Femoral Neck Fractures in Young and Middle-Aged Adults: Pearls and Pitfalls.

The management of femoral neck fracture in young and middle-aged adults remains challenging. Although the influence of timing on the outcome is controversial, surgical management within 12 hours is recommended. Reduction quality is the most important modifiable factor that is correlated with outcomes. The rates of osteonecrosis and nonunion remain high and the patients need to be informed of this at the beginning of treatment.

Difficult Diaphyseal Femur Fractures: Pearls and Pitfalls.

Diaphyseal femur fractures are common injuries globally and range in complexity. The most common mechanism worldwide is motor vehicle accidents. Initial evaluation should include Advanced Trauma Life Support protocol and evaluation of the soft tissues, neurovascular examination, and associated injuries. The gold standard for treatment is a closed functional reduction (restoration of length, alignment, and rotation) and fixation with a reamed, statically locked, intramedullary nail. Fracture pattern, associated injuries, and patient factors can increase the difficulty of treatment. Malrotation and limb length discrepancy are not uncommon. Awareness of the problem and knowledge of the how to obtain and verify adequate reduction is critical. Diagnosis of malrotation and/or limb length discrepancy should prompt a detailed discussion of the deformity and treatment options with the patient. Most patients recover remarkably well from diaphyseal femur fractures. They should be followed until union and return to prior functional level with a watchful eye placed on any warning signs of complications such as nonunion and infection.

Intertrochanteric Hip Fractures: Pearls and Pitfalls in Managing Difficult Fractures.

Intertrochanteric hip fractures are among the most common osteoporotic fractures seen by orthopaedic surgeons. These fractures have a significant effect on a patient's mobility, independence, and mortality. In addition, they represent a substantial component of health care spending. Treatment is almost universally surgical, and surgeons must pay attention to patient optimization, fracture characteristics, and surgical planning. The goal of surgical intervention is to maximize the patient's ability to return to preinjury level of function by early postoperative mobilization. This can be achieved by obtaining and maintaining reduction to fracture healing.

Subtrochanteric Femur Fractures: Pearls and Pitfalls.

Management of subtrochanteric femur fractures is challenging because of the multiple planes of fracture deformity. Specific techniques starting with patient positioning and appropriate operating room table selection can improve the efficiency of the surgery. Sequential reduction techniques starting with closed methods, percutaneous techniques, and finally open clamping can be performed to obtain anatomic reduction of the fracture. The gold standard implant for definitive fixation is a locked intramedullary nail and overall outcomes are excellent if anatomic alignment and stable fixation is achieved.

Fractures of the Talus and Pantalar Dislocations.

Talar fractures and pantalar dislocations are usually the results of high-energy trauma. Dislocations and open injuries are managed urgently. Temporary stabilization with splinting, Kirschner wires, or external fixation may be performed until the soft tissues are ready for definitive fixation. A CT scan is critical to identify all injuries and is helpful in planning treatment including reduction of dislocations and definitive fixation. Lateral and posterior process fractures are often missed initially and require a high index of suspicion.

Displaced Intra-articular Calcaneus Fractures: Extensile Lateral and Less Invasive Approaches.

Treatment of displaced intra-articular calcaneal fractures is controversial and must be individualized by patient and fracture type. With an extensile lateral approach, all components of the deformity in displaced intra-articular calcaneal fractures can be addressed. The extensile lateral approach is indicated in more complex fracture patterns and when delay of surgery is necessary because of severe soft-tissue injury beyond 2 to 3 weeks. Careful patient selection, proper surgical timing, incision placement, and soft-tissue handling minimize the high rate of wound healing complications associated with the extensile lateral approach. The goals of surgical treatment of displaced intra-articular calcaneal fractures may also be achieved using less invasive approaches, such as the sinus tarsi approach and closed reduction with percutaneous fixation, decreasing the risk of wound complications. Multiple factors influence determination of the specific approach.

Interobserver and Intraobserver Reliability of Classification Systems for Radiographic Complications After Radial Head Arthroplasty.

PURPOSE: Although several classifications are used to assess radiographs following radial head arthroplasty (RHA), including the Popovic classification for radiolucency, the Chanlalit classification for stress shielding (SS), the Brooker classification for heterotopic ossification (HO), and the Broberg-Morrey classification for radiocapitellar arthritis, little is known about the reliability of these classification systems. The purpose of this study was to determine the interobserver and intraobserver reliability of these classifications. METHODS: Six orthopedic surgeons at various levels of training reviewed elbow radiographs of 20 patients who underwent RHA and classified them according to the Popovic, Chanlalit, Brooker, and Broberg-Morrey classifications for radiolucency, SS, HO, and RHA, respectively. Four weeks after initial review, radiographic reviews were repeated. Reliability was measured using the Fleiss kappa and the intraclass correlation coefficient. Agreement was interpreted as none (<0), slight (0.01-0.2), fair (0.21-0.4), moderate (0.41-0.6), substantial (0.61-0.8), and almost perfect (0.81-1) based on agreement among attending surgeons. RESULTS: Among fellowship-trained attending surgeons, interobserver reliability was slight for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), fair for radiocapitellar arthritis (Broberg-Morrey) and HO (Brooker), and substantial for the ordinal interpretation of radiolucency (Popovic). Residents had a higher interobserver reliability than attending physicians when using the Brooker classification. Mean intraobserver reliability was fair for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), moderate for HO (Brooker) and radiocapitellar arthritis (Broberg-Morrey), and almost perfect for the ordinal interpretation of radiolucency (Popovic). Trainees had higher intraobserver reliability than attending surgeons using the SS (Chanlalit) classification. CONCLUSIONS: The number of Popovic zones is reliable for communication between physicians, but caution should be taken with the Brooker, Chanlalit, Broberg-Morrey, and categorical interpretation of the Popovic classifications. All the classifications had better intraobserver than interobserver reliability. CLINICAL RELEVANCE: Reliability of classification systems for radiographic complications after RHA is less than substantial except the number of zones of radiolucency; therefore, caution is required when drawing conclusions based on these classifications.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

BACKGROUND: Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. METHODS: All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. RESULTS: Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. CONCLUSION: Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Suture button placed beneath plate fixation for complex distal clavicle fractures and acromioclavicular joint injuries: a technical note.

Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength. At final follow-up over one year after plate removal and suture button retention in thirteen patients, reduction was maintained to coracoclavicular interval 1.5 ± 1.4 mm less than contralaterally. DASH scores at final follow-up averaged 5.7 ± 2.5 (range: 3.3 - 11.7). Placing suture button fixation prior to and beneath plate fixation in complex AC joint injuries and distal clavicle fractures allows for maintained fixation and prevents loss of reduction after plate removal.

Anatomic Radial Head Arthroplasty: The Importance of Implant Angle.

PURPOSE: Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures. The aim of this study was to characterize the risk of RHA failure with respect to the stem angle in anatomic RHA design. METHODS: A retrospective review of patients who underwent anatomic RHA for acute fractures between 2006 and 2019 at 2 academic centers was conducted. Initial postoperative elbow radiographs were reviewed to measure RSA on the anterior-posterior and lateral views. Radiolucency, stress shielding, and radiocapitellar arthritis were also evaluated. Implant failure was defined as prosthesis removal or revision. RESULTS: Implant failure was associated with significantly larger lateral RSA than that in intact implants. Increasing stem shaft angle on a lateral radiograph was associated with decreased implant survival. Radiolucency, stress shielding, and radiocapitellar arthritis were similar between the 2 groups. CONCLUSIONS: Anatomic radial head implants are commonly used; however, the importance of prosthesis positioning, specifically that of the stem within the proximal radius, remains understudied. Higher RSA is associated with the risk of implant failure and need for revision. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center.

BACKGROUND: Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol. METHODS: We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017. RESULTS: A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups. CONCLUSION: With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population. LEVEL OF EVIDENCE: III, therapeutic.

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.

The effect of new preoperative preparation method compared to conventional method in complex acetabular fractures: minimum 2-year follow-up.

OBJECTIVE: This study aimed to compare the efficacy and safety of the new method including 3D printing-based preoperative planning, surgical workshop, and contouring of the plate versus conventional method in the surgical treatment of complex acetabular fractures. METHODS: We retrospectively analyzed the data in a cohort of 88 patients of complex acetabular fracture with mean 29.95 ± 4.84 months (24-41 months) follow-up. Patients were divided into two groups. Group 1 consisting of 41 patients were performed previewed surgery with a 3D printing-based pre-contoured plate on a 3D printing model. Group 2, comprised of 47 patients, were treated by the traditional contoured plate technique. The quality of reduction was assessed using criteria described by Matta. Functional outcome was evaluated using Modified Postel Merle D'Aubigne score. A custom-made quiz was used to evaluate the chief assistant. RESULTS: The study showed no significant differences in measured preoperative variables except for the age between the Group 1 and Group 2 (p > 0.05). Compared with the Group 2, the intraoperative blood loss, operative time was significantly decreased in Group 1 (p < 0.05). There were no significant statistical differences in the quality of reduction and Modified Postel Merle D'Aubigne score (p > 0.05). The result of evaluation of assistant in Group 1 was significantly high than in Group 2 (p < 0.05). CONCLUSION: 3D printing-based pre-contoured plate is a more effective and reliable method than traditional contoured plate technique for treating the complex acetabular fractures. Meanwhile, the 3D printing is a useful orthopedic surgical education tool which can improve the understanding of the complex acetabular fracture for a young surgeon.

Treatment of capitellar and trochlear fractures with posterior comminution: minimum 2-year follow-up.

HYPOTHESIS: This study aimed to evaluate the safety and efficacy of the fixation of Dubberley type B capitellar and trochlear fractures using dorsolateral anatomic plates with support of the distal humerus (DAPSDHs). METHODS: Fifteen patients with Dubberley type B capitellar and trochlear fractures (two type 1B, five type 2B, and eight type 3B) were treated through the extended lateral approach, and fixation was achieved with DAPSDHs. Radiographic evaluation was performed, and range of motion of the elbow and forearm was recorded. Functional outcomes were assessed using the Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand score. RESULTS: The mean follow-up period was 32.5 months (range, 24-54 months). Fracture union was achieved in all cases. At the final follow-up, range of motion was as follows: flexion, 123.7° ± 8.1° (range, 110°-135°); lack of extension, 11.0° ± 7.1° (range, 5°-30°); pronation, 81.7° ± 5.6° (range, 70°-90°); and supination, 78.7° ± 5.2° (range, 70°-85°). At the final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 11.9 ± 4.0 (range, 4.2-20.8) and the mean Mayo Elbow Performance Score was 89.0 ± 7.1 (range, 70-95). The outcome was rated as excellent in 12 patients (80.0%), good in 2 (13.3%), and fair in 1 (6.7%). Avascular necrosis of the capitellum developed in 1 patient. One patient had implant irritation. Heterotopic ossification developed in 1 patient. Ten patients returned to their previous activity levels. CONCLUSION: Capitellar and trochlear fractures with posterior comminution are safely and effectively treated through the extended lateral approach using DAPSDHs, resulting in good radiographic and functional outcomes.

A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures.

PURPOSE: The goal of this study was to evaluate the safety and efficacy of a new technique for posterior column fixation through the standard ilioinguinal approach. METHODS: We conducted a retrospective review involving 33 consecutive patients with complex acetabular fractures treated using a short buttress plate fixation of posterior column through single ilioinguinal approach. Radiographic evaluation was performed using criteria described by Matta. Functional outcome was assessed using modified Postel Merle D'Aubigné score. RESULTS: Between 2008 and 2013, 33 adult patients with mean age of 46 years and mean follow up of 37.5 months were enrolled. Anatomic reduction was obtained in 61 % of cases, imperfect reduction in 24 % of cases and poor reduction in 15 % of cases. The average modified Merle d'Aubigné score was 15: categorized as excellent in seven, good in 18, fair in three, and poor in four. One patient died at 15 days because of pulmonary embolism. Four patients sustained temporary lateral femoral cutaneous palsy. At final follow up, two patients had severe post-traumatic arthritis; one of them underwent a total hip arthroplasty at 93 months. None of the patients had loss of reduction. CONCLUSIONS: A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures is a safe and effective method.

Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty.

We hypothesized that infection rates following total joint arthroplasty (TJA) in those with the human immunodeficiency virus (HIV) without hemophilia or drug use would be similar to rates in HIV-negative patients. Records at an urban HIV referral hospital were searched for patients who underwent primary total hip and knee arthroplasty from 2003 to 2010. The primary outcome was revision for infection. 372 HIV-negative and 22 HIV-positive TJA patients met inclusion criteria. The HIV-positive group had more deep infections than the HIV-negative group (9.1% v 2.2%, P=0.102). There were no infections in those with AIDS-defining CD4 counts. Those with HIV may have a higher risk of developing a deep infection. A low CD4 count is not an absolute contraindication to TJA in HIV positive patients.

Surgical approaches for tibial plateau fractures.

Tibial plateau fractures are common yet complex injuries, and include a wide variety of fracture patterns. They are also potentially associated with significant soft tissue injury. Thus, the surgeon preparing to operate on one of these fractures must choose from a variety of surgical approaches that have been described. The choice of approach is dictated principally by the fracture pattern, with consideration of the soft tissue envelope, patient factors, and associated injuries. Occasionally, associated intra-articular injuries may also need to be addressed. Commonly used approaches to the proximal tibia, which together allow for the treatment of any proximal tibia fracture, will be described in this article.

Acute complications of patients with pelvic fractures after pelvic angiographic embolization.

BACKGROUND: Hemodynamically unstable patients with a pelvic fracture and arterial pelvic bleeding frequently are treated with pelvic angiographic embolization (PAE). PAE is reported to be a safe and effective method of controlling hemorrhage. However, the loss of blood supply and subsequent ischemia from embolization may lead to adverse consequences. OBJECTIVES/PURPOSES: We sought to determine (1) the frequency and types of complications observed after PAE; (2) the mortality after PAE; and (3) the clinical factors associated with complications and mortality after PAE. METHODS: We conducted a retrospective case series descriptive study at a Level I trauma center. Using our institution's trauma registry, we isolated patients with pelvic fractures treated with PAE admitted between June 1999 and December 2007. Complications attributed to PAE occurring in the initial hospital stay were recorded. We identified 98 patients with pelvic fractures treated by PAE with an average hospital stay of 25.3 days. RESULTS: The complication rate was 11% and included six patients with gluteal muscle necrosis (6%), five with surgical wound breakdown (5%), four deep infections (4%), one superficial infection, two patients with of impotence (2%), and one with bladder necrosis. The mortality rate in the PAE group reached 20%. Bilateral embolization was performed in 100% of the patients with complications. Nonselective embolization was performed in 81% of patients with complications. All of the patients with gluteal necrosis had bilateral nonselective embolization. CONCLUSIONS: Bilateral or nonselective PAE is associated with significant complications during the initial hospital stay. The value of PAE should be weighed against its possible adverse consequences. Selective unilateral arterial embolization should be considered whenever possible.

Anatomic Osteochondral Allograft Reconstruction for Concomitant Large Hill-Sachs and Reverse Hill-Sachs Lesions.

Glenohumeral instability causing bipolar bone loss is increasingly being recognized and treated to minimize recurrence. Large Hill-Sachs and reverse Hill-Sachs lesions of the humerus must be addressed at the time of surgery to prevent recurrent dislocations and restore the native anatomic track. For patients with epilepsy, locked dislocations may create defects that must be addressed with bony procedures, including osteochondral allograft reconstruction as soft-tissue remplissage may not adequately addresses the magnitude of the bone loss. Osteochondral allografts have been successfully used to address bony defects ranging from 20% to 30% of humeral bone loss whereas shoulder arthroplasty is indicated for larger defects where the native anatomy can no longer be restored. In this Technical Note, we present a technique to address concomitant large Hill-Sachs and reverse Hill-Sachs lesions.

Humerus fractures: selecting fixation for a successful outcome.

Current evidence suggests at least one-third of humeral shaft fractures initially managed nonoperatively will fail closed treatment, and this review highlights surgical considerations in those circumstances. Although operative indications are well-defined, certain fracture patterns and patient cohorts are at greater risk of failure. When operative intervention is necessary, internal fixation through an anterolateral approach is a safe and sensible alternative. Determining which patients will benefit most involves shared decision-making and careful patient selection. The fracture characteristics, bone quality, and adequacy of the reduction need to be carefully evaluated for the specific operative risks for individuals with certain comorbid conditions, inevitably balancing the patient's expectations and demands against the probability of infection, nerve injury, or nonunion. As our understanding of the etiology and risk of nonunion and symptomatic malunion of the humeral diaphysis matures, adhering to the principles of diagnosis and treatment becomes increasingly important. In the event of nonunion, respect for the various contributing biological and mechanical factors enhances the likelihood that all aspects will be addressed successfully through a comprehensive solution. This review further explores specific strategies to definitively restore function of the upper extremity with the ultimate objective of an uninfected, stable union.