Thursday, 14 November 2024

 

         Septic Arthritis of the Pediatric Hip




                                Dr. KS Dhillon




Introduction

Septic arthritis of the hip in children is an emergent surgical condition. If not treated rapidly, can lead to hip destruction, sepsis, and even death. Septic arthritis of the pediatric hip has to be differentiated from transient synovitis of the hip. Transient synovitis is a non-emergent and non-surgical condition. It can resolve with symptomatic pain management. Significant morbidity may result from the improper diagnosis of either of these conditions. To make a proper diagnosis the infecting organism has to be identified. The organism will vary depending on the comorbidities of the patient and the age of the patient (1-3).


Etiology

The most common mechanism for the development of pediatric septic arthritis is by hematogenous spread of bacteria into the hip joint. In about 80% of the cases the septic arthritis is preceded by an upper respiratory tract infection. The bacteria involved in about 70% of the cases is Kingella kingae a gram-negative coccobacillus. Staphylococcus organisms account for 10% of the cases. Haemophilus species have been the most common organisms causing septic arthritis of the hip in children younger than two years of age (4-6).

Blood pooling in the metaphyseal vessels of long bones permits bacterial seeding into this area. Bacteria then spread through the blood vessels of the bone into the bony epiphysis and result in an intracapsular infection of the hip joint hip.


Epidemiology

About 50% of children presenting with septic arthritis of the hip are younger than 2 years of age. It occurs twice as often in males as compared to females. Children who are immunocompromised, have sickle cell disease, or hemophilia are more likely to develop septic arthritis of the hip. In areas where Lyme disease is endemic, this condition should be considered as a possible diagnosis. This is especially true if other signs of Lyme disease such as transient polyarthralgia, typical erythema migrans (bull's eye rash), heart palpitations, and irregular heartbeat are present. Serological testing (Lyme titer /western blot) can be ordered to confirm the diagnosis of Lyme disease.


Pathophysiology

The release of cytokines in the pus within a septic joint leads to hydrolysis of collagen and proteoglycans in the hyaline cartilage covering the end of the bones within the joint. This leads to the destruction of the hyaline cartilage and articular bone which results in deformity, chronic loss of function, and pain. If the infection is left untreated, septicemia and death can occur.


History and Physical

Children with septic arthritis of the hip usually present with acute onset of pain in the hip joint. If they walk, they may be a limp. They will resist weight bearing on the affected leg. Children who do not walk will usually lie in bed holding their hip in the most comfortable position i.e. flexed and abducted. This is a position that allows the hip capsule to be lax, and it decreases pressure from intraarticular effusion that may be causing pain. They usually do not have fever. The children may have a history of a recent oropharyngeal infection.

When the children are in bed, log rolling of the child will produce severe hip pain. Passive movements of the hip joint are very painful.


Evaluation

It is difficult to differentiate acute hip pain caused by septic arthritis from that caused by transient synovitis of the hip. The best way to differentiate the two is by hip aspiration. The Kocher Criteria for diagnosing septic arthritis of the hip can be used to determine if an aggressive approach to the management of the patient is needed. The four criteria used in order of sensitivity in the Kocher criteria are:

  • Fever higher than 38.5 C

  • ESR more than 40

  • Weight-bearing status (non-weight bearing)

  • White blood cell count of more than 12,000

Children who meet 1 out of 4 of these criteria have a 3% incidence of septic arthritis, 2 out of 4 have a 40% incidence, 3 out of 4 have a 93% incidence, and 4 out of 4 have a 99% incidence (7-9).

X-rays of the hip should be done in older children to rule out the possibility of Perthes disease or a slipped femoral capital epiphysis (10).


Treatment

Children who have pain in the hip but only meet one out of the four Kocher criteria should be observed. They should be watched for further progression of the condition. Children with two or more of the criteria should have hip aspiration with a gram stain and cell count. If bacteria are identified or if the cell count reveals a WBC count of over 50,000 WBC/mm3 with greater than 75% PMN cells and a glucose level of more than 50 mg/dl less than that of the serum level, than the hip joint should be explored and irrigated with saline and an antibacterial agent (11,12).

The synovial fluid WBC count is considered more sensitive than the blood WBC count when diagnosing septic arthritis. A finding of 85% PMNs has an 88% sensitivity.

The duration of intravenous (IV) antibiotic use varies.  Usually, 2 days of IV antibiotics followed by a 3-week course of oral antibiotics is adequate. Some authors recommend one week of IV antibiotic therapy followed by 2  weeks of oral antibiotics. Kingella kingae is known to be resistant to clindamycin and vancomycin. These infections are treated with IV beta-lactamase antibiotics and then their oral forms. The sooner the treatment is started, the better the results. 

Surgical approaches to the hip for treatment of these patients are either anterior or anterior lateral.  Recent literature shows that the results are similar when comparing open drainage of the hip to arthroscopic drainage.

Long-term follow-up is necessary to detect complications of septic arthritis of the hip.  These complications can include growth disturbances of the hip, avascular necrosis of the femoral head, and the development of post-infection arthritis of the hip.


Differential Diagnosis

  • Crystalline Arthritides

  • Drug-Induced Arthritis

  • Arthritis of Intrinsic Bowel Disease

  • Postinfectious Diarrhea

  • Postmeningococcal

  • Postmeningococcal Arthritis

  • Vasculitis


Conclusion

Swift diagnosis and treatment significantly impacts outcome in children with septic arthritis of the hip. Staphylococcus aureus, especially methicillin sensitive strains prevail. Resistant strains are however increasing. Early treatment is crucial. Delays, high CRP/ESR levels, and younger age correlate with worse outcome. Accurate diagnosis can be made by clinical examination and ultrasound. Treatment can include surgery and less invasive methods, often combined with tailored antibiotics. Antibiotic resistance can pose a challenge, requiring ongoing vigilance. Further research is needed to address the evolving landscape of antibiotic resistance and explore potential interventions to improve outcomes in septic arthritis of hip patients.


References

  1. Chewakidakarn C, Nawatthakul A, Suksintharanon M, Yuenyongviwat V. Septic arthritis following femoral neck fracture: A case report. Int J Surg Case Rep. 2019;57:167-169.

  2. Akgün D, Müller M, Perka C, Winkler T. High cure rate of periprosthetic hip joint infection with multidisciplinary team approach using standardized two-stage exchange. J Orthop Surg Res. 2019 Mar 13;14(1):78.

  3. Hoswell RL, Johns BP, Loewenthal MR, Dewar DC. Outcomes of paediatric septic arthritis of the hip and knee at 1-20 years in an Australian urban centre. ANZ J Surg. 2019 May;89(5):562-566.

  4. Momodu II, Savaliya V. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 3, 2023. Septic Arthritis. 

  5. Deore S, Bansal M. Pelvic Osteomyelitis in a Child - A Diagnostic Dilemma. J Orthop Case Rep. 2018 Jul-Aug;8(4):86-88.

  6. Tretiakov M, Cautela FS, Walker SE, Dekis JC, Beyer GA, Newman JM, Shah NV, Borrelli J, Shah ST, Gonzales AS, Cushman JM, Reilly JP, Schwartz JM, Scott CB, Hesham K. Septic arthritis of the hip and knee treated surgically in pediatric patients: Analysis of the Kids' Inpatient Database. J Orthop. 2019 Jan-Feb;16(1):97-100.

  7. Mooney JF, Murphy RF. Septic arthritis of the pediatric hip: update on diagnosis and treatment. Curr Opin Pediatr. 2019 Feb;31(1):79-85. 

  8. Amanatullah D, Dennis D, Oltra EG, Marcelino Gomes LS, Goodman SB, Hamlin B, Hansen E, Hashemi-Nejad A, Holst DC, Komnos G, Koutalos A, Malizos K, Martinez Pastor JC, McPherson E, Meermans G, Mooney JA, Mortazavi J, Parsa A, Pécora JR, Pereira GA, Martos MS, Shohat N, Shope AJ, Zullo SS. Hip and Knee Section, Diagnosis, Definitions: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019 Feb;34(2S): S329-S337. 

  9. Mue DD, Salihu MN, Yongu WT, Ochoga M, Kortor JN, Elachi IC. Paediatric Septic Arthritis in a Nigerian Tertiary Hospital: A 5-Year Clinical Review. West Afr J Med. 2018 May-Aug;35(2):70-74.

  10. Cruz AI, Anari JB, Ramirez JM, Sankar WN, Baldwin KD. Distinguishing Pediatric Lyme Arthritis of the Hip from Transient Synovitis and Acute Bacterial Septic Arthritis: A Systematic Review and Meta-analysis. Cureus. 2018 Jan 25;10(1):e2112.

  11. Higuera CA, Zmistowski B, Malcom T, Barsoum WK, Sporer SM, Mommsen P, Kendoff D, Della Valle CJ, Parvizi J. Synovial Fluid Cell Count for Diagnosis of Chronic Periprosthetic Hip Infection. J Bone Joint Surg Am. 2017 May 03;99(9):753-759.

  12. Ryan DD. Differentiating Transient Synovitis of the Hip from More Urgent Conditions. Pediatr Ann. 2016 Jun 01;45(6):e209-13.

Sunday, 10 November 2024

 

   Total Knee Arthroplasty Periprosthetic Fracture


                                        Dr. KS Dhillon



Introduction

The number of individuals with joint arthroplasty is steadily growing. This is due to the fact that the population is continuously increasing and getting older on one hand, and on the other hand there is demand for high physical performance even at an advanced age. The Endoprostheses Register in Germany in 2018 recorded a total of over 300,000 implantations or revisions of artificial joints. More than 132,000 of these involved the knee joint. Kurtz et al (1) projected that 3.48 million knee arthroplasties will be done in the USA in 2030. With the increasing number of implanted artificial joints, the number of complications will naturally also rise. A major complication is a periprosthetic fracture which has massive socioeconomic consequences. The incidence of periprosthetic fractures is low after primary TKA but the risk increases after revision surgery. Several factors have to be taken into account when treating a periprosthetic fracture. Basic principles of classical fracture management can rarely be applied to periprosthetic fracture management since the biomechanics and bone healing are significantly altered in the presence of an artificial joint. Identifying the cause of the fracture is a key element in determining further treatment. The strategy is significantly affected by the presence of a prosthetic joint infection, aseptic loosening, or a pathological fracture in malignant disease. Since unexpected findings sometimes first manifest themselves intraoperatively, surgical treatment is recommended in a specialized center. 


Epidemiology

The causes of periprosthetic fractures around TKA are diverse. Besides age, gender, the time elapsed since implantation and revision surgery also have an influence on fracture risk (2). The incidence of a periprosthetic fracture after primary TKA is about 2%. In the case of revision surgery, the incidence increases by up to 38%. The most common site for fracture is the femur, followed by the patella and tibia (3,4,5).  High-energy trauma is a rare cause of these fractures. Often, the fracture is preceded by low-energy trauma in patients with general risk factors such as osteoporosis, prosthetic joint infection (PJI), or aseptic loosening of the implants. The treatment depends on the underlying risk factor for the fracture. The periprosthetic fractures can occur intraoperatively or postoperatively. If intraoperative fractures are detected during implantation, they can be treated then and there. In the case of postoperative fractures, the fracture's cause and the components' fixation must be considered to decide whether the implant can be retained or has to be replaced. The required information can be obtained from a detailed medical history and corresponding diagnostics.


Diagnosis

The exact medical history is of great importance for further treatment. If after TKR the patient was never free of symptoms in the area of the affected knee joint, the focus is on PJI, incorrect positioning, or intraoperatively missed periprosthetic fractures. It may be a pathological fracture if the patient suffers from a malignant disease or osteoporosis. The diagnosis is made by doing x-rays of the affected knee joint in two perpendicular planes (anterior-posterior and lateral) and an axial image of the patella. For further planning any implants or prostheses of the neighboring joints must also be displayed. If the pain level and general condition of the patient permits, an x-ray of the whole lower limb is taken to identify axial deviations. A comparison with preexisting imaging if present allows conclusions to be drawn about loosening of the implants, peri-implant osteolysis, or malposition of the components (6). CT imaging can detect non-displaced and X-ray occult fractures. It can help to determine the fracture morphology and bone quality. Rotational malposition of the components can be effectively assessed with CT. In direct proximity to inserted implants, the validity of CT can be limited through metal-related interference artifacts. In exceptional cases, an MRI can provide valuable additional information about the soft tissue envelope, occult fractures, the bone-prosthesis interface, and bone cement (7). Information on bone quality can be obtained by performing a DEXA absorptiometry. This information is used when planning the procedure and selecting implants. If the medical history, imaging, or laboratory tests indicate a PJI, the affected knee joint must be biopsied. The detection or exclusion of a PJI is particularly important because further procedures significantly depend on it. 


Treatment

Distal femur

TKR periprosthetic fractures occur most frequently in the distal femur. The incidence of such fractures is between 0.3% to 2.5% (6). This area is particularly at risk due to the large moments of force that occur in the supracondylar region in patients with low-energy trauma. The Lewis and Rorabeck classification divides distal femoral fractures into 3 types depending on the degree of dislocation and the fixation of the components (Fig. 1). It is well established in clinical practice (8). In type 1 and 2 fractures the components are fixed and they differ only in the degree of dislocation. The results of surgery with nonlocking osteosyntheses were inferior to those of conservative treatment. 

With the introduction of locking plate systems by the AO Foundation in 2000, the results of plate osteosyntheses in supracondylar periprosthetic femoral fractures were good (9,10,11,12). In 2005 the AO Foundation developed special periprosthetic fracture plates that met the mechanical and geometric requirements for treating this kind of fractures even better (13). If the locking mechanism is polyaxially, some of the locking head screws can be placed in the distal fragment without collision with the femoral prosthetic component, even in patients with very distal fractures. Insertion of screws in 8 to 10 cortices above and below the fracture is recommended (3). In patients with an intramedullary implant, extra short screws can be inserted monocortically. It is possible to insert several screws into the bone passing intramedullary implants by using additional modules such as the locking adapting plate, which is screwed onto the plate. Too rigid fixation by plate osteosynthesis has to be avoided so as not to compromise bone healing. By using long plates load sharing can be improved.

Fig 1


The screws should not be placed too close to the fracture site to avoid stress risers (14). Since there is high mechanical load with implants that are already in place, the use of broad and therefore more stable plates, is recommended especially in comminuted fractures to prevent implant failure. If the patient is fit for surgery, surgical treatment with locking plate osteosynthesis should be performed to reduce complications such as non-union. Postoperative exercises can prevent stiffening of the knee joint. Conservative treatment requires the affected extremity to be immobilized across the knee joint for a longer period which leads to knee stiffness (15). Retrograde intramedullary nail osteosynthesis can be done depending on the prosthesis model and taking into account ipsilateral femoral implants. Retrograde intramedullary nail osteosynthesis has lost much of its importance as it is inferior to locking plate osteosynthesis with regards to stability, non-union, and revision procedures. The advantages of intramedullary nailing are less invasiveness and the resulting lower infection rate and less blood loss. For a retrograde intramedullary nailing osteosynthesis, several conditions must be met. The femoral component of the TKA must have an open-box design. The thickest part of the nail must be able to pass through the open intercondylar space during insertion. The prosthesis model must be known. It is important to remember that the nail diameter is usually given for the part of the nail that is diaphyseal in the area of the isthmus. The distal nail end, which has to fit through the intercondylar space of the prosthesis, usually has a larger diameter. For safe nail entry, the affected knee joint must be able to flex at least 60°. Very distal fractures are not suitable for intramedullary nail osteosynthesis because at least 2 locking screws have to be placed in the distal fragment (16,17). Retrograde intramedullary nail osteosynthesis for the treatment of periprosthetic distal femoral fractures around TKA is reserved for situations where there are contraindications for plate osteosynthesis. In all other cases, locking plate osteosynthesis should be carried out.

There is no comminuted zone in Type 1 fractures. The dislocation in such fractures is a maximum of 5 mm with the axial deviation a maximum of 5° (18). High degree of instability is not present. A lateral locking plate osteosynthesis is the osteosynthesis procedure of choice. 

An insertion guide via soft tissue-sparing approaches in the region of the lateral femur can be used to insert modern systems. The proximal screw holes are approached through small incisions. These kinds of fractures rarely require direct exposure. 

A dislocation of more than 5 mm or an axial deviation of more than 5° is referred to as a type 2 fracture. Compared to type 1 fractures, the stability in type 2 fractures is reduced due to the dislocation. In multifragmentary situations with interposed soft tissue, it is often necessary to expose and reduce the fracture. The reduction can be secured with a cerclage wire. When the femoral component does not have a box, the distal fixation of the osteosynthesis is usually not affected. Even in the presence of a box as in varus-valgus-constrained or PS-implants and relatively proximal fracture, a sufficient number of screws can be placed distally. In both of these cases, the single lateral locking plate osteosynthesis is used. If the fracture is far distal and the femoral component has a box or a stem, the distal fixation can be significantly compromised. To stabilize the medial column additional medial plate osteosynthesis and insertion of supplemental distal screws is recommended. This increases the stability of the osteosynthesis (19,20). After knee replacement, the morbidity of the approach for performing medial plate osteosynthesis is a challenge for surgeons since at least two approaches are already present due to the implantation of the prosthesis and the insertion of the lateral plate. The iatrogenic trauma to soft tissues should be kept as small as possible to avoid compromising fracture healing. In this situation, the use of a helix plate is a stable and minimally invasive procedure. For this, a straight locking plate is torqued about 90° to 120° in the axial direction and then bent according to the anatomy of the individual femur. Using a small medial approach in the area of the distal femur, the plate can be inserted under the thigh muscles. The screws can be inserted into the proximal end of the plate through the existing lateral plate osteosynthesis approach. It is important to make sure that the plates do not end at the same level proximally to avoid a stress raiser (21). When there is a comminuted periprosthetic fracture, the exact anatomical reduction of the individual fragments is not recommended. Fracture-bridging biological osteosynthesis should restore the original axis, length, and rotation of the involved femur. It is advisable to use a lateral locking plate osteosynthesis with an additional medial helix plate to provide more stability. Any existing implants in the area of the proximal femur should be taken into account when selecting the osteosynthesis. An appropriately large implant-free bone section between proximal and distal implants has to be kept in mind. Biomechanically, it is better if the implants overlap on a defined area of bone. Kissing implants, in which proximally and distally positioned implants such as intramedullary nails, prosthetic stems, or plates only touch but do not overlap, should be avoided to prevent stress concentration in the junction zone that occurs under load (22). Bone grafts are used to support the medial column and prevent loss of reduction before the introduction of locking plates (23). Bone grafts are sometimes used in the revision of failed osteosyntheses of periprosthetic fractures (3,13,17).  In type 3 fractures, the prosthesis is loose. It has to be replaced during the revision surgery. If a loosening of the implant cannot be safely ruled out before the operative revision, it is essential that an appropriate revision system is available in the treating institution. Due to deficient bone stock, the re-insertion of a surface replacement prosthesis is usually no longer possible. Stemmed revision prostheses are used in such cases. Depending on the bone loss, these prostheses are fixed or supported in the remnant of the femur with augments and cones. The ligamentous apparatus of the knee joint is often affected by the fracture or revision procedure, therefore rotating hinge prostheses are used in this situation. In most cases, the tibial component has also been changed to a stemmed model for reasons of stability and compatibility. If the distal femur has a large bony defect, the distal femoral replacement arthroplasty can be done. Following this procedure full weight-bearing is possible immediately postoperatively. This is of benefit to older patients who are unable to postoperatively ambulate partial weight-bearing. In distal femoral replacement arthroplasty, the force is applied in the area of the diaphysisis and not in the area of the condyles. Stress risers in the area at the tip of the stem lead to frequent fractures. Besides the high implant cost, a further disadvantage is that the origins of the musculus gastrocnemius medialis and lateralis must be detached during the procedure. The implantation of such a modular mega prosthesis is done usually as a salvage procedure (24,25).


Helix plate

Due to the already existing implants in patients with periprosthetic fractures, it is sometimes difficult to achieve a sufficient number of corticales both proximally and distally. This problem can be solved by using the medially inserted helix plate. The postoperative period of partial weight-bearing is about 15 weeks on average. The fracture consolidates with subsequent full weight-bearing. The average knee flexion of 85°–90° can be obtained.

The application of an additional medial helix locking plate seems to be a successful procedure for complex periprosthetic fractures such as interprosthetic fracture, presence of proximal implants, osteoporosis, non-union, or refracture after initial osteosynthesis.


Patella

The incidence of patella fractures in patients with TKR is 1.19%. The majority of these periprosthetic fractures occur in patients with an inlaid patellar resurfacing. Risk factors for such fractures include extensive bone resection when preparing the patella with a remaining patella thickness of less than 15 mm, malalignment with subluxation of the patella, devascularization of the patella through lateral release, incorrect positioning of components, use of cementless implants or implants with a single central fixation peg. 

Radiological diagnostics is of particular importance since the incorrect positioning of the components plays a major role in the occurrence of periprosthetic patella fractures. To analyze the rotation of the components, a rotational CT of the entire affected leg is needed. If there is significant malrotation of the tibial or femoral component, new implantation with correct alignment has to be performed as part of the fracture management. 

Periprosthetic patella fractures are usually not caused by direct trauma (5,26). The Ortiguera and Berry classification is suitable for decision-making in patella fractures around patellar resurfacing (27). This classification takes into consideration the condition of the extensor mechanism, bone stock, and implant fixation. In type 1 fractures, the extensor mechanism is intact and the patellar resurfacing is well-fixed. Type 1 fractures can be treated conservatively with initial immobilization in a cast and then gradual knee mobilization (28). In type 2 fractures there is interruption of the extensor apparatus with or without loosening of the patellar component. For such fractures, reconstruction of the extensor mechanism with osteosynthesis of the patella is needed. If the implant is loose, it has to be replaced. In type 3 fractures, the patella component is loosened but the extensor apparatus is intact. There are 2 subtypes of type 3 fractures. They can be distinguished depending on the bone stock after the removal of the inserted patella component. In subtype A the bone stock is good. A remaining patella thickness of 8 to 12 mm is considered sufficient to replace it with a conventional cemented polyethylene surface (29). A biconvex patella component can be implanted to compensate for the bony deficit if the thickness is less. For this purpose, the remaining bone stock must have a continuous bony margin (30). In patients with pronounced bone loss with poor support of the patella implant, a trabecular metal prosthesis can be used to fill the bony defect and establish good bony contact. The polyethylene component can then be fixed to this metal back with cement (31). In subtype B, the remaining bone stock is so deficient that no new patellar resurfacing can be done. After the removal of the patella component, patelloplasty can be done to shape the remaining patella. A Gullwing osteotomy involves incomplete vertical osteotomy of the patella in its center. Then the lateral and medial halves are arranged in a V-shape to each other to create a central ridge that can enter the groove of the femoral component to improve patella tracking and thus extensor function (32). Another available option is patella augmentation using autologous bone grafting in a retropatellar tissue flap (33). The ultimate option is a patellectomy which can produce significant impairment of the stability and biomechanics of the extensor apparatus (5). 


Tibia

In patients with TKR periprosthetic fractures of the proximal tibia rarely occur. They can be classified according to the Felix classification depending on their localization, stability of the tibial component, and the moment of their occurrence. Type 1 fractures are located far proximally. They affect only a part of the proximal tibia and extend to the cranial interface of the tibial component. In type 2 fractures, the fracture line runs along the shaft of the tibial component, and in type 3 fractures the fracture line runs below it. The periprosthetic fractures that affect the insertion area of the knee joint extensor apparatus are classified as type 4 fractures. In subtype A there is a stable bony fixation of the tibial plateau. In subtype B the tibial implant is loose. Subtypes A and B imply the postoperative occurrence or detection of the fracture. Subtype C describes an intraoperative fracture (34). Risk factors for the occurrence of a periprosthetic fracture of the proximal tibia include the use of non-cemented implants, malposition of the tibial component, prior high tibial osteotomy, forced compaction of the cancellous bone and impaction of the tibial component during implantation, prior loosening of the components, and cortical impingement in long-stem prostheses. The assessment of the prosthesis fixation is important in the choice of the treatment concept. In the case of a loosened tibial component according to subtype B, it is mandatory to change this component, because a single osteosynthesis alone does not provide sufficient stability for the bony fixation of the prosthesis and it consequently leads to a dislocation of the component (3). During the revision of the tibial component, larger bone defects that affect the support of the prosthesis are filled with augments or cones. The treatment of periprosthetic tibial fractures of subtype A follows the usual principles of traumatology. Surgical treatment involves open reduction with plate or screw fixation. Depending on their level intraoperative fractures of subtype C can also be treated with osteosynthesis. In patients with type 3C fractures, the fracture can be bridged by the insertion of a longer prosthetic stem and stabilizing with plate osteosynthesis. Haller et al. described a technique of antegrade intramedullary nail osteosynthesis for diaphyseal type 3 fractures (35). Type 1A and type 1C fractures with small fragments that are not significantly displaced can be treated conservatively with immobilization in a femoral cast (15,36). Type 4 fractures involve the tibial tuberosity. Depending on the size of the fragment, screw or plate osteosynthesis can be carried out (3). Since the extensor apparatus of the knee joint is affected in this type of fracture, the flexion of the affected knee joint should initially be limited utilizing an orthosis and then gradually released to minimize tension on the extensor mechanism. Active extension of the knee against resistance should be avoided for the time of bone healing 6 weeks postoperatively. When planning osteosynthesis for proximal tibial fractures, it should be kept in mind that less soft tissue coverage can be achieved compared to the distal femur. Hence, risks such as postoperative wound healing or infections are more common. 


Conclusion

The treatment goal should be a well-aligned and mobile knee joint combined with a pain-free, unassisted, fully ambulatory patient. 

The decision regarding treatment options should be a team decision, involving an orthopedic surgeon, an anesthesiologist, an internal medicine specialist, and the patient. In patients with stable fractures and those who are not fit for surgery due to medical comorbidities, conservative non-surgical methods can be used that yield acceptable results. In patients who have stable or unstable fractures, but possess good bone stock and stable prosthesis, the choices include both intramedullary nailing and locking plate. External fixation is a method that allows early ambulation with the preservation of soft tissue while showing good results. Fractures with unstable prosthetic components but good bone stock should be treated with revision surgery. Fractures with poor bone stock and unstable prosthesis should be treated with endoprosthesis. 


References

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  2. Meek R.M.D., Norwood T., Smith R., Brenkel I.J., Howie C.R. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96–101. doi: 10.1302/0301-620X.93B1.25087.

  3. Ruchholtz S., Tomás J., Gebhard F., Larsen M.S. Periprosthetic fractures around the knee—the best way of treatment. Eur Orthop Traumatol. 2012;4(2):93–102. doi: 10.1007/s12570-012-0130-x.

  4. Kim K.-I., Egol K.A., Hozack W.J., Parvizi J. Periprosthetic fractures after total knee arthroplasties. Clin Orthop Relat Res. 2006;446:167–175. doi: 10.1097/01.blo.0000214417.29335.19.

  5. Chalidis B.E., Tsiridis E., Tragas A.A., Stavrou Z., Giannoudis P.V. Management of periprosthetic patellar fractures. Injury. 2007;38(6):714–724. doi: 10.1016/j.injury.2007.02.054.

  6. Mittlmeier T., Beck M., Bosch U., Wichelhaus A. Periprosthetic knee fractures. Orthopä. 2015;45(1):54–64. doi: 10.1007/s00132-015-3205-x.

  7. Fritz J., Lurie B., Potter H.G. MR imaging of knee arthroplasty implants. Radiographics. 2015;35(5):1483–1501. doi: 10.1148/rg.2015140216.

  8. Su E.T., DeWal H., Di Cesare P.E. Periprosthetic femoral fractures above total knee replacements. J Am Acad Orthop Surg. 2004;12(1):12–20. doi: 10.5435/00124635-200401000-00003.

  9. Fulkerson E., Tejwani N., Stuchin S., Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007;38(8):965–972. doi: 10.1016/j.injury.2007.02.026. 

  10. Cain P.R., Rubash H.E., Wissinger H.A., McClain E.J. Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop Relat Res. 1986;208:205–214. 

  11. Merkel K.D., Johnson E.W. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am. 1986;68(1):29–43.

  12. Herrera D.A., Kregor P.J., Cole P.A., Levy B.A., Jönsson A., Zlowodzki M. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006) Acta Orthop. 2009;79(1):22–27. doi: 10.1080/17453670710014716.

  13. Wood G.C.A., Naudie D.R., McAuley J., McCalden R.W. Locking compression plates for the treatment of periprosthetic femoral fractures around well-fixed total hip and knee implants. J Arthroplasty. 2011;26(6):886–892. doi: 10.1016/j.arth.2010.07.002.

  14. Graham S.M., Moazen M., Leonidou A., Tsiridis E. Locking plate fixation for Vancouver B1 periprosthetic femoral fractures: a critical analysis of 135 cases. J Orthop Sci. 2013;18(3):426–436. doi: 10.1007/s00776-013-0359-4.

  15. Platzer P., Schuster R., Aldrian S. Management and outcome of periprosthetic fractures after total knee arthroplasty. J Trauma. 2010;68(6):1464–1470. doi: 10.1097/TA.0b013e3181d53f81.

  16. Mittlmeier T., Beck M. Retrograde Verriegelungsmarknagelung bei periprothetischer distaler Femurfraktur nach kondylärem Kniegelenkersatz. Unfallchirurg. 2005;108(6):497–502. doi: 10.1007/s00113-005-0956-6. 

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Saturday, 2 November 2024

 

       Terrible triad injury of the elbow

 

                             Dr. KS Dhillon




Introduction

The terrible triad injury of the elbow was originally described by Hotchkiss in 1996. It constitutes a highly unstable form of fracture-dislocation of the elbow. It consists of elbow dislocation with concomitant radial head or neck and coronoid process fractures [1,2,3]. 

This injury pattern is designated as terrible because of historically poor outcomes and high complication rates. The elbow is well known as one of the most stable joints of the body. The complex anatomical structure and higher functional requirements make treating the elbow injuries more difficult [4].

Owing to its complex anatomical structure, even isolated elbow dislocations without bony fragmentation involve substantial soft tissue injury with capsular and ligamentous disruption. In complex elbow dislocations, there

are fractures of one or more major bony stabilizers. Fractures can involve the radial head, coronoid process, or olecranon. These fractures can destabilize the dislocation and nearly always need operative intervention to restore functional anatomic alignment and joint stability [5].

Controversies remain regarding the appropriate treatment algorithm for these injuries despite clinical and operative advancements and an increased understanding of pathoanatomy and elbow biomechanics. Successful evaluation and treatment require detailed knowledge of the elbow anatomy, functional importance, and its contribution to elbow stability [5].




Anatomy

The elbow joint (fig 1) consists of three sub-joints, namely the humeroradial, humeroulnar, and superior radioulnar joints. The joints are enveloped by a common joint capsule. The humerus, radius, ulna, and related capsules, and ligaments make up these sub-joints. These joints allow elbow flexion and extension, and forearm pronation and supination. The coronoid process is a triangular-shaped protrusion at the proximal ulna and it plays a major role in keeping the elbow stable. Apart from bony structures, several ligaments also contribute to elbow stability. These include the medial collateral ligament complex (MCLC) and the lateral collateral ligament complex (LCLC). The MCLC is composed of three small ligaments namely the anterior medial collateral ligament, the posterior medial collateral ligament, and Cooper's ligament. The LCLC is made up of four small ligaments: the lateral ulnar collateral ligament, the lateral radial collateral ligament, the annular ligament, and the accessory lateral ligament. The stability of the elbow largely depends on the functions of the radial head, coronoid process of the ulna, LCLC, and the anterior medial collateral ligament.

Fig 1- elbow joint



Etiology

About 60% of complex dislocations are caused by a fall from standing height [6]. Considerable force is required to sustain a complex dislocation. Falling on an extended arm that precludes valgus, axial, and posterolateral rotational forces, producing a posterolateral dislocation, is often the mechanism of insult.[1]

Fracture dislocations of the elbow tend to occur in distinct patterns depending on the mechanism of injury. Elbow extension with forearm supination and added valgus stress puts the most strain on the ulnohumeral joint, radial head, and MCL respectively. This causes a posterolateral rotational instability pattern of fracture-dislocation which includes posterior dislocation with a radial head fracture and the terrible triad injury with an added coronoid fracture. An axial load to the elbow in extension and a varus stress will cause compression injury to the medial side of the elbow leading to coronoid fractures, and tension forces acting laterally causing LCL rupture [7]. With the elbow in more flexion, this pattern can also cause a fracture of the olecranon. The outcome from this mechanism of injury is termed as varus posteromedial rotational instability. A direct blow to the posterior aspect of the flexed elbow can cause an anterior dislocation with an olecranon fracture. A hyperextension injury can also cause anterior dislocation with an olecranon fracture.


Epidemiology

Radial head fractures constitute between 20% to 30% of all adult elbow fractures [1]. Eighty-five percent of radial head fractures occur between the ages of 30 to 60 years. The mean occurrence is at age 45 years [8]. 

Coronoid fractures constitute 10% to 15% of elbow injuries. The elbow is the second most commonly dislocated joint, although it is one of the most stable joints in the body. About 20% of dislocations are associated with a fracture [6,9,10].


Pathophysiology

The elbow is made up of three sub-joints namely the humeroradial, humeroulnar, and superior radioulnar joints. The subjoints are made up of the humerus, radius, ulna, and related capsuloligamentous structures [11,12]. 

The radial head is an important restraint to posterolateral rotatory instability and it also acts as a secondary valgus stabilizer. In a normal elbow, the radial radiocapitellar articulation contributes minimally to valgus stability. However, in the event of MCL or coronoid injury, the radial head acts as the primary stabilizer to valgus stresses. It also prevents elbow subluxation[10]. Radial head fractures can be associated with episodic elbow instability, mechanical block to elbow motion, and injury to the distal radioulnar joint and/or the interosseous membrane (Essex-Lopresti) [13].

The coronoid process of the ulna provides ulnohumeral stability anteriorly and a varus buttress while resisting posterior subluxation [11].

The lateral collateral ligament (LCL) and medial collateral ligament (MCL) are the main capsuloligamentous stabilizers of the elbow. The MCL is the main stabilizer of valgus movements. It consists of the anterior bundle, posterior bundle, and transverse ligament. The robust anterior bundle is most important for stability [11]. Cavaderic studies have shown that fracture dislocations of the elbow are most likely to occur between 15 degrees of extension and 30 degrees of flexion, where the MCL is the least effective [14]. The lateral collateral ligament is the primary restraint to posterolateral rotatory instability. It contains four components namely the lateral ulnar collateral ligament, radial collateral ligament, annular ligament, and accessory (posterior) collateral ligament. The lateral ulnar collateral ligament is most important for stability [11]. 

The humeroulnar joint is the primary contributor to elbow stability, with its highly constrained articulation. The anteromedial facet resists varus movements and the muscles crossing the elbow joint contribute dynamically. The osseous and ligamentous structures afford static stability. 

In the terrible triad, the structures of the elbow fail from lateral to medial as the forearm supinates and is loaded. There is disruption of the lateral collateral ligament first, then the anterior capsule, and finally the medial collateral ligament [6]. The pattern of disruption from lateral to anterior/posterior and then medial is commonly referred to as the Horri circle [15].


History and Physical Examination

The initial evaluation should proceed according to the Advanced Trauma Life Support (ATLS) protocol. Concomitant fractures, dislocations, and injuries throughout the ipsilateral extremity have to be excluded.

Distal radioulnar joint (DRUJ) tenderness may represent an interosseous ligament disruption and there may be concurrent Essex-Lopresti injury [13]. 

Fracture-dislocations of the elbow will present with swelling, pain, and deformity. There will be limitation of movements of the elbow [6][4].

A thorough neurovascular examination should be carried out. The ulnar nerve is most vulnerable to injury. Brachial artery injury, although rare, can occur and lead to ischemia and compartment syndrome [16].

Elbow stability is tested by doing a posterolateral drawer and posterolateral pivot shift tests, and varus/valgus instability stress testing. The DRUJ examination is done by palpating over the wrist for tenderness and translation of more than 50% in the sagittal plane. The interosseous membrane is palpated for tenderness. A radial pull test is done at the time of surgery and if there is more than 3 mm translation, there should be a concern for longitudinal forearm instability (Essex-Lopresti) [13]. When the patient presents in a delayed or recurrent fashion, the examiner should assess elbow flexion/extension, forearm rotation, and nerve function.


Evaluation

Anteroposterior and lateral radiographs are done for diagnosis. Additional shoulder, wrist, and hand imaging is done if the injury is suspected in other joints of the ipsilateral limb. Radiographs will help to evaluate the concentricity of humeroulnar and radiocapitellar joints. Lateral films will help in detecting coronoid fractures. Most injuries can be diagnosed with plain radiographs. A computed tomography (CT) scan is always obtained for patients with the terrible triad to identify fracture patterns, comminution, and displacement, that may not be evident on plain radiographs. Reconstructed CT scans are useful to better evaluate the injury pattern and assist with preoperative planning [17].

The CT scan will show coronoid, radial head, or olecranon injuries missed on initial radiographs. Fluoroscopic imaging under anesthesia is beneficial for intraoperative decision-making. When radiographs cannot be done after the injury in select patient populations, performing an examination under anesthesia while taking the elbow through gentle ROM is useful. 

Nonstandard views may need to be obtained for joints that are stiff and the position cannot be changed to further assess the integrity and alignment of articulating surfaces. 

There are several classifications available that can assist in further diagnostics. These are the Mason, Regan and Morrey, and O’Driscoll Classifications [18]. 

The Mason Classification for Radial Head Fractures:

  • Type I radial head fractures are either nondisplaced or minimally displaced (less than 2 mm), with no mechanical block to rotation.

  • Type II are displaced (more than 2 mm) or angulated fractures, with possible mechanical block to forearm rotation.

  • Type III have fracture comminution and displacement with confirmed mechanical block to motion.

  • Type IV radial head fractures are associated with elbow dislocation[11].

The Regan and Morrey Classification system identifies three types of coronoid fractures: 

  • Type I involves the coronoid tip

  • Type II describes a fracture involving 50% or less of coronoid height

  • Type III is determined by a fracture of greater than 50% of coronoid height [6,11].  

The O’Driscoll Classification system subdivides coronoid injuries based on location and the number of coronoid fragments. It recognizes that anteromedial facet fractures are caused by varus posteromedial rotatory forces [19].


Treatment 

The aim of treatment is to reestablish enough stability to permit early movements of the elbow [9,20,21]. Anatomic alignment of osseous structures is re-established. This is followed by restoration of the radial head and radiocapitellar contact. Ligaments are repaired if necessary.

If the elbow is sufficiently stable to allow early mobilization, non-operative management with immobilization in 90 degrees of flexion for 7 to 10 days is indicated. Non-operative treatment is also indicated if the coronoid fracture is small, the radial head fracture does not need surgery, and the humeroulnar and radiocapitellar joints have been anatomically reduced. A progressive range of movement exercises is routinely instituted following one week of immobilization. Strengthening protocols are begun after six weeks. 

An unstable radial head fracture and type III coronoid fracture, with associated elbow dislocation, is an indication for operative intervention. Open reduction internal fixation (ORIF) of the radial head, LCL reconstruction, and coronoid ORIF, with possible MCL reconstruction is carried out. In some situations, a radial head replacement may be necessary. If the instability persists after addressing the radial head and LCL complex, the next step is to proceed with operative MCL reconstruction. 

Isolated dislocations of the elbow are treated by immediate closed reduction. The reduction can be done in the emergency department under sedation. Successful reduction is accompanied by a clunking sound. The elbow should then be tested for stability by moving the elbow through a range of movements. Postreduction X-rays are done to confirm reduction. The elbow is then splinted in 90 degrees of flexion. Splinting should not proceed beyond three weeks. 

When surgery is indicated for radial head fractures, open reduction internal fixation (ORIF) is usually done. Radial head resection in fracture-dislocations may lead to Essex-Lopresti instability and arthrosis. Every effort should be made to maintain radial head integrity [10].

Open reduction and internal fixation is ideally carried out for radial head fractures when the fracture is non-comminuted and involves more than 40% of the articular surface and demonstrates bony continuity between the radial head and neck. Intra-osseous screws, compression screws, retrograde pinning, or anatomic plates can be utilized for fixation. When a plate is used it must be positioned posterolaterally in the safe zone, with the forearm in neutral, to minimize the risk of injuring the posterior interosseous nerve. Radial head arthroplasty is done for patients with a comminuted/displaced fracture of more than three fragments.

For radial head arthroplasty appropriately-sized implants must be used. A prosthetic head that is too small provides a very narrow area of contact which causes LCL laxity. If the head is too large it leads to poor congruence and excessive LCL tensioning, leading to postoperative stiffness. Patients undergoing arthroplasty with radial head replacement have demonstrated fewer postoperative complications, with significantly better ROM, than radial head repair [20]. When there is no coronoid fracture, a radial head fracture with elbow dislocation can be treated non-operatively. 

Type 3 coronoid fractures should be treated operatively [10]. In type 1 and type 2 fractures, there should be radial head conservation, elbow stability, and bony column congruence following soft tissue reconstruction. The coronoid can be repaired with sutures, anchors, screws, or the “suture lasso” technique. Open reduction internal fixation is the most common treatment for terrible triad injuries [6,10]. Coronoid fractures can be fixed via ORIF through the radial head defect laterally.

When a medial approach is used, the median antebrachial cutaneous nerve should be preserved. The coronoid fracture can be exposed between the two heads of the flexor carpi ulnaris. The ulnar nerve should always be visualized and protected. The lateral approach provides better access to the coronoid process. Postoperatively, active and active-assist ROM therapy is begun after 10-14 days. 

The LCL is repaired with the forearm in pronation if the MCL is intact. If MCL is injured, LCL is repaired with the forearm in supination. Postoperatively, it is important to avoid excessive shoulder abduction because that places undue stress on the LCL repair. Stability and adequate elbow function could be operatively restored without repairing the MCL. However, in cases where the elbow remains unstable after fracture fixation and lateral soft tissue (LCL) repair, especially in extension beyond 30 degrees, the MCL should be repaired [10,11,21].

Terrible triad injuries following high-energy insults are often accompanied by severe soft tissue injuries. This further prolongs the time to operative treatment, as soft tissue requirements for successful surgical outcomes are met in the interim. Several studies have documented that longer delays to surgery from injury produces postoperative elbow stiffness. Zhou et al [3] found that prognostication is optimized when surgical treatment is done between 24 hours and 14 days after injury. 

Lindenhovius et al [4] demonstrated a better range of motion in patients who underwent surgery within two weeks after the injury [4]. Wiigger et al. found that every 24-hour delay in surgery following initial injury more than doubles the risk of postoperative elbow stiffness [4].


Prognosis

Terrible triad injury patterns have historically poor outcomes due to persistent instability, stiffness, and arthrosis. A high index of suspicion is needed to expeditiously proceed through a detailed extremity examination, and appropriate imaging studies to make a correct diagnosis and proceed with early proper treatment [13].


Complications

Complications following elbow fracture-dislocation include synostosis, arthrofibrosis, heterotopic ossification (HO), infection, recurrent instability, post-traumatic arthritis, stiffness, nonunion, ulnar neuropathy, loosening of implant, and symptomatic hardware. Surgery to treat terrible triad injuries is associated with a high risk of complications, with up to a 54.5% reoperation rate, averaging between 22% to 30% [6,21,22].

Anatomic reduction of intraarticular fractures is necessary to prevent arthritic changes. A slight loss of extension can be expected. About 5% to 15% of patients with elbow fractures will experience stiffness following surgery [4]. Arthritis is common after high-energy trauma. It is likely a sequela of initial chondral impact and the degree of recurrent elbow instability. 

Some loss of motion after elbow fracture-dislocation can be expected. Patients usually lose more extension than flexion. The amount of stiffness increases with the energy of the initial injury. Heterotopic bone formation and delay of motion after repair also increase the amount of stiffness. 

Post-traumatic calcium deposition in the collateral ligaments and capsule is relatively common. Some reports document just under a 20% occurrence rate. Heterotopic ossification (HO) has occurred in up to 43% of operatively treated fracture dislocations [23,24].

Heterotopic ossification can cause near-complete ankylosis of the elbow. This can be seen on radiographic imaging 3 to 4 weeks after injury. The frequency and severity of HO are associated with the severity of the injury, the extent of soft tissue damage, length of immobilization, neurological injury, infection, delay to surgery, and the presence of associated burns [24]. Heterotopic ossification most often occurs either anteriorly, between the capsule and brachialis, or posteriorly, between the capsule and triceps. 

Distraction forces across the fracture secondary to flexion or active extension can lead to nonunion. Internal fixation failure is most common following radial neck fracture repairs secondary to its inherently poor vascularity. Recurrent instability rates are low. The most common cause is failure to recognize or treat fracture(s) or ligamentous injury. Recurrent instability is more common following type I or II coronoid fractures. 


Postoperative and Rehabilitation Care

Postoperative splinting is done for up to 10 days, depending on the stability achieved and concurrent injuries. The splint may be placed in flexion with the forearm in pronation to provide stability against posterior subluxation. When both MCL and LCL are repaired, the splint is positioned in flexion and neutral rotation. Some patients can start ROM exercises on the first postoperative day, with a majority beginning active ROM within 48 hours. Forearm rotation is usually allowed. Shoulder and wrist exercises are performed without restrictions. Extension within the terminal 30 degrees of motion is avoided for four weeks. 

The terrible triad of elbow injuries is difficult to treat. Despite optimal treatment and compliance with postoperative rehabilitation, rarely is it possible to achieve a full range of motion. Gomide et al [10] showed a mean flexion-extension range of 113 degrees and average flexion contracture of 24 degrees following surgery for terrible triad injuries of the elbow. 




Conclusion

The terrible triad injury of the elbow is the most complex pattern of all dislocations. It combines ligament damage with radial head and coronoid process fractures. Complete dislocations of the elbow joint should be considered as a terrible triad injury unless proven otherwise. The lack of knowledge of this clinical pattern of injury might be detrimental to elbow function. CT scan assessment should be carried out after the dislocation has been reduced for proper investigation of bony lesions. 

The principle objective of surgical management is to restore the bony stabilizing structures i.e. the radial head and coronoid process and radial collateral ligament reconstruction. Isolated radial head resection should be avoided since it appears as a bad prognosis factor for short and long-term outcome. Arthroplasty is advised if radial head fracture cannot be managed with osteosynthesis.

A medial surgical approach is recommended in patients with persistent posterolateral instability following radial collateral ligament reconstruction or when fixation of a large coronoid process fragment is necessary. External fixation is advocated when there is persistent instability following the reconstruction of bony and ligamentous structures. It provides joint stability and protects the reconstruction. 


References

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