Failure after operative repair is higher for ballistic femoral neck fractures than for closed, blunt-injury fractures: a multicenter retrospective cohort study.

Introduction: The purpose of this study was to describe the outcomes after operative repair of ballistic femoral neck fractures. To better highlight the devastating nature of these injuries, we compared a cohort of ballistic femoral neck fractures to a cohort of young, closed, blunt-injury femoral neck fractures treated with open reduction and internal fixation (ORIF). Methods: Retrospective chart review identified all patients presenting with ballistic femoral neck fractures treated at three academic trauma centers between January 2016 and December 2021, as well as patients aged ≤50 with closed, blunt-injury femoral neck fractures who received ORIF. The primary outcome was failure of ORIF, which includes the diagnosis of non-union, avascular necrosis, conversion to total hip arthroplasty, and conversion to Girdlestone procedure. Additional outcomes included deep infection, postoperative osteoarthritis, and ambulatory status at last follow-up. Results: Fourteen ballistic femoral neck fractures and 29 closed blunt injury fractures were identified. Of the ballistic fractures, 7 (50%) patients had a minimum of 1-year follow-up or met the failure criteria. Of the closed fractures, 16 (55%) patients had a minimum of 1-year follow-up or met the failure criteria. Median follow-up was 21 months. 58% of patients with ballistic fractures were active tobacco users. Five of 7 (71%) ballistic fractures failed, all of which involved non-union, whereas 8 of 16 (50%) closed fractures failed (p=0.340). No outcomes were significantly different between cohorts. Conclusion: Our results demonstrate that ballistic femoral neck fractures are associated with high rates of non-union. Large-scale multicenter studies are necessary to better determine optimal treatment techniques for these fractures. Level of evidence: Level III. Retrospective cohort study.

Life Expectancy After Treatment of Metastatic Bone Disease: An International Trend Analysis.

INTRODUCTION: The decision to treat metastatic bone disease (MBD) surgically depends in part on patient life expectancy. We are unaware of an international analysis of how life expectancy among these patients has changed over time. Therefore, we asked (1) how has the life expectancy for patients treated for MBD changed over time, and (2) which, if any, of the common primary cancer types are associated with longer survival after treatment of MBD? METHODS: We reviewed data collected from 2000 to 2022 in an international MBD database, as well as data used for survival model validation. We included 3,353 adults who underwent surgery and/or radiation. No patients were excluded. Patients were grouped by treatment date into period 1 (2000 to 2009), period 2 (2010 to 2019), and period 3 (2020 to 2022). Cumulative survival was portrayed using Kaplan-Meier curves; log-rank tests were used to determine significance at P < 0.05. Subgroup analyses by primary cancer diagnosis were performed. RESULTS: Median survival in period 2 was longer than in period 1 ( P < 0.001). Median survival (at which point 50% of patients survived) had not been reached for period 3. Median survival was longer in period 2 for all cancer types ( P < 0.001) except thyroid. Only lung cancer reached median survival in period 3, which was longer compared with periods 1 and 2 ( P < 0.001). Slow-growth, moderate-growth, and rapid-growth tumors all demonstrated longer median survival from period 1 to period 2; only rapid-growth tumors reached median survival for period 3, which was longer compared with periods 1 and 2 ( P < 0.001). DISCUSSION: Median duration of survival after treatment of MBD has increased, which was a consistent finding in nearly all cancer types. Longer survival is likely attributable to improvements in both medical and surgical treatments. As life expectancy for patients with MBD increases, surgical methods should be selected with this in mind. LEVEL OF EVIDENCE: VI.

Gluteal compartment syndrome: who is most at risk?

PURPOSE: Gluteal compartment syndrome (GCS) is a rare but devastating condition with a paucity of literature to help guide diagnosis and management. This study aims to identify and describe the risk factors and patient characteristics associated with GCS to facilitate early diagnosis. METHODS: This is a retrospective case series of patients undergoing gluteal compartment release between 2015 and 2022 at an academic Level I trauma center. Chart reviews were performed to extract data on patient demographics, presenting symptoms, risk factors, operative findings, and postoperative outcomes. RESULTS: 14 cases of GCS were identified. 12 (85.7%) were male, with a mean age of 39.4 ± 13 years and a mean BMI of 25.1 ± 4.1 kg/m2. 12 (85.7%) patients did not present as traumas and only 3 had ≥ 1 fracture. 9 patients reported drug use. Hemoglobin (Hgb) (11.7 ± 4 g/dL) was generally low (5 had Hgb < 10 g/dL). Creatine kinase (49,617 ± 60,068 units/L) was consistently elevated in all cases, and lactate (2.8 ± 1.6 mmol/L) was elevated in 9. 13 had non-viable muscle requiring debridement. Postoperatively, the mean ICU length of stay was 12 ± 23 days. 2 patients died during admission and all remaining patients required discharge to rehabilitation facilities. CONCLUSION: GCS is more likely to present in a young to middle-aged, otherwise healthy, male using drugs who is either found down or experienced an iatrogenic injury. Recognizing that GCS is different from that of the leg, in terms of etiology, may help avoid delays in diagnosis and treatment.

Association of Body Mass Index With Severity and Lesion Location in Adolescents With Osteochondritis Dissecans of the Knee.

BACKGROUND: The association between body mass index (BMI) and severity of osteochondritis dissecans (OCD) of the knee at presentation is poorly understood. HYPOTHESIS: We hypothesized that adolescents in higher BMI percentiles for age and sex would have OCD lesions that were more severe at their initial presentation and located more posteriorly on the condyle as compared with adolescents in lower BMI percentiles. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included patients aged 10 to 18 years who were treated for knee OCD at a tertiary care hospital from 2006 to 2017. Patients with noncondylar OCD or missing BMI data within 3 months of presentation were excluded. Patients were stratified per the Centers for Disease Control and Prevention guidelines as underweight, normal weight, overweight, or obese, and the groups were compared according to age, side of lesion, 4 markers of lesion severity (cystic changes, loose fragments, subchondral fluid, and subchondral edema), and surgical treatment. Lesion angle was measured in reference to a line parallel to the femoral axis drawn through the center of a best-fit circle covering the distal condyle. Data were analyzed using chi-square tests, relative risk, Student t tests, analysis of variance, and linear regression of cumulative running percentages. Bonferroni correction was performed when applicable. RESULTS: A total of 77 patients met our inclusion criteria (mean age, 14.2 years; range, 10.1-18.8): 2 were underweight, 50 had normal BMI, 13 were overweight, and 12 were obese. We found correlations between BMI percentile and surgical treatment (R 2 = .732), subchondral fluid (R 2 = .716), subchondral edema (R 2 = .63), loose fragments (R 2 = .835), and the presence of at least 1 marker of lesion severity (R 2 = .857) (P < .0001 for all). No correlation was observed for cystic changes (R 2 = .026). There were significant associations between BMI ≥80th percentile and subchondral edema (risk ratio, 2.5; 95% CI, 1.3-4.8), medial condylar lesions (risk ratio, 1.3; 95% CI, 1.01-1.7), and lesions more anterior on the condyle (P < .05). CONCLUSION: Higher BMI in adolescents was strongly correlated with multiple markers of severity of knee OCD at initial presentation as well as with more anterior lesions.