Functional Outcomes of Patella Fractures Treated With Anterior Plate Osteosynthesis at One Year.

OBJECTIVES: To evaluate the functional outcomes of patients with displaced patellar fractures treated with anterior plate constructs. DESIGN: Prospective cohort and retrospective clinical and radiographic assessment. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: Between 2014 and 2018, 18 patients who underwent operative intervention for an isolated, displaced patella fracture (OTA/AO 34C1-3) with a minimum of 1-year follow-up agreed to participate in the study. The mean follow-up was 19.5 ± 6.0 months. INTERVENTION: Patients were treated with 2.4 or 2.7-mm plates and supplemental screws or cerclage wires. MAIN OUTCOME MEASUREMENTS: Patients were evaluated with the Short Form-36 Survey and the Knee Injury and Osteoarthritis Outcome Scores and asked about symptomatic implants. The range of motion was assessed by goniometer. RESULTS: The cohort had no wound complications, infections, nonunion, loss of reduction, or implant failure. Active knee flexion was 131 ± 7 degrees. Five patients (28%) endorsed implant irritation. Only one patient (5.5%) underwent implant removal, which consisted of transverse screw removal alone. Twelve of the 14 patients (86%), who were previously employed, returned to work at 10 ± 7 weeks. All Knee Injury and Osteoarthritis Outcome Scores subscale scores and the Short Form-36 Survey scores for physical functioning, limitations due to physical health, limitations due to mental health, and social functioning were significantly lower than reference population norms (P < 0.05). CONCLUSIONS: Anterior plating provides reliable fixation for displaced patellar fractures and results in a low incidence of implant irritation. However, patients who had anterior fixation for displaced patella fractures continue to exhibit functional deficits at 1-year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures.

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

CT characterizing the anatomy of uninjured ankle syndesmosis.

Although it is expert opinion that transsyndesmotic screws are placed obliquely 30° from posterolateral to anteromedial in the transverse plane, this has not been formally studied, and there is inconsistency regarding the congruency of the distal tibiofibular joint. Thirty-eight computed tomography (CT) scans of the lower extremity were used to examine the rotational profile of the axis of the syndesmotic joint in relation to the femoral transepicondylar axis and to describe the congruency of this joint. The axis of the distal tibiofibular joint was 32°±6° externally rotated in relation to the transepicondylar axis. The average anterior, central, and posterior widths of the syndesmotic joint space 10 mm superior to the joint line were statistically significantly different: 1.7±0.9 mm, 1.7±0.6 mm, and 2.3±1.1 mm, respectively (P=.004). This study demonstrates that the axis of the uninjured distal tibiofibular joint is approximately 30° externally rotated in relation to the transepicondylar axis. Therefore, reduction clamps and screws should be placed at this angle to avoid malreduction of the syndesmosis. The posterior joint space width is significantly wider than the anterior and central joint spaces. This study's results provide a description of the anatomy of the uninjured distal tibiofibular joint to guide reduction maneuvers and establish a baseline for evaluation of postreduction CT scans.

The effect of obesity on early failure after operative syndesmosis injuries.

OBJECTIVE: The goal of this investigation was to determine if obese patients with syndesmotic injuries have a higher incidence of early postoperative failure compared with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Level 1 urban trauma center. PATIENTS AND METHODS: Two hundred thirteen patients with operative syndesmotic injuries were divided into 2 cohorts: obese and nonobese. All syndesmotic injuries were confirmed by intraoperative stress testing, reduced, and stabilized with internal fixation. INTERVENTION: Fixation of displaced syndesmosis injuries with solid 3.5- and 4.5-mm screws. MAIN OUTCOME MEASURES: The primary outcome was early failure of fixation, defined as revision surgery within 3 months for ankle mortise and/or syndesmosis displacement. RESULTS: Two hundred thirteen patients were identified with operative syndesmosis injuries, of which 102 (48%) were obese and 111 (52%) were nonobese. Fifteen percent (n = 15) of patients in the obese cohort sustained a failure of fixation compared with 1.8% (n = 2) of patients in the nonobese cohort (P = 0.0005). Diabetes mellitus, smoking status, and the type of construct used (eg, screw caliber, number of screws, and number of cortices) were not predictive of loss of reduction. Adjusting for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients (odds ratio = 12.0, P = 0.02). CONCLUSIONS: There is a strong association between obesity and loss of reduction after operative treatment of the syndesmosis. Further research is warranted to determine if a stronger mechanical construct or more conservative postoperative protocol can reduce the risk of loss of reduction in obese patients who sustain a syndesmotic injury.

Internal fixation of diaphyseal fractures of the forearm: a retrospective comparison of hybrid fixation versus dual plating.

OBJECTIVES: To compare open reduction and internal fixation using dual plating to a hybrid fixation construct with intramedullary nailing of the ulna and plate fixation of the radius in both-bone forearm fractures. DESIGN: Retrospective comparison study. SETTING: Level I trauma center. PATIENTS: A total of 56 skeletally mature individuals treated surgically for acute both-bone forearm fractures between July 2005 and December 2009. Monteggia, Galeazzi, and pathologic fractures, patients treated with external fixation and patients with traumatic brain injuries were excluded. INTERVENTION: Twenty-seven patients were treated with dual plate fixation, and 29 patients were treated using a hybrid fixation construct. MAIN OUTCOME MEASURES: Time to union, range of motion as assessed using a Grace and Eversmann score, and presence of complications. RESULTS: There was no significant difference in either time to union or Grace and Eversmann scores between the 2 groups. There was 1 nonunion in each of the 2 groups. Nine overall complications, outside nonunions, were reported: 5 in the dual plating group and 4 in the hybrid fixation group. CONCLUSIONS: Hybrid fixation, using open reduction and internal fixation with a plate-and-screw construct on the radius and closed--or minimally open--reduction and interlocked intramedullary fixation of the ulna, is an acceptable method for treating both-bone diaphyseal forearm fractures in skeletally mature patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing of humeral shaft fractures.

The development of interlocking humeral nail systems has greatly broadened the indications for nailing of humeral shaft fracture. Rotational control is better than with earlier nail systems, and most nails have an oblong distal hole that allows axial loading of the fracture site with muscle contraction. When nailing is done with closed technique, loss of the fracture hematoma and periosteal stripping are avoided. Even when open reduction is required, periosteal stripping can be kept to a minimum. Surgical wounds are smaller, even when open reduction is necessary, and when closed nailing is done, bone grafting is unnecessary. Intramedullary nails are ideal for segmental fractures, pathologic fractures, and fractures in osteopenic bone. Because the arm usually is not a weight-bearing extremity, hardware failure is rare and union rates are equivalent to those of compression plate and screw fixation. Compression plates and external fixation certainly have their place for some fracture patterns and for severe wounds that are unsuitable for intramedullary nailing. The surgeon should be well versed in all three techniques and should be able to rapidly choose among these, depending upon the fracture pattern, skin wound, associated injuries, and overall condition of the patient.