Periprosthetic Supracondylar Femoral Fractures Above a Total Knee Replacement: An Updated Compatibility and Technique Guide for Fixation With a Retrograde Intramedullary Nail.

BACKGROUND: Multiple studies have described retrograde nailing as a treatment of periprosthetic supracondylar femoral fractures (OTA/AO type 33A-C) above total knee replacements (TKRs). It is often difficult to discern which TKRs will be compatible with intramedullary nailing because the femoral component design and intercondylar distance is highly variable among total knee designs. The goal of our study is 3-fold: (1) Review and update previous work of intercondylar distances of all currently available prostheses in the United States. (2) Review retrograde nails currently on the market and associated driving end to nail shaft diameter mismatch and opening reamer sizing. (3) Review technical tricks for executing a retrograde femoral nail for the treatment of periprosthetic supracondylar femur fractures. METHODS: Data for the intercondylar distance of the femoral components, diameter of retrograde nails and reamers, and notch compatibility were gathered. RESULTS: The results were compiled and recorded. A "technical tricks" section was included that highlights reduction and fixation techniques. CONCLUSIONS: This update further empowers surgeons to use all the tools available when treating periprosthetic femur fractures and allows efficient identification of the compatibility of different TKR designs with various intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures?

BACKGROUND: Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. METHODS: A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. RESULTS: Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). CONCLUSION: The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. LEVEL OF EVIDENCE: Therapeutic level III.

Results of anterior-inferior 2.7-mm dynamic compression plate fixation of midshaft clavicular fractures.

OBJECTIVES: To evaluate the outcome of operatively treated unstable displaced diaphyseal clavicle fractures with anterior-inferior 2.7-mm dynamic compression plate (DCP) fixation. DESIGN: Retrospective review of clavicle fractures. SETTING: Level-1 trauma teaching center. PATIENTS/PARTICIPANTS: One hundred twenty-nine clavicle fractures. INTERVENTION: An anterior-inferior approach to clavicle fractures was used with the application of a 2.7-mm DCPs. MAIN OUTCOME MEASUREMENT: Radiographic assessment of healing and complication rates. RESULTS: One hundred twenty-five fractures healed (97%). Postoperative complications included 1 superficial wound problem, 3 deep wound problems, 5 nonunions, and 4 prominent implants requiring removal in 3. CONCLUSIONS: Anterior-inferior placement of 2.7-mm DCPs seems safe and is associated with minimal complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures.

OBJECTIVES: To describe the technique and to determine the outcome of operatively treated displaced scapular body or glenoid neck fractures using minifragment fixation through a modified Judet approach. DESIGN: Retrospective review of scapular or glenoid fractures. SETTING: Level 1 teaching trauma center. PATIENTS: All treated scapular or glenoid fractures over 7 years (1999-2005) were determined. Of a total of 227 scapular or glenoid fractures, 37 were treated with open reduction internal fixation and formed the basis of study. All patients were followed for a minimum of 1 year until healing or discharge from care. INTERVENTIONS: All operatively treated scapular fractures were performed in the lateral position on a radiolucent table. A modified Judet approach was used in all patients. The posterior deltoid was incised off the scapular spine cephalad reaching the lateral scapular border. The interval between the teres minor and infraspinatus was paramount for fracture reduction and implant insertion. The 2.7-mm minifragment plates were applied along the lateral border of the scapula. MAIN OUTCOME MEASUREMENT: Radiographic assessment of fracture healing and clinical assessment of shoulder function. RESULTS: The majority of patients were males (31 males, 6 females) who sustained blunt trauma. All scapular fractures maintained fixation and reduction. No wound or muscle dehiscence problems were noted. Average range of motion was 158 degrees (range 90-180 degrees). There were no fixation failures or instances of implant loosening. CONCLUSIONS: The modified Judet approach allows for excellent scapular and glenoid fracture visualization and reduction while preserving rotator cuff function. Minifragment fixation along the lateral scapular border provides excellent plate position, screw length, and fracture stability.

Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity.

BACKGROUND: Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. METHODS: Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. RESULTS: The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. CONCLUSIONS: This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.