SUPPLEMENT ARTICLE
Softer Tissue Issues in Orthopaedic Trauma
Aaron Nauth, MD, MSc,* Kenneth A. Egol, MD,† Timothy Walden, BS, MS,‡ Martin Boyer, MD,§
Jeffrey Anglen, MD,║ and Henry M. Broekhuyse, MD¶
Summary: There are number of significant issues outside of the
bone and/or fracture that are important to consider in the treatment of
orthopaedic trauma. Joint contractures, heterotopic bone formation,
managing a traumatized soft-tissue envelope or substantial soft-
tissue defects represent a few of these important issues. This article
Downloaded from http://journals.lww.com/jorthotrauma by BhDMf5ePHKbH4TTImqenVBZZxeh5YHRLKo7Ovk8NR5tqLn5kYlyQ/iG0RtDXZl/ECbpTavY5ehU= on 12/08/2019
reviews these issues, including the best available evidence on how to
manage them.
Key Words: joint contracture, heterotopic ossification, pilon frac-
ture, tibial plateau fracture, open fracture
(J Orthop Trauma 2019;33:S30–S33)
JOINT CONTRACTURES AFTER INTRA-
ARTICULAR FRACTURE SURGERY: WHERE ARE
WE NOW?
Post-traumatic joint contracture is a significant problem
that impacts the outcome of intra-articular fracture surgery. It
can affect any joint, but is most commonly found in the
elbow, knee, and hip. Contractures can be classified as either
intrinsic (eg, intra-articular adhesion, articular malalignment,
and loss of articular cartilage) or extrinsic (eg, capsular and
ligamentous contracture, heterotopic ossification (HO), extra-
articular malunion, and skin contracture). There is a multitude
of etiologies and associations with post-traumatic joint
contractures, including open fractures, burns, spinal cord
injury, prolonged immobilization, and patient compliance.
Structural changes in the joint capsule after trauma can
contribute significantly to contracture. These changes include
thickening of the capsule (with increases in collagen types I,
III, and V), increased collagen cross-linking, and disorga-
nized fiber orientation.1 Increased migration of lymphocytic
cells leads to a profibrotic environment with increases in
Accepted for publication February 15, 2019.
From the *Orthopaedic Division, Department of Surgery, St. Michael’s Hos-
pital, University of Toronto, Toronto, ON, Canada; †Department of Ortho-
pedic Surgery, NYU School of Medicine, NYU Langone Health, NYU
Langone Orthopedic Hospital, New York, NY; ‡Donald and Barbara Zuck-
er School of Medicine at Hofstra/Northwell, Hempstead, NY; §Department
of Orthopedic Surgery, Washington University School of Medicine, St.
Louis, MO; ║Hughston Clinic Orthopaedic Trauma, Nashville, TN; and
¶Department of Orthopaedic Surgery, University of British Columbia, Van-
couver, BC, Canada.
M. Boyer receives royalties from Wolters Kluwer, CRC Press, and is the
President Elect for ASSH. The remaining authors report no conflict of
interest.
Reprints: Aaron Nauth, MD, Department of Surgery, St. Michael’s Hospital,
University of Toronto, 55 Queen St, Suite 800, Toronto, ON, Canada
M5C 1R6 (e-mail: nautha@smh.ca).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001471
S30 | www.jorthotrauma.com J Orthop Trauma  Volume 33, Number 6 Supplement, June 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
tumor necrosis factor-a (TNF-a), transforming growth fac-
tor-b1 (TGF-b1), fibronectin ED-A, and matrix metallopro-
teinases (MMP-1,2,9,13,15). The key cell involved is the
myofibroblast. Myofibroblasts are specialized fibroblasts that
are characterized by their well-developed contractile appara-
tus that links intracellular stress fibers to the extracellular
matrix (ECM). Their activation and proliferation depends
on mechanical stresses and growth factor signaling. The abil-
ity of these cells to sustain contractile forces in tissue over
time and synthesize new ECM can lead to a positive feedback
loop of generated tension and deposition of ECM that alters
the tension and mechanical properties of native tissues.2 My-
ofibroblasts have been shown to be elevated in pathologic
fibrotic conditions and have been demonstrated to be elevated
in the joint capsule tissue in contractures in both humans and
animals.1 In addition, their numbers have been inversely
related to range of motion of the affected joint.3
Treatment and Outcomes of Specific Joints
The treatment of elbow contractures is generally
directed at obtaining a 100-degree motion arc of the joint.
Nonoperative treatment is typically attempted for less than
6 months and involves splinting in either a static progressive
or dynamic fashion. Operative intervention is considered
when nonoperative means have been exhausted. Arthroscopic
contracture release is technically challenging but can be
useful for simple, intrinsic contractures. It is generally
contraindicated in the face of previous nerve transposition,
severe contracture, or extrinsic causes. However, a pro-
spective study on arthroscopic lysis for extrinsic joint
contracture on 54 patients demonstrated significant improve-
ments with a final arc of motion of 124 6 22.7 degrees at 2-
year follow-up.4 Open treatment allows for mobilization and
identification of nerves, removal of hardware and excision of
heterotopic bone, as well as the treatment of more complex
contractures. Prospective studies on open elbow contracture
release have demonstrated significant gains in range of
motion arc (42–52 degrees), with 1 study demonstrating that
88/103 of patients ultimately achieved a flexion/extension arc
greater than 100 degrees.5
Extension contractures of the knee are typically caused
by posterior impingement, anterior adhesions, soft-tissue
retractions, or patella baja, whereas flexion contractures are
typically caused by anterior impingement, contracture of the
posterior joint capsule, gastrocnemius, and/or anterior
cruciate ligament/posterior cruciate ligament. Operative treat-
ments for knee contracture include arthroscopic release for
flexion with/without extension contracture, open quadriceps
release for extra-articular extension contracture, tibial tubercle
J Orthop Trauma  Volume 33, Number 6 Supplement, June 2019
osteotomy for extension contracture with patella baja, and
posterior capsule release for flexion contracture. Although
studies of both arthroscopic and open contracture release by
quadricepsplasty have demonstrated good results with signif-
icant improvement in range of motion, comparisons of the 2
have shown arthroscopic arthrolysis to have better results and
better postoperative final joint range of motion (105 6 18
degrees vs. 91 6 20 degrees).6
In summary, joint contracture is a problem that
continues to affect patients following trauma and intra-
articular surgery. Several risk factors are well defined, and
the myofibroblast has been identified as the pathognomonic
cellular component of interest. At present, the mainstay of
treatment is operative contracture release when conservative
methods are unsuccessful. Future treatment strategies may be
aimed at prevention or the targeting of cellular mechanisms.
STAGED VERSUS EARLY DEFINITIVE FIXATION
OF HIGH-ENERGY TIBIAL PLATEAU AND PLA-
FOND FRACTURES: WHAT IS BEST FOR THE
SOFT TISSUES AND THE PATIENT?
Bicondylar tibial plateau fractures and pilon fractures
commonly result from a high-energy injury mechanism and are
frequently associated with significant insult to the surrounding
soft-tissue envelope. Although excellent outcomes and low
complication rates were reported in early case series where low-
energy pilon fractures were managed with open reduction and
internal fixation, application of this management to high-energy
pilon and plateau fractures resulted in significantly worse
outcomes and high complication rates.7,8 Many case series re-
ported in the 1990s described complication rates up to 50% or
higher, primarily the result of wound-healing problems and
deep infection. The high rate of occurrence of these complica-
tions was attributed to performing surgery through the compro-
mised soft-tissue envelope that exists immediately following the
high-energy injury mechanisms associated with these injuries.
Implementation of a staged management protocol for
treatment of complex pilon fractures was described in 1999
by Sirkin.7 In that case series of 56 patients with OTA/AO
C type fractures, the average time from application of
external fixation to definitive ORIF was 13 days, and there
was a significant improvement on wound complication rate
when compared with previous reports of early definitive
ORIF. The staged management of high-energy proximal
tibia fractures was described by Egol in 2005,8 in a case
series of 67 patients with OTA/AO A, B, and C type frac-
tures. In that series, the average time from application of
external fixation to definitive ORIF was 15 days, and the
overall incidence of infection or wound problems was 5%.
Subsequent to the reporting of these early studies more
than a decade ago, many other case series have continued
to show improved outcomes and reduced complication
rates after implementation of staged management protocols
for high-energy tibial plateau and pilon fractures. For this
reason, staged management for these injuries has become
widely adopted and is the “standard of care” in most cases
for these injuries.
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Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Softer Tissue Issues
In contrast to this, several recent retrospective cohort
studies have shown that early definitive fixation of high-
energy tibial plateau and plafond fractures can be performed
safely with outcomes and complication rates comparable to
those achieved with staged management protocols.9–11 These
studies point to several factors which seem to be integral to
obtaining improved results with early definitive fixation
including: careful selection of patients appropriate for early
care based on assessment of the soft-tissue envelope, injury to
surgery time typically less than 48 hours, avoidance of tradi-
tional single-incision approaches, and the use of minimally
invasive plate osteosynthesis techniques. Early definitive fix-
ation also has several advantages over the use of a staged
management protocol including: greater ease in obtaining a
surgical reduction and perhaps less complexity when per-
forming the definitive fixation procedure, avoidance of com-
plications related to pin site infection, and significant cost
savings (due to reduced length of hospitalization and avoid-
ance of the implant costs associated with the use of external
fixator components).12
In summary, patients with high-energy tibial plateau
and plafond fractures who present with a clearly compro-
mised soft-tissue envelope (typically demonstrated by severe
soft-tissue swelling, bruising, and blistering) are at high risk
of surgical wound complications and infection when managed
with early definitive fracture fixation. A large body of
evidence has demonstrated that these injuries are best
managed with a staged treatment protocol. However, early
definitive fracture management can be performed with an
acceptably low risk of complications in appropriately selected
cases, by experienced surgeons, using contemporary surgical
techniques, and provides the advantages of lower total cost of
care, decreased length of hospital stay, technically easier
surgery, and less postoperative joint stiffness.
SOFT-TISSUE COVERAGE AFTER OPEN TIBIA
FRACTURES: TIMING AND FLAP SELECTION
Orthopaedic trauma surgeons are accustomed to pro-
viding soft-tissue coverage for traumatic wounds in their
trauma patients requiring bony fixation. It is our assertion that
anatomical knowledge, appropriate careful surgical tech-
nique, and preoperative assessment of the vascularity and
compliance of the soft tissues can lead any capable ortho-
paedic trauma surgeon to do their own muscle or fasciocuta-
neous soft-tissue coverage in the absence of any
microsurgical training. It is necessary for the surgeon to be
able to assess the wound and its capacity to heal in the
absence of surgical intervention, to be able to identify all
options for the coverage of a complex wound, and to be able
to choose the most appropriate option given the “personality”
of the defect.
Five questions are posed. First, where is the defect?
This will allow the surgeon to determine what adjacent local
tissue is available that has a reliable enough blood supply that
can be used as a local flap for adjacent coverage. For
example, a pedicled latissimus dorsi muscle may be used to
cover wound about the shoulder girdle. Second, what is at the
base of the defect? If there is periosteum or peritenon
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Nauth et al
covering the bone or tendon respectively, a skin graft may be
appropriate. However, absence of well vascularized tissue at
the depths of a traumatic wound will preclude use of
nonvascularized coverage options. In addition, it may be ill-
advised to use skin only in the coverage of bone, tendon, or
neurovascular structures. Third, does the wound need to be
covered? This question speaks to the potential for secondary
intention wound healing and the possibility that functionally
this may lead to appropriate and desirable outcome absent any
further surgical intervention. This is the case when well-
perfused muscle or dense regular connective tissue is present
at the base of the wound and secondary intention healing in a
healthy patient might be expected. Fourth, what local tissue is
available? Again, this speaks to the ability to examine local
tissues for their compliance, mobility, and perfusion that they
may be moved to cover adjacent open wounds. Fifth and
finally, if no local tissue is available, what distant tissue is
suitable? If distant tissue is required, it is unlikely that an
orthopaedic trauma surgeon (absent further training in soft-
tissue coverage procedures) would attempt to provide this
service to the patient.
A local flap of fascia and skin, or muscle, is considered
when the defect cannot or should not be closed primarily,
should not be allowed to heal secondarily, and cannot
support a split-thickness or full-thickness skin graft. These
are the perforator-based flaps that are either axial or island in
design, or keystone flaps, which are a type of advancement
flap containing perforators within the flap perimeter so that
they are not truly “random.” Medial or lateral gastrocnemius
muscle flaps that are perfused by the medial or lateral sural
arteries, respectively, or peroneus brevis flaps that are per-
fused by the distal branch of the peroneal artery are examples
of this type of local flap. The vascular supply to the soleus
muscle is slightly more variable and prone to disruption and
as such should not be used on an intermittent or infrequent
basis.
The concept of a “perforator” is useful to understand. A
perforator is a triad of 1 central artery and 2 veins that orig-
inates from a named longitudinally running arteriovenous
bundle to pierce the fascia and supply the skin and subcuta-
neous tissue.13 Knowledge of the location of these perforator
vessels and the ability to predict the likelihood of encounter-
ing these vessels enables the surgeon to plan incisions accord-
ingly and to move adjacent tissue reliably given that perfusion
from a well-defined perforator vessel triad can be counted on
for reliable vascular supply to the flap. Propeller flaps, based
on 1 perforator, or keystone flaps, based on more than one
perforator, can be moved as a fasciocutaneous flap to cover
adjacent tissue. These are especially useful in the middle and
distal aspect of the lower extremity where the posterior tibial
artery, peroneal artery, medial and lateral sural arteries, and
anterior tibial arteries have well-delineated and well-
described perforator anatomy.
In the absence of local tissue, free tissue transfer can be
attempted. Although there is a wide variety of available tissue
types and a large amount of composite tissue can be made
available for transfer, these operations are lengthy, expensive,
cause functional disability at the donor site, and are
technically demanding. The experience of Godina et al has
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J Orthop Trauma  Volume 33, Number 6 Supplement, June 2019
led us to attempt early coverage of severely traumatized
extremities;14,15 however, with the advent of negative pres-
sure wound dressings, there has been a recent tendency
toward extending the period between the initial trauma
debridement and the provision of free tissue coverage. At
present, the debate remains unsettled. However, soft-tissue
coverage within the first 10 days might prove to be reason-
able. In addition, there is ongoing debate about the usefulness
of negative pressure wound therapy as a reliable ongoing
method to treat open tibia fractures.16,17 It may be that as
orthopaedic trauma surgeons become more facile with the
above described soft-tissue coverage procedures, the need
for lengthy negative pressure wound therapy either as an
inpatient or outpatient will be mitigated somewhat. At pres-
ent, the indications are evolving.
HETEROTOPIC OSSIFICATION—STATE OF
THE ART
HO is the pathologic process of benign bone formation
in soft tissues of the body where bone is not generally formed.
The bone formation occurs through enchondral ossification
in a manner similar to the process of fracture healing. HO
occurs in rare genetic disorders, including fibrodysplasia
ossificans progressiva, the study of which has given us some
understanding of the process. It also occurs after some central
nervous system injuries, such as closed-head trauma or spinal
cord injury; after burns or electrical shocks; after muscular
contusion; after amputation due to military blast injury; and
after some fractures and dislocations, particularly injuries of
the hip, elbow, and shoulder. The development of HO
requires an inducing agent or stimulus, the presence of a
potentially osteogenic stem cell, and a “permissive environ-
ment,” which is generally provided by local inflammation.
In post-traumatic HO, such as that after surgical
treatment, stem cell differentiation begins within 16 hours of
the surgery, it appears radiographically by 3–6 weeks, and
reaches maximal extent by 12 weeks. HO can be a complica-
tion of surgical treatment and occurs commonly after posterior
or extensile approaches to the hip. High-grade HO of the hip,
although less than 20% of total HO cases, can cause pain,
restricted motion or anklyosis, and muscle or nerve entrapment.
HO in the amputated extremity can cause ulceration and diffi-
culty with prosthetic use. The actual incidence of postsurgical
HO varies between series, but a systematic literature review
covering .15,000 hips published in 2002 found a 51% inci-
dence after acetabular fracture surgery, with 19% high-grade
cases.18 Many risk factors in addition to surgical approach have
been suggested, but recent literature has focused on length of
stay in the intensive care unit and the need for prolonged
mechanical ventilation. Once it forms, the only treatment for
persistently symptomatic HO is surgical excision, a process
which can be complicated and bloody. Previous recommenda-
tions to delay excision until bone scans were cold or alkaline
phosphatase is normal have been largely discredited.
Suggested prophylaxis for HO after hip surgery has
included vague references to “gentle surgical technique” or
excision of the gluteus minimus (poorly supported in the
literature), the use of nonsteroidal anti-inflammatory
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 33, Number 6 Supplement, June 2019
medications (NSAIDs), primarily indomethacin, the use of
bisphosphonates, and external beam radiation treatment,
which can be performed in a single dose either before or
within 72 hours after surgery. Bisphosphonates seem to delay
mineralization of osteoid but do not reduce its formation.
There is controversy in the literature regarding the effective-
ness of indomethacin treatment, with studies that support a
positive effect and those which do not. A 2009 systematic
review comparing indomethacin with radiation reviewed 5
studies and suggested that radiation was superior to oral indo-
methacin for preventing HO.19 Radiation therapy does have
risks including local impairment of fracture or wound healing
and the very rare induction of sarcoma. Indomethacin treat-
ment increases the risk of nonunion in posterior wall fractures
and in associated long bone fractures.20,21
The indications for prophylaxis remain controversial.
Most trauma surgeons avoid the use of prophylaxis in
uncomplicated surgical cases when treating acetabular or
elbow fractures, provided there are no specific risk factors
for HO development (eg, delay to surgery, central nervous
system injury, and prolonged mechanical ventilation). In the
presence of risk factors for HO development, the benefits of
HO prophylaxis must be weighed against the potential risks of
treatment (primarily nonunion). Many trauma surgeons will
select either NSAID prophylaxis or radiation therapy based on
the specific risk profile of their patient in these select instances.
Secondary prophylaxis of either NSAIDs or radiation is
routinely used after surgical excision of HO, which is generally
performed after fracture healing is largely complete.
Recent studies suggest an important role of peripheral
sensory nerves as the source of osteogenic precursor cells
from the neural crest and creation of an HO-favorable
environment by release of substance P, calcitonin gene-
related peptide, brown adipocyte-like cells, and the activation
of local mast cells.22 This fascinating area of research has
opened new therapeutic possibilities.
CONCLUSIONS
There are number of issues aside from the bony injury
and the direct management of the fracture which substantially
impact outcomes in orthopaedic trauma. Joint contractures,
compromised soft tissues, or soft-tissue defects in the setting
of acute trauma as well as the formation of heterotopic bone
are all issues that orthopaedic trauma surgeons must consider
when managing injuries. A thorough understanding of these
issues and the best available evidence surrounding them is
critical to achieving the best possible outcomes.
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