Distal Femoral Replacement for Fractures Allows for Early Mobilization with Low Complication Rates: A Multicenter Review.

Periprosthetic fractures around a total knee arthroplasty (TKA), comminuted and intra-articular femur fractures, or fracture nonunions in osteoporotic bone represent technically challenging problems. This is particularly true when the fracture involves a loose femoral component or the pattern results in suboptimal fixation potential. These clinical indications often arise in an older and comorbid patient population in whom a principal goal of treatment includes allowing for early mobilization. Limited data indicate that arthroplasty via distal femoral replacement (DFR) is a reasonable alternative to open reduction and internal fixation, allowing for early ambulation with low complication rates. We performed a retrospective review of trauma and arthroplasty surgeries at three tertiary referral institutions. Adult patients treated for the above with a DFR were included. Patients with active infection, open and/or high-energy injuries and revisions unrelated to fracture were excluded. Patient demographics, treatment details, and outcomes were assessed. Between 2002 and 2017, 90 DFR's were performed for the above indications with a mean follow-up of 24 months. Postoperatively, 80 patients (88%) were allowed to weight bear as tolerated, and at final follow-up, 9 patients (10%) remained dependent on a wheelchair. The average arc of motion at final follow-up was 95 degrees. There were seven (8%) implant-related complications requiring secondary surgeries: two infections, one with associated component loosening; one fracture of the hinge mechanism and one femoral component failure in conjunction with a patellofemoral dislocation (both requiring revision); one case of patellofemoral arthrosis in a patient with an unresurfaced patella; one periprosthetic fracture with associated wound dehiscence; and one case of arthrofibrosis. In each of these cases, only modular components of the DFR were exchanged. All nonmodular components cemented into the femur or tibia were retained. DFR provides a viable reconstruction option in the treatment of acute distal femur fractures, periprosthetic femur fractures, and fracture nonunions. We noted that in an elderly patient population with high comorbidities, the complication and secondary surgery rates remained relatively low, while allowing for immediate weight bearing.

Does the Angle of the Nail Matter for Pertrochanteric Fracture Reduction? Matching Nail Angle and Native Neck-Shaft Angle.

OBJECTIVES: To determine whether fixation of pertrochanteric hip fractures with cephalomedullary nails (CMNs) with a neck-shaft angle (NSA) less than the native NSA affects reduction and lag screw cutout. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients treated with a CMN for unstable pertrochanteric femur fractures (OTA/AO 31-A2.2 and 31-A2.3) between 2005 and 2014. INTERVENTION: CMN fixation. MAIN OUTCOME MEASUREMENT: NSA reduction and lag screw cutout. RESULTS: Patients fixed with a nail angle less than their native NSA were less likely to have good reductions [17% vs. 60%, 95% confidence interval (CI), -63% to -18%; P = 0.0005], secondary to more varus reductions (41% vs. 10%, 95% CI, 9%-46%; P = 0.01) and more fractures with ≥4 mm of displacement (63% vs. 35%, 95% CI, 3%-49%; P = 0.03). The cutout was not associated with the use of a nail angle less than the native NSA (60% vs. 76%, 95% CI, -56% to 18%; P = 0.5), varus reductions (60% vs. 32%, 95% CI, -13% to 62%; P = 0.3), or poor reductions (20% vs. 17%, 95% CI, -24% to 44%; P = 1.0). CONCLUSIONS: The fixation of unstable pertrochanteric hip fractures with a nail angle less than the native NSA was associated with more varus reductions and fracture displacement but did not affect the lag screw cutout. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Allgöwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography.

OBJECTIVE: The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. DESIGN: Prospective, randomized. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. MAIN OUTCOME MEASUREMENTS: Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. RESULTS: Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. CONCLUSIONS: The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

All-Polyethylene Tibial Components: An Analysis of Long-Term Outcomes and Infection.

BACKGROUND: There is debate regarding tibial component modularity and composition in total knee arthroplasty (TKA). Biomechanical studies have suggested improved stress distribution in metal-backed tibias; however, these results have not translated clinically. The purpose of this study was to analyze the outcomes of all-polyethylene components and to compare the results to those with metal-backed components. METHODS: We reviewed 31,939 patients undergoing a primary TKA over a 43-year period (1970-2013). There were 28,224 (88%) metal-backed and 3715 (12%) all-polyethylene tibial components. The metal-backed and all-polyethylene groups had comparable demographics with respect to gender, age and body mass index (BMI). Mean follow-up was 7 years. RESULTS: The mean survival for all primary TKAs at the 5-, 10-, 20- and 30-year time points was 95%, 89%, 73%, and 57%, respectively. All-polyethylene tibial components were found to have a significantly improved (P < .0001) survivorship when compared with their metal-backed counterparts. All-polyethylene tibial components were also found to have a significantly lower rate of infection, instability, tibial component loosening, and periprosthetic fracture. The all-polyethylene group had improved survival rates in all age groups, except in patients 85 years old or greater, where there was no significant difference. All-polyethylene tibial components had improved survival for all BMI groups except in the morbidly obese (BMI ≥ 40) where there was no significant difference. CONCLUSION: All-polyethylene tibial components had significantly improved implant survival, reduced rates of postoperative infection, fracture, and tibial component loosening. All polyethylene should be considered for most of the patients, regardless of age and BMI.

Does Ankle Aspiration for Acute Ankle Fractures Result in Pain Relief? A Prospective Randomized Double-Blinded Placebo Controlled Trial.

OBJECTIVES: Does ankle aspiration help with pain control in patients with ankle fractures? DESIGN: Prospective, double-blind, randomized, placebo-controlled trial. SETTING: Level 1 Academic Medical Center. PATIENTS/PARTICIPANTS: Consecutive skeletally mature patients with ankle fractures. INTERVENTION: Randomized between ankle aspiration and sham procedure. MAIN OUTCOME MEASUREMENTS: Pain scores for 72 hours after injury and pain medicine usage. RESULTS: Comparison between study subjects receiving ankle aspiration and sham procedure showed no significant differences in pain scores acutely in the emergency department or within 3 days after injury. There were also no statistically significant differences in pain medicine usage within 3 days after injury. Secondary outcomes, including lower leg volume, 6-month functional outcome scores, and complication rate, also showed no significant differences between subjects receiving aspiration and the sham procedure. CONCLUSIONS: Aspiration of acute ankle fractures does not result in decreased pain scores or opioid usage after aspiration. Aspiration of acute ankle fractures does not provide measurable clinical benefit. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Catastrophic Head-Neck Dissociation of a Modular Cementless Femoral Component.

CASE: We report two cases of modular head-neck junction failure involving the Stryker Accolade TMZF stem leading to sudden dissociation of the femoral head from the stem. Both patients presented with mechanical symptoms in the hip followed by pain and hip dysfunction. Disassembly of the head and deformation of the male taper were seen on preoperative radiographs. Intraoperatively, both patients had substantial metallosis with a markedly damaged taper requiring stem revision. CONCLUSION: We recommend regular clinical and radiographic surveillance of patients with the Stryker Accolade TMZF stem, especially those patients with pain and/or mechanical symptoms.

Campylobacter prosthetic joint infection.

A 75-year-old man was diagnosed with probable Campylobacter jejuni prosthetic knee infection after a diarrheal illness. Joint aspirate and operative cultures were negative, but PCR of prosthesis sonicate fluid was positive, as was stool culture. Nineteen additional cases of Campylobacter prosthetic joint infection reported in the literature are reviewed.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures.

Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

Total hip arthroplasty for femoral neck fracture: comparing in-hospital mortality, complications, and disposition to an elective patient population.

Patients treated with total hip arthroplasty (THA) for osteoarthritis (OA) and femoral neck fracture (FNF) between 1990-2007 were compared using the National Hospital Discharge Survey (NHDS). In-hospital, post-operative complications and disposition were compared at six-year intervals to establish trends over time. A total of 2,160,061 THAs were performed for OA, while 174,641 were performed for FNF. Peri-operative mortality and pulmonary embolism rates following elective THA were lower at each interval when compared to THA performed for FNF (P<0.001). Hematomas, infections, and dislocations were also higher in the traumatic group. The FNF group showed improvements with respect to mortality and rates of pulmonary embolism, infection, and dislocation over time. During the most recent interval, there was no difference in dislocation rates between the two groups. The length of stay and the percentage of patients discharging to a rehab facility were significantly higher in the FNF group at each time interval.

Incidence of radiographic cam-type impingement in young patients (<50) after femoral neck fracture treated with reduction and internal fixation.

BACKGROUND: Cam-type femoral impingement is caused by structural abnormalities of the hip and is recognized as a cause of degenerative hip arthritis. Identifiable etiologies of this structural abnormality include congenital malformation, pediatric hip disease, and malunion of femoral neck fractures after internal fixation. PURPOSE: The purpose of this study was to determine the prevalence of radiographic impingement in healed Orthopaedic Trauma Association (OTA) type 31B fractures treated with reduction and internal fixation. METHODS: Seventy OTA 31B hip fractures treated with internal fixation were identified from our institutional trauma database and radiographs were retrospectively reviewed for signs of impingement. Mean follow-up was 53 months after fracture. Alpha angle, Mose templates, and femoral head retroversion were the measurements used to determine impingement. RESULTS: The overall prevalence of any sign of radiographic impingement was 75%. Alpha angle was elevated in 32 hips (46%), asphericity was present in 46 femoral heads (65%), and femoral head retroversion was present in 26 hips (37%). The rates were highest in displaced subcapital fractures (OTA 31B-3) with a 63% (13/19) prevalence of elevated alpha angle, 68% (14/19) prevalence of asphericity, and 47% (10/19) prevalence of retroversion. CONCLUSIONS: Prevalence of radiographic signs of impingement in this population is higher than expected based on population-based controls. Surgeons must be vigilant about reduction and fixation of femoral neck fractures. Malunion should be recognized as early intervention may be beneficial in improving long-term outcomes.

Arthroscopic management of native shoulder septic arthritis.

BACKGROUND: There is little information on the results of arthroscopic treatment of native shoulder sepsis. Therefore, the purpose of this study was to determine the presentation, preoperative indices, intraoperative findings, and outcomes related to native shoulder sepsis treated with arthroscopy. MATERIALS AND METHODS: We retrospectively reviewed 50 consecutive native shoulders with septic arthritis between 1994 and 2008. Patients (75% male) were an average age of 66 years. Four patients had bilateral involvement. All underwent arthroscopic irrigation and debridement. The mean follow-up was 31 months (range, 1-185 months). RESULTS: Patients were immunocompromised in 57% of cases. The mean preoperative values (normal reference ranges) included white blood cell count, 13 × 10(9)/L (3.5-10.5 × 10(9)/L); erythrocyte sedimentation rate, 66 mm/h (0-29 mm/h), and C-creative protein, 83 mg/L (0-10 mg/L). The average aspiration cell count was 110,988, with a mean differential of 87% neutrophils. The most common organisms were methicillin-susceptible Staphylococcus aureus (44%). Repeat irrigation and debridement was required within the first month in 16 of 50 shoulders (32%). Within 1 year, 17% of patients had died. Final Gächter staging was I or II for 32 shoulders and III or IV for 18 shoulders. CONCLUSIONS: Most patients with native shoulder sepsis are elderly and immunocompromised and present with increased inflammatory markers and a supporting aspiration cell count. Patients and surgeons must be aware that after initial arthroscopy, 1 in 3 patients will require additional surgical intervention, whether anticipated or not. LEVEL OF EVIDENCE: Level IV, Case Series, Treatment Study.

Does prior infection alter the outcome of TKA after tibial plateau fracture?

UNLABELLED: Total knee arthroplasty performed after tibial plateau fracture has a known high rate of complications. We hypothesized TKAs performed after infected tibial plateau fractures would have an even higher complication rate when compared with noninfected tibial plateau fractures. In a matched case-control study, we retrospectively reviewed 19 patients who underwent primary TKAs after infected tibial plateau fractures between 1971 and 2005. The mean time from the most recent infection to arthroplasty was 5.6 years. The minimum clinical followup after TKA was 2 years (mean, 6.4 years; range, 2-15.1 years). Case patients were matched for age, gender, and arthroplasty year with 19 control subjects who underwent TKAs for tibial plateau fractures with no history of infections. After surgery, the Knee Society scores for the study group improved from 45 to 63 for pain and from 37 to 63 for function. Ten case patients (53%) sustained complications, including surgery for wound breakdown (three), manipulation (one), aseptic loosening (two), definitive resection arthroplasty (two), and above-knee amputation (two). Recurrent infections occurred in five patients (26%) at a mean of 1.1 years. Previously infected knees were 4.1 times more likely to require additional procedures compared with knees with no previous infection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography.

As a screening tool, CT angiography has excellent sensitivity and specificity combined with fewer complications compared to conventional arteriography.

Operative versus nonoperative management of distal femur fracture in myelopathic, nonambulatory patients.

Treatment of supracondylar femur fractures in myelopathic, nonambulatory patients has traditionally been nonoperative, emphasizing careful skin protection, limited mobilization, and acceptance of malunion. This study compares the results of surgical treatment with nonsurgical treatment in this patient population. The records of all myelopathic, nonambulatory patients treated for supracondylar femur fractures (OTA code 33) between 2001 and 2006 were reviewed: 25 patients (29 fractures) were discovered (11 women, 14 men; average age, 51 years). Surgical treatment was performed in 17 fractures (13 retrograde intramedullary rods and 4 plates) and nonsurgical treatment in 12 fractures. Union was obtained in all operatively treated fractures and in 90% of nonsurgically treated fractures. Average follow-up was 16 months. One patient treated with a retrograde nail sustained a nondisplaced intertrochanteric hip fracture treated nonoperatively. One patient treated operatively developed a late deep infection. There were no other surgical-related complications. Skin or wound complications developed in no patients treated surgically and in 4 patients treated nonsurgically (P=.0208). Three patients with nonoperatively treated fractures required eventual surgery (3 above-knee amputations). Operative treatment of femoral fractures in nonambulatory patients with myelopathy is safe and effective. There were fewer skin and wound complications in the surgically treated supracondylar femur fractures.