Is It Safe to Resume Direct Oral Anticoagulants upon Discharge after Hip Fracture Surgery? A Retrospective Study.

This study aimed to examine the incidence rate of early reoperations following hip fracture surgery and determine the safety of resuming direct oral anticoagulants. Many orthopedic surgeons are reluctant to resume chronic anticoagulation therapy for patients after surgical intervention for hip fractures. One of the main reasons is the potential for reoperation in the case of surgical complications. We conducted a retrospective cohort study at an Academic Level I trauma center, reviewing the records of 425 geriatric patients (age > 60) who underwent hip fracture surgery between 2018 and 2020, including a subgroup treated with direct oral anticoagulants prior to hospitalization. The study assessed the incidence rate of complications requiring early reoperation. Out of the 425 patients, only nine (2%) required reoperation within a month after discharge, with two (0.5%) on chronic anticoagulation therapy. None of the reoperations were urgent, and all were performed at least 24 h after re-admission. The findings revealed a very low incidence rate of reoperations in patients who underwent hip fracture surgery, with no reoperations performed within 24 h of re-admission. Consequently, we believe that resuming chronic direct oral anticoagulants is a safe and effective approach when discharging patients after hip fracture surgery.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

PURPOSE: Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. METHODS: Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. RESULTS: The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. CONCLUSIONS: Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. CLINICAL RELEVANCE: Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

When giants talk; robotic dialog during thoracolumbar and sacral surgery.

BACKGROUND: Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery. METHODS: Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics). RESULTS: Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12-86). Average radiation exposure time 40 s (range 12-114 s). Average radiation exposure dose 11,584 ± SD uGym2 (range 4454-58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5-11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration. CONCLUSIONS: Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Evolution of treatment of femoral shaft fracture in polytrauma: Did damage control orthopaedics improve the outcome? A retrospective study.

BACKGROUND: Treatment of polytrauma patients with femoral shaft fracture has changed considerably during the past few decades. A transition from early total care (ETC) to "Damage Control" Orthopaedics (DCO) in selected patients was proposed in order to decrease mortality. The aim of the study was to investigate whether this policy change resulted in improved patient outcome. METHODS: We present a retrospective, comparative study, held in a Level I trauma center in Jerusalem, Israel. Polytrauma patients with Injury Severity Score higher than 16 with femoral shaft fracture were included. Data was extracted from our institute's electronic trauma registry. The study examines two time periods: Between the years 1996 and 2006 patients were treated according to the ETC protocol, with immediate intramedullary nailing (IMN) within 12 h. From 2007 until 2019 a DCO policy was adopted, implementing temporary external fixator for high risk patients, according to the "Hannover" criteria. Following resolution of the acute phase, these were converted to IMN. Patients eligible for DCO were matched to controls who received ETC during the earlier period. RESULTS: A total of ninety-six patients were included (DCO n = 44, ETC n = 52). The groups were comparable in terms of age, gender, mechanism of injury, injury to surgery time and Injury severity score (DCO median 31.5, ETC median 29). No statistical difference was found between the groups in terms of mortality (P = 0.757), acute respiratory distress syndrome (P = 0.534), sepsis (P = 0.519) and hospital stay (DCO median 24 days, ETC median 21.5 days) or ICU stay (Median 7 days in both groups). CONCLUSIONS: This pilot study did not demonstrate better outcome by implementing DCO concepts in the polytrauma patient. LEVEL OF EVIDENCE: III prognostic.

Effects of Covid-19 on orthopaedic trauma services: early experiences in South Africa and Israel.

South Africa and Israel have significantly different health systems. As South Africa is geographically 500 times as large and has a population nearly 7 times as large as the state of Israel, major differences in the challenges and subsequent handling of the pandemic between these countries were to be expected. South Africa's challenges included being under-resourced, particularly related to trauma, and severe and radical measures had to be undertaken that included extended strict lockdowns, bans on alcohol sales, and cancellation of the majority of the elective surgery during this initial period of the pandemic. Although Israel is much smaller and thereby theoretically easier to control, a complex political situation created difficulties and delays in controlling the pandemic after the initial response, leading to a second wave and additional lockdown. Although massively engaged initially, the Israeli trauma systems had continued functioning almost normally throughout the COVID-19 crisis.

Hip fracture care and national systems in Israel and South Africa.

Despite the same latitude on earth, Israel and South Africa have a wide variety of healthcare systems and approaches. Israel is a developed country with life expectancy within the first decile of the modern world. South Africa is a developing country where available resources and health care varies greatly across the country. Israeli policy makers have realized in 1999 the importance of early surgery for hip fractures as the single most important factor contributing to decreased mortality. After an introduction of a newer reimbursement system in 2004, and public advertising of early hip fracture treatment as a quality tag for hospitals, in more than 85% of the cases patients are operated on early (within 8 hours) with a significant decrease in mortality. However, other issues such as patient preparation, rehabilitation, and prevention are still at their beginning. South Africa deals with significant challenges with high energy hip fractures in a younger population, although osteoporosis is on the rise in certain parts of the country. Due to limited resources and distances, time to surgery differs among hospital systems in the country. In public hospitals, a delay up to a week may be common, whereas in private hospitals most patients are operated early within 48 to 72 hours. Due to decreased life expectancy, arthroplasty is more aggressively used in displaced femoral neck fractures. Rehabilitation is mostly done within the families. Prevention and orthogeriatric teamwork are not being commonly practiced. Generally speaking, more attention to hip fractures is needed from healthcare funders.

Outcome of femoral fractures in poliomyelitis patients.

BACKGROUND AND PURPOSE: As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients. PATIENTS AND METHODS: Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score. RESULTS: Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome. CONCLUSIONS: Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Robotic assisted fixation of sacral fractures: A pilot study.

OBJECTIVES: Sacral fractures that require fixation are a challenge for the orthopaedic surgeon. Due to anatomical consideration, implant insertion is not risk free, and requires a steep learning curve. A robotic system has been successfully used in pedicle screws insertion and can be also used for iliosacral screws. The aim of the study was to demonstrate the use of the robot in the treatment of unstable sacral fractures. DESIGN: Retrospective case series. SETTING: An academic level I trauma center. PATIENTS: Fourteen patients with sacral fractures were eligible for robotic assisted treatment. These included 9 high-energy fractures, 4 osteoporotic fractures, and 1 pathological fracture. INTERVENTION: Fixation constructs included iliosacral screws, transiliac screws, lumbopelvic fixation, sacroplasty, or a combination of the above techniques. A Renaissance robot was mounted on a multidirectional bridge that was attached to the patients spine and implant trajectories were planned either on preoperative or intraoperative 3D scans. Guide wires were inserted percutaneously and screws were placed subsequently. MAIN OUTCOME MEASUREMENTS: Accuracy of implant placement, operating room and fluoroscopy time. RESULTS: Mean patient age was 36 (17-84), and number of screws, including iliosacral and pedicular ranged 1-14 per patient (average 4.25). Mean operative time was 150 minutes (range 90-300). Average fluoroscopic time was 18 seconds (7-42) for 2D and 40 seconds (12-72) for 3D imaging. All fractures healed, no hardware failure was observed. All hardware was always within bony confines, and no procedure-related neurological deficits were observed. CONCLUSION: Robotic assisted fixation of sacral fracture is a safe and reproduceable method, allowing precise and accurate implant placement.

[FLUOROSCOPIC BASED NAVIGATION IN ORTHOPAEDIC TRAUMA - A REVIEW OF A LARGE CENTER'S EXPERIENCE].

INTRODUCTION: Computer Assisted Orthopaedic Surgery (CAOS) was introduced in the late 1990's and early 2000's. Since then its application in orthopaedic trauma has been utilized mainly as augmented fluoroscopy for intraoperative navigation. From 2010 our center implemented an advanced system allowing further expansion of this technology. AIMS: The aim of this study was to describe the experience with an advanced fluoroscopic based CAOS system in our center. METHODS: The BrainLabTM Trauma 3.0 utilizes a handheld fluoroscope tracker, enables tracking of two anatomical objects and intraoperative planning. We implemented this system for the performance of 126 navigated procedures between the years 2011-2014. The procedures included 58 cases of navigated hip fracture pinning, 9 plate navigation for distal femoral fractures, 19 iliosacral screw insertions, 20 femoral fracture reductions, and 12 other procedures (acetabular screws, osteotomies etc). RESULTS: The mean age of patients was 52 years (range 16-82 years); 46 male and 80 female patients. The mean operating room time was 157 minutes (range 70 to 470 minutes). The average radiation required was 550 rad cm2 (~30 sec fluoroscopic time). Overall estimated additional OR time was estimated as 10-15 minutes for hip pinning, 15-20 minutes for pelvic iliosacral screws and 30-45 minutes of additional OR time for femur fracture reduction for length and rotation. In 5% of cases (6 patients), navigation was aborted due to technical reasons. No misplaced hardware due to the use of navigation was documented. CONCLUSIONS: CAOS is a powerful tool in trauma surgery with 95% success rate, with a reasonable added burden time. Although 3D navigation may be more useful in the pelvis, even two-dimensional navigation increases precision and implant placement. Femoral fracture reduction for accurate length and rotation control is solely enabled by CAOS. In the future, more time efficient and user-friendly systems will enable widespread use of these technologies in orthopaedic trauma.

Use of fully threaded cannulated screws decreases femoral neck shortening after fixation of femoral neck fractures.

BACKGROUND: Femoral neck fractures (FNF) are becoming increasingly common as population ages. Nondisplaced fractures are commonly treated by cancellous, parallel placed, partially threaded cannulated screws (PTS). This allows controlled fracture impaction. However, sliding implants can lead to femoral neck shortening (FNS) that has been shown to be correlated with reduced quality of life and impaired gait pattern. Recently, in our institution we have changed the fixation of FNF to fully threaded screws (FTS) with or without an additional partially threaded screw in order to minimize this phenomenon. The aim of this study was to compare the FNS in patients treated with FTS as compared with our historical controls treated with PTS. PATIENTS AND METHODS: Between 2014 and 2016, 38 patients with FNF were treated with FTS. Out of the 38, 24 were available for radiographic follow-up. 41 patients treated previously with PTS were available as a control group. Radiographic analysis was performed to assess the FNF in three vectors: Horizontal (X), Vertical (Y) and overall (Z) according to the neck-shaft angle. RESULTS: Time for admission to surgery was longer in the PTS group (p = 0.04). Patient demographics and major complication rates were similar in the two patient groups. Average FNS in the X axis was significantly smaller in the FTS group than in the PTS group (2.8 ± 3.6 vs 7.6 ± 4.2 mm, p < 0.01) as well as the Y axis (1.2 ± 2.6 vs 4.9 ± 4.2 mm, p < 0.01) and thus also decreased overall Z shortening (2.3 ± 3.5 vs 6.23 ± 4.5 mm, p < 0.01). There was a tendency towards a more valgus reduction in the PTS (137° vs 134°, p = 0.08). There was a significantly smaller number of FTS patients with moderate (5-10 mm) or severe (> 10 mm) FNS. Screw pull-out > 5 mm occurred in 17/41 patients in the PTS but none in the FTS group (p < 0.01). CONCLUSION: This study proves that use of FTS improves the radiographic results following FNF fixation using cannulated screws.

Radiographic markers for measuring tibial rotation based on CT-reconstructed radiographs: an accuracy and feasibility study.

OBJECTIVES: Malreduction in the axial plane (malrotation) following tibial fracture surgery is often undiagnosed. A few clinical and radiographic methods have been proposed for measuring tibial rotation intraoperatively, yet have failed to match the accuracy of computed tomography (CT). The aim of this study was to develop radiographic tools for future intraoperative assessment of the tibial shaft rotation profile. METHODS: The setting was a laboratory computerized analysis. Twenty lower limb CT scans were used to construct a three-dimensional (3D) model using AMIRA© software. A virtual 3D cylinder was implanted in the posterior condylar line and in the transmalleolar axis. The 3D models were used to simulate four standard knee and ankle plain radiographs. On each radiograph, four landmarks were depicted by two observers and their relation with the cylinder was measured and analyzed for accuracy and reproducibility. A cadaveric lower leg was implanted with two Kirschner wires. A CT scan was performed in addition to 2D fluoroscopy. The simulated radiographs and the fluoroscopy were compared for accuracy. RESULTS: Measurement of the landmarks showed reliability in most of the knee anteroposterior and ankle mortise radiographs (coefficients of variation < 0.01 and = 0.01) respectively. Cadaveric measurement of the landmarks using real fluoroscopy and simulated radiographs were similar. CONCLUSIONS: To date, no reliable and common methods have been reported for the evaluation of tibial axial rotation. We propose a model in which simple radiographic landmarks can be used to calculate a 3D coordinate system that accurately assesses the axial rotation angle of the tibial shaft.

Outcome of delayed primary internal fixation of distal radius fractures: a comparative study.

INTRODUCTION AND AIM: Operative fixation of distal radius fractures using fixed-angle devices has become increasingly common. Although good to excellent results have been reported in acute fractures, little is currently known regarding the fixation of healing displaced distal radius fractures that were presented late. The aim of this study was to evaluate the results of internal fixation of distal radius fractures presented late (>21 days) as compared with an acute-care control group. METHODS: Forty patients operated on for displaced distal radius fractures, presenting more than 21 days after injury (delayed treatment (DT) group), were compared with 75 age-matched controls with acute fracture repair (≤21 days). The same surgical approach was used in both groups, together with dorsal soft-tissue and brachioradialis release. No osteotomy was required. Direct and indirect reduction aids were used. A fixed-angle device (DVR; Biomet Inc., Warsaw, IN, USA) was used in both groups. Mean follow-up was 3.4 years. Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Short Form 12 scores were used to evaluate outcome, as well as radiographic analysis for Arbeitsgemeinschaft für Osteosynthesefragen(AO)/Orthopaedic Trauma Association(OTA) classification, volar tilt, radial inclination and radial length. RESULTS: Average age was 53 years in both groups and male to female (M/F) ratio was similar in the study groups. Mean time to surgery was 30 days in the DT group and 8 days in the control group. There were significantly more type C (91.5% vs. 67.5%) fractures in the control group. The average quick DASH score was 27.1 in the DT group as compared with 6.3 in the control group (p<0.03); however, when controlling for two outlier cases with complications (hardware irritation and a sensory neuropathy) there was no significant difference. Volar tilt, radial inclination and length were similar in both groups and were within normal anatomical values. CONCLUSIONS: Delayed primary operative fixation of displaced unstable distal radial fractures is a viable option for cases that were presented late, with predictable, favourable results. Neither extensile approaches nor formal osteotomies are required.

Use of three-dimensional fluoroscopy to determine intra-articular screw penetration in proximal humeral fracture model.

BACKGROUND: Proximal humeral locking plates have significantly improved the treatment of proximal humeral fractures in recent years; however, they are not devoid of complications. Inadvertent screw penetration into the joint is a well-documented complication. Intraoperative 3-dimensional (3D) imaging may assist in detecting intra-articular implant penetration. This study compared the performance of a standard C-arm fluoroscope with a novel 3D imaging fluoroscope in detecting penetrating implants in a proximal humeral fracture model. METHODS: Zinc-sprayed proximal humerus sawbones were affixed with a proximal humeral locking plate. Six different constructs were assembled. In each specimen, 1 screw, 2 screws, or no screws were inserted 2-mm proud of the articular surface. Each specimen was imaged with a conventional fluoroscope and a 3D imaging fluoroscope. Overall, 36 image sets were prepared for each modality. These were evaluated by 2 fellowship-trained surgeons for intraobserver and interobserver reliability as well for the accuracy of detecting prominent implants in the 2 imaging methods. RESULTS: Overall accuracy for observer A was 89.9% compared with 100% for C-arm fluoroscopy and 3D imaging fluoroscopy (P < .01) and for observer B was 91.1% and 100% (P = .01), respectively. The κ values were 0.74 with C-arm fluoroscopy and 1.0 for the 3D imaging fluoroscopy for observer A, and 0.93 and 1.0, respectively, for observer B. CONCLUSIONS: In a proximal humeral fracture model, C-arm fluoroscopy is a highly accurate imaging modality that can minimize the incidence of penetrating screws into the joint. Further clinical studies are required to establish this modality.

Computerized navigation for length and rotation control in femoral fractures: a preliminary clinical study.

OBJECTIVE: Operative treatment of femoral fractures yields a predictably high union rate, but residual malrotation and leg length discrepancy remain a clinically significant problem. The aim of this study was to determine the safety and efficacy of using computerized navigation in controlling the length and rotation in femoral fracture surgery. DESIGN: Prospective consecutive case series of 16 skeletally mature patients with femoral fractures undergoing surgical fixation; 14 were fixed with intramedullary nails and 2 with plates. SETTING: An Academic Level I trauma center. INTERVENTION: Computerized navigation was used to determine the length and rotation of the operated extremity as compared with the intact healthy contralateral side. MAIN OUTCOME MEASURE: All patients underwent postoperative computed tomography scanogram for determining the length and rotation. RESULTS: All fractures healed. Mean rotational difference between the treated and nontreated sides was 3.45 degrees (range, 0-7.7 degrees). Mean length difference between the 2 extremities as calculated by the computed tomography scan was 5.83 mm (range, 0-13 mm). Additional operative time required for computerized navigation was measured in 2 of the cases and totaled ∼30-35 min/case. CONCLUSION: Computerized navigation was accurate and precise at restoring femoral length and rotation during femoral fracture fixation when the intact contralateral femur was used for reference. Further, large-scale randomized studies are required. Additionally, improvements aimed at decreasing operative time and improving user interface of these systems are recommended. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of the levels of evidence.

Training femoral neck screw insertion skills to surgical trainees: computer-assisted surgery versus conventional fluoroscopic technique.

BACKGROUND: : Femoral neck fractures are among the most common orthopaedic injuries impacting the health care system. Surgical management of such fractures with cannulated screws is a commonly performed procedure. The acquisition of surgical skills necessary to perform this procedure typically involves learning on real patients with fluoroscopic guidance. This study attempts to determine if a novel computer-navigated training model improves the learning of this basic surgical skill. METHODS: A multicenter, prospective, randomized, and controlled study was conducted using surgical trainees with no prior experience in surgically managing femoral neck fractures. After a training session, participants underwent a pretest by performing the surgical task (screw placement) on a simulated hip fracture using fluoroscopic guidance. Immediately after, participants were randomized into either undergoing a training session using conventional fluoroscopy or computer-based navigation. Immediate posttest, retention (4 weeks later), and transfer tests were performed. Performance during the tests was determined by radiographic analysis of hardware placement. RESULTS: Screw placement by trainees was ultimately equal to the level of an expert surgeon with either training technique. Participants who trained with computer navigation took fewer attempts to position hardware and used less fluoroscopy time than those trained with fluoroscopy. When those trained with fluoroscopy used computer navigation at the transfer test, less fluoroscopy time and dosage was used. The concurrent augmented feedback provided by computer navigation did not affect the learning of this basic surgical skill in surgical novices. No compromise in learning occurred if the surgical novice trained with one type of technology and transferred to using the other. CONCLUSIONS: The findings of this study suggest that computer navigation may be safely used to train surgical novices in a basic procedure. This model avoids using both live patients and harmful radiation without a compromise in the acquisition of a 3-dimensional technical skill.

Femoral neck shortening and varus collapse after navigated fixation of intracapsular femoral neck fractures.

OBJECTIVE: Assessing femoral neck shortening (FNS) and varus collapse after internal fixation of femoral neck fractures using computerized navigation (CN). DESIGN: Retrospective cohort study. SETTINGS: Academic Level I trauma center. PATIENTS AND METHODS: Forty-one patients who had healed femoral neck fractures treated with CN between the years 2003 and 2008. Average age was 65 years (range, 14-91 years). Thirty-six patients had nondisplaced fractures and five had displaced fractures. INTERVENTION: Screws were placed using CN in an inverted triangle formation Follow-up films were digitized into a PACS system, calibrated, and analyzed using CAD software. OUTCOME MEASURES: The following parameters were recorded: abductor lever arm shortening (termed x), corresponding vertical femur shortening (termed y), and the resultant femoral neck shortening vector (z). Fifteen patients were available for clinical outcome measures by the means of SF-12 survey RESULTS: Significant FNS of the x component (greater than 5 mm) occurred in 30 of 42 (71%) patients with severe shortening (greater than 10 mm) in 25% of the patients. Significant y shortening occurred in 43% of the patients and severe shortening in 17%. Overall (z) femoral neck shortening occurred in 56% of the patients with severe shortening in 22% of patients. Varus collapse (greater than 5°) did not occur in any patient. Screw pullout (greater than 5 mm) occurred in 17 (41%) patients. Seven patients required late (greater than 6 months) arthroplasty postoperatively. FNS did not significantly correlate with fracture type, quality of reduction, age, or neck shaft angle. SF-12 results were negatively correlated with overall FNS. CONCLUSIONS: Our results show a high degree of FNS associated with the use of CN for fixation of femoral neck fractures, similar to recently published series using nonnavigated implants. However, no varus collapse occurred in our series. Our preliminary clinical data show a trend toward an adverse effect of FNS on quality-of-life measures.

The outcome of surgically treated femur fractures associated with long-term bisphosphonate use.

INTRODUCTION: Bisphosphonates (BPs) evolved as the mainstay for the treatment of osteoporosis, reducing the incidence of fractures. Recently several publications described the occurrence of low-energy subtrochanteric and femoral shaft fractures associated with long-term BP use. The aim of this study was to describe the outcome of surgically treated femur fractures associated with prolonged BP use. PATIENTS: Fifteen patients suffering from 17 atypical femoral fragility fractures associated with long-term (>3 years) BP use were located. Data included fracture type, time of BP use, last bone mineral density DEXA scores for the femoral neck and spine, type of surgery, and the need for revision. RESULTS: Fourteen female patients and one male patient were identified. The median age was 73 years (range, 51-80 years). The mean BP use was 7.8 years (range, 4-13 years). Fourteen patients had low-energy traumatic femoral shaft (proximal and distal) or low subtrochanteric fractures. The mean lumbar spine (for 13 patients) bone mineral density T-score was -3.0, whereas mean femoral neck T-score was -1.8 with only three patients in the osteoporotic range.Fracture healing after the first procedure for patients treated with nails was 54%, with 46% of patients requiring revision surgery. These included nail dynamization, exchange nailing, and one revision to a blade plate. All of these eventually healed. CONCLUSIONS: BP-related fractures are a recently described phenomenon. Despite initial osteoporosis, the DEXA scan may appear outside the osteoporotic range for the femoral neck in these patients. In addition, a much higher failure rate with intramedullary nailing requiring revision surgery may occur with these patients.

Assessment of two 3-D fluoroscopic systems for articular fracture reduction: a cadaver study.

OBJECTIVE: The most commonly used imaging device for assessment of fracture reduction is the two-dimensional X-ray fluoroscope. Two recently introduced 3D fluoroscopic devices, the Siremobil ISO-C3D (Siemens) and the C-InSight (Mazor Surgical Technologies), enable the surgeon to obtain spatial information for the assessment of articular reduction and hardware placement. The purpose of this study was to assess the reliability and accuracy of these two 3D fluoroscopic systems in measuring articular reduction in a cadaveric tibial plateau fracture. METHODS: Six cadaveric knee specimens were osteotomized at the lateral tibial plateau and fixed with a maximal articular step-off of 0, 1, 2.5, 5 and 7.5 mm. Each specimen was scanned 10 times with two 3D fluoroscopes, the Siremobil ISO-C3D and the C-InSight. The resulting images were reformatted and interpreted for articular displacements at four different locations at the plateau level and were compared with high-resolution CT scans by an independent observer. RESULTS: For the non-displaced fracture, no displacement (mean < 0.1 mm) was observed in either modality. The mean scanning time for the ISO-C3D was 2 min, while each C-InSight scan took 20 s. The readings at four different points along the malreduced fractures were similar for most measurements with either of the two modalities. The C-InSight readings were less accurate than those of the ISO-C3D, relative to the CT scan, but most errors were within clinically acceptable limits (< 2 mm) and used less radiation. CONCLUSIONS: Intraoperative 3D fluoroscopes can detect clinically significant intra-articular step-off with acceptable measurement errors, using newer devices that enable the use of a conventional C-arm and reduced radiation.