Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty?

PURPOSE: This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. METHODS: A retrospective review was conducted of patients > 50 years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. RESULTS: Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0 years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8 weeks, p = 0.005). CONCLUSION: Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50 years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. LEVEL OF EVIDENCE:  : Level III, Retrospective Comparative Study.

Impact of Intraoperative Femoral Fractures During Cemented Hemiarthroplasty for Femoral Neck Fractures.

BACKGROUND: There have been several studies on intraoperative femoral fractures (IFFs) during primary total hip arthroplasty, but it is not well understood how this complication affects the patient population undergoing cemented hemiarthroplasty. This study aimed to analyze the impact of IFFs sustained during cemented hemiarthroplasty for the treatment of femoral neck fractures. METHODS: A retrospective review was conducted of all patients who were treated for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association 31B fractures with cemented hemiarthroplasty between January 1, 2000 and December 31, 2021, at a single academic level 1 trauma center. An initial cohort was constructed of all patients who sustained an IFF during their surgery, yielding 31 patients after excluding those who sustained a pathologic fracture or had incomplete data. These patients were matched 1:2 on age, sex, and body mass index to patients in a control cohort. The primary outcome measure was implant failure. Secondary outcome measures included complications, all-cause mortality, and radiographic outcomes (subsidence, femoral component loosening, acetabular wear, and heterotopic ossification) postoperatively. RESULTS: Subsequent implant revision was required in 3.2% (n = 1) of patients who sustained an IFF and 1.6% (n = 1) of patients who did not. After adjusting for comorbidities, there was no observed excess risk of implant failure in the fracture cohort when compared to the control cohort (hazard ratio [HR] = 0.30, P = 0.740). There was no observed excess risk of morbidity (HR = 0.69, P = 0.621) or all-cause mortality (HR = 0.23, P = 0.330). Radiographic outcomes also did not significantly differ between the 2 cohorts (P > 0.05). CONCLUSIONS: Intraoperative fractures during cemented hemiarthroplasty do not contribute to an increased risk of secondary surgery, morbidity, or mortality after surgery. They also do not adversely affect radiographic outcomes postoperatively. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Cannulated Screws or Hemiarthroplasty for Femoral Neck Fractures: Is There a Mortality Difference?

OBJECTIVES: To determine the difference in mortality and reoperation rate between femoral neck fractures (FNFx) treated with cannulated screw fixation (CS) or hemiarthroplasty (HA). METHODS: Design: Retrospective study. SETTING: Institutional registry data from a single Level I trauma center. PATIENT SELECTION CRITERIA: Inclusion criteria were patients ≥60 years old with a FNFx (AO/OTA 31-B) who underwent primary operative treatment with a HA or CS. OUTCOME MEASURES AND COMPARISONS: Mortality and reoperation rates following primary operative treatment between patients treated with either hemiarthroplasty or cannulated screws. Kaplan-Meier survival curves were generated. Comparisons in the primary outcomes were made between the hemiarthroplasty or cannulated screw cohorts using univariate and multivariate analysis where appropriate. RESULTS: A total of 2,211 patients were included in the study (1,721 HA and 490 CS) and followed for an average of 34.5 months. The average age was 82.3 years (60-106 years) and predominantly female (66.3%). 1-year mortality was higher for the HA group compared to CS with a HR of 1.37 (p=0.03), however over the lifetime of patient or to final follow up, survival was not statistically significant with a RR of 0.95 95% CI, 0.83-1.1, p=0.97) The rate of reoperation at one year was lower for HA (5.0%) than for CS (10.1%), (HR 3.0, 95% CI, 2.1-4.34, p<0.0001). CONCLUSIONS: Patients with FNFx treated with hemiarthroplasty had the same risk of mortality as those patients treated with cannulated screws across lifetime of patients or until final follow up. There is no difference in mortality at the 30- and 90-day timepoint, but a significant difference in mortality at 1 year. Hemiarthroplasty treatment was associated with a significantly lower reoperation risk when compared to cannulated screws across the lifetime of the patient or until final follow up. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Antibiotic Therapy Before Arthrocentesis on Synovial Fluid Cell Count and Differential for Diagnosis of Native Joint Septic Arthritis.

We examined the effect of preoperative antibiotic exposure and duration on synovial fluid samples from patients with native joint septic arthritis of the hip/knee. While exposure before diagnostic arthrocentesis did not affect fluid parameters, increased duration was associated with a decreased total nucleated cell count, underscoring the complex antibiotic effects on synovial fluid parameters.

Surgical treatment and outcomes of trans-ulnar basal coronoid fracture-dislocations.

BACKGROUND: Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations. MATERIALS AND METHODS: Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade. RESULTS: Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10°-150°), and the mean pronation-supination arc was 137° (range 0°-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3). DISCUSSION: Trans-ulnar basal coronoid fracture-dislocations are severe injuries associated with high rates of reoperation, HO, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty.

BACKGROUND: Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury. METHODS: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at 1 institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean body mass index was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than 1 year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21). RESULTS: Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < .001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < .001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < .001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = .88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < .001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = .08). CONCLUSIONS: Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like nonarthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Omega Plate Fixation of Comminuted Olecranon Fractures: Technique and Case Series.

Fixation of olecranon fractures, especially those with minimal proximal bone and those that present with significant comminution, can be technically challenging. Current open reduction and internal fixation (ORIF) methods, such as tension band wire (TBW) constructs, plate fixation (PF), and intramedullary screws (IMSF), have demonstrated high rates of reoperation and symptomatic implants. We present the omega plate technique, which utilizes a mini-fragment plate passed under the triceps tendon insertion, allowing maximal implant surface area contact with small, proximal olecranon fracture fragments. The mini-fragment plate is not placed on the dorsal subcutaneous border of the ulna, which allows it to capture medial and lateral fragments of cortical comminution and may contribute to less soft tissue irritation.

Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases.

CASE: A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery. CONCLUSION: Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.

Effect of Preoperative Antibiotic Therapy on Operative Culture Yield for Diagnosis of Native Joint Septic Arthritis.

BACKGROUND: Native joint septic arthritis (NJSA) is definitively diagnosed by a positive Gram stain or culture, along with supportive clinical findings. Preoperative antibiotics are known to alter synovial fluid cell count, Gram stain and culture results and are typically postponed until after arthrocentesis to optimize diagnostic accuracy. However, data on the impact of preoperative antibiotics on operative culture yield for NJSA diagnosis are limited. METHODS: We retrospectively reviewed adult cases of NJSA who underwent surgery at Mayo Clinic facilities from 2012-2021 to analyze the effect of preoperative antibiotics on operative culture yield through a paired analysis of preoperative culture (POC) and operative culture (OC) results using logistic regression and generalized estimating equations. RESULTS: Two hundred ninety-nine patients with NJSA affecting 321 joints were included. Among those receiving preoperative antibiotics, yield significantly decreased from 68.0% at POC to 57.1% at OC (p < .001). In contrast, for patients without preoperative antibiotics there was a non-significant increase in yield from 60.9% at POC to 67.4% at OC (p = 0.244). In a logistic regression model for paired data, preoperative antibiotic exposure was more likely to decrease OC yield compared to non-exposure (OR = 2.12; 95% CI = 1.24-3.64; p = .006). Within the preoperative antibiotic group, additional antibiotic doses and earlier antibiotic initiation were associated with lower OC yield. CONCLUSION: In patients with NJSA, preoperative antibiotic exposure resulted in a significant decrease in microbiologic yield of operative cultures as compared to patients in whom antibiotic therapy was held prior to obtaining operative cultures.

Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study.

OBJECTIVES: To compare three fluoroscopic methods for determining femoral rotation. METHODS: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur. RESULTS: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques ( p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference ( p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods ( p = 0.020). CONCLUSIONS: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems.

BACKGROUND: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

BACKGROUND: Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS: Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS: The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION: Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined With Percutaneous Reduction Techniques Is Safe and Results in a Low Rate of Cutout.

OBJECTIVES: To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. DESIGN: Retrospective cohort study. SETTING: Level-1 trauma center. PATIENTS: Two-hundred 20 consecutive patients with intertrochanteric fractures. INTERVENTION: Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. MAIN OUTCOME MEASUREMENTS: Radiographic outcome including union, cutout, and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. RESULTS: Mechanical complications (nonunion, cutout, and varus collapse) occurred in 8.8% of patients at 1 year. Eleven of 13 patients who developed these complications had either suboptimal implant placement (tip-to-apex distance >25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, P = 0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and 1 patient (0.7%) who did not have an accessory incision developed a postoperative infection. CONCLUSIONS: The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracture reduction and optimal implant placement and not hesitate to use an accessory incision to assist with fracture reduction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Use of the Piriformis Fossa Radiographic Landmark to Predict "In-Out-In" Placement of the Posterosuperior Femoral Neck Screw.

OBJECTIVES: To investigate the correlation between a screw's radiographic relationship to the piriformis fossa with position on CT in the clinical setting. METHODS: Intraoperative fluoroscopic images of patients treated with cannulated screw fixation of a femoral neck fracture, who also had a postoperative CT scan, were retrospectively evaluated by 4 fellowship-trained orthopaedic trauma surgeons. The posterosuperior screw on the AP fluoroscopic view was determined to be above the piriformis fossa (APF) or below the piriformis fossa (BPF). Using CT scan to determine IOI placement, the ability to predict IOI position based on fluoroscopic imaging was evaluated by calculating accuracy, sensitivity, specificity, and interobserver reliability. RESULTS: 73 patients met inclusion criteria. The incidence of IOI screw placement was 59% on CT evaluation. The use of the PF landmark accurately predicted CT findings in 89% of patients. A screw placed APF was 90% sensitive and 88% specific in predicting cortical breach, with near-perfect interobserver agreement (κ = 0.81). CONCLUSION: The use of the PF radiographic landmark is highly sensitive and specific in predicting the placement of an IOI posterosuperior femoral neck screw. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Association Between Preoperative International Normalized Ratio Values and Postoperative Outcomes including Mortality in Geriatric Femoral Neck Fractures Treated With Hemiarthroplasty.

OBJECTIVES: To evaluate the association between preoperative international normalized ratio (INR) and postoperative mortality and other outcomes after hemiarthroplasty for geriatric femoral neck fractures. DESIGN: Retrospective cohort study. SETTING: A single Level-I trauma center. PATIENTS/PARTICIPANTS: Patients ≥55 years of age with OTA/AO 31B proximal femur fractures [1556 patients (1616 hips)]. INTERVENTION: Hip hemiarthroplasty. MAIN OUTCOME MEASUREMENTS: Ninety-day mortality, postoperative transfusion within 72 hours, and 90-day postoperative outcomes. RESULTS: Adjusting for confounders, the association of preoperative INR and 90-day mortality was not statistically significant [hazard ratio (HR): 1.3; 95% confidence interval (CI): 0.97, 1.8; P = 0.08]. Dementia (HR: 1.9; 95% CI: 1.4-2.6; P < 0.001), Charlson Comorbidity Index (HR: 1.1; 95% CI: 1.1-1.2; P < 0.001), and age by decade (HR: 1.4; 95% CI: 1.1-1.8; P = 0.002) were associated with 90-day mortality. Increasing INR was significantly associated with blood transfusion [odds ratio (OR) 1.4; 95% CI 1.03-1.6; P = 0.031]. Preoperative hemoglobin <10 g/dL (OR 13.7; 95% CI 8.4-23.3; P < 0.001) was also associated with a postoperative transfusion, whereas intraoperative tranexamic acid use (OR 0.3; 95% CI 0.2-0.5; P < 0.001) was inversely associated with postoperative transfusion rate. INR was associated with superficial wound infection (HR: 2.0; 95% CI: 1.1-3.7; P = 0.02) and noninfected wound complications (HR: 1.6; 95% CI: 1.1-2.4; P = 0.007). Risk of superficial infection increased when INR was >1.8. CONCLUSION: When controlling for confounders, preoperative INR was not significantly associated with 90-day mortality. Underlying medical conditions contribute to postoperative mortality more than an elevated INR. However, INR is associated with superficial wound complications. This risk becomes statistically significant as INR rises above 1.8. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patella Fracture Fixation With Novel Wagon Wheel Construct Versus Tension-Band Construct: A Technical Trick.

SUMMARY: Internal fixation of patella fractures remains technically challenging. Cannulated screws with an anterior tension band have been associated with high rates of implant prominence, and fracture comminution can make appropriate application of a tension band impractical. We present the results of a novel technique using a transtendinous/transligamentous mini-fragment plate positioned peripherally around the patella with radially directed screws: termed the wagon-wheel (WW) construct. Compared with a cohort of fractures treated with cannulated screws with an anterior tension band, there was no difference in final range of motion and rate of nonunion. The WW construct had a significantly decreased incidence of symptomatic implants (5% vs. 32%, P = 0.02), rate of reoperation (9% vs. 38%, P = 0.018), dependency on gait aids (10% vs. 38%, P = 0.031), and a faster time to union (HR: 2.2; 95% CI, 1.28-3.95, P = 0.005). In summary, the WW was designed with the goal of obtaining peripheral plate fixation to maximize fragment-specific fixation while minimizing implant prominence. Patients treated with the WW demonstrated reduced rates of implant prominence and reoperation.

Computed tomography provides effective detection of traumatic arthrotomy of the elbow.

BACKGROUND: Failure to identify a traumatic arthrotomy of the elbow (TAE) can lead to septic arthritis with devastating complications. The gold standard for TAE detection remains controversial, and evidence is limited. While multiple clinical and cadaveric studies have validated the use of computed tomography (CT) to detect traumatic arthrotomies about the knee, other studies have called into question whether the use of CT to detect traumatic arthrotomy is applicable to the elbow. A prior cadaveric study utilizing a direct posterior (transtendon) traumatic arthrotomy model failed to detect traumatic arthrotomy via CT in 100% of cases. The aim of this study was to determine the sensitivity and specificity for detecting TAE with CT, utilizing a lateral traumatic arthrotomy model. METHODS: Ten fresh-frozen upper extremity transhumeral cadaveric specimens were utilized. Only specimens with an intact elbow joint and no known elbow surgery or injury were included. CT scans were performed to screen for intra-articular air prior to arthrotomy. A full-thickness 10 mm incision was performed over the soft spot, just distal to the lateral epicondyle. The elbow was taken through full range of motion in flexion and extension, as well as forearm pronation and supination 10 times. CT scans were then repeated and screened for the presence of intra-articular air. Lastly, a saline load test was performed on all specimens, and the volume of saline required to detect the arthrotomy was recorded. RESULTS: Of the 10 specimens, 0% (n = 0) demonstrated intra-articular air of the elbow joint on CT scan prior to arthrotomy and 100% (n = 10) demonstrated intra-articular air on CT scan following arthrotomy. CT scan demonstrated 100% sensitivity and 100% specificity for TAE. For the saline load test, 90% (n = 9) were positive for TAE at an average of 12 mL (range: 4 mL-47 mL), providing 90% sensitivity. CONCLUSION: In this cadaveric study utilizing a more commonly observed direct lateral traumatic laceration, CT was able to detect 100% (n = 10) of TAEs with 100% sensitivity and specificity. These results show that CT scans can effectively diagnose lateral traumatic arthrotomy in a cadaveric model and can be a viable option for diagnosis in a clinical setting. Clinical correlation is required to confirm in these in vitro findings.

Modular Fluted Tapered Stems for Periprosthetic Femoral Fractures: Excellent Results in 171 Cases.

BACKGROUND: Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B2 and B3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems in a large series of patients. METHODS: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m2. The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years. RESULTS: The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71). CONCLUSIONS: In this large series of 171 Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Intramedullary Nail Fixation for Metastatic Disease: Impending and Pathologic Fractures.

BACKGROUND/AIM: Intramedullary nail (IMN) fixation has become a treatment mean for impending and pathologic femur fractures. Currently there continues to be a lack of data examining functional outcomes, complications, and survivorship of patients treated with IMNs for metastatic disease of the femur. PATIENTS AND METHODS: We retrospectively identified 183 IMNs placed for impending (n=145) or pathologic (n=38) metastatic fractures from 2010 to 2018. Functional outcomes and complications including blood transfusions, venous thromboembolisms (VTEs) and reoperations were studied. RESULTS: Patients with impending lesions were more likely to be ambulatory at final follow-up (pathologic: 82%, impending: 99%, p<0.0001) and reported greater musculoskeletal tumor society scores (p<0.0001). Likewise, pathologic fractures were associated with greater discharge to non-home locations (p<0.0001) and were more likely to require a postoperative transfusion (pathologic: 66%, impending: 22%, p=0.0001). However, there was no difference in the incidence of VTEs (p=1.00) or reoperations (p=0.69) between cohorts. Patients treated for impending fractures had improved overall survival at 1 year (54% vs. 26%, p<0.0001). CONCLUSION: IMN fixation was durable in impending and pathologic femoral fractures. Early identification of metastases remains critical as patients treated for impending lesions had greater functional outcomes, fewer complications and improved survivorship compared to patients treated for pathologic fractures.

Distal femoral replacement versus ORIF for severely comminuted distal femur fractures.

INTRODUCTION: Distal femoral replacement (DFR) and open reduction and internal fixation (ORIF) are surgical options for comminuted distal femur fractures. Comparative outcomes of these techniques are limited. The aims of this study were to compare implant survivorship, perioperative factors, and clinical outcomes of DFR vs. ORIF for comminuted distal femur fractures. METHODS: Ten patients treated with rotating hinge DFRs for AO/OTA 33-C fractures from 2005 to 2015 were identified and matched 1:2 based on age and sex to 20 ORIF patients. Patients treated with DFR and ORIF had similar ages (80 vs. 76 years, p = 0.2) and follow-up (20 vs. 27 months, p = 1.0), respectively. Implant survivorship, length of stay (LOS), anesthetic time, estimated blood loss (EBL), ambulatory status, knee range of motion (ROM), and Knee Society scores (KSS) were assessed at final follow-up. RESULTS: Survivorship free from any revision at 2 years was 90% and 65% for the DFR and ORIF groups, respectively (p = 0.59). Survivorship free from any reoperation at 2 years was 90% for the DFR group and 50% for the ORIF group (p = 0.16). Three ORIF patients (15%) went on to nonunion and two went on to delayed union. Mean EBL and LOS were significantly higher for the DFR group: 592 mL vs. 364 mL, and 13 vs. 6.5 days, respectively. Knee ROM (p = 0.71) and KSSs (p = 0.36) were similar between groups. CONCLUSIONS: Comminuted distal femur fractures treated with DFR trended toward lower revision and reoperation rates, with similar functional outcomes when compared to ORIF. We noted a trend toward increased EBL and LOS in the DFR group. LEVEL OF EVIDENCE: Level IV.