Clinical outcome and quality of life of patients with periprosthetic distal femur fractures and retained total knee arthroplasty treated with polyaxial locking plates: a single-center experience.

PURPOSE: The number of total knee arthroplasties (TKA) increased rapidly. In conjunction with higher implantation rates, periprosthetic femur fractures following TKA are also gradually increasing. Purpose of this study was to evaluate polyaxial locking plate treatment of periprosthetic femoral fractures with retained total knee replacement using polyaxial locking plates in regard to quality of life, functional outcome and complications. METHODS: The Study design is a single-center retrospective cohort analysis. Included were patients with periprosthetic supracondylar femoral fractures with a well-fixed knee prosthesis initially treated with NCB plate (Non-contact bridging plate, Zimmer Inc., Warsaw, IN). Primary outcome was measured including quality of life and functional status using the SMFA-D score (German short musculoskeletal function assessment questionnaire), the mortality rate and union rate. Formerly published SMFA-data presenting representative randomly chosen cross-sectional data from general population of the USA and Dutch population was used as historic control group. RESULTS: In total, 45 patients with a mean age of 74 years were included (10 males; 35 females). Body mass index averaged 27.4 kg/m2. Follow-up averaged 52 months. Comparison of the SMFA-D scores showed higher scores according to bother index (41.5 vs. 15.7/13.8) and function index (42.5 vs. 14.5/12.7). Mortality rate was 26.7%. The CCI was directly related to the mortality rate (p = 0.033). Union was achieved in 35 of 45 fractures (78%) six months after the index procedure. The ultimate union rate including following procedures at last follow-up was 95.6%. CONCLUSION: Besides already highlighted limitations in range of motion, we quantified patient-related limitations in daily living. A large number of patients after surgery are not self-reliant mobile or on orthopedic aids. A high CCI was directly related to the mortality rate and can be used as a predictive factor for postoperative mortality.

Lost to follow-up: reasons and outcomes following tibial plateau fractures.

INTRODUCTION: Different reasons for lost to follow-up are assumed. Besides "objective" reasons, "subjective" reasons and satisfaction contribute to treatment adherence. Retrospective studies usually lack the possibility of acquisition of additional outcome information. Purpose of this study was to determine outcome and factors for patients not returning for follow-up. METHODS: Between 2002 and 2009, 380 patients underwent internal fixation for tibial plateau fractures. Short Musculoskeletal Function Assessment (SMFA) was collected at 6, 12, and 24 months as long as patients returned for follow-up. Pain and range of motion were measured. Records were studied for reasons of termination of follow-up. Statistical analysis was performed comparing lost to follow-up versus continued office visits regarding demographics, contributing factors, and SMFA. RESULTS: Two hundred fifty-nine patients were followed until treatment was completed (PRN), while 120 patients (32 %) terminated further follow-up. Patients in the 12- and 24-month follow-up groups were older (p = 0.02; p < 0.01, respectively). Pain (VAS ≥ 3) was noticed in 22 % of the patients terminating follow-up before the 6-month survey and 41 % of the patients returning for the 24-month SMFA survey (χ 2 = 0.06). Improvements were found with time in SMFA subscores but arm and hand. No differences in SMFA subscores at 6 or 12 months were found between those leaving treatment untimely and those being released from office visits. CONCLUSION: Follow-up remains important to obtain as much up-to-date information as possible. The current study does not support the assumption that patients lost to follow-up have a different SMFA outcome than patients returning until PRN. LEVEL OF EVIDENCE: III.

Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries.

BACKGROUND: Double disruptions of the superior suspensory shoulder complex, commonly referred to as 'floating shoulder' injuries, are ipsilateral midshaft clavicular and scapular neck/body fractures with a loss of bony attachment of the glenoid. The treatment of 'floating shoulder' injuries has been debated controversially for many years. The purpose of this study was to demonstrate the clinical and functional outcomes of patients with 'floating shoulder' injuries who underwent operative fixation of the clavicle fracture only. MATERIALS AND METHODS: Between 2002 and 2010, 32 consecutive floating shoulder injuries were identified in skeletally mature patients at a level I trauma center and followed in a single private practice. Thirteen patients met the inclusion and exclusion criteria for this retrospective study with a minimum 12-month follow-up. Clavicle and scapular fractures were identified by Current Procedural Technology codes and classified based on Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen criteria. 'Floating shoulder' injuries were surgically managed with only clavicular reduction and fixation utilizing modern plating techniques. Nonunion, malunion, implant removal, range of motion, need for secondary surgery, pain according to the visual analog scale (VAS), and return to work were measured. RESULTS: All injuries were the result of high-energy mechanisms. Fracture union of the clavicle was seen after initial surgical fixation in the majority of patients (12; 92.3 %). Final pain was reported as minimal (11 cases; 1-3 VAS), moderate (1 case; 4-6 VAS), and high (1 case; 7-10 VAS) at last follow-up. Excellent range of motion (180° forward flexion and abduction) was observed in the majority of patients (8; 61.5 %). The Herscovici score was 12.9 (range 10-15) at 3 months. Unplanned surgeries included two clavicular implant removals and one nonunion revision. None of the patients required reconstruction for scapula malunion after nonoperative management. Twelve patients returned to previous work without restrictions. CONCLUSIONS: 'Floating shoulder' injuries with only clavicular fixation return to function despite persistent scapular deformity and some residual pain. LEVEL OF EVIDENCE: Level IV.

Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis.

PURPOSE: Treatment of knee dislocation is still controversial. There is no evidence to favour ligament suture or reconstruction. Until now, no meta-analyses have examined suture versus reconstruction of cruciate ligaments in knee dislocations with respect to injury pattern and rupture classification. METHODS: We searched Medline, the Cochrane Controlled Trial Database, and EMBASE for studies on surgical treatment for 'knee dislocation' and 'multiple ligament injured knee'. A meta-analysis was performed using individual patient data. RESULTS: Nine studies including 195 patients (200 knees) with a mean age of 31.4 (±13) years fulfilled the study requirements. Thirteen cases of type II dislocations, 63 cases of type III medial, 84 cases of type III lateral, and 40 cases of type IV dislocations, according to Schenck's classification, were found. Poor or moderate results were found in 70 % of patients without surgical treatment of ACL or PCL (n = 27). Patients (n = 40) treated by sutures of the ACL and PCL demonstrated a significantly greater proportion of excellent or good results (40 and 37.5 %, respectively) (p < 0.001). Patients who underwent reconstruction of the ACL and PCL (n = 75) showed excellent or good results (28 and 45 %, respectively). No significant difference was found when comparing suture versus reconstruction of the ACL and PCL (n.s.). The outcome depends considerably on Schenck's injury pattern classification. CONCLUSION: Conservative treatment after knee dislocation yields poor clinical results. Suture repair of cruciate ligaments can still serve as an alternative option for multiligament injuries of the knee and achieve good clinical results, which are comparable to those of ligament reconstruction. The data provided by this meta-analysis should be reinforced by a prospective study, in which suture repair and ligament reconstruction are compared. LEVEL OF EVIDENCE: IV.

Improvement of vertebral body fracture reduction utilizing a posterior reduction tool: a single-center experience.

BACKGROUND: Extensive research regarding instabilities and prevention of kyphotic malalignment in the thoracolumbar spine exists. Keystones of this treatment are posterior instrumentation and anterior vertebral height restoration. Anterior column reduction via a single-stage procedure seems to be advantageous regarding complication, blood loss, and OR-time. Mechanical elevation of the anterior cortex of the vertebra may prevent the necessity of additional anterior stabilization or vertebral body replacement. The purpose of this study was to examine (1) if increased bony reduction in the anterior vertebral cortex could be achieved by utilization of an additional reduction tool, (2) if postoperative loss of vertebral height could be reduced, and (3) if anterior column reduction is related to clinical outcome. METHODS: From one level I trauma center, 173 patients underwent posterior stabilization for fractures of the thoracolumbar region between 2015 and 2020. Reduction in the vertebral body was performed via intraoperative lordotic positioning or by utilization of an additional reduction tool (Nforce, Medtronic). The reduction tool was mounted onto the pedicle screws and removed after tightening of the locking screws. To assess bony reduction, the sagittal index (SI) and vertebral kyphosis angle (VKA) were measured on X-rays and CT images at different time points ((1) preoperative, (2) postoperative, (3) ≥ 3 months postoperative). Clinical outcome was assessed utilizing the Ostwestry Disability Index (ODI). RESULTS: Bisegmental stabilization of AO/OTA type A3/A4 vertebral fractures was performed in 77 patients. Thereof, reduction was performed in 44 patients (females 34%) via intraoperative positioning alone (control group), whereas 33 patients (females 33%) underwent additional reduction utilizing a mechanical reduction tool (instrumentation group). Mean age was 41 ± 13 years in the instrumentation group (IG) and 52 ± 12 years in the control group (CG) (p < 0.001). No differences in terms of gender and comorbidities were found between the two groups. Preoperatively, the sagittal index (SI) was 0.69 in IG compared to 0.74 in CG (p = 0.039), resulting in a vertebral kyphosis angle (VKA) of 15.0° vs. 11.7° (p = 0.004). Intraoperatively, a significantly greater correction of the kyphotic deformity was achieved in the IG (p < 0.001), resulting in a compensation of the initially more severe kyphotic malalignment. The SI was corrected by 0.20-0.88 postoperatively, resulting in an improvement of the VKA by 8.7°-6.3°. In the CG, the SI could be corrected by 0.12-0.86 and the VKA by 5.1°-6.6°. The amount of correction was influenced by the initial deformity (p < 0.001). Postoperatively, both groups showed a loss of correction, resulting in a gain of 0.08 for the SI and 4.1° in IG and 0.03 and 2.0°, respectively. The best results were observed in younger patients with initially severe kyphotic deformity. Considering various influencing factors, clinical outcome determined by the ODI showed no significant differences between both groups. CONCLUSION: Utilization of the investigated reduction tool during posterior stabilization of vertebral body fractures in a suitable collective of young patients with good bone quality and severe fracture deformity may lead to better reduction in the ventral column of the fractured vertebral body and angle correction. Therefore, additional anterior stabilization or vertebral body replacement may be prevented.

Can lumbopelvic fixation salvage unstable complex sacral fractures?

BACKGROUND: Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function. QUESTIONS/PURPOSES: We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications. METHODS: We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12-41 months). RESULTS: Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities. CONCLUSION: Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Persistent impairment after surgically treated lateral compression pelvic injury.

BACKGROUND: Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear. QUESTIONS/PURPOSES: We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain. METHODS: We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months). RESULTS: SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup. CONCLUSIONS: Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Adjuncts in posterior lumbar spine fusion: comparison of complications and efficacy.

PURPOSE: The purpose of this study was to define the efficacy of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) and Demineralized Bone Matrix (DBM) compared to autograft in posterior lumbar spine fusion by comparing complication rates. METHODS: During a 7-year period (2003-2009), all patients undergoing posterior lumbar fusion were retrospectively evaluated within a large orthopedic surgery private practice. Patient demographics, comorbidities, number of levels, type of surgery, and types of bone void filler and osteobiologics were analyzed. Complications were defined as reoperation secondary to failed symptomatic fusion, hyper-reaction with fluid collections, bone overgrowth, and infections. RESULTS: 1,398 patients were evaluated with 41.1 % males and 58.9 % females. Mean age was 60 years and BMI 30.6 kg/m². Patients were subdivided in treatment groups: rhBMP-2, 947 (67.7 %), DBM 306 (21.9 %), and autograft 145 (10.4 %). The overall infection rate was 2.1 %. No significant differences were found between the three groups. The incidence of seroma formation was higher in the BMP group (3.2 %) than in the DBM or autograft group (2.0 and 1.4 %, respectively) but this was not significant (p = 0.286 and p = 0.245, respectively). 103 patients (7.4 %) underwent redo surgery for clinically significant nonunion. We found significantly fewer nonunions (4.3 %) in the rhBMP-2 group (p < 0.001) compared to the DBM or autograft group (13.1 and 15.2 %, respectively). CONCLUSION: ICBG is the gold standard. DBM leads to comparable fusion rates and does not increase infection or seroma formation. rhBMP-2 supplementation instead of ICBG or bone marrow aspirate results in higher fusion rates compared to autograft alone or autograft plus DBM.

Factors Associated With Major Complications and Mortality During Hospitalization in Patients With Ankylosing Spondylitis Undergoing Surgical Management for a Spine Fracture.

STUDY DESIGN: Retrospective study. OBJECTIVES: To analyze factors associated with major complications (MC) in patients with ankylosing spondylitis (AS) undergoing surgical management for a spine fracture. METHODS: Included were all persons with spine fractures and AS in a teriary health care center between 2003 and 2019. Clinical data and MC were characterized with descriptive characteristics. Multivariable analyses were used to find factors associated with MC. RESULTS: In total, 174 traumatic fracture incidents in 166 patients with AS were included, with a mean patient age of 70.7 ± 13.1 years. The main reason for spine fracture was minor trauma (79.9%). Spinal cord injuries (SCI) were described in 36.7% of cases. The majority of patients (54.6%) showed more than one fracture of the spine, with cervical fractures being the most common (50.5%). Overall, the incidences of surgical site infection, implant failure, nosocomial pneumonia (NP), and mortality were 17.2%, 9.2%, 31%, and 14.9%, respectively. ICU stay > 48 hours was associated with MC (including death). Posterior approach for spondylodesis, ICU stay > 48 hours and cervical SCI were related to MC (excluding death). Age > 70 years, NP and Charlson comorbidity index > 5 points were associated with in-hospital mortality. CONCLUSIONS: Patients with AS and surgical treatment of spine fractures are at high risk for MC. Therefore, our results might give physicians better insight into the incidence and sequelae of major complications and therefore might improve patient and family expectations.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures.

BACKGROUND: Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures. PURPOSE: The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment. METHODS: Over a 4-year period (2016-2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively. RESULTS: Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001). CONCLUSION: Bilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

Does isolated atlantoaxial fusion result in better clinical outcome compared to occipitocervical fusion?

BACKGROUND: The C0 to C2 region is the keystone for range of motion in the upper cervical spine. Posterior procedures usually include a fusion of at least one segment. Atlantoaxial fusion (AAF) only inhibits any motion in the C1/C2 segment whereas occipitocervical fusion (OCF) additionally interferes with the C0/C1 segment. The purpose of our study was to investigate clinical outcome of patients that underwent OCF or AAF for upper cervical spine injuries. METHODS: Over a 5-year period (2010-2015), consecutive patients with upper cervical spine disorders were retrospectively identified as having been treated with OCF or AAF. The Numeric Pain Rating Scale (NPRS) and the Neck Disability Index (NDI) were used to evaluate postoperative neck pain and health restrictions. Demographics, follow-up, and clinical outcome parameters were evaluated. Infection, hematoma, screw malpositioning, and deaths were used as complication variables. Follow-up was at least 6 months postoperatively. RESULTS: Ninety-six patients (male = 42, female = 54) underwent stabilization of the upper cervical spine. OCF was performed in 44 patients (45.8%), and 52 patients (54.2%) were treated with AAF. Patients with OCF were diagnosed with more comorbidities (p = 0.01). Follow-up was shorter in the OCF group compared to the AAF group (6.3 months and 14.3 months; p = 0.01). No differences were found related to infection (OCF 4.5%; AAF 7.7%) and revision rate (OCF 13.6%; AAF 17.3%; p > 0.05). Regarding bother and disability, no differences were discovered utilizing the NDI score (AAF 21.4%; OCF 37.4%; p > 0.05). A reduction of disability measured by the NDI was observed with greater follow-up for all patients (p = 0.01). CONCLUSION: Theoretically, AAF provides greater range of motion by preserving the C0/C1 motion segment resulting in less disability. The current study did not show any significant differences regarding clinical outcome measured by the NDI compared to OCF. No differences were found regarding complication and infection rates in both groups. Both techniques provide a stable treatment with comparable clinical outcome.

Functional outcome of traumatic spinopelvic instabilities treated with lumbopelvic fixation.

The aim of this study was to assess the functional outcome after lumbopelvic fixation (LPF) using the SMFA (short musculoskeletal functional assessment) score and discuss the results in the context of the existing literature. The last consecutive 50 patients who underwent a LPF from January 1st 2011 to December 31st 2014 were identified and administered the SMFA-questionnaire. Inclusion criteria were: (1) patient underwent LPF at our institution, (2) complete medical records, (3) minimum follow-up of 12 months. Out of the 50 recipients, 22 questionnaires were returned. Five questionnaires were incomplete and therefore seventeen were included for analysis. The mean age was 60.3 years (32-86 years; 9m/8f) and the follow-up averaged 26.9 months (14-48 months). Six patients (35.3%) suffered from a low-energy trauma and 11 patients (64.7%) suffered a high-energy trauma. Patients in the low-energy group were significantly older compared to patients in the high-energy group (72.2 vs. 53.8 years; p = 0.030). Five patients (29.4%) suffered from multiple injuries. Compared to patients with low-energy trauma, patients suffering from high-energy trauma showed significantly lower scores in "daily activities" (89.6 vs. 57.1; p = 0.031), "mobility" (84.7 vs. 45.5; p = 0.015) and "function" (74.9 vs. 43.4; p = 0.020). Our results suggest that patients with older age and those with concomitant injuries show a greater impairment according to the SMFA score. Even though mostly favorable functional outcomes were reported throughout the literature, patients still show some level of impairment and do not reach normative data at final follow-up.

Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures.

INTRODUCTION: The OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant. Intramedullary fixation using different types of nails is commonly preferred. The purpose of this study is to evaluate intertrochanteric femoral fractures with intramedullary nail treatment in regard to surgical procedure, complications, and clinical outcomes. METHODS: From one level 1 trauma center, 216 consecutive adult intertrochanteric femoral fractures (OTA/AO type 31 A3) were retrospectively identified with intramedullary nail fixation from 2004 through 2013. Of these, 193 patients (58.5% female) met the inclusion criteria. The average age was 70 years (range 19-96 years). RESULTS: Cephalomedullary nails were utilized in 176 and reconstruction nails in 17 patients. After the index procedure, 86% healed uneventfully. Nonunion development was observed in 6% and 5% had an unscheduled reoperation due to implant or fixation failure. Active smoking was reported in 16.6%. Current smokers had an increased nonunion risk compared to those who do not currently smoke (15.6% vs. 4.3%; p = 0.016). The femoral neck angle averaged 128.0° ± 5°. Fixation failure occurred in 11.1% of patients with a neck-shaft-angle < 125° compared to 2.6% (4/155) of patients with a neck-shaft angle ≥125° (p = 0.021). Patients treated with a reconstruction nail required a second surgical intervention in 23.5%, which was no different compared to 25.0% in the cephalomedullary group (p = 0.893). In the cephalomedullary group, 4.5% developed a nonunion compared to 23.5% in the reconstruction group (p = 0.002). Painful hardware led to hardware removal in 8.8%. All of them were treated with a cephalomedullary device (p = 0.180). During the last office visit, two-thirds of the patients reported no or only mild pain but most patients had reduced hip range of motion. CONCLUSION: Intramedullary nailing is a reliable surgical technique when performed with adequate reduction. Varus reduction with a neck-shaft angle < 125° resulted in an increase in fixation failures. Patient and implant factors affected nonunion formation. Smoking increased nonunion formation. Utilization of a cephalomedullary device reduced the nonunion rate, but had higher rates of painful prominent hardware compared to reconstruction nailing.

Early percutaneous dilational tracheostomy does not lead to an increased risk of surgical site infection following anterior spinal surgery.

BACKGROUND: Most patients with cervical spinal cord injuries require tracheostomy. The optimal timing is still a matter of debate. Previous studies showed that patients receiving early tracheostomy had fewer ventilator days and decreased rates of pneumonia and were mobilized earlier. Because of the proximity of the anterior approach to the tracheostoma, there is concern about an increased risk of surgical site infection (SSI) related to tracheostomy. METHODS: This was a retrospective analysis at a Level I trauma center of patient records from 2008 to 2014, identifying all patients with spinal cord injury who received anterior cervical spinal surgery and had early percutaneous dilational tracheostomy (PDT). Follow-up for SSI was performed throughout hospital stay (mean, 110 days; median, 96 days, with lower quartile 89 days and upper quartile 119 days) and at 6 weeks and 3 months (clinical examination and computed tomography scans). RESULTS: Fifty-one patients underwent anterior spinal surgery with PDT performed within a median of 5 days (range, 1-18 days). Seventy-eight percent (n = 40) of patients had anterior spinal surgery, whereas 22% (n = 11) had a combined anterior-posterior repair. All percutaneous dilational tracheostomies were performed using the Ciaglia single-step dilation technique. Despite an SSI of one patient's cannulation site, no SSI of the anterior approach was observed. CONCLUSION: Performing a PDT in a timely fashion after anterior spinal surgery does not increase the risk of SSI. LEVEL OF EVIDENCE: Therapeutic study, level V.

A 23-year-old patient with secondary tumoral calcinosis: Regression after subtotal parathyroidectomy: A case report.

INTRODUCTION: Tumoral calcinosis (TC) is a rare disorder defined by hyperphosphatemia and ectopic calcifications in various locations. The most common form of TC is associated with disorders such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The primary (hereditary) TC is caused by inactivating mutations in either the fibroblast growth factor 23 (FGF23), the GalNAc transferase 3 (GALNT3) or the KLOTHO (KL) gene. PRESENTATION OF CASE: We report here a case of secondary TC in end-stage renal disease. The patient was on regular hemodialysis and presented with severe painful soft-tissue calcifications around her left hip and shoulder that had been increasing over the last two years. Initially, she was treated with dietary phosphate restriction and phosphate binders. Because of high phosphate blood levels, which were not yet managed with dialysis and medical therapy, a subtotal parathyroidectomy (sP) was performed. This approach demonstrated significant response. Three months after surgery a rapid regression of the tumors was observed. DISSCUSION: Regardless of the etiology, the two types of TC do not differ in their radiologic or histopathologic presentations but need to be diagnosed correctly to initiate targeted and effective treatment. Considering the primary TC, primary treatment is early and complete surgical excision. In case of secondary TC surgical excision of the tumoral masses should be avoid because of extensive complications. These patients benefit from sP. CONCLUSION: After initial conservative therapy chronic kidney disease patients with TC might benefit from sP to avoid prolonged suffering and potential mutilations.

Fate of Patients With a "Surprise" Positive Culture After Nonunion Surgery.

OBJECTIVE: Review the impact of unexpected positive cultures from definitive surgery for nonunion regarding postoperative treatment and ultimate result. DESIGNS: Retrospective multicenter case series. SETTING: Three level-one trauma centers. PATIENTS: Six-hundred sixty-six consecutive nonunions were treated during the study period. Four-hundred fifty-three cases (68%) were considered at risk for indolent infection (prior open fracture, surgery, or infection) and had cultures taken at the time of definitive surgery. INTERVENTION: Intraoperative cultures during definitive operative treatment of nonunions. MAIN OUTCOME MEASUREMENT: The incidence of "surprise" positive cultures was determined, and the course of the patients was documented including the use of antibiotics, surgery performed, and the outcome regarding infection and union. RESULTS: Ninety-one (20%) cases had a surprise positive culture despite negative inflammatory markers. Most of bacteria isolated from the cultures were Staphylococcus species. Eight (9%) of the ninety-one cultures were considered probable contaminants and no antibiotics were given, 5 of these patients healed. The other 83 patients were treated with antibiotics, initially 66 (80%) healed and 12 (14%) remained infected. Eighty-two percent of patients with augmentation healed as compared with 86% of those not grafted. CONCLUSIONS: The treatment of nonunions is challenging, and in patients with a history of surgery or open fracture, we found that 20% had positive intraoperative cultures from the definitive surgery. We recommend intraoperative cultures for all patients undergoing revision surgery. The use of culture-specific antibiotics is justified based on the overall low rate of infection in this complex population and the high rate of chronic infection (25%) for those treated as contaminants. Patients may be counseled that a positive culture after nonunion surgery is a treatable problem but does increase the risk of infection and additional surgery as compared with those with a negative intraoperative culture. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures.

OBJECTIVES: To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails. DESIGN: Retrospective analysis. SETTING: Level I trauma center with follow-up in a private orthopaedic practice. MAIN OUTCOME MEASUREMENTS: Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation. PATIENTS: A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing. RESULTS: Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal. CONCLUSIONS: Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does plate type influence the clinical outcomes and implant removal in midclavicular fractures fixed with 2.7-mm anteroinferior plates? A retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate surgical healing rates, implant failure, implant removal, and the need for surgical revision with regards to plate type in midshaft clavicle fractures fixed with 2.7-mm anteroinferior plates utilizing modern plating techniques. METHODS: This retrospective exploratory cohort review took place at a level I teaching trauma center and a single large private practice office. A total of 155 skeletally mature individuals with 156 midshaft clavicle fractures between March 2002 and March 2012 were included in the final results. Fractures were identified by mechanism of injury and classified based on OTA/AO criteria. All fractures were fixed with 2.7-mm anteroinferior plates. Primary outcome measurements included implant failure, malunion, nonunion, and implant removal. Secondary outcome measurements included pain with the visual analog scale and range of motion. Statistically significant testing was set at 0.05, and testing was performed using chi-square, Fisher's exact, Mann-Whitney U, and Kruskall-Wallis. RESULTS: Implant failure occurred more often in reconstruction plates as compared to dynamic compression plates (p = 0.029). Malunions and nonunions occurred more often in fractures fixed with reconstruction plates as compared to dynamic compression plates, but it was not statistically significant. Implant removal attributed to irritation or implant prominence was observed in 14 patients. Statistically significant levels of pain were seen in patients requiring implant removal (p = 0.001) but were not associated with the plate type. CONCLUSIONS: Anteroinferior clavicular fracture fixation with 2.7-mm dynamic compression plates results in excellent healing rates with low removal rates in accordance with the published literature. Given higher rates of failure, 2.7-mm reconstruction plates should be discouraged in comparison to stiffer and more reliable 2.7-mm dynamic compression plates.

Biomechanical evaluation of fracture fixation constructs using a variable-angle locked periprosthetic femur plate system.

BACKGROUND: In the United States there are more than 230,000 total hip replacements annually, and periprosthetic femoral fractures occur in 0.1-4.5% of those patients. The majority of these fractures occur at the tip of the stem (Vancouver type B1). The purpose of this study was to compare the biomechanically stability and strength of three fixation constructs and identify the most desirable construct. METHODS: Fifteen medium adult synthetic femurs were implanted with a hip prosthesis and were osteotomized in an oblique plane at the level of the implant tip to simulate a Vancouver type B1 periprosthetic fracture. Fractures were fixed with a non-contact bridging periprosthetic proximal femur plate (Zimmer Inc., Warsaw, IN). Three proximal fixation methods were used: Group 1, bicortical screws; Group 2, unicortical screws and one cerclage cable; and Group 3, three cerclage cables. Distally, all groups had bicortical screws. Biomechanical testing was performed using an axial-torsional testing machine in three different loading modalities (axial compression, lateral bending, and torsional/sagittal bending), next in axial cyclic loading to 10,000 cycles, again in the three loading modalities, and finally to failure in torsional/sagittal bending. RESULTS: Group 1 had significantly greater load to failure and was significantly stiffer in torsional/sagittal bending than Groups 2 and 3. After cyclic loading, Group 2 had significantly greater axial stiffness than Groups 1 and 3. There was no difference between the three groups in lateral bending stiffness. The average energy absorbed during cyclic loading was significantly lower in Group 2 than in Groups 1 and 3. CONCLUSIONS: Bicortical screw placement achieved the highest load to failure and the highest torsional/sagittal bending stiffness. Additional unicortical screws improved axial stiffness when using cable fixation. Lateral bending was not influenced by differences in proximal fixation. CLINICAL RELEVANCE: To treat periprosthetic fractures, bicortical screw placement should be attempted to maximize load to failure and torsional/sagittal bending stiffness.

Recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in posterolateral lumbar spine fusion: complications in the elderly.

STUDY DESIGN: Retrospective cohort study of 1430 patients undergoing lumbar spinal fusion from 2002 - 2009. OBJECTIVE: The goal of this study was to compare and evaluate the number of complications requiring reoperation in elderly versus younger patients. SUMMARY OF BACKGROUND DATA: rhBMP-2 has been utilized off label for instrumented lumbar posterolateral fusions for many years. Many series have demonstrated predictable healing rates and reoperations. Varying complication rates in elderly patients have been reported. MATERIALS AND METHODS: All patients undergoing instrumented lumbar posterolateral fusion of ≤ 3 levels consenting to utilization of rhBMP-2 were retrospectively evaluated. Patient demographics, body mass index, comorbidities, number of levels, associated interbody fusion, and types of bone void filler were analyzed. The age of patients were divided into less than 65 and greater than or equal to 65 years. Complications related to the performed procedure were recorded. RESULTS: After exclusions, 482 consecutive patients were evaluated with 42.1% males and 57.9% females. Average age was 62 years with 250 (51.9%) < 65 and 232 (48.1%) ≥ 65 years. Patients ≥ 65 years of age stayed longer (5.0 days) in the hospital than younger patients (4.5 days) (p=0.005).Complications requiring reoperation were: acute seroma formation requiring decompression 15/482, 3.1%, bone overgrowth 4/482, 0.8%, infection requiring debridement 11/482, 2.3%, and revision fusion for symptomatic nonunion 18/482, 3.7%. No significant differences in complications were diagnosed between the two age groups. Statistical differences were noted between the age groups for medical comorbidities and surgical procedures. Patients older than 65 years underwent longer fusions (2.1 versus 1.7 levels, p=0.001). DISCUSSION: Despite being older and having more comorbidities, elderly patients have similar complication and reoperation rates compared to younger healthier patients undergoing instrumented lumbar decompression fusions with rhBMP-2.