Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age.

BACKGROUND: Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients. METHODS: We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations. RESULTS: We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications. CONCLUSIONS: Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur. LEVEL OF EVIDENCE: IV.

Exploring metal artifact reduction using dual-energy CT with pre-metal and post-metal implant cadaver comparison: are implant specific protocols needed?

OBJECTIVE: To quantify and optimize metal artifact reduction using virtual monochromatic dual-energy CT for different metal implants compared to non-metal reference scans. METHODS: Dual-energy CT scans of a pair of human cadaver limbs were acquired before and after implanting a titanium tibia plate, a stainless-steel tibia plate and a titanium intramedullary nail respectively. Virtual monochromatic images were analyzed from 70 to 190 keV. Region-of-interest (ROI), used to determine fluctuations and inaccuracies in CT numbers of soft tissues and bone, were placed in muscle, fat, cortical bone and intramedullary tibia canal. RESULTS: The stainless-steel implant resulted in more pronounced metal artifacts compared to both titanium implants. CT number inaccuracies in 70 keV reference images were minimized at 130, 180 and 190 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively. Noise, measured as the standard deviation of pixels within a ROI, was minimized at 130, 150 and 140 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively. CONCLUSION: Tailoring dual-energy CT protocols using implant specific virtual monochromatic images minimizes fluctuations and inaccuracies in CT numbers in bone and soft tissues compared to non-metal reference scans.

What is the hardware removal rate after anteroinferior plating of the clavicle? A retrospective cohort study.

BACKGROUND: Plate position in the operative treatment of displaced midshaft clavicle fractures or nonunions is most often on the superior side. However, superior clavicular plating often results in complaints of plate prominence and local soft tissue irritation, necessitating hardware removal. We have used anteroinferior placement of the plate in the hope of increasing biomechanical stability and fixation and also of lowering complaints of plate prominence and soft tissue irritation. In this report, we set out to study the percentage of hardware removal in our group of patients treated with anteroinferior plating of the clavicle after long-term follow-up. METHODS: In this retrospective review, we evaluated all patients who were surgically treated with anteroinferior plating for midshaft clavicle fracture, delayed union, or nonunion by the senior author between February 2003 and July 2015. Patients required a minimum age of 16 years at time of surgery and a follow-up of >12 months. Patients with malunion, plating on the superior aspect, or double plating were excluded. RESULTS: The medical records of 53 patients (54 fractures) were reviewed after a mean follow-up duration of 6.4 years (range, 1.1-13.1). The mean age at follow-up was 47.8 years (range, 20.4-80.7). All fractures and nonunions healed. In only 3 cases (5.6%), hardware removal was requested by the patient because of plate prominence. CONCLUSIONS: Anteroinferior plating of midshaft clavicle fractures, delayed unions, and nonunions resulted in low hardware removal rates in our cohort.

Composite Fixation of Proximal Tibial Nonunions: A Technical Trick.

Nonunion after a proximal tibia fracture is often associated with poor bone stock, (previous) infection, and compromised soft tissues. These conditions make revision internal fixation with double plating difficult. Combining a plate and contralateral 2-pin external fixator, coined composite fixation, can provide an alternative means of obtaining stability without further compromising soft tissues. Three patients with a proximal tibia nonunion precluding standard internal fixation with double plating were treated with composite fixation. All 3 patients achieved union with deformity correction at a mean of 5.2 months (range, 5-5.5 months). The average range of motion (ROM) arc was 100° (range, 100°-115°) and postoperative ROM returned to pre-injury levels.Composite fixation can be a helpful adjunct in the treatment of this challenging problem.

Pauwels Osteotomy for Femoral Neck Nonunion in Two Adult Siblings with Osteogenesis Imperfecta.

This is a retrospective review of two adult siblings with osteogenesis imperfecta (OI) type III (according to Sillence classification), who sustained a spontaneous femoral neck fracture and subsequent nonunion. The diagnosis of OI in these two patients was made based on clinical, radiological and genetic findings. The fracture was most likely caused by femoroacetabular impingement secondary to OI induced acetabular protrusio. A valgus osteotomy according to Pauwels'principles and fixation of the osteotomy and nonunion with a locking plate resulted in healing despite compromised bone quality and limited bone stock. Long-term follow up (4.5 years and 6.5 years, respectively) is provided. When treating this difficult problem, improving the mechanobiological environment and decreasing the femoroacetabular impingement by a Pauwels type osteotomy should be considered.

Periprosthetic femoral nonunions treated with internal fixation and bone grafting.

INTRODUCTION: Periprosthetic femoral nonunions (PPFN) have a reported incidence of 3-9%. Literature on PPFN management is scarce. The study aim was to review combined results of two academic teaching hospitals using comparable PPFN treatment strategies. MATERIALS AND METHODS: A retrospective review was conducted of all patients treated for a PPFN between February 2005 and December 2016. All patients treated with internal fixation for a PPFN with complete clinical and radiological follow-up until healing were included. Nineteen patients were identified (mean age 71.2 years, range 49-87). Treatment consisted of failed hardware removal, debridement, reduction, and rigid internal fixation with or without bone graft. For revision PPFN surgery, use of dual-plating and bone graft augmentation was common. RESULTS: Eighteen of 19 patients (94.7%) progressed to osseous union. One patient was converted to a total femoral prosthesis. No patients were lost to follow-up. All were ambulatory at last follow-up and mean follow-up was 39.8 months. Fourteen patients (73.7%) united after our index nonunion surgery at mean 9.8 months. Five patients (26.3%) required revision surgery after our index nonunion treatment and in 4 of these cases union was achieved at mean 18.0 months. CONCLUSIONS: Our results suggest debridement, revision of fixation and liberal use of bone grafting can lead to reliable healing in the majority of PPFNs. For those PPFNs that do not heal following initial treatment, good healing potential persists with an additional procedure. LEVEL OF EVIDENCE: Prognostic Level III.

Early Revision Surgery for Tibial Plateau Fractures.

OBJECTIVE: To describe patients' outcomes after revision of tibial plateau fracture fixation within 12 months of the initial surgical procedure. To assess differences in objective outcome scores [International Knee Documentation Committee (IKDC), short form-36, arthrosis score, physical examination] depending on whether patients were treated for malreduction, malunion, or nonunion. DESIGN: Retrospective case series. PATIENTS: Twenty-seven patients who underwent revision within 1 year of primary surgery and with a minimum follow-up of 1 year. MAIN OUTCOME MEASUREMENT: IKDC Subjective Knee Form, alignment, osteoarthritis, timed up and go test, range of motion, and physical and mental health (using the short form-36 survey). RESULTS: At the most recent follow-up, the mean IKDC subjective knee score of all patients within the study group was 62 (SD 17). In the malreduction group, the mean was 71 (SD 17), in the malunion group the mean was 56 (SD 17), and in the nonunion group, the mean was also 56 (SD 12; χ 0.94; P = 0.624). Comparing the malreduction group with the malunion and nonunion groups combined, there was a significantly higher IKDC score (P = 0.019) in the malreduction group. CONCLUSION: A suboptimal outcome after open reduction and internal fixation of a tibial plateau fracture is common. If the underlying cause of the fracture is malreduction, malunion, or a nonunion, salvage of the joint without a knee replacement is worthwhile. When using a strategy incorporating revision plate fixation, osteotomy (intra- and/or extraarticular), debridement, and bone grafting when needed, patients should experience favorable long-term outcomes, including less residual pain and functional limitations. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Presumed Aseptic Long-Bone Nonunions With Positive Intraoperative Cultures Through a Single-Stage Surgical Protocol.

OBJECTIVE: To evaluate the outcomes of a single-stage surgical protocol to treat a presumed aseptic long-bone nonunion with positive intraoperative cultures obtained at the time of surgery. DESIGN: Retrospective comparative series. SETTING: Orthopaedic specialty hospital. PATIENTS AND METHODS: We retrospectively identified 77 patients with long-bone nonunions thought to be aseptic preoperatively, which grew bacteria from cultures obtained at the time of index nonunion surgery. INTERVENTION: Fifty (65%) patients underwent open debridement of the nonunion site followed by surgical stabilization through plates and screws. Twenty-seven (35%) patients underwent exchange nailing with canal reamings used for cultures. MAIN OUTCOME MEASUREMENT: Rate of radiographic union, time to clinical and radiographic union, nonunion rate after index nonunion surgery, and final union rate after revision procedures. RESULTS: Osseous union after the index nonunion surgery was achieved in 84% of the patients (65 of 77). Time to clinical union was 6.3 months (range, 1-24 months), and time to radiographic union was 7.4 months (range, 2-24 months). Eighteen percent (14 of 77 patients) did not heal after the index nonunion surgery and required additional surgeries. The final union rate after revision surgery was 99% (76 of 77 patients). CONCLUSIONS: Eighty-four percent of presumed aseptic nonunions of long-bone fractures with positive intraoperative cultures fully healed after a single-stage surgical protocol and long-term antibiotic when appropriate. When patients are diagnosed with a subclinical infected nonunion, they should be counseled about the higher likelihood of reoperation, but in most cases can expect excellent union rates after 1 additional surgery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Quantitative and Qualitative Assessment of the Relative Arterial Contributions to the Calcaneus.

BACKGROUND: The purpose of this study was to quantitatively and qualitatively assess relative arterial contributions to the calcaneus. METHOD: Fourteen cadaveric ankle pairs were used. In each specimen, the posterior tibial artery, peroneal artery, and anterior tibial artery were cannulated and used for contrast-enhanced magnetic resonance imaging (MRI) and computed tomography (CT). Quantitative MRI analysis of the pre- and postcontrast MRI scans facilitated assessment of relative arterial contributions. In addition, postcontrast MRIs were used to measure all perfused arterial entry points and scaled to a 3-dimensional calcaneus model. Contrast-enhanced CT imaging was assessed to further delineate the extraosseous arterial course. Two pairs underwent infusion of diluted BaSO4 through a constant-pressure pump using extended infusion duration. RESULTS: Quantitative MRI findings indicated the peroneal artery provided 52.6% of the calcaneal arterial supply, 31.6% from the posterior tibial artery, and 15.8% from the anterior tibial artery. The cortical entry points were found in fairly consistent patterns along calcaneal cortical surfaces. All specimens demonstrated intraosseous anastomoses between lateral and medial entry points at common locations. CONCLUSIONS: The peroneal artery was found to provide the largest calcaneal arterial contribution, followed by the posterior tibial artery and anterior tibial artery. A rich anastomotic arterial network was found supplying the calcaneus. CLINICAL RELEVANCE: This study provides quantitative and qualitative findings of the relative arterial contribution of the calcaneus. This knowledge can help expand our understanding of calcaneal vascularization, demonstrate the vascular impact of calcaneal fracture and surgery, and facilitate future research on the arterial anatomy of the calcaneal soft tissue envelope.

Effect of the Containment Type on Clinical Outcomes in Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation.

BACKGROUND: Uncontained-type osteochondral lesions of the talus (OLTs) have been shown to have inferior clinical outcomes after treatment with bone marrow stimulation. While autologous osteochondral transplantation (AOT) is indicated for larger lesions, no study has reported on the prognostic significance of the containment of OLTs treated with the AOT procedure. PURPOSE: To clarify the effect of the containment of OLTs on clinical and radiological outcomes in patients who underwent AOT for OLTs. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: A retrospective cohort study comparing patients with contained-type and uncontained-type OLTs was undertaken to include all patients who underwent AOT for the treatment of OLTs between 2006 and 2014. Analyses were performed by grouping the patients according to the containment type. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and the 12-Item Short Form Health Survey (SF-12) preoperatively and at final follow-up. Magnetic resonance imaging (MRI) at 2 years' follow-up was evaluated with the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Multivariate regression models were used to evaluate factors affecting postoperative FAOS, SF-12, and MOCART scores. RESULTS: Ninety-four patients were included: 31 patients with a contained-type OLT and 63 patients with an uncontained-type OLT. The median patient age was 34 years (interquartile range [IQR], 28-48 years) in the contained-type group and 36 years (IQR, 27-46 years) in the uncontained-type group. The median follow-up time was 45 months (IQR, 38-63 months) in the contained-type group and 52 months (IQR, 40-66 months) in the uncontained-type group. The median FAOS and SF-12 scores improved significantly after surgery in both contained-type and uncontained-type lesions ( P < .001). The median postoperative FAOS score of patients with contained-type OLTs was higher than that of patients with uncontained-type OLTs (91.7 vs 85.0, respectively; P = .009), but no significant differences were found between the contained-type and uncontained-type groups for postoperative SF-12 and MOCART scores. The multivariate regression models showed that patients with contained-type OLTs had an approximately 10-point better score on the FAOS compared with patients with uncontained-type OLTs ( P = .006). There was a nonsignificant trend for the rate of cystic occurrence in uncontained-type OLTs to be higher than that of contained-type OLTs (55.6% vs 38.7%, respectively; P = .125). CONCLUSION: Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

Surgical Technique: Treatment of Distal Humerus Nonunions.

BACKGROUND: Open reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully. QUESTIONS/PURPOSES: The purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients. METHODS: A few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft. RESULTS: The vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation. CONCLUSION: Important components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with-locking-plates and liberal use of bone graft.

Hemorrhagic-Induced Cardiovascular Complications During Reamer-Irrigator-Aspirator-Assisted Femoral Nonunion Treatment.

UNLABELLED: The reamer-irrigator-aspirator (RIA) is a device that has recently been developed to retrieve bone graft from the medullary canal of the femur and the tibia. As for most new surgical procedures, complications arise as part of the learning curve and/or imperfections in the design or technique. To increase awareness of potential complications and to prevent unnecessary harm to the patient, new complications need to be reported. We present case reports of 2 patients who developed severe intraoperative cardiac events presumably caused by excessive and rapid blood loss during RIA bone graft harvesting. This complication has not been described before. Increased awareness of excessive blood loss and subsequent cardiac events during an RIA procedure is warranted. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.