SUPPLEMENT ARTICLE
What Is Important Besides Getting the Bone to Heal? Impact
on Tissue Injury Other Than the Fracture
Michael J. Gardner, MD,* Thomas A. Higgins, MD,† William H. Harvin, MD,‡
James P. Stannard, MD,§ Mark A. Lee, MD,k and Brett D. Crist, MD§
Downloaded from https://journals.lww.com/jorthotrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+5UxwP5IFlBD9KwJYCFGgxWp17zOrfICl/C95nwBsgc= on 05/20/2020
Summary: Fracture surgeons do a great job of managing bone
issues, but they may overlook the associated soft tissue injuries
that play a significant role in the final outcome after musculo-
skeletal injury. The soft tissue reconstruction ladder can help
guide reconstructive procedures based on the least complex
procedure that allows the best chance of fracture healing.
Muscle injury, volume loss, and deconditioning occur with
traumatic injury and during the recovery phase. Neuromuscular
stimulation, nutrition, and strength training are potential ways to
aid in recovery. Complex periarticular knee injuries have a high
rate of associated soft tissue injuries that may affect outcome if
associated with knee instability. Identifying and addressing
these injuries can increase the likelihood of a good outcome.
Articular cartilage loss can make articular reconstruction
impossible. Large fresh osteoarticular allografts can be a recon-
structive option. Addressing all the damaged structures involved
with a fracture may be the next step in improving patient
outcomes.
Key Words: soft tissue injury, muscle damage, ligament reconstruc-
tion, articular cartilage injury
(J Orthop Trauma 2018;32:S21–S24)
INTRODUCTION
Fracture surgeons frequently overlook injuries to soft
tissues and related muscle deconditioning after osseous
injuries. Although high-energy injuries to bone in the setting
of open fractures can create significant bone healing chal-
lenges, frequently the injuries to the surrounding soft tissues
are so severe that no reconstructive option is available.
However, recognizing the spectrum of injuries to the soft
tissue envelope and articular surface associated with fractures
and how they are managed may lead to improved outcomes.
Accepted for publication December 11, 2017.
From the *Stanford University, Palo Alto, CA; †University of Utah, Salt Lake
City, UT; ‡University of Texas-Houston, Houston, TX; §University of
Missouri, Columbia, MO; and kUniversity of California-Davis, Sacramen-
to, CA.
The authors report no conflict of interest.
Reprints: Brett D. Crist, MD, FAAOS, FACS, FAOA, University of
Missouri, One Hospital Dr., Columbia, MO 65212 (e-mail: cristb@
health.missouri.edu).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001125
J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
FRACTURES DO NOT HEAL WITHOUT SOFT
TISSUE COVERAGE: UNDERSTANDING THE
SOFT TISSUE RECONSTRUCTIVE LADDER
Several current theories on bone regeneration do not
emphasize the soft tissue envelope.1 Adequate soft tissue
coverage of a fracture includes (1) healthy periosteum to pro-
vide the cellular and growth factor components necessary for
fracture healing; (2) a stable muscle envelope, depending on
the specific anatomic region, which also provides local blood
flow to modulate fracture healing and provide immune cells;
and (3) intact skin to create a sterile barrier to the external
environment.
Traumatic extremity injuries disrupt each of these
components to varying degrees. As the energy of the injury
increases, larger volumes of skin or muscle are lost or
necrotic, and more complex soft tissue envelope reconstruc-
tion is necessary if limb salvage is chosen. Determination of
when to employ more complex soft tissue techniques, and
which ones to use, can be extremely complex and difficult.
To address this difficult situation, the concept of the
“reconstructive ladder” was introduced initially by Gillies in
the World War I era2 and was revisited in the modern era by
Levin.3 This concept was initially described as a systematic
way for reconstructive surgeons to organize and prioritize
microvascular procedures necessary to treat a specific
injury.2,4 The general concept is that various procedure op-
tions can be organized as rungs on a ladder, such that as 1
moves up the ladder, the procedures become more complex
and invasive. Procedures should be chosen based on the least
complex procedure (lowest rung on the ladder) necessary to
allow durable and expeditious wound and fracture healing,
and then the surgeon can move up the ladder as necessary.5
More recently, this concept has been adapted to an “ortho-
plastic” approach to include soft tissue coverage procedures
that do not involve microsurgery and can be employed by the
orthopaedic trauma surgeon.4,5
Based on these principles, the reconstructive ladder
begins with primary wound closure on the lowest rung and
progresses up to secondary closure, skin grafts, rotational
flaps, regional flaps, and finally free tissue flaps. Although
visualizing this hierarchy can be a useful thought experiment,
some authors have questioned the practicality of such a step-
wise approach in clinical practice. Sometimes, skipping rungs
on the ladder is necessary, and perhaps the analogy of
a “reconstructive elevator” is more appropriate.6 This implies
that the initial procedure selected has the highest chance of
success, instead of progressing through several less complex
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Gardner et al J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
procedures that fail. Furthermore, with modern advancements
in microsurgical techniques, some would recommend that
often the best approach is proceeding right to the top of the
ladder to provide the patient the best chance at avoiding
infection, achieving wound healing, and obtaining fracture
union.7 Overall, regardless of how these various procedures
are conceptualized and organized, the selection of the appro-
priate soft tissue coverage technique for a specific patient is
often difficult. Surgeon experience in evaluating complex
wounds and performing coverage procedures should be taken
into account, and consultation with colleagues can provide
important insight before undertaking reconstruction.
MUSCULAR RECOVERY: HOW MUCH IS LOST
WITH INJURY?
The ramifications and extent of muscle damage are
frequently underestimated. There are 3 individual settings in
orthopaedic trauma that merit further evaluation in reference
to muscle loss and recovery: patients with isolated limb
fractures, the polytrauma or intensive care unit (ICU) patient,
and the patient with geriatric hip fracture.
The muscle loss and damage associated with open
single limb injuries or isolated crush injuries is often obvious,
but isolated closed injuries will frequently lead to a slower,
insidious muscle loss over the time course of skeletal healing.
For example, 6 weeks of a short leg cast leads to a 17% loss in
muscle volume below the knee.8 For a long-term perspective,
even at 16 years after closed treatment of tibial shaft fractures,
injured limbs demonstrated a 15% loss of posterior compart-
ment cross-sectional muscle volume compared with contra-
lateral uninjured limbs.9 One potential solution may be
neuromuscular electrical stimulation (NMES) that mitigates
muscle volume loss during immobilization but does not affect
strength.10 NMES has also been shown to reverse some of the
muscle loss associated with knee osteoarthritis and yield sub-
sequent improvements in function.11
For acute cases of muscle volume loss caused by open
injuries, animal models have demonstrated persistent func-
tional deficits beyond volumetric loss.12 In humans, the lost
fibers are not replaced, and any volume recovery must come
from hypertrophy of remaining tissue.13 Studies exploring
minced muscle as a type of “autograft slurry” have shown
some promise for replacement of volume loss in experimental
models.14
In addition to the catabolic effects of polytrauma, the
sustained bed rest inherent in an ICU stay has a prolonged
negative effect on muscle volume. Within the first week of
bed rest, protein synthesis declines 14%, but at the muscular
level, protein incorporation drops 50%, with more profound
decline in the second week.15 This is even more profound in
the elderly ICU patient, where skeletal muscle volume corre-
lates with ventilator-free days, ICU-free days, and mortality.16
Some studies have suggested a therapeutic role for NMES in
maintaining muscle mass in critically ill patients, but other
reviews have been mixed.17,18
Sarcopenia, the decline in muscle strength and volume,
is associated with the normal physiologic changes of aging.
This manifests itself in altered cellular turnover,
S22 | www.jorthotrauma.com
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mitochondrial dysfunction, and disorganized muscular archi-
tecture. Ten days of bed rest in healthy elderly patients leads
to a significant loss of lean body mass, protein synthesis, and
strength, with no difference between the sexes.19 Although
decreased body mass index and lean body mass are estab-
lished risk factors for geriatric hip fractures, the actual bone–
muscle interaction plays a role as well.20,21 In animal models,
chemically induced short-term muscle atrophy has been
demonstrated to impair fracture healing in the adjacent
skeleton.22
Two main areas of potential intervention have been
considered for addressing sarcopenia in the geriatric popula-
tion: nutrition and strength training. A Cochrane review
concluded that progressive resistance training 2–3 times per
week demonstrates improved function, most frequently mea-
sured with gait speed and timed-up-and-go.23 Both protein
supplementation and vitamin D have been shown to help
address sarcopenia but must be coupled with a physical exer-
cise regimen to be maximally effective.24–26 Multiple phar-
macologic interventions are being considered, but definitive
effectiveness of these interventions has not yet been
demonstrated.27
At this time, the evidence of the detrimental effects of
muscle loss in the fracture setting and with aging is
convincing, but the best routes for intervention remain
unclear. Looking to the future, potential areas of progress
may lie in resistance exercise, NMES, muscle grafting,
nutrition, and protein synthesis.
PERIARTICULAR KNEE FRACTURES:
LIGAMENTOUS STABILITY AFFECTS SUCCESS
Patients with complex periarticular knee fractures may
have poor outcomes—including stiffness, instability, and
chronic pain—unless certain parameters are restored: knee
stability, mechanical alignment, condylar width, and near
anatomic articular reductions (,2 mm incongruity).28–32
Most of the knee periarticular fracture literature is focused
on restoration of limb alignment. Despite the fact that the
knee is not inherently congruent and relies significantly on
soft tissue constraints, little literature has been dedicated to
concomitant soft tissue and bone injuries.
Tibial plateau fractures are the typical injury where soft
tissues can play a significant role in outcome with up to 91%
of plateau fractures having a positive finding on magnetic
resonance imaging (MRI).33–35 For collateral ligament inju-
ries, repair at the time of plateau fixation had significantly
better outcomes than those with neglected ligament injuries.32
Likewise, repair of avulsion fractures and conservative treat-
ment of soft tissue collateral injuries, particularly the medial
collateral ligament, can result in good functional outcomes.36
Although surgical treatment of ligament or meniscal pathol-
ogy may not always influence outcomes, 1 study showed the
best predictor of poor outcomes was the residual articular
incongruity of .5 mm.37 Last, a long-term outcomes study
of tibial plateau fractures found no significant increase in knee
laxity on comparison stress radiographs.38
Menisci affect knee stability and tears are common with
tibial plateau fractures.33,34,39 MRI has detected meniscal
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
pathology in 42%–91% of these fractures.33–35 However, the
question is which pathology affects outcomes. Clinically rel-
evant unstable meniscal tears occur in approximately 36% of
plateau fractures.34 MRI alters the treatment plan in 19%–
23% of cases, usually to address unstable meniscal tears.35,40
Addressing clinically relevant meniscal pathology leads to
good functional outcomes and may lead to a similar outcome
as if the patient had no meniscal tear.41
To optimize functional outcomes, one should have
a high index of suspicion for combined bone and soft tissue
injuries about the knee. Moore described 5 fracture patterns
with marked joint instability, which are often considered
fracture–dislocations.42 Several markers on injury radio-
graphs can help identify significant soft tissue injuries: fem-
orotibial joint subluxation, rim avulsion or depression
fractures, epicondylar or fibular head fractures, proximal ti-
biofibular subluxation, and large tibial eminence or cruciate
avulsions. If preoperative MRI is not routinely obtained, the
above findings may be used to indicate the need for MRI to
identify soft tissue injuries. Intraoperative stress imaging is
helpful, but it can be difficult to determine the location of
collateral ligament injury without directly exposing the liga-
ment. Another intraoperative finding that may indicate sig-
nificant ligament injury is joint subluxation or asymmetric
joint widening, with unilateral application of a universal
distractor. Soft tissue injuries with joint instability are not
isolated to tibial plateau fractures and can also occur with
distal femur fractures.
Mid-substance collateral ligament injuries can be
treated conservatively with bracing and therapy; however,
large collateral sleeve avulsion injuries from either femoral or
tibial sides heal less predictably and should ideally be
anatomically repaired to restore joint stability and allow early
motion. Avulsed meniscal root or meniscocapsular attach-
ments should be repaired to restore normal stress distribution
across the compartment as well as to restore stability,
particularly with medial-sided injuries. Cruciate injuries likely
should not be acutely treated unless joint stability cannot be
maintained or an avulsion fracture blocks motion.
Although the literature is somewhat limited on peri-
articular knee injuries and the effects of the soft tissue injury
on outcomes, outcomes seem to be optimized when the
primary goals of restoring alignment and stability are
achieved, regardless if these derangements are related to
bone or soft tissue injuries. The first place to start is to have
a high level of suspicion for injury and determine whether
advanced imaging or surgical exploration is necessary.
WHAT TO DO WHEN THE ARTICULAR
CARTILAGE DOES NOT HEAL OR CANNOT
BE RECONSTRUCTED?
Articular cartilage lesions after trauma in young
patients are injuries that have defied successful treatment.
Current options include restoring the overall mechanical
alignment and overall articular surface alignment with either
accepting chondral loss, microfracture or staged articular
grafting with cartilage autograft or allograft, or osteochondral
autograft or allograft. Fresh osteoarticular allograft (OCA)
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Impact on Tissue Injury
transplants have been the most successful treatment to date
with potentially large defects treatable but have been
hampered by graft availability and short time limit for
chondrocyte viability. Ten- to 15-year survival rates for
OCAs have been reported as 71%–85%.43–50 It has recently
been established that chondrocyte viability is a critical factor
in success of OCA transplants.51,52
The importance of viable chondrocytes was investi-
gated using a canine model and 2 different chondrocyte
preservation techniques.51,52 Sixteen dogs with 32 OCAs
were evaluated with grafts that were preserved for either 28
or 60 days using the 2 different preservation techniques.
Chondrocyte viability ranged from 23% to 99%. Every graft
that had 70% or more viable chondrocytes was successful in
this canine model with long-term follow-up. Every graft with
62% or less viable chondrocytes failed when evaluated over
the same period. A fluorescent in situ hybridization assay
suggested that the surviving chondrocytes were from the
donor in successful grafts and that failures were repopulated
with fibrocytes from the recipient.51,52
The clinical relevance of this study is that large defects
may be treated with fresh OCAs if adequate chondrocyte
viability is maintained in the graft. Another factor for success
is graft thickness. Increasing the bone thickness increases
biomechanical properties but also increases the chances of
immune response and inhibits the diffusion required to
provide nourishment to the cartilage cells. Graft thickness
between 6 and 8 mm, including the bone represents the ideal
thickness to allow diffusion of blood and nutrients to the bone
and cartilage while also maximizing graft strength to allow
weight bearing.53
Articular surface loss is a challenge to address when it
is larger than a few millimeters. This is particularly challeng-
ing in open fractures or high-energy injuries where the
cartilage is either lost or sheared off the subchondral bone.
Fresh OCAs may represent an option for these patients.
However, there are still changes related to the need for donor
matching, chondrocyte viability, and prolonged recovery
period. The envisioned future is off-the-shelf availability as
preservation systems continue to improve and cost decreases.
SUMMARY
Although orthopaedic trauma surgeons are experts in
stabilization of bony injuries, our limited recognition and
training in management of soft tissue or articular cartilage
loss, muscle injury or deconditioning, or ligamentous insta-
bility may contribute to poor outcomes. Recognition and
training in the specific management of the full spectrum of
associated soft tissue injuries and articular cartilage may
improve our ability to manage these complicated and
multifaceted injury patterns.
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