Management of vertical femoral neck fractures in young adults has been a challenging clinical problem, resulting in mixed clinical outcomes. A thorough understanding of the fracture morphology for ...this injury pattern is lacking, which may contribute to frequent failures of treatment. This study is designed to produce a detailed description of the pathoanatomy of these fractures, which may ultimately be helpful in developing more informed reduction and fixation strategies.
Retrospective study of patient records, plain radiographs, and computed tomography scans to determine the morphology the Pauwels III femoral neck fractures (coronal angle >50 degrees) in young adults.
Two level I and 1 level II regional trauma centers.
All patients 18-49 years of age with a surgically repaired, high-energy high shear angle (>50 degrees) femoral neck fracture from January 1, 2007, to December 31, 2010.
One hundred thirty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 33 met all study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, comminution, deformity, characteristics of the inferomedial fracture spike, and the associated inferomedial calcar's cortical buttress.
The vertical (coronal) fracture averaged 60 degrees and axial fracture obliquity averaged 24 degrees with relative deficiency of the posterior neck on the head-neck fragment. Major femoral neck comminution (>1.5 cm in any dimension) was identified in 96% of cases, mostly located in the inferior (94%) and posterior (82%) quadrants. The apical fracture spike of the head segment was found to be in line (within 10 degrees) of the neck-shaft axis on the proximal femur 63% of the time. Deformity in external rotation averaged 44 degrees (range, 10-68 degrees) and shortening of the femur averaged 1.8 cm (range, 0.9-4.4 cm).
This study investigated the fracture morphology of isolated, high shear angle femoral neck fractures in young adults, which may ultimately lead to improved operative reduction and fixation tactics. Given this injury's characteristic findings, including fracture orientation, deformity, and comminution, surgeons should be cognizant of this pattern's innate instability and potential for treatment failure with typical implant constructs.
To identify the current implant and diagnostic imaging preferences among orthopaedic trauma experts for the treatment of high-energy vertical femoral neck fractures in young adult patients.
Web-based ...survey.
Not available.
Active members of the OTA.
A cross-sectional expert opinion survey was administered to the active members of the OTA to determine their preferences for implant use and imaging in the surgical treatment of a vertical femoral neck fracture in a young adult patient (e.g., 60-degree Pauwels angle fracture in a healthy 30-year-old patient). Questions were also asked regarding the reason why this implant was selected, whether the surgeon felt that their choice was supported by the literature, and what imaging studies are routinely obtained to guide decision making. Data were collected using simple multiple-choice questions and/or a 5-point Likert item.
Two hundred seventy-two surgeons (47%) responded to the survey. The preferred constructs for a vertical femoral neck fracture in a healthy young patient were a sliding hip screw with or without an anti-rotation screw (47%), parallel cannulated screws with an off-axis screw (28%), and parallel cannulated screw constructs (15%). When asked if their designated construct "was clearly supported by the literature," 46% were either unsure or disagreed. Seventy percent of surgeons chose their preferred implant because it was "biomechanically most stable." Most surgeons required anteroposterior pelvis (70%) and standard hip (88%) radiographs; however only 29% of surgeons required a computed tomography (59% found computed tomography helpful but not required). Twenty-seven percent of surgeons have changed their implant choice intraoperatively.
Femoral neck fractures in young adult patients are a challenging problem with high rates of failed treatment. Many options for treatment exist and a consensus on the best method remains elusive. Our survey demonstrates the diversity and disagreement among OTA member "expert" orthopaedic traumatologists for the "best" treatment choice for this important clinical scenario. Our survey shows a divided level of confidence in the current literature and highlights the need for further study of this problem.
Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
To better describe the pathoanatomy of young patients' femoral neck fractures with the goal of improving surgeons' decisions for treatment including reduction and fixation.
This is a retrospective ...study of patient records, plain radiographs, and the modern computed tomography scans to study the pathoanatomy of Pauwels II and III femoral neck fractures (coronal angle >30 degrees) in young adults.
One American College of Surgeons Level 1 trauma center.
All patients 18-49 years of age with a surgically repaired Pauwels' II and III (>30 degrees) femoral neck fracture between 2013 and 2017.
Fifty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 30 met study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, characteristics of fracture morphology including size, shape, and dimensions, comminution, displacement, and deformity.
Fracture morphology typically included a wide-based caudal head-neck segment (80%) that ends at a variable location along the medial calcar, sometimes as caudal as the lesser trochanter. Comminution was present in 90% of cases mostly located in the inferior quadrant, but anterior or posterior to the void left by the head-neck's caudal segment. The fractures orientations and deformities were reported by means and ranges.
We investigated and reported on the pathoanatomy of high-energy femoral neck fractures in young adults with the goal of increasing understanding of the injury and improving surgeons' ability to provide for improved treatment decisions and quality fracture repair.
Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this study was to compare clinical and functional outcomes of patients with distal tibia fractures treated with minimally invasive plating (MIPO) or intramedullary nailing (IMN).
...Cohort study.
Level II regional trauma center.
Overall, 86 patients with metaphyseal distal fractures (within 5 cm of joint) with simple or no articular involvement treated by a single, fellowship trained, orthopedic trauma surgeon from 2002 to 2013.
Intramedullary nailing or minimally invasive plate osteosynthesis.
Clinical and radiographic results were evaluated at a minimum of 1-year follow-up. Limb-specific outcomes (American Orthopedic Foot and Ankle Surgeons' ankle-hindfoot instrument) and whole-person measures Short Form 36 (SF-36) instrument were assessed at the final follow-up.
We studied 86 patients with distal tibia fractures treated with MIPO (43 patients) and IMN (43 patients). Thirty-seven patients in the MIPO group and 27 in the IMN group met inclusion criteria. All patients ultimately healed, with the average time to union of 23 weeks in both the groups. Complications were similar between the 2 groups (MIPO vs. IMN, respectively), including nonunion (8% vs. 7%), malalignment (3.6% vs. 3%), wound complications (3.6% vs. 3%), and infection (0% vs. 3.6%). The need for secondary procedures for the removal of implants was 25.9% in the IMN group (distal locking screws only in 6/7) versus 8.3% in the MIPO group (P = 0.05). Additionally, the American Orthopedic Foot and Ankle Surgeons and all SF-36 version 2 domain scores were quantitatively higher for the IMN group, although only Role Emotional reached a level of statistical superiority between the groups.
Similar clinical results and marginally enhanced functional outcomes were seen when treating nonarticular or minimally articular metaphyseal distal tibia fractures with IMN compared with MIPO. However, patients treated with IMN required more frequent secondary surgeries for the removal of painful distal locking screws.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Stress Modulation of Fracture Fixation Implants Beltran, Michael J; Collinge, Cory A; Gardner, Michael J
Journal of the American Academy of Orthopaedic Surgeons,
2016-October, Volume:
24, Issue:
10
Journal Article
Peer reviewed
Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining ...absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.
Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of ...this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures.
Retrospective review.
Three level I or II trauma centers.
Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers.
All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment.
Risk factors for reoperation to promote union, deep infection, and implant failure.
After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure.
Prognostic level II. See instructions for authors for a complete description of levels of evidence.
Posterior pelvic ring injuries (i.e., sacro-iliac joint dislocations, fracture-dislocations, sacral fractures, pelvic non-unions/malunions) are challenging injury patterns which require a significant ...level of surgical training and technical expertise. The modality of surgical management depends on the specific injury patterns, including the specific bony fracture pattern, ilio-sacral joint involvement, and the soft tissue injury pattern. The workhorse for posterior pelvic ring stabilization has been cannulated iliosacral screws, however, trans-sacral screws may impart increased fixation strength. Depending on injury pattern and sacral anatomy, trans-sacral screws can potentially be more beneficial than iliosacral screws. In this article, the authors will briefly review pelvic mechanics and discuss their rationale for ilio-sacral and/or trans-sacral screw fixation. Keywords: Iliosacral, Trans-sacral, Screw, Posterior pelvic ring, Pelvic fracture, Injury mechanism
Fractures of the distal femur, even those with articular extension, are well suited to surgical fixation with modern precontoured anatomic plates and nails. Numerous adjuvant techniques are available ...to the treating surgeon to obtain and maintain reduction while preserving fracture biology. Yet despite their proven track record and benefits over older implants, technical errors are common and must be overcome with proper preoperative planning and intraoperative attention to detail. This review summarizes the current state of the art regarding distal femur fractures, with an emphasis on relevant modern plate and nail surgical techniques, tempered by our current understanding of implant biomechanics, fracture healing, and long-term outcomes.
Unfamiliarity with the location of the femoral artery in the medial thigh has tempered surgeons' enthusiasm for medial approaches to the distal femur. The purpose of this study was to define the ...relationship of the femoral artery to the mid- and distal femur to assist in safely approaching the femur for fracture care.
Fifteen patients undergoing CT with angiography (CTA) of the lower extremity (CTA) were evaluated. From three-dimensional CTA images, the distance of the artery at the anterior border, midsagittal line, and posterior border of the femur from the distal femur at both the adductor tubercle and medial femoral condyle was measured.
The average distances of the adductor tubercle to the femoral artery were 23.2 cm (±3.3), 18.8 cm (±3.4), and 14.3 cm (±4.1) at the level of the anterior border, midsagittal line, and posterior border of the femur, respectively. The descending genicular artery (DGA) originated 10.8 cm (±1.3) proximal to the adductor tubercle.
A wide safe zone exists in the medial distal femur. The artery crosses the midsagittal axis of the medial femur an average of 18.8 cm proximal to the adductor tubercle.
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