Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study.

OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. SETTING: Three level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. OUTCOME MEASURES AND COMPARISONS: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Results of Low Distal Femur Periprosthetic Fractures.

OBJECTIVES: To compare retrograde intramedullary nail (RIMN) and open reduction internal fixation (ORIF) in very distal periprosthetic distal femur fractures (PDFFs) to determine whether RIMN is an acceptable option for these fractures that are often considered too distal for IMN due to limited bone stock. DESIGN: Retrospective comparative series. SETTING: Level 1 trauma center. PATIENTS: Patients were treated with fracture fixation for a very distal PDFF, defined as the fracture extending to the anterior flange of the implant or distal. Fifty-six patients met inclusion criteria, with 8 excluded for less than 12 months of follow-up. INTERVENTION: The intervention involved fracture fixation with RIMN or ORIF. MAIN OUTCOME MEASUREMENTS: The primary outcome was unplanned return to surgery. Secondary outcomes included fracture union, radiographic alignment, visual analog score, and Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference. RESULTS: The mean follow-up period was 27 months. Twelve patients were treated with ORIF and 36 with RIMN. Twenty-one fractures were at the flange, and 27 extended distal to the flange. There were no differences between fixation methods for reoperation, deep infection, nonunion, malunion, visual analog score pain score, and PROMIS Pain Interference score. The mean PROMIS PF score was higher in the RIMN group compared with that in the ORIF group. There were 5 reoperations in the RIMN group (14%) and 3 in the ORIF group (25%). CONCLUSIONS: This is the largest series, to the best of our knowledge, of a subset of very distal PDFFs. The results suggest that RIMN may be an acceptable treatment option for these very difficult fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective Clinical Trial Comparing Surgical Fixation Versus Nonoperative Management of Minimally Displaced Complete Lateral Compression Pelvis Fractures.

OBJECTIVE: To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN: Prospective clinical trial. SETTING: Two academic trauma centers. PATIENTS: Forty-eight adult patients with LC pelvic ring injuries with <10 mm of displacement were treated nonoperatively and 47 with surgical fixation. Sixty percent of participants were randomized. Seventy-three percent of the fractures were displaced <5 mm, and 71% were LC-1 patterns. INTERVENTION: Operative fixation versus nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome was patient-reported pain using the 10-point Brief Pain Inventory. Functional outcome was measured using the Majeed pelvic score. Outcomes were analyzed using hierarchical Bayesian models to compare the average treatment effect from injury to 12 and 52 weeks postinjury. The probability of the mean treatment benefit exceeding a clinically important difference was determined. RESULTS: The 3-month average treatment effect of surgery compared with nonoperative management was a 1.2-point reduction in pain [95% credible interval (CrI): 0.4-1.9] and an 8% absolute improvement in the Majeed score (95% CrI: 3%-14%). Similar results persisted to 1 year. Patients with initial fracture displacement ≥5 mm experienced a larger reduction in pain (2.2, 95% CrI: 0.9-3.5) compared with those patients with less initial displacement (0.9, 95% CrI: 0.1-1.8). CONCLUSION: On average, surgical fixation likely provides a small improvement in pain and functional outcome for up to 12 months. Patients with ≥5 mm of posterior pelvic ring displacement are more likely to experience clinically important improvements in pain. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.

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.

How to Avoid Failures in Tibial Plafond Fractures.

Tibial plafond fractures include a wide spectrum of injuries that show their complexity. Soft-tissue injury in tibial plafond fractures is much more important than bony injury. Commonly, a staged treatment, that is, temporary external fixation followed by definitive surgery when the soft tissue is ready, is performed. Knowledge of multiple surgical approaches is a prerequisite for open reduction and internal fixation of tibial plafond fractures because of the large variation of fracture patterns.

Tibial Fracture Healing Score: A Novel Tool to Predict Tibial Nonunion.

The aim of the study was to investigate the utility of a simple office-based tool in predicting the need for secondary intervention to obtain union in patients with tibial fractures. All patients 18 years and older with isolated tibial shaft fractures (OTA 41A, 42A-C, and 43A) treated with intramedullary nailing from 2013 to 2017 were screened. Eighty-seven patients met enrollment criteria. Surgeon assessment of the following 3 clinical parameters was performed at routine office visits and scored as follows: (1) pain (none/mild/decreased=1, no change/increased=0); (2) function (minimal limp/able to perform a single-leg stance=1, significant limp/unable to perform single-leg stance=0); and (3) examination (no/minimal pain with manipulation=1, pain with manipulation=0). Radiographic healing was assessed by the adjusted radiographic union scale in tibial fractures (aRUST). The tibial fracture healing score (TFHS) is the sum of 3 clinical scores (0 to 3) and aRUST score (1 to 3) at 3 months postoperatively. The overall nonunion rate was 11%. A RUST score of 5 or less and a sum of the 3 clinical scores of less than 2 at 3 months were found be predictive of nonunion. A TFHS of less than 3 at 3 months was more reliable in identifying patients requiring nonunion repair, especially for those with minimal radiographic healing (RUST score 6 or 7) at 3 months. The TFHS is a simple office-based clinical tool that may identify patients at high risk of nonunion (TFHS <3) following isolated tibial shaft fracture more effectively than clinical examination or radiographic assessment alone. [Orthopedics. 2020;43(4);e323-e328.].

Significant Improvement in the Value of Surgical Treatment of Tibial Plateau Fractures Through Surgeon Practice Standardization.

INTRODUCTION: It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value. METHODS: This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities. RESULTS: Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001). DISCUSSION: We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Intramedullary Nailing of Periarticular Fractures.

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed.

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures.

OBJECTIVES: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION: Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES: Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS: One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS: Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training.

INTRODUCTION: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not. METHODS: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment. RESULTS: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001). DISCUSSION: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group. LEVEL OF EVIDENCE: Level III.

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

BACKGROUND: A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making. QUESTIONS/PURPOSES: We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis? METHODS: Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review. RESULTS: With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision. CONCLUSIONS: Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. LEVEL OF EVIDENCE: Level III, therapeutic study.

Frequent complications and severe bone loss associated with the repiphysis expandable distal femoral prosthesis.

BACKGROUND: The treatment of choice for distal femur malignancies in skeletally immature patients remains controversial. An expandable endoprosthesis device (Repiphysis Limb Salvage System; Wright Medical Technology, Arlington, TN, USA) allows for limb preservation and noninvasive lengthening but has been associated with significant complications; however, the extent and implications of bone loss associated with this implant have not been reported. QUESTIONS/PURPOSES: Our goals were to report (1) the 2-year minimum clinical outcomes after placement of the Repiphysis expandable prosthesis for pediatric distal femur malignancies; (2) the complications associated with this prosthesis; (3) the failure rate of this prosthesis; and (4) the revision alternatives available for salvage procedures. METHODS: Between 2002 and 2010, one surgeon (SG) treated all skeletally immature patients (mean age, 10.1 years; range, 4.7-13.6 years) with distal femoral osteosarcoma using a Repiphysis expandable prosthesis. Of the 12 patients who met these criteria, two were excluded for death from disease before 2 years, and mean followup for the remaining 10 was 72 months (range, 26-119 months). Medical records were retrospectively reviewed for complications and clinical outcomes, as assessed by the Musculoskeletal Tumor Society (MSTS) scoring system. Radiographs at final followup were reviewed for bone loss and analyzed by the two senior authors (SG, WWV) to determine reconstruction options available for future revisions. RESULTS: MSTS scores averaged 67%, and we observed 37 implant-related complications requiring a total of 15 reoperations. Six patients underwent implant revisions with aseptic loosening being the predominant mode of failure; ultimately, four of these were converted to adult modular oncology prostheses, and two underwent total femoral replacements. Bone loss in this series was severe in terms of femoral length, cortical thinning, and metadiaphyseal compromise, and most patients will not have sufficient bone stock to permit future revision using standard stem fixation. CONCLUSIONS: The bone loss around the stem of this prosthesis limits subsequent revision options, often resulting in a total femoral prosthesis. Although the decision to use the Repiphysis device must be made on an individual basis, surgeons should recognize the potential for significant bone compromise limiting revision options and consider other options. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

New radiographic parameters to describe anterior acetabular rim trimming during hip arthroscopy.

PURPOSE: The purpose of this study was to describe additional radiographic parameters that may detect changes within the acetabular cavity during acetabular rim trimming for pincer-type femoroacetabular impingement. METHODS: Cadaveric hips that met the inclusion criteria were stripped of all tissue and had a portion of their labra removed; 5 mm of anterior acetabulum was measured in the 12- to 3-o'clock position and resected with a Dremel device (Robert Bosch Tool, Mount Pleasant, IL). Anteroposterior radiographs were obtained with a C-arm image intensifier. Radiographic measurements were subsequently obtained using the anterior rim angle (ARA), anterior wall angle (AWA), and anterior margin ratio (AMR). RESULTS: Statistically significant changes were seen in the ARA, AWA, and AMR. Mean pre- and post-trimming changes were 81.0° and 85.7°, respectively, for the ARA; 34.8° and 29.2°, respectively, for the AWA; and 0.66 and 0.57, respectively, for the AMR. CONCLUSIONS: Although much attention has been focused on the center-edge angle, the anterior aspect of the acetabulum has not previously been characterized. In conjunction with the center-edge angle and Tönnis angle, the new parameters of ARA, AWA, and AMR can be used to provide a more comprehensive description of the acetabulum. The ARA, AWA, and AMR can be used to guide the surgeon intraoperatively and postoperatively in further clarifying acetabular morphology and in determining whether the rim resection was adequate. This study determined that there exist new radiographic parameters with significant changes in the anterior acetabulum as quantified by the ARA, AWA, and AMR that can be used to describe the radiographic changes after acetabular rim resection. CLINICAL RELEVANCE: The new parameters of ARA, AWA, and AMR can be used to provide a more comprehensive description of the acetabulum. These radiographic measurements can also be used by hip arthroscopists to better describe their surgical contribution to anterior rim trimming.

Use of the reamer-irrigator-aspirator may reduce tumor dissemination during intramedullary fixation of malignancies.

Intramedullary nail fixation is the treatment of choice for impending and pathologic fractures secondary to metastatic cancer; however, this procedure has been shown to cause systemic embolization of intramedullary contents. This article reports the use of the reamer-irrigator-aspirator (RIA) (Synthes, Paoli, Pennsylvania) instead of a standard femoral reamer to decrease tumor intravasation during femoral intramedullary nail fixation for impending or pathologic fractures.Twenty-one consecutive patients indicated for fixation of malignant femoral lesions were treated with intramedullary nail placement. The RIA was used for canal preparation, and solid reamings were collected and submitted for analysis by a single pathologist. The volume of each specimen was recorded, and representative samples were examined histologically to determine their percent tumor content. These data were then used to estimate the volume of tumor retrieved by the RIA in each case. The mean volume of reamings collected by the RIA was 75.0 cc per case (range, 23.4-196.0 cc), and the mean tumor content was 24.8% (range, 1.0%-60.0%). The mean estimated volume of tumor retrieved in each case was 16.7 cc (range, 0.35-36.0 cc). In 2 cases, the tip of the RIA dissociated from the device intraoperatively but was retrieved without adverse consequence to the patient. Use of the RIA in cases of femoral intramedullary nail fixation for pathologic lesions or fractures effectively retrieves variable amounts of intramedullary contents, including tumor. By preventing the systemic dissemination of malignant cells, this technique may reduce the risk of distant metastases.

Hip pain in active patients: what you may be missing.

When a patient who's physically active complains of hip pain, don't be too quick to label it a "hip pointer" that requires time and rest to heal. Consider this more nuanced-and effective-approach.

Treatment of acetabular fractures in an older population.

OBJECTIVE: To identify factors predicting poor radiographic and functional outcome and delayed total hip arthroplasty in operatively managed acetabular fractures in patients 55 years of age and older. DESIGN: Retrospective chart and radiographic review of a prospectively maintained database. SETTING: Tertiary care hospital. PATIENTS: Ninety-three with a mean age of 67 years met all inclusion criteria and had follow up averaging 5 years. INTERVENTION: Open reduction and internal fixation and less commonly acute total hip arthroplasty for displaced acetabular fractures in an older cohort. MAIN OUTCOME MEASUREMENT: Three validated patient self-assessment measures were used: the Musculoskeletal Functional Assessment, the Short Musculoskeletal Functional Assessment, and the SF-36. RESULTS: The overall rate of hip replacement in our study was 30.95%. Poor fracture reduction (P < 0.02), development of avascular necrosis (P < 0.001), and previous contralateral hip arthroplasty (P = 0.02) were statistically associated with the need for secondary surgeries. Functional outcome scores in the current study compared favorably with functional outcome scores reported for acetabular fractures in younger populations and with age-matched "non-injured" norms published in recent literature. CONCLUSIONS: There was an acceptably low rate of major complications in 93 operatively managed fractures in this population. Nearly 70% of patients achieved functional outcomes similar to age- and injury-matched control subjects without the need for secondary surgeries. Thirty percent of patients required secondary total hip arthroplasty for posttraumatic arthritis. These patients achieved outcomes similar to patients in the other outcome groups and to injury- and age-matched norms.

Intercalary allograft reconstructions using a compressible intramedullary nail: a preliminary report.

BACKGROUND: Although intercalary allograft reconstructions are commonly performed using intramedullary devices, they cannot generate compression across host-allograft junctions. Therefore, they sometimes are associated with gap formation and suboptimal healing conditions. QUESTIONS/PURPOSES: We describe a new technique and present preliminary results for intercalary allograft reconstructions for tumors using a compressible intramedullary nail. PATIENTS AND METHODS: We retrospectively reviewed 10 patients (19 host-allograft junctions) who underwent intercalary allograft reconstruction using the compression nailing technique. Two patients were excluded as they had additional vascularized fibular autografts, leaving 15 junctions in eight patients for analysis. Three of the intercalary reconstructions had supplemental plate fixation at one junction. All patients received host bone reamings and cancellous allograft and one had bone marrow aspirate and demineralized bone matrix in addition to the cancellous allograft. The minimum followup was 3 months (mean, 18 months; range, 3-39 months). RESULTS: Thirteen of 15 junctions healed without additional surgery. Two diaphyseal-diaphyseal junctions did not unite after allograft arthrodeses. One patient underwent revision for nonunion 8 months after the initial procedure, with subsequent healing. The second patient had no evidence of union at 6 months, after which he was lost to followup. There were no allograft fractures or infections in any reconstruction. One patient died of metastatic renal cell carcinoma, and one patient had multicentric local soft tissue recurrences of a periosteal osteosarcoma requiring resection. CONCLUSIONS: Our early observations indicate newer compressible intramedullary nails reliably address junctional gap formation, providing for a high rate of union while retaining the long-term benefits of intramedullary stabilization. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.