Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination, multicenter analysis.

BACKGROUND: This study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture. METHODS: The ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed. RESULTS: In total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate. CONCLUSION: Ipsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.

Effect of distal interlocking of a cephalomedullary femoral nail on peri-implant fractures: A sawbone biomechanical analysis.

BACKGROUND: A large proportion of hip fractures involve inter-trochanteric fractures which are managed by cephalomedullary nails. There is ongoing debate about the advantages and disadvantages of locked versus unlocked long cephalomedullary femoral nails in the treatment of intertrochanteric fractures. The objectives of our study are to evaluate the biomechanical effects of a distal interlocking bolt on the type of peri-implant fractures in a healed intertrochanteric fracture with long cephalomedullary nail fixation. METHODS: 20 femoral sawbone specimens were prepared with the TFN-ADVANCED Proximal Femoral Nailing System (TFNA) and divided into 2 groups: locked and unlocked. The specimens were subjected to axial loading force until failure. Compressive forces, strain and fracture patterns were compared between the 2 groups. RESULTS: There was no significant difference in the mean load to failure of the unlocked specimens compared to locked specimens. However, there was significant difference in the mean compressive stress at the time of failure with the unlocked specimen (1.79±0.17 MPa) compared to the locked group (1.92±0.05 MPa) (p < 0.05). Video review analysis showed unlocked specimens consistently having basi-cervical type peri-implant fractures while locked specimens showed complex, compound fractures of the head-neck region with 2 or more fracture propagation points. CONCLUSION: Distal-locked long cephalomedullary nails in a healed intertrochanteric fracture model are able to tolerate higher compressive stress at the point of failure but demonstrate more complex peri-implant fracture patterns in the femoral head-neck region as compared to unlocked specimens.

Optimisation of postoperative X-ray acquisition for orthopaedic patients.

Postoperative X-rays are a key part of management of orthopaedic patients. These X-rays serve to check stability of orthopaedic fixation as well as to ensure that there are no peri-implant fractures and periprosthetic fractures following surgical fixation of fractures and arthroplasty procedures, respectively. Timely accurate interpretation of postoperative X-rays are crucial in guiding weight-bearing status as well as rehabilitation. Therefore, delays in X-ray acquisition may impact initiation of postoperative rehabilitation and overall length of stay negatively. The aim of this project is to optimise acquisition of postoperative X-rays in patients undergoing implant surgery and as a result increase efficiency of deployed healthcare staff. A multidisciplinary team was formed to study the efficacy of a new workflow for patients to undergo X-rays immediately after surgery while en-route to the ward. Pretrial and in-trial delays in acquiring X-rays and total man-hours spent on transport were recorded. These processes were refined and integrated to optimise the new workflow. Compared with the old workflow, delays in obtaining X-rays were significantly reduced from the longest of 20 hours and 40 min to no delays at all. Overall man-hours spent on transport of these patients were reduced by a mean of 12 and 16 min for nurses and porters, respectively. The trial workflow has since been adopted successfully by our institution and since inception has become standard practice, allowing timely review of postoperative X-rays. This has led to increased workforce efficiency as well as timely rehabilitation and discharge of patients.

Radiographic Outcomes Following the Suture Fixation of Mid-pole Patellar Fractures.

Background Mid-pole patellar fractures are typically fixed with metal implants in the conventional "11-8" tension band construct. However, this technique is fraught with numerous implant-related complications. The aim of this study is to evaluate the union rate following "all-suture" fixation of mid-pole patellar fractures. Methods We retrospectively evaluated a consecutive case series of patients with displaced mid-pole patella fractures treated with "all-suture" fixation in our institution. Fifteen cases were available for this study. The average age was 61.5 years. Clinical and radiological outcomes were evaluated. Union time, complications, and revision rate were recorded. The minimum follow-up was one year. Results There were eight males and seven females, with a mean age of 61.5 ± 13.3 years. Fourteen out of 15 cases (93.3%) achieved radiographic union at 12 weeks postoperatively. The average time to radiographic union was 8.0 ± 2.7 weeks. Five cases (33.3%) had an increase in the fracture gap (>2 mm) at around four to six weeks postoperatively. Four of these cases had an eventual union, whereas one patient had fibrous non-union. There was one case of superficial surgical site infection and one case of infected hematoma. None of the patients required revision surgery. Conclusion "All-suture" fixation of mid-pole transverse patellar fractures is a safe and viable alternative to the conventional "11-8" tension band constructs with metal implants, with good union time, rates, and added benefits of not requiring additional surgery for implant removal.

Surgical Fixation of Subtrochanteric Fracture in Patient with Cancellous Screw Fixation for Neck of Femur Fracture: Surgical Decision-Making and Outcome.

INTRODUCTION: Cannulated screw fixation is a common technique employed for the closed reduction and fixation of minimally or non-displaced neck of femur (NOF) fractures. A rare but potentially devastating complication is a peri-implant subtrochanteric fracture. Given the possibility of dealing with two potentially unstable fractures in close proximity from an incomplete union of the femoral neck, surgical fixation must be carefully planned with the option of retaining the existing cancellous screws to maintain femoral neck stability. The authors describe a case of subtrochanteric fracture in a patient with an existing NOF fracture which was previously fixed with cancellous screw fixation and have provided our approach to such patients. CASE REPORT: The patient is a 73-year-old Chinese male with a previous cancellous screw fixation for an undisplaced NOF fracture 10 months before sustaining another fall resulting in a subtrochanteric fracture. Radiographs and computed tomography imaging revealed a peri-implant subtrochanteric fracture with fracture line originating distal to the inferior screw at the level of the lesser trochanter.The patient subsequently underwent a Trochanteric Fixation Nail-Advanced Proximal Femoral Nailing System (TFNA, Depuy Synthes) fixation of peri-implant subtrochanteric fracture. Two previous cancellous screws (superior-posterior and inferior-central) were first removed to allow the passage of the TFNA nail which just skirted the remaining superior-anterior screw.Postoperatively, the patient was allowed full weight-bearing with the patient managing to ambulate with a roller frame support on the immediate 1stpost-operative day. The subsequent progress was uneventful and at the final follow-up 6-month postoperatively, X-ray showed complete bony union and the patient is pain free and walking independently. CONCLUSION: Peri-implant subtrochanteric fractures following NOF fractures treated with cancellous screws are surgically challenging. A robust system of evaluating such fractures and decision-making aids perioperative planning. An intimate understanding of implant geometries and basic science principles can significantly help in difficult cases and may reduce the likelihood of intraoperative difficulties and complications. Further large-scale studies are required to evaluate the validity of the approach we have proposed.

Non-prosthetic peri-implant fractures: classification, management and outcomes.

INTRODUCTION: Non-prosthetic peri-implant fractures (NPPIFs) are an under-reported entity. Management is challenging because of alterations in anatomy, the presence of orthopaedic implants and phenomena such as stress shielding, disuse osteopenia and fracture remodeling. The aims of this paper were to review patterns of injury, management and outcomes and to propose a classification system to aid further research. MATERIALS AND METHODS: This study is a multi-centered retrospective case series. Patients were identified from the orthopaedic department trauma databases of public hospitals in Singapore and individual surgeon case series of members of the Singapore Orthopaedic Research Collaborative (SORCE) group. RESULTS: We collected a series of 60 NPPIFs in 53 patients. 38 fractures involved the femur, 12 the radius/ulna, 5 humeri, 3 tibia/fibula and 1 clavicle. 39 patients had fractures around plates and screws, 12 around nails, and 3 around screws. Fractures were managed with a variety of surgical techniques. Six patients had surgical complications with refracture in four and non-union in two cases. Two patients had multiple refractures (total 12 additional fractures). All surgical complications required further surgery. Three patients had deep vein thrombosis and one patient died of post-operative pneumonia. Fractures were classified according to the initial implant (plate or nail), the position of the new fracture relative to the original implant (at the tip or distant) and the status of the original fracture (healed, not healed or failing). Surgical strategies for common subtypes were reviewed. CONCLUSIONS: This study represents the largest series in the literature. NPPIFs are a challenging clinical problem with a high rate of post-operative complications. They are distinct from peri-prosthetic fractures and should be understood as a separate entity. We, therefore, propose a novel classification system. Further research is needed to determine the optimal treatment for the various subtypes. LEVEL OF EVIDENCE: Therapeutic Level IV-case series.

Healing of Atypical Subtrochanteric Femur Fractures After Cephalomedullary Nailing: Which Factors Predict Union?

OBJECTIVES: The purpose of this study was to determine the healing rate and time to union of atypical subtrochanteric fractures treated with cephalomedullary nailing. DESIGN: Retrospective review, descriptive, and analytic study. SETTING: Six level 1 trauma centers. PATIENTS/PARTICIPANTS: The study included 42 patients with 48 displaced, atypical, bisphosphonate-associated subtrochanteric femur fractures who underwent surgical intervention. INTERVENTION: Cephalomedullary femur nailing. MAIN OUTCOME MEASUREMENT: The main outcome measures were radiologic healing and time to union. RESULTS: The primary healing rate after cephalomedullary nailing of bisphosphonate-associated subtrochanteric femur fractures was 68.7% (33/48 patients). Mean time to union was 10.7 months. Malalignment was determined using the differences in neck-shaft angle (the difference between the normal side and the surgically repaired side) and sagittal angulation. These all proved to be significantly correlated with failure and delayed healing time. The cutoff points for neck-shaft angle, difference in neck-shaft angle, and sagittal angulation were 125.6, 4.4, and 5.5 degrees, respectively (receiver operating characteristic curve analysis). CONCLUSIONS: The healing rate of atypical subtrochanteric femur fractures treated with cephalomedullary nailing is lower than that previously reported for atypical femur fractures. The quality of fracture reduction proved to be the most important factor in bony union and time to union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial.

PURPOSE: Despite reduction in radiological outliers in previous randomized trials comparing robotic-assisted versus conventional total knee arthroplasty (TKA), no differences in short-term functional outcomes were observed. The aim of this study was to determine whether there was improvement in functional outcomes and quality-of-life (QoL) measures between robotic-assisted and conventional TKA. METHODS: All 60 knees (31 robotic-assisted; 29 conventional) from a previous randomized trial were available for analysis. Differences in range of motion, Knee Society (KSS) knee and function scores, Oxford Knee scores (OKS), SF-36 subscale and summative (physical PCS/mental component scores MCS) were analysed. In addition, patient satisfaction, fulfilment of expectations and the proportion attaining a minimum clinically important difference (MCID) in KSS, OKS and SF-36 were studied. RESULTS: Both robotic-assisted and conventional TKA displayed significant improvements in majority of the functional outcome scores at 2 years. Despite having a higher rate of complications, the robotic-assisted group displayed a trend towards higher scores in SF-36 QoL measures, with significant differences in SF-36 vitality (p = 0.03), role emotional (p = 0.02) and a larger proportion of patients achieving SF-36 vitality MCID (48.4 vs 13.8 %, p = 0.009). No significant differences in KSS, OKS or satisfaction/expectation rates were noted. CONCLUSION: Subtle improvements in patient QoL measures were observed in robotic-assisted TKA when compared to conventional TKA. This finding suggests that QoL measures may be more sensitive and clinically important than surgeon-driven objective scores in detecting subtle functional improvements in robotic-assisted TKA patients. LEVEL OF EVIDENCE: II.

Robot-assisted total knee arthroplasty accurately restores the joint line and mechanical axis. A prospective randomised study.

Robot-assisted Total Knee Arthroplasty (TKA) improves the accuracy and precision of component implantation and mechanical axis (MA) alignment. Joint-line restoration in robot-assisted TKA is not widely described and joint-line deviation of>5mm results in mid-flexion instability and poor outcomes. We prospectively randomised 60 patients into two groups: 31 patients (robot-assisted), 29 patients (conventional). No MA outliers (>±3° from neutral) or notching was noted in the robot-assisted group as compared with 19.4% (P=0.049) and 10.3% (P=0.238) respectively in the conventional group. The robot-assisted group had 3.23% joint-line outliers (>5mm) as compared to 20.6% in the conventional group (P=0.049). Robot-assisted TKA produces similar short-term clinical outcomes when compared to conventional methods with reduction of MA alignment and joint-line deviation outliers.

Preoperative thyroid dysfunction predicts 30-day postoperative complications in elderly patients with hip fracture.

OBJECTIVES: To investigate the relationship between thyroid function and short-term outcomes in elderly patients undergoing surgery for hip fracture. METHODS: Patients aged >60 years admitted from July 2009 to June 2010 who underwent surgical fixation of low-energy hip fracture, excluding those with pathological or periprosthetic fracture, were enrolled in a retrospective observational cohort study. Patients were classified as having biochemically overt or subclinical hyperthyroidism or hypothyroidism, normal thyroid function, or nonclassifiable state based on preoperative thyroid-stimulating hormone and free thyroxine values. Outcome data were collected from hospital records. Biochemical thyroid dysfunction was not systematically treated. Outcomes measured were length of stay (LOS), 30-day postoperative complications, readmissions, and mortality. RESULTS: A total of 254 patients were analyzed; 64 (25.2%) were male and mean age was 77.8 years. There were 128 (50.4%) patients with euthyroid, 68 (26.8%) nonclassifiable, 13 (5.1%) overtly hyperthyroid, 20 (7.9%) subclinically hyperthyroid, 4 (1.6%) overtly hypothyroid, and 21 (8.3%) subclinically hypothyroid. The 30-day postoperative complication rate was 38% (96 patients). The most common complication was urinary tract infection (12.6%), followed by cardiac events (8.3%) and delirium (5.5%). Patients with overt hyperthyroidism had an increased risk of complications in multivariate analysis (odds ratio 3.75, 95% confidence interval 1.10-12.84). Complications in this group were similar to those in the overall cohort. Thyroid function did not predict LOS, readmissions, or mortality. CONCLUSION: Older patients frequently develop complications following surgery for hip fractures. This risk appears to be increased by preoperative biochemically overt hyperthyroidism. Further study is warranted to confirm this finding and to determine whether preoperative treatment improves outcomes.

The femur: a good alternative source of bone graft using a new reamer system when options run out.

Following a post-traumatic incident, orthopaedic surgeons often struggle to look for an abundant source of alternative bone graft because the bone defect is too big or when nonunion is refractory to treatment. We present two cases where the patients' bone grafts were harvested from the healthy femur. This process involved the use of a new intramedullary reamer, which allowed the bone graft to be harvested simultaneously during the reaming process.

Subtalar arthroscopy and flurosocopy in percutaneous fixation of intra-articular calcaneal fractures: the best of both worlds.

BACKGROUND: Fixation of intra-articular calcaneal fractures has traditionally been guided by intraoperative fluoroscopy. Recent reports indicate that there is a role for subtalar arthroscopy in surgical fixation of these fractures. The earliest reports described the use of subtalar arthroscopy for joint assessment during late hardware removal. It then served as an adjunct for joint inspection in open reduction and internal fixation. In its final permutation, percutaneous arthroscopy was performed with minimally invasive reduction and fixation, minimizing soft tissue complications commonly associated with the open approach. In practiced hands, this technique yields good results with minimal morbidity. METHODS: We performed a prospective analysis of 22 consecutive patients with Sanders II, AO-OTA 83-C2 intra-articular calcaneal fractures who underwent dual-modality imaging (subtalar arthroscopic- and intraoperative fluoroscopic-) guided percutaneous fracture fixation with a minimum follow-up of 2 years. Maximum accepted postreduction step-off was 1 mm. Fractures were fixed definitively with four to eight percutaneous cancellous screws. RESULTS: There was significant correction of Böhler's tuberosity-joint angle from 4.2 degrees±11.1 degrees preoperatively to 21.3 degrees±8.8 degrees on immediate postoperative radiographs, with minimal subsidence to 20.1 degrees±8.2 degrees at 2 years. Böhler's angle correction and joint surface restoration could not be achieved percutaneously in one patient with an impacted, depressed joint fragment. Compared with preoperative values, there was significant improvement in mean Visual Analog Scale, American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score, and Short Form-36 (Physical Function) scores at 3 months, with further improvement up to 2-years. CONCLUSIONS: Subtalar arthroscopy augments intraoperative fluoroscopy in anatomic reduction of the posterior calcaneal facet of the subtalar joint and is most useful for Sanders type II, AO-OTA 83-C2 fractures. The percutaneous approach further avoids soft tissue complications associated with open reduction. However, this procedure has a steep learning curve, and conversion to open reduction must be considered when percutaneous reduction fails.

LCP external fixation--external application of an internal fixator: two cases and a review of the literature.

The locking compression plate (LCP) is an angle-stable fixator intended for intracorporeal application. In selected cases, it can be applied externally in an extracorporeal location to function as a monolateral external fixator. We describe one patient with Schatzker V tibial plateau fracture and one patient with Gustillo IIIB open tibia shaft fracture treated initially with traditional external fixation for whom exchange fixation with externally applied LCPs was performed. The first case went on to bony union while the second case required bone grafting for delayed union. Both patients found that the LCP external fixators facilitated mobilization and were more manageable and aesthetically acceptable than traditional bar-Schanz pin fixators.