Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Locked plates reduce displacement of vertically unstable pelvic fractures in a Mechanical Testing Model.

BACKGROUND: The purpose of this study is to compare a locked screw construct to a single iliosacral screw for fixation of a vertically unstable pelvic ring injury in a transforaminal sacral fracture model. METHODS: Orthopaedic Trauma Association type 61-C1.3a2c5 fractures were created in 10 fresh frozen cadaveric pelvis specimens. Specimens were divided into two groups of five. In both groups, the anterior ring was stabilized with a six-hole 3.5-mm reconstruction plate. In the locked plate (LP) group, the posterior injury was stabilized using a two-hole locking plate with one solid 5.0-mm locking iliosacral screw directed onto the S1 body and a second locking screw directed into the lateral sacral ala. In the iliosacral screw group, the posterior injury was stabilized using a single cannulated 7.3-mm screw. Testing was conducted on a Materials Testing System. Values for displacement and rotation were recorded. Each pelvis was axially loaded with a compressive sine wave from 175 N to 350 N for 10,000 cycles to simulate limited weight bearing, with data recorded at 1,000 cycle increments. RESULTS: Two specimens in the iliosacral screw group displaced more than 1 cm during the first 1,000 cycles. These two specimens displayed gross fracture motion in all planes. All five specimens in the LP group completed 10,000 cycles of testing with less than 1 cm of displacement. A vector displacement calculation from the plane displacement data revealed that the LP group had significantly less displacement (median 1.9 mm) than the specimens in the iliosacral group (median 6.7 mm; p = 0.008) after 10,000 cycles. CONCLUSIONS: A two-hole plate locked head screw construct resulted in less displacement than a single iliosacral screw in a transforaminal sacral fracture model.

Incidence of deep venous thrombosis after temporary joint spanning external fixation for complex lower extremity injuries.

OBJECTIVE: The purpose of this study was to determine the incidence of deep venous thrombosis (DVT) in a prospective protocol of early spanning external fixation with the concurrent use of low-molecular weight heparin (LMWH) in patients with high-energy lower extremity trauma. SETTING: Three level I trauma centers. DESIGN: Prospective observational study. PATIENTS: One hundred thirty-six consecutive patients with 151 complex lower extremity injuries were treated with a protocol of immediate joint spanning external fixation application and LMWH administration within 24 hours of admission. A total of 143 external fixators were applied. Early patient mobilization was encouraged and possible due to the skeletal stability provided by the external fixator. There were 87 men and 49 women with a mean age of 43 years. There were 62 proximal tibia fractures (Orthopaedic Trauma Association [OTA] Fracture Classification 41), 4 tibial shaft fractures (OTA 42), 49 distal tibia-fibula fractures (OTA 43, 44), 14 femur fractures (OTA 32, 33), 8 calcaneus fractures (OTA 73), 10 knee dislocations, and 4 talus fracture dislocations. Forty-eight injuries (32%) were open. INTERVENTION: Temporary joint spanning external fixator placement, LMWH administration, and early mobilization within 24 hours of admission. Duplex ultrasonography of the bilateral lower extremities within 1 day to 3 days before fixator removal and definitive fixation procedure. MAIN OUTCOME MEASUREMENTS: Presence of DVT on duplex ultrasound examination. RESULTS: Duplex ultrasonography was negative for DVT in all but three patients for an incidence of 2.1% (3 of 143 fixators). There were no bleeding complications secondary to the use of LMWH while the temporary external fixator was in place. CONCLUSION: The incidence of DVT in patients treated with a protocol of early joint spanning external fixation and LMWH administration does not exceed historical controls. The early restoration of limb length, alignment, and stability allows early mobilization, which may contribute to the prevention of DVT.

The management of complications associated with tibial fractures.

Tibial fractures are common and frequently require surgical stabilization. These two factors mean that complications when treating this difficult injury are to be expected. The objectives in the treatment of open tibial shaft fractures are to prevent sepsis, achieve union, and restore function of the limb. However, these goals are often compromised by infection, compartment syndromes, and bone loss associated with many tibial shaft fractures. Recent studies provide a better understanding of the factors involved in the initial care of patients with open tibial fractures and have challenged prior dogmas and practices. An example is studies that define the relationship between the time to débridement of open fractures and subsequent infection. The diagnosis of compartment syndromes continues to be challenging. Careful review of clinical criteria will assist physicians in the early recognition and the management of compartment syndromes. Despite uncomplicated initial care, infections will occur. However, improved knowledge in the basic science of infections, specifically infections about orthopaedic implants, has led to the development of protocols for treatment and obtaining union. Bone loss, a result of either infection or trauma, is one of the most difficult complications to manage. Research regarding bone morphogenesis and the synthesis of multiple compounds has created new options for treating tibial fractures with bone loss.

Acute total hip arthroplasty versus open reduction internal fixation for posterior wall acetabular fractures in middle-aged patients.

INTRODUCTION: Open reduction internal fixation (ORIF) is the standard of care for displaced acetabular fractures, but the inability to achieve anatomic reduction, involvement of the posterior wall, articular impaction, and femoral head cartilaginous injury are known to lead to poorer outcomes. Acute total hip arthroplasty (THA) is a reasonable treatment option for older patients with an acetabular fracture and risk factors for a poor outcome, but it is only described in case series. The purpose of this study is to compare outcomes of ORIF and acute THA in middle-aged patients with an acetabular fracture from a single center. METHODS: Retrospective case-controlled study of patients aged 45 to 65 years old with acetabular fractures involving the posterior wall treated with acute THA or ORIF at a level 1 trauma center between 1996 and 2011. Patients were matched by fracture pattern and age at a 2 (ORIF):1 (acute THA) ratio. Functional outcome, complications, and reoperation rates of acute THA and ORIF were compared. RESULTS: Sixteen acute THA patients (average age 56.4 years) and 32 ORIF patients (average age 54.3 years) were evaluated at an average follow-up of 6.2 years (range 1-15.2). The average Oxford Hip Score in the acute THA group was 44 compared to 40 in the ORIF group (P = .075). Complication rates were similar between both the groups. Twelve hips (37%) in the ORIF group had undergone THA or been referred for THA, and 2 revisions (13%) had occurred in the acute THA group. A Kaplan-Meier survival analysis showed that those undergoing acute THA had significantly better survival of their index procedure (P = .031). CONCLUSIONS: Both ORIF and acute THA for high-energy acetabular fractures involving the posterior wall in middle-aged patients can provide excellent results, with acute THA patients achieving improved survival of the index procedure and improved functional scores.

Intramedullary nailing following external fixation in femoral and tibial shaft fractures.

BACKGROUND: Intramedullary nailing is the standard of care for the definitive management of lower extremity long bone fractures. Occasionally, temporary external fixation is used in fractures with severe open wounds or vascular injury before definitive intramedullary nailing. Secondary intramedullary nailing following external fixation is somewhat controversial, especially with respect to the duration of external fixation that is allowable before the risk of infection following later nailing becomes too great. Several recent studies have provided further insight into this issue. OBJECTIVE: The primary objective is to evaluate infection and nonunion rates in patients treated with temporary external fixation and secondary intramedullary nailing for lower extremity long bone fractures. The secondary objective is to evaluate whether the duration of external fixation and the interval time (defined as the time from external fixator removal to intramedullary nailing) influence the risk of infection after intramedullary nailing.

Surgical treatment of intertrochanteric hip fractures with associated femoral neck fractures using a sliding hip screw.

OBJECTIVE: The purpose of this study was to report the results of surgical treatment of a subset of intertrochanteric fractures with posteromedial comminution and extension of the fracture line into the femoral neck using a sliding hip screw. DESIGN: Retrospective review. SETTING: Level I county trauma center. PATIENTS: Twenty-nine fractures (8%) with this pattern were identified from 381 intertrochanteric hip fractures treated at a single institution over a 10-year period. Nine patients were excluded (2 died, 7 had incomplete radiographic follow-up), leaving 20 patients for assessment. INTERVENTION: All fractures were treated with a sliding hip screw. MAIN OUTCOME MEASUREMENTS: Radiographs at a mean follow-up of 17 months were recorded as demonstrating: 1) fixation failure; 2) fracture union; or 3) fracture nonunion. The tip-apex distance, amount of lag screw collapse, screw position in the femoral head, and adequacy of reduction were determined. RESULTS: Treatment failed according to these radiographic measures in 5 of 20 (25%) fractures. Failures included fracture nonunion (1 case), lag screw cutout (2 cases), and combined nonunion/lag screw cutout (2 cases). All 5 failures had complete collapse of the lag screw, whereas 4 of the 15 successfully treated fractures had complete collapse. The amount of collapse was significantly greater for the treatment failures (mean, 38 mm) than in the successfully treated hips (mean, 20 mm). There was no significant association between treatment success or failure and tip-apex distance, lag screw position, and adequacy of reduction. CONCLUSION: We conclude that intertrochanteric hip fractures with associated femoral neck fractures should not be managed with a standard sliding hip screw.

Expected outcomes after pelvic ring injury.

Pelvic ring injuries are a result of high-energy trauma and are often associated with nonskeletal injuries. Although malunions and nonunions are rare with the use of current techniques of reduction and fixation, outcome studies show that these injuries have long-lasting effects. Associated urologic and neurologic injuries are commonly the determinants of outcome.

Surgical management of pelvic ring injuries.

Posterior pelvic ring injuries disrupt the weight-bearing function of the pelvis and cause deformity that results in pain and loss of function. The indications for reduction and fixation are the presence of instability and/or deformity. Surgical fixation of the pelvic ring is divided into anterior and posterior ring injuries. In many instances, reduction and fixation of the anterior pelvic ring is not needed after reduction and fixation of the posterior pelvic ring. Although techniques exist for both open and closed reductions, the main dfficulty remains achieving anatomic restoration of the pelvis. Whether posterior pelvic ring injuries are best treated using closed reduction and fixation or open reduction and fixation remains a controversial topic.

Instability of the posterior pelvic ring associated with disruption of the pubic symphysis.

The patient with instability of the posterior pelvic ring and disruption of the pubic symphysis is a challenging problem for orthopedic surgeons. These represent high-energy injuries and management of these patients requires a multidisciplinary team approach. The orthopedic surgeon's understanding of the injury patterns, their associated injuries, and effective treatment strategies can reduce morbidity and mortality for patients.

Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries.

OBJECTIVES: The purposes of this study were to evaluate the relationship between body mass index (BMI) and postoperative complications and to determine the incidence of reoperation after surgical treatment of pelvic ring injuries. SETTING: Three Level I trauma centers. PATIENTS/PARTICIPANTS: A retrospective review of 184 consecutive surgically treated pelvic ring injuries (Orthopaedic Trauma Association 61) was performed. Two patients died in the initial postoperative period, and the remaining 182 patients were followed for a minimum of 3 months. MAIN OUTCOME MEASUREMENTS: Complications that were evaluated included wound infection and dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis, pneumonia, and the development of decubitus ulcers. Body mass index was calculated for each patient, and a BMI greater than 30 kg/m considered to be obese as defined by the National Institutes of Health. RESULTS: There were 132 males and 50 females with an average age of 36.4 years (range, 14-83 years). There were 48 (26%) patients with a BMI over 30 kg/m. Complications occurred in 46 of 182 patients (25.3%) with 26 occurring in the 48 patients with BMI greater than 30 kg/m (54.2% complication rate) and 20 occurring in the 134 patients with BMI less than 30 kg/m (14.9% complication rate). Complications included 20 infections (four superficial wound dehiscence and 16 deep), 23 losses of reduction, five deep vein thromboses, three pulmonary embolus, three pneumonia, two decubitus ulcers, and three iatrogenic nerve injuries. Reoperation was required in 29 of 182 (15.9%) patients with 16 (8.8%) irrigation and débridement, and 17 (9.3%) refixation procedures. All wound complications occurred after open exposures. Open exposures were performed for the anterior pelvic ring in 143 of 182 (78.6%) patients, the posterior pelvic ring in 64 of 182 (35.2%) patients, and percutaneous treatment of the posterior pelvic ring was performed in 80 of 182 (44.0%) patients. Logistic regression modeling analyzing BMI as a continuous variable found a relationship between increasing BMI and complication rate (P < 0.0001) and need for reoperation (P = 0.0013). Odds ratios analysis revealed that obese patients (BMI greater than 30 kg/m) were 6.87 (95% confidence interval, 3.25-14.49) times more likely to have a complication and 4.68 (95% confidence interval, 2.03-10.76) times more likely to undergo reoperation than patients with BMI less than 30 kg/m. CONCLUSIONS: Body mass index correlates with an increased rate of complications and reoperation after operative treatment of pelvic ring injuries.

Single-leg-stance radiographs in the diagnosis of pelvic instability.

BACKGROUND: In the nonacute setting, the diagnosis of pelvic instability is difficult. Patients who present with pelvic pain may have underlying instability. The purpose of the present study was to report the effectiveness of single-leg-stance radiographs in the diagnosis of pelvic instability in a consecutive series of patients presenting with pelvic pain. METHODS: Thirty-eight consecutive patients (twenty-four women and fourteen men) ranging in age from eighteen to seventy-eight years who presented with pelvic pain and a history of injury (twenty-seven), childbirth (seven [four primiparous and three multiparous]), or osteopenia (four) were evaluated with a visual analog scale pain score and a standard series of radiographs in an attempt to identify pelvic instability. The average time from the onset of symptoms to the evaluation was forty-one months (range, six weeks to twenty-seven years). Each patient was evaluated with supine anteroposterior, inlet, and outlet pelvic radiographs; a standing anteroposterior pelvic radiograph; and two single-leg-standing pelvic radiographs (one with the patient standing on the left leg and one with the patient standing on the right leg). A positive finding was defined as >or=0.5 cm of vertical translation measured at the symphyseal bodies between the two single-leg-stance radiographs. RESULTS: Of the thirty-eight patients, twenty-five demonstrated pelvic instability (average, 1.98 cm; range, 0.5 to 5 cm). With the numbers available, the average visual analog scale pain score for the patients with a stable pelvis was not significantly different from that for the patients with an unstable pelvis (6.4 +/- 2.9 compared with 7.3 +/- 1.9; p = 0.28). CONCLUSIONS: Standing anteroposterior and single-leg-stance pelvic radiographs aid in the diagnosis of pelvic instability more effectively than do the standard three radiographs of the pelvis made in the supine position or a standing anteroposterior radiograph of the pelvis alone. Additional studies will be needed to correlate this instability with clinical symptoms. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.