Bilateral Atypical Femoral Fracture in a Bisphosphonate-Naïve Patient with Prior Long-Term Denosumab Therapy: A Case Report of the Management Strategy and a Literature Review.

The benefits of denosumab as an antiresorptive therapy and in reducing fragility fractures are well documented. However, its association with atypical femur fractures (AFFs), especially in the absence of prior bisphosphonate use, remains poorly understood and warrants further investigation. This case report presents a rare instance of bilateral AFFs in a 78-year-old bisphosphonate-naïve patient with a history of long-term denosumab therapy for previous metastatic breast cancer. Management involved intramedullary nail fixation after initial presentation with a unilateral AFF and a recommendation to cease denosumab therapy. However, the patient subsequently experienced a contralateral periprosthetic AFF below a total hip implant 5 months thereafter and was treated with open reduction internal fixation. This case report highlights the critical need for orthopedic surgeons to maintain a high level of suspicion and vigilance in screening for impending AFFs, especially in patients with a prolonged history of denosumab therapy without prior bisphosphonate use. Furthermore, the growing report of such cases emphasizes the urgent need for comprehensive research aimed at refining treatment protocols that balance the therapeutic benefits of denosumab and its associated risks of AFFs.

No Difference in Acute Outcomes for Patients Undergoing Fix and Replace Versus Fixation Alone in the Treatment of Geriatric Acetabular Fractures.

OBJECTIVES: To compare acute outcomes between patients undergoing fix and replace (FaR) versus open-reduction and internal fixation (ORIF) alone in the treatment of geriatric acetabular fractures. DESIGN: Retrospective Cohort Study. SETTING: Single Level 2 Trauma Center. PATIENT SELECTION CRITERIA: Consecutive acetabular fracture patients ≥ 55 years of age treated by two orthopaedic trauma surgeons at one tertiary care center from January 2017 to April 2022 with FaR versus ORIF were identified. Included were those with complete datasets within the 180-day global period. Excluded were patients with previous ORIF of the acetabulum or femur, or revision total hip arthroplasty. OUTCOME MEASURES AND COMPARISONS: The primary outcomes were length of hospital stay (LOS), postoperative weight-bearing status, postoperative disposition, time to postoperative mobilization, and 90-day readmission rates. Secondary outcomes compared included demographic information, injury mechanism, surgical time, complications, revisions, and preoperative and postoperative Hip Disability and Osteoarthritis Outcomes Score for Joint Replacement (HOOS Jr.) scores. These were compared between FaR and ORIF groups. RESULTS: Seventeen FaR patients (average age 74.5 ± 9.0 years) and 11 ORIF patients (average age 69.4 ± 9.6 years) met inclusion criteria. Mean follow-up was 26.4 months (range: 6-75.6 months). More FaR group patients were ordered immediate weight-bearing as tolerated or partial weight-bearing compared with ORIF alone (70% vs. 9.0%, P = 0.03). More patients in the FaR group had pre-existing hip osteoarthritis compared with ORIF alone (71% vs. 27%, P = 0.05). Fracture classification ( P = 0.03) and Charlson Comorbidity Index ( P = 0.02) differed between the 2 groups. There were no other differences in demographics, LOS ( P = 0.99), postoperative disposition ( P = 0.54), time to postoperative mobilization ( P = 0.38), 90-day readmission rates ( P = 0.51), operative time ( P = 0.06), radiographic union ( P = 0.35), time to union ( P = 0.63), pre- ( P = 0.32) or postoperative HOOS Jr. scores ( P = 0.80), delta HOOS Jr. scores ( P = 0.28), or reoperation rates between groups ( P = 0.15). CONCLUSIONS: FaR and ORIF seem to be sound treatment options in the management of geriatric acetabular fractures. Patients in the FaR group achieved immediate or partial weight-bearing earlier than the ORIF group; however, time to postoperative mobilization did not differ between the two groups. The remainder of acute postoperative outcomes (LOS, postoperative disposition, and 90-day readmission rates) did not differ between the two groups. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early versus Standard Weight Bearing Following Operative Treatment of Tibial Plateau Fractures: Do We Really Have to Wait So Long?

Postoperative management of tibial plateau fractures classically involves a prolonged period between 10 and 12 weeks of nonweight bearing or partial weight bearing. In recent years, there has been some support for earlier weight-bearing protocols although this remains controversial. The goal of this study was to investigate the difference in outcomes between early weight-bearing (EWB) and traditional weight-bearing (TWB) protocols. This investigation is a retrospective review of 92 patients treated with open reduction and internal fixation of tibial plateau fractures at a single institution, from August 2018 to September 2020. Subjects were divided into EWB (< 10 weeks) and traditional nonweight bearing groups (≥ 10 weeks). Key outcome measures collected include injury classification, mechanism of injury, surgical fixation method, bone grafting, time to full weight bearing, radiographic time to union, range-of-motion, all-cause complications, and subsidence at an average follow-up time of 1 year. The EWB group had an earlier average time to weight bearing versus the TWB group (6.5 ± 1.4 vs. 11.8 ± 2.3 weeks, p < 0.0001). There was no difference in the classification of fractures treated between the two groups, with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association B3 fractures the most common in the EWB group, and C3 fractures the most common in the TWB group. Radiographic time to union was no different between the two groups (93.5 ± 53.7 days for EWB vs. 103.7 ± 77.6 days for TWB, p = 0.49). There was no significant difference in complication rates or subsidence. Following operative treatment of tibial plateau fractures, patients who underwent a weight-bearing protocol earlier than 10 weeks were able to recover faster with similar outcomes and complications compared with patients who started weight bearing after 10 weeks or more. LEVEL OF EVIDENCE: III.

Outcomes of Antibiotic-Impregnated Calcium Sulfate, Reamer-Irrigator-Aspirator, and Locked Intramedullary Static Spacer in the Treatment of Periprosthetic Joint Infection in the Multiply Revised and Infected Knee: A Single-Center Case Series.

Background: Periprosthetic joint infection after total knee arthroplasty is commonly treated via 2-stage revision utilizing either articulating or static antibiotic cement spacers. While recent literature exhibits a slight functional advantage in favor of articulating spacers, those patients with a history of recurrent infection/multiple revision procedures are frequently excluded from these studies. The purpose of this study was to report infection eradication rates and efficacy of utilizing antibiotic-loaded locked intramedullary nail for infection for the multiply revised, infected total knee arthroplasty. Methods: A retrospective review was performed of all consecutive patients receiving static spacers between 2017 and 2020 at an academic medical center. Surgical techniques for all patients included irrigation and debridement using a reamer-irrigator-aspirator, injection of antibiotic-loaded calcium sulfate into the intramedullary canal, and nail placement. Antibiotic-loaded cement is then used to create a spacer block in the joint space. A Cox proportional hazard regression was run to identify risk factors for reinfection. Results: Forty-two knees in 39 patients were identified meeting inclusion criteria. Overall, there was an 68.8% infection eradication rate at an average of 46.9 months following spacer placement. The only risk factors identified on cox regression were increasing number of previous spacers, a surrogate for previous infections (hazards ratio = 14.818, P value = .021), and increasing operative time during spacer placement (hazards ratio = 1.014, P value = .039). Conclusions: Use of static spacers, in conjunction with reamer-irrigator-aspirator and antibiotic-loaded calcium sulfate, can be effective in treating chronic, complex periprosthetic joint infections in the setting of bone loss and or soft-tissue compromise and produced similar results to more simple infection scenarios.

Does a delay to surgery for preoperative echocardiogram affect outcomes in patients with hip fracture?

Introduction: Delay to surgery >24 hours has been shown to correlate with mortality rates in patients with hip fracture when left untreated. Many of these patients have multiple comorbidities, including aortic stenosis (AS), and undergo workup for operative clearance, which may delay time to surgery. The purpose of this study was to examine whether preoperative echocardiogram workup affects time to surgery, complications, and mortality after operative fixation for hip fracture. Methods: Our institutional hip fracture registry was retrospectively reviewed for inclusion over a 3-year period. Patients who had a preoperative echocardiogram (yECHO) for operative clearance were compared with those who did not (nECHO). Demographic data, time to surgery, overall complication rate, and mortality at 30 days, 90 days, and 1 year were collected. Results: Two cohorts consisted of 136 yECHO patients (45.8%) and 161 nECHO patients (54.2%). Thirty-two yECHO patients (23.5%) had AS. Patients in the yECHO cohort were more likely to have a complication for any cause compared with nECHO patients (25.7% vs. 10.6%, P = 0.01) and have a higher mortality rate at 1 year (38.9% vs. 17.4%, P = 0.001). There was no association found between AS and all-cause complication (P = 0.54) or 30-day (P = 0.13) or 90-day mortality rates (P = 0.79). However, patients with AS had a significantly higher mortality rate at 1 year (45.8% vs. 25.1%, P = 0.03). Conclusion: This study reinforces the benefits of ensuring less than a 24-hour time to surgery in the setting of a hip fracture and identifies an area of preoperative management that can be further optimized to prevent unnecessary prolongation in time to surgery. Patients with known aortic stenosis are not associated with increased 30-day or 90-day mortality or all-cause complications. Surgical delays in the yECHO cohort were attributed to preoperative medical assessments, including echocardiograms and the management of comorbidities. Therefore, the selective utilization of preoperative echocardiograms is needed and should be reserved to ensure they have a definitive role in guiding the perioperative care of patients with hip fracture. Level of Evidence: III.

Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature.

INTRODUCTION: To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications. MATERIALS AND METHODS: A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width). RESULTS: A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups. CONCLUSION: Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes. LEVEL OF EVIDENCE: Therapeutic Level III.

Intraoperative Fluoroscopy Versus Navigation to Determine Cup Anteversion in Direct Anterior Total Hip Replacement: A Technical Trick for Obtaining "True" Anteversion.

During acetabular cup positioning, intraoperative measurements of cup anteversion were taken using both fluoroscopy and navigation system. With the C-arm introduced at 40°, an anteroposterior view of the pelvis is taken. The C-arm is then centered over the hip, showing an anteverted cup with an approximate inclination of 40°. The axial C-arm is tilted away until the cup opening is visualized as a straight line, indicating that the beam of the fluoroscopy is aligned with the cup's anteversion. The tilt angle on the C-arm and anteversion reading on the navigation workstation were recorded. The high degree of agreement between fluoroscopic and navigation measurement of acetabular cup anteversion supports the use of fluoroscopy in settings with limited access to navigation systems in direct anterior total hip arthroplasty.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS: A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS: Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION: Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE: Therapeutic Level IV.

Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures.

OBJECTIVES: To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation. DESIGN: Retrospective pre-post study design. SETTING: Single Level II Trauma Center. PATIENT SELECTION CRITERIA: All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group. OUTCOME MEASURES AND COMPARISONS: The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days. RESULTS: Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups. CONCLUSION: This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using the Equatorial Talar Line as a Radiographic Predictor of Sanders Type 3 and 4 Calcaneus Fractures and Lateral Wall Blowout.

OBJECTIVE: To assess the equatorial talar line (ETL) as a sensitive radiographic parameter to predict Sanders type III and IV fractures and the presence of lateral wall blowout. METHODS: Reliability of the ETL was assessed using the intraclass correlation coefficient (ICC) and receiver operating curve (ROC) to predict sensitivity. Using lateral ankle radiographs, raters determined whether the calcaneal tuberosity was "above" (predicting Sanders type I or II) or "below" (predicting Sanders type III or IV and lateral wall blowout). RESULTS: In determining the "above" or "below" location of the ETL, the calculated ICC was 1.0 for each session. As a predictor of Sanders fracture classification type, the calculated ICC was 0.93 for the first session and 0.89 for the second session for an overall ICC of 0.91. As a predictor of Sanders fracture type, ROC analysis yielded an overall sensitivity of 0.82. As a predictor of lateral wall blowout, ROC analysis yielded an overall sensitivity of 0.81. CONCLUSION: The ETL is a reproducible radiographic parameter that can be reliably used to crudely predict between Sanders type I or II (ETL is "above") and Sanders type III or IV (ETL is "below") calcaneus fractures as well as the presence of lateral wall blowout.

Reverse Total Shoulder Arthroplasty for Younger Patients: A Comparable Analysis of Patients Older and Younger Than 65 Years.

INTRODUCTION: Reverse total shoulder arthroplasty (rTSA) has become a popular option for the surgical management of rotator cuff arthropathy and complex fractures of the proximal humerus. However, there is a paucity of studies evaluating outcomes, especially between patients of different age groups. The purpose of this study was to compare functional outcomes and survivorship between patients older than 65 years (o65) and those 65 years and younger (y65). METHODS: A retrospective review was conducted at a single academic medical center identifying a consecutive cohort of patients undergoing rTSA between 2018 and 2020. The minimum follow-up time was 2 years. Patients were stratified into two groups for comparative analyses (y65 and o65). Patient demographics, perioperative and postoperative data, and functional outcomes were collected. A Kaplan-Meier survival analysis was conducted to determine survivorship, defined as revision surgery or implant failure. RESULTS: Forty-eight patients were included for final analysis. Nineteen patients comprised the y65 group while 29 patients comprised the o65 group. No difference was observed in Quick Disabilities of the Arm, Shoulder, and Hand scores at baseline nor at the latest follow-up between the two groups. Patients in the y65 group had significantly greater internal and external rotation (IR/ER) from 3 months to 2 years compared with patients in the o65 group (P ≤ 0.05). Finally, there were no differences in revision surgery rates between the y65 group and the o65 group (11% vs. 14%, P = 1.0). A KM survival analysis revealed no difference in implant failure, necessitating revision surgery between the two groups at the latest follow-up (P = 0.69). DISCUSSION: Despite a notable difference in the number of baseline comorbidities, there were no notable differences in functional outcomes, survivorship, and revision surgery rates between each cohort. Although both groups had a similar function initially, by 3 months postoperatively, the y65 group had markedly greater range of motion in IR and ER. Longer term survivorship is needed; however, rTSA may offer a reliable option for shoulder reconstruction even in the y65 patient group.

Are complications related to the perineal post on orthopaedic traction tables for surgical fracture fixation more common than we think? A systematic review.

BACKGROUND: Traction tables have long been utilized in the management of fractures by orthopaedic surgeons. The purpose of this study was to systematically review the literature to determine the complications inherent to the use of a perineal post when treating femur fractures using a traction table. METHODS: A systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) using PubMed, EMBASE, and Cochrane Library. The search phrase used was "fracture" AND "perineal" AND "post" AND ("femur" OR "femoral" OR "intertrochanteric" OR "subtrochanteric"). Inclusion criteria for this review were: level of evidence (LOE) of I - IV, studies reporting on patients surgically treated for femur fractures, studies reporting on patients treated on a fracture table with a perineal post, and studies that reported the presence or absence of perineal post-related complications. The rate and duration of pudendal nerve palsy were analyzed. RESULTS: Ten studies (2 prospective and 8 retrospective studies; 2 LOE III and 8 LOE IV) were included consisting of 351 patients of which 293 (83.5%) were femoral shaft fractures and 58 (16.5%) were hip fractures. Complications associated with pudendal nerve palsies were reported in 8 studies and the mean duration of symptoms ranged between 10 and 639 days. Three studies reported a total of 11 patients (3.0%) with perineal soft tissue injury including 8 patients with scrotal necrosis and 3 patients with vulvar necrosis. All patients that developed perineal skin necrosis healed through secondary intention. No permanent complications relating to pudendal neurapraxia or soft tissue injuries were reported at final follow-up timepoints. CONCLUSION: The use of a perineal post when treating femur fractures on a fracture table poses risks for pudendal neurapraxia and perineal soft tissue injury. Post padding is mandatory and supplemental padding may also be required. Appropriate perineal skin examination prior to use is also important. Occurring at a higher rate than previously thought, appropriate post-operative examination for any genitoperineal soft tissue complications and sensory disturbances should not be ignored.

Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy.

INTRODUCTION: Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA). METHODS: All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition. RESULTS: A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015). CONCLUSION: The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.

Response to Letter to the Editor: Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

We would like to thank the editors for the opportunity to respond to their letter regarding our study, "Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?" published in the Indian Journal of Orthopaedics. The authors greatly appreciate the insight and thoughtful feedback regarding the findings of our study, which may be skewed by heterogenous data and/or technical aspects of surgical plating and intramedullary nailing. We agree with the editors and believe that higher level randomized trials along with specific studies focused on studying modes and causes for treatment failure are necessary to further elucidate the heterogenous data. Nonetheless, with an overall union rate of about 90% and without significant differences in outcomes, at this juncture, we conclude that either intramedullary nailing or locked plate fixation is acceptable treatment options for distal femur fractures.

Distal femur: nail plate combination and the linked construct.

Operative fixation of distal femur fractures in patients with osteoporotic bone can be challenging. Treatment with either lateral locking plate or retrograde intramedullary nail alone may not provide adequate fixation to allow for early mobilization. Rather, fixation using the nail plate combination (NPC) to treat distal femur fractures in the elderly may offer improved biomechanical stability to achieve immediate weight-bearing, especially in the setting of complex fracture patterns and osteoporosis. Here, we describe the rationale, step-by-step technique, and outcome following 2 cases: 1 patient treated with a true NPC procedure using retrograde intramedullary nail and standard locking plate, as well as a NPC procedure using a novel locking attaching washer plate.

Scapulothoracic Dissociation: A Review of an Orthopedic Emergency.

Scapulothoracic dissociation is a rare and devastating injury that is considered an orthopedic emergency. It is critical to recognize this injury early based on mechanism, physical examination, and radiographic parameters. Initial management should be focused on resuscitation and evaluation for potential limb-threatening ischemia.

Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

INTRODUCTION: Distal femur fractures make up < 1% of all fractures and 3-6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other. METHODS: Systematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria. RESULTS: Forty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment. CONCLUSION: Compiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures.