Dogs can detect an odor profile associated with Staphylococcus aureus biofilms in cultures and biological samples.

Introduction: The study investigated the utilization of odor detection dogs to identify the odor profile of Staphylococcus aureus (S. aureus) biofilms in pure in vitro samples and in in vivo biosamples from animals and humans with S. aureus periprosthetic joint infection (PJI). Biofilms form when bacterial communities aggregate on orthopedic implants leading to recalcitrant infections that are difficult to treat. Identifying PJI biofilm infections is challenging, and traditional microbiological cultures may yield negative results even in the presence of clinical signs. Methods: Dogs were trained on pure in vitro S. aureus biofilms and tested on lacrimal fluid samples from an in vivo animal model (rabbits) and human patients with confirmed S. aureus PJI. Results: The results demonstrated that dogs achieved a high degree of sensitivity and specificity in detecting the odor profile associated with S. aureus biofilms in rabbit samples. Preliminary results suggest that dogs can recognize S. aureus volatile organic compounds (VOCs) in human lacrimal fluid samples. Discussion: Training odor detection dogs on in vitro S. aureus, may provide an alternative to obtaining clinical samples for training and mitigates biosecurity hazards. The findings hold promise for culture-independent diagnostics, enabling early disease detection, and improved antimicrobial stewardship. In conclusion, this research demonstrates that dogs trained on in vitro S. aureus samples can identify the consistent VOC profile of PJI S. aureus biofilm infections. The study opens avenues for further investigations into a retained VOC profile of S. aureus biofilm infection. These advancements could revolutionize infectious disease diagnosis and treatment, leading to better patient outcomes and addressing the global challenge of antimicrobial resistance.

Proximal humerus fractures: Postoperative protocols and factors affecting treatment decisions among shoulder and elbow and orthopedic trauma surgeons.

Background: Proximal humerus fractures (PHFs) can lead to functional decline in geriatric and polytraumatized patients. Treatment of PHFs is an area of much debate and much variability between practitioners. Objectives: We surveyed orthopedic trauma (OT) and shoulder and elbow (SE) surgeons to evaluate differences in postoperative protocols when treating acute PHFs with open reduction internal fixation (ORIF), intramedullary nailing (IMN), or hemi or reverse shoulder arthroplasty (rTSA). Materials and methods: We distributed a web-based survey to three OT and SE associations between August 2018-April 2019. Questions included practice characteristics, standard postoperative protocols for weight-bearing, lifting, and range of motion (ROM) by treatment modality, and factors affecting modality and postoperative protocol decisions. We compared the subspecialties. Results: 239 surgeons [100 (42.2 %) OT, 118 (49.8 %) SE] completed the survey. OT were more likely to allow immediate ROM, lifting, and weight bearing following intramedullary nailing (IMN), open reduction internal fixation with a locking plate (ORIF), or arthroplasty (all p < 0.025), and to allow earlier unrestricted use of the extremity following IMN and arthroplasty (p = 0.001, p = 0.021 respectively). OT were more likely to consider operating on a PHF if there was contralateral upper extremity injury or need of the injured arm for work or activities of daily living (all p < 0.026). The subspecialties did not differ significantly on factors affecting their postoperative protocols. OT preferred IMN and SE surgeons preferred rTSA for allowing immediate unrestricted postoperative weight bearing, ROM, or lifting (all p < 0.001). Conclusion: There are significant differences in postoperative protocols between trauma and SE surgeons when treating PHFs. Postoperative protocols should be further studied to balance surgical outcomes and the risks of functional decline when treating patients with PHFs.

Limb Rotation in Lower Extremity Fractures.

Fractures of the tibia and femur are common. Rotation of the limb can affect the outcome of the injury, both in the immediate term and the long term. Because plain radiographs are two dimensional, rotation is hard to assess radiographically. As a result, rotational malalignment is common. It is important to provide technical tips on the assessment of rotation preoperatively, intraoperatively, and postoperatively. The goal is to better assess rotation so that deformity can be minimized. This applies to fractures of the tibia and femur. Even after careful treatment, rotational deformities can occur. When they are symptomatic, correction should be considered. Techniques for correction of malrotation of both tibial and femoral fractures are presented.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lateral femoral distraction is a safe and necessary adjunct for articulator visualization during the operative treatment of tibial plateau fractures.

Introduction: Recent evidence suggests use of lateral femoral distractor (LFD) to aid in visualization during surgery for tibial plateau fractures (TPF) may result in an unacceptably high rate of iatrogenic peroneal nerve palsy. We sought to evaluate femoral distractor use for open reduction internal fixation (ORIF) of TPF and quantify the incidence of peroneal nerve palsy. Methods: We retrospectively evaluated all patients undergoing ORIF of TPF between 2014 and 2019 by a single fellowship trained orthopaedic traumatologist at a single Level 1 trauma center. Inclusion criteria were use of a LFD during ORIF of TPF. Exclusion criteria were preoperative neurovascular injury in the operative extremity and distraction via pre-existing external fixator. Parameters included patient demographic variables, intraoperative techniques, postoperative outcomes, and fracture classification. Documented clinical exam was used to evaluate peroneal nerve status and injuries were classified as complete or incomplete. Incomplete injuries were classified as sensory or motor. Results: Of 303 patients undergoing ORIF for a TPF, femoral distraction was used in 254 (83.8%) cases, with 201 utilizing applied intraoperative femoral distraction and 53 utilizing pre-existing knee-spanning external fixation for distraction. Three patients were excluded for preoperative sensory peroneal nerve palsy with 175 patients meeting inclusion criteria. The most common fracture type was lateral split depression (n = 130). Zero patients developed complete or incomplete peroneal nerve palsy. Discussion: Our study found no incidence of peroneal nerve palsy when using lateral femoral distraction. This study supports the utilization of lateral distraction for articular visualization and reduction during ORIF of TPF.

A cortical screw based tension band construct for transverse patella fractures: An evolving strategy for addressing common modes of failure.

INTRODUCTION: Displaced patella fractures represent a clinical challenge. We evaluate the effectiveness of an alternative fixation construct to address common modes of fixation failure. METHODS: A retrospective review of 49 patients who underwent fixation via the specific construct at a single institution between 2013 and 2019. RESULTS: Median follow-up was 52.7 weeks (Mean: 75.4 weeks; SD: 54.9; range: 27-267.7 weeks). Construct failure rate was 6.1% (3/49). This included two mechanical hardware failures, one the result of trauma and the other due to noncompliance. CONCLUSIONS: The modified construct represents a safe and effective means of treating transverse patella fractures. LEVEL OF EVIDENCE: Level 4.

Fracture-Associated Microbiome and Persistent Nonunion: Next-Generation Sequencing Reveals New Findings.

INTRODUCTION: Fracture nonunion remains a devastating complication and may occur for several reasons, though the microbial contribution remains poorly estimated. Next-generation sequencing (NGS) techniques, including 16S rRNA gene profiling, are capable of rapid bacterial detection within clinical specimens. Nonunion cases may harbor microbes that escape detection by conventional culture methods that contribute to persistence. Our aim was to investigate the application of NGS pathogen detection to nonunion diagnosis. METHODS: In this prospective multicenter study, samples were collected from 54 patients undergoing open surgical intervention for preexisting long-bone nonunion (n = 37) and control patients undergoing fixation of an acute fracture (n = 17). Intraoperative specimens were sent for dual culture and 16S rRNA gene-based microbial profiling. Patients were followed for evidence of fracture healing, whereas patients not healed at follow-up were considered persistent nonunion. Comparative analyses aimed to determine whether microbial NGS diagnostics could discriminate between nounions that healed during follow-up versus persistent nonunion. RESULTS: Positive NGS detection was significantly correlated with persistent nonunion, positive in 77% more cases than traditional culture. Nonunion cases were observed to have significantly increased diversity and altered bacterial profiles from control cases. DISCUSSION: NGS seems to be a useful adjunct in identification of organisms that may contribute to nonunion. Our findings suggest that the fracture-associated microbiome may be a significant risk factor for persistent nonunion. Ongoing work aims to determine the clinical implications of isolated organisms detected by sequencing and to identify robust microbial predictors of nonunion outcomes. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reinforced reconstruction: A technique for the treatment of periacetabular metastases.

PURPOSE: To describe a single-stage reconstruction of intraarticular periacetabular metastases that utilizes a cemented acetabular liner reinforced with percutaneous screws oriented along various osseous fixation pathways. METHODS: A retrospective evaluation of all patients with intraarticular periacetabular metastases who underwent the procedure outlined. RESULTS: 16 procedures (1 bilateral) were included. There were no intraoperative complications or postoperative mechanical failures to date despite allowing the patients to immediately weight bear in the postoperative setting. DISCUSSION: Utilizing osseous fixation pathways to reinforce a cemented acetabular cup represents a safe and effective strategy to allow for immediate weightbearing in patients with periacetabular metastases.

Validation of the AO Spine Sacral Classification System: Reliability Among Surgeons Worldwide.

OBJECTIVES: To (1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons and subspecialists universally around the world and (2) delineate those injury subtypes that are most difficult to classify reliably to refine the classification before evaluating clinical outcomes. DESIGN: Agreement study. SETTING: All-level trauma centers, worldwide. PARTICIPANTS: One hundred seventy-two members of the AO Trauma and AO Spine community. INTERVENTION: The AO Sacral Classification System was applied by each surgeon to 26 cases in 2 independent assessments performed 3 weeks apart. MAIN OUTCOME MEASUREMENTS: Interobserver reliability and intraobserver reproducibility. RESULTS: A total of 8097 case assessments were performed. The kappa coefficient for interobserver agreement for all cases was 0.72/0.75 (assessment 1/assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the kappa coefficient was 0.84/0.85, corresponding to excellent reliability. The kappa coefficients for interobserver reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall kappa statistic for intraobserver reliability was 0.82 (range 0.18-1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average kappa value was 0.87 (range 0.18-1.00), representing excellent reproducibility. CONCLUSION: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial interobserver and excellent intraobserver reliability.

Management of Ankle Fractures With Syndesmotic Disruption: A Survey of Orthopaedic Surgeons.

INTRODUCTION: With no current "gold standard" fixation strategy for syndesmotic injuries and differences in preferred preoperative and intraoperative diagnostic techniques and criteria, methods of reduction, fixation constructs, and postoperative management, the goals of this study were to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption, as well as to identify surgeon demographics predictive of syndesmotic management techniques. METHODS: This study was conducted as a web-based survey of foot and ankle fellowship-trained surgeons, Orthopaedic Trauma Association (OTA) members, and Canadian Orthopaedic Association (COA) members. The survey, sent and completed via the HIPAA-compliant Research Electronic Data Capture (REDCap) system, consisted of 18 questions: 6 surgeon demographic questions and 12 specific syndesmotic management questions regarding perioperative protocols and syndesmotic fixation construct techniques. RESULTS: One hundred and ten orthopaedic surgeons completed our survey. Years of practice and type of fellowship were found to be the variables that influenced perioperative syndesmotic management strategies the most, while a number of fractures operated on per year, country of practice, and practice setting also influenced management decisions. Additionally, 59% (65/110) surgeons indicated that the way they have managed syndesmotic injuries has changed at some point in their career, while 33% (36/110) specified that they could foresee themselves changing their management of these injuries in the future. CONCLUSIONS: There was significant variability among responders in preoperative and intraoperative assessment technique, fixation construct, screw removal protocol, and postoperative weightbearing protocol. This study raises awareness of differences in and factors predictive of management strategies and should be used for further discussion when determining a potential gold standard for the management of these complex injuries.

The Use of Integra Dermal Regeneration Templates and Cortical Bone Fenestrations over Exposed Tibia.

We present the case of an 86-year-old woman who suffered full-thickness soft tissue loss secondary to degloving injury to the lower left limb, resulting in an exposed tibia. This patient underwent drilling to create artificial fenestrations in the cortical bone followed by placement of Integra dermal regeneration template. The technique of drilling fenestrations to expose underlying vasculature of cortical bone has not previously been described in its relationship with Integra dermal regeneration templates in large degloving injuries of the lower limb. This technique enabled us to perform earlier skin grafting and ultimately resulted in complete and timely wound closure. We present this case as a comparable alternative treatment in cases of reconstructive surgery secondary to severe burns or trauma to reduce the time required for successful wound closure over exposed bone in full-thickness tissue loss injuries of the lower limb.

Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study.

OBJECTIVES: We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications. DESIGN: Retrospective case-control study. SETTING: Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area. PATIENTS/PARTICIPANTS: Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non-weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85). INTERVENTION: IWBAT and IROM after ankle ORIF versus NWB for 6 weeks. MAIN OUTCOME MEASUREMENTS: Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction. RESULTS: There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation. CONCLUSIONS: We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short Term Complications in Geriatric Ankle Fractures Using a Protocolized Approach to Surgical Treatment: Is Early Weight Bearing Safe?

Background: Surgical management of geriatric ankle fractures requires unique considerations in addressing operative risks. Prior studies have reached varying conclusions regarding optimal treatment strategies. The primary aim of this study was to determine if surgical fixation following a predetermined treatment protocol was safe and effective. The secondary aim was to determine if immediate weight bearing as tolerated (IWBAT) in a subset of patients was safe or conferred any short-term benefits. Methods: This retrospective study included all patients over the age 65 treated surgically for an ankle fracture by a single surgeon over a five-year period. A protocol was used including: augmented fixation techniques, IWBAT for select patients, and specific strategies to minimize soft tissue damage. Complications associated with operative treatment were analyzed. A subgroup analysis of patients with isolated ankle injuries was carried out to compare patients made IWBAT to patients made non-weight bearing (NWB) postoperatively. Results: Thirty-four patients were included in the study. Fracture types were predominantly OTA 44B2 (18/34, 53%) and 44B3 (8/34, 24%). Union rate was 100%. Augmented fixation techniques were used in 14/34, 41% of patients. Twenty-one of 34, 62% of patients were allowed IWBAT. There were 4 complications, 12%: 1 malunion, 1 superficial infection, and 2 wound dehiscence. Two patients returned to the operating room for removal of hardware and irrigation and debridement. In the subgroup analysis, the IWBAT group was discharged to a rehabilitation facility at a significantly lower rate than the NWB group, 25% (4/16) vs 90% (9/10; p=0.0036). There were no differences in the complication rates between the two groups. Conclusion: Acceptable outcomes can be reliably obtained when following a standardized approach to geriatric ankle fracture management. In addition, immediate weight bearing in select patients does not seem to increase complications and may benefit patients by increasing rate of discharge to home.Level of Evidence: IV.

Description and Reliability of the AOSpine Sacral Classification System.

BACKGROUND: Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons. METHODS: A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3). RESULTS: Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20). CONCLUSIONS: To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.

An Adjunct Indicator for the Diagnosis of Fracture-Related Infections: Platelet Count to Mean Platelet Volume Ratio.

Introduction: Fracture-related infection (FRI) is a common complication associated with orthopaedic fracture care. Diagnosing these complications in the preoperative setting is difficult. Platelets are a known acute phase reactant with indices that change in accordance with infection and inflammation. The purpose of our study was to assess the diagnostic utility of platelet indices at assessing FRI. Methods: A retrospective review performed for all patients who underwent revision surgery for fracture nonunion between 2013 and 2018. Radiographs were employed to define nonunion. Intraoperative cultures were used to define FRI. Receiver operator characteristic (ROC) curve analysis was used to assess the diagnostic ability of preoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and the platelet count/mean platelet volume ratio (P/V) at recognizing FRI. Results: Of the 53 revision surgeries that were performed for fracture nonunion, 17 (32.1%) were identified as FRI. There were no significant demographic differences between the two cohorts. Patients with FRIs exhibited higher values for ESR (54.82 vs. 19.16, p<0.001), CRP (0.90 vs. 0.35, p=0.003), and P/V (37.4 vs. 22.8, p<0.001) as compared to those within the aseptic nonunion cohort. ROC curve analysis for P/V demonstrated that at an optimal ratio of 23, area under the curve (AUC) is 0.814, specificity is 55.6%, and sensitivity is 100.0%. There was no significant difference in the diagnostic performance of the serum biomarkers but only ESR and P/V had an AUC greater than 0.80. The negative predictive value (NPV) for P/V, ESR, and CRP was 100.0%, 84.6%, and 78.6%, respectively. Conclusion: The P/V ratio may serve as a reliable screening test for FRI.

Single-Incision 4-Compartment Fasciotomy of the Lower Leg: Safe, Effective, and Advantageous.

The optimal surgical approach for acute compartment syndrome (ACS) of the lower leg remains debatable. Although a majority of surgeons tend to use a 2-incision approach to 4-compartment fasciotomies, the authors have used a single-incision technique followed by protocolized, staged skin closure. The purpose of this study was to determine the safety, efficacy, and complication rate of this strategy. This retrospective study included all patients treated for ACS by a single surgeon during a 3-year period. A protocol was used including a single-incision technique followed by vacuum-assisted wound-closure dressing, periodic return to the operating room at 48- to 72-hour intervals, and sequential wound closure with vertical mattress sutures. Complications associated with this protocol were analyzed. Eleven patients were included in the study. Average length of follow-up was 12 months (range, 2-35 months). There were no instances of malunion, deep or superficial infection, intraoperative neurovascular injury, or progressive neurologic deficits-indicating adequate release of all 4 compartments through a single incision. All patients were closed primarily without need for skin grafting. Average time to primary closure was 4.5 days. One patient had a tibial fracture nonunion and 1 had distal wound breakdown, which healed by secondary intention. A single-incision approach to 4-compartment fasciotomies followed by protocolized skin closure is safe and effective and may reduce the need for skin grafting. [Orthopedics. 2020;43(4):e225-e230.].

Upper-Extremity Deep Venous Thrombosis following a Fracture of the Proximal Humerus: An Orthopaedic Case Report.

Deep venous thrombosis of the lower extremities following orthopaedic surgery is well-documented. Though less common than its lower extremity counterpart, upper extremity deep venous thrombosis (UEDVT) has been documented in the literature as well, largely in the context of arthroscopic shoulder surgery. However, there is a paucity of literature documenting UEDVT following surgical fixation of upper extremity fractures, specifically fractures involving the proximal humerus. We present a case of UEDVT following a fracture to the proximal humerus and subsequent surgery. Though UEDVT is considered a rare complication following this type of surgery based on a lack of documentation within the literature, we believe a high-index of suspicion is required to prevent potentially life-threatening sequelae, such as pulmonary embolism (PE) and post-thrombotic syndrome.

Treatment of Distal Fibular Malunion with Corrective Osteotomy: Yablon Revisited.

Yablon originally described that late posttraumatic degenerative ankle arthritis was due to ongoing tibio-talar joint incongruity, and more importantly that anatomic reduction of the lateral malleolus was key to anatomic reduction of the ankle joint, as the talus "faithfully followed that of the lateral malleolus." Ankle fractures involving the lateral malleolus, left unreduced, can lead to malunion and posttraumatic degenerative arthritis. Treatment of this often includes a fibular osteotomy to restore length and rotation. We revisit Yablon's original principles and present a review of the literature pertaining to techniques and outcomes of lateral malleolus malunions treated with distal fibular osteotomies as well as a case report highlighting the challenges and considerations when facing this problem.

Helical Blade Versus Screw Fixation in the Treatment of Hip Fractures With Cephalomedullary Devices: Incidence of Failure and Atypical "Medial Cutout".

OBJECTIVE: To evaluate the rates and mechanisms of failure for cephalomedullary nail fixation using helical blade versus screw fixation and to identify the predictors of failure. DESIGN: Retrospective study. SETTING: Community teaching hospital. PATIENTS/PARTICIPANTS: A total of 126 patients were treated with cephalomedullary fixation for low-energy hip fractures. INTERVENTION: All procedures used the Trochanteric Fixation Nail (Synthes) with either a helical blade [71 (56.3%)] or screw [55 (43.7%)]. MAIN OUTCOME MEASUREMENTS: Failures, defined by nonunion, hardware cutout, and need for revision surgery were independently reviewed by a fellowship-trained orthopaedic trauma surgeon for an assessment of reduction quality and hardware placement. RESULTS: Seven failures of fixation (5.6%) occurred, all of which used a helical blade. Five failures resulted from medial migration of the helical blade through the femoral head, whereas 2 resulted from typical superolateral cutout and varus collapse. There was no difference in the average tip apex distance between the cases using blade versus screw fixation or between failures and the remainder of the cohort. Basicervical fractures had a significantly higher rate of failure than other fracture patterns. CONCLUSIONS: This study showed a higher failure rate with use of the blade and supports the use of screw fixation in these fractures. In addition, we confirm an atypical mode of failure, lateral migration of the femoral head with protrusion of the helical blade, which contributes significantly to the overall failure rate of this implant and occurs despite appropriate fracture reduction and hardware placement. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.