Surgical outcomes of subtypes of periprosthetic tibia fractures after total knee arthroplasty.

Surgical outcomes of subtypes of periprosthetic tibia fractures after total knee arthroplasty were evaluated by using the Felix et al. classification system. Type 3 fractures were the most common classification of periprosthetic tibial fractures. Type 2 fractures had the highest rates of revision and nonunion. Type 3 fractures exhibited longer healing times than types 2 and 4. Far type 3 fractures showed the longest healing time of all fracture types but had very minimal complications. Type 4 fracture managed by K-wire/cerclage wire may require hardware removal or debridement but exhibited the shortest healing time compared to types 2 and 3.

Arthrodesis or Open Reduction Internal Fixation for Lisfranc Injuries: A Meta-analysis.

The purpose of this study is to determine if arthrodesis, compared with open reduction and internal fixation (ORIF), produces favorable American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) scores, and to determine if differences in complication, revision surgery, and secondary arthrodesis rates exist for patients with Lisfranc fracture/dislocation injuries. Searches were performed in PubMed using the keywords "Lisfranc fracture," "metatarsal fracture," "ORIF," "open reduction internal fixation," "arthrodesis," and "fusion." These criteria left 183 articles for review. Exclusions left 21 articles and 2 translations of Chinese abstracts. Data analysis was performed using Student's 2-sample t test for samples of equal variance, and chi-square test for goodness of fit. The t test revealed a significant difference (P = .03) between the average AOFAS score for patients who underwent primary arthrodesis (84.7 ± 6.14) compared with those who were treated with ORIF (78.9 ± 5.09). There was no significant difference for the average VAS scores (P = .33) of the arthrodesis and ORIF groups. The complication rate of arthrodesis patients was significantly lower than ORIF patients (P = .04), and the rates of revision surgery (P = .22) and secondary arthrodesis (P = .53) were not significant between the groups. The results of this study indicate that arthrodesis may be a better surgical option than ORIF, due to the higher functional scores and the lower complication rate.Levels of Evidence: Level III: A meta-analysis.

Mycobacteriumabscessus-associated vertebral osteomyelitis in an immunocompetent patient: a rare case report and literature review.

Introduction: Vertebral osteomyelitis (VO) is an uncommon infection with Staphylococcus aureus as the most commonly implicated organism. VO caused by nontuberculous mycobacteria (NTM) such as Mycobacteriumabscessus (M. abscesscus) is exceedingly rare with only eight cases reported in literature. Case presentation: We report a rare case of an 82-year-old male with a remote history of trauma who was diagnosed with NTM vertebral osteomyelitis. The patient initially underwent a vertebroplasty of T12 and kyphoplasty of L1 for pathologic compression fractures. Subsequent cultures revealed M. abscessus. The patient further underwent an anterior T12-L2 corpectomy and debridement with instrumented fusion, as well as a posterior T9-L4 instrumentation and fusion. He received multi-agent antibiotic therapy; however, was ultimately unable to tolerate the aggressive treatment regimen and his prolonged postoperative course. Discussion: Nontuberculous mycobacteria vertebral osteomyelitis is exceedingly rare. NTM vertebral osteomyelitis is challenging to treat. Surgical management plays a limited role in early VO, but is the mainstay treatment in chronic VO. Early recognition of the condition and shared patient management with multidisciplinary teams is key to successfully treating cases of NTM VO.

The association between medial malleolar fracture geometry, injury mechanism, and syndesmotic disruption.

BACKGROUND: Precise correlations between medial malleolar fracture geometry and fracture mechanism have not been thoroughly described. This study sought to determine the prevalence of different medial malleolar fracture types and to elucidate the association between fracture geometry and fracture mechanism. METHODS: The records of 112 medial malleolar ankle fractures were reviewed. For each fracture, the direction of the fracture line in the medial malleolus (transverse, oblique, vertical, or comminuted), the Lauge-Hansen classification, and the presence or absence of syndesmotic injury was recorded. Bivariate correlation analysis was performed to determine if correlations existed. RESULTS: Transverse fractures were the most prevalent type of medial malleolar fracture [n=64 (57%)], and they correlated with supination-external rotation injuries. These were followed by oblique fractures [29 (26)], which correlated with pronation-external rotation injuries [29 (26)], and vertical fractures [7 (6)], which correlated with supination-adduction injuries [9 (8)]. Comminuted fractures [12 (11)] and pronation-abduction injuries [22 (20)] did not correlate with any other categories. Syndesmotic injuries were correlated with transverse fractures, bimalleolar fractures, and pronation-external rotation injuries. CONCLUSION: Medial malleolar fractures can be divided into four fracture types: transverse fractures, which correlated with supination-external rotation injuries; oblique fractures, which correlated with pronation-external rotation injuries; vertical fractures, which correlated with supination-adduction injuries; and comminuted fractures, which did not correlate with a particular type of injury. Syndesmotic injury was positively correlated with transverse fractures of the medial malleolus, bimalleolar fractures, and pronation-external rotation injuries. These findings suggest that medial malleolar fracture geometry can provide valuable information for the clinician when classifying and managing ankle fractures.

Challenge of managing distal femur fractures with long-stemmed total knee implants.

OBJECTIVE: Treatment of distal femur fractures by long-stemmed total knee arthroplasty (TKA) is challenging, because of poor bone stock, decreased blood supply, history of multiple knee surgeries and an absence of standard treatment. Few published studies are available concerning this. The purpose of this study was to share surgical technique and better describe our patients' comorbidities, which add to the challenge of managing individuals with these fractures. METHODS: Between August 2008 and September 2013, seven patients presented to our level I trauma center with distal femoral fractures associated with long-stemmed TKA implants. Their average age was 68.71 years (range, 52-81 years).The most common mechanism of injury was fall (five patients), followed by a traumatic fracture of the femur while walking (one patient), and being lifted out of bed (the one nonambulatory patient). This retrospective study reports a treatment protocol, including surgical technique, and short-term outcome in seven patients in whom locking compression plates (LCP) were used. RESULTS: Six fractures were classified as Rorabeck type II, and one as type III. The average time to full-weight-bearing was 5.5 months. At this institution, good short-term results have been achieved by using an LCP with screws placed proximal to the long-stem and distal to the fracture. The six patients all achieved full-weight-bearing,taking an average of 5.5 months (range, 3-7 months). CONCLUSIONS: LCP is an effective form of management of distal femur fractures around long stem TKAs. An individualized operative approach possibly incorporating bone-graft substitutes, cerclage wire and a post-operative bone stimulator is recommended.

Interprosthetic femoral fractures treated with locking plate.

PURPOSE: Interprosthetic fractures are challenging to manage. Although treatment of femoral fractures around a single implant has been described, there is little literature for treatment of interprosthetic femoral fractures. This study analyses the management and outcomes of 15 patients with interprosthetic femoral fractures treated with locking plates. METHODS: A retrospective chart review was conducted of 17 patients with interprosthetic femur fracture treated with locking plates from 2002 to 2013. Patient demographics and comorbidities were collected. Preoperatively, patients were classified with the Vancouver or Su classification system. Intraoperative use of bone graft and/or cerclage cables was also examined. Clinical and radiographic outcomes were evaluated for union, time to full weight bearing, return to preinjury level of activity, and pain assessed with visual analog scale (VAS). RESULTS: There were 15 patients with interprosthetic fractures meeting criteria for this study. Average patient age was 80.53 (range, 61-92) years. Bone grafting was used in 23.5% (four of 17) and cerclage cables in 29.4% (five of 17). Patients achieved complete union and return to full weight bearing an average of 4.02 (range, two to six) months later. Average VAS pain score was 1.00 (range, zero to six). All patients returned to their preoperative ambulatory status. CONCLUSION: Locking plates could achieve satisfactory results for interprosthetic fractures. Considering an individual's fracture type, bone quality and protheses to determine the appropriate plate length and optional use of cerclage and/or bone graft was essential. In this limited sample size, interprosthetic fractures occurred at similar rates at the supracondylar region and diaphysis.

High complication rate in locking plate fixation of lower periprosthetic distal femur fractures in patients with total knee arthroplasties.

Fixation of the distal portion of the femur in patients with total knee arthroplasties can be challenging. Locking plates have emerged as a promising treatment. Twenty-seven patients with periprosthetic distal femur fractures after total knee arthroplasties were treated using a contralateral reverse distal femoral locking plate. The average time for union and weight-bearing was 4.5 ± 2.7 months. The union rate was 89%. Thirty-seven percent experienced complications, with 2 delayed unions (7.4%), 1 nonunion (3.7%), and 7 fixation failures (26%). Alteration in blood supply and biomechanics as well as poor existing bone quality and minimal distal femur bone stock may contribute to treatment difficulties.

The influence of correction loss in thoracolumbar fractures treated by posterior instrumentation: a minimum 7-year follow-up.

We retrospectively studied patients who underwent posterior pedicle screw instrumentation for thoracolumbar fractures to explore the relationship between correction loss after the operation and clinical outcome. The study included 52 patients, with a minimum postoperative follow-up of 7 years (mean of 9.8 years). From the analysis of radiological and clinical outcomes, we found that the relevant factors related to functional outcome were: (i) preoperative anterior vertebral height (AVH; regression coefficient [B]=-0.075, p=0.045); and (ii) the latest follow-up AVH (B=-0.100, p=0.043). This indicates that function is likely to be worse if the anterior vertebral column is compressed more severely at the time of injury, and that function will also be worse if the AVH is decreased at the latest follow-up. However, loss of AVH was not correlated with functional outcome. Therefore, we recommend that the AVH should be restored as much as possible by posterior instrumentation during the treatment of thoracolumbar fractures. Reducing the loss of correction to maintain the postoperative AVH is also critical to maintain the AVH at latest follow-up.

The suprascapular nerve and its articular branch to the acromioclavicular joint: an anatomic study.

HYPOTHESIS: The suprascapular nerve and its articular branch innervate the acromioclavicular (AC) joint. Documenting the detailed anatomy of this innervation in the AC joint, including the pertinent surgical and anatomic relationships of the suprascapular nerve and its branches to the AC joint, will aid in the prevention of injury and the reduction of risk of denervation during shoulder surgery. MATERIALS AND METHODS: Twelve shoulders from 6 embalmed human cadavers were bilaterally dissected to study the course of the suprascapular nerve and its motor and sensory branches. RESULTS: The sensory branch runs superiorly to the supraspinatus muscle towards the AC joint. The average distance from the supraglenoid tubercle to the nerve at the coracoid base was 15 mm. The average distance from the coracoclavicular ligaments to the nerve at the coracoid base was 6 mm. The average distance from the spinoglenoid notch to the sensory branch at the suprascapular notch was 22 mm. The average length of the sensory branch was 30 mm. In half of the specimen shoulders, the suprascapular artery accompanied the nerve at the suprascapular notch under the transverse scapular ligament. DISCUSSION: The innervation of the AC joint by the suprascapular nerve has been described, along with pertinent distances to anatomic landmarks. The sensory branch of the suprascapular nerve, which passed through the scapular notch inferior to the transverse scapular ligament, was found in 100% of the study specimens. CONCLUSION: The sensory branch of the suprascapular nerve runs superiorly to the supraspinatus muscle towards the AC joint. The detailed information can be used to help decrease the risk of nerve injury during shoulder surgery and to aid in effectively diagnosing and treating AC joint-related disorders.