Early Complications of a Novel Retrograde Intramedullary Femoral Nail in the Treatment of Femur Fractures.

OBJECTIVES: To determine the early implant failure rate of a novel retrograde intramedullary femoral nail. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS SELECTION CRITERIA: Patients aged 18 years and older with an acute OTA/AO 32-A, 32-B, 32-C, and 33-A fractures or periprosthetic distal femur fracture from April 2018 to April 2022 were included in the study. The 2 interventions compared were the Synthes Expert retrograde/antegrade femoral nail (or control implant) versus the next-generation retrograde femoral nail (RFN)-advanced retrograde femoral nail (RFNA or experimental implant) (Synthes, West Chester, PA). OUTCOME MEASURES AND COMPARISONS: Early implant-related complications between the experimental and control implants were assessed including locking screw back out, screw breakage, intramedullary nail failure, need for secondary surgery, and loss of fracture reduction. RESULTS: Three hundred fourteen patients were identified with a mean age of 31.0 years, and 62.4% of the patients being male. Open fractures occurred in 32.5% of patients with 3.8% of injuries being distal femur periprosthetic fractures. Fifty-six patients were in the experimental group and 258 patients in the control group. Mean follow-up was 46.8 weeks for the control cohort and 21.0 weeks for the experimental cohort. Distal interlocking screw back out occurred in 23.2% (13 of 56) of the experimental group patients and 1.9% (5 of 258) of the control group patients ( P < 0.0001). Initial diagnosis of interlocking screw back out occurred at an average of 3.2 weeks postoperatively (range, 2-12 weeks). Fifty-four percent of patients who sustained screw back out underwent a secondary operation to remove the symptomatic screws (12.5% of all patients treated with the experimental implant required an unplanned secondary operation due to screw back out). A logistic regression model was used to predict screw back out and found the experimental implant group was 4.3 times as likely to experience distal locking screw back out compared with the control group ( P = 0.01). CONCLUSIONS: The retrograde femoral nail-advanced implant was associated with a significantly higher rate of screw back out with a substantial number of unplanned secondary surgeries compared with the previous generation of this implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating. DESIGN: Retrospective cohort study. SETTING: Ten Level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019. OUTCOME MEASURES AND COMPARISONS: Surgery for nonunion stratified by risk for nonunion. RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05). CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study.

OBJECTIVE: (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION: External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS: FRI and unplanned reoperation rates. RESULTS: 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS: Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures.

OBJECTIVE: To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures. DESIGN: Retrospective chart review. SETTING: Level 1 academic trauma center. PATIENTS: Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020. INTERVENTION: External fixation and/or open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results. RESULTS: Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019). CONCLUSIONS: History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation and Management of Posterior Wall Acetabulum Fractures.

Posterior wall acetabulum fractures typically result from high-energy mechanisms and can be associated with various orthopaedic and nonorthopaedic injuries. They range from isolated simple patterns to multifragmentary with or without marginal impaction. Determination of hip stability, which can depend on fragment location, size, and displacement, directs management. Although important in the assessment of posterior wall fractures, CT is unreliable when used to determine stability. The dynamic fluoroscopic examination under anesthesia (EUA) is the benchmark in assessment of hip stability, and fractures deemed stable by EUA have good radiographic and functional outcomes. In fractures that meet surgical criteria, accurate joint reduction guides outcomes. Joint débridement, identification and elevation of impaction, and adjunctive fixation of posterosuperior and peripheral rim fragments along with standard buttress plate fixation are critical. Complications of the fracture and surgical fixation include sciatic nerve injury, posttraumatic osteoarthritis, osteonecrosis of the femoral head, and heterotopic ossification. Although accuracy of joint reduction is paramount for successful results, other factors out of the surgeon's control such as comminution, femoral head lesions, and dislocation contribute to poor outcomes. Even with anatomic restoration of the joint surface, good clinical outcomes are not guaranteed and residual functional deficits can be expected.

Complications and Risk Factors Influencing Hardware Removal after Open Reduction and Internal Fixation of the Radius or Ulna: A Nationwide Study.

Indications for open reduction and internal fixation (ORIF) of forearm fractures vary, and some patients require removal of hardware (ROH) for various complications. Currently, limited data exist to evaluate the epidemiology of and risk factors for ROH of the radius/ulna. We examine associations between radius/ulna fractures and (1) characteristics of fractures requiring ORIF, (2) indications for ROH, (3) demographic risk factors for ROH, (4) length of stay, and (5) total hospital charges. We use the Nationwide Inpatient Sample (NIS) to identify patients admitted for radius/ulna ORIF and ROH between 1998 and 2010 in the United States. To identify fracture locations, comorbidities, and indications for ROH, the International Classification of Diseases (ICD)-9 codes were accessed. We identify 423,727 ORIF patients and 12,868 patients (3.0% of ORIF admissions) who underwent ROH. Logistic regression analyses and independent sample t-tests are used to assess risk factors and differences. Among fractures requiring ORIF, the most common is for distal, closed fractures of radius and ulna. The most common indications for ROH are implant infection and mechanical complication. Risk factors for ROH include male gender, Caucasian ethnic group, and Deyo comorbidity scores of 1 or greater. Length of hospital stay and total charges are significantly higher for ROH patients compared to those with ORIF only. ROH following ORIF for radius/ulnar fractures is an infrequent but serious complication that increases patient morbidity and burdens patients and providers. Patient demographics of male gender, Caucasian ethnic group, payer status, and comorbid conditions were identified as independent risk factors for ROH.

Talus Fractures: Evaluation and Treatment.

The talus is unique in having a tenuous vascular supply and 57% of its surface covered by articular cartilage. Fractures of the head, neck, or body regions have the potential to compromise nearby joints and impair vascular inflow, necessitating surgical treatment with stable internal fixation in many cases. The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Percutaneous screw fixation has also demonstrated success in certain patterns. Despite this modern technique, osteonecrosis and osteoarthritis remain common complications. A variety of new treatments for these complications have been proposed, including vascularized autograft, talar replacement, total ankle arthroplasty, and improved salvage techniques, permitting some patients to return to a higher level of function than was previously possible. Despite these advances, functional outcomes remain poor in a subset of severely injured patients, making further research imperative.

Pearls and Pitfalls With Intramedullary Nailing of Proximal Tibia Fractures.

Intramedullary fixation of proximal tibia fractures remains a challenging surgical technique, with malalignment reported as high as 84%. The pull from the extensor mechanism, the hamstring and iliotibial band, in addition to the lack of endosteal fit from the nail, has made surgical fixation of these fractures difficult. Commonly held principles to reduce angular deformity include ensuring adequate imaging, obtaining an optimal start and trajectory for the implant, and obtaining and maintaining a reduction throughout the duration of the procedure. Some adjunctive techniques to assist in the application of these principles include use of a semiextended technique, clamping, blocking screws/wires, and unicortical plates. Understanding the challenges involved in intramedullary nailing of proximal tibia fractures and considering a wide array of techniques in the orthopaedic surgeon's armamentarium to combat these challenges is important.

Combined Labeled Leukocyte and Technicium 99 Sulfur Colloid Bone Marrow Imaging: Differentiating Primary Pyomyositis Pseudotumor from Osteomyelitis and Multiple Bone Infarcts.

A 53 year old-female patient with lupus had undergone a cephalo-medullary nailing for a femur shaft fracture 30 years ago. This was complicated by osteomyelitis, requiring multiple debridement procedures and hardware removal. Recently, she developed a painful soft tissue mass in the same region, which was ultimately diagnosed as pyomyositis. Because of chronic bone changes due to her past history, traditional imaging could not differentiate between osteomyelitis infarction and pseudotumor. A combined indium-labeled leukocyte scan with a technetium-99 sulfur colloid marrow scan ruled out osteomyelitis and guided proper treatment without osseous debridement and thus prevented unnecessary cross-contamination of the bone.

What are the Risk Factors for Hardware Removal After Tibia or Fibula Fracture?

Indications for open reduction and internal fixation (ORIF) of tibia and/or fibula fractures vary; however, some patients require removal of hardware (ROH) due to various complications. Currently, data evaluating the epidemiology of and risk factors for ROH of the tibia/fibula are limited. We examined the associations between tibia/fibula fractures and (1) characteristics of fractures requiring ORIF, (2) indications for ROH, (3) demographic risk factors for ROH; (4) length of stay, and (5) total hospital charges. The Nationwide Inpatient Sample (NIS) was used to identify patients admitted for tibia/fibula ORIF and ROH between 1998 and 2010 in the United States. We used ICD-9 codes to identify fracture locations, comorbidities, and indications for ROH. We identified 1,610,149 ORIF patients, and 56,864 of these patients (3.5%) underwent ROH. Logistic regression analyses and independent sample t-tests were used to assess risk factors and differences. Among fractures requiring ORIF, the most common were for closed fractures of both tibia and fibula. The most common indications for ROH were infection and osteomyelitis. Risk factors for ROH included men and Deyo comorbidity scores of 1 and 2 or more. Age and race were not risk factors for ROH. The length of stay and total charges were significantly higher for ROH compared to those with ORIF only. Hardware removal is a serious complication following ORIF for fractures of the tibia/fibula. The results of the current study suggest that gender, presence of comorbidities, and payer status were all significant factors in predicting hardware removal for the tibia/fibula following ORIF.

Embolization of pelvic arterial injury is a risk factor for deep infection after acetabular fracture surgery.

OBJECTIVE: To determine whether embolization of pelvic arterial injuries before open reduction and internal fixation (ORIF) of acetabular fractures is associated with an increased rate of deep surgical site infection. METHODS: Retrospective review of patients who underwent ORIF of acetabular fractures at our institution from 1995 through 2007 (n = 1440). We compared patients with acetabular fractures who underwent angiography and embolization of a pelvic artery (n = 12) with those who underwent angiography but did not undergo embolization (n = 14). Primary outcome was presence of infection requiring return to the operating room. RESULTS: Seven (58%) of the 12 patients who underwent embolization developed deep surgical site infection compared with only 2 (14%) of the patients who underwent angiography but did not require pelvic vessel embolization (P < 0.05, Fisher exact test). CONCLUSIONS: The combination of an acetabular fracture that requires ORIF and a pelvic arterial injury that requires angiographic embolization is rare. However, the 58% infection rate of the patients who underwent embolization before ORIF is an order of magnitude higher than typical historical controls (2%-5%) and significantly higher than that of the control group of patients who underwent angiography without embolization (14%). In addition, a disproportionate number of the patients who developed infection had their entire internal iliac artery embolized. Surgeons should be aware that embolization of a pelvic arterial injury is associated with a high rate of infection after subsequent ORIF of an acetabular fracture. Embolization of the entire iliac artery should be avoided whenever possible. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.