High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures

Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. The minimum followup was 3 months (mean, 25 months; range, 3–68 months). Twenty-four patients (39%) had fractures of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup; however, with the limited power the detection rates were similar without and with the protocol. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. A protocol including computed tomography of the ankle may detect more injuries in a larger study

Complications of Recombinant Human BMP-2 for Treating Complex Tibial Plateau Fractures: A Preliminary Report

Bone morphogenic proteins (BMPs) are potent osteoinductive agents. Their use in fracture surgery is still being studied and the clinical indications are evolving. Heterotopic bone after BMP use in spine surgery is a known complication. While some literature describes the ability of BMP to enhance fracture healing, few articles describe complications of BMP. In tibial plateau fractures, after elevating the cartilage en mass, a subchondral void may be created in these fractures. Structural support provided by bone void-filling agents can be augmented with osteoinduction achieved by BMP. We asked whether heterotopic bone formation would occur more frequently with BMP-2 when used in tibial plateau fractures and whether BMP-2 enhanced the ability to maintain surgically restored subchondral bone integrity. Heterotopic bone developed more frequently in patients receiving BMP (10 of 17) than in patients not receiving BMP (one of 23). Four patients receiving BMP and no patients not receiving BMP underwent removal of heterotopic bone. Maintenance of subchondral bone integrity was similar without and with the use of BMP. BMP is a potent osteoinductive agent; however, when used for an off-label indication in periarticular situations, complications such as heterotopic bone are common and increase reoperation rates