The perfect reduction: approaches and techniques

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture

OBJECTIVE

To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches.

DESIGN

Retrospective cohort study.

SETTING

Twelve Level 1 North American trauma centers.

PATIENTS

Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation.

INTERVENTION

Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons.

MAIN OUTCOME

Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs.

RESULTS

No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006).

CONCLUSIONS

No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The morphometry, localization, and shape types of the fovea capitis femoris, and their relationship with the femoral head parameters

PURPOSE

The aim of this study was to investigate the morphometric properties of the fovea capitis femoris (FCF) and its localization on the femoral head, the shape types, and the relationship with the femoral head parameters.

METHODS

This study was performed on 146 dry femora. The morphological and morphometric properties were evaluated on dry bones and digital images of these bones. Some of the FCF and femoral head parameters were measured with a caliper on dry bones while others were measured using ImageJ software on digital images.

RESULTS

The most common localization type was the Type 2 localization and the shape type was the oval type. The FCF sizes [except depth of the FCF (D_FCF)] were found to be smaller in the Type 1 localization. The femoral neck shaft angle (NSA) was found to be greater in the triangular type than the round (or circular) type on the left side and in all cases. The vertical diameter of the femoral head (FHD-V), the anteroposterior diameter of the femoral head (FHD-AP), and the area of the femoral head (AREA_HOF) values were greater in the triangular types than in the oval types in all cases. There was no relationship between the localization types and the shape types of the FCF.

CONCLUSION

Results showed that the morphometric properties, localization, and shape types of the FCF were related to some femoral head parameters. It is thought that our findings contributed to orthopedic and radiological applications and anthropological sciences.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years

OBJECTIVES

To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation.

DESIGN

Retrospective cohort study with radiograph and chart review.

SETTING

Twelve Level 1 North American trauma centers.

PATIENTS

Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty.

INTERVENTION

Open or closed reduction technique during internal fixation.

MAIN OUTCOME

Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs.

RESULTS

Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty.

CONCLUSIONS

Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Evolution and principles of intramedullary locked nailing]

Key factors for successful osteosynthetic fracture stabilization are anatomical fracture reduction, restoration of axis and torsion alignment as well as tissue-preserving operative techniques. In long bone fractures, the use of intramedullary long bridging nailing offers ideal conditions for bone healing, as axial and rotational stability is provided by canal-filling nails and locking screws. In addition, the tissue in the fracture region is protected as the intramedullary nail insertion is distant from the fracture. The indication spectrum for modern intramedullary locked nailing includes diaphyseal fractures of long bones, metaphyseal fractures and reconstructions, as well as treatment of nonunion, osteotomy and arthrodesis of the lower extremities. Continuous improvements in nail design and instrumentation as well as the introduction of anatomical reconstruction nails will optimize the spectrum and effectiveness of intramedullary osteosynthesis even further.

The position and morphometry of the fovea capitis femoris in computed tomography of the hip

Purpose

The position of the fovea of the femoral head is usually considered to be inferior or inferoposterior, despite the fact that few detailed anatomical studies have been performed. This study was performed to assess the position of the fovea in computed tomography and its correlation with standard radiographic measures of the proximal femur.

Methods

Computed tomography scans of the hip of 107 patients (54 women and 53 men) were evaluated. The semi-coronal and transverse views were used to assess the femoral neck–shaft angle and the neck version, as well as the size and position of the fovea in relation with the femoral neck axis and the size of the head.

Results

The fovea was always located inferior to the neck axis in the semi-coronal plane. In the transverse plane, the fovea was always slightly posterior to the femoral neck axis, as approximately ¾ of its diameter was posterior to the axis. The position was unrelated to the neck–shaft axis and the neck–trochanter minor angle. There were no differences in the position between men and women; however, in women, the fovea is slightly larger than in men when related to the femoral head size.

Conclusion

The femoral neck axis in the transverse plane always crosses the anterior aspect of the fovea. Its position is unrelated to the angular geometry of the proximal femur, but related to the femoral head size. It is found to be relatively larger in women.

Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

BACKGROUND

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated.

QUESTIONS/PURPOSES

(1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches?

METHODS

Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation.

RESULTS

After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470).

CONCLUSIONS

In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach.

CLINICAL RELEVANCE

Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Modulation of cartilage's response to injury: Can chondrocyte apoptosis be reversed?

Osteoarthritis is characterized by a chronic, progressive and irreversible degradation of the articular cartilage associated with joint inflammation and a reparative bone response. More than 100 million people are affected by this condition worldwide with significant health and welfare costs. Our available treatment options in osteoarthritis are extremely limited. Chondral or osteochondral grafts have shown some promising results but joint replacement surgery is by far the most common therapeutic approach. The difficulty lies on the limited regeneration capacity of the articular cartilage, poor blood supply and the paucity of resident progenitor stem cells. In addition, our poor understanding of the molecular signalling pathways involved in the senescence and apoptosis of chondrocytes is a major factor restricting further progress in the area. This review focuses on molecules and approaches that can be implemented to delay or even rescue chondrocyte apoptosis. Ways of modulating the physiologic response to trauma preventing chondrocyte death are proposed. The use of several cytokines, growth factors and advances made in altering several of the degenerative genetic pathways involved in chondrocyte apoptosis and degradation are also presented. The suggested approaches can help clinicians to improve cartilage tissue regeneration.

Early reduction of acetabular fractures decreases the risk of post-traumatic hip osteoarthritis?

BACKGROUND

Acetabular fractures are complex high-energy injuries. Increasing in recent years with the increased use of high-speed motor vehicles. One of the most important complications of acetabular fracture is the post-traumatic hip osteoarthritis; this complication has been associated to poor fracture reduction, type of fracture and delay in the reduction and fixation of acetabular fracture (Timing surgery). The aims of this study were to determine the incidence of post-traumatic hip osteoarthritis after acetabulum fracture and demonstrate whether the delay surgery is associated to early post-traumatic hip osteoarthritis.

METHODS

Using the database of patients with acetabular fractures treated with open reduction and internal fixation (ORIF) over 3 years (2011-2014) with minimum of 2 years follow-up. Data was acquired and saved in a digital format. Demographic information was obtained from each patient with minimum of 2 years follow-up. Acetabular fracture was distributed according to the classification of Judet. The quality of reduction was classified in anatomic (0-1 mm) and non-anatomic (>1 mm) and the timing surgery, early (<7 days) and delay (>7 days). Clinical and radiographic follow-up was generally performed at six weeks, three months, one and two years after fracture fixation. Multivariate logistic regression analyses were performed to assess the strength of the covariates in relation to the development of post-traumatic hip osteoarthritis.

RESULTS

59 (48%) patients of 122, developed post-traumatic hip osteoarthritis before 2 years. Posterior wall fracture with or without transverse fracture was associated with higher post-traumatic hip osteoarthritis compared with other types of fractures (p < 0.05). Patients with better anatomical reduction had less post-traumatic hip osteoarthritis compared with those who had nonanatomic reduction (p < 0.05). There was no evidence of association between early timing of the surgical procedure and the presence post-traumatic hip osteoarthritis (p = 7092).

CONCLUSIONS

According to our results, the anatomical reduction of the articular surface in acetabular fractures is the most important factor in hip osteoarthritis prevention. This factor is strongly associated with early surgical treatment, preferably done within seven days. The timing surgery it is not a factor associated with post-traumatic osteoarthritis.

Preliminary results of the treatment of proximal femoral fractures with the AFFIXUS nail

Contemporary fixation of the proximal femur is performed utilising a number of implants adopting different concepts and techniques. Cephalomedullary nails in particular represent one of two main options, the other being dynamic hip screw (DHS). The aim of this cohort study is to present the early experience of two large units from different countries of the use of the AFFIXUS nail for stabilisation of proximal femoral fractures. Over a period of almost three years, data from 476 proximal femoral fractures were collected and analysed using a specific research protocol, assessing data relevant to basic demographic details, in-hospital stay, surgical technique and post discharge outcomes with a minimum follow up of 6 months. Both the short and long versions of the nail were used in both centres, however, with some statistically significant differences as far as the type of fractures stabilised with the nail, which also translated to differences in the combination or not of 2 lag screws, and the static or dynamic mode of the proximal fixation construct. Other areas of difference amongst the 2 units, were the length of hospital stay and return of patients to their pre-injury residence, most likely reflecting the different social circumstances between the 2 countries. Overall mortality at a median follow up period of 17 months (range 6 to 35) was limited to 6.3%, nonunion and cut out rates 2.7%, whilst revision surgery occurred in just 2.5%. Over the first 6 months of follow up 63.6% returned to their pre-injury ambulatory status and 90.5% to their pre-injury residence. Further studies and higher level of scientific evidence is needed to verify the findings of this retrospective cohort study as to the effectiveness and safety of this new cephalomedullary nail.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.