Fractures of the trochanteric region in children and young adolescents-a treatment algorithm for a rare injury.

For femoral fractures of the trochanteric region in children and adolescents, only two mechanisms have been identified to cause a fracture of the proximal femur: high-energy trauma or predisposing bone pathologies with inadequate trauma (e.g., simple fall, movement). We identified 20 patients between 1993 and 2018 with a trochanteric fracture under the age of 18 (12 males; 8 females; mean age, 12 years; range, 4-17 years) who were treated operatively at our department. The mean follow-up of all patients was 50.06 months. All 20 patients were treated operatively. Complications occurred after a mean time of 6.27 months (range, 0.47 to 12.07 months) in two patients. Harris Hip Score was evaluated in all patients with a mean score of 94.16 (range 11 to 100). Eighty-five percent of the patients reached an excellent clinical outcome after treatment. Trochanteric femoral fractures in children and adolescents are very rare accounting for only 1% of all trochanteric fractures. Excellent long-term results can be achieved with an adequate fracture reduction.Conclusion: Physicians treating pediatric trauma have to be aware of other predisponding diseases when low-energy trauma leads to a trochanteric fracture as in this study, 50% of the trochanteric fractures were associated with bone pathologies. What is Known: • Trochanteric femoral fractures in children and adolescents are very rare • In all patients with trochanteric femoral fractures, malignancies have to be ruled out What is New: • Awareness of an underlying bone pathology in a high number of cases • Awareness for necessity of a good fracture reduction leading to highly satisfactory results.

Management and outcome of interprosthetic femoral fractures.

INTRODUCTION: Interprosthetic femoral fractures following ipsilateral hip and knee arthroplasty are a rare but serious complication in clinical practice. In most cases, adequate management of these injuries might constitute a challenging problem. However, the literature provides only few data regarding the treatment and outcome of interprosthetic femoral fractures, and there are only few classifications available, which might assist in finding an appropriate treatment concept. The purpose of this study was to analyse our experience in the management of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. MATERIALS AND METHODS: We reviewed the clinical and radiographic records of 23 patients (15 female and eight male, average age: 79.2 years) with an interprosthetic fracture after ipsilateral hip and knee joint replacement between 1992 and 2008. For the classification of interprosthetic femoral fractures, the fractures were divided into three types, depending on the fracture site and the adjacency to the prostheses. All patients underwent operative stabilisation, either by lateral plate fixation (n=19), by revision arthroplasty using a long stem (n=2) or by plate fixation and revision arthroplasty (n=2). RESULTS: Referring to the clinical outcome, 16 patients returned to their pre-injury activity level and were satisfied with their clinical outcome. In six patients, we saw a relevant decrease of hip or knee function and severe limitations in gait and activities of daily living. We had a mean Harris Hip Score (HHS) of 78.4 points, and a mean Knee injury and Osteoarthritis Outcome Score (KOOS) of 71.8 points. Relating to the radiographic outcome, successful fracture healing was achieved in 19 of 22 patients (86%) within 6 months. Failures of reduction and fixation were noted in four (18%) of 22 patients. CONCLUSION: We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. Compared to the rare data in current literature, we had promising functional result and high rate of bony fusion. Regarding the complexity and challenges in many of these cases, interprosthetic fractures require an adequate analysis of the fracture aetiology and a suitable transfer into the best possible treatment concept.

Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study.

PURPOSE: To compare the efficacy of extended-duration thromboprophylaxis with enoxaparin for 20 days in the outpatient setting with in-hospital thromboprophylaxis with enoxaparin (3 to 8 days) only in patients who had undergone arthroscopic surgery of the anterior cruciate ligament (ACL). METHODS: This was a single-center, randomized, double-blind, prospective trial investigating 175 ACL surgery patients. All patients received subcutaneous enoxaparin 40 mg once daily 12 to 18 hours presurgery and 3 to 8 days postsurgery during hospitalization. After discharge, patients were randomized to 40 mg enoxaparin (n = 87) or placebo (n = 88) self-administered once daily subcutaneously for 20 days. The primary efficacy end-points were the incidences of symptomatic and asymptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE). Primary safety endpoints were the incidences of major and minor bleeding. RESULTS: Thirty-five patients were excluded because of noncompliance with the predefined protocol. No patient had DVT confirmed by magnetic resonance venography (MRV) at discharge. Of 140 patients in the intention-to-treat population, 2 (2.8%) who received postdischarge enoxaparin (n = 72) and 28 (41.2%) who received placebo (n = 68) had DVT confirmed by MRV (P < .001). No patients were diagnosed with PE. No major bleeds occurred. Minor bleeding occurred in 13 (2.5%) out of 513 postdischarge enoxaparin injections and 10 (2.0%) out of 492 placebo injections (P = .595). Risk factors for DVT during the 20 days postdischarge were age >30 years (odds ratio [OR]: 3.241; 95% confidence interval [CI], 1.015 to 10.349) and immobilization before surgery (OR 18.195; 95% CI, 2.046 to 161.837). CONCLUSIONS: Extended-duration postdischarge thromboprophylaxis for 20 days with enoxaparin in the outpatient setting significantly reduced the incidence of DVT in ACL surgery patients compared with enoxaparin limited to in-hospital thromboprophylaxis without increasing major or minor bleeding. LEVEL OF EVIDENCE: Level I, high-quality randomized controlled trial.