± 20 degrees).6
In summary, joint contracture is a problem that continues to affect patients following trauma and intra-articular surgery. Several risk factors are well defined, and the myofibroblast has been identified as the pathognomonic cellular component of interest. At present, the mainstay of treatment is operative contracture release when conservative methods are unsuccessful. Future treatment strategies may be aimed at prevention or the targeting of cellular mechanisms.
STAGED VERSUS EARLY DEFINITIVE FIXATION OF HIGH-ENERGY TIBIAL PLATEAU AND PLAFOND FRACTURES: WHAT IS BEST FOR THE SOFT TISSUES AND THE PATIENT?
Bicondylar tibial plateau fractures and pilon fractures commonly result from a high-energy injury mechanism and are frequently associated with significant insult to the surrounding soft-tissue envelope. Although excellent outcomes and low complication rates were reported in early case series where low-energy pilon fractures were managed with open reduction and internal fixation, application of this management to high-energy pilon and plateau fractures resulted in significantly worse outcomes and high complication rates.7,8 Many case series reported in the 1990s described complication rates up to 50% or higher, primarily the result of wound-healing problems and deep infection. The high rate of occurrence of these complications was attributed to performing surgery through the compromised soft-tissue envelope that exists immediately following the high-energy injury mechanisms associated with these injuries.
Implementation of a staged management protocol for treatment of complex pilon fractures was described in 1999 by Sirkin.7 In that case series of 56 patients with OTA/AO C type fractures, the average time from application of external fixation to definitive ORIF was 13 days, and there was a significant improvement on wound complication rate when compared with previous reports of early definitive ORIF. The staged management of high-energy proximal tibia fractures was described by Egol in 2005,8 in a case series of 67 patients with OTA/AO A, B, and C type fractures. In that series, the average time from application of external fixation to definitive ORIF was 15 days, and the overall incidence of infection or wound problems was 5%. Subsequent to the reporting of these early studies more than a decade ago, many other case series have continued to show improved outcomes and reduced complication rates after implementation of staged management protocols for high-energy tibial plateau and pilon fractures. For this reason, staged management for these injuries has become widely adopted and is the “standard of care” in most cases for these injuries.
In contrast to this, several recent retrospective cohort studies have shown that early definitive fixation of high-energy tibial plateau and plafond fractures can be performed safely with outcomes and complication rates comparable to those achieved with staged management protocols.9–11 These studies point to several factors which seem to be integral to obtaining improved results with early definitive fixation including: careful selection of patients appropriate for early care based on assessment of the soft-tissue envelope, injury to surgery time typically less than 48 hours, avoidance of traditional single-incision approaches, and the use of minimally invasive plate osteosynthesis techniques. Early definitive fixation also has several advantages over the use of a staged management protocol including: greater ease in obtaining a surgical reduction and perhaps less complexity when performing the definitive fixation procedure, avoidance of complications related to pin site infection, and significant cost savings (due to reduced length of hospitalization and avoidance of the implant costs associated with the use of external fixator components).12
In summary, patients with high-energy tibial plateau and plafond fractures who present with a clearly compromised soft-tissue envelope (typically demonstrated by severe soft-tissue swelling, bruising, and blistering) are at high risk of surgical wound complications and infection when managed with early definitive fracture fixation. A large body of evidence has demonstrated that these injuries are best managed with a staged treatment protocol. However, early definitive fracture management can be performed with an acceptably low risk of complications in appropriately selected cases, by experienced surgeons, using contemporary surgical techniques, and provides the advantages of lower total cost of care, decreased length of hospital stay, technically easier surgery, and less postoperative joint stiffness.
SOFT-TISSUE COVERAGE AFTER OPEN TIBIA FRACTURES: TIMING AND FLAP SELECTION
Orthopaedic trauma surgeons are accustomed to providing soft-tissue coverage for traumatic wounds in their trauma patients requiring bony fixation. It is our assertion that anatomical knowledge, appropriate careful surgical technique, and preoperative assessment of the vascularity and compliance of the soft tissues can lead any capable orthopaedic trauma surgeon to do their own muscle or fasciocutaneous soft-tissue coverage in the absence of any microsurgical training. It is necessary for the surgeon to be able to assess the wound and its capacity to heal in the absence of surgical intervention, to be able to identify all options for the coverage of a complex wound, and to be able to choose the most appropriate option given the “personality” of the defect.
Five questions are posed. First, where is the defect? This will allow the surgeon to determine what adjacent local tissue is available that has a reliable enough blood supply that can be used as a local flap for adjacent coverage. For example, a pedicled latissimus dorsi muscle may be used to cover wound about the shoulder girdle. Second, what is at the base of the defect? If there is periosteum or peritenon covering the bone or tendon respectively, a skin graft may be appropriate. However, absence of well vascularized tissue at the depths of a traumatic wound will preclude use of nonvascularized coverage options. In addition, it may be ill-advised to use skin only in the coverage of bone, tendon, or neurovascular structures. Third, does the wound need to be covered? This question speaks to the potential for secondary intention wound healing and the possibility that functionally this may lead to appropriate and desirable outcome absent any further surgical intervention. This is the case when well-perfused muscle or dense regular connective tissue is present at the base of the wound and secondary intention healing in a healthy patient might be expected. Fourth, what local tissue is available? Again, this speaks to the ability to examine local tissues for their compliance, mobility, and perfusion that they may be moved to cover adjacent open wounds. Fifth and finally, if no local tissue is available, what distant tissue is suitable? If distant tissue is required, it is unlikely that an orthopaedic trauma surgeon (absent further training in soft-tissue coverage procedures) would attempt to provide this service to the patient.
A local flap of fascia and skin, or muscle, is considered when the defect cannot or should not be closed primarily, should not be allowed to heal secondarily, and cannot support a split-thickness or full-thickness skin graft. These are the perforator-based flaps that are either axial or island in design, or keystone flaps, which are a type of advancement flap containing perforators within the flap perimeter so that they are not truly “random.” Medial or lateral gastrocnemius muscle flaps that are perfused by the medial or lateral sural arteries, respectively, or peroneus brevis flaps that are perfused by the distal branch of the peroneal artery are examples of this type of local flap. The vascular supply to the soleus muscle is slightly more variable and prone to disruption and as such should not be used on an intermittent or infrequent basis.
The concept of a “perforator” is useful to understand. A perforator is a triad of 1 central artery and 2 veins that originates from a named longitudinally running arteriovenous bundle to pierce the fascia and supply the skin and subcutaneous tissue.13 Knowledge of the location of these perforator vessels and the ability to predict the likelihood of encountering these vessels enables the surgeon to plan incisions accordingly and to move adjacent tissue reliably given that perfusion from a well-defined perforator vessel triad can be counted on for reliable vascular supply to the flap. Propeller flaps, based on 1 perforator, or keystone flaps, based on more than one perforator, can be moved as a fasciocutaneous flap to cover adjacent tissue. These are especially useful in the middle and distal aspect of the lower extremity where the posterior tibial artery, peroneal artery, medial and lateral sural arteries, and anterior tibial arteries have well-delineated and well-described perforator anatomy.
In the absence of local tissue, free tissue transfer can be attempted. Although there is a wide variety of available tissue types and a large amount of composite tissue can be made available for transfer, these operations are lengthy, expensive, cause functional disability at the donor site, and are technically demanding. The experience of Godina et al has led us to attempt early coverage of severely traumatized extremities;14,15 however, with the advent of negative pressure wound dressings, there has been a recent tendency toward extending the period between the initial trauma debridement and the provision of free tissue coverage. At present, the debate remains unsettled. However, soft-tissue coverage within the first 10 days might prove to be reasonable. In addition, there is ongoing debate about the usefulness of negative pressure wound therapy as a reliable ongoing method to treat open tibia fractures.16,17 It may be that as orthopaedic trauma surgeons become more facile with the above described soft-tissue coverage procedures, the need for lengthy negative pressure wound therapy either as an inpatient or outpatient will be mitigated somewhat. At present, the indications are evolving.
HETEROTOPIC OSSIFICATION—STATE OF THE ART
HO is the pathologic process of benign bone formation in soft tissues of the body where bone is not generally formed. The bone formation occurs through enchondral ossification in a manner similar to the process of fracture healing. HO occurs in rare genetic disorders, including fibrodysplasia ossificans progressiva, the study of which has given us some understanding of the process. It also occurs after some central nervous system injuries, such as closed-head trauma or spinal cord injury; after burns or electrical shocks; after muscular contusion; after amputation due to military blast injury; and after some fractures and dislocations, particularly injuries of the hip, elbow, and shoulder. The development of HO requires an inducing agent or stimulus, the presence of a potentially osteogenic stem cell, and a “permissive environment,” which is generally provided by local inflammation.
In post-traumatic HO, such as that after surgical treatment, stem cell differentiation begins within 16 hours of the surgery, it appears radiographically by 3–6 weeks, and reaches maximal extent by 12 weeks. HO can be a complication of surgical treatment and occurs commonly after posterior or extensile approaches to the hip. High-grade HO of the hip, although less than 20% of total HO cases, can cause pain, restricted motion or anklyosis, and muscle or nerve entrapment. HO in the amputated extremity can cause ulceration and difficulty with prosthetic use. The actual incidence of postsurgical HO varies between series, but a systematic literature review covering >15,000 hips published in 2002 found a 51% incidence after acetabular fracture surgery, with 19% high-grade cases.18 Many risk factors in addition to surgical approach have been suggested, but recent literature has focused on length of stay in the intensive care unit and the need for prolonged mechanical ventilation. Once it forms, the only treatment for persistently symptomatic HO is surgical excision, a process which can be complicated and bloody. Previous recommendations to delay excision until bone scans were cold or alkaline phosphatase is normal have been largely discredited.
Suggested prophylaxis for HO after hip surgery has included vague references to “gentle surgical technique” or excision of the gluteus minimus (poorly supported in the literature), the use of nonsteroidal anti-inflammatory medications (NSAIDs), primarily indomethacin, the use of bisphosphonates, and external beam radiation treatment, which can be performed in a single dose either before or within 72 hours after surgery. Bisphosphonates seem to delay mineralization of osteoid but do not reduce its formation. There is controversy in the literature regarding the effectiveness of indomethacin treatment, with studies that support a positive effect and those which do not. A 2009 systematic review comparing indomethacin with radiation reviewed 5 studies and suggested that radiation was superior to oral indomethacin for preventing HO.19 Radiation therapy does have risks including local impairment of fracture or wound healing and the very rare induction of sarcoma. Indomethacin treatment increases the risk of nonunion in posterior wall fractures and in associated long bone fractures.20,21
The indications for prophylaxis remain controversial. Most trauma surgeons avoid the use of prophylaxis in uncomplicated surgical cases when treating acetabular or elbow fractures, provided there are no specific risk factors for HO development (eg, delay to surgery, central nervous system injury, and prolonged mechanical ventilation). In the presence of risk factors for HO development, the benefits of HO prophylaxis must be weighed against the potential risks of treatment (primarily nonunion). Many trauma surgeons will select either NSAID prophylaxis or radiation therapy based on the specific risk profile of their patient in these select instances. Secondary prophylaxis of either NSAIDs or radiation is routinely used after surgical excision of HO, which is generally performed after fracture healing is largely complete.
Recent studies suggest an important role of peripheral sensory nerves as the source of osteogenic precursor cells from the neural crest and creation of an HO-favorable environment by release of substance P, calcitonin gene-related peptide, brown adipocyte-like cells, and the activation of local mast cells.22 This fascinating area of research has opened new therapeutic possibilities.
There are number of issues aside from the bony injury and the direct management of the fracture which substantially impact outcomes in orthopaedic trauma. Joint contractures, compromised soft tissues, or soft-tissue defects in the setting of acute trauma as well as the formation of heterotopic bone are all issues that orthopaedic trauma surgeons must consider when managing injuries. A thorough understanding of these issues and the best available evidence surrounding them is critical to achieving the best possible outcomes.
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