Low reoperation rate after fixation of displaced femoral neck fractures with the femoral neck system (FNS).

PURPOSE: Operative fixation of femoral neck fractures (FNFs) remains challenging. Complications are not infrequent, especially in displaced patterns. Numerous fixation techniques have been previously described in the literature; however, there remains a paucity of data regarding outcomes of these injuries treated with the femoral neck system (FNS). METHODS: Patients with a displaced FNF (OTA/AO 31B) treated with the FNS at a single level 1 academic trauma center between 1/1/2019 and 1/1/2023 were identified. Radiographs were reviewed to assess fracture displacement, location, and characteristics. Patient records were further reviewed to assess for complications, reoperations, and osseous union. RESULTS: Forty-three patients (65% male) with 44 FNFs were identified with a mean age of 35.0 years (range, 13-61 years). Two patients developed a deep infection requiring surgical debridement, four patients underwent a total hip arthroplasty, and one patient underwent a valgus intertrochanteric osteotomy for nonunion. There were three cases of femoral head AVN. Mean follow-up was 482.5 days among all patients, and 36 fractures had at least 6 months of follow-up or reached bony union. CONCLUSIONS: Here, we present a series of patients treated with the FNS for internal fixation and report a 18% reoperation rate. This is lower than the average rate that has been previously reported in similar patient populations in the literature treated with alternative methods of internal fixation. Thus, the FNS appears to be a safe and effective option for treatment of these injuries.

Multidimensional Fluoroscopy to Assess Closed Reduction in Displaced Young Femoral Neck Fractures: A Report of 3 Cases.

CASE: The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts. CONCLUSION: Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.

Open Reduction and Internal Fixation of Pediatric Scapula Fractures: A Report of 2 Cases.

CASE: Two pediatric patients with displaced, extra-articular scapula fractures who underwent surgery because of concerns for persistent deformity and decreased function with continued nonoperative management. CONCLUSION: We advocate careful consideration of all patient factors and treatment options when addressing pediatric scapula fractures. Specific fracture patterns with altered shoulder girdle mechanics may warrant surgical intervention to restore anatomic alignment and stability.

The injury characteristics of open pilon fractures predictive of complications.

OBJECTIVE: Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C). DESIGN: Retrospective Case Series. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria. INTERVENTION: The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required. MAIN OUTCOME MEASUREMENTS: Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications. RESULTS: Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication. CONCLUSIONS: Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment. LEVEL OF EVIDENCE: Level III.

Is retrograde nailing superior to lateral locked plating for complete articular distal femur fractures?

INTRODUCTION: Nonunion rates for distal femur fractures treated with lateral locked plating (LLP) remains as high as 18-22% despite significant advances with implant design and construct modulation. However, whether treatment of distal femur fractures with rIMN has improved outcomes compared to LLP has not been well characterized. The purpose of this study was to compare outcomes of complete articular distal femur fractures (AO/OTA 33-C) treated with either LLP or rIMN. METHODS: 106 distal femur fractures in 106 patients between January 2014 and January 2018 were identified. Medical records were reviewed to collect patient age, gender, body mass index, sagittal and coronal plane alignment on immediate postoperative radiographs, time to union, incidence of nonunion, and incidence of secondary operative procedures for repair of a nonunion. RESULTS: Of 106 patients, 50 underwent rIMN and 56 underwent LLP. The mean age at the time of injury was 51 years (21 to 86 years) and there were 55 males. Average coronal alignment of 83.7° of anatomic lateral distal femoral angle (aLDFA) and sagittal alignment of <1° of apex anterior angulation in the rIMN group. In the LLP group there was an average of 87.9° of aLDFA and 1.9° of apex anterior angulation (p = .005 and p = .36). Average time to union in the rIMN group was 6 months and 6.6 months in the LLP group (p = .52). Incidence of nonunion in the rIMN group was 11.8% and 27.5% in the LLP group (p = .008). There were 8 secondary procedures for nonunion in the rIMN group and 18 in the LLP group (p = .43). CONCLUSIONS: Our results demonstrated a higher nonunion rate and coronal plane malalignment with LLP compared to rIMN. While prospective data is required, rIMN does appear to be an appropriate treatment for complete articular distal femur fractures with a potentially decreased rate of nonunion .

Implementation of a novel MRI protocol for diagnosing femoral neck fractures in high energy femoral shaft fractures: One year results.

INTRODUCTION: Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation. METHODS: Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria. RESULTS: From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized. DISCUSSION/CONCLUSION: The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.

Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures.

➤: Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation. ➤: In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF). ➤: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty. ➤: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.

Improving the Diagnosis of Ipsilateral Femoral Neck and Shaft Fractures: A New Imaging Protocol.

BACKGROUND: Despite increased awareness of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures and advanced imaging with thin-cut high-resolution computed tomography (CT), failure of diagnosis remains problematic. The purpose of the present study was to determine if the preoperative diagnosis of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with magnetic resonance imaging (MRI) compared with radiographic and CT imaging. METHODS: In response to delayed diagnoses of femoral neck fractures despite thin-cut high-resolution CT, our institutional imaging protocol for acute, high-energy femoral shaft fractures was altered to include rapid limited-sequence MRI to evaluate for occult femoral neck fractures. All patients received standard radiographic imaging as well as thin-cut high-resolution pelvic CT imaging upon presentation. Rapid limited-sequence MRI of the pelvis was obtained to evaluate for an occult femoral neck fracture. RESULTS: Thirty-seven consecutive patients with 39 acute, high-energy femoral shaft fractures resulting from blunt trauma were included. The average age of the patients was 29.1 years (range, 14 to 82 years). Ten (25.6%) of the 39 femoral shaft fractures were open. Two femoral shaft fractures (5.1%) were associated with ipsilateral femoral neck fractures that were detected on radiographs, and no MRI was performed. None of the remaining 37 femoral shaft fractures were associated with a femoral neck fracture that was identified on CT imaging. Thirty-three (89.2%) of 37 patients underwent pelvic MRI to evaluate the ipsilateral femoral neck. Four (12.1%) of those 33 patients were diagnosed with a femoral neck fracture (2 complete, 2 incomplete) that was not identified on thin-cut high-resolution CT or radiographic imaging. CONCLUSIONS: Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. Our results suggest that the frequency of femoral neck fractures may be underrepresented on CT imaging; rapid limited-sequence MRI was feasible without delaying definitive treatment even in polytraumatized patients. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Subscapularis Peel for Open Reduction and Internal Fixation of Proximal Humerus Fractures With a Head Split.

Proximal humerus fractures involving an articular head split are rare and complex injuries. In the elderly population, arthroplasty is the optimal treatment, whereas in younger patients, the utility of arthroplasty procedures is limited by concerns of long-term implant survival. As a result, open reduction and internal fixation is still often the first-line treatment option for head-splitting injuries. The traditionally described deltopectoral or anterolateral surgical approaches to the proximal humerus rely on indirect reduction and limited visualization of the articular fragments. We present a case series of younger patients with head-split proximal humerus fractures treated with open reduction and internal fixation through a deltopectoral approach with a subscapularis peel to improve humeral head visualization, reduction, and fixation. The improved reduction may lead to better long-term outcomes and reduce the need for additional surgical procedures. In addition, there were no cases of avascular necrosis in this series.

Scapulothoracic Dissociation: Evaluation and Management.

Scapulothoracic dissociation is a rare, potentially limb- and life-threatening injury of the shoulder girdle. The injury is characterized by lateral displacement of the scapula resulting from traumatic disruption of the scapulothoracic articulation. The typical physical examination findings consist of substantial swelling of the shoulder girdle, along with weakness, numbness, and pulselessness in the ipsilateral upper extremity. Radiographic evaluation includes measurement of the scapular index on a nonrotated chest radiograph and assessment for either a distracted clavicle fracture or a disrupted acromioclavicular or sternoclavicular joint. Although vascular injury occurs in most patients, emergent surgery is performed only in patients with either limb-threatening ischemia or active arterial hemorrhage. Management of neurologic injury can be delayed if necessary. The location and severity of neurologic injury determine whether observation, nerve grafting, nerve transfer, or above-elbow amputation is performed. Skeletal stabilization procedures include plate fixation of clavicle fractures and reduction of distracted acromioclavicular or sternoclavicular joints. The extent of neurologic injury determines clinical outcomes. Medical Outcomes Study 36-Item Short Form scores are significantly lower in patients with complete brachial plexus avulsion injury than in patients with postganglionic injury.

Symptomatic Implant Removal Following Dual Mini-Fragment Plating for Clavicular Shaft Fractures.

OBJECTIVES: To determine the proportion of patients requiring secondary surgery for symptomatic implant removal after open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures. DESIGN: Retrospective observational study. SETTING: Single university Level 1 trauma center. PATIENTS: Eighty-one patients treated with open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures (OTA/AO 15-B1, B2, and B3) with minimum 12-month follow-up (median 477 days; range 371-1549 days). INTERVENTION: Open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures. MAIN OUTCOME MEASUREMENTS: Incidence of secondary surgery, QuickDASH (Disabilities of the Arm, Shoulder, and Hand) scores. RESULTS: Six of 81 patients (7.4%) underwent secondary surgery for implant removal for any reason. Of these, 3 (3.7%) underwent symptomatic implant (soft-tissue irritation) removal, 2 (2.5%) required implant removal in the setting of infection, and 1 patient (1.2%) required revision open reduction internal fixation for early implant failure. The mean QuickDASH score in this series was 8.44 (±6.94, range 0-77.27). The associated implant cost of the typical construct utilized in this series was $1511.38. The mean surgical time was 97 minutes (range 71-143 minutes). CONCLUSIONS: The utilization of a dual mini-fragment plating technique in the treatment of clavicular shaft fractures results in a low rates of secondary surgery for symptomatic implant removal (3.7%) and similar QuickDASH scores when compared with historical controls treated with 3.5-mm plates placed on the superior clavicle. Potential disadvantages in using this technique include a higher surgical implant cost and length of surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Mechanical Failures of the Synthes Variable Angle Locking Distal Femur Plate.

OBJECTIVES: To document the high failure rate of a specific implant: the Synthes Variable Angle (VA) Locking Distal Femur Plate. DESIGN: Retrospective. SETTING: Urban University Level I Trauma Center. PATIENT/PARTICIPANTS: All distal femur fractures (OTA/AO 33-A, B, C) treated from March 2011 through August 2013 were reviewed from our institutional orthopaedic trauma registry. Inclusion criteria were fractures treated with a precontoured distal femoral locking plate and age between 18 and 84. Exclusion criteria were fractures treated with intramedullary nails, arthroplasty, non-precontoured plates, dual plating, or screw fixation alone. The population was divided into 3 groups: less invasive stabilization system (LISS) group (n = 21), treated with LISS plates (Synthes, Paoli, PA); locking condylar plates (LCPs) group (n = 10), treated with LCPs (Synthes, Paoli, PA); and VA group (n = 36), treated with VA distal femoral LCPs (Synthes, Paoli, PA). Average age was 54.6 ± 17.5 years. INTERVENTION: Open reduction internal fixation with one of the above implants was performed. MAIN OUTCOME MEASURES: The patients were followed radiographically for early mechanical implant failure defined as loosening of locking screws, loss of fixation, plate bending, or implant failure. RESULTS: There were no statistically significant differences between groups for age, gender, open fracture, mechanism of injury, or medial comminution. There were 3 failures (14.3%) in group LISS, no failures (0%) in group LCP, and 8 failures (22.2%) in group VA. All 3 failures in group LISS were in A-type fractures (2 periprosthetic) and all failures in group VA were in C-type fractures. When all fractures for all 3 groups were compared for failure rate, there was no statistically significant difference (P = 0.23). However, when only 33-C fractures were compared, there was significantly greater failure rate in the VA group (P = 0.03). The mean time to failure in group VA was 147 days (range 24-401 days) and was significantly earlier (P = 0.034) when compared with group LISS (mean 356 days; range 251-433 days). CONCLUSIONS: Early mechanical failure with the VA distal femoral locking plate is higher than traditional locking plates (LCP and LISS) for OTA/AO 33-C fractures. We caution practicing surgeons against the use of this plate for metaphyseal fragmented distal femur fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

BACKGROUND: Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. QUESTIONS/PURPOSES: (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? METHODS: After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. RESULTS: Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). CONCLUSIONS: Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. LEVEL OF EVIDENCE: Level III, therapeutic study.