Peri-implant fractures of the upper and lower extremities: a case series of 61 fractures.

PURPOSE: To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS: Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS: Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION: PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.

THE EFFECTS OF HYPONATREMIA ON BONE DENSITY AND FRACTURES: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Objective: Hyponatremia decreases bone mineral density and is a major risk factor for fragility fractures. Objectives of our systematic review and meta-analysis were to analyze the overall effects of hyponatremia on bone fractures, osteoporosis, and mortality. Methods: We extracted data from Medline, Cochrane Central, and EMBASE 1960-2017 and conference abstracts from 2007-2017. We included studies with data on serum sodium, fractures, bone density, or diagnoses of osteoporosis. Studies were independently reviewed by two authors and assessed for bias using the Newcastle-Ottawa scale. Random effect models meta-analysis was used when at least three studies reported the same outcome measures. We reported summary odds ratios (ORs) and 95% confidence intervals (CIs). Results: We included 26 studies for qualitative analysis. Fifteen studies were included in the meta-analysis to evaluate the effects of hyponatremia on fractures, four studies for bone mineral density changes, and six for mortality. Hyponatremia increased the odds of fractures at all sites (summary OR, 2.34 [95% CI, 1.86, 2.96]. There was an increase in the odds of osteoporosis (summary OR, 2.67 [95% CI, 2.07, 3.43]). Mortality risk among the included studies remained high (summary OR, 1.31 [95% CI, 1.16, 1.47]). Conclusion: Our meta-analysis confirms a statistically significant association of hyponatremia with bone fractures and osteoporosis along with higher mortality. Long-term prospective studies evaluating the impact of correcting hyponatremia on bone health, fractures, and mortality are required. Abbreviations: AVP = arginine vasopressin; CI = confidence interval; CKD = chronic kidney disease; OR = odds ratio; SIADH = syndrome of inappropriate antidiuretic hormone.

Long Term Treatment Results for Deep Infections of Total Knee Arthroplasty.

This study aims to identify the long-term outcomes of total knee arthroplasty (TKA) treated for deep infection. 3270 consecutive primary and 175 revision TKAs were followed prospectively. There were 39 deep infections (1.16%): 29 primary (0.9%) and 10 revision (5.7%) cases. Two-stage resection and re-implantation procedure was performed in 13 primary cases with 10/13 (77%) successfully resolved. Early (<1 month) Irrigation and Debridement (I&D) was performed in 16 primary cases with 100% success. Late (>4 months) I&D was performed in 6 cases with 5/6 (83.3%) successful. Infection following revision TKA resulted in poor outcomes with both two-stage (2/4 successful) and I&D (2/6 successful). Deep infection after primary TKA can be successfully resolved with I&D and appropriate antibiotic treatment in the early postoperative course.

Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients.

BACKGROUND: Femoral neck fractures are a major public health problem. Multiple-screw fixation is the most commonly used surgical technique for the treatment of stable femoral neck fractures. QUESTIONS/PURPOSES: We determined (1) the proportion of hips that had conversion surgery to THA, and (2) the proportion of hips that underwent repeat fracture surgery after percutaneous screw fixation of stable (Garden Stages I and II) femoral neck fractures in patients older than 65 years and the causes of these reoperations. METHODS: We performed a retrospective study of all patients older than 65 years with stable femoral neck fractures secondary to low-energy trauma treated surgically at our institution between 2005 and 2008. We identified 121 fractures in 120 patients older than 65 years as stable (Garden Stage I or II); all were treated with percutaneous, cannulated screw fixation in an inverted triangle without performing a capsulotomy or aspiration of the fracture hematoma at the time of surgery. The average age of the patients at the time of fracture was 80 years (range, 65-100 years). Radiographs, operative reports, and medical records were reviewed. Fracture union, nonunion, osteonecrosis, intraarticular hardware, loss of fixation, and conversion to arthroplasty were noted. Followup averaged 11 months (range, 0-5 years) because all patients were included, including those who died. The mortality rate was 40% for all patients at the time of review. RESULTS: Twelve patients (10%) underwent conversion surgery to THA at a mean of 9 months after the index fracture repair (range, 2-24 months); the indications for conversion to THA included osteonecrosis, nonunion, and loss of fixation. Two others had periimplant subtrochanteric femur fractures treated by surgical repair with cephalomedullary nails and two patients had removal of hardware. CONCLUSIONS: Revision surgery after osteosynthesis for stable femoral neck fractures was more frequent in this series than previously has been reported. The reasons for this higher frequency of reoperation may be related to poor bone quality, patient age, and some technical factors, which leads us to believe other treatment options such as nonoperative management or hemiarthroplasty may be viable options for some of these patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection.

Patients with diabetes have a higher incidence of infection after total joint arthroplasty (TJA) than patients without diabetes. Hemoglobin A1c (HbA1c) levels are a marker for blood glucose control in diabetic patients. A total of 3468 patients underwent 4241 primary or revision total hip arthroplasty or total knee arthroplasty at one institution. Hemoglobin A1c levels were examined to evaluate if there was a correlation between the control of HbA1c and infection after TJA. There were a total of 46 infections (28 deep and 18 superficial [9 cellulitis and 9 operative abscesses]). Twelve (3.43%) occurred in diabetic patients (n = 350; 8.3%) and 34 (0.87%) in nondiabetic patients (n = 3891; 91.7%) (P < .001). There were 9 deep (2.6%) infections in diabetic patients and 19 (0.49%) in nondiabetic patients. In noninfected, diabetic patients, HbA1c level ranged from 4.7% to 15.1% (mean, 6.92%). In infected diabetic patients, HbA1c level ranged from 5.1% to 11.7% (mean, 7.2%) (P < .445). The average HbA1c level in patients with diabetes was 6.93%. Diabetic patients have a significantly higher risk for infection after TJA. Hemoglobin A1c levels are not reliable for predicting the risk of infection after TJA.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Postoperative Complications of Hip Fractures Patients on Chronic Coumadin: A Comparison Based on Operative International Normalized Ratio.

In current clinical practice, orthopedic surgeons often delay the surgery intervention on geriatric hip fracture patients to optimize the international normalized ratio (INR), in order to decrease the risk of postoperative hematological complications. However, some evidence suggests that full reversal protocols may not be necessary, especially for patients with prior thromboembolic history. Our study aims to compare the surgical outcomes of patients with normal versus elevated INR values. We conducted a retrospective chart review on 217 patients who underwent surgeries on hip fractures at two academic trauma centers. We found that in our group (n = 124) of patients with an INR value of 1.5-3.0, there was only one reoperation for a hematoma, but there was a trend for more blood transfusions. There was no statistically significant difference in the odds of reoperation or overall complications. Nevertheless, there were significantly more events of postoperative anemia in this high INR patient group.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Garden 1 and 2 Femoral Neck Fractures Collapse More Than Expected After Closed Reduction and Percutaneous Pinning.

OBJECTIVES: To report on the final displacement after in situ percutaneous pinning for Garden type 1 and 2 fractures in height, femoral neck fracture collapse, and loss of offset. DESIGN: Retrospectively reviewed case series. SETTING: Three Academic Medical Centers. Boston University Medical Center (Level 1 Trauma Center), Lahey Hospital and Medical Center (Level 2 Trauma Center), and Geisinger Medical Center (level 2 Trauma Center). PATIENTS/PARTICIPANTS: One hundred thirty skeletally mature patients with 130 fractures (78 garden 1 and 52 garden 2) who were treated between January 2000 and January 2014 at participating hospitals with percutaneous pinning with a cannulated screw system to successful union after sustaining an intracapsular femoral neck fracture without complete displacement. INTERVENTION: In situ percutaneous pinning with 3 cannulated, partially threaded screws in an inverted triangle orientation. MAIN OUTCOME MEASUREMENTS: Femoral neck fracture collapse (mm), femoral height shortening (mm), and femoral offset shortening (mm). RESULTS: A total of 130 patients (81F, 49M), average age 72 years, sustained 78 Garden 1 and 52 Garden 2 femoral neck fractures. Maximal collapse occurred in the plane of the femoral neck. Thirty-three of 78 (42%) Garden 1 fractures and 33/52 (63%) Garden 2 fractures demonstrated >10 mm fracture collapse. The range of displacements was 0-39 mm as measured along the plane of the femoral neck. CONCLUSIONS: Garden 1 fractures collapse less frequently than Garden 2 fractures, but both have high rates of fracture collapse when treated to union with in situ percutaneous pin fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Previous Implant Fractures: A New Descriptive Classification System.

OBJECTIVES: To propose a previous implant fractures (PIFs) classification system with good interobserver reliability. DESIGN: Retrospective classification. SETTING: Four academic medical centers. PATIENTS/PARTICIPANTS: A retrospective review of PIFs treated at 4 academic medical centers over 10 years was performed. Data collected included initial implant and PIF radiographs. There were 103 PIFs in 96 patients during the study period. Seventy-three (70.9%) were about plate/screw (PS) constructs and 30 (29.1%) were about intramedullary (IM) devices. INTERVENTION: Assignment of PIF classification. MAIN OUTCOME MEASUREMENTS: PIFs were classified based on initial implant (PS or IM) and fracture location with respect to the initial implant (proximal or distal to the implant, at the tip of the construct, or within the construct). Reliability of this scheme was assessed among 5 observers using Fleiss' kappa tests. RESULTS: Of PIFs about plate/screw constructs, 26.0% were proximal/distal to the implant (classification: PS1), 57.5% involved bone between the most proximal/distal screw and the same end of the plate (classification: PS2), and 16.4% involved only bone between the most proximal and distal screws (classification: PS3). Of PIFs about IM, 43.3% were distal to the device (classification: IM1), 46.7% involved bone between the most proximal/distal locking bolt and the same end of the device (classification: IM2), and 10.0% involved only bone between locking bolts (classification: IM3). Interobserver reliability for the classification system was excellent between observers, κ = 0.839, P < 0.0005. CONCLUSIONS: The proposed system offers a simple method to classify and describe fractures that occur about a previously implanted fracture device. Development of a classification system will allow for comparison of treatment modalities between injury types.

Magnetic Resonance Imaging of Trauma Patients Treated With Contemporary External Fixation Devices: A Multicenter Case Series.

OBJECTIVES: To report the safety and clinical outcomes of placing current magnetic resonance imaging (MRI) components inside and outside the MRI bore during MRIs. DESIGN: Retrospective case series. SETTING: Four trauma centers (3 Level I and 1 Level II), from January 2005 to January 2015. PATIENTS: All patients who had MRIs with external fixators in place either inside or outside the MRI bore. INTERVENTION: MRI of patients with external fixator in place. MAIN OUTCOME MEASUREMENTS: Adverse events were defined as catastrophic pullout of the external fixator during the MRI, thermal injury to the skin, severe field distortions precluding the intended imaging, alterations of the magnetic field, or visible structural damage to the magnet casing. RESULTS: Thirty-eight patients with 44 external fixators were identified who had MRI with the fixator inside or outside the MRI bore. Twelve patients with 13 external fixators had MRI with the external fixator inside the MRI bore. Twenty-seven patients with 32 external fixators had MRI with the external fixator outside the MRI bore. There were no adverse events. CONCLUSIONS: Although no universal guidelines exist, there are circumstances in which obtaining MRIs of patients with external fixators can be safe. This is the first clinical series with the primary outcome of safety when placing modern external components both inside and outside an MRI bore during a scan. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

INTRODUCTION: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Knee Injury Associated With Acetabular Fractures: A Multicenter Study of 1273 Patients.

OBJECTIVES: The purpose of this study was to determine the incidence and pattern of the knee injury associated with acetabular fractures. DESIGN: Retrospective cohort study. SETTING: Three level I and one level II trauma centers. PATIENTS: A total of 1273 skeletally mature patients treated at 4 trauma centers between November 2004 and December 2013 for acetabular fractures were retrospectively identified from orthopaedic trauma databases. INTERVENTION: Analysis of all acetabular fractures with knee injury regarding type of acetabular fracture, mechanism of injury, energy of injury, pattern of the knee injury, knee examination findings at initial presentation, intraoperative and on follow-up, requirement for surgery/conservative management, and the associated injuries. The clinical data entered during inpatient stay and office visits were analyzed. MAIN OUTCOME MEASURES: Incidence and pattern of the knee injury. RESULTS: One hundred ninety-three of 1273 patients (15%) were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes including bone bruises, wounds, and swelling. Associated injuries included 85 patients with ipsilateral hip dislocation (45%), 59 pelvic injuries (31%), 61 extremity injuries (32%), 38 head injuries (20%), 37 chest injuries (20%), 23 abdominal and genitourinary injuries (12%), and 7 injuries of the spine (4%). CONCLUSION: Based on this study, we conclude that knee injuries associated with high-energy acetabular fractures constitute a significant portion of the patient population. Ligament injuries are frequently overlooked and thorough clinical evaluation and utilization of magnetic resonance imaging in selected cases will help in early detection and prevention of long-term complications. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Incidence of Distal Femoral Periprosthetic Fractures after Total Knee Arthroplasty.

BACKGROUND: The incidence of distal femoral periprosthetic fractures associated with total knee arthroplasty (TKA) has been reported as 0.3% to 2.5%. This study examined the incidence of distal femoral periprosthetic fractures at one hospital over a 16-year period. We hypothesized that the incidence of these fractures would be lowered after the introduction of lugged femoral implants and insertion of a distal femoral intramedullary bone graft during TKA. METHODS: From 1994 to 2010, 4,943 primary TKAs were performed. Following these TKA operations, 21 distal femoral fractures occurred. The surgical technique and implant design changed during this interval. Lugged femoral implants were introduced in 2000. Intramedullary bone grafting of the distal femoral intramedullary guide hole was introduced in 2002. RESULTS: The incidence of distal femoral periprosthetic fracture in this series of 4,943 TKA operations was 0.42% (21/4943). Six fractures occurred in 1,236 knees with femoral implants without femoral fixation lugs (0.49%). Fifteen fractures occurred in 3,707 knees with femoral implants with femoral fixation lugs (0.40%). Eight fractures occurred in 1,653 knees that did not have intramedullary bone grafts (0.48%). Thirteen fractures occurred in 3,290 knees that had intramedullary bone grafts (0.40%). Two fractures occurred in 417 knees with lugged femoral implants and no bone graft (0.48%). CONCLUSIONS: In this series, there was no significant difference in the incidence of distal femoral periprosthetic fractures associated with adding fixation lugs to the femoral implant and filling the femoral intramedullary hole with bone graft.

The use of clopidogrel (Plavix) in patients undergoing nonelective orthopaedic surgery.

OBJECTIVE: To assess the effects of Plavix on patients requiring nonelective orthopaedic surgery. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching institutions. PATIENTS AND PARTICIPANTS: The orthopaedic trauma registry was used to retrospectively identify all patients taking clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, NJ) who required nonelective orthopaedic surgery from 2004 to 2008. Twenty-nine patients were identified on Plavix (PG) and 32 matched patients in the control group not taking Plavix (NPG). The Plavix group was separated into those with a surgical delay less than 5 days of the last dose (PG < 5) (n = 28) and a delay greater than 5 days (PG > 5) (n = 1). A randomized age- and injury-matched control group not on Plavix was separated with surgical delay less than 5 days (NPG < 5) (n = 29) and delay greater than 5 days (NPG > 5) (n = 3). INTERVENTION: A retrospective review was performed comparing pre- and postoperative hemoglobin, blood transfusion requirements, surgical delay, 30-day mortality, and postoperative complications. MAIN OUTCOME MEASUREMENTS: Statistical analyses were performed using the Student t test and chi square test to identify differences between the groups. RESULTS: : The mean preoperative hemoglobin of the PG and the NPG was 11.2 g/dL and 12.3 g/dL (P = 0.03). Transfusion rates were similar with 18 of 28 in the PG compared with 13 of 29 in the NPG (P = 0.22). The mean surgical delay between the PG and NPG was 1.88 and 1.68 days (P = 0.64). Overall complications between the PG and NPG was nine of 28 and nine of 29 (P = 0.92). In both groups, two patients had postoperative wound drainage, which resolved without intervention. One patient in each group required revision surgery for nonunion. The 30-day mortality in the Plavix group was zero of 28 (0%) compared with one of 29 (3%) in the control group (cardiac arrest) (P = 0.32). CONCLUSIONS: In this study, there were no serious complications or increased transfusion requirements in the Plavix group. Avoiding surgical delay for patients on Plavix requiring nonelective orthopaedic surgery appears to be safe. The goal should be early operative intervention to decrease the morbidity and mortality of surgical delay. This is especially true for patients with hip fractures, which was the most common nonelective orthopaedic surgery required of patients on Plavix in this study.