The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation.

OBJECTIVES: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DESIGN: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. RESULTS: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. CONCLUSIONS: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric and clinical study.

In the course of ilioinguinal exposure, significant bleeding can occur from anastomotic vascular channels along the posterior aspect of the superior public ramus. A cadaveric study was undertaken to quantify and qualify these communicating vascular systems. We made bilateral ilioinguinal exposures on 40 cadavers. All vessels > 2 mm in diameter, connecting the obturator system with a more superficial system, were singled out and their courses recorded. Fifty-eight of 79 sides (73%) had at least one large-diameter communicating vascular channel along the posterior aspect of the superior pubic ramus. In 47 of the 79 exposures (59%) communicating veins were noted. Arterial channels were identified in 34 exposures (43%). A prospective clinical study was also performed. Thirty-eight consecutive patients with displaced acetabular fractures were treated surgically using ilioinguinal exposures. Fourteen of the patients (37%) had anastomotic vessels. This study confirms the variability of the retropubic vascular system.

Advances in arthroscopic surgery.

Removal of the whole meniscus from the knee has been shown to be associated with a high incidence of degenerative change. The degeneration is proportional to the amount of meniscus removed. After meniscal injury, retention of the meniscus in part (partial meniscectomy) or in whole (meniscal suture) is preferable. Replacement of a previously removed meniscus (meniscal transplantation) may be feasible in the future. Fifty patients had arthroscopic partial meniscectomies performed alternately by standard mechanical techniques or by electrosurgical techniques. The latter group was found to have less pain and swelling. Another 46 patients had meniscal sutures performed on one or more menisci. Twenty-one of these patients had a follow-up arthroscopy for recurrence of symptoms and only one meniscus had not healed. Another single patient had a meniscal transplant, and a follow-up arthroscopy six months after surgery revealed the meniscus to be largely intact.