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.

Triceps Tenotomy as an Alternative Exposure for Fixation of OTA/AO 13-C Fractures: A Technical Trick.

SUMMARY: Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate.

BACKGROUND: Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology. METHODS: Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years. RESULTS: There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation. CONCLUSIONS: ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study.

OBJECTIVE: To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail. DESIGN: Prospective, randomized. SETTING: Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN. PATIENTS/PARTICIPANTS: Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts. MAIN OUTCOME MEASURES: The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation. RESULTS: SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures. CONCLUSIONS: Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Vascularized Medial Femoral Condyle Graft for Manubrium Nonunion: Case Report and Review of the Literature.

Fractures of the sternum are rare. Persistent nonunions, however, can lead to chronic pain and significant functional limitations. The vascularized medial femoral condyle is a versatile tool in the surgeon's armamentarium. Traditionally, it has been used as a thin corticoperiosteal graft in the treatment of nonunion of tubular bones. Its use as a structural corticocancellous graft has also been expanding. This report presents a case of a patient with a recalcitrant symptomatic nonunion of the manubrium treated with the unique combined corticoperiosteal and corticocancellous vascularized bone graft from the medial femoral condyle and reviews the literature concerning these uncommon nonunions. (Journal of Surgical Orthopaedic Advances.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures.

Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

Technical tips for fixation of proximal humeral fractures in elderly patients.

Despite the application of modern locking plate technology, complications remain common after fixation of proximal humeral fractures in elderly patients. Varus deformity and intra-articular hardware are most often responsible; fortunately, both of these complications can be avoided. Recent advances in imaging, reduction techniques, fixation methods, and postoperative care have made surgical outcomes more reliable. Particular attention should be directed to obtaining high-quality fluoroscopic images, avoiding varus reductions, supporting the osteoporotic humeral head, using appropriate screw length, using tension band sutures liberally, and protecting the construct postoperatively. With these methods, many proximal humeral fractures in patients older than 75 years can be reliably fixed.

Complications and outcomes of functional free gracilis transfer in brachial plexus palsy.

The purpose of this study was to evaluate the outcomes and complications following free functional gracilis transfer for restoration of elbow flexion and/or finger flexion in patients with acute or chronic brachial plexus injuries. A review of 130 free functioning gracilis muscles transferred for brachial plexus injuries was undertaken to evaluate the failure rate as well as late complications. The overall failure rate (defined as a non-function muscle or one that failed acutely) was 15.4%. The most common late complication was fracture of the clavicle (5.4%). A technical modification of the procedure resulted in a decrease in these complications from a early rate of 7.9% graft failures and 7.9% clavicle fractures to a 2.4% (n = 1) failure rate and zero clavicle fractures in the subsequent 41 consecutive cases. Observations made in this series lead to a technique change, which has thus far resulted in no clavicle fractures, no bowstringing, improved graft viability and function, and a statistically significant decrease in overall complications (p < 0.001) associated with use of functioning free gracilis transfer in brachial plexus reconstruction.

Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique.

BACKGROUND: Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level. METHODS: Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically. RESULTS: Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirty-two fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99 degrees . The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three. CONCLUSIONS: Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.

Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique.

BACKGROUND: Severe comminution, bone loss, and osteopenia at the site of a distal humeral fracture increase the risk of an unsatisfactory result, often secondary to inadequate fixation. The purpose of this study was to determine the outcome of treating these fractures with a principle-based technique that maximizes fixation in the articular fragments and stability at the supracondylar level. METHODS: Thirty-four consecutive complex distal humeral fractures were fixed with two parallel plates applied (medially and laterally) in approximately the sagittal plane. The technique was specifically designed to satisfy two principles: (1) fixation in the distal fragments should be maximized and (2) screw fixation in the distal segment should contribute to stability at the supracondylar level. Twenty-six fractures were AO type C3, and fourteen were open. Thirty-two fractures were followed for a mean of two years. The patients were assessed clinically with use of the Mayo Elbow Performance Score (MEPS) and radiographically. RESULTS: Neither hardware failure nor fracture displacement occurred in any patient. Union of thirty-one of the thirty-two fractures was achieved primarily. Five patients underwent additional surgery to treat elbow stiffness. There was one deep infection that resolved without hardware removal and did not impede union. At the time of the most recent follow-up, twenty-eight elbows were either not painful or only mildly painful, and the mean flexion-extension arc was 99 degrees . The mean MEPS was 85 points. The result was graded as excellent for eleven elbows, good for sixteen, fair for two, and poor for three. CONCLUSIONS: Stable fixation and a high rate of union of complex distal humeral fractures can be achieved when a principle-based surgical technique that maximizes fixation in the distal segments and stability at the supracondylar level is employed. The early stability achieved with this technique permits intensive rehabilitation to restore elbow motion.

Locking plate fixation for proximal humeral fractures: initial results with a new implant.

Treatment of proximal humeral fractures remains controversial, with multiple reported techniques and variable results. Recently, locking plates have become available for fixation of osteopenic and comminuted fractures. This study reports our initial experience with a new locking plate designed specifically for proximal humeral fractures. We observed 16 patients until union or revision with a mean of 12 months' follow-up. Of the 16 patients, 9 had high-energy injuries. There were nine 3-part, five 2-part, and two 4-part fractures. Twelve of sixteen patients healed without complications. There were 4 nonunions; all occurred in patients with 3-part fractures with metadiaphyseal comminution, 3 of whom were heavy smokers. In patients with united fractures, mean elevation was 132 degrees and mean external rotation was 43 degrees, with mean internal rotation to T11. Locking plate fixation achieved union in 75% of patients in this series. Risk factors for delayed union or nonunion included comminution, smoking, and 3-part fractures. These fractures remain challenging despite the availability of locked plating systems.

Neurovascular compression following isolated popliteus muscle rupture: a case report.

This case report concerns an unusual complication of neurovascular compression following an isolated popliteus muscle rupture. A 59-year-old man, after a fall from a horse, gradually developed symptoms of a swollen leg, dysesthesias in the sole of his foot, and muscle weakness of his toe flexors. At presentation, he was found to have a complete tibial nerve injury at the level of the popliteal fossa and significant neuropathic pain. MRI demonstrated a rupture in the muscular portion of the popliteus muscle with extensive edema and hemorrhage compressing the tibial nerve in the popliteal fossa. The edema extended up to the distal part of sciatic nerve where there was evidence of intraneural hemorrhage. In the course of recovery, the patient additionally developed deep venous thrombosis in the ipsilateral popliteal vein. Spontaneous recovery was documented on serial clinical and electrodiagnostic examinations. The patient's neuropathic pain improved significantly within 6 months and his neurologic function recovered nearly fully by 2 years.

Bankart repair in patients aged fifty years or greater: results of arthroscopic and open repairs.

Currently, there is little information on the results of Bankart repairs in older patients. Therefore, the purpose of this study was to determine the results, complications, and rates of revision among patients aged 50 years or greater undergoing Bankart repairs. Between 1992 and 1999, 12 Bankart repairs were performed on patients aged 50 years or greater (mean, 57 years) at our institution. Eleven patients with complete clinical records, operative reports, and minimum 3-year follow-up (mean, 6.5 years) were included in the study. All patients had shoulder instability as a result of specific trauma. Six patients underwent open repairs, and five underwent arthroscopic repairs. There were no patients with full-thickness rotator cuff tears. At the most recent follow-up, there were no shoulders with recurrent instability. The mean simple shoulder test score was 10.8 in the open group and 9.8 in the arthroscopic group. The mean American Shoulder and Elbow Surgeons score was 98 in the open group versus 87 in the arthroscopic group. At the most recent follow-up, mean elevation in the open group was 178 degrees versus 174 degrees in the arthroscopic group. Mean external rotation was 70 degrees in the open group and 72 degrees in the arthroscopic group. The data from this study suggest that Bankart repair in older patients is associated with a low recurrence rate, and similar results may be obtained with either open or arthroscopic procedures.

Radiographic analysis of polyethylene glenoid components using modern cementing techniques.

The purpose of this study was to examine the initial radiographic appearance and changes occurring over time in patients who have undergone total shoulder arthroplasty by modern methods of bone preparation and current cement techniques. Sixty-five patients underwent seventy total shoulder arthroplasties by use of a cemented all-polyethylene, keeled glenoid component. The surface radius was equal to the radius of a one-piece humeral component. The mean clinical follow-up was 4.18 years (range, 2-8.6 years); radiographic follow-up averaged 3.9 years (range, 2-8.6 years). Three observers evaluated radiographs 1 to 2 months postoperatively and at final follow-up. The glenoid component was considered at risk for clinical problems if there was a complete lucent line surrounding the component and some part of the line was 1.5 mm or greater in width or two of three or all three observers identified a shift in component position. Similarly, a humeral component was judged to be at risk if three or more zones had lucent lines 2 mm or greater in width or a shift in component position had occurred. On the early radiographs, 10 glenoid components had incomplete lucencies behind the keel. On the most recent radiographs, 59 glenoid components had incomplete lucent lines and 3 had complete lucent lines. Eight components were judged to have shifted in position. When data for lucent lines and shifting were combined, 10 (14%) of the glenoid components were at risk. At follow-up, no cemented humeral components were at risk whereas 3 (6%) of the 54 tissue ingrowth components were at risk for clinical loosening. Given the number of shoulders in this study, there were no associations between radiographic changes and clinical results. Improvements have occurred in glenoid component fixation. However, additional advances are possible and may occur from improved surgical technique, decreased particle-related osteolysis, enhanced joint kinematics, or novel fixation methods.

Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years.

BACKGROUND: There is a paucity of data on the treatment of femoral neck fractures in young patients. The purpose of the present study was to review the results and complications associated with the treatment of femoral neck fractures with internal fixation in a large consecutive series of young patients. METHODS: Between 1975 and 2000, eighty-three femoral neck fractures in eighty-two consecutive patients who were between fifteen and fifty years old were treated with internal fixation at our institution. Two patients died, and eight were lost to follow-up. Seventy-three fractures were followed until union, until conversion to hip arthroplasty, or for a minimum of two years; the mean duration of follow-up was 6.6 years. Fifty-one of the seventy-three fractures were displaced, and twenty-two were nondisplaced. The results and complications of treatment were retrospectively reviewed, and the effects of fracture displacement, reduction quality, and capsular decompression on outcome were evaluated. Function was assessed by evaluating pain, walking capacity, and the need for gait aids. The mean duration of follow-up for the fifty-seven patients (fifty-eight fractures) who had not undergone early conversion to arthroplasty was 8.1 years. RESULTS: Fifty-three (73%) of the seventy-three fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. Osteonecrosis developed in association with seventeen fractures (23%), and a nonunion developed in association with six (8%). Four of the six nonunions later healed after a secondary procedure. At the time of the final follow-up, thirteen patients had had a conversion to a total hip arthroplasty because of osteonecrosis (eleven), nonunion (one), or both (one). Five (9.8%) of the fifty-one displaced fractures were associated with the development of nonunion, and fourteen (27%) were associated with the development of osteonecrosis. Three (14%) of the twenty-two nondisplaced fractures were associated with the development of osteonecrosis, and one (4.5%) was associated with the development of nonunion. Eleven (24%) of the forty-six displaced fractures with a good to excellent reduction were associated with the development of osteonecrosis, and two (4%) were associated with the development of nonunion. Four of the five displaced fractures with a fair or poor reduction were associated with the development of osteonecrosis, nonunion, or both. CONCLUSIONS: The ten-year survival rate of the native femoral head free of conversion to total hip arthroplasty was 85%. Osteonecrosis was the main reason for conversion to total hip arthroplasty, but not all patients with osteonecrosis required further surgery. The results of treatment were influenced by fracture displacement and the quality of reduction.

Treatment of supracondylar femur nonunions with open reduction and internal fixation.

We reviewed a consecutive series of 22 adults with 22 supracondylar femoral nonunions treated with open reduction and internal fixation (ORIF) to determine the results and complications associated with the procedure. Twenty-one of 22 nonunions (95%) healed. Knee Society pain scores improved from 18 to 88 (P < 0.001). Mean Knee Society functional scores improved from 4 to 55 (P < 0.001). Mean range of motion at follow-up was 1 degree to 96 degrees. ORIF and bone grafting of properly selected patients with nonunions of the distal femur resulted in high rate of union with few associated complications. All patients had improvement in pain scores and the great majority had improvements in functional scores.

Infection after shoulder instability surgery.

Currently, there are no reported series on the outcome of patients treated for infection after shoulder instability surgery. Therefore, the purpose of this study was to review patients who were treated for infection after shoulder instability surgery at our institution between 1980 and 2001 to determine the functional outcome and organisms responsible for infection. During this period, six patients were treated for infection after shoulder instability surgery. Three patients had an early postoperative infection, presenting 6 weeks or less from the time of instability surgery. Three patients had a late infection, presenting 8 months or greater from the time of surgery. Each of the three patients with a late infection had a sinus leading to a retained nonabsorbable suture. None of the six patients have had recurrent shoulder instability. Three patients had a polymicrobial infection and three patients had single organisms. Infection may be acute or significantly delayed from the time of the instability procedure. Additionally, among patients with late infection, there should be a high degree of suspicion for a nidus of infection surrounding nonabsorbable sutures.

Intramedullary fixation of diaphyseal femoral fractures in elderly patients: analysis of outcomes and complications.

The efficacy of intramedullary fixation for diaphyseal femoral fractures in young patients has been well documented. There is a paucity of data, however, on the efficacy of intramedullary techniques used in the ever growing elderly population. The purpose of this study was to analyze the outcomes and rate of perioperative complications associated with using intramedullary fixation to treat diaphyseal femur fractures in patients older than 65 years. We retrospectively reviewed the medical records and radiographs of 21 patients (17 men, 4 women) with isolated diaphyseal femoral fractures treated with anterograde intramedullary nailing at our institution. All fractures united. Ten surgical complications occurred in 9 (43%) of the 21 patients, and 7 medical complications occurred in 4 patients (19%); overall, 17 medical or surgical complications occurred in 11 patients (52%). Although more than half of the patients had an intraoperative or postoperative complication, intramedullary fixation is an effective method for achieving union in elderly patients with diaphyseal femoral fractures.