Single-Incision Fasciotomy Decreases Infection Risk Compared with Dual-Incision Fasciotomy in Treatment of Tibial Plateau Fractures With Acute Compartment Syndrome.

OBJECTIVES: Comparison of surgical site infection (SSI) rates in tibial plateau fractures with acute compartment syndrome treated with single-incision (SI) versus dual-incision (DI) fasciotomies. DESIGN: Retrospective cohort study. SETTING: Two, Level-1, academic, trauma centers. PATIENTS: Between January 2001 and December 2021, one-hundred ninety patients with a diagnosis of tibial plateau fracture and acute compartment syndrome met inclusion criteria (SI: n = 127, DI: n = 63) with a minimum of 3-month follow-up after definitive fixation. INTERVENTION: Emergent 4-compartment fasciotomy, using either SI or DI technique, and eventual plate and screw fixation of the tibial plateau. OUTCOMES: The primary outcome was SSI requiring surgical debridement. Secondary outcomes included nonunion, days to closure, method of skin closure, and time to SSI. RESULTS: Both groups were similar in demographic variables and fracture characteristics (all P > 0.05). The overall infection rate was 25.8% (49 of 190), but the SI fasciotomy patients had significantly fewer SSIs compared with the DI fasciotomy patients [SI 18.1% vs. DI 41.3%; P < 0.001; OR 2.28, (confidence interval, 1.42-3.66)]. Patients with a dual (medial and lateral) surgical approach and DI fasciotomies developed an SSI in 60% (15 of 25) of cases compared with 21.3% (13 of 61) of cases in the SI group ( P < 0.001). The nonunion rate was similar between the 2 groups (SI 8.3% vs. DI 10.3%; P = 0.78). The SI fasciotomy group required fewer debridement's ( P = 0.04) until closure, but there was no difference in days until closure (SI 5.5 vs. DI 6.6; P = 0.09). There were zero cases of incomplete compartment release requiring return to the operating room. CONCLUSIONS: Patients with DI fasciotomies were more than twice as likely to develop an SSI compared with SI patients despite similar fracture and demographic characteristics between the groups. Orthopaedic surgeons should consider prioritizing SI fasciotomies in this setting. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Type III Open Tibia Fractures Treated With Single-Stage Immediate Medullary Nailing and Attempted Primary Closure Yield Low Rates of Flap Coverage.

OBJECTIVE: The purpose of this study was to determine whether type III open high-energy tibia fractures treated with immediate intramedullary nailing (IMN) and primary closure yield low rates of flap coverage. METHODS: Patients with high-energy type IIIA open tibia (OTA/AO42/43) fractures treated with IMN over a 10-year period at a level 1 academic center with at least 90 days of in-person postoperative follow-up were included. Single-stage reamed IMN with acute primary skin closure using Allgower-Donati suture technique was utilized in patients without notable skin loss. The primary outcome was treatment failure of acute primary skin closure requiring subsequent soft-tissue coverage procedures. RESULTS: A total of 111 patients with type IIIA tibia fractures met inclusion criteria. Of 107 of the 111 patients (96%) with skin closure at the index surgery, 95 of the 107 patients (89%) healed their soft-tissue envelop uneventfully. Among the patients who failed primary closure (11%), five required free tissue transfers, five required local rotational flaps, and two underwent split thickness skin grafting only. Patients who failed acute primary closure declared within an average of 8 weeks postoperatively. DISCUSSION: Treatment of type IIIA open high-energy tibia fractures with immediate IMN and primary closure using meticulous soft-tissue handling yields low rates of flap coverage.

Mathematically Directed Single-Cut Osteotomy.

A mathematically directed osteotomy (MDO) is a surgical planning technique for correcting long bone deformities. Using a mathematically derived osteotomy plane, the single-cut correction simultaneously addresses angular deformity, axial malrotation, and minor shortening. This review describes an MDO's indications for use, defines its input and output variables, includes the required graphs for osteotomy planning, and provides intraoperative tips and tricks for successful execution. Finally, the authors present a digital MDO calculator to simplify the complex computations and allow for more precise planning.

Simultaneous Posterolateral and Posteromedial Approaches for Fractures of the Entire Posterior Tibial Plafond: A Safe Technique for Effective Reduction and Fixation.

OBJECTIVE: To determine the short-term results of surgical treatment with dual posterolateral and posteromedial approaches for fractures of the entire posterior tibial plafond and secondarily to identify common fracture characteristics. DESIGN: Retrospective. SETTING: Single academic Level 1 trauma center. PATIENTS: Thirty-five patients with posterior pilon fractures followed until fracture union (minimum 3 months). INTERVENTION: Surgical treatment using simultaneous combined posterolateral and posteromedial exposures for fracture reduction and internal fixation. MAIN OUTCOME MEASUREMENT: (1) Surgical outcomes including rate of wound complications and accuracy of the articular reduction. (2) Fracture characteristics including the incidence of articular impaction, comminution interfering with reduction, syndesmosis injury, and the type of fibula fracture. RESULTS: The rate of wound problems was low (6%), and 94% of patients had an articular reduction with less than 1 mm of step or gap. There were high rates of articular comminution (83%) and posteromedial articular impaction (63%) and a 17% rate of syndesmosis injury requiring repair. CONCLUSIONS: Surgical fixation using simultaneous, combined posterolateral and posteromedial approaches for posterior pilon fractures had a low rate of wound complications and was an effective strategy for obtaining an accurate reduction. The rate of syndesmotic instability requiring fixation was lower than previous work reporting on fixation using a single approach. This may be a useful technique for surgeons who treat these injuries. Careful assessment of the preoperative imaging is required in patients with posterior pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Strategies in Pilon Fixation.

The treatment of tibial pilon fractures has evolved substantially over the past decades due to ever-increasing high-energy injuries. Open reduction and internal fixation of these intra-articular fractures requires an appreciation for a number of basic principles: respect the soft tissues, understand the fracture pattern, use safe surgical approaches, and provide stability that allows for early motion of the ankle. Surgical strategy should be customized based on the fracture pattern, access needed for fracture visualization and reduction, and status of the soft tissues. Given the ability to obtain an accurate stable reduction, smaller implants are typically adequate using multiple small incisions. We view this surgical tactic as continuing the evolution of complex fracture treatment whose origins lie in the influences of pioneers such as Dr Sigvard T. Hansen Jr.

Pilon Fractures in Patients Older Than 60 Years of Age: Should We Be Fixing These?

OBJECTIVES: To compare complications after operatively treated pilon fracture between elderly patients (≥60 years) and younger patients (<60 years). DESIGN: Retrospective comparative study. SETTING: Two Level-1 academic trauma. PATIENTS/PARTICIPANTS: Of the 740 tibial plafond fractures (OTA/AO 43-B & 43-C) treated January 2006 through December 2016, 538 patients had a minimum of 1 year follow up. INTERVENTION: Open reduction-internal fixation (ORIF). MAIN OUTCOME MEASUREMENT: Treatment failure defined as either nonunion or arthrosis. RESULTS: A total of 72 patients comprised the elderly group (mean age 66 years) and 466 patients comprised the younger group (mean age 44 years) (P < 0.001). Besides significantly more tobacco use in the younger group, patient demographics and fracture characteristics did not differ. Locking plates were used significantly more in elderly patients (47% vs. 32%, P = 0.01). Using chi-square analysis, we were unable to detect a difference in treatment failure (elderly 43% vs. young 37%, P = 0.33), infection (elderly 10% vs. young 13%, P = 0.4), or malunion (elderly 3% vs. young 4%, P = 1.0). Using regression analysis, age >60 was not associated with treatment failure [odds ratio (OR) 1.2 (0.7-2.1), P = 0.52]. Bone loss (OR 2.7 [1.8-4.1], P < 0.001), open fracture (OR 1.6 [1-2.5], P = 0.03), and malreduction (OR 4.2 [2.5-7.3], P < 0.001) were associated with failure. CONCLUSIONS: Age >60 years is not an independent predictor of surgical treatment failure of pilon fractures as defined by nonunion or arthrosis. This is the largest cohort of pilon fracture in elderly patients and indicates that we should continue to treat elderly patients similar to their younger counterparts using ORIF. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Tibial Plafond Nonunion: Medial Column Fixation May Reduce Nonunion Rates.

OBJECTIVES: To identify the incidence and risk factors for development of tibial plafond nonunion. DESIGN: Retrospective comparative study. SETTING: Two Level 1 academic trauma centers. PATIENTS/PARTICIPANTS: Seven hundred forty tibial plafond fractures (OTA/AO 43B3 and 43C) treated January 2006 to December 2015. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENT: Nonunion. RESULTS: Five hundred eighteen patients with a mean age of 43 years (range, 18-81 years) and mean follow-up of 27 months (range, 12-115 months) were involved. Seventy-two patients (72/518, 14%) were identified as having a nonunion. Surgical approach was not associated with nonunion in univariate analysis. Multiple regression model 1 identified OTA/AO 43C [odds ratio (OR) = 4.43; 95% confidence interval (CI), 1.01-19.41; P = 0.048], tobacco use (OR = 2.02; 95% CI, 1.10-3.71; P = 0.024), both minimal and substantial bone loss (P = 0.006 and P < 0.001, respectively), and open fracture (OR = 1.96; 95% CI, 1.10-3.48; P = 0.022) as risk factors for tibial plafond nonunion. Model 2 identified locking plate (OR = 1.97; 95% CI, 1.13-3.40; P = 0.016) and failure to treat the medial column (vs. screw P = 0.047, or plate P = 0.038) as risk factors. CONCLUSIONS: The tibial plafond nonunion rate was 14%. Bone loss, open fracture, failure to treat the medial column, locking plates, and tobacco use were all significant risk factors for developing tibial plafond nonunion. Equally important, surgical approach was not significantly associated with plafond nonunion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Syndesmosis and Syndesmotic Equivalent Injuries in Tibial Plafond Fractures.

OBJECTIVES: To identify the incidence and fracture characteristics associated with syndesmotic injury in tibial plafond fractures and report the incidence of posttraumatic osteoarthrosis (PTOA). DESIGN: Retrospective comparative study. SETTING: Two level-1 academic trauma centers. PATIENTS/PARTICIPANTS: Of the 735 tibial plafond fractures (OTA/AO 43-B3 and 43-C) treated from January 2006 through December 2015, 108 patients (108/735, 15%) were identified with syndesmosis injury. INTERVENTION: Either acute or missed syndesmotic injury. MAIN OUTCOME MEASUREMENT: PTOA. RESULTS: Fourteen fractures (14/735, 2%) had missed syndesmotic injury. Volkmann fragment of ≤10 mm (P = 0.04) and fibular avulsion fracture (P = 0.05) were significantly more common in missed syndesmosis. Ninety fractures (14/14 missed, 76/94 acute) had greater than 12-month follow-up (mean, 26 months; range, 12-102 months). Nearly all patients with missed syndesmosis injury developed arthrosis (13/14, 93%), and 45% (34/76 fractures) of plafond fractures with acute syndesmosis injury developed arthrosis (P < 0.001). Although controlling for malreduction, patients with missed syndesmosis had significantly more PTOA development (P = 0.018). Controlling for malreduction, patients with syndesmotic fixation and a ≤10-mm Chaput or Volkmann fragment or fibular avulsion fracture (8/31, 26%) were less likely to develop PTOA than if they had a similar fracture pattern without syndesmotic fixation (9/10, 90%) (P = 0.011). CONCLUSIONS: Fifteen percent of tibia plafond fractures have a syndesmosis or syndesmotic equivalent injury. Missed syndesmosis injury has a high rate of PTOA development. Patients with a ≤10-mm Chaput or Volkmann fragment and/or fibular avulsion fracture benefit from syndesmotic fixation. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

It's All About the Timing: When Do I Take This Injury to the Operating Room?

Over time, what was considered urgent or emergent in orthopaedic trauma has been revisited, and as awareness of factors associated with outcomes has increased, priorities have changed. There are multiple procedures performed urgently in the belief that early intervention allowed for better outcomes for the injury and the patient. Classic examples of conditions for which urgent intervention has been implemented include open fractures, femoral neck fractures in the young adult, talus fractures, and compartment syndrome. All of these conditions are considered nonurgent except for compartment syndrome, which requires urgent and timely intervention. Studies have demonstrated that these injuries need to be managed in a timely fashion but not necessarily in the middle of the night. Outcomes can be improved by measures such as early antibiotic administration for open fractures, closed reduction of talus fracture-dislocations, and anatomic reduction of femoral neck fractures. These measures are more important and useful than an emergent trip to the operating room by inexperienced surgeons with staff who may be unprepared. Orthopaedic surgeons should be familiar with open fractures and the timing of irrigation and débridement, the relative urgency of managing talus fractures, and the need for immediate reduction and fixation of femoral neck fractures. For each of these injuries, factors other than timing that affect outcomes will be described. Finally, the emergent nature of diagnosis and management of compartment syndrome must also be understood.

Trends in Orthopedic Fracture and Injury Severity: A Level I Trauma Center Experience.

The purpose of this study was to define the trends in fracture complexity and overall injury severity of orthopedic trauma patients at a level I trauma center. A retrospective review of a prospectively collected trauma database was performed to determine the Injury Severity Score (ISS) and AO/OTA classification of the most common fractures among all patients presenting from 1995 to 1999 and from 2008 to 2012. Inclusion criteria were lower extremity fractures of the femur and tibia and pelvic fractures within the years of interest. Exclusion criteria were age younger than 18 years, pathologic fractures, and insufficient medical records to determine ISS or AO/OTA classification. The total number of fractures increased from 4869 between 1995 and 1999 to 5902 between 2008 and 2012. There was an increase in the percentage of lower extremity periarticular fractures (20.7% to 23.4%, P<.001) and the percentage of pelvic and acetabular fractures (32.7% to 39.9%, P<.001) and a decrease in the percentage of lower extremity extra-articular fractures (46.6% to 36.7%, P<.001). The ratios of tibial pilon and plateau fractures relative to extra-articular tibial fractures increased from 0.29 to 0.60 (P<.001) and from 0.49 to 0.81 (P<.001), respectively. The average ISS had increased from 2008 to 2012 compared with from 1995 to 1999 (19.2 vs 15.1, P<.001). The complexity of certain lower extremity fractures and the severity of injury of patients treated at this referral institution are high and continue to increase. As US health care economics continue to change, with provider and hospital reimbursements shifting toward a patient outcomes basis with potential penalties for complications and readmissions, hospitals and providers must recognize these trends. Trauma centers must continue to measure the complexity of fracture care provided to properly risk-stratify their patient population. [Orthopedics. 2018; 41(2):e211-e216.].

Biomechanical Analysis of the Proximal Femoral Locking Compression Plate: Do Quality of Reduction and Screw Orientation Influence Construct Stability?

OBJECTIVES: To investigate biomechanically in a human cadaveric model the failure modes of the proximal femoral locking compression plate and explore the underlying mechanism. METHODS: Twenty-four fresh-frozen paired human cadaveric femora with simulated unstable intertrochanteric fractures (AO/OTA 31-A3.3) were assigned to 4 groups with 6 specimens each for plating with proximal femoral locking compression plate. The groups differed in the quality of fracture reduction and plating fashion of the first and second proximal screws as follows: (1) anatomic reduction with on-axis screw placement; (2) anatomic reduction with off-axis screw placement; (3) malreduction with on-axis screw placement; (4) malreduction with off-axis screw placement. The specimens were tested until failure using a protocol with combined axial and torsional loading. Mechanical failure was defined as abrupt change in machine load-displacement data. Clinical failure was defined as 5 degrees varus tilting of the femoral head as captured with optical motion tracking. RESULTS: Initial axial stiffness (in N/mm) in groups 1 to 4 was 213.6 ± 65.0, 209.5 ± 134.0, 128.3 ± 16.6, and 106.3 ± 47.4, respectively. Numbers of cycles to clinical and mechanical failure were 16,642 ± 10,468 and 8695 ± 1462 in group 1, 14,076 ± 3032 and 7449 ± 5663 in group 2, 8800 ± 8584 and 4497 ± 2336 in group 3, and 9709 ± 3894 and 5279 ± 4119 in group 4. Significantly higher stiffness and numbers of cycles to both clinical and mechanical failure were detected in group 1 in comparison with group 3, P ≤ 0.044. CONCLUSIONS: Generally, malreduction led to significantly earlier construct failure. The observed failures were cut-out of the proximal screws in the femoral head, followed by either screw bending, screw loosening, or screw fracture. Proper placement of the proximal screws in anatomically reduced fractures led to significantly higher construct stability. Our data also indicate that once the screws are placed off-axis (>5 degrees), the benefit of an anatomic reduction is lost.

Quality of fracture reduction assessed by radiological parameters and its influence on functional results in patients with pilon fractures-A prospective multicentre study.

INTRODUCTION: The management of pilon fractures remains a challenging issue. Due to the complexity of factors that influence the outcome, it has been questioned if anatomical reductions of articular fracture are relevant. The lack of a commonly accepted assessment of quality of fracture reduction compounded the uncertainty of the importance of anatomical reduction in pilon fracture. The current study aimed to define parameters that can better assess the reduction quality and to investigate the influence of reduction quality on functional outcomes. METHODS: Patients with unilateral pilon fracture of the AO/OTA type 43-B or 43-C were consecutively recruited to the study and followed up for 2 years after surgery. Postoperative radiographs of the injured and the contralateral joints were evaluated and 13 radiological parameters measured by 2 independent surgeons. The reliability of the measurements for each parameter was assessed by the Intraclass Correlation Coefficient (ICC), and 4 parameters with the highest ICC scores were deemed most reliable and were selected for further analyses. Functional outcome was assessed by the Foot and Ankle Ability Measure (FAAM) for daily living and sports activities. The 4 most reliable radiologic parameters, together with 3 possible baseline confounders (age, AO/OTA fracture type, and open versus closed injury), were analysed using both univariable and multivariable analysis for their association with the FAAM scores. Secondary outcome measures including pain, ankle range of motion (ROM), quality of life (QoL), and adverse events were also reported. RESULTS: The length of lateral malleolus (LLM), anterior distal tibia angle, anterior talar shift, and length of medial malleolus scored highest on reliability in ICC assessment (ICC=0.76, 0.72, 0.58, and 0.45, respectively). Only LLM exhibited statistical significant association with the 2-year FAAM results. At the 2-year follow-up, the injured joints on average achieved a ROM of 70.7% (95% CI=63.9-77.6) when compared to the contralateral joints, and patients did not regain the pre-injury QoL overall. CONCLUSION: The multivariable analysis showed that LLM (independent of age, AO/OTA fracture type, and open/closed injury) was a reliable indicator of reduction quality and a prognostic factor for patient outcome in pilon fracture surgery.

Intertrochanteric Osteotomy for Femoral Neck Nonunion: Does "Undercorrection" Result in an Acceptable Rate of Femoral Neck Union?

OBJECTIVES: To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy. DESIGN: Retrospective cohort study. SETTING: Level-1 trauma center. PATIENTS: Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy. INTERVENTION: Valgus-producing intertrochanteric osteotomy with a blade plate. MAIN OUTCOME MEASUREMENTS: Femoral neck and intertrochanteric osteotomy osseous union. RESULTS: Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014). CONCLUSIONS: Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Buttress Plating Versus Anterior-to-Posterior Lag Screws for Fixation of the Posterior Malleolus: A Biomechanical Study.

OBJECTIVES: The preferred method of fixation for posterior malleolus fractures remains controversial, and practices vary widely among surgeons. The purpose of this study was to compare anterior-to-posterior (AP) lag screws with posterior buttress plating for fixation of posterior malleolus fractures in a human cadaveric model. METHODS: Posterior malleolus fractures involving 30% of the distal tibial articular surface were created in 7 pairs of fresh frozen cadaveric ankles. One specimen in each pair was randomly assigned to fixation with either 2 AP lag screws or a one-third tubular buttress plate without supplemental lag screws. Each specimen was then subjected to cyclic loading from 0% to 50% of body weight for 5000 cycles followed by loading to failure. Outcome measures included permanent axial displacement during each test cycle (axial displacement at no load), peak axial displacement during each test cycle (axial displacement at 50% body weight), load at 1-mm axial displacement, ultimate load, and axial displacement at ultimate load. RESULTS: The buttress plate group showed significantly less peak axial displacement at all time points during cyclic loading. Permanent axial displacement was significantly less in the buttress plate group beginning at cycle 200. There were no significant differences between the 2 groups during load-to-failure testing. CONCLUSION: Posterior malleolus fractures treated with posterior buttress plating showed significantly less displacement during cyclical loading compared with fractures fixed with AP lag screws. Surgeons should consider these findings when selecting a fixation strategy for these common fractures. Further research is warranted to investigate the clinical implications of these biomechanical findings.

Coronal Plane Small-Fragment Fixation in Supracondylar Intercondylar Femur Fractures.

Supracondylar intercondylar distal femur fractures are devastating injuries that frequently have a concurrent coronal plane fracture, which mandates dedicated operative fixation. The purpose of this study was to determine whether small-fragment cortical lag screws oriented in the sagittal plane were sufficient to stabilize coronal plane fractures associated with supracondylar intercondylar distal femur fractures. The authors evaluated short-term radiographic outcomes in 56 coronal plane fractures in 44 knees (27 [61.4%] male, 17 [38.6%] female; mean age, 43 years [range, 19-97 years]) sustaining a supracondylar intercondylar distal femur fracture between January 2001 and November 2013. Coronal plane fractures were stabilized with sagittally oriented small-fragment cortical lag screws measuring 3.5 mm or smaller, and the supracondylar intercondylar component was stabilized with a lateral periarticular plate. Fracture displacement was defined as greater than 2 mm of gapping/translation of the coronal plane fragment on any radiographic view. Thirty-three (75.0%) knees had open injuries. Fifty-five (98.2%) of 56 coronal plane fractures went on to radiographic union with no displacement of the coronal fragment; one knee developed avascular necrosis and required arthrodesis. Fifteen (34.1%) of 44 knees required secondary procedures unrelated to the coronal plane fracture. The reduction of coronal plane fractures associated with supracondylar intercondylar distal femur fractures can be reliably maintained when stabilized with small-fragment cortical lag screws oriented in the sagittal plane.

How much articular displacement can be detected using fluoroscopy for tibial plateau fractures?

INTRODUCTION: While there is conflicting evidence regarding the importance of anatomic reduction for tibial plateau fractures, there are currently no studies that analyse our ability to grade reduction based on fluoroscopic imaging. The purpose of this study was to determine the accuracy of fluoroscopy in judging tibial plateau articular reduction. METHODS: Ten embalmed human cadavers were selected. The lateral plateau was sagitally sectioned, and the joint was reduced under direct visualization. Lateral, anterior-posterior (AP), and joint line fluoroscopic views were obtained. The same fluoroscopic views were obtained with 2mm displacement and 5mm displacement. The images were randomised, and eight orthopaedic traumatologists were asked whether the plateau was reduced. Within each pair of conditions (view and displacement from 0mm to 5mm) sensitivity, specificity, and intraclass correlations (ICC) were evaluated. RESULTS: The AP-lateral view with 5mm displacement yielded the highest accuracy for detecting reduction at 90% (95% CI: 83-94%). For the other conditions, accuracy ranged from (37-83%). Sensitivity was highest for the reduced lateral view (79%, 95% CI: 57-91%). Specificity was highest in the AP-lateral view 98% (95% CI: 93-99%) for 5mm step-off. ICC was perfect for the AP-lateral view with 5mm displacement, but otherwise agreement ranged from poor to moderate at ICC=0.09-0.46. Finally, there was no additional benefit to including the joint-line view with the AP and lateral views. CONCLUSION: Using both AP and lateral views for 5mm displacement had the highest accuracy, specificity, and ICC. Outside of this scenario, agreement was poor to moderate and accuracy was low. Applying this clinically, direct visualization of the articular surface may be necessary to ensure malreduction less than 5mm.

Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures.

Malleolar ankle fractures associated with syndesmotic injuries are common. Diagnosis of the syndesmotic injury can be difficult and often requires intraoperative fluoroscopic stress testing. Accurate reduction and stable fixation of the syndesmosis are critical to maximize patient outcomes. Recent literature has demonstrated that the unstable syndesmosis is particularly prone to iatrogenic malreduction. Multiple types of malreduction can occur, including translational, rotational, and overcompression. Knowledge of the technical details regarding intraoperative reduction methods and reduction assessment can minimize the risk of syndesmotic malreduction and improve patient outcomes.

What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study.

PURPOSE: Recently, several cases of clinical failure have been reported for the Proximal Femoral Locking Compression Plate (PF-LCP). The current study was designed to explore biomechanically the underlying mechanism and to determine whether the observed failure was due to technical error on insertion or to implant design. METHODS: A foam block model simulating an unstable intertrochanteric fracture was created for 3 study groups with 6 specimens each. Group C was correctly instrumented according to the manufacturer's guidelines. In Group P and Group A, the first or second proximal screw was placed with a posterior or anterior off-axis orientation by 2° measured in the transversal plane, respectively. Each construct was cyclically tested until failure using a test setup and protocol simulating complex axial and torsional loading. Radiographs were taken prior to and after the tests. Force, number of cycles to failure and failure mode were compared. RESULTS: A screw deviation of 2° from the nominal axis led to significantly earlier construct failure in Group P and Group A in comparison to Group C. The failure mode was characterised by loosening of the off-axis screw due to disengagement with the plate, resulting in loss of construct stiffness and varus collapse of the fracture. CONCLUSIONS: In our biomechanical test setup, the clinical failure modes observed with the PF-LCP were reproducible. A screw deviation of 2° from the nominal axis consistently led to the failure. This highlights how crucial is the accurate placement of locking screws in the proximal femur.

Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases.

OBJECTIVES: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN: Retrospective review. SETTING: Three level I or II trauma centers. PATIENTS/PARTICIPANTS: Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers. INTERVENTION: All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS: Risk factors for reoperation to promote union, deep infection, and implant failure. RESULTS: After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS: The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure. LEVEL OF EVIDENCE: Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Salvage of an infected periprosthetic failed fracture fixation in a nonagenarian.

Infected nonunions resulting in segmental bone loss are a devastating complication for patients and a difficult problem for surgeons. Adequate soft tissue coverage, return of mobility, fracture stability, and long-term freedom from infection are all important goals of treatment. Although there are numerous published studies that provide some treatment guidelines, there are patients who require unique and individualized solutions. In this report, we present a case in which an antibiotic-impregnated cement spacer was used as a component of the definitive treatment in a geriatric patient with segmental bone loss of the femur secondary to severe infection as a salvage technique to avoid amputation.