Showing papers in "Journal of Orthopaedic Trauma in 2019"
TL;DR: It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.
Abstract: Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.
292 citations
TL;DR: This guideline attempts to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury and graded the evidence to both support recommendations and identify gap areas for future research.
Abstract: Purpose:We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.Methods:A panel of 15 members with expertise in orthopaedic trauma, pain manage
142 citations
TL;DR: In this article, the authors outline the rationale, technical steps, and early clinical outcomes after nail plate combination in the treatment of osteoporotic distal femur (native or periprosthetic) fractures.
Abstract: In the elderly, low-energy distal femur fractures (native or periprosthetic) can be devastating injuries, carrying high rates of morbidity and mortality, comparable with the hip fracture population. Poor, osteoporotic bone quality facilitates fracture in a vulnerable anatomical region, and as a result, operative fixation can be challenging. With goals of early mobilization to reduce subsequent complication risk, using the nail plate combination technique can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. We outline the rationale, technical steps, and early clinical outcomes after nail plate combination in the treatment of osteoporotic distal femur (native or periprosthetic) fractures.
86 citations
TL;DR: The available techniques for fracture fixation at the femoral neck (cannulated screws, hip screw systems, proximal femur plates, and cephallomedullary nails) are reviewed with respect to their competence to provide biomechanical stability.
Abstract: Fractures of the femoral neck can occur in young healthy individuals due to high loads occurring during motor vehicle accidents, impacts, or falls. Failure forces are lower if impacts occur sideways onto the greater trochanter as compared with vertical loading of the hip. Bone density, bone geometry, and thickness of cortical bone at the femoral neck contribute to its mechanical strength. Femoral neck fractures in young adults require accurate reduction and stable internal fixation. The available techniques for fracture fixation at the femoral neck (cannulated screws, hip screw systems, proximal femur plates, and cephallomedullary nails) are reviewed with respect to their competence to provide biomechanical stability. Mechanically unstable fractures require a load-bearing implant, such as hip screws, with antirotational screws or intramedullary nails. Subcapital or transcervical fracture patterns and noncomminuted fractures enable load sharing and can be securely fixed with cannulated screws or solitary hip screw systems without compromising fixation stability.
69 citations
TL;DR: The mFI-5 is an independent predictor of postoperative morbidity and mortality in elderly patients undergoing surgery for hip fractures and can be used by hospitals and surgeons to identify high-risk patients, accurately council patients and families with transparency, and guide perioperative care to optimize patient outcomes.
Abstract: Introduction Although the 11-factor modified frailty index (mFI-11) has been shown to predict adverse outcomes in elderly patients undergoing surgery for hip fractures, the newer 5-factor index has not been evaluated in this population. The goal of this study is to evaluate the mFI-5 as a predictor of morbidity and mortality in elderly patients undergoing surgical management for hip fractures. Methods The NSQIP database was queried for patients 60 years of age and older who underwent surgical management for hip fractures between 2005 and 2016. The 5-factor score, which comprised diabetic status, history of COPD or current pneumonia, congestive heart failure, hypertension requiring medication, and nonindependent functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and 30-day postoperative complications. Results A total of 58,603 patients were identified. After adjusting for comorbidities, the mFI-5 was a strong predictor for total complications, serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, extended hospital length of stay, and mortality (P ≤ 0.008). For each point increase, the risk for any complication increased by 29.8%, serious medical complications 35.4%, surgical site infections 14.7%, readmission 24.6%, and mortality 33.7%. Conclusions The mFI-5 is an independent predictor of postoperative morbidity and mortality in elderly patients undergoing surgery for hip fractures. This clinical tool can be used by hospitals and surgeons to identify high-risk patients, accurately council patients and families with transparency, and guide perioperative care to optimize patient outcomes. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
59 citations
TL;DR: In this paper, the authors show that a satisfactory outcome can be expected if the fracture reduction is perfect, and in some cases it would have been better to accept the result which might have been obtained by conservative methods.
Abstract: Twenty-two years of experience in this field allow us to say that a perfect open reduction is the method of choice to treat displaced acetabular fractures. But difficult cases require experience. Late follow-up of hips treated by open reduction and internal fixation supports the contention that a satisfactory outcome can be expected if the fracture reduction is perfect. The converse applies, and in some instances it would have been better to accept the result which might have been obtained by conservative methods. The type of fracture dictates the choice of approach, but the indication for operative treatment as well as the result of acetabular fracture treatment is the degree of congruence achieved between the acetabulum and the femoral head. Incongruence may be total, partial or apparent. Total incongruence is seen in both persistent posterior or central dislocation in which, on all three standard radiographs, the fragments of the acetabulum are seen separated from the femoral head. The situation may exist from the moment of trauma or following attempts at reduction. In all instances, operative treatment is indicated. With partial incongruence, the femoral head lies well centered beneath an undisplaced fragment of roof, but other fragments of articular surface remain displaced. A very good clinical result cannot be expected in more than 55% of hips left in this state, and neglecting operative complications, the same can be expected following conservative management. A small degree of incongruence can be accepted but one of the difficulties lies in determining the size of the fragment "roof" left in situ. Certainly, congruency seen on one standard radiograph and not in the others must not be accepted, and surgical treatment is indicated. With apparent congruence, the fragments of shattered acetabulum have regrouped around a displaced femoral head and exhibit a fair degree of congruence in this displaced position. Examples like this can often be treated conservatively because while surgery may achieve a better true congruence, this cannot be guaranteed and will be accompanied by the risks of operation. Further, the result could be worse. In nine acetabular fractures, it has been possible to achieve an apparent congruence by reconstituting displaced acetabular fragments around the femoral head but accepting the overall displacement. Seven of these obtained very good clinical results but it should be emphasized that the need to resort to this approach has been very infrequent.
59 citations
TL;DR: The Tightrope device appears to compare favorably to two, 3.5 mm, 3- cortex screw fixation for syndesmosis injuries, suggesting the study was adequately powered for radiographic results only.
Abstract: Objective:To compare the rate of malreduction after high fibular fractures associated with syndesmosis injury treated with open reduction and internal fixation, with either 2 screws or 1 knotless TightRope device.Design:Prospective randomized controlled multicenter trial.Setting:Eleven academic and
57 citations
TL;DR: The results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment.
Abstract: OBJECTIVE To report the mortality data and life expectancy of geriatric hip fracture patients who underwent nonoperative management and compare that with a matched operative cohort. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS Geriatric (65 years of age and older) femoral neck or intertrochanteric fracture (OTA/AO 31A and 31B) patients. INTERVENTION Operative treatment with either arthroplasty, cannulated screws, sliding hip screw device, or cephalomedullary nail compared with nonoperative cohort. MAIN OUTCOME MEASUREMENTS In-hospital, 30-day, and 1-year mortality. RESULTS Two hundred thirty-one patients, comprising 154 operative and 77 nonoperative patients, were compared. There were no significant differences among age, sex, fracture location, Charlson Comorbidity Index, preinjury living location, dementia, and history of cardiac arrhythmia between the 2 cohorts. Nonoperatively managed patients were found to have a significantly higher percent in-hospital (28.6 vs. 3.9; P < 0.0001), 30-day (63.6 vs. 11.0; <0.0001), and 1-year (84.4 vs. 36.4; P < 0.0001) mortality. The mean life expectancy after a hip fracture for the nonoperative cohort was significantly shorter than the operative group (221 vs. 1024 days; P < 0.0001). CONCLUSIONS Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that was significantly higher than a matched operative cohort. Our results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment. Our findings offer helpful information by providing updated mortality data when discussing nonoperative hip fracture management with patients and their family. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
55 citations
TL;DR: Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and Harris Hip scores at 3 months.
Abstract: Objective:To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail.Design:Prospective, randomized.Setting:Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester
53 citations
TL;DR: It was found that increasing femoral neck shortening was associated with inferior hip function, while internal fixation often results in successful union, patients that heal in a shortened position report poorer functional outcomes.
Abstract: Objective:To describe the distribution of femoral neck shortening after internal fixation and to determine whether shortening is associated with inferior hip function at 24 months after a hip fracture in patients 50 years of age or older.Design:Retrospective cohort study.Setting:A secondary analysis
51 citations
TL;DR: There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor and combining malnutrition and frailty revealed predictive synergy.
Abstract: Objective:To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.Design:Retrospective observational cohort study.Setting:Urban, American College of Surgeons–Verified, Level-1, Trauma Center.Patients/Participa
TL;DR: Aggregating available research suggests that RSA results in improved range of motion, clinical outcome scores, and rates of all-cause reoperation with no difference in infection rates.
Abstract: OBJECTIVES We sought to compare range of motion, clinical outcome scores, and complications after reverse total shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in geriatric patients with acute proximal humerus fractures. DATA SOURCES We searched MEDLINE (1946-2017), EMBASE (1947-2017), the Cochrane Central Register of Controlled Trials (1898-2017) and ClinicalTrials.gov in October 2017. No limits were used in the database search. We also manually reviewed reference lists of included studies. We did not restrict studies based on language. STUDY SELECTION We included all randomized controlled trials and cohort studies in which the study population had a mean age of 65 years or older, received RSA or HA to treat an acute proximal humerus fracture, and had a minimum follow-up of 6 months. DATA EXTRACTION Two independent reviewers used a standardized data collection form to extract relevant information from included studies. Discrepancies were resolved by a consensus or a third party if consensus could not be reached. Study authors were contacted for missing or incomplete data. DATA SYNTHESIS Using a random effects model, we calculated mean differences (MD) and standardized mean differences (SMD) for continuous outcomes; we calculated relative risk for dichotomous outcomes. RESULTS Fifteen studies were included in the meta-analysis, including 421 patients treated with RSA and 492 treated with HA for a total of 913 patients. Compared with HA, the RSA group had significantly improved pain scores (SMD = 0.74, P < 0.001), outcome scores (SMD = 0.63, P < 0.001), and forward flexion (MD = 24.3 degrees, P < 0.001). Compared with RSA, the HA group had a significantly increased risk of reoperation (relative risk = 2.8, P = 0.02). There were no differences between the groups with regard to external rotation (P = 0.31) or deep infection (P = 0.90). CONCLUSIONS Aggregating available research suggests that RSA results in improved range of motion, clinical outcome scores, and rates of all-cause reoperation with no difference in infection rates. Using RSA for the treatment of acute proximal humerus fractures in the elderly population may result in improved short- and medium-term outcomes compared with HA. Future work should evaluate long-term outcomes to see if the benefits of RSA persist. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The anterior tibiofibular distance (aTFD) correlated with clinical outcome and a 2 mm difference in aTFD seems to predict poorer clinical outcome.
Abstract: Objectives:To evaluate the relationship between syndesmosis reduction and outcome.Design:Retrospective cohort study.Setting:One Level 1 and 1 Level 3 Trauma Center.Patients:Ninety-seven patients with syndesmosis injury.Intervention:Stabilization of syndesmosis injury. Open reduction and internal fix
TL;DR: The results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur.
Abstract: Objectives To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. Design Retrospective cohort study. Setting Four Level 1 Academic Trauma Centers. Patients/participants All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. Intervention Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks. Main outcome measurements Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. Results One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN." Conclusions This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: Early operative fixation of patients who cannot be mobilized within three to five days was associated a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than two years, Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.
Abstract: OBJECTIVE To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome. DESIGN Retrospective. SETTING Two trauma centers. PATIENTS AND METHODS Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively. MAIN OUTCOME MEASUREMENTS Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up. RESULTS At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910). CONCLUSION Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The PROMIS Mobility CAT and Physical Function 8a short form demonstrated reliability, convergent and known groups discriminant validity, and responsiveness in a sample of patients with a lower extremity orthopaedic trauma injury.
Abstract: Objectives To evaluate the reliability, convergent validity, known-groups validity, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility Computer Adaptive Test (CAT) and PROMIS Physical Function 8a Short Form. Design Prospective cohort study. Setting Two Level-I trauma centers. Patients Eligible adults with an isolated lower extremity trauma injury receiving treatment were approached consecutively (n = 402 consented at time 1, median = 80 days after treatment). After 6 months, 122 (30.3%) completed another assessment. Intervention Cross-sectional and longitudinal monitoring of patients. Main outcome measurements Floor and ceiling effects, reliability (marginal reliability and Cronbach's alpha), convergent validity, known-groups discriminant validity (weight-bearing status and fracture severity), and responsiveness (Cohen's d effect size) were evaluated for the PROMIS Mobility CAT, PROMIS Physical Function 8a Short Form, and 5 other measures of physical function. Results PROMIS PFSF8a and Foot and Ankle Ability Measure Activities of Daily Living Index had ceiling effects. Both PROMIS measures demonstrated excellent internal consistency reliability (mean marginal reliability 0.94 and 0.96; Cronbach's alpha = 0.96). Convergent validity was supported by high correlations with other measures of physical function (r = 0.70-0.87). Known-groups validity by weight-bearing status and fracture severity was supported as was responsiveness (Mobility CAT effect size = 0.81; Physical Function Short Form 8a = 0.88). Conclusions The PROMIS Mobility CAT and Physical Function 8a Short Form demonstrated reliability, convergent and known-groups discriminant validity, and responsiveness in a sample of patients with a lower extremity orthopaedic trauma injury.
TL;DR: The naive Bayes machine-learning algorithm provided excellent accuracy and responsiveness in the prediction of length of stay and cost of an episode of care for hip fracture using preoperative variables, demonstrating that the cost of delivery of hip fracture care is dependent on largely nonmodifiable patient-specific factors.
Abstract: Objectives:With the transition to a value-based model of care delivery, bundled payment models have been implemented with demonstrated success in elective lower extremity joint arthroplasty. Yet, hip fracture outcomes are dependent on patient-level factors that may not be optimized preoperatively du
TL;DR: Hook plate fixation achieves a similar functional outcome and union rate compared with CC stabilization and locking plate fixation but has a superior functional result compared with TBW, and the complication rate is higher compared withCC stabilization andlocking plate fixation and is lower compared withTBW.
Abstract: OBJECTIVES: To compare the outcome of hook plate fixation with other techniques in surgical fixation of acute unstable distal clavicle fractures. DATA SOURCES: In July 2018, a systematic search of electronic databases (PubMed, Medline, Embase, and Cochrane databases for systematic reviews) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles were limited to English language. STUDY SELECTION: Studies were included if they compared the results of hook plate fixation of acute unstable distal clavicle fracture in adults with other surgical techniques. DATA EXTRACTION: Data on the study setting, functional outcome, union, and complication rates were extracted. A quality assessment was performed using the Newcastle-Ottawa Scale. DATA SYNTHESIS: Eleven studies were found that met the inclusion criteria. Six hundred thirty-four patients were pooled using a random effects model. There were 397 male and 237 female patients. Primary outcome measure was functional result, and the secondary outcome measures were union and complication rates. There was no significant difference between the functional outcome and union rate between hook plate fixation, coracoclavicular (CC) stabilization, and locking plate fixation. Hook plate fixation resulted in a higher Constant-Murley score compared with tension band wiring (TBW) [odds ratio (OR), 3.52; 95% confidence interval (CI), 0.79-6.26]. It was also associated with a higher complication rate compared with CC stabilization (OR, 3.68; 95% CI, 1.19-11.33) and the locking plate (OR, 5.19; 95% CI, 1.58-17.06). Compared with TBW, hook plate fixation was associated with a lower complication rate (OR, 0.28; 95% CI, 0.10-0.77). CONCLUSIONS: Hook plate fixation achieves a similar functional outcome and union rate compared with CC stabilization and locking plate fixation. However, it has a superior functional result compared with TBW. The complication rate is higher compared with CC stabilization and locking plate fixation and is lower compared with TBW. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The authors found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs, and suggested earlier HF fixation might be indicated in DOAC patients.
Abstract: OBJECTIVE To assess the impact of direct oral anticoagulant (DOAC) intake compared with Coumadin (COU) in patients suffering hip fractures (HFs). DESIGN Retrospective cohort analysis. SETTING Level 1 Trauma Center. INTERVENTION Timing of surgical hip fixation. PATIENTS Three-hundred twenty patients 65 years of age or older with isolated HF were enrolled into the study: 207 (64.7%) without any antithrombotic therapy (no-ATT), 59 (18.4%) on COU, and 54 (16.9%) on DOACs. MAIN OUTCOME MEASUREMENTS Time to surgery, blood loss, mortality, hospital length of stay, red blood cell transfusion, use of reversal agents, and Charlson Comorbidity Index. RESULTS Patients on COU and DOACs had a higher Charlson Comorbidity Index compared with the no-ATT group (P < 0.0001). Despite the fact that significantly more patients received reversal agents in the COU group compared with DOAC medication (P < 0.0001), percentage of transfused patients were similar (54.2% vs. 53.7%). Time to surgery was significantly shorter in the no-ATT group when compared with DOAC patients (12-29.5 hours, respectively). No difference in postoperative hemorrhage, intensive care unit length of stay, and mortality was observed between groups. CONCLUSIONS DOAC medication in HF patients caused long elapse time until surgical repair. We found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs. Earlier HF fixation might be indicated in DOAC patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: It is found that supplementation of a lateral locked plate with a medial plate or an IMN to be biomechanically superior to lateral locked plating alone regarding stiffness, survivability, and cycles to failure.
Abstract: OBJECTIVES To investigate the biomechanical properties of a lateral locked plate alone or in combination with a supplemental medial plate or an intramedullary nail (IMN). METHODS Intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C) were simulated with a standardized model in 28 synthetic femora and divided into 4 groups. Group I was instrumented with a 4.5-mm lateral locked distal femoral plate alone, group II with a lateral locked plate plus a low-profile precontoured 3.5-mm medial distal tibial plate, group III with a lateral locked plate plus a medial 3.5-mm reconstruction plate, and group IV with a lateral locked plate plus a retrograde IMN. Specimens were then axially loaded and cycled to failure or runout. Outcomes of interest were baseline stiffness, survivability, and cycles to failure. RESULTS Groups III and IV have a significantly higher baseline stiffness (P < 0.001) when compared with groups I and II. Furthermore, groups III and IV had a higher max load to failure (P < 0.01) when compared with groups I and II. The survivability in groups III and IV was 71% and 100%, respectively, while no specimens in group I or II survived maximum loading. There was no significant difference between group III and IV regarding stiffness, survivability, and cycles to failure. CONCLUSION When considering fixation for intra-articular distal femur fractures with metaphyseal comminution (OTA/AO 33-C), we found that supplementation of a lateral locked plate with a medial plate or an IMN to be biomechanically superior to lateral locked plating alone regarding stiffness, survivability, and cycles to failure. A low-profile precontoured plate did not add significantly to the construct stiffness in this study.
TL;DR: In this paper, a 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures was evaluated in a comparison study over a two-year period, and the authors found that the longer time to both initial debridement and definitive reconstruction was not significantly associated with infection, infection, and nonunion.
Abstract: Objective To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. Design Retrospective comparative cohort study over a 2-year period. Setting Level 1 trauma center. Patients/participants A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. Intervention Time to initial debridement and definitive management. Main outcome measurement Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. Results Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. Conclusions Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The induced membrane technique showed a substantial rate of failure in the acute trauma setting in the lower limb and is now used in selected cases only in the absence of sound published evidence.
Abstract: Objective To present our technique and early results using the Masquelet technique. Design Retrospective cohort study. Patients/participants Thirteen patients with 14 open fractures of the femur and tibia were included between November 2013 and December 2014. Intervention A Masquelet technique was used to manage the open fractures. Main outcome measure Infection and union rate. Results The mean follow-up was 17 months. The mean bone defect was 56.6 mm. Eight fractures (57.1%) progressed to union at an average of 42.1 weeks. Infection developed in 3 fractures (21.4%). Overall, the induced membrane technique was abandoned in 5 (35.7%) cases. Conclusions The induced membrane technique showed a substantial rate of failure in the acute trauma setting in the lower limb. In the absence of sound published evidence, the authors now use the technique in selected cases only. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate and clinical outcome.
Abstract: Objectives To evaluate tuberosity union rate and clinical outcome after 3- and 4-part proximal humerus fractures in the elderly. Design Retrospective, multicenter database cohort study. Setting Level I and Level II trauma centers. Patients Fifty-five patients older than 65 years had insertion of reverse shoulder arthroplasty (RTSA) for OTA/AO 11-B and 11-C proximal humerus fractures. Intervention Treatment with RTSA using a dedicated low profile onlay fracture stem using variable tuberosity fixation. Main outcome measures Constant score, the American Shoulder and Elbow Surgeons score, Shoulder Pain and Disability Index score, University of California at Los Angeles score, Simple Shoulder Test score, visual analog pain score, shoulder function score, active range of motion, external rotation (ER)-specific tasks and position, rate of greater tuberosity healing, effect of tuberosity healing on overall clinical metrics, incidence of humeral lucency, and scapular notching. Results Eighty-three percent of the greater tuberosities that were repaired united. Greater tuberosity union resulted in greater active ER (P = 0.0415). There was a statistically significant difference in the ability to do ER-type activities between the 2 cohorts reflected in the ability to position one's hand behind their head with the elbow forward (P = 0.002) and comb their hair (P Conclusion The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate. Greater tuberosity healing significantly influences ER and ER-type activities that are not apparent by analysis of the overall metrics studied. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting.
Abstract: Objectives To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA). Design Case series. Setting A single Level I trauma center. Patients/participants A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years. Intervention Uncemented RTSA. Main outcome measures (1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score. Results Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%. Conclusions Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: The 2 most commonly used constructs are reviewed and 2 novel fixation constructs for the fixation of femoral neck fractures in physiologically young patients are presented, including the Smith & Nephew Conquest system and the Aesculap Targon system.
Abstract: Fixation of young femoral neck fractures represents a challenge in the field of orthopaedic trauma surgery. Conventional methods, including cannulated screw and sliding hip screw constructs, have been studied and found to have similar results with regards to patient outcomes, which has made choosing an optimum fixation strategy difficult. In all of these cases, quality of reduction has been shown to be the most important factor when it comes to creating a favorable environment for fracture healing. Some of these patients, however, continue to have negative sequelae including nonunion, avascular necrosis, femoral head collapse, and poor hip function as a result. In this article, we review the 2 most commonly used constructs and present 2 novel fixation constructs for the fixation of femoral neck fractures in physiologically young patients, including the Smith & Nephew Conquest system and the Aesculap Targon system. We outline techniques for usage of these systems and proposed advantages to these systems compared with conventional fixation methods. We also discuss the results of previously published studies regarding conventional fixation methods and compare with some limited studies that have been published on these newer technologies.
TL;DR: The challenges inherent to managing Femoral neck fractures in the physiologically young patient are highlighted and techniques and implants that may help mitigate some of these challenges are discussed.
Abstract: Femoral neck fractures in the physiologically young patient are challenging injuries to manage. A tenuous blood supply and the intrasynovial nature of the fracture create a challenging biological environment. To make matters worse, the biomechanics are equally problematic. Frequently, these fractures in younger populations are high Pauwel angle fractures that see considerable force, especially shear. These factors combine to make nonunion and avascular necrosis all too common. In the current study, we will highlight the challenges inherent to managing these injuries and will discuss techniques and implants that may help mitigate some of these challenges.
TL;DR: Based on clinical experience, a comprehensive classification of pelvic fragility fractures separate from the existing pelvic ring injury classification is proposed to provide a framework for distinguishing the different fragility fracture types and their recommended treatment.
Abstract: Fragility fractures of the pelvis are occurring with increasing frequency. These fractures, occurring in the geriatric patient population, are low-energy injuries and are dissimilar in many ways from those caused by high-energy trauma. For example, the mechanism of injury is different and emergency treatment is usually not necessary. Having diminished bone strength, fragility fracture lines follow areas of low bone mineral density and loss of pelvic stability may increase over time. Based on our clinical experience, we propose a comprehensive classification of pelvic fragility fractures separate from the existing pelvic ring injury classification to provide a framework for distinguishing the different fragility fracture types and their recommended treatment. This classification is derived first from the degree of fracture instability, followed by the location of the fracture. Anterior pelvic fractures are differentiated from posterior pelvic ring fractures, nondisplaced fractures from displaced, and unilateral from bilateral. It is our belief that this new in-depth analysis of these lesions will assist the clinician in identifying the specific patterns of fragility fracture instability and selecting the appropriate choice of treatment. Further investigation is required to determine the ultimate value of this proposed pelvic fragility fracture classification system. LEVEL OF EVIDENCE:: Diagnostic Level V.
TL;DR: Fifty-five years after the publication of Letournel's original case series, data indicate that currently, surgical treatment is a common and necessary option in the therapy of acetabular fractures in elderly patients.
Abstract: Objective In his original series of 129 surgically treated acetabular fractures, Letournel did not operate on patients older than 60 years. Almost 30 years later, he still emphasized that no patients with reduced bone quality should be operated on. The aim of the study was to analyze epidemiologic characteristics and treatment modes for today's cohort of elderly patients with acetabular fractures. Design Retrospective analysis. Setting Multicenter registry/Level I trauma center. Patients Three thousand seven hundred ninety-three patients who had sustained a fracture of the acetabulum. Intervention Operative and nonoperative treatment of acetabular fractures. Main outcome measurements Epidemiologic characteristics, treatment mode, in-hospital mortality, rate of secondary hip arthroplasty, and quality of life indicated by EQ-5D score. Results For the multicenter registry, more than 50% of all patients with acetabular fractures had an age of 60 years or over. The age peak was found at 75-80 years. Fifty percent of the elderly patients were treated surgically. The in-hospital mortality was significantly higher in elderly patients than patients younger than 60 years. In our Level I trauma center, surgical treatment by open reduction and internal fixation did not influence in-hospital mortality or quality of life of elderly patients with acetabular fractures. Conclusions Today, elderly persons represent the dominant cohort among patients with fractures of the acetabulum. Fifty-five years after the publication of Letournel's original case series, data indicate that currently, surgical treatment is a common and necessary option in the therapy of acetabular fractures in elderly patients. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
TL;DR: Seventy percent of screws that were judged to be radiographically contained had cortical breach near the area where the lateral epiphyseal vessels enter the femoral neck.
Abstract: Objectives To determine the frequency where a posterior and cranial screw in a femoral neck that appeared contained on fluoroscopy violates the cortex. Methods Ten specimens including the hemipelvis with the proximal femur were obtained from unidentified embalmed specimens that were to be cremated after an institutional review board waiver was granted. Under fluoroscopy, the posterior and cranial screw of the inverted triangle configuration for the femoral neck was placed using standard technique with a cannulated 6.5-mm screw. Anterior-posterior and lateral images of the final screw placement were blinded to 2 orthopaedic traumatologists and 1 musculoskeletal radiologist who were asked to determine whether the screw radiographically breached the posterior and cranial cortex. Cadavers were stripped of soft tissues and inspected for screw perforation. Screws were grouped as contained, thread extrusion, or core extrusion. Results Reviewers classified all 10 screws as radiographically contained within the femoral neck. Cadavers were inspected and found to show: 4 of 10 with core extrusion, 3 of 10 with thread extrusion, and 3 of 10 screws contained within the femoral neck. Conclusions Seventy percent of screws that were judged to be radiographically contained had cortical breach near the area where the lateral epiphyseal vessels enter the femoral neck. We urge caution against placement of posterior-cranial implants with fluoroscopy alone even if they appear radiographically contained.
TL;DR: Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%.
Abstract: OBJECTIVES (1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. DESIGN Prospective cohort study using an international online database. SETTING Multiple hospitals in LMICs worldwide. PATIENTS/PARTICIPANTS A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. INTERVENTION Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. MAIN OUTCOME MEASUREMENTS Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. RESULTS The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. CONCLUSIONS Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.