Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol.

INTRODUCTION: This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures. MATERIALS AND METHODS: A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented. RESULTS: The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score. CONCLUSIONS: Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

Predictable healing of femoral neck fractures treated with intraoperative compression and length-stable implants.

OBJECTIVES: A healed, yet shortened, femoral neck has historically been deemed a success in fracture treatment. This, however, comes at the price of diminished physical function and quality of life. We analyzed the outcomes of our treatment algorithm, which attempts to minimize postoperative shortening of femoral neck fractures and determined which preoperative factors were associated with femoral neck shortening and failure of surgical fixation. LEVEL OF EVIDENCE: This is level IV retrospective study. MATERIALS: Fifty-four patients underwent open reduction and internal fixation for acute femoral neck fracture with nonsliding constructs. The collapse of the femoral neck in the horizontal (X), vertical (Y), and along the resultant along the (Z) vector (X+Y=Z) was measured on anteroposterior radiographs corrected for leg rotation. The migration of the superior-most screw tip in all axes was measured. Age, gender, Garden grade, and Pauwel's angle were analyzed for their association with shortening or failure of surgical fixation. RESULTS: The average age of the patients was 78.1 years. There were 23 Garden I, 2 Garden II, 14 Garden III, and 15 Garden IV fractures. Fifty-one (94%) healed successfully without complications. The minimum follow-up was 9 months (average, 17.6 months; range, 9-30 months). Surgical fixation failed in two patients, and one patient developed avascular necrosis. The average displacement of the femoral head and the screw tip was 1.23, 0.86, 1.98 mm and 0.7 mm, 0.9 mm, and 1.7 mm in the X, Y, and Z (resultant) vectors, respectively. DISCUSSION: With careful consideration to reduction, we fixed femoral neck fractures with nonsliding constructs, resulting in a high union rate with very minimal shortening of the femoral neck.

Outcomes of length-stable fixation of femoral neck fractures.

INTRODUCTION: The most common implants for treating unstable femoral neck fractures are sliding constructs, which allow postoperative collapse. Successful healing, typically, is a malunion with a shortened femoral neck. Functional sequelae resulting from altered femoral neck biomechanics have been increasingly reported. Re-operation rate due to nonunion, avascular necrosis, hardware cut-out and prominence is high with this treatment modality. We evaluated the outcomes of patients with femoral neck fractures treated with stable calcar pivot reduction, intraoperative compression across the fracture, and stabilization with length-stable implants. MATERIALS AND METHODS: Fifty-four patients with femoral neck fractures underwent open reduction and internal fixation. Average follow up duration was 23.6 months (range: 15-36 months). There were 23 Garden I, 2 Garden II, 14 Garden III and 15 Garden IV fractures. Reduction was achieved through a modified Smith-Petersen approach. Fractures were compressed initially, and subsequently stabilized with a length-stable device. Post-operative radiographs were assessed for change in fracture alignment. Variation in the femoral neck offset and abductor lever arm measurements was performed using the contralateral hip as control. Functional outcome was assessed using SF-36, Harris Hip Score (HHS) and a gait analysis device. The average patient age was 78 years. Fifty-one (94%) healed without complications. Surgical fixation failed in two patients and one patient developed avascular necrosis. The average femoral neck shortening was 1.7 mm. RESULTS: The average difference in femoral neck offset and the abductor lever arm measurement at the latest follow up was 3.5 and 1.5 mm respectively. The average score on physical, mental components of SF-36 and HHS was 42 and 47 and 87 respectively. By 6 months, patients on average recovered 94% of the single limb stance time, 98% of cadence, 90% of cycle duration, 96% in stride length compared to the uninjured side. CONCLUSION: Reduction with a stable calcar pivot, intraoperative compression and length-stable fixation can achieve high union rates with minimal femoral neck shortening and improved functional outcomes. LEVEL OF EVIDENCE: IV, retrospective with historical controls.

Complications of recombinant human BMP-2 for treating complex tibial plateau fractures: a preliminary report.

UNLABELLED: Bone morphogenic proteins (BMPs) are potent osteoinductive agents. Their use in fracture surgery is still being studied and the clinical indications are evolving. Heterotopic bone after BMP use in spine surgery is a known complication. While some literature describes the ability of BMP to enhance fracture healing, few articles describe complications of BMP. In tibial plateau fractures, after elevating the cartilage en mass, a subchondral void may be created in these fractures. Structural support provided by bone void-filling agents can be augmented with osteoinduction achieved by BMP. We asked whether heterotopic bone formation would occur more frequently with BMP-2 when used in tibial plateau fractures and whether BMP-2 enhanced the ability to maintain surgically restored subchondral bone integrity. Heterotopic bone developed more frequently in patients receiving BMP (10 of 17) than in patients not receiving BMP (one of 23). Four patients receiving BMP and no patients not receiving BMP underwent removal of heterotopic bone. Maintenance of subchondral bone integrity was similar without and with the use of BMP. BMP is a potent osteoinductive agent; however, when used for an off-label indication in periarticular situations, complications such as heterotopic bone are common and increase reoperation rates. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Osteochondral lesions of talus associated with ankle fractures.

BACKGROUND: Residual ankle pain and stiffness is not uncommon after ankle fractures. Proposed etiologies include ligamentous instability, joint arthrosis and osteochondral injuries. We studied the incidence of osteochondral lesions of the talus (OCLT) with various ankle fracture patterns and assessed their impact on functional outcome. MATERIALS AND METHODS: Preoperative MRI of 153 patients with ankle fractures who underwent operative fixation was studied. Ligamentous structures around the ankle and OCLT were assessed by MRI. The OCLT was graded as follows: 0, normal; 1, hyperintense but morphologically intact cartilage; 2, fibrillations or fissures not extending into the bone; 3, cartilage flap or bone exposed; 4, loose undisplaced fragment; 5, displaced fragments. Functional outcome was assessed using Foot and Ankle Outcome Scoring (FAOS) at a minimum of 6 months. Outcome between the OCLT and non OCLT group with similar fracture pattern was compared using Fischer's exact test. RESULTS: There were 26 (17%) associated OCLT; four grade I, five grade II, one grade III, eight grade IV, and eight grade V lesions. Three were associated with supination adduction, 21 with supination external rotation injuries and two with pronation external rotation injuries. In the OCLT and the non OCLT group, the average symptom score, pain score, activities of daily living score, sports/recreation score and quality of life score was 80, 72, 79, 45, 50 and 73, 73, 79, 60, 45, respectively. There was no statistically significant difference between the two groups (p > 0.1). CONCLUSION: Osteochondral lesions were frequently associated with ankle fractures; however they had no significant impact on the functional outcome when associated with ankle fractures.

Acute compartment syndrome in patients with tibia fractures transferred for definitive fracture care.

We sought to determine if patients evaluated at an outside institution for a tibia fracture and transferred to a referral hospital for fracture management were at risk for having acute compartment syndrome (ACS) on arrival. We conducted a database search for cases in which patients were referred for definitive fixation of tibia fractures, and on initial evaluation at our institution were diagnosed with ACS that necessitated fasciotomy. Incidence, demographics, fracture type, early complications, and factors that predict ACS were evaluated. Between 1996 and 2008, 9 patients (6 men, 3 women; mean age, 44.4 years) were transferred for definitive fixation of a tibia fracture and on presentation had ACS of the involved extremity (1.0% of all tibia fractures treated during this period). Two of the 9 patients developed contractures. Seven of the 9 patients had a good clinical result, and there were no amputations. There is increased risk for ACS in all patients with musculoskeletal trauma, irrespective of age, sex, fracture type, or injury mechanism. Given this risk, physicians must closely monitor patients. A patient should not be transferred until a fasciotomy is performed, if there is a significant risk of developing compartment syndrome prior to or during transport.

Functional and radiographic outcomes of intertrochanteric hip fractures treated with calcar reduction, compression, and trochanteric entry nailing.

OBJECTIVES: Shortening after intertrochanteric hip fractures with sliding constructs is an increasingly recognized problem by the orthopaedic community. It often results in a limb length discrepancy causing maladaptation of the abductor lever arm. Functional limitations can also result from altered hip biomechanics and negatively influence patient outcomes. We hypothesized that with trochanteric entry nailing, calcar reduction, and intraoperative compression, a near-normal restoration of gait parameters and satisfactory outcomes can be achieved. DESIGN: Level 4, prospective descriptive study. SETTINGS: Level 1 trauma care center. PATIENTS/PARTICIPANTS: Fifty-eight patients with intertrochanteric hip fractures were managed operatively from 2007 to 2008. A strict exclusion criterion was used to analyze the data of interest for a final cohort of 30 patients. INTERVENTION: Stable fixation was achieved with trochanteric entry nail after calcar reduction and intraoperative compression of the fracture site. Patients were grouped into stable (n = 17) and unstable (n = 13) fracture types based on the OTA classification. OUTCOME/MEASUREMENTS: Postoperative collapse was measured as telescoping of the lag screw from lateral cortex and blade tip migration within the femoral head. Alteration in femoral head offset and abductor lever arm was measured at the last follow-up visit. Gait parameters were recorded and compared with contralateral side at 6-week, 3-, 6-, and 12-month follow-up visits. Functional outcomes were assessed through 36-item short form health survey (version 2) and Harris Hip Scores at 1 year. RESULTS: Fracture type (stable or unstable) significantly predicted telescoping (P = 0.007). Mean telescoping was 3.3 mm (SD = 2.41 mm) in the unstable group versus 1.2 mm (SD = 0.81 mm) in the stable group (P = 0.004). The stable group recovered 95% of the single limb stance versus 91% in the unstable group, at 1 year. (P = 0.02). Return of single limb stance improved from 76% to 95% between 6 weeks and 6 months. No improvement in gait was seen after 6 months (P > 0.05). The average scores on the physical and mental components of 36-item short form health survey and Harris Hip Scores were 44, 53, and 89, respectively. The radiographic union rate was 100%. There was 1 (3%) screw cutout that did not require a revision surgery in our series. There were no cases with implant failure, femur fracture, or any wound complications. CONCLUSIONS: Satisfactory functional outcomes with near-normal gait restoration can be achieved in cases of intertrochanteric hip fractures with an emphasis on calcar reduction and compression after fixation with trochanteric entry nail. LEVEL OF EVIDENCE: Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Locked plating of the proximal humerus using an endosteal implant.

PURPOSE: To report on the use of a supplemental medial endosteal implant to prevent varus collapse and screw cutout in proximal humerus fractures treated with a laterally placed locking plate. METHODS: Twenty-seven patients meeting study inclusion criteria were included in the study. Follow-up averaged 63.1 weeks (minimum 37 weeks and maximum 120 weeks). All patients were either older than 70 years or had sustained a proximal humerus fracture with medial comminution. Using the anterolateral acromial approach, a proximal humeral locking plate augmented with a medial endosteal implant (fibular allograft in 23 patients and semitubular plate in 4 patients) was used for fixation. Intraoperative fluoroscopic images and the most recent follow-up radiographs were used to measure the head-shaft angle and loss of height between the implant and the articular surface. RESULTS: Only 1 of 27 patients had significant loss of reduction with collapse of the fracture into varus (4.2 mm change). Ninety-six percent of patients maintained their original reduction with an average loss of height of 1.2 mm and an average change in shaft-head angle of 2.2 degrees. There were no implant failures or screw perforations of the articular surface and no radiographic or clinical evidence of AVN. CONCLUSIONS: Use of a medial endosteal implant as a supplement to a lateral locking plate is effective in maintaining operative reduction, preventing varus collapse, and implant failure in fractures with medial comminution and/or poor bone quality. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The anterolateral approach to the proximal humerus for nonunions and delayed unions.

Nonunions of proximal humerus fractures can be disabling as a result of pain, deformity and instability, and are often found in geriatric patients with poor bone quality. There are relatively few studies examining the treatment of nonunions of the proximal third of the humerus and the ideal treatment and surgical approach remains unclear. This case series reports the successful use of the anterolateral acromial approach for treatment of the symptomatic proximal third humerus nonunions in a geriatric group of patients with clear challenges as a result of patient comorbidities and bone quality.

Dual plating for fractures of the distal third of the humeral shaft.

In this study, we present a novel method for performing dual plating of extra-articular fractures of the distal third of the humerus. Since 2006, we have treated 15 such fractures with dual plates from a single posterior midline incision. In the first part of the study, we provide the surgical protocol we have used in addressing these fractures. In the second part, the charts of these patients were reviewed retrospectively to examine their clinical and radiographic outcomes. Using this technique, we have achieved an excellent union rate without significant complications while allowing early and aggressive range of motion.

Management of nonunions of the proximal humeral diaphysis.

It has been reported that the majority of nonunions of the humeral shaft evaluated are within the proximal one-third of the diaphysis. We are not aware of any reported series of humeral nonunions dealing specifically with the proximal diaphysis. We therefore sought to identify patients with a humeral shaft nonunion from an orthopaedic trauma service database, determine the frequency of those within the proximal one-third and review our treatment strategy and resulting clinical outcomes for these difficult fractures. Clinical and radiographical follow-up was available for 19 patients with a mean age of 70 years (range 29-94 years). This represented 46% of all humeral shaft nonunions treated during the study period. Dual plating was used in 11 cases to get adequate fixation in the proximal segment. Post-operative alignment was within 5° of anatomic in all cases. All nonunions healed at an average of 15.2 weeks (range 8-36 weeks). The mean length of follow-up was 12.5 months (range 6-122 months). All patients reported significant improvement in pain. The mean range of motion following fracture union was forward flexion 137°, external rotation 41° and internal rotation 30°. There were two minor complications and neither required a secondary surgery. The surgical technique we have used emphasising a thorough debridement of the nonunion site, correction of the deformity, fracture site compression with a rigid construct and bone grafting provides excellent rates of union and clinical outcomes.

The use osteochondral allograft in the treatment of a severe femoral head fracture.

This study reviews the second case in the literature involving the use of frozen osteochondral allograft to reconstruct a femoral head fracture-dislocation. The case involved significant, unreconstructable damage to the weightbearing area of the femoral head in an 18-year-old male. Clinical and diagnostic imaging follow up at 46 months revealed that despite magnetic resonance imaging and radiographic evidence of progressive arthrosis in the hip, including subchondral cystic change in the femoral head and localized cartilage loss in the acetabulum and femoral head, the patient had excellent function with no complications (Harris hip score 100, hip dysfunction and osteoarthritis outcome score 62, musculoskeletal function assesment score 22, SF-36 score 81). The use of osteochondral allograft may serve as a useful tool for the orthopaedic surgeon faced with an unreconstructable femoral head fracture-dislocation in a young patient.

Functional outcomes after syndesmotic screw fixation and removal.

OBJECTIVES: Ankle fractures with a syndesmotic injury have historically been treated with syndesmotic screw fixation. We compared range of motion and functional outcomes' scores to assess patient benefit from syndesmotic screw and plate removal. DESIGN: Level IV--case series. SETTING: Level I--trauma center. PATIENTS/PARTICIPANTS: Twenty-five consecutive patients with unstable ankle fractures and syndesmotic injury confirmed on magnetic resonance imaging. INTERVENTION: Locked syndesmotic screws and plates were removed; functional outcomes and range of motion were measured before and after screw removal. MAIN OUTCOME MEASUREMENTS: Foot and Ankle Outcome Score, Olerud and Molander Ankle Score, and physical examination RESULTS: There was a significant improvement in range of motion, Foot and Ankle Outcome, and Olerud and Molander Ankle scores at the immediate postoperative visit. This was not significantly changed at longer follow-up. There were no adverse events or complications in these patients. No patient had radiographic loss of syndesmotic reduction after screw removal. CONCLUSIONS: Locked screw and plate removal improved function both subjectively and objectively. Transsyndesmotic implant removal seems to assist improvements in the speed of rehabilitation.