The American Journal of Orthopedics

The proximal interphalangeal (PIP) joint plays a crucial role in hand function, accounting for an estimated 85% of the motion required to grasp an object.¹ The anatomy and biomechanics of the PIP joint, however, make it particularly prone to injury.^2,3 Dorsal PIP fracture-dislocations represent a subset of PIP injuries that often require surgical intervention.² The stability of these fracture-dislocations largely depends on the extent of articular involvement of the base of the middle phalanx. Fractures that involve less than 30% of the joint surface typically remain stable after reduction.^2,4,5 In cases in which involvement ranges from 30% to 50%, PIP joint stability is more tenuous, and more joint flexion is required to maintain concentric reduction. Fractures that involve more than 50% of the articular surface are unstable and require operative intervention.^2,5,6 Fractures that require more than 30° of flexion for reduction maintenance are generally considered unstable and may benefit from surgical intervention.²

The goals of treatment for this injury are to restore a stable, concentrically reduced joint and initiate early joint mobilization to prevent stiffness, pain, recurrent instability, and posttraumatic arthritis.^3,7 Numerous surgical interventions for unstable PIP fracture-dislocations have been proposed, including open reduction and internal fixation (ORIF),^8-10 extension-block pinning (EBP),^11-13 dynamic external fixation,^14-17 volar plate arthroplasty,^18,19 and hemi-hamate resurfacing arthroplasty.^20,21 Many of these techniques can be technically demanding and may require prolonged immobilization. EBP can be performed easily and efficiently and allows for early joint motion.

Extension-block pinning—placing a Kirschner wire (K-wire) into the head of the proximal phalanx at an angle that blocks PIP extension and prevents joint subluxation—was first described by Sugawa and colleagues¹² in 1979. In a study by Inoue and Tamura,¹¹ patients treated with EBP had a mean PIP range of motion (ROM) of 94° at a mean follow-up of 14 months. In a series of 3 case reports, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM in patients treated with EBP.

We conducted a study to expand on previous research on pain, function, and satisfaction outcomes in addition to ROM. We hypothesized that percutaneous EBP is an effective treatment for unstable dorsal PIP fracture-dislocations and has efficacy similar to that of more complex and technically demanding methods of treatment.

Materials and Methods

We retrospectively reviewed patient charts to identify candidates for this study. Inclusion criteria were unstable dorsal PIP fracture-dislocations treated with EBP and minimum 4-month follow-up. (Fracture-dislocations were deemed unstable if they involved at least 30% of the articular surface or required more than 30° of flexion for reduction maintenance.) Exclusion criteria were open injury, neurovascular or tendon injury, or any prior injury to the PIP joint.

Twelve patients (5 females, 7 males) treated over a 4-year period (2002–2006) met the inclusion criteria. Mean age was 30 years (range, 15-64 years). Each surgery was performed by Dr. Hagberg or Dr. Balk. Half the cases involved the dominant hand. Two small fingers, 4 ring fingers, 2 long fingers, and 4 index fingers were injured. The injuries were sustained in an all-terrain vehicle accident (n = 1), in falls (n = 2), while swimming (n = 1), or while playing softball (n = 3), football (n = 4), or soccer (n = 1). Mean time from injury to surgery was 7.5 days (range, 4-27 days). Extent of articular surface involvement of the base of the fractured middle phalanx was calculated using preoperatively obtained lateral radiographs.

Surgical intervention was performed in a reproducible fashion. All patients were treated with closed reduction of the PIP joint under fluoroscopic guidance. Before pinning, joint stability was assessed fluoroscopically both at rest and through an arc of motion. A single smooth 0.045-in K-wire was then inserted percutaneously into the distal and dorsal aspects of the proximal phalanx in retrograde fashion (Figure 1). During wire insertion, the distal interphalangeal joint was flexed to relax the intrinsic mechanism, and the central slip tendon was pierced just proximal to its insertion. We have not noted significant adhesion formation about the central slip with this technique, likely because of limited tendon excursion in this location. Stable joint reduction was confirmed with fluoroscopy. No attempt was made to reduce the intra-articular fracture at the base of the middle phalanx.

A therapy program was initiated 2 to 9 days after surgery. At the first postoperative visit, patients were allowed to perform active ROM (AROM) with the pin in place (Figure 1). K-wires were removed a mean of 25 days (range, 17-31 days) after surgery. A static dorsal block splint was then applied, and patients were encouraged to remove it several times per day for AROM between 20° and full flexion until 6 weeks after surgery. At that time, formal occupational therapy was commenced for another 6 weeks. If there was residual flexion contracture of the PIP joint, dynamic extension splinting was initiated after fracture consolidation.

Mean follow-up was 35.5 months (range, 4-94 months). Postoperative anteroposterior and lateral radiographs were used to evaluate maintenance of joint congruity, fracture union, remodeling, and evidence of degenerative changes. At final follow-up, grip strength of injured and contralateral hands was measured with a dynamometer (Jamar; Patterson Medical, Warrenville, Illinois). AROM and passive ROM (PROM) of the PIP joint was documented at follow-up visits. In addition, patients rated their pain on a 0-to-10 visual analog scale (VAS), with 0 representing no pain and 10 representing excruciating pain. Patients also completed a questionnaire assessing satisfaction with surgical outcome. Physical function and disability were assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Any complications, including the need for further surgeries, were documented. Pearson correlation coefficients and Student t tests (with significance set at P < .05) were used to compare outcomes.

Results

Radiographic reduction of joint dislocation was achieved and maintained in 11 of the 12 patients at a mean follow-up of 35.5 months (range, 4-94 months). Extent of joint surface involvement, based on preoperative lateral radiographs, averaged 43% (range, 25%-75%). Although no direct articular reduction was performed, remodeling of the joint surface was consistently noted at follow-up (Figure 2). Mild radiographic degenerative changes were noted at final follow-up in 4 patients, and moderate changes were noted in 1 patient. Radiographic union was achieved in all cases, and no pin-tract infections were noted.

Mean AROM of the PIP joint at final follow-up was 84° (range, 50°-110°), with patients lacking a mean of 7° of full extension and achieving mean flexion of 91°. Mean PROM was 93° (range, 75°-110°). There was no correlation between extent of articular surface involvement and ROM. Furthermore, no correlation was found between time from injury to surgery and ROM. Patients regained full grip strength in the operative hand. At final follow-up, mean grip strength was 79.4 pounds in the operative hand and 79.6 pounds in the contralateral hand, demonstrating equal grip strengths bilaterally.

Patients overall had very low levels of pain; mean VAS score was 0.64 (range, 0-3). Mean QuickDASH score was 5.7 (range, 0-30), suggesting minimal functional impairment. One patient developed a malunion of the middle phalanx fracture resulting in a rotational deformity and required corrective osteotomy. This patient’s VAS score (3) and QuickDASH score (30) were significantly higher than those of the other patients in the study. No other complications were noted by final follow-up.

A higher level of patient satisfaction was found to be directly related to length of follow-up (P < .05). Satisfaction was inversely related to higher VAS score (P < .05) and higher QuickDASH score (P < .001). Pain at work correlated with lower satisfaction level (P < .05). There was no correlation between patient satisfaction and AROM or PROM.

Discussion

The results of this study demonstrate the efficacy of EBP in the treatment of dorsal PIP joint fracture-dislocations. EBP maintained joint dislocation reduction and allowed for early mobilization, which resulted in good ROM, minimal pain, and good functional outcomes. Of note, postoperative patient satisfaction correlated with pain but not with ROM. It is possible that EBP yielded sufficient functional ROM in all patients such that improvement beyond this threshold did not lead to further improvement in satisfaction. Hume and colleagues²³ found that mean PIP joint flexion of 60° is needed for activities of daily living. As mean PIP active flexion was 91° (range, 70°-105°) in the present study, it is possible that satisfaction did not correlate with ROM, as all 12 patients achieved active flexion of more than 60°. Despite the lack of correlation between ROM and satisfaction, early PIP joint mobilization is likely a key contributor to positive outcomes because of its significant role in cartilage healing.²⁴

Postoperative ROM in the present study is consistent with that in other reports of patients with PIP joint fracture-dislocations treated with EBP.^11,12,22 In a study by Inoue and Tamura,¹¹ 14 such patients had mean PIP ROM of 94° at a mean follow-up of 14 months. Viegas²² followed a series of 3 patients for a mean of 7 weeks. At final follow-up, their mean PIP arc of motion was 71°; they lacked 12° of full extension and achieved 83° of flexion. The larger PIP arc of motion (84°) found in the present study may be due to our significantly longer follow-up (35 months). Unlike us, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM. Our finding a lack of correlation may be a result of the significant amount of joint remodeling noted on follow-up radiographs.

Studies of transarticular pinning of PIP joints after dorsal PIP fracture-dislocations have reported outcomes similar to ours.^25,26 Newington and colleagues²⁵ evaluated 10 cases of transarticular pinning of the PIP joint and found mean arc of motion of 85° and equal grip strengths between injured and contralateral hands. In a series of 19 patients with PIP fracture-dislocations, Aladin and Davis²⁶ noted similar outcomes of transarticular K-wire fixation and ORIF. In both of their treatment groups, however, there was evidence of PIP joint incongruity and subluxation. Of note, PIP arc motion was lower in their study than in ours.

Recent studies have evaluated unstable PIP fracture-dislocations treated with both EBP and percutaneous reduction and pinning with a second K-wire.^13,27 At a mean follow-up of 18 months, Vitale and colleagues¹³ noted maintenance of concentric fracture reduction, good PIP ROM (mean range, 4°-93°), and low VAS and DASH scores (1.4 and 8, respectively). Waris and Alanen²⁷ noted mean PIP AROM of 83° and low VAS and DASH scores (1 and 4, respectively). The EBP technique used in the present study did not involve percutaneous fracture reduction but achieved equally good ROM and VAS and QuickDASH scores.

Clinical outcomes of EBP of PIP joint fracture-dislocations are also comparable to outcomes of more complex treatment methods.^{8-10,15-19,21,26,28-33} Dynamic distraction external fixation has led to equally good ROM (mean AROM, 80°-85°^15,16) and VAS scores, but with a higher incidence of pin-site infection.^14-17 ORIF of the intra-articular middle phalanx fracture has the advantage of obtaining a direct anatomical reduction, but clinical outcomes are similar to those in the present study (mean AROM, 70°; 78% pain-free⁹), and flexion contractures have been noted.^8-10 Furthermore, reduction of the fractured PIP joint articular surface has not been shown to be necessary for good outcomes.^16,34 This may be explained in part by PIP joint remodeling, which has been routinely observed on long-term follow-up by the senior authors of the present study. Hemi-hamate autografting and volar plate arthroplasty are other options that have had promising results in the treatment of acute and chronic unstable PIP fracture-dislocations.^18-21 However, the postoperative ROM (mean AROM, 61°-85°^18,21), VAS scores, and patient satisfaction (91% very satisfied²¹) of these operations are similar to those of EBP in the present study and may not justify the longer operative times and technical challenges associated with these techniques.

We believe that our study group’s 1 complication, a malunion that was treated with corrective osteotomy, resulted from lack of appreciation of the degree of injury. The teenaged female patient’s index finger PIP joint had a rotational malalignment that was not appreciated before or during surgery. After pinning and after ROM was restored, the index finger was observed crossing over the middle finger with digital flexion. The patient returned to the operating room for corrective osteotomy.

We recommend that surgeons assess alignment carefully, before and during surgery, when considering this technique. Although complications are rare, the technique is not for patients with rotational malalignment; ORIF may be more suitable in these cases. In addition, though EBP may be appropriate for pilon-type injuries, as it allows for early AROM, our procedure of choice for pilon fracture is dynamic external fixation, which in addition to allowing for AROM provides ligamentotaxis. In the event that a large volar articular fragment extends into the middle phalanx diaphysis, we typically proceed with ORIF through a volar shotgun approach. At our institution, injuries lasting more than 3 months are often treated with volar plate arthroplasty or hemi-hamate resurfacing. Finally, we believe that caution should be exercised when using this technique in patients with more than 50% articular involvement. In the present study, though we used this treatment in cases of up to 75% surface involvement, alternative techniques, such as hemi-hamate resurfacing arthroplasty, may provide a better volar bony buttress and limit the risk for recurrent instability. Despite its relative contraindications, our technique has been appropriate for more than 90% of the acute PIP fracture-dislocations we have seen.

This study expands on prior research by demonstrating good function, satisfaction, and pain outcomes of percutaneous EBP in the treatment of unstable dorsal PIP fracture-dislocations. In addition, this study demonstrated that the efficacy of EBP is similar to that of more complex and technically demanding methods of treatment. Our technique has the advantage of simplicity. It obviates the soft-tissue damage required for ORIF and more complex fixation techniques. Furthermore, use of this simple technique may save time and costs and lead to more reproducible outcomes.

One limitation of this study is its small sample size. It is possible that outcomes may have been different with a larger sample. Furthermore, we did not make a direct comparison with other treatment methods. To better determine the optimal treatment method for this fracture type, future studies should prospectively evaluate outcomes for multiple treatment modalities in a randomized fashion.

The proximal interphalangeal (PIP) joint plays a crucial role in hand function, accounting for an estimated 85% of the motion required to grasp an object.¹ The anatomy and biomechanics of the PIP joint, however, make it particularly prone to injury.^2,3 Dorsal PIP fracture-dislocations represent a subset of PIP injuries that often require surgical intervention.² The stability of these fracture-dislocations largely depends on the extent of articular involvement of the base of the middle phalanx. Fractures that involve less than 30% of the joint surface typically remain stable after reduction.^2,4,5 In cases in which involvement ranges from 30% to 50%, PIP joint stability is more tenuous, and more joint flexion is required to maintain concentric reduction. Fractures that involve more than 50% of the articular surface are unstable and require operative intervention.^2,5,6 Fractures that require more than 30° of flexion for reduction maintenance are generally considered unstable and may benefit from surgical intervention.²

The goals of treatment for this injury are to restore a stable, concentrically reduced joint and initiate early joint mobilization to prevent stiffness, pain, recurrent instability, and posttraumatic arthritis.^3,7 Numerous surgical interventions for unstable PIP fracture-dislocations have been proposed, including open reduction and internal fixation (ORIF),^8-10 extension-block pinning (EBP),^11-13 dynamic external fixation,^14-17 volar plate arthroplasty,^18,19 and hemi-hamate resurfacing arthroplasty.^20,21 Many of these techniques can be technically demanding and may require prolonged immobilization. EBP can be performed easily and efficiently and allows for early joint motion.

Extension-block pinning—placing a Kirschner wire (K-wire) into the head of the proximal phalanx at an angle that blocks PIP extension and prevents joint subluxation—was first described by Sugawa and colleagues¹² in 1979. In a study by Inoue and Tamura,¹¹ patients treated with EBP had a mean PIP range of motion (ROM) of 94° at a mean follow-up of 14 months. In a series of 3 case reports, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM in patients treated with EBP.

We conducted a study to expand on previous research on pain, function, and satisfaction outcomes in addition to ROM. We hypothesized that percutaneous EBP is an effective treatment for unstable dorsal PIP fracture-dislocations and has efficacy similar to that of more complex and technically demanding methods of treatment.

Materials and Methods

We retrospectively reviewed patient charts to identify candidates for this study. Inclusion criteria were unstable dorsal PIP fracture-dislocations treated with EBP and minimum 4-month follow-up. (Fracture-dislocations were deemed unstable if they involved at least 30% of the articular surface or required more than 30° of flexion for reduction maintenance.) Exclusion criteria were open injury, neurovascular or tendon injury, or any prior injury to the PIP joint.

Twelve patients (5 females, 7 males) treated over a 4-year period (2002–2006) met the inclusion criteria. Mean age was 30 years (range, 15-64 years). Each surgery was performed by Dr. Hagberg or Dr. Balk. Half the cases involved the dominant hand. Two small fingers, 4 ring fingers, 2 long fingers, and 4 index fingers were injured. The injuries were sustained in an all-terrain vehicle accident (n = 1), in falls (n = 2), while swimming (n = 1), or while playing softball (n = 3), football (n = 4), or soccer (n = 1). Mean time from injury to surgery was 7.5 days (range, 4-27 days). Extent of articular surface involvement of the base of the fractured middle phalanx was calculated using preoperatively obtained lateral radiographs.

Surgical intervention was performed in a reproducible fashion. All patients were treated with closed reduction of the PIP joint under fluoroscopic guidance. Before pinning, joint stability was assessed fluoroscopically both at rest and through an arc of motion. A single smooth 0.045-in K-wire was then inserted percutaneously into the distal and dorsal aspects of the proximal phalanx in retrograde fashion (Figure 1). During wire insertion, the distal interphalangeal joint was flexed to relax the intrinsic mechanism, and the central slip tendon was pierced just proximal to its insertion. We have not noted significant adhesion formation about the central slip with this technique, likely because of limited tendon excursion in this location. Stable joint reduction was confirmed with fluoroscopy. No attempt was made to reduce the intra-articular fracture at the base of the middle phalanx.

A therapy program was initiated 2 to 9 days after surgery. At the first postoperative visit, patients were allowed to perform active ROM (AROM) with the pin in place (Figure 1). K-wires were removed a mean of 25 days (range, 17-31 days) after surgery. A static dorsal block splint was then applied, and patients were encouraged to remove it several times per day for AROM between 20° and full flexion until 6 weeks after surgery. At that time, formal occupational therapy was commenced for another 6 weeks. If there was residual flexion contracture of the PIP joint, dynamic extension splinting was initiated after fracture consolidation.

Mean follow-up was 35.5 months (range, 4-94 months). Postoperative anteroposterior and lateral radiographs were used to evaluate maintenance of joint congruity, fracture union, remodeling, and evidence of degenerative changes. At final follow-up, grip strength of injured and contralateral hands was measured with a dynamometer (Jamar; Patterson Medical, Warrenville, Illinois). AROM and passive ROM (PROM) of the PIP joint was documented at follow-up visits. In addition, patients rated their pain on a 0-to-10 visual analog scale (VAS), with 0 representing no pain and 10 representing excruciating pain. Patients also completed a questionnaire assessing satisfaction with surgical outcome. Physical function and disability were assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Any complications, including the need for further surgeries, were documented. Pearson correlation coefficients and Student t tests (with significance set at P < .05) were used to compare outcomes.

Results

Radiographic reduction of joint dislocation was achieved and maintained in 11 of the 12 patients at a mean follow-up of 35.5 months (range, 4-94 months). Extent of joint surface involvement, based on preoperative lateral radiographs, averaged 43% (range, 25%-75%). Although no direct articular reduction was performed, remodeling of the joint surface was consistently noted at follow-up (Figure 2). Mild radiographic degenerative changes were noted at final follow-up in 4 patients, and moderate changes were noted in 1 patient. Radiographic union was achieved in all cases, and no pin-tract infections were noted.

Mean AROM of the PIP joint at final follow-up was 84° (range, 50°-110°), with patients lacking a mean of 7° of full extension and achieving mean flexion of 91°. Mean PROM was 93° (range, 75°-110°). There was no correlation between extent of articular surface involvement and ROM. Furthermore, no correlation was found between time from injury to surgery and ROM. Patients regained full grip strength in the operative hand. At final follow-up, mean grip strength was 79.4 pounds in the operative hand and 79.6 pounds in the contralateral hand, demonstrating equal grip strengths bilaterally.

Patients overall had very low levels of pain; mean VAS score was 0.64 (range, 0-3). Mean QuickDASH score was 5.7 (range, 0-30), suggesting minimal functional impairment. One patient developed a malunion of the middle phalanx fracture resulting in a rotational deformity and required corrective osteotomy. This patient’s VAS score (3) and QuickDASH score (30) were significantly higher than those of the other patients in the study. No other complications were noted by final follow-up.

A higher level of patient satisfaction was found to be directly related to length of follow-up (P < .05). Satisfaction was inversely related to higher VAS score (P < .05) and higher QuickDASH score (P < .001). Pain at work correlated with lower satisfaction level (P < .05). There was no correlation between patient satisfaction and AROM or PROM.

Discussion

The results of this study demonstrate the efficacy of EBP in the treatment of dorsal PIP joint fracture-dislocations. EBP maintained joint dislocation reduction and allowed for early mobilization, which resulted in good ROM, minimal pain, and good functional outcomes. Of note, postoperative patient satisfaction correlated with pain but not with ROM. It is possible that EBP yielded sufficient functional ROM in all patients such that improvement beyond this threshold did not lead to further improvement in satisfaction. Hume and colleagues²³ found that mean PIP joint flexion of 60° is needed for activities of daily living. As mean PIP active flexion was 91° (range, 70°-105°) in the present study, it is possible that satisfaction did not correlate with ROM, as all 12 patients achieved active flexion of more than 60°. Despite the lack of correlation between ROM and satisfaction, early PIP joint mobilization is likely a key contributor to positive outcomes because of its significant role in cartilage healing.²⁴

Postoperative ROM in the present study is consistent with that in other reports of patients with PIP joint fracture-dislocations treated with EBP.^11,12,22 In a study by Inoue and Tamura,¹¹ 14 such patients had mean PIP ROM of 94° at a mean follow-up of 14 months. Viegas²² followed a series of 3 patients for a mean of 7 weeks. At final follow-up, their mean PIP arc of motion was 71°; they lacked 12° of full extension and achieved 83° of flexion. The larger PIP arc of motion (84°) found in the present study may be due to our significantly longer follow-up (35 months). Unlike us, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM. Our finding a lack of correlation may be a result of the significant amount of joint remodeling noted on follow-up radiographs.

Studies of transarticular pinning of PIP joints after dorsal PIP fracture-dislocations have reported outcomes similar to ours.^25,26 Newington and colleagues²⁵ evaluated 10 cases of transarticular pinning of the PIP joint and found mean arc of motion of 85° and equal grip strengths between injured and contralateral hands. In a series of 19 patients with PIP fracture-dislocations, Aladin and Davis²⁶ noted similar outcomes of transarticular K-wire fixation and ORIF. In both of their treatment groups, however, there was evidence of PIP joint incongruity and subluxation. Of note, PIP arc motion was lower in their study than in ours.

Recent studies have evaluated unstable PIP fracture-dislocations treated with both EBP and percutaneous reduction and pinning with a second K-wire.^13,27 At a mean follow-up of 18 months, Vitale and colleagues¹³ noted maintenance of concentric fracture reduction, good PIP ROM (mean range, 4°-93°), and low VAS and DASH scores (1.4 and 8, respectively). Waris and Alanen²⁷ noted mean PIP AROM of 83° and low VAS and DASH scores (1 and 4, respectively). The EBP technique used in the present study did not involve percutaneous fracture reduction but achieved equally good ROM and VAS and QuickDASH scores.

Clinical outcomes of EBP of PIP joint fracture-dislocations are also comparable to outcomes of more complex treatment methods.^{8-10,15-19,21,26,28-33} Dynamic distraction external fixation has led to equally good ROM (mean AROM, 80°-85°^15,16) and VAS scores, but with a higher incidence of pin-site infection.^14-17 ORIF of the intra-articular middle phalanx fracture has the advantage of obtaining a direct anatomical reduction, but clinical outcomes are similar to those in the present study (mean AROM, 70°; 78% pain-free⁹), and flexion contractures have been noted.^8-10 Furthermore, reduction of the fractured PIP joint articular surface has not been shown to be necessary for good outcomes.^16,34 This may be explained in part by PIP joint remodeling, which has been routinely observed on long-term follow-up by the senior authors of the present study. Hemi-hamate autografting and volar plate arthroplasty are other options that have had promising results in the treatment of acute and chronic unstable PIP fracture-dislocations.^18-21 However, the postoperative ROM (mean AROM, 61°-85°^18,21), VAS scores, and patient satisfaction (91% very satisfied²¹) of these operations are similar to those of EBP in the present study and may not justify the longer operative times and technical challenges associated with these techniques.

We believe that our study group’s 1 complication, a malunion that was treated with corrective osteotomy, resulted from lack of appreciation of the degree of injury. The teenaged female patient’s index finger PIP joint had a rotational malalignment that was not appreciated before or during surgery. After pinning and after ROM was restored, the index finger was observed crossing over the middle finger with digital flexion. The patient returned to the operating room for corrective osteotomy.

We recommend that surgeons assess alignment carefully, before and during surgery, when considering this technique. Although complications are rare, the technique is not for patients with rotational malalignment; ORIF may be more suitable in these cases. In addition, though EBP may be appropriate for pilon-type injuries, as it allows for early AROM, our procedure of choice for pilon fracture is dynamic external fixation, which in addition to allowing for AROM provides ligamentotaxis. In the event that a large volar articular fragment extends into the middle phalanx diaphysis, we typically proceed with ORIF through a volar shotgun approach. At our institution, injuries lasting more than 3 months are often treated with volar plate arthroplasty or hemi-hamate resurfacing. Finally, we believe that caution should be exercised when using this technique in patients with more than 50% articular involvement. In the present study, though we used this treatment in cases of up to 75% surface involvement, alternative techniques, such as hemi-hamate resurfacing arthroplasty, may provide a better volar bony buttress and limit the risk for recurrent instability. Despite its relative contraindications, our technique has been appropriate for more than 90% of the acute PIP fracture-dislocations we have seen.

This study expands on prior research by demonstrating good function, satisfaction, and pain outcomes of percutaneous EBP in the treatment of unstable dorsal PIP fracture-dislocations. In addition, this study demonstrated that the efficacy of EBP is similar to that of more complex and technically demanding methods of treatment. Our technique has the advantage of simplicity. It obviates the soft-tissue damage required for ORIF and more complex fixation techniques. Furthermore, use of this simple technique may save time and costs and lead to more reproducible outcomes.

One limitation of this study is its small sample size. It is possible that outcomes may have been different with a larger sample. Furthermore, we did not make a direct comparison with other treatment methods. To better determine the optimal treatment method for this fracture type, future studies should prospectively evaluate outcomes for multiple treatment modalities in a randomized fashion.

The proximal interphalangeal (PIP) joint plays a crucial role in hand function, accounting for an estimated 85% of the motion required to grasp an object.¹ The anatomy and biomechanics of the PIP joint, however, make it particularly prone to injury.^2,3 Dorsal PIP fracture-dislocations represent a subset of PIP injuries that often require surgical intervention.² The stability of these fracture-dislocations largely depends on the extent of articular involvement of the base of the middle phalanx. Fractures that involve less than 30% of the joint surface typically remain stable after reduction.^2,4,5 In cases in which involvement ranges from 30% to 50%, PIP joint stability is more tenuous, and more joint flexion is required to maintain concentric reduction. Fractures that involve more than 50% of the articular surface are unstable and require operative intervention.^2,5,6 Fractures that require more than 30° of flexion for reduction maintenance are generally considered unstable and may benefit from surgical intervention.²

The goals of treatment for this injury are to restore a stable, concentrically reduced joint and initiate early joint mobilization to prevent stiffness, pain, recurrent instability, and posttraumatic arthritis.^3,7 Numerous surgical interventions for unstable PIP fracture-dislocations have been proposed, including open reduction and internal fixation (ORIF),^8-10 extension-block pinning (EBP),^11-13 dynamic external fixation,^14-17 volar plate arthroplasty,^18,19 and hemi-hamate resurfacing arthroplasty.^20,21 Many of these techniques can be technically demanding and may require prolonged immobilization. EBP can be performed easily and efficiently and allows for early joint motion.

Extension-block pinning—placing a Kirschner wire (K-wire) into the head of the proximal phalanx at an angle that blocks PIP extension and prevents joint subluxation—was first described by Sugawa and colleagues¹² in 1979. In a study by Inoue and Tamura,¹¹ patients treated with EBP had a mean PIP range of motion (ROM) of 94° at a mean follow-up of 14 months. In a series of 3 case reports, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM in patients treated with EBP.

We conducted a study to expand on previous research on pain, function, and satisfaction outcomes in addition to ROM. We hypothesized that percutaneous EBP is an effective treatment for unstable dorsal PIP fracture-dislocations and has efficacy similar to that of more complex and technically demanding methods of treatment.

Materials and Methods

We retrospectively reviewed patient charts to identify candidates for this study. Inclusion criteria were unstable dorsal PIP fracture-dislocations treated with EBP and minimum 4-month follow-up. (Fracture-dislocations were deemed unstable if they involved at least 30% of the articular surface or required more than 30° of flexion for reduction maintenance.) Exclusion criteria were open injury, neurovascular or tendon injury, or any prior injury to the PIP joint.

Twelve patients (5 females, 7 males) treated over a 4-year period (2002–2006) met the inclusion criteria. Mean age was 30 years (range, 15-64 years). Each surgery was performed by Dr. Hagberg or Dr. Balk. Half the cases involved the dominant hand. Two small fingers, 4 ring fingers, 2 long fingers, and 4 index fingers were injured. The injuries were sustained in an all-terrain vehicle accident (n = 1), in falls (n = 2), while swimming (n = 1), or while playing softball (n = 3), football (n = 4), or soccer (n = 1). Mean time from injury to surgery was 7.5 days (range, 4-27 days). Extent of articular surface involvement of the base of the fractured middle phalanx was calculated using preoperatively obtained lateral radiographs.

Surgical intervention was performed in a reproducible fashion. All patients were treated with closed reduction of the PIP joint under fluoroscopic guidance. Before pinning, joint stability was assessed fluoroscopically both at rest and through an arc of motion. A single smooth 0.045-in K-wire was then inserted percutaneously into the distal and dorsal aspects of the proximal phalanx in retrograde fashion (Figure 1). During wire insertion, the distal interphalangeal joint was flexed to relax the intrinsic mechanism, and the central slip tendon was pierced just proximal to its insertion. We have not noted significant adhesion formation about the central slip with this technique, likely because of limited tendon excursion in this location. Stable joint reduction was confirmed with fluoroscopy. No attempt was made to reduce the intra-articular fracture at the base of the middle phalanx.

A therapy program was initiated 2 to 9 days after surgery. At the first postoperative visit, patients were allowed to perform active ROM (AROM) with the pin in place (Figure 1). K-wires were removed a mean of 25 days (range, 17-31 days) after surgery. A static dorsal block splint was then applied, and patients were encouraged to remove it several times per day for AROM between 20° and full flexion until 6 weeks after surgery. At that time, formal occupational therapy was commenced for another 6 weeks. If there was residual flexion contracture of the PIP joint, dynamic extension splinting was initiated after fracture consolidation.

Mean follow-up was 35.5 months (range, 4-94 months). Postoperative anteroposterior and lateral radiographs were used to evaluate maintenance of joint congruity, fracture union, remodeling, and evidence of degenerative changes. At final follow-up, grip strength of injured and contralateral hands was measured with a dynamometer (Jamar; Patterson Medical, Warrenville, Illinois). AROM and passive ROM (PROM) of the PIP joint was documented at follow-up visits. In addition, patients rated their pain on a 0-to-10 visual analog scale (VAS), with 0 representing no pain and 10 representing excruciating pain. Patients also completed a questionnaire assessing satisfaction with surgical outcome. Physical function and disability were assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Any complications, including the need for further surgeries, were documented. Pearson correlation coefficients and Student t tests (with significance set at P < .05) were used to compare outcomes.

Results

Radiographic reduction of joint dislocation was achieved and maintained in 11 of the 12 patients at a mean follow-up of 35.5 months (range, 4-94 months). Extent of joint surface involvement, based on preoperative lateral radiographs, averaged 43% (range, 25%-75%). Although no direct articular reduction was performed, remodeling of the joint surface was consistently noted at follow-up (Figure 2). Mild radiographic degenerative changes were noted at final follow-up in 4 patients, and moderate changes were noted in 1 patient. Radiographic union was achieved in all cases, and no pin-tract infections were noted.

Mean AROM of the PIP joint at final follow-up was 84° (range, 50°-110°), with patients lacking a mean of 7° of full extension and achieving mean flexion of 91°. Mean PROM was 93° (range, 75°-110°). There was no correlation between extent of articular surface involvement and ROM. Furthermore, no correlation was found between time from injury to surgery and ROM. Patients regained full grip strength in the operative hand. At final follow-up, mean grip strength was 79.4 pounds in the operative hand and 79.6 pounds in the contralateral hand, demonstrating equal grip strengths bilaterally.

Patients overall had very low levels of pain; mean VAS score was 0.64 (range, 0-3). Mean QuickDASH score was 5.7 (range, 0-30), suggesting minimal functional impairment. One patient developed a malunion of the middle phalanx fracture resulting in a rotational deformity and required corrective osteotomy. This patient’s VAS score (3) and QuickDASH score (30) were significantly higher than those of the other patients in the study. No other complications were noted by final follow-up.

A higher level of patient satisfaction was found to be directly related to length of follow-up (P < .05). Satisfaction was inversely related to higher VAS score (P < .05) and higher QuickDASH score (P < .001). Pain at work correlated with lower satisfaction level (P < .05). There was no correlation between patient satisfaction and AROM or PROM.

Discussion

The results of this study demonstrate the efficacy of EBP in the treatment of dorsal PIP joint fracture-dislocations. EBP maintained joint dislocation reduction and allowed for early mobilization, which resulted in good ROM, minimal pain, and good functional outcomes. Of note, postoperative patient satisfaction correlated with pain but not with ROM. It is possible that EBP yielded sufficient functional ROM in all patients such that improvement beyond this threshold did not lead to further improvement in satisfaction. Hume and colleagues²³ found that mean PIP joint flexion of 60° is needed for activities of daily living. As mean PIP active flexion was 91° (range, 70°-105°) in the present study, it is possible that satisfaction did not correlate with ROM, as all 12 patients achieved active flexion of more than 60°. Despite the lack of correlation between ROM and satisfaction, early PIP joint mobilization is likely a key contributor to positive outcomes because of its significant role in cartilage healing.²⁴

Postoperative ROM in the present study is consistent with that in other reports of patients with PIP joint fracture-dislocations treated with EBP.^11,12,22 In a study by Inoue and Tamura,¹¹ 14 such patients had mean PIP ROM of 94° at a mean follow-up of 14 months. Viegas²² followed a series of 3 patients for a mean of 7 weeks. At final follow-up, their mean PIP arc of motion was 71°; they lacked 12° of full extension and achieved 83° of flexion. The larger PIP arc of motion (84°) found in the present study may be due to our significantly longer follow-up (35 months). Unlike us, Viegas²² noted an inverse relationship between extent of articular surface involvement and postoperative ROM. Our finding a lack of correlation may be a result of the significant amount of joint remodeling noted on follow-up radiographs.

Studies of transarticular pinning of PIP joints after dorsal PIP fracture-dislocations have reported outcomes similar to ours.^25,26 Newington and colleagues²⁵ evaluated 10 cases of transarticular pinning of the PIP joint and found mean arc of motion of 85° and equal grip strengths between injured and contralateral hands. In a series of 19 patients with PIP fracture-dislocations, Aladin and Davis²⁶ noted similar outcomes of transarticular K-wire fixation and ORIF. In both of their treatment groups, however, there was evidence of PIP joint incongruity and subluxation. Of note, PIP arc motion was lower in their study than in ours.

Recent studies have evaluated unstable PIP fracture-dislocations treated with both EBP and percutaneous reduction and pinning with a second K-wire.^13,27 At a mean follow-up of 18 months, Vitale and colleagues¹³ noted maintenance of concentric fracture reduction, good PIP ROM (mean range, 4°-93°), and low VAS and DASH scores (1.4 and 8, respectively). Waris and Alanen²⁷ noted mean PIP AROM of 83° and low VAS and DASH scores (1 and 4, respectively). The EBP technique used in the present study did not involve percutaneous fracture reduction but achieved equally good ROM and VAS and QuickDASH scores.

Clinical outcomes of EBP of PIP joint fracture-dislocations are also comparable to outcomes of more complex treatment methods.^{8-10,15-19,21,26,28-33} Dynamic distraction external fixation has led to equally good ROM (mean AROM, 80°-85°^15,16) and VAS scores, but with a higher incidence of pin-site infection.^14-17 ORIF of the intra-articular middle phalanx fracture has the advantage of obtaining a direct anatomical reduction, but clinical outcomes are similar to those in the present study (mean AROM, 70°; 78% pain-free⁹), and flexion contractures have been noted.^8-10 Furthermore, reduction of the fractured PIP joint articular surface has not been shown to be necessary for good outcomes.^16,34 This may be explained in part by PIP joint remodeling, which has been routinely observed on long-term follow-up by the senior authors of the present study. Hemi-hamate autografting and volar plate arthroplasty are other options that have had promising results in the treatment of acute and chronic unstable PIP fracture-dislocations.^18-21 However, the postoperative ROM (mean AROM, 61°-85°^18,21), VAS scores, and patient satisfaction (91% very satisfied²¹) of these operations are similar to those of EBP in the present study and may not justify the longer operative times and technical challenges associated with these techniques.

We believe that our study group’s 1 complication, a malunion that was treated with corrective osteotomy, resulted from lack of appreciation of the degree of injury. The teenaged female patient’s index finger PIP joint had a rotational malalignment that was not appreciated before or during surgery. After pinning and after ROM was restored, the index finger was observed crossing over the middle finger with digital flexion. The patient returned to the operating room for corrective osteotomy.

We recommend that surgeons assess alignment carefully, before and during surgery, when considering this technique. Although complications are rare, the technique is not for patients with rotational malalignment; ORIF may be more suitable in these cases. In addition, though EBP may be appropriate for pilon-type injuries, as it allows for early AROM, our procedure of choice for pilon fracture is dynamic external fixation, which in addition to allowing for AROM provides ligamentotaxis. In the event that a large volar articular fragment extends into the middle phalanx diaphysis, we typically proceed with ORIF through a volar shotgun approach. At our institution, injuries lasting more than 3 months are often treated with volar plate arthroplasty or hemi-hamate resurfacing. Finally, we believe that caution should be exercised when using this technique in patients with more than 50% articular involvement. In the present study, though we used this treatment in cases of up to 75% surface involvement, alternative techniques, such as hemi-hamate resurfacing arthroplasty, may provide a better volar bony buttress and limit the risk for recurrent instability. Despite its relative contraindications, our technique has been appropriate for more than 90% of the acute PIP fracture-dislocations we have seen.

This study expands on prior research by demonstrating good function, satisfaction, and pain outcomes of percutaneous EBP in the treatment of unstable dorsal PIP fracture-dislocations. In addition, this study demonstrated that the efficacy of EBP is similar to that of more complex and technically demanding methods of treatment. Our technique has the advantage of simplicity. It obviates the soft-tissue damage required for ORIF and more complex fixation techniques. Furthermore, use of this simple technique may save time and costs and lead to more reproducible outcomes.

One limitation of this study is its small sample size. It is possible that outcomes may have been different with a larger sample. Furthermore, we did not make a direct comparison with other treatment methods. To better determine the optimal treatment method for this fracture type, future studies should prospectively evaluate outcomes for multiple treatment modalities in a randomized fashion.

Soft-tissue complications are a known problem in the treatment of pilon fractures of the distal end of the tibia. These fractures typically occur as the result of a high-energy mechanism, and axial load and shear forces often lead to a severe soft-tissue injury. In many cases, these injuries may require additional procedures to provide adequate soft-tissue coverage. These procedures can include use of either a rotational muscle flap or a free flap transfer. In some cases, however, these flaps are not possible secondary to vascular compromise.

In this article, we report the case of a pilon fracture combined with severe soft-tissue injury and vascular compromise of the leg. A cross-leg fasciocutaneous flap was performed as a salvage procedure for coverage of the soft-tissue defect. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 23-year-old man sustained a left grade III open pilon fracture after a fall off a cherry picker. He was initially treated with irrigation and débridement of the open anteromedial wound, wound closure, application of external fixation, and open reduction and internal fixation (ORIF) of the concomitant comminuted fibular fracture. Operative fixation of the pilon was performed 3 weeks after injury, once skin and soft tissues were in acceptable condition (Figure 1). Skin closure was performed with 2-0 Vicryl sutures (Ethicon, Inc, Somerville, New Jersey) followed by 3-0 nylon skin sutures and No. 2 nylon retention sutures to reduce tension at the incision.

On postoperative day 17, the patient was found to have skin necrosis with exposed hardware over the medial laceration that had resulted from the open fracture (Figure 2). The wound measured 7×6 cm. The plastic surgery team was consulted, and a soft-tissue flap was recommended. Preoperative computed tomography angiogram (Figure 3) revealed 1 vessel runoff in the leg, constituting the peroneal artery, and a conventional angiogram confirmed this finding (Figure 4). Despite these findings, the patient was taken to the operating room 4 weeks after initial injury to try to find a vessel compatible with anastomosis. Intraoperative wound exploration confirmed no patent blood supply for local soft-tissue flap coverage. Therefore, the wound was irrigated and débrided, and a vacuum-assisted closure (VAC) dressing was applied despite exposed hardware and bone. A decision was then made to attempt a cross-leg flap as a salvage procedure, and VAC dressing therapy was continued for several weeks to prepare the recipient site (Figure 5).

Seven weeks after injury, the patient was taken to the operating room by the orthopedic surgery and plastic surgery teams. After débridement, a fasciocutaneous flap was raised from the middle third of the contralateral leg (Figure 6) based on a posterior tibial artery perforator. The flap, which measured 7×7 cm (sufficient to cover the defect), was raised from lateral to medial from the posterior aspect of the leg with the pedicle located on the medial aspect of the right leg. Flap placement was facilitated by flexing the left knee to 80°. The flap was sutured into place with 4-0 Vicryl deep sutures followed by 4-0 nylon and superficial sutures in an interrupted fashion (Figure 7). Rigid external fixation was then applied to both extremities, bridging them together in optimal position (Figure 8). This construct included 2 short bars that would elevate the patient’s heels off the bed to reduce the chance of heel decubiti. Although including the feet in the external fixator construct may help prevent equinus contracture, we splinted the ankles in neutral position immediately after surgery so that we could begin early range-of-motion (ROM) exercises of the ankles to prevent stiffness. Ankle ROM exercises were started once the flap incorporated, 3 weeks after placement of the external fixator. Lacking medical insurance coverage, the patient could not be admitted to a rehabilitation facility or receive home care. He lived independently and had no help at home, so he had to remain hospitalized after placement of the external fixator. While hospitalized, the surgical site was treated with frequent dressing changes, including use of bacitracin and nonadherent dressing.

After flap coverage and 4 weeks of bed rest, a base clamping test confirmed the flap was incorporated into the recipient bed. The patient was then returned to the operating room for removal of the external fixator and skin grafting of the donor site. After surgery, he was started on physical therapy, including exercises for bilateral hip, knee, and ankle ROM and strengthening of the lower extremities. Four months after initial injury, the fracture was healed, based on bone consolidation, seen on radiographs, that is consistent with other pilon fractures treated at our institution. Six months after external fixator removal, the patient was able to ambulate independently with minimal discomfort (Figure 9). Passive and active ankle ROM was 20° of dorsiflexion and 25° of plantarflexion, compared with 25° of dorsiflexion and 45° of plantarflexion on the contralateral extremity. Subtalar motion had some stiffness with a 10° arc, compared with a 25° arc on the contralateral extremity. On simple manual testing, the patient had 5/5 motor strength with dorsiflexion, plantarflexion, inversion, and eversion. He returned to full duty as a landscaper about 1 year after initial injury and had no recurrence of wound complications or infection.

Discussion

Fractures of the distal tibia are commonly known as pilon or plafond fractures. They represent up to 10% of all tibial fractures. The injury consists of an intra-articular fracture of the tibiotalar joint with varying degrees of proximal extension into the tibial metaphysis. The etiology is an axial load on the tibia with or without a rotational force.¹ Treatment is challenging. The literature includes many reports of wound and soft-tissue complications after ORIF. In 1969, Rüedi and Allgöwer² published recommendations that have become the standard for treatment of pilon fractures. Twelve percent of the 84 fractures included in their study were associated with wound complications. In 2004, Sirkin and colleagues³ suggested that wound problems associated with ORIF of pilon fractures may be caused by attempts at immediate fixation through swollen soft tissue. They postulated that staging the procedure and waiting for decreased soft-tissue swelling may reduce the incidence of wound complications. In their series, only 2.9% of closed pilon fractures and only 9.1% of open fractures had any wound complications, and none of their patients required skin grafts, rotation flaps, or free tissue transfers.

However, soft-tissue complications still remain a significant threat in the treatment of pilon fracture, and cases that require additional procedures for soft-tissue coverage are common. In some cases, wound necrosis may lead to below-knee amputation.⁴ There are several coverage options, including local rotational flaps using the soleus muscle^5,6 as well as free flaps using the latissimus dorsi, gracilis, or rectus abdominis muscles.⁷ These options require a sufficient blood supply to the region.

Many high-energy pilon fractures may be associated with vascular injury, and therefore flap survival may be compromised. We have reported such a case in the present article. Our patient’s preoperative angiogram indicated he had 1-vessel runoff to the distal leg—a situation incompatible with free tissue transfer. It is not clear whether this finding is secondary to trauma to the leg or is caused by an anatomical anomaly. Nevertheless, the poor vascularity posed a challenge to providing soft-tissue coverage. Cross-finger⁸ and cross-foot⁹ flaps have been described in upper and lower extremity injuries. In 2006, Zhao and colleagues¹⁰ reported on 5 patients with tibia and/or hardware exposure after operative fixation of tibia fractures. These patients had poor local soft tissue around the wound and therefore underwent cross-leg flap for coverage. It is not clear where the soft-tissue defects were located and whether any studies were performed to assess the local blood flow.

From our patient’s case, we learned that multiple factors should be considered when assessing such high-energy injuries. First, respecting the soft tissues is of paramount importance. Our initial management on presentation consisted of irrigation and débridement of the wound, fixation of the fibula, and application of an external fixator to allow for soft-tissue healing before definitive fixation of the pilon. Although ultimately the patient required soft-tissue coverage, soft-tissue healing and viability are important in preventing unnecessary soft-tissue procedures, and therefore we would not have handled our initial treatment differently.

Patient selection is also important. The ideal candidate for a cross-leg flap is a young, healthy person who is compliant and has a strong support system to help with activities of daily living. Unfortunately, because of financial issues and lack of home support, our patient remained hospitalized during his treatment course. For a patient who has support, it is possible to be discharged either home or to a rehabilitation facility once flap viability has been confirmed after surgery.

Another consideration is type of immobilization. Immobilization options include casting, use of Kirschner wires (K-wires), and use of rigid external fixation. For cross-leg flaps, external fixation is superior to casting and K-wires, as it provides a more rigid construct and easier access to the flap for serial evaluation. Further, it is easier for the patient to maintain personal hygiene, and it can provide heel rises to avoid pressure ulcers.

Conclusion

To our knowledge, there have been no reports of using a cross-leg flap for wound complications in high-energy pilon fractures. As already mentioned, many of these fractures may be associated with severe soft-tissue injury and may need flap coverage. A cross-leg flap with external fixation of both legs provides a limb salvage option with satisfactory patient outcomes.

Soft-tissue complications are a known problem in the treatment of pilon fractures of the distal end of the tibia. These fractures typically occur as the result of a high-energy mechanism, and axial load and shear forces often lead to a severe soft-tissue injury. In many cases, these injuries may require additional procedures to provide adequate soft-tissue coverage. These procedures can include use of either a rotational muscle flap or a free flap transfer. In some cases, however, these flaps are not possible secondary to vascular compromise.

In this article, we report the case of a pilon fracture combined with severe soft-tissue injury and vascular compromise of the leg. A cross-leg fasciocutaneous flap was performed as a salvage procedure for coverage of the soft-tissue defect. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 23-year-old man sustained a left grade III open pilon fracture after a fall off a cherry picker. He was initially treated with irrigation and débridement of the open anteromedial wound, wound closure, application of external fixation, and open reduction and internal fixation (ORIF) of the concomitant comminuted fibular fracture. Operative fixation of the pilon was performed 3 weeks after injury, once skin and soft tissues were in acceptable condition (Figure 1). Skin closure was performed with 2-0 Vicryl sutures (Ethicon, Inc, Somerville, New Jersey) followed by 3-0 nylon skin sutures and No. 2 nylon retention sutures to reduce tension at the incision.

On postoperative day 17, the patient was found to have skin necrosis with exposed hardware over the medial laceration that had resulted from the open fracture (Figure 2). The wound measured 7×6 cm. The plastic surgery team was consulted, and a soft-tissue flap was recommended. Preoperative computed tomography angiogram (Figure 3) revealed 1 vessel runoff in the leg, constituting the peroneal artery, and a conventional angiogram confirmed this finding (Figure 4). Despite these findings, the patient was taken to the operating room 4 weeks after initial injury to try to find a vessel compatible with anastomosis. Intraoperative wound exploration confirmed no patent blood supply for local soft-tissue flap coverage. Therefore, the wound was irrigated and débrided, and a vacuum-assisted closure (VAC) dressing was applied despite exposed hardware and bone. A decision was then made to attempt a cross-leg flap as a salvage procedure, and VAC dressing therapy was continued for several weeks to prepare the recipient site (Figure 5).

Seven weeks after injury, the patient was taken to the operating room by the orthopedic surgery and plastic surgery teams. After débridement, a fasciocutaneous flap was raised from the middle third of the contralateral leg (Figure 6) based on a posterior tibial artery perforator. The flap, which measured 7×7 cm (sufficient to cover the defect), was raised from lateral to medial from the posterior aspect of the leg with the pedicle located on the medial aspect of the right leg. Flap placement was facilitated by flexing the left knee to 80°. The flap was sutured into place with 4-0 Vicryl deep sutures followed by 4-0 nylon and superficial sutures in an interrupted fashion (Figure 7). Rigid external fixation was then applied to both extremities, bridging them together in optimal position (Figure 8). This construct included 2 short bars that would elevate the patient’s heels off the bed to reduce the chance of heel decubiti. Although including the feet in the external fixator construct may help prevent equinus contracture, we splinted the ankles in neutral position immediately after surgery so that we could begin early range-of-motion (ROM) exercises of the ankles to prevent stiffness. Ankle ROM exercises were started once the flap incorporated, 3 weeks after placement of the external fixator. Lacking medical insurance coverage, the patient could not be admitted to a rehabilitation facility or receive home care. He lived independently and had no help at home, so he had to remain hospitalized after placement of the external fixator. While hospitalized, the surgical site was treated with frequent dressing changes, including use of bacitracin and nonadherent dressing.

After flap coverage and 4 weeks of bed rest, a base clamping test confirmed the flap was incorporated into the recipient bed. The patient was then returned to the operating room for removal of the external fixator and skin grafting of the donor site. After surgery, he was started on physical therapy, including exercises for bilateral hip, knee, and ankle ROM and strengthening of the lower extremities. Four months after initial injury, the fracture was healed, based on bone consolidation, seen on radiographs, that is consistent with other pilon fractures treated at our institution. Six months after external fixator removal, the patient was able to ambulate independently with minimal discomfort (Figure 9). Passive and active ankle ROM was 20° of dorsiflexion and 25° of plantarflexion, compared with 25° of dorsiflexion and 45° of plantarflexion on the contralateral extremity. Subtalar motion had some stiffness with a 10° arc, compared with a 25° arc on the contralateral extremity. On simple manual testing, the patient had 5/5 motor strength with dorsiflexion, plantarflexion, inversion, and eversion. He returned to full duty as a landscaper about 1 year after initial injury and had no recurrence of wound complications or infection.

Discussion

Fractures of the distal tibia are commonly known as pilon or plafond fractures. They represent up to 10% of all tibial fractures. The injury consists of an intra-articular fracture of the tibiotalar joint with varying degrees of proximal extension into the tibial metaphysis. The etiology is an axial load on the tibia with or without a rotational force.¹ Treatment is challenging. The literature includes many reports of wound and soft-tissue complications after ORIF. In 1969, Rüedi and Allgöwer² published recommendations that have become the standard for treatment of pilon fractures. Twelve percent of the 84 fractures included in their study were associated with wound complications. In 2004, Sirkin and colleagues³ suggested that wound problems associated with ORIF of pilon fractures may be caused by attempts at immediate fixation through swollen soft tissue. They postulated that staging the procedure and waiting for decreased soft-tissue swelling may reduce the incidence of wound complications. In their series, only 2.9% of closed pilon fractures and only 9.1% of open fractures had any wound complications, and none of their patients required skin grafts, rotation flaps, or free tissue transfers.

However, soft-tissue complications still remain a significant threat in the treatment of pilon fracture, and cases that require additional procedures for soft-tissue coverage are common. In some cases, wound necrosis may lead to below-knee amputation.⁴ There are several coverage options, including local rotational flaps using the soleus muscle^5,6 as well as free flaps using the latissimus dorsi, gracilis, or rectus abdominis muscles.⁷ These options require a sufficient blood supply to the region.

Many high-energy pilon fractures may be associated with vascular injury, and therefore flap survival may be compromised. We have reported such a case in the present article. Our patient’s preoperative angiogram indicated he had 1-vessel runoff to the distal leg—a situation incompatible with free tissue transfer. It is not clear whether this finding is secondary to trauma to the leg or is caused by an anatomical anomaly. Nevertheless, the poor vascularity posed a challenge to providing soft-tissue coverage. Cross-finger⁸ and cross-foot⁹ flaps have been described in upper and lower extremity injuries. In 2006, Zhao and colleagues¹⁰ reported on 5 patients with tibia and/or hardware exposure after operative fixation of tibia fractures. These patients had poor local soft tissue around the wound and therefore underwent cross-leg flap for coverage. It is not clear where the soft-tissue defects were located and whether any studies were performed to assess the local blood flow.

From our patient’s case, we learned that multiple factors should be considered when assessing such high-energy injuries. First, respecting the soft tissues is of paramount importance. Our initial management on presentation consisted of irrigation and débridement of the wound, fixation of the fibula, and application of an external fixator to allow for soft-tissue healing before definitive fixation of the pilon. Although ultimately the patient required soft-tissue coverage, soft-tissue healing and viability are important in preventing unnecessary soft-tissue procedures, and therefore we would not have handled our initial treatment differently.

Patient selection is also important. The ideal candidate for a cross-leg flap is a young, healthy person who is compliant and has a strong support system to help with activities of daily living. Unfortunately, because of financial issues and lack of home support, our patient remained hospitalized during his treatment course. For a patient who has support, it is possible to be discharged either home or to a rehabilitation facility once flap viability has been confirmed after surgery.

Another consideration is type of immobilization. Immobilization options include casting, use of Kirschner wires (K-wires), and use of rigid external fixation. For cross-leg flaps, external fixation is superior to casting and K-wires, as it provides a more rigid construct and easier access to the flap for serial evaluation. Further, it is easier for the patient to maintain personal hygiene, and it can provide heel rises to avoid pressure ulcers.

Conclusion

To our knowledge, there have been no reports of using a cross-leg flap for wound complications in high-energy pilon fractures. As already mentioned, many of these fractures may be associated with severe soft-tissue injury and may need flap coverage. A cross-leg flap with external fixation of both legs provides a limb salvage option with satisfactory patient outcomes.

Soft-tissue complications are a known problem in the treatment of pilon fractures of the distal end of the tibia. These fractures typically occur as the result of a high-energy mechanism, and axial load and shear forces often lead to a severe soft-tissue injury. In many cases, these injuries may require additional procedures to provide adequate soft-tissue coverage. These procedures can include use of either a rotational muscle flap or a free flap transfer. In some cases, however, these flaps are not possible secondary to vascular compromise.

In this article, we report the case of a pilon fracture combined with severe soft-tissue injury and vascular compromise of the leg. A cross-leg fasciocutaneous flap was performed as a salvage procedure for coverage of the soft-tissue defect. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 23-year-old man sustained a left grade III open pilon fracture after a fall off a cherry picker. He was initially treated with irrigation and débridement of the open anteromedial wound, wound closure, application of external fixation, and open reduction and internal fixation (ORIF) of the concomitant comminuted fibular fracture. Operative fixation of the pilon was performed 3 weeks after injury, once skin and soft tissues were in acceptable condition (Figure 1). Skin closure was performed with 2-0 Vicryl sutures (Ethicon, Inc, Somerville, New Jersey) followed by 3-0 nylon skin sutures and No. 2 nylon retention sutures to reduce tension at the incision.

On postoperative day 17, the patient was found to have skin necrosis with exposed hardware over the medial laceration that had resulted from the open fracture (Figure 2). The wound measured 7×6 cm. The plastic surgery team was consulted, and a soft-tissue flap was recommended. Preoperative computed tomography angiogram (Figure 3) revealed 1 vessel runoff in the leg, constituting the peroneal artery, and a conventional angiogram confirmed this finding (Figure 4). Despite these findings, the patient was taken to the operating room 4 weeks after initial injury to try to find a vessel compatible with anastomosis. Intraoperative wound exploration confirmed no patent blood supply for local soft-tissue flap coverage. Therefore, the wound was irrigated and débrided, and a vacuum-assisted closure (VAC) dressing was applied despite exposed hardware and bone. A decision was then made to attempt a cross-leg flap as a salvage procedure, and VAC dressing therapy was continued for several weeks to prepare the recipient site (Figure 5).

Seven weeks after injury, the patient was taken to the operating room by the orthopedic surgery and plastic surgery teams. After débridement, a fasciocutaneous flap was raised from the middle third of the contralateral leg (Figure 6) based on a posterior tibial artery perforator. The flap, which measured 7×7 cm (sufficient to cover the defect), was raised from lateral to medial from the posterior aspect of the leg with the pedicle located on the medial aspect of the right leg. Flap placement was facilitated by flexing the left knee to 80°. The flap was sutured into place with 4-0 Vicryl deep sutures followed by 4-0 nylon and superficial sutures in an interrupted fashion (Figure 7). Rigid external fixation was then applied to both extremities, bridging them together in optimal position (Figure 8). This construct included 2 short bars that would elevate the patient’s heels off the bed to reduce the chance of heel decubiti. Although including the feet in the external fixator construct may help prevent equinus contracture, we splinted the ankles in neutral position immediately after surgery so that we could begin early range-of-motion (ROM) exercises of the ankles to prevent stiffness. Ankle ROM exercises were started once the flap incorporated, 3 weeks after placement of the external fixator. Lacking medical insurance coverage, the patient could not be admitted to a rehabilitation facility or receive home care. He lived independently and had no help at home, so he had to remain hospitalized after placement of the external fixator. While hospitalized, the surgical site was treated with frequent dressing changes, including use of bacitracin and nonadherent dressing.

After flap coverage and 4 weeks of bed rest, a base clamping test confirmed the flap was incorporated into the recipient bed. The patient was then returned to the operating room for removal of the external fixator and skin grafting of the donor site. After surgery, he was started on physical therapy, including exercises for bilateral hip, knee, and ankle ROM and strengthening of the lower extremities. Four months after initial injury, the fracture was healed, based on bone consolidation, seen on radiographs, that is consistent with other pilon fractures treated at our institution. Six months after external fixator removal, the patient was able to ambulate independently with minimal discomfort (Figure 9). Passive and active ankle ROM was 20° of dorsiflexion and 25° of plantarflexion, compared with 25° of dorsiflexion and 45° of plantarflexion on the contralateral extremity. Subtalar motion had some stiffness with a 10° arc, compared with a 25° arc on the contralateral extremity. On simple manual testing, the patient had 5/5 motor strength with dorsiflexion, plantarflexion, inversion, and eversion. He returned to full duty as a landscaper about 1 year after initial injury and had no recurrence of wound complications or infection.

Discussion

Fractures of the distal tibia are commonly known as pilon or plafond fractures. They represent up to 10% of all tibial fractures. The injury consists of an intra-articular fracture of the tibiotalar joint with varying degrees of proximal extension into the tibial metaphysis. The etiology is an axial load on the tibia with or without a rotational force.¹ Treatment is challenging. The literature includes many reports of wound and soft-tissue complications after ORIF. In 1969, Rüedi and Allgöwer² published recommendations that have become the standard for treatment of pilon fractures. Twelve percent of the 84 fractures included in their study were associated with wound complications. In 2004, Sirkin and colleagues³ suggested that wound problems associated with ORIF of pilon fractures may be caused by attempts at immediate fixation through swollen soft tissue. They postulated that staging the procedure and waiting for decreased soft-tissue swelling may reduce the incidence of wound complications. In their series, only 2.9% of closed pilon fractures and only 9.1% of open fractures had any wound complications, and none of their patients required skin grafts, rotation flaps, or free tissue transfers.

However, soft-tissue complications still remain a significant threat in the treatment of pilon fracture, and cases that require additional procedures for soft-tissue coverage are common. In some cases, wound necrosis may lead to below-knee amputation.⁴ There are several coverage options, including local rotational flaps using the soleus muscle^5,6 as well as free flaps using the latissimus dorsi, gracilis, or rectus abdominis muscles.⁷ These options require a sufficient blood supply to the region.

Many high-energy pilon fractures may be associated with vascular injury, and therefore flap survival may be compromised. We have reported such a case in the present article. Our patient’s preoperative angiogram indicated he had 1-vessel runoff to the distal leg—a situation incompatible with free tissue transfer. It is not clear whether this finding is secondary to trauma to the leg or is caused by an anatomical anomaly. Nevertheless, the poor vascularity posed a challenge to providing soft-tissue coverage. Cross-finger⁸ and cross-foot⁹ flaps have been described in upper and lower extremity injuries. In 2006, Zhao and colleagues¹⁰ reported on 5 patients with tibia and/or hardware exposure after operative fixation of tibia fractures. These patients had poor local soft tissue around the wound and therefore underwent cross-leg flap for coverage. It is not clear where the soft-tissue defects were located and whether any studies were performed to assess the local blood flow.

From our patient’s case, we learned that multiple factors should be considered when assessing such high-energy injuries. First, respecting the soft tissues is of paramount importance. Our initial management on presentation consisted of irrigation and débridement of the wound, fixation of the fibula, and application of an external fixator to allow for soft-tissue healing before definitive fixation of the pilon. Although ultimately the patient required soft-tissue coverage, soft-tissue healing and viability are important in preventing unnecessary soft-tissue procedures, and therefore we would not have handled our initial treatment differently.

Patient selection is also important. The ideal candidate for a cross-leg flap is a young, healthy person who is compliant and has a strong support system to help with activities of daily living. Unfortunately, because of financial issues and lack of home support, our patient remained hospitalized during his treatment course. For a patient who has support, it is possible to be discharged either home or to a rehabilitation facility once flap viability has been confirmed after surgery.

Another consideration is type of immobilization. Immobilization options include casting, use of Kirschner wires (K-wires), and use of rigid external fixation. For cross-leg flaps, external fixation is superior to casting and K-wires, as it provides a more rigid construct and easier access to the flap for serial evaluation. Further, it is easier for the patient to maintain personal hygiene, and it can provide heel rises to avoid pressure ulcers.

Conclusion

To our knowledge, there have been no reports of using a cross-leg flap for wound complications in high-energy pilon fractures. As already mentioned, many of these fractures may be associated with severe soft-tissue injury and may need flap coverage. A cross-leg flap with external fixation of both legs provides a limb salvage option with satisfactory patient outcomes.

Open treatment of ankle fractures is one of the most common procedures performed by orthopedic surgeons.¹ Among the younger patient population, ankle fractures represent a significant proportion of orthopedic injuries.² The reported incidence of illicit drug and alcohol use in the urban trauma population ranges from 36% to 86%,² and medical and anesthetic complications associated with illicit drug use have been well documented in surgical patients.² However, patients with a recent history of drug abuse may be subject to a separate but related set of complications of open treatment of ankle fractures.

The perioperative complications associated with open treatment of ankle fractures in patients with diabetes mellitus have been well described.^3-6 Similarly, previous studies have suggested that peripheral vascular disease, complicated diabetes, and smoking are risk factors for poor outcomes in patients who require open reduction and internal fixation (ORIF) in lower extremity trauma.^7-9 However, there are few data on the complications specifically associated with illicit drug use and orthopedic surgery. Properly identifying these high-risk groups and being cognizant of commonly associated complications are likely important in ensuring proper perioperative care and may alter follow-up protocols in these patients.

We conducted a study to identify the complications associated with open treatment of ankle fractures in patients who tested positive for illicit drugs on urine drug screen (UDS). We hypothesized that patients who had a history of positive UDS and underwent ORIF of an ankle fracture would have a higher incidence of major and minor complications.

Materials and Methods

After obtaining institutional review board approval, we retrospectively reviewed the cases of 142 patients who underwent open treatment of an ankle fracture between 2006 and 2010. Data sources included patient demographic information, radiographs, preoperative UDS, attending surgeons’ clinical office notes, and clinical laboratory data. Our institution’s standard protocol for ankle fractures was followed for all patients in the study. All patients were evaluated by an orthopedic physician, in either the emergency department or the office, during application of a well-padded Jones splint before surgery. Oral narcotic pain medication was routinely prescribed. All patients were seen, within 10 days of injury, for surgery planning. A board-certified orthopedic surgeon surgically stabilized the ankle fractures. The postoperative treatment regimen, per protocol, included non-weight-bearing in a padded Jones splint dressing; oral narcotic pain medication; physical therapy; and routine scheduled follow-up. In open fracture cases, patients were taken urgently to the operating room for irrigation and débridement with stabilization. Which treatment would be initially used—external fixation or ORIF—was determined on a case-by-case basis.

The sample consisted of adults (age, >18 years) who had undergone definitive ORIF of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture during the study period. Polytrauma patients, patients with external fixation as definitive treatment, and patients with nonoperative treatment were excluded. Before surgical management, all patients were tested for recent illicit drug use by UDS (standard protocol at our institution). UDS, measured for cocaine, marijuana, PCP (phencyclidine), opiates, and barbiturates, was obtained in the office setting or emergency department or on day of surgery. The patients were divided into 2 groups, positive and negative UDS. Patients with documented receipt of narcotic pain medication before UDS were excluded.

The outcomes identified as dependent variables included nonunion, malunion, superficial or deep infection, amputation, delay in treatment, days to healing, repeat surgery, long-term bracing, and loss to follow-up. A nonunion was defined as lasting longer than 9 months and not showing radiographic signs of progression toward healing for 3 consecutive months. These complications were identified with use of attending surgeon clinical progress notes, laboratory values, radiographic parameters, and inpatient readmissions/surgeries associated with these outcomes. Nonunion, malunion, superficial or deep infection, and amputation were then grouped as major complications and analyzed as pooled major complications.

The Fisher exact test was used to analyze categorical variables with respect to UDS. The Wilcoxon rank sum test was used to determine statistical significance for continuous variables. Univariate logistic regression examined both continuous and categorical variables to evaluate predictors for a selected outcome. Statistical significance was set a priori at P ≤ .05, with significant factors indicating an increase (or decrease) in the outcome variable being tested.

Results

We retrospectively reviewed the cases of 142 patients. Table 1 lists the number of cases by fracture type. Bimalleolar fractures were most common, accounting for 99 (69.8%) of the 142 cases. Isolated lateral malleolar fractures accounted for 16 cases (11.2%), and trimalleolar fractures accounted for 27 cases (19%).

Twenty-five (18%) of the 142 patients tested positive for illicit drugs. Mean age was 45.2 years for positive UDS patients and 41.5 years for negative UDS patients. Open fracture cases represented 4.3% of negative UDS patients and 16% of positive UDS patients. Fifty-two percent of positive UDS patients and 32% of negative UDS patients were also tobacco users. These data were statistically significant (P = .003) There were no significant differences in age, sex, incidence of diabetes, incidence of open fracture, or time to surgery between the groups (Table 2).

Incidence of nonunion was higher in positive UDS patients (n = 5; P = .01), as was incidence of deep infection (n = 4; P = .05) (Table 3).

Mean time to radiographic healing was 50.7 days in negative UDS patients and 82.8 days in positive UDS patients (P > .99). Incidence of nonunion was 3.5% in negative UDS patients and 20% in positive UDS patients (P = .01). There were no malunions in negative UDS patients and 2 malunions in positive UDS patients. Incidence of deep infections was 2.5% in negative UDS patients and 16% in positive UDS patients (P = .04). No significant differences were found in incidence of malunions, superficial infections, amputations, need for repeat surgery, continued bracing, or loss to follow-up.

Major complications were defined as superficial or deep infections, amputations, malunions, and nonunions. The rate of major complication was significantly (P = .03) higher in positive UDS patients (24.24%) than in negative UDS patients (7.69%) (Table 4).

Discussion

In the present study, we retrospectively reviewed the cases of patients treated with ORIF for varying types of ankle fractures. Important major and minor complications were analyzed. The overall incidence of major complications in negative UDS patients was only 7.69%, consistent with previously reported results in patients with ankle fractures.^6,10 However, a statistically significant (P = .03) increased incidence of major complications—an alarmingly high rate of almost 1 in 4—was found in positive UDS patients. Our results also demonstrated a significantly higher rate of nonunion and deep infection in positive UDS patients. Calculated odds ratios were 7.37 and 4.27 for nonunion and deep infection, respectively—arguably 2 of the most devastating postoperative complications in positive UDS patients.

Previous studies have found that open fractures, age, and medical comorbidities are significant predictors of short-term complications, such as wound healing, infection, persistent pain, and delayed union.^3-6 Levy and colleagues¹¹ examined the incidence of orthopedic trauma in positive UDS patients. These patients had orthopedic injuries that were more severe and required longer hospitalization. However, the study did not address patients with ankle fractures or the incidence of major complications. Diabetes and peripheral vascular disease are significant risk factors for many surgical procedures in orthopedic surgery.^3,7-9,12,13 Tight glycemic control and optimization of medical comorbidities decrease postoperative complications.^12,13 SooHoo and colleagues⁶ found that history of diabetes and history of peripheral vascular disease were significant predictors of short-term complications of mortality, infection, reoperation, and amputation. The rate of infection in the complicated diabetes group was statistically higher as well. The effect of illicit drug use was not analyzed in that study. We think the findings of the present study highlight the importance of screening for high-risk populations (eg, patients with diabetes, patients with peripheral vascular disease, drug abusers) before orthopedic surgery, especially during definitive treatment of ankle fracture.

Recently, Nåsell and colleagues¹⁰ found that a well-implemented smoking cessation program was associated with a statistically significant reduction in complications 6 and 12 weeks after surgery. The target treatment groups were patients who underwent major lower extremity and upper extremity orthopedic surgery. The most common surgery performed in the study was ORIF of ankle fractures. The authors concluded that a smoking cessation intervention program during the first 6 weeks after acute fracture surgery decreases the risk for postoperative complications. However, no recommendations were made for treating patients with other addictions, such as alcohol and illicit drug addictions.

To our knowledge, our study is the first to critically examine postoperative complications in ankle fracture patients with a history of illicit drug abuse as determined by preoperative positive UDS. These data suggest the importance of critically evaluating this patient population. The rates of deep infection, nonunion, and pooled major complications were all notable. Furthermore, compared with negative UDS patients, positive UDS patients were more than 7 times likely to develop a nonunion and more than 4 times likely to develop a deep infection. The reasons are likely multifactorial but may involve factors such as injury severity, poor nutrition, suboptimal living conditions, difficulty complying with weight-bearing restrictions, and, possibly, poor compliance with wound-care recommendations. Determining the influence of each factor was beyond the scope of this study. However, further investigation is warranted.

The difference in incidence of smoking between the 2 groups was statistically significant. As smoking has been well documented as contributing to poor wound and bone healing,^14-16 it is likely to have been a contributory factor. However, nicotine levels are not routinely part of UDS, and people who quit smoking typically take 7 to 10 days to demonstrate a measurable drop in cotinine levels. On the other hand, screening for drugs takes only a few minutes and can provide useful information during the preoperative period. It was suggested that positive UDS patients were significantly likely to be tobacco users as well.

The 2 groups were not significantly different with respect to mean follow-up time or loss to follow-up. Although mean follow-up was longer in negative UDS patients, the standard deviation was large in both groups. Given the positive UDS patients’ higher incidence of deep infection and nonunion, both of which typically prolong the course of treatment, the results were likely deceptive. Patients with a history of illicit drug use have confounding variables (eg, psychiatric disorders, financial strife) that make treatment compliance and follow-up difficult.¹⁷

Some of the weaknesses of this study are inherent to its retrospective design and limited sample size. Furthermore, patient satisfaction scores and ankle-specific outcome measures, such as AOFAS (American Orthopaedic Foot and Ankle Society) scores, were not considered. Prospective collection of data that include patient satisfaction scores and ankle-specific outcome measures would be optimal. Our current recommendation is to obtain preoperative UDS and illicit drug use history for all trauma patients. In addition, operating surgeons should exercise caution when caring for patients who test positive for illicit drugs.

Conclusion

We evaluated the incidence of complications experienced by positive UDS patients undergoing surgical treatment of ankle fractures. It is well documented that illicit drug users who receive general anesthesia have complications. However, little is known about the untoward effects of illicit drugs on postoperative complications. Furthermore, the efficacy of drug cessation programs in minimizing these complications has not been fully explored.

In conclusion, similar to patients with diabetes, patients with a history of recent illicit drug use, as evidenced by preoperative positive UDS, are at increased risk for complications during treatment for ankle fracture. These data suggest that practicing orthopedists should be more vigilant when caring for ankle fracture patients with preoperative positive UDS.

Open treatment of ankle fractures is one of the most common procedures performed by orthopedic surgeons.¹ Among the younger patient population, ankle fractures represent a significant proportion of orthopedic injuries.² The reported incidence of illicit drug and alcohol use in the urban trauma population ranges from 36% to 86%,² and medical and anesthetic complications associated with illicit drug use have been well documented in surgical patients.² However, patients with a recent history of drug abuse may be subject to a separate but related set of complications of open treatment of ankle fractures.

The perioperative complications associated with open treatment of ankle fractures in patients with diabetes mellitus have been well described.^3-6 Similarly, previous studies have suggested that peripheral vascular disease, complicated diabetes, and smoking are risk factors for poor outcomes in patients who require open reduction and internal fixation (ORIF) in lower extremity trauma.^7-9 However, there are few data on the complications specifically associated with illicit drug use and orthopedic surgery. Properly identifying these high-risk groups and being cognizant of commonly associated complications are likely important in ensuring proper perioperative care and may alter follow-up protocols in these patients.

We conducted a study to identify the complications associated with open treatment of ankle fractures in patients who tested positive for illicit drugs on urine drug screen (UDS). We hypothesized that patients who had a history of positive UDS and underwent ORIF of an ankle fracture would have a higher incidence of major and minor complications.

Materials and Methods

After obtaining institutional review board approval, we retrospectively reviewed the cases of 142 patients who underwent open treatment of an ankle fracture between 2006 and 2010. Data sources included patient demographic information, radiographs, preoperative UDS, attending surgeons’ clinical office notes, and clinical laboratory data. Our institution’s standard protocol for ankle fractures was followed for all patients in the study. All patients were evaluated by an orthopedic physician, in either the emergency department or the office, during application of a well-padded Jones splint before surgery. Oral narcotic pain medication was routinely prescribed. All patients were seen, within 10 days of injury, for surgery planning. A board-certified orthopedic surgeon surgically stabilized the ankle fractures. The postoperative treatment regimen, per protocol, included non-weight-bearing in a padded Jones splint dressing; oral narcotic pain medication; physical therapy; and routine scheduled follow-up. In open fracture cases, patients were taken urgently to the operating room for irrigation and débridement with stabilization. Which treatment would be initially used—external fixation or ORIF—was determined on a case-by-case basis.

The sample consisted of adults (age, >18 years) who had undergone definitive ORIF of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture during the study period. Polytrauma patients, patients with external fixation as definitive treatment, and patients with nonoperative treatment were excluded. Before surgical management, all patients were tested for recent illicit drug use by UDS (standard protocol at our institution). UDS, measured for cocaine, marijuana, PCP (phencyclidine), opiates, and barbiturates, was obtained in the office setting or emergency department or on day of surgery. The patients were divided into 2 groups, positive and negative UDS. Patients with documented receipt of narcotic pain medication before UDS were excluded.

The outcomes identified as dependent variables included nonunion, malunion, superficial or deep infection, amputation, delay in treatment, days to healing, repeat surgery, long-term bracing, and loss to follow-up. A nonunion was defined as lasting longer than 9 months and not showing radiographic signs of progression toward healing for 3 consecutive months. These complications were identified with use of attending surgeon clinical progress notes, laboratory values, radiographic parameters, and inpatient readmissions/surgeries associated with these outcomes. Nonunion, malunion, superficial or deep infection, and amputation were then grouped as major complications and analyzed as pooled major complications.

The Fisher exact test was used to analyze categorical variables with respect to UDS. The Wilcoxon rank sum test was used to determine statistical significance for continuous variables. Univariate logistic regression examined both continuous and categorical variables to evaluate predictors for a selected outcome. Statistical significance was set a priori at P ≤ .05, with significant factors indicating an increase (or decrease) in the outcome variable being tested.

Results

We retrospectively reviewed the cases of 142 patients. Table 1 lists the number of cases by fracture type. Bimalleolar fractures were most common, accounting for 99 (69.8%) of the 142 cases. Isolated lateral malleolar fractures accounted for 16 cases (11.2%), and trimalleolar fractures accounted for 27 cases (19%).

Twenty-five (18%) of the 142 patients tested positive for illicit drugs. Mean age was 45.2 years for positive UDS patients and 41.5 years for negative UDS patients. Open fracture cases represented 4.3% of negative UDS patients and 16% of positive UDS patients. Fifty-two percent of positive UDS patients and 32% of negative UDS patients were also tobacco users. These data were statistically significant (P = .003) There were no significant differences in age, sex, incidence of diabetes, incidence of open fracture, or time to surgery between the groups (Table 2).

Incidence of nonunion was higher in positive UDS patients (n = 5; P = .01), as was incidence of deep infection (n = 4; P = .05) (Table 3).

Mean time to radiographic healing was 50.7 days in negative UDS patients and 82.8 days in positive UDS patients (P > .99). Incidence of nonunion was 3.5% in negative UDS patients and 20% in positive UDS patients (P = .01). There were no malunions in negative UDS patients and 2 malunions in positive UDS patients. Incidence of deep infections was 2.5% in negative UDS patients and 16% in positive UDS patients (P = .04). No significant differences were found in incidence of malunions, superficial infections, amputations, need for repeat surgery, continued bracing, or loss to follow-up.

Major complications were defined as superficial or deep infections, amputations, malunions, and nonunions. The rate of major complication was significantly (P = .03) higher in positive UDS patients (24.24%) than in negative UDS patients (7.69%) (Table 4).

Discussion

In the present study, we retrospectively reviewed the cases of patients treated with ORIF for varying types of ankle fractures. Important major and minor complications were analyzed. The overall incidence of major complications in negative UDS patients was only 7.69%, consistent with previously reported results in patients with ankle fractures.^6,10 However, a statistically significant (P = .03) increased incidence of major complications—an alarmingly high rate of almost 1 in 4—was found in positive UDS patients. Our results also demonstrated a significantly higher rate of nonunion and deep infection in positive UDS patients. Calculated odds ratios were 7.37 and 4.27 for nonunion and deep infection, respectively—arguably 2 of the most devastating postoperative complications in positive UDS patients.

Previous studies have found that open fractures, age, and medical comorbidities are significant predictors of short-term complications, such as wound healing, infection, persistent pain, and delayed union.^3-6 Levy and colleagues¹¹ examined the incidence of orthopedic trauma in positive UDS patients. These patients had orthopedic injuries that were more severe and required longer hospitalization. However, the study did not address patients with ankle fractures or the incidence of major complications. Diabetes and peripheral vascular disease are significant risk factors for many surgical procedures in orthopedic surgery.^3,7-9,12,13 Tight glycemic control and optimization of medical comorbidities decrease postoperative complications.^12,13 SooHoo and colleagues⁶ found that history of diabetes and history of peripheral vascular disease were significant predictors of short-term complications of mortality, infection, reoperation, and amputation. The rate of infection in the complicated diabetes group was statistically higher as well. The effect of illicit drug use was not analyzed in that study. We think the findings of the present study highlight the importance of screening for high-risk populations (eg, patients with diabetes, patients with peripheral vascular disease, drug abusers) before orthopedic surgery, especially during definitive treatment of ankle fracture.

Recently, Nåsell and colleagues¹⁰ found that a well-implemented smoking cessation program was associated with a statistically significant reduction in complications 6 and 12 weeks after surgery. The target treatment groups were patients who underwent major lower extremity and upper extremity orthopedic surgery. The most common surgery performed in the study was ORIF of ankle fractures. The authors concluded that a smoking cessation intervention program during the first 6 weeks after acute fracture surgery decreases the risk for postoperative complications. However, no recommendations were made for treating patients with other addictions, such as alcohol and illicit drug addictions.

To our knowledge, our study is the first to critically examine postoperative complications in ankle fracture patients with a history of illicit drug abuse as determined by preoperative positive UDS. These data suggest the importance of critically evaluating this patient population. The rates of deep infection, nonunion, and pooled major complications were all notable. Furthermore, compared with negative UDS patients, positive UDS patients were more than 7 times likely to develop a nonunion and more than 4 times likely to develop a deep infection. The reasons are likely multifactorial but may involve factors such as injury severity, poor nutrition, suboptimal living conditions, difficulty complying with weight-bearing restrictions, and, possibly, poor compliance with wound-care recommendations. Determining the influence of each factor was beyond the scope of this study. However, further investigation is warranted.

The difference in incidence of smoking between the 2 groups was statistically significant. As smoking has been well documented as contributing to poor wound and bone healing,^14-16 it is likely to have been a contributory factor. However, nicotine levels are not routinely part of UDS, and people who quit smoking typically take 7 to 10 days to demonstrate a measurable drop in cotinine levels. On the other hand, screening for drugs takes only a few minutes and can provide useful information during the preoperative period. It was suggested that positive UDS patients were significantly likely to be tobacco users as well.

The 2 groups were not significantly different with respect to mean follow-up time or loss to follow-up. Although mean follow-up was longer in negative UDS patients, the standard deviation was large in both groups. Given the positive UDS patients’ higher incidence of deep infection and nonunion, both of which typically prolong the course of treatment, the results were likely deceptive. Patients with a history of illicit drug use have confounding variables (eg, psychiatric disorders, financial strife) that make treatment compliance and follow-up difficult.¹⁷

Some of the weaknesses of this study are inherent to its retrospective design and limited sample size. Furthermore, patient satisfaction scores and ankle-specific outcome measures, such as AOFAS (American Orthopaedic Foot and Ankle Society) scores, were not considered. Prospective collection of data that include patient satisfaction scores and ankle-specific outcome measures would be optimal. Our current recommendation is to obtain preoperative UDS and illicit drug use history for all trauma patients. In addition, operating surgeons should exercise caution when caring for patients who test positive for illicit drugs.

Conclusion

We evaluated the incidence of complications experienced by positive UDS patients undergoing surgical treatment of ankle fractures. It is well documented that illicit drug users who receive general anesthesia have complications. However, little is known about the untoward effects of illicit drugs on postoperative complications. Furthermore, the efficacy of drug cessation programs in minimizing these complications has not been fully explored.

In conclusion, similar to patients with diabetes, patients with a history of recent illicit drug use, as evidenced by preoperative positive UDS, are at increased risk for complications during treatment for ankle fracture. These data suggest that practicing orthopedists should be more vigilant when caring for ankle fracture patients with preoperative positive UDS.

Open treatment of ankle fractures is one of the most common procedures performed by orthopedic surgeons.¹ Among the younger patient population, ankle fractures represent a significant proportion of orthopedic injuries.² The reported incidence of illicit drug and alcohol use in the urban trauma population ranges from 36% to 86%,² and medical and anesthetic complications associated with illicit drug use have been well documented in surgical patients.² However, patients with a recent history of drug abuse may be subject to a separate but related set of complications of open treatment of ankle fractures.

The perioperative complications associated with open treatment of ankle fractures in patients with diabetes mellitus have been well described.^3-6 Similarly, previous studies have suggested that peripheral vascular disease, complicated diabetes, and smoking are risk factors for poor outcomes in patients who require open reduction and internal fixation (ORIF) in lower extremity trauma.^7-9 However, there are few data on the complications specifically associated with illicit drug use and orthopedic surgery. Properly identifying these high-risk groups and being cognizant of commonly associated complications are likely important in ensuring proper perioperative care and may alter follow-up protocols in these patients.

We conducted a study to identify the complications associated with open treatment of ankle fractures in patients who tested positive for illicit drugs on urine drug screen (UDS). We hypothesized that patients who had a history of positive UDS and underwent ORIF of an ankle fracture would have a higher incidence of major and minor complications.

Materials and Methods

After obtaining institutional review board approval, we retrospectively reviewed the cases of 142 patients who underwent open treatment of an ankle fracture between 2006 and 2010. Data sources included patient demographic information, radiographs, preoperative UDS, attending surgeons’ clinical office notes, and clinical laboratory data. Our institution’s standard protocol for ankle fractures was followed for all patients in the study. All patients were evaluated by an orthopedic physician, in either the emergency department or the office, during application of a well-padded Jones splint before surgery. Oral narcotic pain medication was routinely prescribed. All patients were seen, within 10 days of injury, for surgery planning. A board-certified orthopedic surgeon surgically stabilized the ankle fractures. The postoperative treatment regimen, per protocol, included non-weight-bearing in a padded Jones splint dressing; oral narcotic pain medication; physical therapy; and routine scheduled follow-up. In open fracture cases, patients were taken urgently to the operating room for irrigation and débridement with stabilization. Which treatment would be initially used—external fixation or ORIF—was determined on a case-by-case basis.

The sample consisted of adults (age, >18 years) who had undergone definitive ORIF of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture during the study period. Polytrauma patients, patients with external fixation as definitive treatment, and patients with nonoperative treatment were excluded. Before surgical management, all patients were tested for recent illicit drug use by UDS (standard protocol at our institution). UDS, measured for cocaine, marijuana, PCP (phencyclidine), opiates, and barbiturates, was obtained in the office setting or emergency department or on day of surgery. The patients were divided into 2 groups, positive and negative UDS. Patients with documented receipt of narcotic pain medication before UDS were excluded.

The outcomes identified as dependent variables included nonunion, malunion, superficial or deep infection, amputation, delay in treatment, days to healing, repeat surgery, long-term bracing, and loss to follow-up. A nonunion was defined as lasting longer than 9 months and not showing radiographic signs of progression toward healing for 3 consecutive months. These complications were identified with use of attending surgeon clinical progress notes, laboratory values, radiographic parameters, and inpatient readmissions/surgeries associated with these outcomes. Nonunion, malunion, superficial or deep infection, and amputation were then grouped as major complications and analyzed as pooled major complications.

The Fisher exact test was used to analyze categorical variables with respect to UDS. The Wilcoxon rank sum test was used to determine statistical significance for continuous variables. Univariate logistic regression examined both continuous and categorical variables to evaluate predictors for a selected outcome. Statistical significance was set a priori at P ≤ .05, with significant factors indicating an increase (or decrease) in the outcome variable being tested.

Results

We retrospectively reviewed the cases of 142 patients. Table 1 lists the number of cases by fracture type. Bimalleolar fractures were most common, accounting for 99 (69.8%) of the 142 cases. Isolated lateral malleolar fractures accounted for 16 cases (11.2%), and trimalleolar fractures accounted for 27 cases (19%).

Twenty-five (18%) of the 142 patients tested positive for illicit drugs. Mean age was 45.2 years for positive UDS patients and 41.5 years for negative UDS patients. Open fracture cases represented 4.3% of negative UDS patients and 16% of positive UDS patients. Fifty-two percent of positive UDS patients and 32% of negative UDS patients were also tobacco users. These data were statistically significant (P = .003) There were no significant differences in age, sex, incidence of diabetes, incidence of open fracture, or time to surgery between the groups (Table 2).

Incidence of nonunion was higher in positive UDS patients (n = 5; P = .01), as was incidence of deep infection (n = 4; P = .05) (Table 3).

Mean time to radiographic healing was 50.7 days in negative UDS patients and 82.8 days in positive UDS patients (P > .99). Incidence of nonunion was 3.5% in negative UDS patients and 20% in positive UDS patients (P = .01). There were no malunions in negative UDS patients and 2 malunions in positive UDS patients. Incidence of deep infections was 2.5% in negative UDS patients and 16% in positive UDS patients (P = .04). No significant differences were found in incidence of malunions, superficial infections, amputations, need for repeat surgery, continued bracing, or loss to follow-up.

Major complications were defined as superficial or deep infections, amputations, malunions, and nonunions. The rate of major complication was significantly (P = .03) higher in positive UDS patients (24.24%) than in negative UDS patients (7.69%) (Table 4).

Discussion

In the present study, we retrospectively reviewed the cases of patients treated with ORIF for varying types of ankle fractures. Important major and minor complications were analyzed. The overall incidence of major complications in negative UDS patients was only 7.69%, consistent with previously reported results in patients with ankle fractures.^6,10 However, a statistically significant (P = .03) increased incidence of major complications—an alarmingly high rate of almost 1 in 4—was found in positive UDS patients. Our results also demonstrated a significantly higher rate of nonunion and deep infection in positive UDS patients. Calculated odds ratios were 7.37 and 4.27 for nonunion and deep infection, respectively—arguably 2 of the most devastating postoperative complications in positive UDS patients.

Previous studies have found that open fractures, age, and medical comorbidities are significant predictors of short-term complications, such as wound healing, infection, persistent pain, and delayed union.^3-6 Levy and colleagues¹¹ examined the incidence of orthopedic trauma in positive UDS patients. These patients had orthopedic injuries that were more severe and required longer hospitalization. However, the study did not address patients with ankle fractures or the incidence of major complications. Diabetes and peripheral vascular disease are significant risk factors for many surgical procedures in orthopedic surgery.^3,7-9,12,13 Tight glycemic control and optimization of medical comorbidities decrease postoperative complications.^12,13 SooHoo and colleagues⁶ found that history of diabetes and history of peripheral vascular disease were significant predictors of short-term complications of mortality, infection, reoperation, and amputation. The rate of infection in the complicated diabetes group was statistically higher as well. The effect of illicit drug use was not analyzed in that study. We think the findings of the present study highlight the importance of screening for high-risk populations (eg, patients with diabetes, patients with peripheral vascular disease, drug abusers) before orthopedic surgery, especially during definitive treatment of ankle fracture.

Recently, Nåsell and colleagues¹⁰ found that a well-implemented smoking cessation program was associated with a statistically significant reduction in complications 6 and 12 weeks after surgery. The target treatment groups were patients who underwent major lower extremity and upper extremity orthopedic surgery. The most common surgery performed in the study was ORIF of ankle fractures. The authors concluded that a smoking cessation intervention program during the first 6 weeks after acute fracture surgery decreases the risk for postoperative complications. However, no recommendations were made for treating patients with other addictions, such as alcohol and illicit drug addictions.

To our knowledge, our study is the first to critically examine postoperative complications in ankle fracture patients with a history of illicit drug abuse as determined by preoperative positive UDS. These data suggest the importance of critically evaluating this patient population. The rates of deep infection, nonunion, and pooled major complications were all notable. Furthermore, compared with negative UDS patients, positive UDS patients were more than 7 times likely to develop a nonunion and more than 4 times likely to develop a deep infection. The reasons are likely multifactorial but may involve factors such as injury severity, poor nutrition, suboptimal living conditions, difficulty complying with weight-bearing restrictions, and, possibly, poor compliance with wound-care recommendations. Determining the influence of each factor was beyond the scope of this study. However, further investigation is warranted.

The difference in incidence of smoking between the 2 groups was statistically significant. As smoking has been well documented as contributing to poor wound and bone healing,^14-16 it is likely to have been a contributory factor. However, nicotine levels are not routinely part of UDS, and people who quit smoking typically take 7 to 10 days to demonstrate a measurable drop in cotinine levels. On the other hand, screening for drugs takes only a few minutes and can provide useful information during the preoperative period. It was suggested that positive UDS patients were significantly likely to be tobacco users as well.

The 2 groups were not significantly different with respect to mean follow-up time or loss to follow-up. Although mean follow-up was longer in negative UDS patients, the standard deviation was large in both groups. Given the positive UDS patients’ higher incidence of deep infection and nonunion, both of which typically prolong the course of treatment, the results were likely deceptive. Patients with a history of illicit drug use have confounding variables (eg, psychiatric disorders, financial strife) that make treatment compliance and follow-up difficult.¹⁷

Some of the weaknesses of this study are inherent to its retrospective design and limited sample size. Furthermore, patient satisfaction scores and ankle-specific outcome measures, such as AOFAS (American Orthopaedic Foot and Ankle Society) scores, were not considered. Prospective collection of data that include patient satisfaction scores and ankle-specific outcome measures would be optimal. Our current recommendation is to obtain preoperative UDS and illicit drug use history for all trauma patients. In addition, operating surgeons should exercise caution when caring for patients who test positive for illicit drugs.

Conclusion

We evaluated the incidence of complications experienced by positive UDS patients undergoing surgical treatment of ankle fractures. It is well documented that illicit drug users who receive general anesthesia have complications. However, little is known about the untoward effects of illicit drugs on postoperative complications. Furthermore, the efficacy of drug cessation programs in minimizing these complications has not been fully explored.

In conclusion, similar to patients with diabetes, patients with a history of recent illicit drug use, as evidenced by preoperative positive UDS, are at increased risk for complications during treatment for ankle fracture. These data suggest that practicing orthopedists should be more vigilant when caring for ankle fracture patients with preoperative positive UDS.

Chronic plantar fasciitis is a major health care problem worldwide and affects nearly 10% of the US population. Plantar fasciitis presents as heel pain in the mornings and usually gets better and then gets worse. Inflammation at the plantar fascia attachment causes acute and sometimes disabling pain. Chronic pain at the site can develop as time goes on because of long-standing inflammatory changes. Fibrotic tissues may develop at the site. On a continuum, symptoms may begin in an insidious phase and progress to chronic pain. Although most cases resolve with conservative care, the numerous treatments for refractory plantar fasciitis attest to the lack of consensus regarding these cases. The condition frustrates patient and physician alike.

Treatments for refractory plantar fasciitis include conservative measures, including rest, analgesics, walking orthosis, heel cup, night splint, walking boot, and then, in a standard and logical progression, cortisone or platelet-rich plasma injections. Improved magnetic resonance imaging and ultrasonographic imaging allow accurate localization of the pathologic process,^1-3 and this localization in turn provides an opportunity to deliver a more reliable and focused intervention, as in needle-guided therapy.⁴ Surgical procedures for plantar fasciitis have included open or endoscopically assisted plantar fasciectomies with or without gastrocnemius recession; these procedures have had varying results. The emerging goals for this condition are a minimally invasive percutaneous intervention that is safe, effective, and well-tolerated and has minimal morbidity and a low complication rate.

We conducted a prospective study in which patients were allowed either to continue with noninvasive treatment or to undergo focal aspiration and partial fasciotomy with an ultrasonic probe. Study inclusion criteria were plantar fasciitis symptoms lasting 12 months or longer. Exclusion criteria were unwillingness to participate in the study. Prior treatments, even surgeries, were not exclusionary.

Twelve patients with refractory plantar fasciitis lasting a mean of 19 months (minimum, 12 months; range, 12-24 months) chose the procedure. They all had failed conservative care, including physical therapy, casting, shockwave therapy, and invasive procedures such as injections and endoscopic partial releases. Four of the 12 had undergone an open or endoscopic partial release at a different institution but had experienced no improvement in symptoms.

Based on the study protocol, patients continued noninvasive care (night splint, stretching exercises) for 2 to 6 weeks after the initial visit. When this conservative care failed, they were offered focal partial fasciectomy with a percutaneous ultrasonic probe. American Orthopaedic Foot and Ankle Society (AOFAS) scores were obtained before and after surgery. Follow-up consisted of clinic visits 2 weeks after surgery and monthly thereafter. I saw all 12 patients 3 months after surgery (range, 11-14 weeks), and all 12 underwent postoperative physical therapy.

Technique

The TX1 Tissue Removal System (Tenex Health, Lake Forest, California) (Figure 1) consists of an energy module, a pump/suction cassette that provides irrigation and suction through a probe, and the probe itself, the TX1, which is the size of an 18-gauge needle and delivers ultrasonic energy. The cassette is inserted into the energy module, and the ultrasonic energy probe is primed so it will deliver the irrigation fluid, normal saline. The safety features of the energy module are such that no energy is expended unless the system is properly irrigating and aspirating the diseased tissue. Ultrasonic treatment may be performed in a clinical or ambulatory surgical center. The patient is placed supine on an operating table, on a clinical examining table, or, if in a cast room, on a cart. A pillow is placed under the distal tibia so the knees can flex slightly, and the patient is positioned so the feet are free of the edge of the bed or gurney (Figure 2).

The pathology is first confirmed by ultrasonography (Figures 3–5). The first step is to identify the calcaneus with the sensor along the long axis of the foot. Then the plantar fascia is visualized and followed along its long axis to the site of attachment at the medial tubercle. As the pathologic process involves the medial site of attachment, a transverse image may also be obtained to better understand the medial/lateral extent of the disease process. The ultrasonographic image of plantar fasciitis has been well characterized.^2,5 The pathology is visualized as an area of edema or of disruption of the linear appearance of the fascia as it attaches to the calcaneus. While the diagnosis is being confirmed, the optimal site for probe insertion should be considered based on the location of the pain and the localization of the pathology by the 2 orthogonal images.

The area is prepared as if for an injection and is squared off with sterile towels. Then the sensor is placed in the sterile sleeve. The area of maximum tenderness is again confirmed. Determining the location of the probe insertion site is a crucial step. We use the ultrasonic sensor in the longitudinal and transverse planes to direct the injection of a fast-acting local anesthetic to the medial aspect of the calcaneus. A skin wheal is created, and the fast-acting local anesthetic (3-4 mL) is injected into the region of the fascia pathology.

An 11-blade knife is used to create a site for the probe through the skin wheal at the medial aspect of the heel, in line with the pathology (Figure 6). The probe is then introduced through the puncture site and is identified, along with the pathology, with the sensor, which may be oriented transverse or longitudinal to the long axis of the foot.

Once the pathologic area is identified, the ultrasonic energy is delivered to the region by the probe, which is activated with a foot pedal, effectively releasing the pathologic tissue from its insertion at the medial tubercle of the calcaneus. The probe is moved in a linear fashion medially and laterally within the lesion across the site of attachment. Treatment continues until the entire soft-tissue lesion is addressed.

Postoperative Care

The wound or wounds are closed with a nylon stitch and Steri-Strip (3M, St. Paul, Minnesota) and covered with Tegaderm (3M) or similar dressing (Figure 7). A compressive dressing is applied. The dressing is removed in 2 to 3 days; the Steri-Strip and stitch are removed in 10 to 14 days. A walking boot is put on immediately after the procedure (most patients in this study already have a boot) and is worn for a few days, or until the symptoms have resolved. How long the boot is used is very much based on patient preference. Patients may continue stretching exercises at home, but there should be no high-impact activity. As-needed ice and analgesics are recommended for the first few days.

The 12 patients had a mean preoperative AOFAS score of 30 (range, 17-46) and a mean postoperative score of 88 (range, 25-92). By the 3-month postoperative visit, symptoms were resolved in 11 patients (no activity restricted by plantar fascia pain). On physical examination, 11 patients had no palpable tenderness at the site of preoperative pain. Pain relief was documented as having occurred between 5 and 13 weeks after treatment. One patient had bilateral procedures. One foot was treated, pain resolved by the 3-month postoperative visit, and the patient asked for the other foot to be treated. Three months after the second procedure, he had minimal non-activity-restricting pain. There were no postoperative infections or wound complications.

I phoned my patients during postoperative month 24. All 12 patients (13 feet) indicated they were essentially pain-free. None admitted to activity restriction or required over-the-counter pain medication. All indicated they were satisfied with the procedure and would have it again.

The refractory nature of plantar fasciitis, and the resistance to and unpredictability of current treatment options, is well known. Considerable efforts have been made to develop treatment guidelines and algorithms.⁶ A standard and logical treatment plan involves initial attempts with rest, analgesics, and a walking orthosis and then, if those fail, cortisone or platelet-rich plasma injections. Reluctance to perform surgery is well justified because of the unpredictability of the intervention. As might be expected, the utility of ultrasonography has been on the rise. The diagnostic value of ultrasonography, first recognized in the early 1970s, is of increasing importance.^7,8 Subsequent use of ultrasonographic imaging as guidance for various treatments, including percutaneous release, has also been recognized and documented.^4,9-12 The present article is the first to describe and document the outcome of using ultrasonic energy for percutaneous release of the diseased attachment of the plantar fascia.

This report is preliminary and was designed to alert the orthopedic community to a safe and promising treatment for a chronic, refractory condition. The safety and efficacy of this treatment are reflected in our experience and have been documented for tennis elbow as well.¹³

This study was limited by its single-surgeon and relatively small clinical experience. Nevertheless, the benefits of this novel technique—effectiveness, safety, tolerability, and rapid recovery—are encouraging enough to share at this time. Prospective randomized controlled studies are needed.

Conclusion

This is the first report of a plantar fascia partial release guided by ultrasonic energy delivered by a percutaneously inserted probe under local anesthesia. The procedure appears to be a safe, effective, well-tolerated treatment for a condition that is refractory to other options. More studies are needed to further validate the safety and efficacy of this innovative treatment modality.

Chronic plantar fasciitis is a major health care problem worldwide and affects nearly 10% of the US population. Plantar fasciitis presents as heel pain in the mornings and usually gets better and then gets worse. Inflammation at the plantar fascia attachment causes acute and sometimes disabling pain. Chronic pain at the site can develop as time goes on because of long-standing inflammatory changes. Fibrotic tissues may develop at the site. On a continuum, symptoms may begin in an insidious phase and progress to chronic pain. Although most cases resolve with conservative care, the numerous treatments for refractory plantar fasciitis attest to the lack of consensus regarding these cases. The condition frustrates patient and physician alike.

Treatments for refractory plantar fasciitis include conservative measures, including rest, analgesics, walking orthosis, heel cup, night splint, walking boot, and then, in a standard and logical progression, cortisone or platelet-rich plasma injections. Improved magnetic resonance imaging and ultrasonographic imaging allow accurate localization of the pathologic process,^1-3 and this localization in turn provides an opportunity to deliver a more reliable and focused intervention, as in needle-guided therapy.⁴ Surgical procedures for plantar fasciitis have included open or endoscopically assisted plantar fasciectomies with or without gastrocnemius recession; these procedures have had varying results. The emerging goals for this condition are a minimally invasive percutaneous intervention that is safe, effective, and well-tolerated and has minimal morbidity and a low complication rate.

We conducted a prospective study in which patients were allowed either to continue with noninvasive treatment or to undergo focal aspiration and partial fasciotomy with an ultrasonic probe. Study inclusion criteria were plantar fasciitis symptoms lasting 12 months or longer. Exclusion criteria were unwillingness to participate in the study. Prior treatments, even surgeries, were not exclusionary.

Twelve patients with refractory plantar fasciitis lasting a mean of 19 months (minimum, 12 months; range, 12-24 months) chose the procedure. They all had failed conservative care, including physical therapy, casting, shockwave therapy, and invasive procedures such as injections and endoscopic partial releases. Four of the 12 had undergone an open or endoscopic partial release at a different institution but had experienced no improvement in symptoms.

Based on the study protocol, patients continued noninvasive care (night splint, stretching exercises) for 2 to 6 weeks after the initial visit. When this conservative care failed, they were offered focal partial fasciectomy with a percutaneous ultrasonic probe. American Orthopaedic Foot and Ankle Society (AOFAS) scores were obtained before and after surgery. Follow-up consisted of clinic visits 2 weeks after surgery and monthly thereafter. I saw all 12 patients 3 months after surgery (range, 11-14 weeks), and all 12 underwent postoperative physical therapy.

Technique

The TX1 Tissue Removal System (Tenex Health, Lake Forest, California) (Figure 1) consists of an energy module, a pump/suction cassette that provides irrigation and suction through a probe, and the probe itself, the TX1, which is the size of an 18-gauge needle and delivers ultrasonic energy. The cassette is inserted into the energy module, and the ultrasonic energy probe is primed so it will deliver the irrigation fluid, normal saline. The safety features of the energy module are such that no energy is expended unless the system is properly irrigating and aspirating the diseased tissue. Ultrasonic treatment may be performed in a clinical or ambulatory surgical center. The patient is placed supine on an operating table, on a clinical examining table, or, if in a cast room, on a cart. A pillow is placed under the distal tibia so the knees can flex slightly, and the patient is positioned so the feet are free of the edge of the bed or gurney (Figure 2).

The pathology is first confirmed by ultrasonography (Figures 3–5). The first step is to identify the calcaneus with the sensor along the long axis of the foot. Then the plantar fascia is visualized and followed along its long axis to the site of attachment at the medial tubercle. As the pathologic process involves the medial site of attachment, a transverse image may also be obtained to better understand the medial/lateral extent of the disease process. The ultrasonographic image of plantar fasciitis has been well characterized.^2,5 The pathology is visualized as an area of edema or of disruption of the linear appearance of the fascia as it attaches to the calcaneus. While the diagnosis is being confirmed, the optimal site for probe insertion should be considered based on the location of the pain and the localization of the pathology by the 2 orthogonal images.

The area is prepared as if for an injection and is squared off with sterile towels. Then the sensor is placed in the sterile sleeve. The area of maximum tenderness is again confirmed. Determining the location of the probe insertion site is a crucial step. We use the ultrasonic sensor in the longitudinal and transverse planes to direct the injection of a fast-acting local anesthetic to the medial aspect of the calcaneus. A skin wheal is created, and the fast-acting local anesthetic (3-4 mL) is injected into the region of the fascia pathology.

An 11-blade knife is used to create a site for the probe through the skin wheal at the medial aspect of the heel, in line with the pathology (Figure 6). The probe is then introduced through the puncture site and is identified, along with the pathology, with the sensor, which may be oriented transverse or longitudinal to the long axis of the foot.

Once the pathologic area is identified, the ultrasonic energy is delivered to the region by the probe, which is activated with a foot pedal, effectively releasing the pathologic tissue from its insertion at the medial tubercle of the calcaneus. The probe is moved in a linear fashion medially and laterally within the lesion across the site of attachment. Treatment continues until the entire soft-tissue lesion is addressed.

Postoperative Care

The wound or wounds are closed with a nylon stitch and Steri-Strip (3M, St. Paul, Minnesota) and covered with Tegaderm (3M) or similar dressing (Figure 7). A compressive dressing is applied. The dressing is removed in 2 to 3 days; the Steri-Strip and stitch are removed in 10 to 14 days. A walking boot is put on immediately after the procedure (most patients in this study already have a boot) and is worn for a few days, or until the symptoms have resolved. How long the boot is used is very much based on patient preference. Patients may continue stretching exercises at home, but there should be no high-impact activity. As-needed ice and analgesics are recommended for the first few days.

The 12 patients had a mean preoperative AOFAS score of 30 (range, 17-46) and a mean postoperative score of 88 (range, 25-92). By the 3-month postoperative visit, symptoms were resolved in 11 patients (no activity restricted by plantar fascia pain). On physical examination, 11 patients had no palpable tenderness at the site of preoperative pain. Pain relief was documented as having occurred between 5 and 13 weeks after treatment. One patient had bilateral procedures. One foot was treated, pain resolved by the 3-month postoperative visit, and the patient asked for the other foot to be treated. Three months after the second procedure, he had minimal non-activity-restricting pain. There were no postoperative infections or wound complications.

I phoned my patients during postoperative month 24. All 12 patients (13 feet) indicated they were essentially pain-free. None admitted to activity restriction or required over-the-counter pain medication. All indicated they were satisfied with the procedure and would have it again.

The refractory nature of plantar fasciitis, and the resistance to and unpredictability of current treatment options, is well known. Considerable efforts have been made to develop treatment guidelines and algorithms.⁶ A standard and logical treatment plan involves initial attempts with rest, analgesics, and a walking orthosis and then, if those fail, cortisone or platelet-rich plasma injections. Reluctance to perform surgery is well justified because of the unpredictability of the intervention. As might be expected, the utility of ultrasonography has been on the rise. The diagnostic value of ultrasonography, first recognized in the early 1970s, is of increasing importance.^7,8 Subsequent use of ultrasonographic imaging as guidance for various treatments, including percutaneous release, has also been recognized and documented.^4,9-12 The present article is the first to describe and document the outcome of using ultrasonic energy for percutaneous release of the diseased attachment of the plantar fascia.

This report is preliminary and was designed to alert the orthopedic community to a safe and promising treatment for a chronic, refractory condition. The safety and efficacy of this treatment are reflected in our experience and have been documented for tennis elbow as well.¹³

This study was limited by its single-surgeon and relatively small clinical experience. Nevertheless, the benefits of this novel technique—effectiveness, safety, tolerability, and rapid recovery—are encouraging enough to share at this time. Prospective randomized controlled studies are needed.

Conclusion

This is the first report of a plantar fascia partial release guided by ultrasonic energy delivered by a percutaneously inserted probe under local anesthesia. The procedure appears to be a safe, effective, well-tolerated treatment for a condition that is refractory to other options. More studies are needed to further validate the safety and efficacy of this innovative treatment modality.

Chronic plantar fasciitis is a major health care problem worldwide and affects nearly 10% of the US population. Plantar fasciitis presents as heel pain in the mornings and usually gets better and then gets worse. Inflammation at the plantar fascia attachment causes acute and sometimes disabling pain. Chronic pain at the site can develop as time goes on because of long-standing inflammatory changes. Fibrotic tissues may develop at the site. On a continuum, symptoms may begin in an insidious phase and progress to chronic pain. Although most cases resolve with conservative care, the numerous treatments for refractory plantar fasciitis attest to the lack of consensus regarding these cases. The condition frustrates patient and physician alike.

Treatments for refractory plantar fasciitis include conservative measures, including rest, analgesics, walking orthosis, heel cup, night splint, walking boot, and then, in a standard and logical progression, cortisone or platelet-rich plasma injections. Improved magnetic resonance imaging and ultrasonographic imaging allow accurate localization of the pathologic process,^1-3 and this localization in turn provides an opportunity to deliver a more reliable and focused intervention, as in needle-guided therapy.⁴ Surgical procedures for plantar fasciitis have included open or endoscopically assisted plantar fasciectomies with or without gastrocnemius recession; these procedures have had varying results. The emerging goals for this condition are a minimally invasive percutaneous intervention that is safe, effective, and well-tolerated and has minimal morbidity and a low complication rate.

We conducted a prospective study in which patients were allowed either to continue with noninvasive treatment or to undergo focal aspiration and partial fasciotomy with an ultrasonic probe. Study inclusion criteria were plantar fasciitis symptoms lasting 12 months or longer. Exclusion criteria were unwillingness to participate in the study. Prior treatments, even surgeries, were not exclusionary.

Twelve patients with refractory plantar fasciitis lasting a mean of 19 months (minimum, 12 months; range, 12-24 months) chose the procedure. They all had failed conservative care, including physical therapy, casting, shockwave therapy, and invasive procedures such as injections and endoscopic partial releases. Four of the 12 had undergone an open or endoscopic partial release at a different institution but had experienced no improvement in symptoms.

Based on the study protocol, patients continued noninvasive care (night splint, stretching exercises) for 2 to 6 weeks after the initial visit. When this conservative care failed, they were offered focal partial fasciectomy with a percutaneous ultrasonic probe. American Orthopaedic Foot and Ankle Society (AOFAS) scores were obtained before and after surgery. Follow-up consisted of clinic visits 2 weeks after surgery and monthly thereafter. I saw all 12 patients 3 months after surgery (range, 11-14 weeks), and all 12 underwent postoperative physical therapy.

Technique

The TX1 Tissue Removal System (Tenex Health, Lake Forest, California) (Figure 1) consists of an energy module, a pump/suction cassette that provides irrigation and suction through a probe, and the probe itself, the TX1, which is the size of an 18-gauge needle and delivers ultrasonic energy. The cassette is inserted into the energy module, and the ultrasonic energy probe is primed so it will deliver the irrigation fluid, normal saline. The safety features of the energy module are such that no energy is expended unless the system is properly irrigating and aspirating the diseased tissue. Ultrasonic treatment may be performed in a clinical or ambulatory surgical center. The patient is placed supine on an operating table, on a clinical examining table, or, if in a cast room, on a cart. A pillow is placed under the distal tibia so the knees can flex slightly, and the patient is positioned so the feet are free of the edge of the bed or gurney (Figure 2).

The pathology is first confirmed by ultrasonography (Figures 3–5). The first step is to identify the calcaneus with the sensor along the long axis of the foot. Then the plantar fascia is visualized and followed along its long axis to the site of attachment at the medial tubercle. As the pathologic process involves the medial site of attachment, a transverse image may also be obtained to better understand the medial/lateral extent of the disease process. The ultrasonographic image of plantar fasciitis has been well characterized.^2,5 The pathology is visualized as an area of edema or of disruption of the linear appearance of the fascia as it attaches to the calcaneus. While the diagnosis is being confirmed, the optimal site for probe insertion should be considered based on the location of the pain and the localization of the pathology by the 2 orthogonal images.

The area is prepared as if for an injection and is squared off with sterile towels. Then the sensor is placed in the sterile sleeve. The area of maximum tenderness is again confirmed. Determining the location of the probe insertion site is a crucial step. We use the ultrasonic sensor in the longitudinal and transverse planes to direct the injection of a fast-acting local anesthetic to the medial aspect of the calcaneus. A skin wheal is created, and the fast-acting local anesthetic (3-4 mL) is injected into the region of the fascia pathology.

An 11-blade knife is used to create a site for the probe through the skin wheal at the medial aspect of the heel, in line with the pathology (Figure 6). The probe is then introduced through the puncture site and is identified, along with the pathology, with the sensor, which may be oriented transverse or longitudinal to the long axis of the foot.

Once the pathologic area is identified, the ultrasonic energy is delivered to the region by the probe, which is activated with a foot pedal, effectively releasing the pathologic tissue from its insertion at the medial tubercle of the calcaneus. The probe is moved in a linear fashion medially and laterally within the lesion across the site of attachment. Treatment continues until the entire soft-tissue lesion is addressed.

Postoperative Care

The wound or wounds are closed with a nylon stitch and Steri-Strip (3M, St. Paul, Minnesota) and covered with Tegaderm (3M) or similar dressing (Figure 7). A compressive dressing is applied. The dressing is removed in 2 to 3 days; the Steri-Strip and stitch are removed in 10 to 14 days. A walking boot is put on immediately after the procedure (most patients in this study already have a boot) and is worn for a few days, or until the symptoms have resolved. How long the boot is used is very much based on patient preference. Patients may continue stretching exercises at home, but there should be no high-impact activity. As-needed ice and analgesics are recommended for the first few days.

The 12 patients had a mean preoperative AOFAS score of 30 (range, 17-46) and a mean postoperative score of 88 (range, 25-92). By the 3-month postoperative visit, symptoms were resolved in 11 patients (no activity restricted by plantar fascia pain). On physical examination, 11 patients had no palpable tenderness at the site of preoperative pain. Pain relief was documented as having occurred between 5 and 13 weeks after treatment. One patient had bilateral procedures. One foot was treated, pain resolved by the 3-month postoperative visit, and the patient asked for the other foot to be treated. Three months after the second procedure, he had minimal non-activity-restricting pain. There were no postoperative infections or wound complications.

I phoned my patients during postoperative month 24. All 12 patients (13 feet) indicated they were essentially pain-free. None admitted to activity restriction or required over-the-counter pain medication. All indicated they were satisfied with the procedure and would have it again.

The refractory nature of plantar fasciitis, and the resistance to and unpredictability of current treatment options, is well known. Considerable efforts have been made to develop treatment guidelines and algorithms.⁶ A standard and logical treatment plan involves initial attempts with rest, analgesics, and a walking orthosis and then, if those fail, cortisone or platelet-rich plasma injections. Reluctance to perform surgery is well justified because of the unpredictability of the intervention. As might be expected, the utility of ultrasonography has been on the rise. The diagnostic value of ultrasonography, first recognized in the early 1970s, is of increasing importance.^7,8 Subsequent use of ultrasonographic imaging as guidance for various treatments, including percutaneous release, has also been recognized and documented.^4,9-12 The present article is the first to describe and document the outcome of using ultrasonic energy for percutaneous release of the diseased attachment of the plantar fascia.

This report is preliminary and was designed to alert the orthopedic community to a safe and promising treatment for a chronic, refractory condition. The safety and efficacy of this treatment are reflected in our experience and have been documented for tennis elbow as well.¹³

This study was limited by its single-surgeon and relatively small clinical experience. Nevertheless, the benefits of this novel technique—effectiveness, safety, tolerability, and rapid recovery—are encouraging enough to share at this time. Prospective randomized controlled studies are needed.

Conclusion

This is the first report of a plantar fascia partial release guided by ultrasonic energy delivered by a percutaneously inserted probe under local anesthesia. The procedure appears to be a safe, effective, well-tolerated treatment for a condition that is refractory to other options. More studies are needed to further validate the safety and efficacy of this innovative treatment modality.

Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,¹ nerve damage,² tendon damage,³ cartilage damage from heat transfer⁴) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.^5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface⁷ and skin burns related to overheated arthroscopic fluid.⁸

In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.

The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.

The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.

After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.

Discussion

Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.

Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin⁷ and overheating of the arthroscopy fluid.^5,6,8 Huang and colleagues⁸ reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).⁶ There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.⁸

Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues⁷ described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao⁹ reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.⁹ Skin burns secondary to use of skin antiseptics have been reported,¹⁰ but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.¹¹

Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.^12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.¹⁴ Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.^12,13

To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.

Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,¹ nerve damage,² tendon damage,³ cartilage damage from heat transfer⁴) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.^5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface⁷ and skin burns related to overheated arthroscopic fluid.⁸

In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.

The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.

The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.

After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.

Discussion

Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.

Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin⁷ and overheating of the arthroscopy fluid.^5,6,8 Huang and colleagues⁸ reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).⁶ There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.⁸

Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues⁷ described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao⁹ reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.⁹ Skin burns secondary to use of skin antiseptics have been reported,¹⁰ but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.¹¹

Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.^12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.¹⁴ Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.^12,13

To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.

Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,¹ nerve damage,² tendon damage,³ cartilage damage from heat transfer⁴) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.^5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface⁷ and skin burns related to overheated arthroscopic fluid.⁸

In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.

The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.

The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.

After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.

Discussion

Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.

Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin⁷ and overheating of the arthroscopy fluid.^5,6,8 Huang and colleagues⁸ reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).⁶ There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.⁸

Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues⁷ described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao⁹ reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.⁹ Skin burns secondary to use of skin antiseptics have been reported,¹⁰ but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.¹¹

Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.^12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.¹⁴ Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.^12,13

To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.