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Displaced Intra-articular Calcaneal Fractures: Classification and Treatment
The calcaneus is the most commonly fractured tarsal bone. Displaced intraarticular calcaneal fractures are usually caused by a fall from height with one or both heels directly hitting the ground. Displaced intra-articular calcaneal fractures are complex and highly disabling injuries. There is ongoing debate regarding the optimal treatment for each type of displaced intra-articular calcaneal fracture. This review aims to summarize the classification of, various treatment options for, prevention of perioperative complications in, and management algorithms for displaced intra-articular calcaneal fractures. [Orthopedics. 2017; 40(6):e921-e929.]
Fracture Severity Based on Classification Does Not Predict Outcome Following Proximal Humerus Fracture
This study was conducted to determine whether proximal humerus fracture patterns as defined by the Orthopaedic Trauma Association (AO/OTA) classification and the Neer 4-part system predicted functional outcomes for patients treated with open reduction and internal fixation with locked plates and, if so, which system correlated better with outcomes. During a 12-year period, 213 patients with a displaced proximal humerus fracture who underwent surgical treatment with a locking plate at 1 academic institution were prospectively followed. All patients were treated in a similar way and were followed by the operating surgeon at routine intervals. Functional outcomes were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Of these patients, 164 were available for analysis. Functional outcomes based on DASH scores did not differ significantly by Neer system, AO/OTA classification, or varus/valgus humeral head alignment at more than 12 months postoperatively. However, patients with Neer 4-part fracture and AO/OTA type 11-C fracture had worse shoulder range of motion in terms of forward elevation and external rotation. Time to healing and complication rates also were not significantly different based on either classification system. Fracture classification can predict shoulder range of motion 12 months after surgical fixation, but its use is limited in predicting functional outcome scores, time to healing, and complication rates. Patients who undergo surgical repair of a proximal humerus fracture can expect good functional results independent of the initial injury pattern, but more severe fracture patterns may lead to decreased shoulder range of motion. [Orthopedics. 2017; 40(6):368-374.]
Hip fractures in 2016, where do we stand and have we made any progress?
With the baby boomers entering their 70s, the epidemiology of hip fractures is about to change with an increase in the second peak of the bimodal distribution [1]. The so-called epidemic of hip fractures will affect a physically active population that has high expectations and longer life expectancy. Despite such anticipated changes, meaningful progress on the various multifaceted topics related to hip fractures has been scarce and the 1 -ear mortality has not changed significantly. Preventative measures such as early diagnosis/treatment of osteoporosis and fall prevention have now been implemented in most developed countries [2]. Strategies such as fast tracking of patients with hip fractures or enhanced recovery programs are now well in place [3, 4]. Treatment options to improve fracture reduction and fixation with the use of novel implants, construct designs and fixation augmentation are being utilized and studied [5, 6]. For elderly patients with displaced femoral neck fractures, the total hip arthroplasty remains the gold standard, providing improved functional outcomes and early return to activities.
Midshaft Clavicle Fractures: A Critical Review
The clavicle is the most commonly broken bone in the human body, accounting for up to 5% to 10% of all fractures seen in hospital emergency admissions. Fractures of the middle third, or midshaft, are the most common, accounting for up to 80% of all clavicle fractures. Traditional treatment of midshaft clavicle fractures is usually nonoperative management, using a sling or figure-of-eight bandage. The majority of adults treated nonoperatively for midshaft clavicle fractures will heal completely. However, newer studies have shown that malunion, pain, and deformity rates may be higher than previously reported with traditional management. Recent evidence demonstrates that operative treatment of midshaft clavicle fractures can result in better functional results and patient satisfaction than nonoperative treatment in patients meeting certain criteria. This article provides a review of relevant anatomy, classification systems, and injury mechanisms for midshaft clavicle fractures, as well as a comparison of various treatment options. [Orthopedics. 2016; 39(5):e814-e821.]
Intramedullary Nailing of Open Tibial Fractures: Provisional Plate Fixation
Tibia fracture is the most common type of long bone fracture, and intramedullary nailing is the preferred treatment. In open fractures, a provisional plate is often used to maintain reduction. It is unknown whether this practice increases the risk of infection or other complications. This study retrospectively compared patients who were treated at a level 1 trauma center with intramedullary nailing of an open tibia fracture. Patients who were included: (1) were 18 years or older; (2) were treated between January 1, 2005, and June 30, 2013; (3) had an open fracture of the tibia; and (4) were treated operatively with intramedullary nailing, with or without provisional plate fixation. Patient sex, history of diabetes, history of smoking, mechanism of injury, and side of injury were analyzed. Postoperative complications included infection, delayed union or nonunion, compartment syndrome, and death. After the authors controlled for age, Gustilo-Anderson type, and AO/Orthopaedic Trauma Association classification, they found that provisional plate use did not significantly increase the risk of infection (adjusted odds ratio, 1.64; 95% confidence interval, 0.51-5.32; P=.41) or any other complications (adjusted odds ratio, 1.24; 95% confidence interval, 0.46-3.35; P=.67). In the subgroup of patients who had a provisional plate (n=35), removal of the plate did not significantly decrease the risk of infection (adjusted odds ratio, 0.43; 95% confidence interval, 0.07-2.69; P=.36) or other complications (adjusted odds ratio, 0.55; 95% confidence interval, 0.12-2.46; P=.44). In open tibia fractures treated with intramedullary nailing, provisional plate stabilization, a valuable reduction aid, did not increase the risk of infection or other complications. Because of the small subgroup size, however, definitive conclusions cannot be drawn about removal of these provisional plates. [Orthopedics. 2016; 39(5):e931-e936.]
Propionibacterium prosthetic joint infection: experience from a retrospective database analysis
Background: With improved diagnostic methods and longer prosthesis indwelling time, the frequency of diagnosed Propionibacterium prosthetic joint infections (PJI) is increasing. Data on clinical, microbiological, radiological and surgical treatment are limited, and importance of this organism in PJI is probably underestimated. Materials and methods: We retrospectively analyzed patients with PJI caused by Propionibacterium spp. diagnosed at our institution between 2000 and 2012. Patient data were retrieved through chart review, and the outcome was evaluated at patient follow-up visits. Results: Of 15 included patients (median age 65 years, range 44„87), 8 hip, 4 shoulder, 2 knee and 1 ankle PJI were recorded. The median time from implantation to diagnosis of PJI was 44.2 months (range 2„180 months). Most PJI (8 patients, 53 %) were diagnosed late ([24 months after arthroplasty). Persistent pain was present in 13, local joint symptoms in 8, fever in 4 and sinus tract in 3 patients. Radiological signs of loosening were present in 11 patients (73 %). Organisms were detected in intraoperative biopsy (n = 5), sonication (n = 4) or preoperative joint puncture (n = 4). In three cases coinfection with a coagulase-negative staphylococcus was diagnosed. Revision surgery was performed in all cases. After a mean follow-up of 16 months after revision surgery (range 4„37 months), 14 patients (93 %) showed no signs or symptoms of infection and had a functional prosthesis; one patient experienced a new infection with another organism (Staphylococcus epidermidis). Conclusion: Patients with persistent postoperative pain and/or loosening of implants should be screened for PJI with low-virulent organisms such as Propionibacterium, including.
Thirty-day mortality after hip fractures: has anything changed?
Bone density insufficiency is the main cause for significant musculoskeletal trauma in the elderly population following low-energy falls. Hip fractures, in particular, represent an important public health concern taking into account the complicated needs of the patients due to their medical comorbidities as well as their rehabilitation and social demands. The annual cost for the care of these patients is estimated at around 2 billion pounds (£) in the UK and is ever growing. An increased early and late mortality rate is also recognised in these injuries together with significant adversities for the patients. Lately, in order to improve the outcomes of this special cohort of patients, fast-track care pathways and government initiatives have been implemented. It appears that these measures have contributed in a steady year-by-year reduction of the 30-day mortality rates. Whether we have currently reached a plateau or whether an ongoing reduction in mortality rates will continue to be observed is yet to be seen.
Complications of Distal Radius Fractures Treated by Volar Locking Plate Fixation
The current study investigated the incidence of complications after surgery for distal radial fractures. This multicenter retrospective study was conducted at 11 institutions. A total of 824 patients who had distal radius fractures that were treated surgically between January 2010 and August 2012 were identified. The study patients were older than 18 years and were observed for at least 12 weeks after surgery for distal radius fractures with a volar locking plate. Sex, age, fracture type according to AO classification, implants, wrist range of motion, grip strength, fracture consolidation rate, and complications were studied. Analysis included 694 patients, including 529 women and 165 men, with a mean age of 64 years. The mean follow-up period was 27 weeks. The fracture consolidation rate was 100%. There were 52 complications (7.5%), including 18 cases of carpal tunnel syndrome, 12 cases of peripheral nerve palsy, 8 cases of trigger digit, 4 cases of tendon rupture (none of the flexor pollicis longus), and 10 others. There was no rupture of the flexor pollicis longus tendon because careful attention was paid to the relationship between the implant and the tendon. Peripheral nerve palsy may have been caused by intraoperative traction in 7 cases, temporary fixation by percutaneous Kirschner wires in 3 cases, and axillary nerve block in 1 case; 1 case appeared to be idiopathic. Tendon ruptures were mainly caused by mechanical stress. [Orthopedics. 2016; 39(5):e893-e896.]
Posterior Approach in Treating Sacral Fracture Combined With Lumbopelvic Dissociation
Type III Denis fracture of the sacrum is rare clinically, constituting approximately 16% of all sacral fractures. Because it is often complicated with neurologic injuries, treatment is crucial and difficult. Several surgical options are available for the treatment of type III Denis sacral fracture with lumbopelvic dissociation. The authors report 21 patients admitted to the hospital from February 2002 to May 2012 who had type III Denis sacral fracture combined with lumbopelvic dissociation. All of the patients were treated with posterior sacral lamina decompression, sacral nerve root decompression, fracture reduction, an integrated lumbopelvic internal fixation system, and posterolateral fusion. The authors recorded pre- and postoperative complications, fracture reduction, bone graft healing, and improvements in neurologic function, according to the Gibbons grading standard. The average surgical time was 190 minutes (range, 170-210), and the average amount of intraoperative bleeding was 960 mL (range, 930-1500). No intraoperative complications occurred. Twelve patients had complete recovery of neurologic function; 5 patients showed great improvement except for foot drop and impaired lower limb sensation; and 4 patients showed no improvement in lower limb, bladder, and rectum function. Gibbons grade decreased from an average of 3.43±0.51 before surgery to 1.76±1.09 at the last follow-up. Deep infections were noted in 2 cases, and in 1 case, vertebral screw loosening was observed 1 year postoperatively. Surgical reduction with lumbopelvic fixation is an ideal method for treating type III Denis sacral fracture with neurologic injury and lumbopelvic dissociation.
Hardware-Related Complications After Dorsal Plating for Displaced Distal Radius Fractures
There has been a trend away from dorsal fixation of distal radius fractures secondary to a historically higher complication rate. However, the literature on low-profile dorsal plates and titanium implants for the treatment of these fractures is limited. The goal of the current study was to evaluate hardware-related complications and removal rates after open reduction and internal fixation of unstable, displaced distal radius fractures using a dorsal approach with a low-profile titanium plate. A single surgeon treated 125 patients with isolated, unstable, dorsally displaced distal radius fractures by open reduction and internal fixation using a low-profile titanium dorsal plating system. A total of 110 patients were followed for a minimum of 1 year, and mean follow-up was 27 months (range, 12-74). Outcomes were assessed radiographically and clinically. Satisfactory alignment was achieved in all cases, and no fracture went on to nonunion. Nine patients (8%) required removal of hardware at an average of 12 months (range, 6-34). Six patients (5%) had evidence of extensor tenosynovitis intraoperatively, but no extensor tendon ruptures were identified. Overall, using the Gartland and Werley score, results were excellent in 82 patients, good in 22 patients, fair in 5 patients, and poor in 1 patient. Six complications accounted for the fair and poor results. The average Disabilities of the Arm, Shoulder and Hand (DASH) score at latest follow-up was 6 (range, 0-25). This series showed that the technique of dorsal plating with a low-profile titanium plate is safe and effective.
Percutaneous Fixation of Anterior and Posterior Column Acetabular Fractures
standard of care for acetabular fractures, recent advancements in minimally invasive techniques have allowed percutaneous fixation to gain popularity. Percutaneous technique has been described in the literature as an adjuvant to ORIF. However, isolated percutaneous fixation has the advantage of limiting soft tissue disruption, length of surgery, and blood loss when compared with ORIF. The technique also allows for earlier return to activity and better pain control when compared with nonsurgical management. This article reviews both indications and limitations, while highlighting the technique for percutaneous fixation of both anterior and posterior column acetabular fractures. [Orthopedics. 2014; 37(10):675„678.] The authors are from the Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado. The authors have no relevant financial relationships to disclose.
Higher reoperation rates noted after dynamic hip screw fixation of pertrochanteric hip fractures vs. intramedullary nails
In patients with pertrochanteric hip fractures coupled with a fractured greater trochanter, intramedullary hip screws achieved superior results compared to dynamic hip screws, according to orthopaedic investigators. Henrik Palm, MD, of the Hvidovre Hospital, University of Denmark, and colleagues assessed the outcomes of 635 consecutive patients with pertrochanteric hip fractures who underwent either intramedullary hip screw (IMHS) or dynamic hip screw (DHS) fixation. They focused on a subgroup of 311 pertrochanteric hip fracture patients with a preoperative fractured greater trochanter. Fixation with IMHS was performed in 158 patients, and DHS were used in 153, according to the study abstract. „However, the present study is a retrospective cohort study, and future randomized trials in this subgroup of fractures should be performed before profound conclusions,â? Palm told Orthopaedics Today Europe in an interview conducted prior to the presentation of the study of the EFORT Congress 2010.
Assessment of Mortality Risk in Elderly Patients After Proximal Femoral Fracture
Mortality after hip fracture is a major problem in the Western world, but its mechanismsremain uncertain. This study assessed the 2-year mortality rate after hip fracturein elderly patients by including hospital factors (eg, intervention type, surgical delay),underlying health conditions, and, for a subset, lifestyle factors (eg, body mass index,smoking, alcohol). A total of 828 patients (183 men) 70 to 99 years old experiencinga hip fracture in 2009 in the province of Varese were included in the study. The riskfactors for death were assessed through Kaplan-Meier analysis and Cox proportionalhazards analysis. Hip fracture incidence per 1000 persons was higher in women (8.4vs 3.7 in men) and in elderly patients (12.4 for 85-99 years vs 4.4 for 70-84 years).The mortality rate after 1, 6, 12, and 24 months was 4.7%, 16%, 20.7%, and 30.4%,respectively. For the province of Varese, sex (hazard ratio, 0.39 for women), age group(hazard ratio, 2.2 for 85-99 years), and Charlson Comorbidity Index score (hazard ratio,2.06 for score greater than 1) were found to be statistically significant. The 2-yearmortality rate in hip fractures is associated with sex, age, and comorbidities. Male sex,age older than 85 years, and Charlson Comorbidity Index score greater than 1 are associatedwith a higher risk. Surgical delay was significant in the Kaplan-Meier survivaltime analysis but not in the Cox hazard analysis, suggesting that early surgery reducesrisk in patients with numerous comorbidities.