Outcomes of Distal Third Femur Fractures in Patients 18 Years and Older: A Pilot Study.

INTRODUCTION: The selection of the most optimal fixation method for fractures of the distal femur, whether intramedullary nail (NL), lateral locking plate (PL), or nail/plate (NP) is not always clear. This study retrospectively evaluates surgical patients with distal femur fractures and introduces a pilot study using cluster analysis to identify the most optimal fracture fixation method for a given fracture type. METHODS: This is a retrospective cohort study of patients 18 years and older with an isolated distal femur fracture who presented to our Level-1 trauma center between January 1, 2012, and December 31, 2022, and obtained NL, PL, or NP implants. Patients with polytrauma and those without at least six months of follow-up were excluded. A chart review was used to obtain demographics, fracture classification, fixation method, and postoperative complications. A cluster analysis was performed. The following factors were used to determine a successful outcome: ambulatory status pre-injury and 6-12 months postoperatively, infection, non-union, mortality, and implant failure. RESULTS: A total of 169 patients met inclusion criteria. No statistically significant association between the fracture classification and fixation type with overall outcome was found. However, patients treated with an NP (n = 14) had a success rate of 92.9% vs only a 68.1% success rate in those treated with a PL (n = 116) (p = 0.106). The most notable findings in the cluster analysis (15 total clusters) included transverse extraarticular fractures demonstrating 100% success if treated with NP (n = 6), 50% success with NL (n=2), and 78.57% success with PL fixation (n=14). NP constructs in complete articular fractures demonstrated success in 100% of patients (n = 5), whereas 77.78% of patients treated with NL (n = 9) and 61.36% of those treated with PL (n = 44). CONCLUSIONS: Plate fixation was the predominant fixation method used for distal third femur fractures regardless of fracture classification. However, NP constructs trended towards improved success rates, especially in complete intraarticular and transverse extraarticular fractures, suggesting the potential benefit of additional fixation with these fractures. Cluster analysis provided a heuristic way of creating patient profiles in patients with distal third femur fractures. However, a larger cohort study is needed to corroborate these findings to ultimately develop a clinical decision-making tool that also accounts for patient specific characteristics.

Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent.

BACKGROUND: Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation. METHODS: Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles. RESULTS: For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116). CONCLUSIONS: Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use.

BACKGROUND: Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established. METHODS: Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI. RESULTS: A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers. CONCLUSION: Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not. LEVEL OF EVIDENCE: Level III, Retrospective database study.

Urgent Care Versus Emergency Department Utilization for Foot and Ankle Fractures.

INTRODUCTION: Foot and ankle fractures are common injuries for which patients may need urgent evaluation and care. Many such injuries are managed in emergency departments (EDs), but urgent care facilities may sometimes be an appropriate setting. Understanding which foot and ankle fractures are managed at which facility might help define care algorithms, improve patient experience, and suggest directions for containing costs. METHODS: This retrospective cohort study used the 2010 to 2020 M151 PearlDiver administrative database. Adult patients less than 65 years old presenting to EDs and urgent care facilities for foot and ankle fractures were identified using ICD-9 and ICD-10 diagnosis codes, excluding polytrauma, and Medicare patients. Patient/injury variables associated with urgent care utilization relative to ED utilization and utilization trends of urgent care relative to ED were assessed with univariable and multivariable analyses. RESULTS: From 2010 to 2020, 1,120,422 patients with isolated foot and ankle fractures presented to EDs and urgent care facilities. Urgent care visits evolved from 2.2% in 2010 to 4.4% in 2020 (P , 0.0001). Independent predictors of urgent care relative to ED utilization were defined. In decreasing odds ratios (ORs), these were insurance (relative to Medicaid, commercial OR 8.03), geographic region (relative to Midwest, Northeast OR 3.55, South OR 1.74, West OR 1.06), anatomic location of fracture (relative to ankle, forefoot OR 3.45, midfoot 2.20, hindfoot 1.63), closed fracture (OR 2.20), female sex (OR 1.29), lower ECI (OR 1.11 per unit decrease), and younger age (OR 1.08 per decade decrease) (P , 0.0001 for all). DISCUSSION: A small but increasing minority of patients with foot and ankle fractures are managed in urgent care facilities relative to EDs. While patients with certain injury types were associated with increased odds of urgent care relative to ED utilization, the greatest predictors were nonclinical, such as geographic regions and insurance type, suggesting areas for optimizing access to certain care pathways. LEVEL OF EVIDENCE: III.

Gouty Tophi Encompassing Retained Suture Material 7 Years After Achilles Tendon Rupture Repair.

CASE: We report the case of a 32-year-old male patient with no history of gout who developed gouty tophi encompassing retained suture material 7 years after initial repair of a ruptured Achilles tendon. The patient had a posterior ankle mass concerning for abscess. Monosodium urate crystals were identified, and uric acid level was elevated at the time of irrigation and debridement. CONCLUSION: Surgical site gout is a rare but important phenomenon to recognize in the treatment of patients with Achilles tendon repairs, particularly in patients with a history of abscess, infection, or collections localized to retained suture material.

Lag Screw Trajectory in Supination-External Rotation Fractures: Does the Direction of the Fibula Lag Screw Have an Effect?

BACKGROUND: The fracture obliquity of supination-external rotation injury of the fibula is often amenable to lag screw insertion. The purpose of the study was to determine whether biomechanical differences exist between lag screws inserted from an anterior to posterior direction and from a posterior to anterior direction and the thickness of the anterior and posterior fibular cortices were correlated with biomechanical testing. METHODS: Ten cadaver fibulae were harvested and submitted to material testing following 3.5-mm cortical screw insertion from either an anterior to posterior direction or a posterior to anterior direction. Screw torsional insertion strength and axial pullout strength were measured. Computed tomography images of 40 consecutive patients undergoing preoperative planning for fractures excluding the fibula were examined to define fibular cortical thickness and correlate anatomic findings with the biomechanical testing. RESULTS: The axial pullout strength of lag screws inserted from posterior to anterior was significantly greater than that of lag screws inserted from anterior to posterior (p < 0.05). Screw insertion torque measurements demonstrated a similar trend although the data did not reach statistical significance (p = 0.056). The anterior cortex of the distal fibula exhibited a radiographically greater thickness than that of the posterior cortex at the same level (p < 0.001). CONCLUSIONS: For oblique fractures of the distal fibula, posterior to anterior lag screw insertion exhibited improved biomechanical properties when compared with a similar screw inserted from anterior to posterior. These results correlated with the thicker cortical bone present along the anterior fibula.

Negative predictive value of CT for occult fractures of the hip and pelvis with imaging follow-up.

PURPOSE: To determine the negative predictive value of multidetector CT for radiographically occult fracture of the hip or pelvis in an elderly population presenting to the emergency department. METHODS: Two hundred thirty-seven elderly patients with suspected fracture were identified over a 5-year period with negative radiographs acquired in the emergency department followed by an index CT of the hip/pelvis within 24 h. There were 81 cases with a negative index CT, as determined by 2 musculoskeletal radiologists, and with some form of imaging follow-up (MRI, CT, or x-ray) performed within 18 months of the index CT. Follow-up imaging was reviewed by 2 musculoskeletal radiologists for the presence of fracture to determine the performance of the index CT. The electronic medical record was used to exclude the possibility of intervening trauma between the time of the index CT and follow-up imaging. RESULTS: There were 39 cases with follow-up imaging performed within 6 weeks of the negative index CT, and 42 with follow-up imaging within 6 weeks to 18 months of the negative index CT. Eight of 81 patients demonstrated a fracture on follow-up imaging, with 3 of 8 involving the femoral neck or intertrochanteric femur. The negative predictive value of the index CT for the detection of a radiographically occult hip or pelvic fracture was 90.1%. If considering only surgically relevant fractures (femoral neck and intertrochanteric fractures), the negative predictive value improved to 96.3%. CONCLUSION: Computed tomography for occult hip fractures has a high negative predictive value but there are cases not detected with surgical implications.

Reliability of Radiographic Union Scoring in Humeral Shaft Fractures.

OBJECTIVES: To establish the reliability of 2 radiographic union scoring systems for nonoperative humeral shaft fractures. DESIGN: Retrospective medical record review. Patients identified had humeral shaft fractures and radiographs at various follow-up time points, which were graded according to the both the standard (RUST) and modified radiographic union scoring systems (mRUST). SETTING: A single North American Level-1 Trauma center in Connecticut, including emergency department and clinic follow-up visits. PATIENTS/PARTICIPANTS: Forty-five adult patients (162 image sets) met the following inclusion criteria: diaphyseal humerus fracture, initial nonoperative management, and greater than 2 weeks of follow-up with imaging. INTERVENTION: All 162 image sets of anterior-posterior and lateral radiographs were scored and divided into 4 tiers based on increasing score. Anterior-posterior and lateral image sets were randomly selected from each tier for a total of 50 that were then scored by 7 different reviewers using both the RUST and mRUST systems. MAIN OUTCOME MEASURES: The intraclass correlation coefficients for the cortical and system scores for the RUST and mRUST systems. RESULTS: Interobserver reliability was 0.795 for the RUST system and 0.801 for mRUST. Intraobserver reliability was 0.909 for RUST and 0.949 for mRUST. For mRUST, 92% of values were within ± 1 point from each other. CONCLUSIONS: The RUST and mRUST systems can be applied to humeral shaft fractures with excellent reliability. They have the potential to assist in the diagnosis of humeral shaft union by providing an objective and standardized method to assess healing of bone over time.

Safe Zones for Cerclage Wiring of the Humeral Diaphysis.

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.

Comparison of fluoroscopic techniques for assessment of femoral rotational alignment.

OBJECTIVES: Anatomic rotational reduction of diaphyseal femur fractures is essential in restoring limb mechanics. Errors in reproducing anteroposterior (AP) or lateral knee reference radiographs of the contralateral limb could result in inaccuracies during rotational reduction. The objective of this study was to examine whether fluoroscopic rotational variation can be observed with the same degree of precision with AP and lateral distal femur projections. METHODS: AP and lateral radiographs were obtained from intact knees of 7 cadaveric specimens using fluoroscopy. The lateral condylar width and coronal femoral width from the AP images and the posterior condylar offset and sagittal femoral width from the lateral images were measured by 3 reviewers. Interclass correlation coefficients (ICCs) among the 3 reviewers were calculated. The mean data from all reviewers were plotted against angle of rotation, and the slope (M) and regression of the line were then determined. RESULTS: ICCs were 0.997 (lateral) and 0.994 (AP), demonstrating excellent interobserver agreement. The mean (±SD) M value for lateral images was 0.016 ±â€Š0.001 and for AP images was 0.009 ±â€Š0.001 (P < .0001). The higher lateral M value represents a more appreciable difference in size of the measured segment for the same rotational change. CONCLUSIONS: The observed rotational change was 1.76 times greater on lateral images compared to AP images; thus, the lateral images may be more precise as a reference for rotation. The routine use of lateral knee radiographs to guide intraoperative rotational alignment of the femur may therefore be justified.

Posterior facet cartilage injury in operatively treated intra-articular calcaneus fractures.

BACKGROUND: Direct visualization of the posterior facet in displaced intra-articular calcaneus fractures (DIACF) frequently shows partial or full thickness cartilage delamination. This is felt to be secondary to the depression of an osteoarticular segment of the posterior facet within the calcaneal body and the subsequent contact with fracture edges as it impacts caudally. The purpose of this study was to determine the frequency of cartilage injury and if it correlates with fracture classification. METHODS: A single surgeon prospective, observational series of 28 patients with 28 DIACFs was reviewed for patient demographic and injury data, radiographic fracture characterization, and intraoperative observation of articular injury size, depth, and location over the time period of February 2010 to December 2012. Observations were correlated with the OTA and Sanders classification systems. RESULTS: Age, sex, mechanism of injury, and depth and location of cartilage injury were not significantly different between the 13 OTA/Sanders type 2 and 15 type 3 DIACFs evaluated in this study. Posterior facet articular cartilage delamination was found in 77% of type 2 and 100% of type 3 fractures (P = .09). Location of cartilage injury was common (56%) along the distal, lateral aspect of the posterior facet (P < .05). The percentage area of cartilage injury was significantly larger in type 3 fractures (3.1%) then type 2 (1.3%) (P < .02). CONCLUSIONS: DIACFs had a consistent location of posterior facet articular cartilage delamination along the distal lateral aspect of the osteoarticular fragment. This lesion was larger in OTA/Sanders classification type 3 fractures compared to type 2 fractures. LEVEL OF EVIDENCE: Level IV, prospective, observational series.

Surgical techniques for complex proximal tibial fractures.

In managing complex proximal tibia fractures, several options are available to the treating surgeon. Closed management with or without external fixation, formal open reduction and internal fixation, and intramedullary nail fixation have been described in the literature. There is a lack of consensus regarding the optimal treatment method for complex bicondylar patterns or proximal metadiaphyseal fractures with or without involvement of the articular surface. It is helpful to review the standard and alternative surgical approaches to bicondylar tibial plateau fractures and to be aware of the intramedullary nail as an alternative approach for complex proximal metadiaphyseal patterns.

Dorsalis pedis artery pseudoaneurysm after Lisfranc surgery.

We present a 44-year-old man who sustained a Lisfranc dislocation complicated by a dorsalis pedis pseudoaneurysm. This case represents a rare complication of a commonly performed orthopaedic procedure.

The retropatellar portal as an alternative site for tibial nail insertion: a cadaveric study.

OBJECTIVE: To define spatial relationships between major intra-articular structures of the knee and the entry site of a tibial nail inserted using a retropatellar portal. DESIGN: Cadaveric study using 16 fresh-frozen limbs. SETTING: University-affiliated cadaver and anatomy laboratory. RESULTS: The mean distance of the nail entry site and the medial and lateral menisci were 6.6 ± 3.2 mm and 6.4 ± 4.4 mm, respectively. The distance to the medial and lateral articular surfaces were 5.6 ± 3.6 mm and 7.4 ± 4.2 mm, respectively. The mean distance to the anterior cruciate ligament footprint was 7.5 ± 3.5 mm. The lateral meniscus was never injured during the procedure. The anterior cruciate ligament was undisturbed in all specimens. The medial meniscus was injured 1 to 2 mm in 12.5% of specimens. The intermeniscal ligament was injured 1 to 2 mm in 81.2% of the specimens. CONCLUSION: The intermeniscal ligament and medial meniscus are at the most risk during intramedullary nailing of the tibia using the retropatellar technique. This may be corrected by avoiding an excessively medial start point. Damage to the intermeniscal ligament and medial meniscus occurs more commonly with the retropatellar portal, but this damage was never more than 1 to 2 mm. This risk, however, appears similar to the pattern and incidence of injury that occurred in prior studies investigating tibial nail insertion through a standard patellar tendon approach. The retropatellar technique demands clinical investigation to further define both its safety and its use.

Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods.

BACKGROUND: The objective of this study is to compare locking and nonlocking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fracture model. We hypothesized that posteromedial fragment fixation with medial and lateral nonlocked constructs would tolerate higher loads than with lateral locked constructs alone. METHODS: Thirty composite tibiae were fractured (AO 41-C1.3). Six constructs were tested: (1) lateral 3.5-mm conventional nonlocking proximal tibial plate (CP); (2) CP + posteromedial 3.5-mm limited contact dynamic compression plate; (3) CP + posteromedial 1/3 tubular plate (CP + 1/3 tubular); (4) 3.5-mm Zimmer Proximal Tibial Locking plate; (5) 3.5-mm Synthes Locking Compression plate; and (6) Less Invasive Stabilization System tibial plate. Specimens were cyclically loaded to failure or a maximum of 4000 N. RESULTS: Failure occurred at the posteromedial fragment first. The CP + 1/3 tubular had the highest average load to failure (3040 N). The CP + 1/3 tubular demonstrated higher load at failure compared with the 3.5-mm Synthes Locking Compression plate (p = 0.0060) and the Less Invasive Stabilization System (p = 0.0360). The CP + 1/3 tubular did not demonstrate a difference in load at failure when compared with the CP (p = 0.4225), the CP + posteromedial 3.5-mm limited contact dynamic compression plate (p = 0.4799), or the 3.5-mm Zimmer Proximal Tibial Locking plate (p = 0.1595). CONCLUSIONS: The posteromedial fragment tolerated higher loads with the CP + 1/3 tubular plate construct. The superiority of this construct may be caused by unreliable penetration of this fragment by the lateral locking screws.

Neurovascular risks of anteroinferior clavicular plating.

Anteroinferior plating has been described for internal fixation of clavicular fractures, citing improved bicortical fixation, less hardware prominence, and safer drill trajectories compared with other plate configurations. This anatomic study defined structures at risk during anteroinferior clavicular plating. Four paired cadaveric specimens (8 clavicles) from ages 75 to 93 years were systematically dissected. Using the screw paths associated with an anteroinferior plate (anteroinferior to superoposterior), the distance from the posterior clavicle cortex to the nearest vital structure was measured at 5 different positions along the clavicle. In the medial half of the clavicle, the subclavian artery is in closest proximity to the clavicle, measuring, on average, 22.95 mm and 15.10 mm at point A and B. At the lateral three-fifths point of the clavicle (point C), the brachial plexus is 12.76 mm from the posterior clavicle and is more at risk than the subclavian artery. Lateral to the three-fifth point of the clavicle, there were no vital structures that could be injured by overdrilling. Our results suggest that more care should be observed with placement of screws in the medial half of the clavicle where subclavian artery damage is more likely.

Unusual Variant of the Nutcracker Fracture of the Calcaneus and Tarsal Navicular.

A 62-year-old woman with severe seizure disorder presented with right ankle and foot pain after being found down, presumably following a seizure recurrence. Imaging showed an acute comminuted fracture of the anterolateral aspect of the right calcaneus, as well as an acute avulsion fracture of the right navicular tuberosity at the site of insertion of the tibialis posterior tendon. This fracture pattern suggests forced abduction of the midfoot or forefoot with severe compression of the lateral column and failure of the medial column under tension, an entity that has previously been described as the nutcracker fracture. This mechanism of injury should prompt particularly careful evaluation of the navicular, cuboid, and calcaneus for any signs of injury. Subtle fractures of the navicular and calcaneus may be overlooked in the emergency setting, leading to a delay in surgical treatment and ultimately chronic foot deformities that can result in significant functional disability.