Preoperative and Postoperative Therapeutic Anticoagulation in Orthopaedic Surgery Increases the Risk of Bleeding: A Systematic Review and Meta-Analysis.

INTRODUCTION: Patients requiring postoperative therapeutic anticoagulation may have increased risk of bleeding complications, infection, and poor wound healing. The purpose of this study was to perform a systematic review and meta-analysis assessing bleeding complication rates among orthopaedic surgery patients receiving perioperative therapeutic anticoagulation. METHODS: A systematic review and meta-analysis was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta Analysis 2020 guidelines. PubMed was queried for articles related to therapeutic anticoagulation in orthopaedic surgery and complications using keywords and medical subject headings. Inclusion/exclusion criteria were any study reporting bleeding complications after orthopaedic surgery among patients on perioperative therapeutic anticoagulation with a minimum 1-year follow-up. Studies were reviewed for heterogeneity and risk of bias. Pooled analysis was done to determine postoperative complication rates among patients on therapeutic anticoagulation. RESULTS: Thirty-seven studies with 3,990 patients were included. Studies were grouped by their surgical subspecialty with 16 from arthroplasty, one foot and ankle, two spine, one sports, 13 trauma, and four upper extremity. Among patients on therapeutic anticoagulation, the pooled rate and 95% confidence intervals of bleeding complications was 8% (5 to 11%) overall, 10% (5 to 15%) in arthroplasty, 6% (3 to 11%) in trauma, and 5% (1 to 30%) in upper extremity. The overall rates (95% CI) of venous thromboembolism (VTE) were 2% (2 to 4%), infection 5% (3 to 10%), and revision surgery 4% (3 to 6%). Upper extremity VTE rates were 0% (0 to 15%), infection 4% (3 to 6%), and revision surgery 4% (3 to 6%). Trauma VTE rates were 4% (2 to 5%), infection 2% (1 to 6%), and revision surgery 3% (2 to 4%). Arthroplasty VTE rates were 2% (1 to 5%), infection 9% (4 to 18%), and revision surgery 4% (2 to 7%). CONCLUSIONS: Therapeutic postoperative anticoagulation may increase the risk of bleeding complications when compared with the general population. Incidence of VTE was similar when compared with historical data.

Outcomes of isolated medial tibial plateau fractures by fracture morphology.

PURPOSE: To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines. METHODS: Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected. RESULTS: One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %. CONCLUSIONS: Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study.

OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange. DESIGN: Retrospective review. SETTING: Eight academic level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP. OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP. RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008). CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Type III Open Tibia Fractures Treated With Single-Stage Immediate Medullary Nailing and Attempted Primary Closure Yield Low Rates of Flap Coverage.

OBJECTIVE: The purpose of this study was to determine whether type III open high-energy tibia fractures treated with immediate intramedullary nailing (IMN) and primary closure yield low rates of flap coverage. METHODS: Patients with high-energy type IIIA open tibia (OTA/AO42/43) fractures treated with IMN over a 10-year period at a level 1 academic center with at least 90 days of in-person postoperative follow-up were included. Single-stage reamed IMN with acute primary skin closure using Allgower-Donati suture technique was utilized in patients without notable skin loss. The primary outcome was treatment failure of acute primary skin closure requiring subsequent soft-tissue coverage procedures. RESULTS: A total of 111 patients with type IIIA tibia fractures met inclusion criteria. Of 107 of the 111 patients (96%) with skin closure at the index surgery, 95 of the 107 patients (89%) healed their soft-tissue envelop uneventfully. Among the patients who failed primary closure (11%), five required free tissue transfers, five required local rotational flaps, and two underwent split thickness skin grafting only. Patients who failed acute primary closure declared within an average of 8 weeks postoperatively. DISCUSSION: Treatment of type IIIA open high-energy tibia fractures with immediate IMN and primary closure using meticulous soft-tissue handling yields low rates of flap coverage.

A Staged Protocol for Treatment of High-Energy Tongue-Type Calcaneus Fractures: Surgical Technique and Case Series.

SUMMARY: Displaced tongue-type calcaneus fractures are frequently associated with severe soft tissue injuries, and urgent relief of the displaced tongue fragment on the posterior soft tissues is essential to preventing soft tissue complications. If there is a complex articular injury, the soft tissue envelope often needs time for swelling to resolve to allow for a safe open anatomic reduction because premature open reduction internal fixation is often associated with increased complications. We have found that in high-energy tongue-type calcaneus fractures with complex articular injuries, a staged protocol consisting of initial percutaneous reduction and fixation with later definitive reconstruction is soft tissue friendly, allows early restoration of calcaneal morphology, and affords extensile approaches for eventual reconstruction. The purpose of this study was to describe our protocol of staged treatment of high-energy tongue-type calcaneus fractures, along with postoperative surgical outcomes, in a case series of 53 patients.Our series of patients had a high rate of intra-articular injury with marked initial displacement (mean Bohler angle -8.4 ± 20.8 degrees). They were treated initially with percutaneous reduction and fixation at median 1 day postinjury (interquartile range [IQR] 0-1) and definitively at median 16 days postinjury (IQR 10-33). In this series, 2 of 53 (3.8%) patients developed a deep wound infection.In high-energy tongue-type calcaneus fractures at risk for soft tissue compromise or with a significantly displaced tongue fragment without initial soft tissue compromise, we found that staged management represents a feasible management strategy to mitigate risk of soft tissue complications and therefore helps facilitate safe definitive open treatment.

Cross-species comparisons reveal resistance of human skeletal stem cells to inhibition by non-steroidal anti-inflammatory drugs.

Fracture healing is highly dependent on an early inflammatory response in which prostaglandin production by cyclo-oxygenases (COX) plays a crucial role. Current patient analgesia regimens favor opioids over Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) since the latter have been implicated in delayed fracture healing. While animal studies broadly support a deleterious role of NSAID treatment to bone-regenerative processes, data for human fracture healing remains contradictory. In this study, we prospectively isolated mouse and human skeletal stem cells (SSCs) from fractures and compared the effect of various NSAIDs on their function. We found that osteochondrogenic differentiation of COX2-expressing mouse SSCs was impaired by NSAID treatment. In contrast, human SSCs (hSSC) downregulated COX2 expression during differentiation and showed impaired osteogenic capacity if COX2 was lentivirally overexpressed. Accordingly, short- and long-term treatment of hSSCs with non-selective and selective COX2 inhibitors did not affect colony forming ability, chondrogenic, and osteogenic differentiation potential in vitro. When hSSCs were transplanted ectopically into NSG mice treated with Indomethacin, graft mineralization was unaltered compared to vehicle injected mice. Thus, our results might contribute to understanding species-specific differences in NSAID sensitivity during fracture healing and support emerging clinical data which conflicts with other earlier observations that NSAID administration for post-operative analgesia for treatment of bone fractures are unsafe for patients.

Relationship of Aging, Inflammation, and Skeletal Stem Cells and Their Effects on Fracture Repair.

PURPOSE OF REVIEW: This review summarizes recent investigations into the cellular and molecular effects of skeletal aging on the inflammatory response and stem cell function after fracture. RECENT FINDINGS: Proper regulation of the inflammatory phase of fracture healing is essential. Aging is associated with chronic inflammation, which inhibits bone formation and promotes bone resorption. Osteogenic differentiation and anti-senescence pathways in skeletal stem cells are impaired in geriatric fractures. As the population ages, fragility fractures will continue to represent a significant clinical problem, which will require innovative clinical solutions. Skeletal stem cells in geriatric individuals demonstrate defects in anti-senescence pathways that lead to impaired osteogenic differentiation in vitro in humans. Small molecule-based therapies can partially reverse the aging phenotype. In the future, molecular- or cell-based therapies modulating either inflammatory cells or skeletal stem cells represent potential therapeutic targets to augment contemporary fracture healing interventions in osteoporotic or aging individuals.

Posteromedial Talar Body Fracture: Case Discussion and Surgical Technique.

SUMMARY: Posteromedial talar body fractures are a rare form of talus fracture that involves the tibiotalar and subtalar joints. In cases of displaced injuries, open reduction and internal fixation is typically recommended to minimize the risk of instability and post-traumatic osteoarthritis. This video presents a case of a posteromedial talar body fracture and highlights the technique for operative fixation through a posteromedial approach. Multiple methods to obtain reduction are discussed, and considerations with implant placement are described. The indications for surgical intervention are reviewed, and published outcomes following operative and nonoperative management of these injuries are presented.

Risk of Revision After Hip Fracture Fixation Using DePuy Synthes Trochanteric Fixation Nail or Trochanteric Fixation Nail Advanced: A Cohort Study of 7,979 Patients.

BACKGROUND: Prior reports of the DePuy Synthes Trochanteric Fixation Nail Advanced (TFNA) revealed a potential mode of fatigue failure at the proximal screw aperture following fixation of extracapsular hip fractures. We sought to compare the revision risk between the TFNA and its prior-generation forebear, the Trochanteric Fixation Nail (TFN). METHODS: A retrospective cohort study was performed using data from a U.S. integrated health-care system's hip fracture registry. The study sample comprised patients who underwent cephalomedullary nail fixation for hip fracture with a TFN (n = 4,007) or TFNA (n = 3,972) from 2014 to 2019. We evaluated the charts and radiographs for patients who underwent any revision. Multivariable Cox regression was used to evaluate the risk of revision related to the index fracture. RESULTS: At the 3-year follow-up, the cumulative probability of revision related to the index fracture was 1.8% for the TFN and 1.9% for the TFNA. After adjustment for covariates, no difference was observed in revision risk (hazard ratio [HR], 1.18 [95% confidence interval (CI), 0.80 to 1.75]; p = 0.40) for the TFNA compared with the TFN. The TFNA was associated with a higher risk of revision for nonunion than the TFN (HR, 1.86 [95% CI, 1.11 to 3.12]; p = 0.018). At the 3-year follow-up, implant breakage was 0.06% for the TFN and 0.2% for the TFNA; with regard to aperture failures related to the index fracture, there were 1 failure for the TFN group and 3 failures for the TFNA group. CONCLUSIONS: In a large cohort from a U.S. hip fracture registry, the TFNA had an overall revision rate that was similar to that of the earlier TFN, with implant breakage being a rare revision reason for both groups. Chart and radiographic review found that the TFNA was associated with a higher risk of revision for nonunion. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mini-fragment plating of olecranon fractures is comparable to precontoured small-fragment plating.

INTRODUCTION: Though long-term functional outcomes of olecranon fracture plate fixation are favorable, postoperative implant irritation commonly leads to elective removal. We hypothesized that mini-fragment plates will decrease implant removal compared to precontoured plates. METHODS: Patients with isolated olecranon fracture (AO/OTA 2U1-B1) treated with plate fixation were retrospectively reviewed. Patients were stratified into groups based on whether they underwent open reduction and internal fixation with a (1) surgeon contoured mini-fragment or (2) precontoured olecranon-specific plate. Rates of symptomatic implants and implant removal were compared. RESULTS: 98 and 32 patients were treated with precontoured and mini-fragment plates, respectively. Baseline demographics and comorbidities were similar. Mean follow-up was 20.6 months. There were no differences in rates of postoperative complication (22/98, 22.4% vs. 5/32, 15.6%; p = 0.41) or reoperation (37/98, 37.8% vs. 8/32, 25%; p = 0.19). Symptomatic implants were common in the precontoured cohort (44/98, 44.9% vs. 7/32, 21.9%; p < 0.05). Implant removal rates were 36.7% and 18.8%, respectively (p = 0.06). DISCUSSION/CONCLUSION: Olecranon fracture stabilization with mini-fragment plate is associated with lower rates of symptomatic implants, with no difference in postoperative complications or reoperations. Mini-fragment plating is a safe and promising alternative to precontoured plating.

A bioactive synthetic membrane improves bone healing in a preclinical nonunion model.

OBJECTIVES: High energy long bone fractures with critical bone loss are at risk for nonunion without strategic intervention. We hypothesize that a synthetic membrane implanted at a single stage improves bone healing in a preclinical nonunion model. METHODS: Using standard laboratory techniques, microspheres encapsulating bone morphogenic protein-2 (BMP2) or platelet derived growth factor (PDGF) were designed and coupled to a type 1 collagen sheet. Critical femoral defects were created in rats and stabilized by locked retrograde intramedullary nailing. The negative control group had an empty defect. The induced membrane group (positive control) had a polymethylmethacrylate spacer inserted into the defect for four weeks and replaced with a bare polycaprolactone/beta-tricalcium phosphate (PCL/ß-TCP) scaffold at a second stage. For the experimental groups, a bioactive synthetic membrane embedded with BMP2, PDGF or both enveloped a PCL/ß-TCP scaffold was implanted in a single stage. Serial radiographs were taken at 1, 4, 8, and 12 weeks postoperatively from the definitive procedure and evaluated by two blinded observers using a previously described scoring system to judge union as primary outcome. RESULTS: All experimental groups demonstrated better union than the negative control (p = 0.01). The groups with BMP2 incorporated into the membrane demonstrated higher average union scores than the other groups (p = 0.01). The induced membrane group performed similarly to the PDGF group. Complete union was only demonstrated in groups with BMP2-eluting membranes. CONCLUSIONS: A synthetic membrane comprised of type 1 collagen embedded with controlled release BMP2 improved union of critical bone defects in a preclinical nonunion model.

Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence.

INTRODUCTION: Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. METHODS: The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria. RESULTS: 801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group. CONCLUSIONS: Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.

Distal Femur Replacement Versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF). DATA SOURCES: PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies. STUDY SELECTION: Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with nonlocking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to the PRISMA criteria. DATA EXTRACTION: Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study. DATA SYNTHESIS: Fifty-eight studies with 1484 patients were included in the meta-analysis. Complications assessed {incidence rate ratio [IRR] [95% confidence interval (CI)]: 0.78 [0.59-1.03]} and reoperation or revision [IRR (95% CI): 0.71 (0.49-1.04)] were similar between the DFR and ORIF cohorts. The mean knee range of motion was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, P < 0.05). The mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, P = 0.35) and return to preoperative ambulatory status were similar [IRR (95% CI): 0.82 (0.48-1.41)]. CONCLUSIONS: In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee range of motion was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short versus long cephalomedullary nailing of intertrochanteric fractures: a meta-analysis of 3208 patients.

OBJECTIVES: The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures. DATA SOURCES: A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019). The queries were performed in June 2019. STUDY SELECTION: The following search term query was used: "Intramedullary Nail AND Intertrochanteric Fracture OR "Long OR Short Nail AND intertrochanteric Fracture." Studies were excluded if they were "single-arm" studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded. DATA EXTRACTION: Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review. DATA SYNTHESIS: Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths. CONCLUSIONS: Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures. STUDY DESIGN/LEVEL OF EVIDENCE: Meta-analysis; Level III, therapeutic.

To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons.

INTRODUCTION: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures. METHODS: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly. RESULTS: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001). DISCUSSION: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.

Incidence and Management of Articular Impaction in Geriatric Olecranon Fractures.

INTRODUCTION: Olecranon fractures are common in the elderly. Articular impaction is encountered occasionally, but the incidence and outcomes after treatment of this injury pattern have not been well characterized. METHODS: We evaluated a cohort of geriatric olecranon fractures to determine the incidence of articular impaction and describe a technique for open reduction and internal fixation. RESULTS: Of the 63 patients in our series, 31 had associated intraarticular impaction (49.2%). Patients with articular impaction did not have significantly different rates of postoperative complications (11/31, 35.5% versus 10/31, 32.3%; P = 1.00) or revision surgery (10/31, 32.3% versus 8/31, 25.8%; P = 0.780) compared with those without articular impaction. CONCLUSION: Articular impaction is a common feature of geriatric olecranon fractures. Surgeons must maintain a high index of suspicion and have a surgical plan in place for managing this component of the injury.

Medial Column Support in Pilon Fractures Using Percutaneous Intramedullary Large Fragment Fixation.

SUMMARY: Pilon fractures are complex injuries to the tibial plafond requiring stable fixation in the setting of effective soft tissue management, particularly in high-energy injuries, open fractures, or in geriatric individuals. Medial column support of the distal tibial metaphysis is often an essential component when applying balanced fixation. However, the biologic implications of multiple surgical approaches in the setting of damaged tissue, devitalized bone, or significant bone loss may contribute to increased complications. Percutaneous intramedullary large fragment screws offer both stability and a soft tissue-friendly approach for stabilizing the medial column. Here, we present our technique and indications for medial column support in pilon fractures using percutaneous large fragment fixation, along with our early clinical experience in a case series of 7 patients. At minimum 6-month follow-up, all patients healed their injuries with maintained alignment and without complications or further reoperation. Medial column support with percutaneous large fragment fixation in pilon fractures is a viable option to provide mechanical stability while effectively managing tenuous soft tissue envelopes.

Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws.

OBJECTIVES: Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws. DESIGN: Retrospective cohort study. SETTING: Single U.S. Level I Trauma Center. PATIENTS: 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up. INTERVENTION: Lag screw or helical blade in a cephalomedullary nail. OUTCOME MEASURES: The primary outcome was fracture site collapse at 3 months. RESULTS: There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7 mm, inter-quartile range 2.5-7.8 mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2 mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5 mm less collapse (95%CI - 4.2, - 0.72 mm, p 0.006) and lower likelihood of excessive collapse (> 10 mm at 3 months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern. CONCLUSIONS: Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.

Orthopaedic Basic Science for the Practicing Physician: Optimizing Mechanobiology of Fracture Healing.

The practicing orthopaedic surgeon must understand the relationship between fracture biomechanics and fracture biology to optimize patient outcomes. Patient characteristics, fracture pattern, and desired type of bone healing all drive decision making. The benefits of performing an open approach to a fracture, obtaining an anatomic reduction, and achieving absolute stability must be weighed against the biologic cost to the tissues and the potential to compromise healing. Similarly, the decision to perform a closed fracture reduction; apply a splint, bridge plate, or intramedullary nail; and achieve relative stability requires that the surgeon understand the implications of increased strain at a given fracture site. The purpose of this chapter is to review the basic science of primary and secondary bone healing with special attention given to the clinical implications for practicing surgeons.