Assessment of Prophylactic Antibiotic Coverage in Culture-positive Traumatic Open Fractures.

Guidelines provide varying recommendations for the prophylactic antimicrobial treatment of open fractures. This single-center, retrospective cohort study was conducted to determine how well an institutional prophylactic antibiotic protocol covered pathogens associated with open fractures. The authors included adult trauma patients with one or more open fractures and a positive culture from the site of the open fracture, and compared outcomes between patients who were covered by prophylactic antibiotics with patients not covered by prophylactic antibiotics. Of 957 patients evaluated, 75 were included, with 40 patients (53%) covered by the prophylactic antibiotics received. Multidrug-resistant pathogens were isolated in 23 (58%) patients covered versus 26 (74%) patients not covered (p = 0.128). The median time to positive culture was less in patients not covered by initial antibiotics compared with those who were covered (30.2 vs. 102.1 days; p = 0.003). Over half of the patients developed cultures with pathogens that were covered by their initial antibiotic prophylaxis. (Journal of Surgical Orthopaedic Advances 33(2):084-087, 2024).

Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age.

OBJECTIVES: To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)]. DESIGN: Multicenter retrospective comparative cohort series. SETTING: Twenty-six North American Level 1 Trauma Centers. PATIENT SELECTION CRITERIA: Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs. OUTCOME MEASURES AND COMPARISONS: Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years). RESULTS: Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. CONCLUSIONS: Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Optimal Fixation Strategies for Displaced Femoral Neck Fractures in Patients 18-59 Years of Age: An Analysis of 565 Cases Treated at 26 Level 1 Trauma Centers.

OBJECTIVES: The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy. DESIGN: This is a retrospective, comparative cohort study. SETTING: Twenty-six Level 1 North American trauma centers. PATIENT SELECTION CRITERIA: Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017. OUTCOME MEASURES AND COMPARISONS: Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy. RESULTS: Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and "antirotation" (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036). CONCLUSIONS: Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Fractures With Associated Ipsilateral Femoral Shaft Fractures in Young Adults <50 Years Old: A Multicenter Comparison of 80 Cases Versus Isolated Femoral Neck Fractures.

OBJECTIVES: To analyze patients, injury patterns, and treatment of femoral neck fractures (FNFs) in young patients with FNFs associated with shaft fractures (assocFNFs) to improve clinical outcomes. The secondary goal was to compare this injury pattern to that of young patients with isolated FNFs (isolFNFs). DESIGN: Retrospective multicenter cohort series. SETTING: Twenty-six North American level-1 trauma centers. PATIENT SELECTION CRITERIA: Skeletally mature patients, <50 years old, treated with operative fixation of an FNF with or without an associated femoral shaft fracture. OUTCOME MEASURES AND COMPARISONS: The main outcome measurement was treatment failure defined as nonunion, malunion, avascular necrosis, or subsequent major revision surgery. Odds ratios for these modes of treatment were also calculated. RESULTS: Eighty assocFNFs and 412 isolFNFs evaluated in this study were different in terms of patients, injury patterns, and treatment strategy. Patients with assocFNFs were younger (33.3 ± 8.6 vs. 37.5 ± 8.7 years old, P < 0.001), greater in mean body mass index [BMI] (29.7 vs. 26.6, P < 0.001), and more frequently displaced (95% vs. 73%, P < 0.001), "vertically oriented" Pauwels type 3, P < 0.001 (84% vs. 43%) than for isolFNFs, with all P values < 0.001. AssocFNFs were more commonly repaired with an open reduction (74% vs. 46%, P < 0.001) and fixed-angle implants (59% vs. 39%) (P < 0.001). Importantly, treatment failures were less common for assocFNFs compared with isolFNFs (20% vs. 49%, P < 0.001) with lower rates of failed fixation/nonunion and malunion (P < 0.001 and P = 0.002, respectively). Odds of treatment failure [odds ratio (OR) = 0.270, 95% confidence interval (CI), 0.15-0.48, P < 0.001], nonunion (OR = 0.240, 95% CI, 0.10-0.57, P < 0.001), and malunion (OR = 0.920, 95% CI, 0.01-0.68, P = 0.002) were also lower for assocFNFs. Excellent or good reduction was achieved in 84.2% of assocFNFs reductions and 77.1% in isolFNFs (P = 0.052). AssocFNFs treated with fixed-angle devices performed very well, with only 13.0% failing treatment compared with 51.9% in isolFNFs treated with fixed-angle constructs (P = <0.001) and 33.3% in assocFNFs treated with multiple cannulated screws (P = 0.034). This study also identified the so-called "shelf sign," a transverse ≥6-mm medial-caudal segment of the neck fracture (forming an acute angle with the vertical fracture line) in 54% of assocFNFs and only 9% of isolFNFs (P < 0.001). AssocFNFs with a shelf sign failed in only 5 of 41 (12%) cases. CONCLUSIONS: AssocFNFs in young patients are characterized by different patient factors, injury patterns, and treatments, than for isolFNFs, and have a relatively better prognosis despite the need for confounding treatment for the associated femoral shaft injury. Treatment failures among assocFNFs repaired with a fixed-angle device occurred at a lower rate compared with isolFNFs treated with any construct type and assocFNFs treated with multiple cannulated screws. The radiographic "shelf sign" was found as a positive prognostic sign in more than half of assocFNFs and predicted a high rate of successful treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Comparative Analysis of Supplemental Medial Buttress Plate Fixation for High-Energy Displaced Femoral Neck Fractures in Young Adults.

OBJECTIVES: To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures. DESIGN: Multicenter retrospective matched cohort comparative clinical study. SETTING: Twenty-seven North American Level 1 trauma centers. PATIENTS: Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture. INTERVENTION: Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP. MAIN OUTCOME MEASUREMENTS: Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty. RESULTS: Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001). CONCLUSIONS: The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning . LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of 101 Mechanical Failures in Distal Femur Fractures Treated with 3 Generations of Precontoured Locking Plates.

OBJECTIVES: To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP). DESIGN: This retrospective case-control series evaluated mechanical treatment failures of DFLPs. SETTING: The study was conducted at 8 Level I trauma centers from 2010 to 2017. PATIENTS AND PARTICIPANTS: One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure. INTERVENTION: The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage). MAIN OUTCOME MEASURE: The main outcome measures included injury and DFLP details; modes and timing of failure were studied. RESULTS: One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P < 0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P < 0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P < 0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks). CONCLUSION: Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effects of Technical Errors on the Outcomes of Operatively Managed Femoral Neck Fractures in Adults Less than 50 Years of Age.

OBJECTIVE: To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults. DESIGN: Multicenter retrospective clinical study. SETTING: 26 North American Level 1 Trauma Centers. PATIENTS: Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017. INTERVENTION: Operative repair of femoral neck fracture. MAIN OUTCOME MEASUREMENTS: The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis. RESULTS: Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001). CONCLUSIONS: TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Radiographic changes of implant failure after plating for pubic symphysis diastasis: an underappreciated reality?

BACKGROUND: Implant failure after symphyseal disruption and plating reportedly occurs in 0% to 21% of patients but the actual occurrence may be much more frequent and the characteristics of this failure have not been well described. QUESTIONS/PURPOSES: We therefore determined the incidence and characterized radiographic implant failures in patients undergoing symphyseal plating after disruption of the pubic symphysis. METHODS: We retrospectively reviewed 165 adult patients with Orthopaedic Trauma Association (OTA) 61-B (Tile B) or OTA 61-C (Tile C) pelvic injuries treated with symphyseal plating at two regional Level I and one Level II trauma centers. Immediate postoperative and latest followup anteroposterior radiographs were reviewed for implant loosening or breakage and for recurrent diastasis of the pubic symphysis. The minimum followup was 6 months (average, 12.2 months; range, 6-65 months). RESULTS: Failure of fixation, including screw loosening or breakage of the symphyseal fixation, occurred in 95 of the 127 patients (75%), which resulted in widening of the pubic symphyseal space in 84 of those cases (88%) when compared with the immediate postoperative radiograph. The mean width of the pubic space measured 4.9 mm (range, 2-10 mm) on immediate postoperative radiographs; however, on the last radiographs, the mean was 8.4 mm (range, 3-21 mm), representing a 71% increase. In seven patients (6%), the symphysis widened 10 mm or more; however, only one of these patients required revision surgery. CONCLUSIONS: Failure of fixation with recurrent widening of the pubic space can be expected after plating of the pubic symphysis for traumatic diastasis. Although widening may represent a benign condition as motion is restored to the pubic symphysis, patients should be counseled regarding a high risk of radiographic failure but a small likelihood of revision surgery. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Trans-sacral screw fixation of posterior pelvic ring injuries: review and expert opinion.

Posterior pelvic ring injuries (i.e., sacro-iliac joint dislocations, fracture-dislocations, sacral fractures, pelvic non-unions/malunions) are challenging injury patterns which require a significant level of surgical training and technical expertise. The modality of surgical management depends on the specific injury patterns, including the specific bony fracture pattern, ilio-sacral joint involvement, and the soft tissue injury pattern. The workhorse for posterior pelvic ring stabilization has been cannulated iliosacral screws, however, trans-sacral screws may impart increased fixation strength. Depending on injury pattern and sacral anatomy, trans-sacral screws can potentially be more beneficial than iliosacral screws. In this article, the authors will briefly review pelvic mechanics and discuss their rationale for ilio-sacral and/or trans-sacral screw fixation.

Quantitative Analysis of Growth Factors From Cancellous Bone Graft Collected With a Reamer-Irrigator-Aspirator System From Native Long Bones Versus Previously Reamed Long Bones.

OBJECTIVE: Collection of bone graft with the Reamer-Irrigator-Aspirator (RIA) system has become common practice across the field of orthopaedic surgery. While RIA bone graft is typically obtained from native long bones, grafting material can likewise be harvested from long bones that have previously undergone the placement and removal of an intramedullary nail, a process termed re-reamed RIA (RRR). The purpose of this study was to evaluate the total protein and growth factor concentrations present in native-RIA (NR) compared with RRR samples. METHODS: NR and RRR bone grafts were collected intraoperatively with the RIA system and processed to evaluate both the aqueous and the hard tissue components. Total protein concentration and specific growth factors were analyzed using standard bicinchoninic acid and multiplex assays, respectively. Analyte levels were then normalized to the total amount of protein detected. RESULTS: Total protein levels were comparable between NR and RRR samples for both the aqueous filtrate and the hard tissue samples. When normalized, while levels of bone morphogenic protein-2 and vascular endothelial growth factor were comparable in the hard tissue component, the aqueous filtrate from the RRR sample was found to have elevated levels of growth factors, with bone morphogenic protein-2 reaching statistical significance. CONCLUSIONS: This study demonstrates that ample protein is found within both NR and RRR samples, with comparable or elevated levels of osteogenic growth factors found within RRR samples. Future, larger, prospective studies will be required to evaluate the osteogenic potential and clinical efficacy of NR and RRR cancellous bone grafts to validate their equivalency.

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers.

OBJECTIVES: To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. DESIGN: Large multicenter retrospective cohort series. SETTING: Twenty-six North American Level 1 trauma centers. PATIENTS: Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. INTERVENTION: Operative repair of FNF. MAIN OUTCOME MEASUREMENTS: The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. RESULTS: Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure. CONCLUSIONS: FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mapping of Vertical Femoral Neck Fractures in Young Patients Using Advanced 2 and 3-Dimensional Computed Tomography.

OBJECTIVE: To better describe the pathoanatomy of young patients' femoral neck fractures with the goal of improving surgeons' decisions for treatment including reduction and fixation. DESIGN: This is a retrospective study of patient records, plain radiographs, and the modern computed tomography scans to study the pathoanatomy of Pauwels II and III femoral neck fractures (coronal angle >30 degrees) in young adults. SETTING: One American College of Surgeons Level 1 trauma center. PATIENTS: All patients 18-49 years of age with a surgically repaired Pauwels' II and III (>30 degrees) femoral neck fracture between 2013 and 2017. METHODS: Fifty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 30 met study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, characteristics of fracture morphology including size, shape, and dimensions, comminution, displacement, and deformity. RESULTS: Fracture morphology typically included a wide-based caudal head-neck segment (80%) that ends at a variable location along the medial calcar, sometimes as caudal as the lesser trochanter. Comminution was present in 90% of cases mostly located in the inferior quadrant, but anterior or posterior to the void left by the head-neck's caudal segment. The fractures orientations and deformities were reported by means and ranges. CONCLUSIONS: We investigated and reported on the pathoanatomy of high-energy femoral neck fractures in young adults with the goal of increasing understanding of the injury and improving surgeons' ability to provide for improved treatment decisions and quality fracture repair. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study.

OBJECTIVE: To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model. METHODS: A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch. RESULTS: In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches. CONCLUSION: The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point.

INTRODUCTION: Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation. METHODS: Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured. RESULTS: Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated. DISCUSSION: Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point. LEVEL OF EVIDENCE: Therapeutic level III.

Osteoporosis: management and densitometry for orthopaedic surgeons.

Osteoporosis is a metabolic condition that is increasing in prevalence as people live longer. A fracture is a sentinel event. Despite all the advances in technology, a history of low-energy fracture in adulthood is the best predictor of future fracture-an even better predictor than low bone mineral density. Osteoporosis and the risk of fracture go hand in hand. The orthopaedic surgeon is often viewed as an expert in managing and treating bone disorders. Given that the orthopaedic surgeon is often the first and only physician to evaluate a patient with a fracture, he or she may be in the ideal position to initiate patient evaluation and therapy. However, many times the orthopaedic surgeon is concerned about the adverse effects of the pharmacologic treatment of osteoporosis to the extent that prescribing these drugs is avoided. A treatment approach incorporating nonpharmacologic agents is an effective strategy in the prevention and treatment of osteoporosis.

Setting Yourself Up for Success: Locked Plating for Vancouver B1 Fractures.

This chapter discusses principles and controversies surrounding the treatment of periprosthetic fractures around a hip replacement, specifically the Vancouver B1 injury. Evaluation and treatment decisions, as well as surgical tips and tricks, are discussed.

Course of the Femoral Artery in the Mid- and Distal Thigh and Implications for Medial Approaches to the Distal Femur: A CT Angiography Study.

INTRODUCTION: Unfamiliarity with the location of the femoral artery in the medial thigh has tempered surgeons' enthusiasm for medial approaches to the distal femur. The purpose of this study was to define the relationship of the femoral artery to the mid- and distal femur to assist in safely approaching the femur for fracture care. METHODS: Fifteen patients undergoing CT with angiography (CTA) of the lower extremity (CTA) were evaluated. From three-dimensional CTA images, the distance of the artery at the anterior border, midsagittal line, and posterior border of the femur from the distal femur at both the adductor tubercle and medial femoral condyle was measured. RESULTS: The average distances of the adductor tubercle to the femoral artery were 23.2 cm (±3.3), 18.8 cm (±3.4), and 14.3 cm (±4.1) at the level of the anterior border, midsagittal line, and posterior border of the femur, respectively. The descending genicular artery (DGA) originated 10.8 cm (±1.3) proximal to the adductor tubercle. DISCUSSION: A wide safe zone exists in the medial distal femur. The artery crosses the midsagittal axis of the medial femur an average of 18.8 cm proximal to the adductor tubercle.

Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

OBJECTIVE: To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period. MAIN OUTCOME MEASUREMENTS: We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map. RESULTS: Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs. DISCUSSION: Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.