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.

Risk Factors of Failure in 228 Periprosthetic Distal Femur Fractures: A Multicenter Study.

OBJECTIVES: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). DESIGN: Multicenter retrospective cohort study. SETTING: Ten level-I trauma centers. PATIENT SELECTION CRITERIA: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE: 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.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience.

INTRODUCTION: Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. PATIENTS AND METHODS: A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. RESULTS: The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. CONCLUSION: Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

Obturator dislocations of the hip associated with pelvic ring injuries: Case report and review of the literature.

Case: An obturator hip dislocation with an associated open book pelvic ring injury is an extremely rare injury pattern. This case report will discuss challenges to closed reduction, acute management strategies and review the literature on combined hip dislocations and open book pelvic ring injuries. Conclusion: This injury pattern presents unique reduction challenges that should be recognized early in order to provide effective resuscitation and preserve the femoral head blood supply. Failing to close reduce the hip delays reducing the pelvic ring volume because sheets and binders are precluded from working effectively.

No Difference in Short-Term Complications following Treatment of Closed Tibial Shaft Fractures with Intramedullary Nailing versus Plate Fixation.

Objectives: Tibial shaft fractures are treated with both intramedullary nailing (IMN) and plate fixation (ORIF). Using a large national database, we aimed to explore the differences in thirty-day complication rates between IMN and ORIF. Methods: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had undergone either tibial IMN or ORIF for closed fractures from 2010 to 2018 were identified using current procedural terminology (CPT) codes. After excluding all patients with open fractures, the propensity score was matching. Univariate and multivariate logistic regressions were used to identify risk factors associated with the thirty-day incidence of complications in the two cohorts. Results: A total of 5,400 patients were identified with 3,902 (72.3%) undergoing IMN and 1,498 (27.7%) ORIF. After excluding any ICD-10 diagnosis codes not pertaining to closed, traumatic tibial shaft fractures, 2,136 IMN and 621 ORIF cases remained. After matching, the baseline demographics were not significantly different between the cohorts. Following matching, the rate of any adverse event (aae) did not differ significantly between the IMN (7.08% (n = 44)) and ORIF (8.86% (n = 55)) cohorts (p=0.13). There was also no significant difference in operative time (IMN = 98.5 min, ORIF = 100 min; p=0.3) or length of stay (IMN = 3.7 days, ORIF = 3.3 days; p=0.08) between the cohorts. Conclusion: There were no significant differences in short-term complications between cohorts. These are important data for the surgeon when considering surgical management of closed tibial shaft fractures.

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.

Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study.

OBJECTIVES: To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1107). INTERVENTION: Surgical fixation of distal femur fracture. MAIN OUTCOME MEASUREMENT: The outcome of interest was deep surgical site infection. RESULTS: There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%). CONCLUSIONS: Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Reoperation to Promote Union in 1111 Distal Femur Fractures.

OBJECTIVES: To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1111). INTERVENTION: Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. MAIN OUTCOME MEASUREMENTS: The outcome of interest was unplanned reoperation to promote union. RESULTS: There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive. CONCLUSIONS: Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience.

OBJECTIVES: To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level 1 trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or 33C fractures. INTERVENTION: Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). MAIN OUTCOME MEASUREMENTS: The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. RESULTS: One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). CONCLUSIONS: Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dual Plate Minifragment Fixation of Clavicle Fractures- Technique and Approach.

SUMMARY: The treatment of midshaft clavicle fractures continues to evolve, with a variety of fixation techniques and constructs used. Symptomatic hardware is a common complication related to plate fixation of the clavicle, and often results in secondary surgery for implant removal. The minifragment dual plate fixation technique for clavicle fractures provides a construct that may result in fewer implant related complications with comparable fixation stability to precontoured locking plates. Our case presentation demonstrates our approach to midshaft clavicle fractures, the benefits of this surgical technique, and reported outcomes from this fixation method.

Acute Management of Combined Floating Hip and Knee Injury: A Case Report.

Introduction: Surgical management of isolated acetabular fracture dislocations, femoral shaft fractures, and tibial shaft fractures are well-documented, but there is limited literature on the acute management of these injuries when they occur concomitantly in the same patient on the ipsilateral extremity. We present a case of the acute treatment of a 33-year-old patient with a right ipsilateral floating hip and knee injury secondary to a motor vehicle accident. We offer a unique surgical technique for the urgent management of this rare combined injury. Case Presentation: A 33-year-old female presented to our trauma center with an ipsilateral acute posterior wall fracture dislocation, femoral head impaction fracture, femoral shaft fracture, and tibial shaft fracture. After a failed hip reduction attempt in the emergency department, she was urgently brought to the operating room for further management. She underwent percutaneous-assisted schanz pin reduction of the hip, intramedullary nail fixation of the femur and tibia, and dynamic fluoroscopic examination of the hip under anesthesia. Conclusion: Successful management of the rare combined floating hip and knee injury requires urgent intervention. The reduction of the hip dislocation is difficult due to the associated injuries. We recommend urgent surgical intervention and the utilization of a percutaneous schanz pin in the proximal femur with gentle manipulation. In most cases, this can effectively reduce the hip without a formal open approach.

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.

High- Versus Low-Energy Acetabular Fracture Outcomes in the Geriatric Population.

INTRODUCTION: High-energy mechanisms of acetabular fracture in the geriatric population are becoming increasingly common as older adults remain active later in life. This study compared outcomes for high- versus low-energy acetabular fractures in older adults. MATERIALS AND METHODS: We studied outcomes of 22 older adults with acetabular fracture who were treated at a level-I trauma center over a 4-year period. Fourteen patients were categorized as low-energy mechanism of injury, and 8 were identified as a high-energy mechanism. We analyzed patient demographics with univariate logistic regressions performed to assess differences in high- and low-energy group as well as patient characteristics compared with surgical outcomes. RESULTS: Most high-energy mechanisms were caused by motor vehicle collision (n = 4, 50.0%), with most having posterior wall fractures (50.0%). Among patient characteristics, the mechanism of injury, hip dislocation, fracture types, and fracture gap had the largest differences between energy groups effect size (ES: 2.45, 1.43, 1.36, and 0.83, respectively). The high-energy group was more likely to require surgery (odds ratio [OR] = 2.80, 95% CI: 0.26-30.70), develop heterotopic bone (OR = 4.33, 95% CI: 0.33-57.65), develop arthritis (OR = 3.60, 95% CI: 0.45-28.56), and had longer time to surgery (mean = 4.8 days, standard deviation [SD] = 5.8 days) compared to low-energy group (mean = 2.5 days, SD = 2.3 days). DISCUSSION: The results of this case series confirm previous findings that patients with high-energy acetabular fractures are predominantly male, younger, and have fewer comorbidities than those who sustained low-energy fractures. Our results demonstrate that the majority of the high-energy fracture patients also suffered a concurrent hip dislocation with posterior wall fracture and experienced a longer time to surgery than the low-energy group. CONCLUSION: Geriatric patients who sustained high-energy acetabular fractures tend to have higher overall rates of complications, including infection, traumatic arthritis, and heterotopic bone formation when compared with patients with a low-energy fracture mechanism.

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.