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PURPOSE: Intra-articular distal femur fractures in patients with a lower extremity amputation can present a technical challenge for the treating surgeon in what may be otherwise considered a routine procedure in non-amputees. Difficulties with positioning, fracture reduction, limb contractures, and stump osteoporosis can present challenges with treatment. Here, we describe the surgical technique and outcome of a case series of amputee patients with AO/OTA 33C femur fractures. METHODS: Retrospective case series of five patients with a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation treated with retrograde intramedullary nail at a single Level 1 trauma center from January 1, 2021, to January 1, 2023. Baseline demographic and clinical data were recorded. Rate of bony union and complications were documented. RESULTS: Five patients (three females and two males) with a mean age of 48 years who were treated for a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation were identified. At the time of final follow-up (mean 109.3 days, range 29-183 days), all patients had healed their incisions and were progressing to return of function with their prosthesis. All patients were treated with the surgical technique described in this article, and no postoperative complications were reported. CONCLUSION: This is an effective and safe technique for surgical treatment of comminuted intra-articular distal femur fractures in patients with an ipsilateral below-knee amputation. We believe that this technique can be utilized by any orthopedic surgeon taking trauma call and can avoid unnecessary transfers or delays to care.
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Amputação Cirúrgica , Fraturas do Fêmur , Fixação Intramedular de Fraturas , Fraturas Cominutivas , Humanos , Fraturas do Fêmur/cirurgia , Feminino , Masculino , Fixação Intramedular de Fraturas/métodos , Fixação Intramedular de Fraturas/efeitos adversos , Fixação Intramedular de Fraturas/instrumentação , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto , Fraturas Cominutivas/cirurgia , Amputação Cirúrgica/métodos , Pinos Ortopédicos , Resultado do Tratamento , Consolidação da Fratura , IdosoRESUMO
PURPOSE: Operative fixation of femoral neck fractures (FNFs) remains challenging. Complications are not infrequent, especially in displaced patterns. Numerous fixation techniques have been previously described in the literature; however, there remains a paucity of data regarding outcomes of these injuries treated with the femoral neck system (FNS). METHODS: Patients with a displaced FNF (OTA/AO 31B) treated with the FNS at a single level 1 academic trauma center between 1/1/2019 and 1/1/2023 were identified. Radiographs were reviewed to assess fracture displacement, location, and characteristics. Patient records were further reviewed to assess for complications, reoperations, and osseous union. RESULTS: Forty-three patients (65% male) with 44 FNFs were identified with a mean age of 35.0 years (range, 13-61 years). Two patients developed a deep infection requiring surgical debridement, four patients underwent a total hip arthroplasty, and one patient underwent a valgus intertrochanteric osteotomy for nonunion. There were three cases of femoral head AVN. Mean follow-up was 482.5 days among all patients, and 36 fractures had at least 6 months of follow-up or reached bony union. CONCLUSIONS: Here, we present a series of patients treated with the FNS for internal fixation and report a 18% reoperation rate. This is lower than the average rate that has been previously reported in similar patient populations in the literature treated with alternative methods of internal fixation. Thus, the FNS appears to be a safe and effective option for treatment of these injuries.
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Fraturas do Colo Femoral , Fixação Interna de Fraturas , Reoperação , Humanos , Fraturas do Colo Femoral/cirurgia , Reoperação/estatística & dados numéricos , Reoperação/métodos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Fixação Interna de Fraturas/métodos , Adolescente , Adulto Jovem , Estudos Retrospectivos , Complicações Pós-Operatórias/etiologia , Consolidação da Fratura , Artroplastia de Quadril/métodos , Artroplastia de Quadril/efeitos adversosRESUMO
BACKGROUND: Patients with pelvic ring displacement and instability can benefit from surgical reduction and instrumentation to stabilize the pelvis and improve functional outcomes. Current treatments include iliosacral screw or transsacral-transiliac screw, which provides greater biomechanical stability. However, controversy exists regarding the effects of placement of a screw across an uninjured sacroiliac joint for pelvis stabilization after trauma. QUESTIONS/PURPOSES: Does transsacral-transiliac screw fixation of an uninjured sacroiliac joint increase pain and worsen functional outcomes at minimum 1-year followup compared with patients undergoing standard iliosacral screw fixation across the injured sacroiliac joint in patients who have sustained pelvic trauma? METHODS: All patients between ages 18 and 84 years who sustained injuries to the pelvic ring (AO/OTA 61 A, B, C) who were surgically treated between 2011 and 2013 at an academic Level I trauma center were identified for selection. We included patients with unilateral sacroiliac disruption or sacral fractures treated with standard iliosacral screws across an injured hemipelvis and/or transsacral-transiliac screws placed in the posterior ring. Transsacral-transiliac screws were generally more likely to be used in patients with vertically unstable sacral injuries of the posterior ring as a result of previous reports of failures or in osteopenic patients. We excluded patients with bilateral posterior pelvic ring injuries, fixation with a device other than a screw, previous pelvic or acetabular fractures, associated acetabular fractures, and ankylosing spondylitis. Of the 110 patients who met study criteria, 53 (44%) were available for followup at least 12 months postinjury. Sixty patients were unable to be contacted by phone or mail and seven declined to participate in the study. Outcomes were obtained by members of the research team using the visual analog scale (VAS) pain score for both posterior sacroiliac joints, Short Musculoskeletal Functional Assessment (SMFA), and Majeed scores. Patients completed the forms by themselves when able to return to the clinic. A phone interview was performed for others after they received the outcome forms by mail or email. RESULTS: There were no differences between iliosacral and transsacral-transiliac in terms of VAS injured (2.9 ± 2.9 versus 3.0 ± 2.8, mean difference = 0.1 [95% confidence interval, -1.6 to 1.7], p = 0.91), VAS uninjured (1.8 ± 2.4 versus 2.0 ± 2.6, mean difference = 0.2 [-1.3 to 1.6], p = 0.82), Majeed (80.3 ± 19.9, 79.3 ± 17.5, mean difference = 1.0 [-11.6 to 9.6], p = 0.92), SMFA Function (22.8 ± 22.2, 21.0 ± 17.6, mean difference = 1.8 [-13.2 to 9.6], p = 0.29, and SMFA Bother (24.3 ± 23.8, 29.7 ± 23.4, mean difference = 5.4 [-7.8 to 18.6], p = 0.42). CONCLUSIONS: Placement of fixation across a contralateral, uninjured sacroiliac joint resulted in no differences in pain and function when compared with standard iliosacral screw placement across an injured hemipelvis at least 1 year after instrumentation. When needed for biomechanical stability, transsacral-transiliac fixation across an uninjured sacroiliac joint can be used without expectation of positive or negative effects on pain or functional outcomes at minimum 1-year followup. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Parafusos Ósseos , Fixação Interna de Fraturas/instrumentação , Ílio/cirurgia , Dor Pós-Operatória/etiologia , Articulação Sacroilíaca/cirurgia , Sacro/cirurgia , Fraturas da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Humanos , Ílio/diagnóstico por imagem , Ílio/lesões , Ílio/fisiopatologia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Articulação Sacroilíaca/diagnóstico por imagem , Articulação Sacroilíaca/lesões , Articulação Sacroilíaca/fisiopatologia , Sacro/diagnóstico por imagem , Sacro/lesões , Sacro/fisiopatologia , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/fisiopatologia , Fatores de Tempo , Centros de Traumatologia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. QUESTIONS/PURPOSES: (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? METHODS: After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. RESULTS: Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). CONCLUSIONS: Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Acetábulo/cirurgia , Desbridamento , Fixação de Fratura/efeitos adversos , Fraturas Ósseas/cirurgia , Músculo Esquelético/efeitos da radiação , Músculo Esquelético/cirurgia , Ossificação Heterotópica/prevenção & controle , Acetábulo/diagnóstico por imagem , Acetábulo/lesões , Adulto , Nádegas , Feminino , Fraturas Ósseas/diagnóstico por imagem , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Ossificação Heterotópica/etiologia , Fatores de Proteção , Dosagem Radioterapêutica , Radioterapia Adjuvante , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Texas , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
CASE: The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts. CONCLUSION: Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.
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Fraturas do Colo Femoral , Fixação Interna de Fraturas , Humanos , Fixação Interna de Fraturas/métodos , Fraturas do Colo Femoral/diagnóstico por imagem , Fraturas do Colo Femoral/cirurgia , Fixação de Fratura/métodos , FluoroscopiaRESUMO
SUMMARY: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.
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Fraturas Ósseas , Fraturas do Quadril , Ossos Pélvicos , Fraturas da Coluna Vertebral , Humanos , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Fixação Interna de Fraturas/métodos , Parafusos Ósseos , Pelve/cirurgia , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Acetábulo/lesões , Fluoroscopia/métodos , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/cirurgia , Ossos Pélvicos/lesõesRESUMO
OBJECTIVES: To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement. DESIGN: Retrospective case-control. SETTING: Four academic, Level 1 trauma centers. PATIENTS: Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN. INTERVENTION: DAIR versus IMN removal pathways. MAIN OUTCOME MEASUREMENTS: Fracture union. RESULTS: Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing ( P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN ( P < 0.001), McPherson systemic host grade B ( P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst ( P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing ( P = 0.029). CONCLUSIONS: Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fixation of subtrochanteric femur fractures using intramedullary nails can provide high rates of osseous union. However, a lateral starting point or a medial trajectory can result in varus alignment, typically seen with trochanteric entry nails. Even with piriformis nails, medial comminution can result in secondary malalignment and varus. Varus can predictably result in nonunion and need for repeat operations. Medialized trochanteric entry nailing has been reported previously as a method to prevent varus alignment in low-energy, atypical subtrochanteric femur fractures in association with bisphosphonate use. We present a surgical technique using a medialized trochanteric nail entry point to provide proper alignment and avoidance of varus malreduction in 24 patients with a subtrochanteric femur fracture after a high-energy traumatic event.
Assuntos
Fraturas do Fêmur , Fixação Intramedular de Fraturas , Fraturas do Quadril , Humanos , Fixação Intramedular de Fraturas/efeitos adversos , Fixação Intramedular de Fraturas/métodos , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/cirurgia , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Difosfonatos , Pinos Ortopédicos , Resultado do TratamentoRESUMO
INTRODUCTION: Nonunion rates for distal femur fractures treated with lateral locked plating (LLP) remains as high as 18-22% despite significant advances with implant design and construct modulation. However, whether treatment of distal femur fractures with rIMN has improved outcomes compared to LLP has not been well characterized. The purpose of this study was to compare outcomes of complete articular distal femur fractures (AO/OTA 33-C) treated with either LLP or rIMN. METHODS: 106 distal femur fractures in 106 patients between January 2014 and January 2018 were identified. Medical records were reviewed to collect patient age, gender, body mass index, sagittal and coronal plane alignment on immediate postoperative radiographs, time to union, incidence of nonunion, and incidence of secondary operative procedures for repair of a nonunion. RESULTS: Of 106 patients, 50 underwent rIMN and 56 underwent LLP. The mean age at the time of injury was 51 years (21 to 86 years) and there were 55 males. Average coronal alignment of 83.7° of anatomic lateral distal femoral angle (aLDFA) and sagittal alignment of <1° of apex anterior angulation in the rIMN group. In the LLP group there was an average of 87.9° of aLDFA and 1.9° of apex anterior angulation (p = .005 and p = .36). Average time to union in the rIMN group was 6 months and 6.6 months in the LLP group (p = .52). Incidence of nonunion in the rIMN group was 11.8% and 27.5% in the LLP group (p = .008). There were 8 secondary procedures for nonunion in the rIMN group and 18 in the LLP group (p = .43). CONCLUSIONS: Our results demonstrated a higher nonunion rate and coronal plane malalignment with LLP compared to rIMN. While prospective data is required, rIMN does appear to be an appropriate treatment for complete articular distal femur fractures with a potentially decreased rate of nonunion .
Assuntos
Fraturas do Fêmur , Fixação Intramedular de Fraturas , Placas Ósseas , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Consolidação da Fratura , Humanos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C). DESIGN: Retrospective Case Series. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria. INTERVENTION: The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required. MAIN OUTCOME MEASUREMENTS: Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications. RESULTS: Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication. CONCLUSIONS: Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment. LEVEL OF EVIDENCE: Level III.
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Fraturas do Tornozelo , Fraturas Expostas , Fraturas da Tíbia , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Fraturas Expostas/etiologia , Fraturas Expostas/cirurgia , Humanos , Estudos Retrospectivos , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: In 2018, orthopaedic trauma had the lowest match rate among orthopaedic subspecialties. The purpose of this study was to determine the importance of factors evaluated by orthopaedic trauma fellowship directors when ranking applicants after the interview. METHODS: An electronic survey was submitted to fellowship directors and consisted of 16 factors included in a fellowship application. Respondents were asked to rate the importance of these factors for applicants they interviewed on a 1 to 5 Likert scale, with 1 being not at all important and 5 being critical. RESULTS: Thirty-seven fellowship directors responded (63.8%). The highest-rated factor was the applicant interview (mean score 4.82), followed by the quality of letters of recommendation (4.69), personal connections made to the applicant (3.89), and potential to be leader (3.86). Fellowship directors at academic programs rated interest in an academic career (P = 0.003), research experience (P = 0.023), and exposure to well-known orthopaedic traumatologists (P = 0.003) higher than their counterparts at private institutions. Programs with more than one fellow rated potential to be a leader higher than programs with one fellow (P = 0.02). DISCUSSION: Trainees may use this study when compiling an application to optimize their chances of matching at the program of their choice.
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Bolsas de Estudo , Ortopedia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating. MATERIALS AND METHODS: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs. RESULTS: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9). CONCLUSION: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.
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Artroplastia do Joelho , Fraturas do Fêmur , Fixação Intramedular de Fraturas , Fraturas Periprotéticas , Adulto , Idoso , Artroplastia do Joelho/efeitos adversos , Pinos Ortopédicos , Placas Ósseas , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Humanos , Masculino , Fraturas Periprotéticas/diagnóstico por imagem , Fraturas Periprotéticas/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: The study was to determine the effect of locking hole inserts and their insertion torque on the fatigue life of a large fragment Locking Compression Plate (LCP) under bending forces. METHODS: Fatigue strength of the LCP was examined using cyclic three-point bend testing at 80% yield strength of the construct. Locking hole inserts were used in 2, 4, and 6-hole of a 12-hole plate to simulate three different working lengths. Within each working length, plates were tested without locking inserts serving as the control group. In the experimental groups, inserts were tightened to manufacturer recommendations (4 Nm) and using overtorque (8 Nm). RESULTS: Significantly fewer cycles to failure were observed in control groups versus the locking hole insert groups for all working lengths (2-hole: 4 Nm p = 0.003, 8 Nm p = 0.003; 4-hole: 4 Nm p = 0.02, 8 Nm p < 0.001; 6-hole: 4 Nm p = 0.004, 8 Nm p < 0.001). There was a statistically significant increase in fatigue strength when using overtorque in the 4-hole (p = 0.04) and 6-hole (p = 0.01) defect groups. This was not shown in the 2-hole defect group (p = 0.99). CONCLUSIONS: By placing locking inserts in the empty locking regions of Combi holes along the working length, the number of cycles to failure was increased. Tightening inserts to twice the recommended insertion torque further increased cycles to failure in longer working length models. A longer fatigue life has the potential to decease the incidence of plate failure especially in the setting of delayed union due to poor intrinsic healing capacity, fractures in the geriatric population, osteoporosis and periprosthetic fractures.
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INTRODUCTION: Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation. METHODS: Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria. RESULTS: From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized. DISCUSSION/CONCLUSION: The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.
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Fraturas do Fêmur , Fraturas do Colo Femoral , Adulto , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Colo Femoral/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Radiografia , Estudos RetrospectivosRESUMO
Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.
Assuntos
Antibacterianos/uso terapêutico , Infecções por Bactérias Gram-Negativas/prevenção & controle , Infecções por Bactérias Gram-Positivas/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Fraturas da Tíbia/cirurgia , Vancomicina/uso terapêutico , Adulto , Antibacterianos/administração & dosagem , Método Duplo-Cego , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fraturas não Consolidadas/etiologia , Humanos , Fraturas Intra-Articulares/cirurgia , Masculino , Pessoa de Meia-Idade , Pós , Probabilidade , Estudos Prospectivos , Deiscência da Ferida Operatória/etiologia , Infecção da Ferida Cirúrgica/etiologia , Fatores de Tempo , Vancomicina/administração & dosagemRESUMO
BACKGROUND: The purpose of this study was to determine the importance of factors considered by orthopaedic trauma fellowship applicants when evaluating programs. We hypothesized that applicants will prioritize consistent factors when applying to programs. In addition, we assessed how the applicants use the Internet to research potential fellowships. Our goal is to provide fellowships with information to optimize both their fellowship and online contents. METHODS: At the 2018 and 2019 Orthopaedic Trauma Association meetings, a paper survey was given to each attendee of multiple fellowships' informational sessions. The survey consisted of 25 factors that applicants may consider when evaluating fellowships ranked on a 1-to-5 Likert scale. Additional questions were asked to determine how applicants use the Internet and social media when researching fellowships. RESULTS: We received 111 surveys (roughly a 56% response rate). Ninety-eight applicants (88%) indicated that they use fellowship websites to research fellowships. The utilization of fellowship websites was markedly greater than the use of other online resources. The highest rated factors surveyed were surgical experience (mean 4.95; SD 0.26), pelvic and acetabular experience (4.80; 0.52), lower extremity fracture experience (4.75; 0.58), and current faculty at the fellowship (4.55; 0.78). The lowest rated factors were the ability to moonlight (2.04; 1.08), salary (1.88; 1.12), and spine trauma experience (1.45; 0.87). Surgical experience and pelvic/acetabular experience were rated markedly higher than every other factor surveyed. DISCUSSION: To our knowledge, this is the first study to demonstrate that most orthopaedic trauma fellowship applicants use fellowship websites when researching programs. Programs may use this study to optimize their fellowship experience to reflect what the applicants value. In addition, programs may use this study as a guide when updating their websites. Fellowships with informative websites that meaningfully highlight their fellowship experience may have a competitive edge in attracting applicants to their programs.
Assuntos
Educação de Pós-Graduação em Medicina/métodos , Bolsas de Estudo , Internet , Internato e Residência , Ortopedia/educação , Avaliação de Programas e Projetos de Saúde , Feminino , Humanos , Masculino , Mídias Sociais , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Despite increased awareness of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures and advanced imaging with thin-cut high-resolution computed tomography (CT), failure of diagnosis remains problematic. The purpose of the present study was to determine if the preoperative diagnosis of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with magnetic resonance imaging (MRI) compared with radiographic and CT imaging. METHODS: In response to delayed diagnoses of femoral neck fractures despite thin-cut high-resolution CT, our institutional imaging protocol for acute, high-energy femoral shaft fractures was altered to include rapid limited-sequence MRI to evaluate for occult femoral neck fractures. All patients received standard radiographic imaging as well as thin-cut high-resolution pelvic CT imaging upon presentation. Rapid limited-sequence MRI of the pelvis was obtained to evaluate for an occult femoral neck fracture. RESULTS: Thirty-seven consecutive patients with 39 acute, high-energy femoral shaft fractures resulting from blunt trauma were included. The average age of the patients was 29.1 years (range, 14 to 82 years). Ten (25.6%) of the 39 femoral shaft fractures were open. Two femoral shaft fractures (5.1%) were associated with ipsilateral femoral neck fractures that were detected on radiographs, and no MRI was performed. None of the remaining 37 femoral shaft fractures were associated with a femoral neck fracture that was identified on CT imaging. Thirty-three (89.2%) of 37 patients underwent pelvic MRI to evaluate the ipsilateral femoral neck. Four (12.1%) of those 33 patients were diagnosed with a femoral neck fracture (2 complete, 2 incomplete) that was not identified on thin-cut high-resolution CT or radiographic imaging. CONCLUSIONS: Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. Our results suggest that the frequency of femoral neck fractures may be underrepresented on CT imaging; rapid limited-sequence MRI was feasible without delaying definitive treatment even in polytraumatized patients. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Colo Femoral/diagnóstico por imagem , Fraturas Múltiplas/diagnóstico por imagem , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion. DESIGN: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure. INTERVENTION: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion. RESULTS: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis. CONCLUSIONS: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.
Assuntos
Fraturas do Fêmur , Fraturas Periprotéticas , Placas Ósseas , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Fixação Interna de Fraturas/efeitos adversos , Humanos , Fraturas Periprotéticas/diagnóstico por imagem , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/cirurgia , Estudos RetrospectivosRESUMO
Optimal intramedullary treatment of atypical femur fractures associated with bisphosphonate use requires avoidance of postoperative malreduction, particularly varus. This can be difficult to achieve, given the fracture location, errors with nail entry point, endosteal beaking, and underlying patient osteology, all of which can contribute to postoperative varus and predispose the patient to treatment failure. We present a surgical technique and clinical series of 10 patients emphasizing a medialized trochanteric nail entry point and preferential lateral endosteal reaming to secure a biologically and biomechanically favorable reduction and fixation.
Assuntos
Pinos Ortopédicos , Fraturas do Fêmur/cirurgia , Fixação Intramedular de Fraturas/métodos , Conservadores da Densidade Óssea/uso terapêutico , Estudos de Coortes , Difosfonatos/uso terapêutico , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/etiologia , HumanosRESUMO
OBJECTIVES: To describe the surgical technique and clinical outcomes of high-energy proximal femur fractures treated with a 95-degree angled blade plate. DESIGN: Retrospective case series. SETTING: Single academic Level I trauma center. PATIENT/PARTICIPANTS: Forty-five consecutive patients from March 2012 to April 2017 who sustained a high-energy, unstable proximal femur fracture including (OTA/AO 31-A1, 31-A2, 31-A3, 31-B3, 32-A1a, and 32-C3i). INTERVENTION: Open reduction internal fixation with a 95-degree angled blade plate used in conjunction with an articulated tensioning device. MAIN OUTCOME MEASUREMENTS: Nonunion, malunion, secondary operations, and postoperative infection. RESULTS: Twenty six patients were available for follow-up. The mean age was 43.8 (range 22-86) years, and 81% (21/26) were men. The most common fracture pattern was OTA/AO 31-A3.3. Two fractures were open. The articulated tensioner was used in 100% of cases. Average clinical follow-up was 19.2 (range 7-40) months. Twenty-four of 26 patients (92%) achieved osseous union after the index procedure. One patient underwent nonunion repair, and 2 patients had the blade plate removed as it was symptomatic laterally. No other secondary procedures were performed, and no instances of implant failure were seen. No patients had evidence of a superficial or deep infection. CONCLUSIONS: We found that high-energy proximal femur fractures treated with a 95-degree condylar blade plate and articulated tensioning device had a high rate of union with minimal postoperative complications. Although intramedullary nailing of these fractures remains a preferred treatment modality, the angled blade plate with articulated tensioning device is an excellent option to restore anatomical alignment and obtain bony union in certain highly comminuted fracture patterns. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.