Comparative Analysis of Supplemental Medial Buttress Plate Fixation for High-Energy Displaced Femoral Neck Fractures in Young Adults.

OBJECTIVES: To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures. DESIGN: Multicenter retrospective matched cohort comparative clinical study. SETTING: Twenty-seven North American Level 1 trauma centers. PATIENTS: Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture. INTERVENTION: Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP. MAIN OUTCOME MEASUREMENTS: Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty. RESULTS: Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001). CONCLUSIONS: The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning . LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of Technical Errors on the Outcomes of Operatively Managed Femoral Neck Fractures in Adults Less than 50 Years of Age.

OBJECTIVE: To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults. DESIGN: Multicenter retrospective clinical study. SETTING: 26 North American Level 1 Trauma Centers. PATIENTS: Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017. INTERVENTION: Operative repair of femoral neck fracture. MAIN OUTCOME MEASUREMENTS: The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis. RESULTS: Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001). CONCLUSIONS: TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

"Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications.

OBJECTIVES: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. DESIGN: Retrospective cohort study. SETTING: One Level 1 and One Level 2 academic trauma centers. PATIENTS/PARTICIPANTS: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. MAIN OUTCOME MEASUREMENT: Major and minor complications. RESULTS: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). CONCLUSION: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable." LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach.

OBJECTIVE: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). DESIGN: Retrospective. SETTING: Level 1 and level 2 academic centers. PATIENTS: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. METHODS: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1-3 mm step, 5-10 mm gap, and/or 5-15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation. RESULTS: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18-74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). CONCLUSIONS: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Considerations to Reduce Saphenous Neurovascular Bundle Injury During Suture Button Fixation of Syndesmosis Injuries.

OBJECTIVE: To document angles, from 2 difference starting points, or danger zones that should be avoided to minimize risk of injury or irritation to the saphenous neurovascular bundle (SNVB) during suture button (SB) fixation for distal tibiofibular syndesmosis injuries. DESIGN: Retrospective imaging study. SETTING: Academic Level 1 trauma center. PATIENTS: Forty-eight randomly selected patients with healthy ankles and computed tomography scans for nonankle diagnoses. MAIN OUTCOME MEASURES: Computed tomography scans and 3D reconstructed images were used to define the angle between the SNVB and 2 different fibular starting points, using the direct lateral (DL) and the posterolateral (PL) starting points. Descriptive analyses were performed to identify angles that should be avoided during suture button fixation. Distances from the SNVB using preset angles of 0, 10, 20, and 30 degrees were analyzed. In addition, the width of the SNVB, the midsubstance angle of the SNVB, and the distance from the 30-degree point to the tibialis anterior were recorded. RESULTS: The mean angle between the SNVB and the standard DL starting point was 13.7 ± 5.0 degrees (P < 0.05), whereas the mean angle using the alternate PL starting point was 17.2 ± 5.3 degrees (P < 0.05). The SNVB width was 5.2 mm [range, 2.6-9.1 mm] (P < 0.05). The distances from the SNVB were greatest for the DL 30-degree group and the PL 0-degree group. CONCLUSIONS: The results document angles that should be avoided when using suture button fixation for syndesmosis injuries. Device characteristics and surgery-related variables may require intraoperative modifications, and knowledge of this anatomical relationship may reduce SNVB injury during those situations. Considering our results, we recommend that surgeons place suture buttons from the DL starting point with a 30-degree trajectory to avoid injuries to the SNVB.