What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

BACKGROUND: Three-part and four-part fracture-dislocations of the proximal humerus are characterized by severe soft tissue disruptions that can compromise the viability of the humeral head. As a result, nonunion and avascular necrosis are more common in these injuries. In such injuries, surgical treatment (internal fixation or arthroplasty) is performed in most patients who are determined to be fit for surgery to potentially restore shoulder function. Although the decision to preserve or replace the humeral head is simple in young patients or those > 65 years, in most other patients, the decision can be complicated, and little is known about which patient-related and injury-related factors may be independently associated with poor shoulder function or complications like avascular necrosis. QUESTIONS/PURPOSES: (1) What proportion of fractures united after internal fixation of a three-part or four-part fracture-dislocation of the proximal humerus, what is the mean Constant score at a minimum of 2 years after this injury, and what proportion had serious complications (such as loss of fixation, nonunion, reoperation, or avascular necrosis)? (2) After controlling for potential confounding variables, what factors are independently associated with poor shoulder function (defined as a Constant score < 55 out of 100) and occurrence of serious complications such as loss of fixation or reduction resulting in revision surgery, nonunion, or radiographic evidence of avascular necrosis of the humeral head? METHODS: Between 2011 and 2017, the senior author of this study (ASG) treated 69 patients with three-part or four-part proximal humerus fracture dislocations. During this time, indications for internal fixation in these patients were adequate humeral bone quality as determined by the surgeon on radiographs, adequate bone stock and volume available for fixation in the humeral head as determined on CT images, and the absence of a head split component as assessed on preoperative radiographs and CT images. On this basis, 87% (60 patients) underwent internal fixation with a locked plate and suture fixation of the tuberosities through a deltopectoral approach. Thirteen percent (nine patients) underwent either a hemiarthroplasty or a reverse total shoulder arthroplasty. Of the 60 patients who underwent internal fixation, four declined to participate in the study and two with brachial plexus palsy were not considered for inclusion. This study focused on the remaining 54 patients who were considered potentially eligible. To be included, a minimum follow-up of 2 years was required; 11% (6 of 54) were lost before that time, and the remaining 48 patients were analyzed at a mean of 48 months ± 17 months in this retrospective study, which drew data from longitudinally maintained institutional databases. Fracture union was assessed by obliteration of fracture lines and the presence of bridging trabecular bone on plain radiographs. Shoulder function was assessed using the Constant score, which is scored from 0 to 100 points, with 0 indicating the most disability and 100 the least disability. The anchor-based minimal clinically important difference for the Constant score is 9.8 points. Twelve patient-related and injury-related factors were analyzed using a multivariate regression model to identify factors that are independently associated with poor results after internal fixation as measured by shoulder function and the occurrence of serious complications. We categorized results as poor if patients had one or more of the following: Constant score < 55 out of 100 at the last follow-up examination (for patients who underwent revision surgery, the Constant score immediately before revision was considered) and loss of fixation or reduction resulting in revision surgery, nonunion, or avascular necrosis of the humeral head. Patients were screened for avascular necrosis at 6 and 12 months after surgery, then annually for another 2 years. Further assessments were made only based on symptoms. RESULTS: Seventy-nine percent of the fractures united within 18 weeks of surgery (38 of 48), and an additional 13% united by 24 weeks (6 of 48), while 8% did not unite (4 of 48). The mean Constant score at the last follow-up was 68 ± 12. Twenty-one percent (10 of 48) had a Constant score < 55, indicating poor shoulder function. Twenty-one percent (10 of 48) experienced avascular necrosis, and 15% (7 of 48) with either nonunion or avascular necrosis underwent revision shoulder arthroplasty. Two patients who underwent arthroplasty had both nonunion and avascular necrosis. After controlling for potentially confounding variables, we found that being a woman (odds ratio 1.7 [95% confidence interval 1.4 to 2.1]; p = 0.01), four-part fracture dislocations (OR 2.1 [95% CI 1.5 to 2.7]; p < 0.001), absence of a metaphyseal head extension (OR 2.4 [95% CI 1.8 to 3.3]; p < 0.001), absence of active back-bleeding from the humeral head (OR 3.4 [95% CI 2.3 to 5.1]; p < 0.001), height of the head segment < 2 cm (OR 2.3 [95% CI 1.8 to 2.8]; p < 0.001), and absence of capsular attachments to the head fragment (OR 2.2 [95% CI 1.6 to 2.9]; p < 0.001) were independently associated with poor shoulder function and the occurrence of complications such as nonunion and avascular necrosis. CONCLUSION: Internal fixation of three-part and four-part proximal humerus fracture dislocations resulted in poor shoulder function and complications in a high number of patients, although fracture union was achieved in most patients. A nonunion proportion of 8%, 21% proportion of avascular necrosis, and 15% proportion of patients who underwent revision surgery suggests this is a fairly terrible injury. Being a woman and injury factors such as four-part fracture dislocation, absent metaphyseal head extension and back-bleeding from the head, height of the fractured head segment < 2 cm, and absence of capsular attachments to the head were independently associated with poor function and complications. Our findings can help surgeons decide between internal fixation and arthroplasty for the surgical treatment of these injuries in patients across different age groups and functional demands. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Is the Likelihood of Union After Coronal Limb Realignment Using Revision Osteosynthesis and Concurrent TKA in Patients with Advanced Arthritis and Loss of Fixation After Distal Metaphyseal Femur Fractures?

BACKGROUND: Metaphyseal fracture healing in the distal femur requires a stable biomechanical environment. The presence of arthritis-induced coronal-plane knee deformities can cause deviation of the mechanical axis, which results in asymmetric loading and increased bending forces in fractures of the distal femur metaphysis. This predisposes patients to nonunions or loss of fixation. Concurrent TKA during revision osteosynthesis might facilitate fracture healing, owing to its ability to correct coronal alignment, thereby restoring normal loading patterns at the fracture site, but to our knowledge, this has not been studied. QUESTIONS/PURPOSES: (1) Does TKA with concurrent revision internal fixation achieve fracture union in patients with coronal-plane deformity from knee arthritis and nonunion or loss of fixation in distal metaphyseal femoral fractures? (2) What is the survivorship and what are the short-term functional outcomes after these reconstructions? (3) What complications occur after these reconstructions? METHODS: Between 2015 and 2018, one surgeon treated 16 patients with a distal metaphyseal femur fracture nonunion and/or loss of fixation using concurrent TKA plus revision internal fixation. Autologous iliac crest bone grafting was performed in five patients with evident gaps at the fracture site. The indications for the procedure included patients older than 55 years of age presenting with a nonunion and/or loss of fixation of a distal metaphyseal femur fracture in the setting of painful Ahlbäck Grade III to V knee arthritis with an associated coronal-plane deformity. All patients meeting these indications were treated with this approach during the study period. Fracture union assessed by radiological bridging of at least three cortices, TKA survival free from revision due to any reason, coronal-plane correction using tibiofemoral angle, and patient mobility status assessed presurgery and at follow-up using the Parker mobility score (scored 0-9 points, with 9 indicating best mobility) were assessed by two surgeons who were not involved in the care of the study patients. Immediate and delayed complications were recorded. Patients were followed for a minimum of 24 months. The median (range) follow-up was 38 months (27 to 52 months). RESULTS: All fractures united after concurrent TKA plus revision internal fixation. In all, 14 of 16 fractures healed before 5 months, while the remaining two fractures united by 6 months. Survivorship analysis revealed a TKA component survival of 94% (95% CI 63% to 99%) at 52 months. The median (range) preoperative Parker mobility score of 5 points (3 to 8) improved to 7 points (2 to 9) at 12 months postoperatively and was maintained at last follow-up (p = 0.001). Four patients experienced complications; these were (1) prolonged surgical wound drainage resulting in debridement and polyethylene liner exchange, (2) deep knee infection needing a staged revision, (3) popliteal vein thrombosis, and (4) prolonged graft site pain. CONCLUSION: Concurrent TKA plus revision internal fixation is effective for achieving union in patients with distal metaphyseal femur nonunion and loss of fixation in the setting of coronal-plane deformity induced by knee arthritis. Short-term TKA survival and improvement in patient mobility are excellent, although 4 of 16 patients in this report experienced complications, as one might expect with a procedure of this magnitude. Based on our results, correction of arthritis-induced coronal-plane knee malalignment can be considered part of the surgical strategy when treating such distal metaphyseal femur nonunions. Better preoperative evaluation of the deformity and control-based comparative studies can further validate the utility of this technique. LEVEL OF EVIDENCE: Level II, therapeutic study.

Choice of surgical approach influences the combined anteversion needed for a stable and impingement-free total hip arthroplasty.

BACKGROUND: Accurate component positioning is the key for successful outcome after total hip arthroplasty (THA). Positioning acetabular and femoral components in a safe zone of 25°-50° on the basis of combined anteversion (CA) has shown to reduce instability and impingement. This safe zone was described for THAs performed through the posterior approach and has not been validated for other surgical approaches. METHODS: Seventy patients who underwent unilateral uncemented THA were included in the study; 35 patients-using posterior approach and the remaining 35-using trans-gluteal approach. All patients included had a stable and impingement-free THA at a mean follow-up of 39.2 ± 9.5 months. CT scan was performed to assess component positioning by calculating CA. The values were compared between the two groups to study possible differences. RESULTS: CA in the trans-gluteal group was significantly lower (32° ± 3.7° vs 38.4° ± 4.6°, P < .001) compared to posterior group. The difference in CA was due to the differences in acetabular anteversion, which was significantly low in the trans-gluteal group than the posterior group (22.1° ± 3.6° vs 27.8° ± 4.2°, P < .001). The mean femoral anteversion was similar in both groups. All trans-gluteal hips fell within the safe zone of 20°-40°, and all posterior hips fell within the safe zone of 25°-50°. CONCLUSION: A safe zone of 25°-50° is valid for THAs performed from the posterior approach but not universally applicable. For trans-gluteal approach, a safe zone of 20°-40° is better to provide a stable and impingement-free THA. CA varies with the surgical approach. THAs performed through the trans-gluteal approach can be stable and impingement-free with lesser CA compared to THAs performed through the posterior approach.

Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures.

BACKGROUND: In the setting of intra-articular distal radius fractures, the volar lunate facet (VLF) is the only articular segment that resists volar carpal subluxation. So, it is important to achieve a stable fixation of this key fragment. The VLF, when small (also called as volar marginal fragment, VMF) is located distal to the watershed line making fixation with the conventional volar locking plates difficult or impossible. METHODS: 18 patients with either an AO: 2R3B3 or a C3 fracture consisting of a VMF underwent surgical repair through a volar approach. The VMF was stabilised using a anatomical volar hook plate. Remaining fracture components were stabilised using 2.4/ 2.0 mm locked plates. Fracture healing, ability of the hook plate to maintain reduction of the VMF and complications were assessed during follow up. Functional outcome was evaluated using Mayo score and patient rated wrist evaluation questionnaires. RESULTS: All fractures united at follow up. Reduction of the VMF was maintained through healing with a stable radiocarpal and distal radioulnar joint. The mean flexion - extension wrist arc was 105° ± 10.2° The mean grip strength reached 74.6 ± 6% of the opposite side. The mean Mayo wrist score was 75 ± 5.3 and the mean patient rated wrist evaluation (PRWE) score was 15.2 ± 4.3 indicating recovery of wrist function. CONCLUSION: It is important to identify VMFs in intra-articular distal radius fractures. Anatomically designed volar hook plate achieves excellent low-profile stable fixation of this key fragment to allow early mobilisation without fearing loss of reduction and volar carpal subluxation.

Trochanteric Flip (Ganz) Anterior Hip Dislocation for Fixation of Pipkin Fracture-Dislocations.

Safe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. This technique also allows associated labral injuries and acetabular fractures to be treated through the same approach. DESCRIPTION: The procedure is performed with use of a conventional Kocher-Langenbeck exposure with the patient in the lateral position. The trochanteric flip is performed, allowing exposure of the anterior capsule, which is incised to dislocate the head anteriorly. Fracture fixation is performed with use of mini-fragment screws followed by relocation of the head, closure of the capsulotomy, and fixation of the osteotomy. ALTERNATIVES: Fixation of femoral-head fractures can also be performed with use of alternate surgical approaches. Anterior-based surgical approaches like the Hueter approach or the Smith-Petersen approach are preferred with the goal of preserving the posterior extraosseous blood supply to the femoral head. The posterior Kocher-Langenbeck approach can also be utilized because there is no clear evidence suggesting that a properly performed posterior approach affects the blood supply of the femoral head. RATIONALE: Surgical hip dislocation is 1 of the preferred techniques for operative treatment of femoral-head fractures and is a versatile approach that provides circumferential exposure of the femoral head and acetabulum through an anterior dislocation. A compromised blood supply to the femoral head is much less likely with use of this approach compared with posterior-based surgical approaches. Compared with anterior-based surgical approaches, which are often restrictive, surgical dislocation is extensile and provides adequate exposure to treat associated injuries to the acetabulum and the labrum of the hip. EXPECTED OUTCOMES: Outcomes following surgical dislocation for femoral-head fractures are reportedly good to excellent in >80% patients. Urgent reduction of the hip joint followed by anatomical reduction of the fracture and stable fixation of the fracture and osteotomy leads to predictably good results. Notable complications include heterotopic ossification, which has been reported in up to 60% patients, as well as osteonecrosis of the femoral head (often related to the initial injury rather than the approach) and degenerative arthritis of the hip joint. IMPORTANT TIPS: The Gibson interval may be utilized to preserve the gluteus maximus.Identify all of the posterior structures starting proximally from the posterior border of the gluteus medius, and continuing to the piriformis, triceps coxae, quadratus femoris, and the vastus lateralis.Aim for a thickness of 1 to 1.5 cm when performing the osteotomy; an osteotomy that is either too thick or too thin can negatively affect outcomes. The osteotomy should begin just anterior to the posterior fibers of the gluteus medius to ensure that the osteotomy is anterior to the piriformis tendon. It should exit distally to the vastus lateralis origin.Carefully elevate the posterior margin of the gluteus minimis from the capsule to avoid the tethering effect during anterior translation of the osteotomized fragment.Capsular tears during the initial dislocation are common and should be incorporated into the anterior capsulotomy.Repair of large posterosuperior labral tears may improve outcomes.Fixation of the fracture can be performed with mini-fragment screws or headless screws. Non-fixable small fragments can be excised.The osteotomy should be reduced and fixed in a stable manner to prevent trochanteric nonunion and preserve abductor function.

Surgical Dislocation or the Modified Heuter Anterior Approach for Pipkin I and II Femoral Head Fracture Dislocations.

OBJECTIVES: To compare outcomes after surgical treatment of Pipkin I and II femoral head fractures treated with either a surgical dislocation (SD) or a direct anterior approach (the modified Heuter approach). STUDY DESIGN: Retrospective, multicentre. SETTING: Three Level I trauma care centers. PATIENTS: Fourty-nine patients operated for Pipkin types I or II femoral head fractures. Twenty-seven using SD and 22 using the modified Heuter approach. INTERVENTIONS: Initial closed reduction of the joint followed by open reduction and internal fixation of the fracture/fragment excision. Fixation was performed using headless or countersunk mini fragment screws. OUTCOME MEASUREMENTS: The 2 groups were compared for (1) perioperative measures: blood loss, surgical time, pain [visual analog scale (VAS)], and length of hospital stay; (2) radiological outcome in terms of fracture union, occurrence of posttraumatic hip arthritis, and femoral head osteonecrosis; and (3) functional outcome using the modified Merle d' Aubigne score and Oxford hip scores. RESULTS: Surgical time, blood loss, and VAS at 24 hours were significantly lower in the modified Heuter group. The VAS at discharge and length of stay were similar in both groups. All fractures had united. No cases of osteonecrosis were observed. Functional outcome and complications were similar in both groups. CONCLUSIONS: Both SD and the modified Heuter approach are effective in treating patients with Pipkin I and II femoral head fractures with comparable radiological and functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Valgus intertrochanteric osteotomy for femur neck pseudoarthrosis: a simple solution to a complex problem that has stood the test of time.

Femoral neck nonunion in young patients has always been a difficult problem to deal with for surgeons. Numerous surgical procedures to address either the biological or mechanical issues at the nonunion have been described and most of them have been associated with variable results. Isolated biological augmentation is often associated with poor results and some techniques like vascularized grafting may require not so commonly available expertise. Valgus osteotomy is aimed to correct the abnormal fracture biomechanics associated with femoral neck fractures. By altering the nature of force transmission across the nonunion, shear forces are converted into compressive forces that lead to rapid osseous union without the need for bone grafting. Though the principles are sound and were described a long time ago, the technical aspects have evolved over time. Various modifications have been described to overcome shortcomings such as limb length discrepancy, reduction of femoral offset, alteration in mechanical axis, and the overall proximal femur anatomy. In this review, we look back at the fundamental principles and recent literature on the results of valgus intertrochanteric osteotomy for femoral neck pseudoarthrosis. We also highlight the important need for accurate preoperative planning and surgical execution. Lastly, we elaborate on the technical improvisations that have happened over time in order to improve functional results and to minimize complications and poor outcome after a valgus osteotomy.

A load-sharing nail - cage construct may improve outcome after induced membrane technique for segmental tibial defects.

INTRODUCTION: Induced membrane technique (IMT) is a well-established technique for treating segmental bone defects. Different variations of the technique have been described. Our objective was to evaluate radiological and functional outcome with IMT using a nail - graft filled titanium cage construct for segmental traumatic bone defects of the tibia. PATIENTS AND METHODS: 26 adult patients with moderate (> 5 cm) or large (> 10 cm) segmental tibial defects after acute open fractures or implant related infected nonunions underwent the procedure. The technique involved 2 stages. After standard debridement +/- implant removal and application of an antibiotic loaded cement spacer in stage 1, the second stage included placement of an intramedullary nail across the defect and an impacted graft filled titanium mesh cage was used to reconstruct the bone defect. Radiographic evidence of bony union, time to painless un-assisted weight bearing, return to work and functional evaluation with lower extremity functional scale (LEFS) were assessed. RESULTS: 5/26 cases were excluded due to failure in controlling infection. 100% union rates were achieved in the remaining 21 patients. 2 patients (9.5%) required repeat bone grafting. The mean time to painless un-assisted painless weight bearing was 26 ± 9.2 days and the mean time to return to work was 45 ± 12.5 days. The mean LEFS at a mean follow up of 27 months was 67 ± 4.7. CONCLUSIONS: Excellent union rates with good functional restoration can be achieved after IMT using the nail - cage construct for segmental tibial defects. Persistent infection is the biggest impediment for successful execution of the technique. Addition of a cage may also improve short-term functional outcome in terms of ability to weight bear and early return to work.