The use of endosteal substitution in the treatment of recalcitrant nonunions of the femur: report of seven cases

Distal femur fractures: basic science and international perspectives

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

[Periprosthetic acetabular fractures and defects : Trauma meets ortho]

BACKGROUND

Periprosthetic acetabular fractures are considered to be a severe and challenging complication in total hip arthroplasty. To date, there are no internationally applicable standardized recommendations which can assist orthopedic surgeons and trauma surgeons in the treatment of patients.

OBJECTIVE

The aim of this article is to report on the current state of knowledge on periprosthetic acetabular fractures, to present the commonly used classification systems and to demonstrate appropriate treatment algorithms together with personal experiences.

MATERIAL AND METHODS

A selective search of the existing literature was carried out and the commonly used classification systems and treatment options for periprosthetic acetabular fractures were compiled and are discussed in relation to the in-house cases.

RESULTS

The comparison of the classification systems showed that frequently only fractures which have a purely traumatic origin are included among periprosthetic acetabular fractures. Insufficiency fractures within the framework of acetabular defects, which also belong to the group of acetabular fractures, are frequently included in revision arthroplasty. The management of defects with appropriate implants represents a challenge. By the combination of osteosynthesis and implant replacement, the selection of implants can often be de-escalated.

CONCLUSION

Periprosthetic acetabular fractures represent a complex operation for both trauma surgeons and for specially trained orthopedic surgeons, which necessitate a high level of expertise. By the cooperation between trauma surgeons and orthopedic surgeons good treatment results can be achieved and recommendations for the selection of implants can be made.

Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions

PURPOSE

Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion.

METHODS

Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome.

RESULTS

In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty.

CONCLUSION

This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.

Endosteal plating for the treatment of malunions and nonunions of distal femur fractures

PURPOSE

To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting.

METHODS

We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented.

RESULTS

Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported.

CONCLUSION

A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality.

LEVEL OF EVIDENCE

Level IV (retrospective case series).

Autologous versus synthetic bone grafts for the surgical management of tibial plateau fractures: a systematic review and meta-analysis of randomized controlled trials

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

Methods

A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout.

Results

Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I² = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I² = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable.

Conclusion

All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision.

Cite this article: Bone Jt Open 2022;3(3):218–228.

Nail diameter significantly impacts stability in combined plate-nail constructs used for fixation of supracondylar distal femur fractures

Objectives:

Plate-nail (PN) combinations have been described for fixation of supracondylar distal femur fractures. Small diameter retrograde intramedullary nails (rIMN) are commonly used. The purpose of this study was to investigate the effect of nail diameter on construct stability. We hypothesized that a larger diameter rIMN would not significantly change the stiffness of the PN construct when tested in torsional or axial loading.

Methods:

Twelve synthetic osteoporotic femurs were used to compare nail diameters in an extraarticular supracondylar distal femur fracture model (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen type 33-A3). Constructs were fixed with a 12-hole 4.5 mm pre-contoured lateral distal femoral locking plate combined with either a 9 mm (n = 6) or an 11 mm (n = 6) retrograde intramedullary nail (rIMN). Specimens were cyclically loaded in torsion and axial compression. The primary outcome was construct stiffness, calculated using the average slope of the force-displacement curves.

Results:

The 11 mm PN construct was approximately 1.6 times stiffer than the 9 mm PN construct averaged across all torsional loads (2.39 +/− 0.41 Nm/deg vs 1.44 +/− 0.17 Nm/deg) and approximately 1.3 times stiffer than the 9 mm PN construct averaged across all axial loads (506.84 +/− 44.50 N/mm vs 376.77 +/− 37.65 N/mm). There were no construct failures.

Conclusions:

In this biomechanical model, nail diameter had a significant effect on both torsional and axial stiffness in PN constructs. While the use of smaller diameter rIMNs has been proposed to allow for easier placement of implants, the effect on overall construct stiffness should be considered in the context of the patient, their fracture and desired postoperative weight bearing recommendations.

Level of Evidence: N/A

Supplemental medial small fragment fixation adds stability to distal femur fixation: A biomechanical study

INTRODUCTION

Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model.

MATERIALS AND METHODS

Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57-68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz.

RESULTS

Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0-0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5-68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23-2.28 kN/degree, p = 0.03).

CONCLUSION

Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.

Endosteal substitution with medial plate in the treatment of acute distal femur fracture (AO/OTA type A): surgical technique and case-series

INTRODUCTION

Distal Femur fractures account for 4- 6% of all femur fractures and can be challenging to treat. The aims of this study are: (1) to describe a surgical technique using a medial distal femur endosteal plate to augment the stability of standard lateral plate fixation; (2) to report the results of a case-series of acute distal femur fractures (AO/OTA Type A/ Vancouver periprosthetic fractures Type C) treated using this technique.

METHODS

This study describes the surgical steps for placement of a medial endosteal plate in combination with lateral locking plate in a cadaver model using fluoroscopy guidance. In addition, a retrospective database chart review for all patients with acute distal femur fractures treated with this technique over the last five years was performed. Exclusion criteria were involvement of type B and C distal femur intraarticular fractures, treatment with other endosteal substitutions (i.e., intramedullary nail fixation and fibula allograft), and treatment for non-union or pathological fractures.

RESULTS

Twelve patients were identified with mean age of 75 years. All patients were female and all of them were allowed full weight bearing and full range of motion exercises immediately post-operatively. The complete follow up for one patient was not available; however, the mean fracture union was confirmed at 3.8 months in 10 of 12 patients. One patient had a failed construct at three months in the context of a periprosthetic fracture with a loose implant that was initially thought to be stable. One acute superficial surgical site infection was reported and healed uneventfully following debridement, primary closure, and antibiotic treatment.

CONCLUSION

We believe that the placement of a medial endosteal plate can be a useful augment for standard lateral plate fixation in acute distal femur fractures, particularly in the context of severe comminution or poor bone quality. Uneventful healing was confirmed in 10 of 12 cases and no patients were restricted with regard to motion or weight bearing immediately post-operatively. Further studies with larger sample size would be required to fully assess this technique.

LEVEL OF EVIDENCE

IV. Therapeutic Study (Surgical technique and Cases-series).

Ankle fracture classification using deep learning: automating detailed AO Foundation/Orthopedic Trauma Association (AO/OTA) 2018 malleolar fracture identification reaches a high degree of correct classification

Background and purpose - Classification of ankle fractures is crucial for guiding treatment but advanced classifications such as the AO Foundation/Orthopedic Trauma Association (AO/OTA) are often too complex for human observers to learn and use. We have therefore investigated whether an automated algorithm that uses deep learning can learn to classify radiographs according to the new AO/OTA 2018 standards.Method - We trained a neural network based on the ResNet architecture on 4,941 radiographic ankle examinations. All images were classified according to the AO/OTA 2018 classification. A senior orthopedic surgeon (MG) then re-evaluated all images with fractures. We evaluated the network against a test set of 400 patients reviewed by 2 expert observers (MG, AS) independently.Results - In the training dataset, about half of the examinations contained fractures. The majority of the fractures were malleolar, of which the type B injuries represented almost 60% of the cases. Average area under the area under the receiver operating characteristic curve (AUC) was 0.90 (95% CI 0.82-0.94) for correctly classifying AO/OTA class where the most common major fractures, the malleolar type B fractures, reached an AUC of 0.93 (CI 0.90-0.95). The poorest performing type was malleolar A fractures, which included avulsions of the fibular tip.Interpretation - We found that a neural network could attain the required performance to aid with a detailed ankle fracture classification. This approach could be scaled up to other body parts. As the type of fracture is an important part of orthopedic decision-making, this is an important step toward computer-assisted decision-making.

[Radiological diagnosis of pelvic ring fractures]

EPIDEMIOLOGY

Traumatic fractures of the pelvic ring are relatively rare, but are associated with increased risk of mortality. Depending on injury mechanism and main vector of energy impact, a distinction is made between anteroposterior compression, lateral compression, and vertical shear (Young and Burgess classification), while the stability-related classification according to Tile distinguishes between type A (stable), type B (rotationally unstable) and type C (completely unstable). A comprehensive modern classification is given by the AO/OTA.

RADIOLOGICAL FRACTURE DIAGNOSIS

Plain pelvis x‑rays lack sufficient sensitivity but are still used to detect highly unstable pelvic fractures. CT has superior sensitivity and specificity. In addition to fracture classification, CT allows reliable assessment of associated vascular and bladder/urethral injuries and large soft tissue hemorrhage. MRI is unparalleled in showing bone marrow edema, cauda and plexus complications, and peripelvic soft tissue damage. MRI may also prove to be a valuable diagnostic tool for pelvic ring injuries in children, adolescents and young women, provided they are hemodynamically stable. Angiography, ultrasonography and bone scintigraphy are additional important diagnostic and therapeutic options.

PRACTICAL RECOMMENDATIONS

Knowledge of basic pelvic trauma mechanisms is important to understand the potential severity of traumatic pelvic fractures and to classify them correctly in terms of stability. Being familiar with typical concomitant injuries in pelvic ring fractures allows reliable diagnosis and their communication with the clinician. CT remains the "diagnostic workhorse". In fragile pelvic fractures, the often prolonged course with fracture progression must be taken into account, which is why MRI is of particular importance herein.

Supplemental Fixation of Supracondylar Distal Femur Fractures: A Biomechanical Comparison of Dual-Plate and Plate-Nail Constructs

OBJECTIVES

This biomechanical study compares the effectiveness of dual-plate (DP) and plate-nail (PN) constructs for fixation of supracondylar distal femur fractures in synthetic and cadaveric specimens.

METHODS

Twenty-four synthetic osteoporotic femurs were used to compare 4 constructs in an extra-articular, supracondylar fracture gap model (OTA/AO type 33-A3). Constructs included: (1) distal lateral femoral locking plate (DLFLP), (2) retrograde intramedullary nail (rIMN), (3) DLFLP + medial locking compression plate (DP construct), and (4) DLFLP + rIMN (PN construct). DP and PN constructs were then directly compared using 7 matched pairs of cadaveric femurs. Specimens underwent cyclic loading in torsion and compression. Biomechanical effectiveness was measured by quantifying the load-dependent stiffness of each construct.

RESULTS

In synthetic osteoporotic femurs, the DP construct had the greatest torsional stiffness (1.76 ± 0.33 Nm/deg) followed by the rIMN (1.67 ± 0.14 Nm/deg), PN construct (1.44 ± 0.17 Nm/deg), and DLFLP (0.68 ± 0.10 Nm/deg) (P < 0.01). The DP construct also had the greatest axial stiffness (507.9 ± 83.1 N/mm) followed by the PN construct (371.4 ± 41.9 N/mm), DLFLP (255.0 ± 45.3 N/mm), and rIMN (109.2 ± 47.6 N/mm) (P < 0.05). In cadaveric specimens, the DP construct was nearly twice as stiff as the PN construct in torsion (8.41 ± 0.58 Nm/deg vs. 4.24 ± 0.41 Nm/deg, P < 0.001), and over one-and-a-half times stiffer in compression (2148.1 ± 820.4 vs. 1387.7 ± 467.9 N/mm, P = 0.02).

CONCLUSIONS

DP constructs provided stiffer fixation than PN constructs in this biomechanical study of extra-articular distal femur fractures. In the clinical setting, fracture morphology, desired healing mode, surgical approach, and implant cost should be considered when implementing these fixation strategies.

Short (175 mm) versus standard (220 mm) length intramedullary nail for trochanteric hip fractures: a randomized trial of 229 patients

AIMS

A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome.

METHODS

We randomized 229 patients with a trochanteric hip fracture between two implants: a 'standard' nail of 220 mm and a shorter nail of 175 mm, which had decreased proximal angulation (4° vs 7°) and a reduced diameter at the level of the lesser trochanter. Patients were followed up for one year by a nurse blinded to the type of implant used to determine if there were differences in mobility and pain with two nail designs. Pain was assessed on a scale of 1 (none) to 8 (severe and constant) and mobility on a scale of 1 (full mobility) to 9 (immobile).

RESULTS

The shorter nail did not require any reaming of the femur and was quicker to insert (mean difference 5.1 minutes; p < 0.001, 95% confidence interval (CI) of the difference 3.16 to 7.04). Those treated by the shorter nail were less mobile (mean difference in reduction in mobility score at one year 0.80; p = 0.007, 95% CI 1.38 to 0.22). In addition, there was a trend toward greater residual pain for those treated with the shorter nail, although this was not statistically significant (mean difference in pain score at one year 0.24; p = 0.064, 95% CI -0.01 to 0.49).

CONCLUSION

These results suggest that the increasing use of this very short intramedullary nail with its design modification may not be appropriate. Cite this article: Bone Joint J 2020;102-B(3):394-399.

Clinical outcomes of femoral shaft non-union: dual plating versus exchange nailing with augmentation plating

Background

By comparing clinical outcomes between dual plating (DP) and exchange nailing with augmentation plating (EN/AP), we aimed to provide better treatment strategies for femoral shaft non-union.

Methods

We retrospectively reviewed 30 patients with aseptic femoral shaft non-union at our level 1 trauma center between January 2014 and January 2017. All patients underwent a one-stage, definitive revision procedure, including DP for 16 patients and EN/AP for 14 patients. Perioperative surgical trauma, fracture healing, complications, and the time to return to work were evaluated.

Results

Twenty-nine patients achieved fracture healing. In the EN/AP group, the fracture healing rate was 100%, the healing time was 5.7 ± 1.7 months, and the time of return to work was 8.2 ± 2.9 months. In the DP group, the fracture healing rate was 94%, the healing time was 8.4 ± 4.1 months, and the time of return to work was 18.4 ± 10.3 months. In terms of fracture healing and return to work, the patients in the EN/AP group required less time than those in the DP group, and the differences were statistically significant (p = 0.024 and p < 0.01 respectively). Except for the length of the incision, the two groups showed no statistically significant differences in operative time, postoperative deformity, and complications.

Conclusions

Both EN/AP and DP are important surgical options for femoral shaft non-union. Compared to DP, EN/AP resulted in a shorter incision, faster fracture healing, and a shorter time to return to work.

Trial registration

ChiCTR-ORC-17014062

Ankle Fracture-Dislocations

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

[Recent advances in treatment of aseptic femoral shaft nonunion]

Objective

To review the recent advances in treatment of aseptic femoral shaft nonunion.

Methods

The clinical studies about the treatments of aseptic femoral shaft nonunion in recent years were widely reviewed and analyzed.

Results

There are several surgical methods for aseptic femoral shaft nonunion. Due to uncertain clinical outcome, dynamization of nail should be carefully selected. The exchange nailing is suitable for the hypertrophic nonunion of the isthmal femoral shaft fracture. The exchange lateral plating is suitable for nonunion with obvious malformation. However, wave plate or dual plate should be chosen when the bone nonuinon is combined with the medial defect. The augmentation plating improves the success rate of nailing for femoral shaft nonunion, but it should be carefully selected for patients with obvious deformity or bone defect. Ilizarov technique is suitable for various bone nonunion, especially with complicated or large segmental bone defects. Induced membrane technique is also an important method for the treatment of bone nonunion with large bone defects. The clinical efficacy of the blocking screw remains to be supported by further evidence. Biological stimulants are mainly used for atrophic nonunion, and the clinical efficacy of them alone are still controversial.

Conclusion

Due to lack of comparative studies between different surgical methods, the orthopedist should choose the appropriate treatment according to the individual situations of the patient and the types of bone nonunion.

Endosteal Substitution With an Intramedullary Rod in Fractures of the Femur

BACKGROUND

Morbid obesity and segmental fracture/bone loss are challenging problems in the treatment of fractures and nonunions of the distal femur. The use of an intramedullary rod as an endosteal substitute for a deficient medial cortex along with a lateral locked plate is 1-tool to combat these problems. This article describes the technique used and its results at a single Level 1 trauma center.

METHODS

Retrospective chart and radiographic review of all patients treated for acute fractures and nonunions of the distal femur using endosteal substitution with an intramedullary nail and a lateral locked plate. Fixation construct was determined at the surgeon's discretion and was strongly influenced by bone loss and patient body habitus.

RESULTS

Seven of 8 acute fractures and 8 of 8 nonunions healed without an unplanned reoperation. There were no cases of secondary displacement after fixation, and only 1 unplanned reoperation in the study group.

CONCLUSION

Endosteal substitution with an intramedullary rod and the use of a lateral locked plate provides the stability needed to allow bone healing under prolonged or supraphysiologic loads seen in morbid obesity or segmental bone loss.

LEVEL OF EVIDENCE

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

Percutaneous Application of a Medial Plate for Dual Plate Stabilization of Supracondylar Femur Fractures

Supracondylar femur fractures with segmental defects can be difficult fractures to treat. When associated with open wounds, these injuries can be associated with numerous complications including nonunion, malunion, infection, and arthrofibrosis. In this article, we review our algorithm for treating these fractures and highlight critical aspects of the process which differs from previous techniques described. We feel that this technique has specific benefits that mitigate infection risk and minimize additional soft-tissue insult without compromising stability. Our results demonstrate good postoperative knee range of motion, a high union rate, with low complication rates.

Radiographic diagnosis of sagittal plane rotational displacement in pelvic fractures: a cadaveric model and clinical case study

PURPOSES

Our objective was to measure the sagittal plane rotational (flexion and extension) displacement of hemipelvis radiologically and analyze the ratio of flexion and extension displacement of unstable pelvic fractures.

METHODS

We used 8 cadaveric models to study the radiographic evidence of pelvic fractures in the sagittal plane. We performed pelvic osteotomy on 8 cadavers to simulate anterior and posterior pelvic ring injury. Radiological data were measured in the flexion and extension group under different angles (5°, 10°, 15°, 20°, and 25°). We retrospectively reviewed 164 patients who were diagnosed with a unilateral fracture of the pelvis. Pelvic ring displacement was identified and recorded radiographically in cadaveric models.

RESULTS

The flexion and extension displacement of pelvic fractures was measured in terms of the vertical distance of fracture from the top of iliac crest to the pubic tubercle (CD) or from the top of iliac crest to the lowest point of ischial tuberosity (AB). Fifty-seven pelves showed flexion displacement and 15 showed extension displacement. Closed reduction including internal fixation and external fixation was successfully used in 141 cases (86.0 %). The success rates of closed reduction in flexion and extension displacement groups were 77 and 73 %, respectively, which were lower than in unstable pelvic ring fractures.

CONCLUSIONS

The sagittal plane rotation (flexion and extension) displacement of pelvic fractures could be measured by special points and lines on the radiographs. Minimally invasive reduction should be based on clearly identified differences between the sagittal plane rotation and the vertical displacement of pelvic fractures.

A challenging case of limb salvage requiring a combination of composite fixation and masquelet technique to address significant segmental bone loss

Cases of limb salvage following skeletal trauma involving significant bone loss pose a particular challenge to the reconstructive surgeon. Certain techniques for addressing this complex issue have been advanced in recent years and have met with considerable success. The Masquelet technique involves a staged procedure in which a temporary skeletal stabilization is paired with implantation of an antibiotic spacer and left in place for 6–8 weeks, during which time a “pseudomembrane” forms around the cement spacer. During the second stage of the procedure, the pseudomembrane is incised, the antibiotic spacer removed, and bone graft is placed. We present a case of significant segmental femur loss in a 19-year-old male opting for limb salvage in which a 17-centimeter segmental loss of bone was essentially regrown using a combination of the Masquelet technique with supplemental endosteal fixation.

Effect of teriparatide on unstable pertrochanteric fractures

We retrospectively analyzed the radiographic and clinical outcomes of unstable pertrochanteric fractures (AO/OTA 31-A2) in 44 patients who underwent dynamic hip screw (DHS) fixation and compared the results with 29 patients who received teriparatide in addition to DHS fixation. A significantly shorter time for fracture healing was recorded in the teriparatide-treated group than in the control group. Rates of lag screw sliding, femoral shortening, and varus collapse were all significantly reduced in the teriparatide-treated group. There were no significant differences with regard to superficial wound infection, pneumonia, urinary tract infection, mortality, malunion, and cutting of the lag screw. The mean overall mobility scores were significantly better in the teriparatide-treated group at 3 and 6 months (P < 0.001 and P < 0.001, resp.) but not at 12 months or the last follow-up. The pain scores were also significantly better in the teriparatide-treated group at 3 and 6 months (P = 0.040 and P = 0.041, resp.) but not at 12 months or the last follow-up. Teriparatide improves radiographic outcomes and yields better clinical outcomes at 3 and 6 months postoperatively. The improvement in union time may be important for elderly populations with unstable pertrochanteric fractures to enable them to return to daily activities and reduce morbidity and mortality.

Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture: a retrospective study using a multivariate analysis

INTRODUCTION

It has recently been reported that the cases with an anterior femoral neck cortex posterior to the distal fragment (subtype P) in the lateral view of a postoperative radiograph have a risk of excessive sliding of lag screws compared to those located anterior to the distal fragment (subtype A) or perfectly continuous to the distal fragment (subtype N) following osteosynthesis for the treatment of a trochanteric fracture. The purpose of this study was to investigate factors that influence the postoperative subtype in the lateral view of radiographs.

PATIENTS AND METHODS

This study reviewed 136 patients who underwent osteosynthesis using an intramedullary hip nail for the treatment of a trochanteric fracture. A closed reduction was performed in 130 patients (95.6 %), while a direct reduction via a small elevator with a small skin incision was performed in the other six patients (4.4 %). The 136 patients were divided into two groups (subtype P and subtype A or N) based on postoperative radiographs taken of the lateral view. Both clinical and radiological factors were analyzed using the univariate and multivariable analyses.

RESULTS

Thirty-nine patients (29 %) were categorized as subtype P and 97 patients (71 %) were categorized as subtype A or N. A multivariate analysis demonstrated that unstable fractures were associated with a significant risk of postoperative subtype P (Odds ratio: 24.45, P = 0.0024).

CONCLUSIONS

The results of this study suggest that direct reduction via a small elevator with a small skin incision or percutaneous intrafocal pinning may be needed in these cases.

Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial

PURPOSE

The reduction of periosteal compression through the use of a locking plate may minimize disturbances of bone blood supply and may improve the rate of bone union. A single-centre, assessor blinded randomized controlled trial was conducted to compare the clinical effectiveness of a locking plate and a non-locking plate.

METHODS

A total of 52 patients with AO/OTA 44B lateral malleolar fractures were included in this study. All patients underwent surgical fixation using a lag screw and neutralization plate. An identical treatment protocol was used in all patients, with exception of plate selection. The rate of radiographic bone union, defined as the complete disappearance of fracture lines confirmed through anteroposterior, lateral, and internal oblique views was compared at three, six, and 12 months following surgery. In addition, the Medical Outcomes 36-Item Short-Form Health Survey (SF-36) score, the time required for resolution of tenderness at the fracture site and the complication rate were evaluated.

RESULTS

Twenty-three patients were randomly assigned to undergo fixation using a locking plate, and 29 patients were assigned to undergo fixation using a non-locking plate. Intention-to-treat analysis showed no difference in the radiographic bone union rate of fibula, SF-36 score, the time for resolution of tenderness at the fracture site and complication rates.

CONCLUSION

No differences were observed in patients with AO/OTA 44B lateral malleolar fractures undergoing fixation with a locking versus non-locking neutralization plate.

Operative treatment for femoral shaft nonunions, a systematic review of the literature

The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.

Currents of plate osteosynthesis in osteoporotic bone

Osteoporotic fractures are becoming more prevalent with ageing of populations worldwide. Inadequate fixation or prolonged immobilization after non-surgical care leads to serious life-threatening events, poor functional results and lifelong disability. Thus, a stable internal fixation and rapid initiation of rehabilitation are required for faster return of function. Conventional internal fixation attempts to achieve the exact anatomy, often with extended soft-tissue stripping and compression of the periosteum, causing disturbance of the metaphyseal and comminuted fracture's bone blood supply. This technique relies on frictional forces between bone and plate. Osteoporotic bone might not be able to generate enough torque with the screw to securely fix the plate to bone. Thus, this surgical management have resulted in increased incidence of poor results in elderly, osteoporotic patients. The newly developed locked internal fixators, locking compression plates and less invasive stabilization system, consist of plate and screw systems where the screws are locked in the plate, minimizing the compressive forces exerted between plate and bone. Thus, the plate does not need to compress the bone nor requires precise anatomical contouring of a plate disturbing the periosteal blood supply. These fixators allowed the development of the minimal invasive percutaneous osteosynthesis. Nowadays, locking plates are the fixation method of choice for osteoporotic, diaphyseal or metaphyseal, severely comminuted fractures.

Augmentation of implant fixation in osteoporotic bone

Osteoporosis presents a dilemma for the orthopedic surgeon. Screw fixation within the bone is crucial for mechanical stabilization, maintenance of reduction, and ultimately, fracture healing. For the patient, soft bones and physiological fragility usually benefit from immediate weight bearing and mobility to avoid further disuse osteoporosis, deconditioning, and immobility. For implant companies, traditional screws, plates, and nails function for simple fractures and compliant patients. Locked plating has improved screw purchase in osteoporotic bone and has expanded fracture fixation capabilities but is not the panacea for all fractures. For orthopedic surgeons, traditional surgical augmentation for osteoporosis consisting of dual plating, augmentation with polymethyl methacrylate, joint replacement, and now locked plating are beneficial. In order to advance orthopedic care in the expanding population of elderly osteoporotic patients, modern solutions utilizing the dual properties of secure fixation and relatively flexible implants are required. Endosteal substitution, extraosteal substitution, and combined nail/plate combinations are methods of utilizing traditional implants in a nontraditional way. Nonsurgical augmentation of fracture fixation is also paramount.

Postoperative stability on lateral radiographs in the surgical treatment of pertrochanteric hip fractures

BACKGROUND

Fixed-angle sliding hip-screw devices are commonly used to treat pertrochanteric fractures. The controlled impaction between the head and neck fragment and the femoral shaft fragment is crucial. However, the poor quality of fracture reduction can intercept controlled impaction and lead to excessive sliding. We hypothesized that excessive sliding occurs when most of the impaction is placed on the fragile posterior cortex of the fracture site.

METHODS

This retrospective study included 128 AO/OTA type 31-A1 or 31-A2 fractures treated with fixed-angle sliding hip-screw devices. Cases involving reduced continuity of the anterior cortex at fracture site were defined as Type 1, those involving head and neck fragment anteriorly displaced relative to the femoral shaft fragment as Type 2, and those involving head and neck fragment posteriorly displaced relative to the femoral shaft fragment as Type 3. The extent of postoperative sliding distance of lag screw was measured.

RESULTS

There were 52 cases of Type 1, 30 of Type 2, and 46 of Type 3, with no differences in patient characteristics between types. The mean ± standard deviation extent of sliding for types 1-3 was 4.5 ± 4.9 mm, 7.8 ± 5.6 mm, and 11.1 ± 6.0 mm, respectively (p < 0.0001). Sliding was significantly greater for Type 3 cases than for Type 1 or 2 (p < 0.0001 and p = 0.044, respectively).

CONCLUSIONS

Excessive sliding occurs in surgical treatment for pertrochanteric fractures with posterior displacement of the head and neck fragment. In such cases, we recommend appropriate reduction prior to internal fixation.

Complications relating to accuracy of reduction of intertrochanteric fractures treated with a compressive hip screw

Intertrochanteric fracture is the most frequent type of fracture in the proximal femur and the compressive hip screw is one of the most popular methods of treatment. The reduction criteria for this type of fracture are ill-defined. The purpose of this study was to validate 3 reduction criteria: displacement, alignment in the anteroposterior and in the lateral plane. We reviewed a cohort of 430 intertrochanteric fractures treated with a compression hip screw. The type of fracture, quality of reduction and technical complications were noted. We observed a relationship between accuracy of reduction and the incidence of complications, even among fractures of the same severity. A displacement bigger than 4mm and failure to accomplish correct alignment (a neck-shaft angle over 125 masculine and less than 20 degrees angulation on the lateral view) was considered a poor reduction and was associated with more complications.

Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes?

There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Pelvic trauma with displaced sacral fractures: functional outcome at one year

STUDY DESIGN

A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with displaced sacral fractures.

OBJECTIVE

To describe the medium term functional outcome in unstable sacral fractures.

SUMMARY OF BACKGROUND DATA

Displaced sacral fractures pose a special challenge in orthopedic surgery due to the high rate of associated injuries. Little information is available on the medium-term functional outcome of patients with injuries which include unstable sacral fractures.

METHODS

We examined 31 patients with displaced sacral fractures having 10 mm or more displacement, 1 year (mean, 1.4 years; range, 1.0-2.5 years) after injury. Data from a previous study were supplemented with functional outcome measures (work status, independence in ADL, and SF-36). An association between outcome and tested variables was sought.

RESULTS

Fifteen months after injury, 65% of the patients had regained their independence in functions pertaining to daily activities; 33% had returned to work. All dimensions of perceived health were affected. Polytrauma and impairments relative to voiding and sexual function had a detrimental effect on outcome. Fracture characteristics were not predictive of poor outcome.

CONCLUSIONS

Although the majority of patients achieved independent living, medium-term follow-up indicated significant residual disability. The complex nature of these fractures and the associated injuries should be considered in the rehabilitation of these patients.

Acute midshaft clavicular fracture

Clavicular fractures represent 2.6% to 5% of all fractures, and middle third fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; the nonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.

Intramedullary strut substitution and impaction allografting cemented revision for the treatment of a periprosthetic fracture in a severely compromised femur

Revision for the treatment of a B3 periprosthetic femoral fracture often requires proximal femoral allograft arthroplasty in physiologically young or tumor prostheses in elderly patients. Extramedullary strut allograft augmentation can only be used when the host femur is structurally adequate for the insertion of the revision stem (periprosthetic femoral fractures type B2) and appears to be an attractive biological concept as early incorporation to the host bone results in a sound biomechanical construct. We report here the simultaneous use of whole femur intramedullary strut substitution along with an extramedullary strut graft placement, with impaction allografting revision to a long cemented femoral prosthesis, to augment the deficient metadiaphyseal bone stock (Paprosky type IV) for the treatment of a complex type B3 periprosthetic femoral fracture.

Radiographic measurement techniques for sacral fractures consensus statement of the Spine Trauma Study Group

STUDY DESIGN

Literature review.

OBJECTIVES

Members of the Spine Trauma Study Group evaluated various imaging methods and compiled standardized approaches to making radiographic measurements for the assessment of sacral fractures.

SUMMARY OF BACKGROUND DATA

The diagnosis of sacral fractures is frequently missed or delayed, and the treatment is controversial, with significant variations in recommendations regarding nonoperative treatment, neural decompression, and internal fixation. A paucity of specific radiographic measurements and criteria exist to aid the clinician in making sound treatment decisions. This may obligate surgeons to base clinical decisions on nonstandardized, nonvalidated recommendations and measures and, in some cases, anecdotal evidence. We think that a critical first step toward valid and optimal clinical decision-making requires an accurate and clear definition of imaging measurement parameters used to evaluate sacral injuries and gather data for future studies.

METHODS

A review of the English-speaking literature was performed to assess cited radiographic measurement techniques of sacral fractures currently in use. This allowed the formulation of detailed radiographic assessments designed to more reliably describe sacral fracture morphometry.

RESULTS

These measurements include: anterior-posterior sacral fracture displacement (axial computed tomography [CT] of the pelvis), vertical sacral fracture displacement (coronal CT reconstruction), anterior-posterior translation and kyphotic angulation (sagittal CT reconstructions), and degree of central canal involvement and foraminal encroachment (axial CT with fine cuts and coronal and sagittal reconstructions). Other radiographic factors that should be considered that may impact treatment outcomes include the level and type of sacral fracture, lumbosacral junction and sacroiliac joint involvement, and associated pelvic ring injury.

CONCLUSIONS

With adoption of these radiographic guidelines, future studies will have a uniform method in which to describe sacral injuries and therefore allow study of the efficacy of various recommended treatment protocols.

Reconstruction with Distraction Osteogenesis for Juxta-articular Nonunions with Bone Loss

BACKGROUND

Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis.

METHODS

Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation.

RESULTS

Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two.

CONCLUSION

Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.

Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating

BACKGROUND

Bicondylar tibial plateau fractures are complex injuries, historically associated with high complication rates. The purpose of this study was: 1) to evaluate the clinical use L.I.S.S plating system for stabilization of bicondylar tibial plateau fractures. 2) To compare the biomechanics of this plating system with a double plate construct.

METHODS AND MATERIALS

Thirty-eight patients who sustained a complex tibial plateau fracture (OTA type 41C) at one of three level-one trauma centers were stabilized using the Less Invasive Stabilization System (L.I.S.S.). The cohort of patients was evaluated clinically and radiographically for outcomes at a mean 15 months. In phase 2 of this study a model of a bicondylar tibial plateau fractures was made in six matched pairs of embalmed, human tibia and randomized to fixation with either a L.I.S.S plate or a standard double plate construct. The tibias were then subjected to an axial cyclic load of 500N for 10 cycles (3Hz) to approximate 2 months in vivo and displacements measured.

RESULTS

Thirty-six of /38 (95%) patients united at 4 months after surgery with no loss of fixation nor infection. Two patients underwent prophylactic autogenous bone grafting for bone loss and united by 3 months postgrafting. Significant loss of knee range of motion (<90) was seen in five patients.Biomechanically, no differences in permanent inferior displacement of the medial fragment were found in initial axial loading and after 10 cycles between the two plate constructs. However, when loaded to 500N the L.I.S.S plate construct demonstrated almost twice the displacement of the medial fragment compared with the dual plate construct. No specimen lost fixation during cycling.

CONCLUSION

The L.I.S.S plating system provides stable fixation of complex bicondylar tibial plateau fractures allowing early range of knee motion with favorable clinical results.

Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system

OBJECTIVE

Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. The Less Invasive Skeletal Stabilization (LISS) internal fixator system has theoretical advantages (minimally invasive fixed angle construct) for the treatment of these injuries. This report presents clinical results of the LISS system for treatment of complex proximal tibia fractures and illustrates the unique properties of the system.

DESIGN

Prospective clinical trial.

SETTING

Level I trauma center.

PATIENTS

Twenty-eight consecutive patients with comminuted proximal tibia metaphyseal fractures (41A3, 41C2, or 41C3) treated with LISS plates.

OUTCOME MEASUREMENTS

Healing, fracture alignment, infectious and implant-related complications, and functional outcome based on the Lower Extremity Measure (LEM).

RESULTS

Average follow-up was 23 months (range 12-48). Thirty-seven of 38 patients healed their fracture after the index procedure. The other healed after implant removal without the need for further fracture repair. Postoperative fracture alignment was satisfactory in 37 of the 38 cases and was maintained in all patients at union. There were no infectious complications. The average LEM score was 88.

CONCLUSIONS

The LISS internal fixator system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use fixed angle internal fixation plating systems should familiarize themselves with the significant technical differences between these and traditional plating systems to assure satisfactory results.

Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures

OBJECTIVE

To summarize the complications and early clinical results of 123 distal femur fractures treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA).

DESIGN

Retrospective analysis of prospectively enrolled patients.

SETTING

Two academic level I trauma centers.

SUBJECTS AND PARTICIPANTS

One hundred nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 fractures) treated by 3 surgeons. One hundred three fractures (68 closed fractures and 35 open fractures) in 99 patients were followed up at least until union (mean follow-up = 14 months, range: 3-50 months).

INTERVENTION

Surgical reduction and fixation of distal femur fractures.

MAIN OUTCOME MEASUREMENTS

Perioperative complications, radiographic union, infection rate, loss of fixation, alignment, and range of motion.

RESULTS

Ninety-six (93%) of 103 fractures healed without bone grafting. All fractures eventually healed with secondary procedures, including bone grafting (1 of 68 closed fractures and 6 of 35 open fractures). There were 5 losses of proximal fixation, 2 nonunions, and 3 acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed. Malreductions of the femoral fracture were seen in 6 fractures (6%). The mean range of knee motion was 1 degrees to 109 degrees .

CONCLUSIONS

Treatment of distal femur fractures with the LISS is associated with high union rates without autogenous bone grafting (93%), a low incidence of infection (3%), and maintenance of distal femoral fixation (100%). No loss of fixation in the distal femoral condyles was observed despite the treatment of 30 patients older than 65 years. The LISS is an acceptable surgical option for treatment of distal femoral fractures.

Locking compression plates for osteoporotic nonunions of the diaphyseal humerus

Poor bone quality increases the technical difficulty and complications of operative treatment of nonunions and delayed unions of the diaphyseal humerus in older patients. Plates with screws that lock to the plate (transforming each screw into a fixed blade) are intended to improve the fixation of poor quality bone. Twenty-four patients (20 women, four men) with an average age of 72 years (range, 52-86 years) were followed up for a minimum of 12 months after locking compression plate fixation of an osteopenic delayed union (nine patients) or nonunion (15 patients) of the diaphyseal humerus. Twelve patients had iliac crest cancellous bone grafts, two patients had local graft, and 13 patients had demineralized bone applied to the fracture site. All the fractures eventually healed; two healed after a second procedure for autogenous bone grafting in patients who initially received demineralized bone. Using a modification of the Constant and Murley shoulder score, the results were good or excellent in 22 patients, and fair in two patients. Locking compression plates provide stable fixation of poor quality bone in patients with delayed union or nonunion of the humerus. Successful union and restoration of function are achieved in most patients. We no longer consider osteoporosis a contraindication to operative fixation of an ununited fracture of the humeral diaphysis.

Pelvic trauma in rapidly fatal motor vehicle accidents

OBJECTIVE

To study the incidence and nature of pelvic fractures in rapidly fatal automobile accidents.

DESIGN

Retrospective.

SETTING

County Medical Examiner's Office.

PATIENTS

The files of 255 consecutive motor vehicle accident fatalities examined at the Jefferson County Coroner/Medical Examiner's office (study period 1996-1998) were reviewed. We correlated this information with our previous findings, derived from a review of 392 such cases (study period 1994-1996).

RESULTS

Approximately 25% of decedents involved in rapidly fatal automobile accidents sustained pelvic fractures. In 93% of the cases, postmortem radiographs were available and suitable for scoring according to the Orthopaedic Trauma Association nomenclature. The distribution of pelvic fractures by type was type A, 16%; type B, 32%; and type C, 52%, with the most common pelvic fracture being type C1 (26%). Additionally, pedestrians and motorcyclists were twice as likely to sustain a pelvic fracture, and the severity of pelvic fracture type seemed to correlate with increasing speed of the automobile. No correlation between drug use or direction of impact and incidence or type of pelvic fracture was observed. Compared with published studies on survivors of automobile accidents, our data suggest that pelvic injuries may tend to be more severe in victims who do not survive to hospitalization.

CONCLUSIONS

Our data indicate that current estimates about the mortality of pelvic fractures may be faulty due to exclusion of victims who fail to survive to hospitalization. This series suggests that an appreciation of the full spectrum of pelvic ring disruptions requires collaboration between orthopaedic surgeons and forensic pathologists.

Ununited diaphyseal fractures of the humerus: techniques for fixation of osteoporotic bone

The elderly population is larger, healthier, and more active than ever. Osteoporosis-related fractures and their sequelae are becoming more commonplace. Successful management of these problems requires adequate internal fixation of osteoporotic bone. Fixation of osteoporotic bone has evolved from the use of cement or allograft-augmented screws to fixed-angle plates, and now to fixed-angle screws that thread into and engage solidly the hole in the plate, creating a fixed blade. Familiarity with these techniques may facilitate the care of elderly patients requiring operative fracture care.

Treatment of osteoporotic fractures

Fractures are the most common problem associated with osteoporosis and despite advances in prevention and treatment of osteoporosis the number of fractures continue to increase. Along with the three classic locations hip, spine and wrist, there are several other fractures that commonly are related to osteoporosis. The weak bone makes it difficult to achieve a stable bone-implant construct and general weakness of the patient often prevents reduction of load on the injured extremity during healing. The main treatment goal should be preservation of function even at the expense of restoration of exact anatomy. By development of dynamic load-sharing implants and less invasive techniques the results following fixation of osteoporotic fractures has improved. A new strategy has also been to develop materials that will enhance the strength of the cancellous bone that surrounds the metal implant. By using bioactive cement in conjunction with metal implants improved strength has been shown in internally fixed metaphyseal fractures. Encouraging results have also been reported after cement injection into compressed vertebral fractures, so called vertebroplasty. The specific demands involved in the treatment of osteoporotic fractures calls for specific solutions. Apart from augmentation of the cancellous bone and development of new load-sharing devices, endoprosthetic replacement with specially designed fracture prosthesis has become more frequent.

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries

BACKGROUND

Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.

METHODS

We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization.

RESULTS

At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively).

CONCLUSIONS

Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.

Endosteal substitution with an allograft cortical strut in the treatment of a periprosthetic femur fracture: a case report

The use of allograft cortical struts in the treatment of periprosthetic fractures of the femur has been well described. Allograft struts are used to supplement cerclage wire fixation or may be placed outside the cortex opposite plate and screw fixation to improve screw fixation in osteoporotic bone. This generally requires extensive soft tissue stripping and may lead to delayed bony union. A technique is described wherein an allograft strut was inserted into the medullary canal through the fracture site and used as an endosteal substitution for osteoporotic cortical bone. This technique can improve screw fixation in osteoporotic bone while avoiding devascularization of the fractured femur.