Effect of Preoperative Antibiotic Therapy on Operative Culture Yield for Diagnosis of Native Joint Septic Arthritis.

BACKGROUND: Native joint septic arthritis (NJSA) is definitively diagnosed by a positive Gram stain or culture, along with supportive clinical findings. Preoperative antibiotics are known to alter synovial fluid cell count, Gram stain and culture results and are typically postponed until after arthrocentesis to optimize diagnostic accuracy. However, data on the impact of preoperative antibiotics on operative culture yield for NJSA diagnosis are limited. METHODS: We retrospectively reviewed adult cases of NJSA who underwent surgery at Mayo Clinic facilities from 2012-2021 to analyze the effect of preoperative antibiotics on operative culture yield through a paired analysis of preoperative culture (POC) and operative culture (OC) results using logistic regression and generalized estimating equations. RESULTS: Two hundred ninety-nine patients with NJSA affecting 321 joints were included. Among those receiving preoperative antibiotics, yield significantly decreased from 68.0% at POC to 57.1% at OC (p < .001). In contrast, for patients without preoperative antibiotics there was a non-significant increase in yield from 60.9% at POC to 67.4% at OC (p = 0.244). In a logistic regression model for paired data, preoperative antibiotic exposure was more likely to decrease OC yield compared to non-exposure (OR = 2.12; 95% CI = 1.24-3.64; p = .006). Within the preoperative antibiotic group, additional antibiotic doses and earlier antibiotic initiation were associated with lower OC yield. CONCLUSION: In patients with NJSA, preoperative antibiotic exposure resulted in a significant decrease in microbiologic yield of operative cultures as compared to patients in whom antibiotic therapy was held prior to obtaining operative cultures.

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems.

BACKGROUND: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

Systemic Osteoporosis and Osteopenia Among Periprosthetic Fractures After Total Hip Arthroplasty.

BACKGROUND: Most periprosthetic fractures following total hip arthroplasty (THA) are fragility fractures that qualify patients for osteoporosis diagnoses. However, it remains unknown how many patients were diagnosed who had osteoporosis before injury or received the proper evaluation, diagnosis, and treatment after injury. METHODS: We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femur fractures treated with a modular fluted tapered stem from 2000 to 2018 at 1 institution. The mean patient age was 75 years (range, 35 to 94), 50% were women, and the mean body mass index was 29 (range, 17 to 60). We identified patients who had osteoporosis or osteopenia diagnoses, a fracture risk assessment tool (FRAX), bone mineral density (BMD) testing, an endocrinology consult, and osteoporosis medications. Age-appropriate BMD testing was defined as no later than 1 year after the recommended ages of 65 (women) or 70 years (men). The mean follow-up was 11 years (range, 4 to 21). RESULTS: Falls from standing height caused 94% of fractures and thus, by definition, qualified as osteoporosis-defining events. The prevalence of osteoporosis diagnosis increased from 20% before periprosthetic fracture to 39% after (P < .001). The prevalence of osteopenia diagnosis increased from 13% before the fracture to 24% after (P < .001). The prevalence of either diagnosis increased from 24% before fracture to 44% after (P < .001). No patients had documented FRAX scores before fracture, and only 2% had scores after. The prevalence of BMD testing was 21% before fracture and 22% after (P = .88). By the end of the final follow-up, only 16% had received age-appropriate BMD testing. The proportion of patients who had endocrinology consults increased from 6% before the fracture to 25% after (P < .001). The proportion on bisphosphonate therapy was 19% before fracture and 25% after (P = .08). CONCLUSIONS: Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. Like nonarthroplasty fragility fractures, a systematic approach is needed after periprosthetic fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Computed tomography provides effective detection of traumatic arthrotomy of the elbow.

BACKGROUND: Failure to identify a traumatic arthrotomy of the elbow (TAE) can lead to septic arthritis with devastating complications. The gold standard for TAE detection remains controversial, and evidence is limited. While multiple clinical and cadaveric studies have validated the use of computed tomography (CT) to detect traumatic arthrotomies about the knee, other studies have called into question whether the use of CT to detect traumatic arthrotomy is applicable to the elbow. A prior cadaveric study utilizing a direct posterior (transtendon) traumatic arthrotomy model failed to detect traumatic arthrotomy via CT in 100% of cases. The aim of this study was to determine the sensitivity and specificity for detecting TAE with CT, utilizing a lateral traumatic arthrotomy model. METHODS: Ten fresh-frozen upper extremity transhumeral cadaveric specimens were utilized. Only specimens with an intact elbow joint and no known elbow surgery or injury were included. CT scans were performed to screen for intra-articular air prior to arthrotomy. A full-thickness 10 mm incision was performed over the soft spot, just distal to the lateral epicondyle. The elbow was taken through full range of motion in flexion and extension, as well as forearm pronation and supination 10 times. CT scans were then repeated and screened for the presence of intra-articular air. Lastly, a saline load test was performed on all specimens, and the volume of saline required to detect the arthrotomy was recorded. RESULTS: Of the 10 specimens, 0% (n = 0) demonstrated intra-articular air of the elbow joint on CT scan prior to arthrotomy and 100% (n = 10) demonstrated intra-articular air on CT scan following arthrotomy. CT scan demonstrated 100% sensitivity and 100% specificity for TAE. For the saline load test, 90% (n = 9) were positive for TAE at an average of 12 mL (range: 4 mL-47 mL), providing 90% sensitivity. CONCLUSION: In this cadaveric study utilizing a more commonly observed direct lateral traumatic laceration, CT was able to detect 100% (n = 10) of TAEs with 100% sensitivity and specificity. These results show that CT scans can effectively diagnose lateral traumatic arthrotomy in a cadaveric model and can be a viable option for diagnosis in a clinical setting. Clinical correlation is required to confirm in these in vitro findings.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

BACKGROUND: Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS: Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS: The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION: Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

Distal femoral replacement versus ORIF for severely comminuted distal femur fractures.

INTRODUCTION: Distal femoral replacement (DFR) and open reduction and internal fixation (ORIF) are surgical options for comminuted distal femur fractures. Comparative outcomes of these techniques are limited. The aims of this study were to compare implant survivorship, perioperative factors, and clinical outcomes of DFR vs. ORIF for comminuted distal femur fractures. METHODS: Ten patients treated with rotating hinge DFRs for AO/OTA 33-C fractures from 2005 to 2015 were identified and matched 1:2 based on age and sex to 20 ORIF patients. Patients treated with DFR and ORIF had similar ages (80 vs. 76 years, p = 0.2) and follow-up (20 vs. 27 months, p = 1.0), respectively. Implant survivorship, length of stay (LOS), anesthetic time, estimated blood loss (EBL), ambulatory status, knee range of motion (ROM), and Knee Society scores (KSS) were assessed at final follow-up. RESULTS: Survivorship free from any revision at 2 years was 90% and 65% for the DFR and ORIF groups, respectively (p = 0.59). Survivorship free from any reoperation at 2 years was 90% for the DFR group and 50% for the ORIF group (p = 0.16). Three ORIF patients (15%) went on to nonunion and two went on to delayed union. Mean EBL and LOS were significantly higher for the DFR group: 592 mL vs. 364 mL, and 13 vs. 6.5 days, respectively. Knee ROM (p = 0.71) and KSSs (p = 0.36) were similar between groups. CONCLUSIONS: Comminuted distal femur fractures treated with DFR trended toward lower revision and reoperation rates, with similar functional outcomes when compared to ORIF. We noted a trend toward increased EBL and LOS in the DFR group. LEVEL OF EVIDENCE: Level IV.

Use of tranexamic acid is not associated with complications following bipolar hemiarthroplasty for metastatic disease.

INTRODUCTION: Advances in the care of cancer patients have resulted in increased survival. The proximal femur is a common site for metastatic disease, often requiring surgical intervention. Tranexamic acid (TXA) has proven to be safe in elective and traumatic femoral hemiarthroplasty; however, its use has not been investigated in oncologic patients. METHOD: We reviewed 66 patients (37 males) with a mean age of 64 ± 3 years undergoing a hemiarthroplasty for metastatic disease in the femoral neck. A total of 22 (33%) patients received intraoperative TXA. Primary outcomes included postoperative blood loss, intraoperative and postoperative transfusion requirement, and postoperative complications. RESULTS: There was no difference in the baseline characteristics between the TXA and non-TXA groups. When comparing the TXA and non-TXA groups, there were no differences in 72 h postoperative blood loss between groups (1.21 L vs. 1.33 L, p = 0.61), percentage of patients requiring transfusion (36.4% vs. 36.4%, p = 1.0), or the incidence of postoperative complications including venous thromboembolism (14% vs. 11%, p = 0.70) and pulmonary embolism (0% vs. 5%, p = 1.0). CONCLUSION: Oncology patients are a high-risk population for thromboembolic events. This initial study supports the safe use of TXA intraoperatively in femoral hemiarthroplasty performed for metastatic disease.

Outcomes of Vancouver C Periprosthetic Femur Fractures.

BACKGROUND: Periprosthetic femur fractures (PFFs) that occur distal to a total hip arthroplasty, Vancouver C fractures, are challenging to treat. We aimed to report patient mortality, reoperations, and complications following Vancouver C PFFs in a contemporary cohort all treated with a laterally based locking plate. METHODS: We retrospectively identified 42 consecutive Vancouver C PFFs between 2004 and 2018. There was a high prevalence of comorbidities, including 9 patients with neurologic conditions, 9 with a history of cancer, 8 diabetics, and 8 using chronic anticoagulation. Mean time from total hip arthroplasty to PFF was 6 years (range 1 month to 25 years). All fractures were treated with a laterally based locking plate. Fixation bypassed the femoral component in 98% of cases and extended as proximal as the lesser trochanter in 18%. Kaplan-Meier survival was used for patient mortality, and a competing risk model was used to analyze survivorship free of reoperation and nonunion. Mean follow-up was 2 years. RESULTS: Patient mortality was 5% at 90 days and 31% at 2 years. Cumulative incidence of reoperation was 13% at 2 years. There were 5 reoperations including revision osteosynthesis for nonunion and/or hardware failure (2), debridement and hardware removal for infection (2), and removal of hardware and total knee arthroplasty for post-traumatic arthritis (1). Cumulative incidence of nonunion was 10% at 2 years. CONCLUSION: Patients who sustained a Vancouver C PFFs had a high mortality rate (31%) at 2 years. Moreover, 13% of patients required a reoperation within 2 years, most commonly for infection or nonunion.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate.

BACKGROUND: Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology. METHODS: Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years. RESULTS: There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation. CONCLUSIONS: ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

Total Knee Arthroplasty After Intramedullary Tibial Nail: A Matched Cohort Study.

BACKGROUND: As the use of intramedullary nails (IMNs) has become more common, there are an increasing number of patients requiring total knee arthroplasty (TKA) who have an indwelling tibial IMN. The purpose of this study is to compare implant survivorship, clinical outcomes, and complications in patients undergoing primary TKA with a history of tibial IMN to those without. METHODS: We retrospectively identified 24 TKAs performed between 2000 and 2017 after ipsilateral tibial IMN. Patients were matched 1:2 to patients undergoing primary TKA without history of tibial IMN based upon age, gender, body mass index, and year of surgery. Mean follow-up was 7 years. RESULTS: The 10-year survivorship free of any revision was 100% for the tibial IMN cohort, and 96% for the control cohort, while the 10-year survivorship free of any reoperation was 91% and 89%, respectively (P = .72). Patients with a history of tibial IMN had similar Knee Society Scores to matched controls at 2 years (P = .77) and 5 years (P = .09). Acquired idiopathic stiffness trended toward being more common (17% vs 6%, P = .21) and operative time trended toward being longer (135 vs 118 min, P = .07) when the tibial IMN was removed, but there was no overall difference in complication rate between cohorts. CONCLUSIONS: To our knowledge, this is the first report of primary TKA in patients with a history of ipsilateral tibial IMN. Compared to a matched cohort of patients without tibial IMN, these patients have similar outcomes in regards to implant survivorship, clinical outcomes, and risk of complications. LEVEL OF EVIDENCE: Therapeutic Level III.

Outcomes of knee arthroplasty for primary treatment of pathologic peri-articular fractures of the distal femur and proximal tibia.

BACKGROUND: Treatment goals for pathologic fractures about the knee include pain relief and unrestricted weight bearing. In cases of condylar destruction, these fractures may not be amenable to internal fixation, and arthroplasty may be considered. The purpose of this study was to analyze the outcomes of knee arthroplasty for primary treatment of impending or pathologic fractures of the distal femur or proximal tibia. METHODS: Fifteen (8 males and 7 females) patients, mean age 62 ± nine years, undergoing arthroplasty for management of a pathologic peri-articular distal femur (n = 11) or proximal tibia (n = 4) fracture between 2001 and 2017 were reviewed. Implants included tumour endoprostheses (n = 11) and rotating hinged total knees (n = 4). Pathology included metastatic disease (n = 14) and lymphoma (n = 1). Eight (53%) patients presented with a fracture while the remainder had large impending lesions. RESULTS: Mean follow-up was 19 months. At final follow-up, 11 patients had died with overall five year survival of 33%. Two (13%) patients required re-operation; including wound irrigation and debridement (n = 1) and above knee amputation for local recurrence (n = 1). An additional two (13%) patients developed post-operative VTE. MSTS, KSS, and KSS-F scores improved from a mean 12 ± 16%, 30 ± 11, and 14 ± 24 pre-operatively to 69 ± 26%, 75 ± 16, and 67 ± 25 at final follow-up, respectively (P < 0.001). Thirteen (87%) patients had severe pain prior to surgery with no patients (0%, P < 0.001) reporting severe pain at last follow-up. CONCLUSION: Knee arthroplasty provided improved function and full weight-bearing making it an effective treatment for pathologic periarticular fractures of the distal femur and proximal tibia.

Sequential fluoroscopic rollover images reliably identify "in-out-in" posterosuperior screws during percutaneous fixation of femoral neck fractures.

INTRODUCTION: Percutaneous screws placed into the posterosuperior femoral neck are frequently extraosseous or "in-out-in" (IOI). These IOI screws are not readily identifiable on anteroposterior (AP) and lateral fluoroscopic images. The purpose of this study was to examine the ability of surgeons to identify IOI guide pins using sequential fluoroscopic rollover images. MATERIALS AND METHODS: A 3.2-mm guide pin was placed into the posterosuperior quadrant of eleven synthetic femur models. Five samples were "all-in" (AI), and six were IOI. Sequential fluoroscopic rollover images were obtained starting with an AP image, then images at 10-degree rollover intervals ending with a direct lateral image. Images were reviewed in a blinded fashion by five attending orthopedic trauma surgeons and 20 resident surgeons to determine whether guide pins were AI or IOI. Accuracy, interobserver reliability, sensitivity, and specificity were assessed. RESULTS: The overall accuracy of responses was 86% with no difference between attending trauma surgeons and residents (p = 0.5). The sensitivity and specificity for an IOI guide pin were 98.0% and 71.2%, respectively. Interobserver reliability among surgeons was good (κ = 0.703). CONCLUSION: The use of the sequential fluoroscopic rollover images after placement of the posterosuperior guide pin into the femoral neck was highly sensitive for detecting an IOI position. The 40-degree rollover image was the best view to evaluate the proximity of the guide pin to the posterior cortex.

High incidence of "in-out-in" posterosuperior screws after cannulated screw fixation of femoral neck fractures.

INTRODUCTION: Cadaveric models have demonstrated a high incidence of extraosseous "in-out-in" (IOI) posterosuperior screws after cannulated screw fixation of femoral neck fractures. The purpose of this study was to determine the incidence of IOI screws in vivo and to evaluate their association with osteonecrosis and revision surgery. METHODS: A total of 104 patients with 107 hips with a pelvis computed tomography (CT) scan after cannulated screw fixation of a femoral neck fractures were included. Screw position was evaluated on postoperative radiographs and CT scan to determine if screws were IOI or all-in. Osteonecrosis and revision surgeries were documented. RESULTS: IOI posterosuperior screws were identified on CT scan in 58 (54%) hips. On postoperative AP and lateral radiographs, IOI screws were a median (interquartile range) of 10 mm (7-11 mm) and 3 mm (0-4 mm) from the cortex, respectively. The sensitivity and specificity of radiographs to detect IOI screws was 39% and 92%, respectively. The incidence of osteonecrosis and revision surgeries in hips, with and without IOI screws, was 6% versus 6% [Odds ratio (OR) 1.1, 95% confidence interval (CI) 0.2-5.3] and 10% versus 10% (OR 1.0, CI 0.3-3.1), respectively; a true clinical difference cannot be excluded due to the width of the confidence intervals. CONCLUSIONS: There was a high incidence of IOI posterosuperior screws on CT scans. Postoperative radiographs had a poor sensitivity for detecting IOI screws. A larger sample size is necessary to evaluate the association of IOI screws with osteonecrosis and revision surgery. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Outcomes of Endoprosthetic Replacement for Salvage of Failed Fixation of Malignant Pathologic Proximal Femur Fractures.

BACKGROUND: Internal fixation is often used to treat pathologic proximal femur fractures. However, nonunion and/or tumor progression may lead to hardware failure. In such cases, endoprosthetic replacement may be considered. The purpose of this study is to analyze the outcome of patients undergoing conversion to an endoprosthetic replacement following failed fixation of a pathological proximal femur fracture. METHODS: We identified 26 patients who underwent conversion hip arthroplasty for salvage of failed fixation of a pathologic proximal femur fracture between 2000 and 2016. Previous surgical hardware included femoral nail (n = 18), dynamic hip screw (n = 5), proximal femoral locking plate (n = 1), blade plate (n = 1), and cannulated screws (n = 1). Twenty-one patients had metastatic disease, 4 myeloma, and 1 lymphoma. All received adjuvant or neoadjuvant radiotherapy at a mean dose of 30 Gy. RESULTS: There were 15 males and 11 females with mean age 63 ± 11 years. Patients underwent conversion arthroplasty at a mean of 13 ± 12 months after initial fixation. At final follow-up, 19 patients had died, with 5-year overall survival of 35%. Conversion to arthroplasty was performed due to disease progression (n = 12), hardware failure (n = 8), and nonunion (n = 6). Eight hips required reoperation, most commonly for infection (n = 4). At last follow-up, the Harris Hip Scores (P < .001) and Musculoskeletal Tumor Society Scores (P < .001) significantly improved from a mean of 24 and 14 preoperatively to 68 and 59 postoperatively, respectively. CONCLUSION: Conversion hip arthroplasty reliably provides improved quality of life and immediate weight bearing, making it an effective treatment for salvage of failed fixation of pathologic proximal femur fractures.

Excision of Physeal Bars of the Distal Femur, Proximal and Distal Tibia Followed to Maturity.

OBJECTIVE: In the 50 years since a premature partial physeal arrest (a physeal bar) was first excised from an epiphysis there have been no large in-depth studies reporting the results in patients followed to skeletal maturity. This paper reports the results of physeal bar resection surgery in a group of patients followed to skeletal maturity, documenting the restored growth of the affected physis, the affected bone, and the final limb-length discrepancy. METHODS: Forty-eight patients underwent physeal bar resection of the distal femur (21), proximal tibia (9), and distal tibia (18) by 1 surgeon (H.A.P.) from 1968 through 1996, and were followed prospectively to skeletal maturity with clinical and radiologic examinations. Factors such as sex, age at time of injury, etiology of the bar, physeal bar location and size, age at time of bar excision, interposition material, and additional surgical procedures were analyzed with respect to physis, bone, and limb growth following bar resection. RESULTS: The mean growth for the entire bone following physeal bar excision was 7.6 cm for the distal femur, 4.7 cm for the proximal tibia, and 7.5 cm for the distal tibia, compared with growth in the contralateral control bone of 6.8 cm in the femur, 5.0 cm in the proximal tibia, and 7.8 cm in the distal tibia. The maximum bone growth following bar excision in a single patient was 21.3 cm for the distal femur, 10.3 cm for the proximal tibia, and 18.6 cm for the distal tibia. The mean limb-length discrepancy at maturity was -1.7 cm for the distal femur, -1.3 cm for the proximal tibia, and -1.1 cm for the distal tibia (all sites combined -1.4 cm). Fourteen patients (29%) had only the 1 bar excision with no other accompanying or subsequent surgery. Thirty-four patients (71%) had 1 to 4 accompanying or subsequent leg length or angular correcting procedures. CONCLUSIONS: Physeal bar excision to restore growth when applied to the appropriate patient is a useful, rewarding procedure, reducing the number of surgical limb length equalizing procedures. It is a demanding surgical procedure and requires diligent and careful follow-up until maturity. Additional limb length equalizing surgery is frequently needed. LEVEL OF EVIDENCE: Case series, level IV.

Total Hip Arthroplasty After In Situ Fixation of Minimally Displaced Femoral Neck Fractures in Elderly Patients.

BACKGROUND: In situ screw fixation remains the most common treatment for minimally displaced femoral neck fractures (FNFs). Total hip arthroplasty (THA) can be used as a salvage procedure, but the results of conversion THA in this population have not been evaluated. The goals of this study were to evaluate (1) unique complications associated with conversion THA, (2) implant survivorship free of revision and reoperation, (3) radiographic results, and (4) clinical outcomes in patients undergoing conversion THA after in situ fixation of nondisplaced FNFs. METHODS: Between 2000 and 2014, 62 consecutive patients >65 years of age who underwent THA after in situ fixation of minimally displaced FNFs were identified. Indications were osteonecrosis (44%), post-traumatic/degenerative arthritis (35%), and nonunion (21%). Mean age was 78 years, and 73% patients were women. Mean follow-up was 5.5 years. RESULTS: One patient was revised for aseptic femoral loosening at 11 years. One patient underwent debridement and modular component exchange at 10 years for acute hematogenous periprosthetic joint infection. Two patients underwent acute reoperation without component exchange (one superficial wound infection, one hematoma evacuation). Survivorship free of reoperation for any indication was 97% at 5 years. No patients with surviving implants had radiographic evidence of loosening at 5 years. Harris hip scores improved from 35-85 (P < .01) after THA. CONCLUSION: Conversion THA was associated with clinical improvement, a low rate of complications, and excellent implant durability. Risks of loosening, dislocation, and periprosthetic fracture can be minimized with appropriate operative strategies and perioperative management.

Risk Factors for Subsidence of Modular Fluted Tapered Stems Used During Revision Total Hip Arthroplasty for Periprosthetic Hip Fractures.

BACKGROUND: The objective of this study was to review Vancouver B2 and B3 periprosthetic hip fractures treated with uncemented modular fluted tapered stems to analyze survivorship, risk factors for stem subsidence, and clinical outcomes. METHODS: We identified 61 Vancouver B2 and B3 periprosthetic hip fractures treated with modular fluted tapered implants. Survivorship, radiographic outcomes, and clinical outcomes were assessed. The mean age at the time of surgery was 72 years, mean body mass index was 30, and mean follow-up was 4.5 years (range, 2-10 years). RESULTS: Survivorship free of reoperation or implant revision at 5 years was 89% and 93%, respectively. Eight (13%) stems subsided a mean distance of 18 ± 8 mm (range, 8-28 mm). Stem subsidence was not correlated with age, gender, Vancouver fracture classification, stem bypass, stem length, or stem diameter. Subsidence was correlated with Dorr C type femora (50% vs 7%, 95% confidence interval 9%-72%; P = .007) and strut grafting (50% vs 9%, 95% confidence interval 6%-70%; P = .01). All cases of subsidence stabilized without revision. Subsidence was not correlated with nonunion, reoperation, revision, or a clinical outcome. CONCLUSIONS: Modular fluted tapered stems had excellent survivorship free of reoperation and implant revision when used for the treatment of Vancouver B2 and B3 periprosthetic femur fractures. Poor bone morphology and the use of strut grafts, both proxies for compromised bone stock and distal fracture patterns, were correlated with stem subsidence. All subsided stems stabilized, and noted subsidence did not portend a worse clinical outcome. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Hip Arthroplasty After Surgical Treatment of Intertrochanteric Hip Fractures.

BACKGROUND: Although use of intramedullary hip screws (IMHS) for intertrochanteric (IT) hip fractures has become more common, limited data have suggested difficulties in conversion to hip arthroplasty. The present study investigates whether conversion of failed IT fracture fixation with an intramedullary vs extramedullary device leads to different rates or types of complications or decreased arthroplasty survivorship. METHODS: One hundred eleven patients were converted to hip arthroplasty after previous surgical treatment of an IT fracture from 2000 to 2010. Seventy hips had been treated with an extramedullary fixation device (EFD) and 41 with an IMHS. RESULTS: Length of hospital stay and operative times were similar (6 days and 206 minutes for EFD vs 6 days and 208 minutes for IMHS; P > .7). The presence of a Trendelenburg gait at last clinical follow-up was similar between groups (37% in EFD group and 38% in IMHS group). Five-year survivorship free of revision was 95% in the EFD group and 94% in the IMHS group (P = 1.0). The overall complication rate was similar (21% for EFD vs 27% for IMHS; P = .51) between groups. The most common complication was late periprosthetic fracture in the EFD patients (6% vs 0% in IMHS; P = .29) and intraoperative femoral fracture in the IMHS patients (12% vs 1% in EFD; P = .02). CONCLUSION: The short-term survivorship of conversion hip arthroplasty after surgical treatment of an IT fracture is excellent regardless of original fracture fixation method. If early complications, particularly periprosthetic fractures, can be minimized, the likelihood of a successful outcome is high. The risk of intraoperative femoral fracture was greater during conversion from an IMHS compared to an EFD.

Porous metal acetabular components have a low rate of mechanical failure in THA after operatively treated acetabular fracture.

BACKGROUND: Total hip arthroplasty (THA) for the treatment of posttraumatic osteoarthritis (OA) after acetabular fracture has been associated with a high likelihood of aseptic loosening, instability, and infection. Porous metal components may help to address the issue of loosening, but there are few data on the use of porous metal acetabular components for posttraumatic OA after acetabular fracture. QUESTIONS/PURPOSES: Using an institutional registry, we aimed to report (1) radiographic evidence of fixation; (2) survivorship free from revision; (3) Harris hip scores; and (4) complications and reoperations after THA with a porous metal acetabular component for posttraumatic OA in patients previously treated with open reduction and internal fixation (ORIF) of a displaced acetabular fracture. METHODS: Thirty primary THAs were performed with a porous metal acetabular component for the treatment of posttraumatic OA after ORIF of an acetabular fracture from 1999 through 2010; of these, 28 (93%) were available for followup at a minimum of 2 years. During that same time, 51 primary THAs were performed using other acetabular designs in patients who had previously undergone ORIF of the acetabulum. During the period in question, the general indications for use of porous metal in this setting included compromised acetabular bone stock or quality to the extent that the treating surgeon believed primary fixation with a titanium shell and screws may have been difficult to achieve. Mean age at the time of arthroplasty was 45 years (range, 23-75 years). Median time from ORIF to THA and from THA to last followup was 107 months (range, 4 months to 42 years) and 60 months (range, 25 months to 10 years), respectively. Radiographs were reviewed for this specific study to evaluate the components for evidence of osteointegration. Survivorship free from revision, hip scores, and complications were extracted from our institutional database and electronic medical record. RESULTS: No acetabular or femoral components were revised for aseptic loosening. Five-year survival with revision for any reason as the endpoint was 88% (95% confidence interval, 0.70-0.96). Harris hip scores improved from a median of 39 preoperatively (range, 3-87) to 82 at last followup (range, 21-100; p<0.01). Three hips (11%) underwent resection for infection and all three had been treated with staged arthroplasty for concern of infection. Two patients (7%) experienced at least one dislocation postoperatively. CONCLUSIONS: The short-term results of the use of porous metal acetabular components in THA for treatment of posttraumatic OA after acetabular fracture demonstrate low rates of mechanical failure. Although infection and instability remain major concerns in patients with this diagnosis seemingly regardless of the implant design used, porous metal components appear to offer a high likelihood of osseointegration in this clinical setting. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.