To evaluate the midterm functional outcomes of patients with isolated operatively treated patella fractures.
Prospective cohort and retrospective clinical and radiographic assessment.
A Level I and ...Level II trauma center.
Two hundred forty-one patients underwent operative intervention for a displaced patella fracture between 1991 and 2007. After appropriate exclusions, 110 patients met criteria. A total of 40 (36%) patients with isolated, unilateral, operatively treated patella fractures with minimum 1-year follow-up agreed to participate in this study and return for functional testing. Mean follow-up was 6.5 years (range, 1.25-17 years).
Enrolled patients were treated with one of the following methods: standard tension band with Kirschner wires, tension band through 2 cannulated screws, longitudinal anterior banding with cerclage, or partial patellectomy.
All enrolled patients were evaluated with the SF-36 and an injury-specific questionnaire (Knee Injury and Osteoarthritis Outcome Scores) and asked to self-report symptomatic hardware. Patients were also evaluated by physical examination assessing range of motion and Biodex bilateral quadriceps isometric and isokinetic comparisons.
The mean normalized SF-36 physical composite score and the mean normalized Knee Injury and Osteoarthritis Outcome Scores subscale scores (pain, 71.7; symptoms, 66.3; activities of daily living, 75.1; sport/recreation, 45.2; quality of life, 49.6) were statistically different (P < 0.05) from reference population norms. Removal of symptomatic fixation was required in 52% of the patients treated with osteosynthesis, whereas 38% of those with retained fixation self-reported implant-related pain at least some of the time. Eight patients (20%) had an extensor lag greater than 5°. A restricted range of flexion of greater than 5° was noted in 15 patients (38%) and restricted range of extension of greater than 5° was noted in 6 patients (15%). Biodex dynamometric testing revealed a mean isometric extension deficit of 26% between the uninvolved and involved sides for peak torque. Extension power was also tested with an angular velocity of 90°/sec and 180°/sec and mean deficits of 31% and 29% were noted, respectively, when compared with the contralateral extremity.
At a mean of 6.5 years after operative treatment for patella fractures, significant symptomatic complaints and functional deficits persist based on validated outcome measures as well as objective physical evaluations. This study fills a void in the literature regarding the functional outcomes of these patients. It also underscores the complexity associated with treating this common fracture and should help guide surgeons to better counsel patients on the expected long-term function after operative treatment of patella fractures.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Report the technical aspects, radiographic results, and complications after minimum 1-year follow up of the anterior intra-pelvic (AIP or modified Rives-Stoppa) approach as an alternative to the ...ilioinguinal approach for the treatment of acetabular fractures.
Retrospective review.
Level I trauma center.
All skeletally mature patients requiring an anterior approach for fixation of an acetabular fracture with minimum 1-year clinical and radiographic follow up were included. Charts and radiographs were reviewed for fracture pattern, time to surgery, operative time, blood loss, quality of reduction, and perioperative complications. A consecutive group of 57 patients treated by a single surgeon using the AIP approach was identified as a subset of a larger series 536 acetabular fractures treated by the same surgeon between February 2004 and February 2008.
Of the 57 patients, average time to operation was 5 days and a supplemental lateral window was required in 34 patients (60%). Average blood loss was 750 mL, and average operative time was 263 minutes. One patient (1.8%) had a vascular injury requiring embolization. One patient (1.8%) had a wound infection in the lateral window, two patients (3.5%) developed a direct inguinal hernia requiring surgical repair, and one patient (1.8%) had atrophy of the ipsilateral rectus abdominus without hernia. Of the 50 patients with minimum 1-year follow up, there were 22 associated both column, 12 anterior column, seven anterior column posterior hemitransverse, six transverse, and three T-type fractures. Seventy percent of the reductions were graded excellent, 22% were graded good, and 8% poor. Clinical outcomes (Merle D'Aubigne) at 1 year were 36% excellent, 55% good, and 10% poor. Thirteen patients (26%) were noted to have significant weakness of the hip adductors (obturator nerve palsy) postoperatively; all but one resolved and improved within 6 months.
Use of the AIP (modified Rives-Stoppa) approach for the treatment of acetabular fractures permits good to excellent reduction in the majority of cases while giving excellent visualization and access to the quadrilateral plate and posterior column. The AIP approach has a complication rate that is comparable to the ilioinguinal approach. We recommend the use of this technique as a potential alternative (but not replacement) to the classic ilioinguinal approach when anterior exposure of the acetabulum is required.
To determine if indomethacin has a positive clinical effect for the prophylaxis of heterotopic ossification (HO) after acetabular fracture surgery. To determine whether indomethacin affects the union ...rate of acetabular fractures.
Prospective randomized double-blinded trial.
Level 1 regional trauma center.
Skeletally mature patients treated operatively for an acute acetabular fracture through a Kocher-Langenbeck approach.
Patients were randomly allocated to 1 of 4 groups comparing placebo (group 1) to 3 days (group 2), 1 week (group 3), and 6 weeks (group 4) of indomethacin treatment.
Factors analyzed included the overall incidence, Brooker class and volume of HO, radiographic union of the acetabular fracture, and pain. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year. Serum levels of indomethacin were drawn at 1 month to assess compliance. Computed tomographic scans were performed at 6 months to assess healing and volume of HO.
Ninety-eight patients were enrolled into this study, 68 completed the follow-up and had the 6-month computed tomographic scan, and there was a 63% compliance rate with the treatment regimen. Overall incidence of HO was 67% for group 1, 29% for group 2 (P = 0.04), 29% for group 3 (P = 0.019), and 67% for group 4. The volume of HO formation was 17,900 mm for group 1, 33,800 mm for group 2, 6300 mm for group 3 (P = 0.005), and 11,100 mm for group 4. The incidence of radiographic nonunion was 19% for group 1, 35% for group 2, 24% for group 3, and 62% for group 4 (P = 0.012). Seventy-seven percent of the nonunions involved the posterior wall segment. Pain visual analog scores (VASs) were significantly higher for patients with radiographic nonunion (VAS 4 vs. VAS 1, P = 0.002).
Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both ...nonoperative and operative cases.
Retrospective cohort study.
Level 1 trauma center.
Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included.
The study intervention included retrospective review of patients' charts and radiographs.
Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern.
Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement.
Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
To describe the technique and results of stress examination with fluoroscopy under anesthesia (EUA) to determine stability and the need for operative stabilization of traumatic pelvic ring injuries.
...Retrospective chart and radiographic review.
Level I trauma center.
Skeletally mature patients with traumatic incomplete posterior pelvic ring injuries.
Patients were consented for EUA if preoperative radiographs and computed tomographic scanning of the pelvis demonstrated an incomplete injury to the posterior pelvic ring (Orthopaedic Trauma Association OTA 61-B type injuries). Patients with nondisplaced anterior compression fractures of the sacral ala without internal rotation or a fracture line exiting the posterior cortex were excluded from this analysis. Similarly, skeletally immature patients or those with complete instability of the pelvic ring (OTA 61-C type injuries) were excluded. All patients meeting inclusion criteria were taken to the operating room, anesthetized, and placed in the supine position for stress examination (EUA) of the pelvic ring using intraoperative dynamic fluoroscopy. Examination consisted of a resting static film followed by internal rotation, external rotation, and push-pull maneuvers of both lower extremities. Each of these maneuvers was performed using the anteroposterior, inlet, and outlet projections, providing a total of 15 distinct images for each patient's examination. The preoperative classification of the pelvic ring injury was then accepted or redefined based on the amount of rotational and translational instability in the axial, coronal, and sagittal planes. The decision to proceed with anterior and/or posterior operative reduction and stabilization was subsequently based on the degree of pelvic ring instability noted during the EUA.
A total of sixty-eight patients underwent an EUA of their pelvis by the senior author. Fifty males and 18 females with an average age of 35 years comprised the study group. In all, 37 anteroposterior compression (APC or OTA 61-B1) injuries and 31 lateral compression (LC or OTA 61-B2) injuries were evaluated. Of the 14 pelvic ring injuries initially classified as an APC-1, seven (50%) were deemed stable and treated nonsurgically, whereas seven (50%) were felt to have sufficient instability (an occult APC-2) to warrant treatment with anterior fixation based on EUA. Of the 23 injuries initially classified as an APC-2, all but one required surgical fixation: 13 (57%) were treated with anterior fixation alone (APC-2a), whereas nine (39%) were treated with anterior fixation and supplemental iliosacral screw placement (APC-2b) based on the degree of instability noted during the EUA. Of the 20 injuries initially classified as an LC-1, 13 (65%) were stable and treated nonsurgically (LC-1a), whereas seven (35%) were treated with anterior and/or posterior stabilization (LC-1b) based on the degree of instability noted during the EUA.
The reported incidence of poor functional outcomes associated with pelvic fracture may be attributable, in part, to inadequate treatment of misdiagnosed injuries and chronic instability and/or malunion. Performing an examination under anesthesia with dynamic stress fluoroscopy as described in this series revealed occult instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. We propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. We conclude that pelvic EUA merits further analysis as an important diagnostic tool that may provide additional information regarding instability of the pelvic ring.
Background
Several construct options exist for transverse acetabular fracture fixation. Accepted techniques use a combination of column plates and lag screws. Quadrilateral surface buttress plates ...have been introduced as potential fixation options, but as a result of their novelty, biomechanical data regarding their stabilizing effects are nonexistent. Therefore, we aimed to determine if this fixation method confers similar stability to traditional forms of fixation.
Questions/purposes
We biomechanically compared two acetabular fixation plates with quadrilateral surface buttressing with traditional forms of fixation using lag screws and column plates.
Methods
Thirty-five synthetic hemipelves with a transverse transtectal acetabular fracture were allocated to one of five groups: anterior column plate + posterior column lag screw, posterior column plate + anterior column lag screw, anterior and posterior column lag screws only, infrapectineal plate + anterior column plate, and suprapectineal plate alone. Specimens were loaded for 1500 cycles up to 2.5x body weight and stiffness was calculated. Thereafter, constructs were destructively loaded and failure loads were recorded.
Results
After 1500 cycles, final stiffness was not different with the numbers available between the infrapectineal (568 ± 43 N/mm) and suprapectineal groups (602 ± 87 N/mm, p = 0.988). Both quadrilateral plates were significantly stiffer than the posterior column buttress plate with supplemental lag screw fixation group (311 ± 99 N/mm, p < 0.006). No difference in stiffness was identified with the numbers available between the quadrilateral surface plating groups and the lag screw group (423 ± 219 N/mm, p > 0.223). The infrapectineal group failed at the highest loads (5.4 ± 0.6 kN) and this was significant relative to the suprapectineal (4.4 ± 0.3 kN; p = 0.023), lag screw (2.9 ± 0.8 kN; p < 0.001), and anterior buttress plate with posterior column lag screw (4.0 ± 0.6 kN; p = 0.001) groups.
Conclusions
Quadrilateral surface buttress plates spanning the posterior and anterior columns are biomechanically comparable and, in some cases, superior to traditional forms of fixation in this synthetic hemipelvis model.
Clinical Relevance
Quadrilateral surface buttress plates may present a viable alternative for the treatment of transtectal transverse acetabular fractures. Clinical studies are required to fully define the use of this new form of fixation for such fractures when accessed through the anterior intrapelvic approach.
The anterior intrapelvic approach can be used for the reduction and fixation of displaced fractures of the acetabulum. Reduction techniques and options for placement of fixation deviate to some ...degree from those used with the traditional ilioinguinal approach secondary to the surgeon's perspective and available vectors. Here, we present several techniques for the application of reduction clamps, reduction techniques, and fixation options for the posterior column in displaced fractures of the acetabulum treated through the anterior intrapelvic approach.
Donor site morbidity and limited volume remain primary drawbacks of using bone graft from the iliac crest and an impetus for finding other sources of autologous bone-graft material. The Synthes ...Reamer/Irrigator/Aspirator (RIA) has been found to have value as an autologous bone-graft harvesting device. The purpose of this study was to compare the cellular and biochemical characteristics of bone grafts obtained with use of the RIA and from the iliac crest of the same patient.
A prospective study was performed on a consecutive series of ten skeletally mature patients presenting for repair of nonunited tibial or femoral fractures. Graft material was harvested from both the iliac crest (in the standard fashion) and the medullary canal of the femur or tibia (with use of the RIA) of each patient. Portions of each autologous graft sample were assessed histologically and by genomewide transcriptional profiling for biochemical markers known to be expressed during fracture-healing.
Principal-component analysis comparing the messenger RNA expression profiles in the RIA and iliac crest samples showed that the expression profile at each harvest site was unique and independent of patient, age, sex, or any identified comorbidity. Transcriptional analysis showed that the RIA samples had greater levels of expression of genes associated with vascular, skeletal, and hematopoietic tissues. Additionally, stem cell markers and growth factors that act early in the osteogenic cascade were more abundant in the RIA samples compared with the iliac crest samples.
This is the first study to directly compare the histological and molecular profiles of bone grafts from reaming debris and the iliac crest of the same patient. The debris generated during intramedullary reaming, harvested with use of the RIA technique, and the bone graft harvested from the iliac crest possessed a similar transcriptional profile for genes known to act in the early stages of bone repair and formation. This suggests that reaming debris may be a viable alternative to iliac crest bone graft when autologous cancellous graft is needed.
To determine if preoperative fever and leukocytosis without an established source of untreated infection are independent risk factors for the development of deep postoperative wound infection (DPWI) ...after surgical treatment of pelvic and acetabular fractures.
Retrospective chart and radiographic review; matched case-control comparison.
: Level 1 regional referral trauma center.
Five hundred ninety-seven skeletally mature patients with pelvic and/or acetabular fractures requiring operative fixation (353 acetabular, 170 pelvic, and 74 combined acetabular and pelvic injuries). Retrospective chart review was performed analyzing for the following variables: injury severity score, preoperative fever, serum and urine white blood cell count; intensive care unit admission, previous infection, Morel-Lavallee lesions, pelvic arterial embolization, open fractures, intraoperative cell saver use, perioperative blood transfusions, subfascial drains, antibiotic use, and obesity BMI (body mass index) >30. Open pelvic or acetabular fractures were excluded. Main outcome measure was diagnosis of DPWI. Patients with a diagnosis of DPWI were then compared with a random 1:4 matched cohort of patients without a history of DPWI. Patients were matched and grouped according to injury pattern, age, and surgical procedure. Statistical comparison of the 2 groups was performed using a Mann-Whitney test, Fisher exact test, and odds ratio (OR) with 95% confidence intervals and positive predictive values (PPVs).
Seventeen patients (2.8%) developed DPWI, distributed as 8 (2.3%) acetabular, 5 (2.9%) pelvic, and 4 (5.4%) pelvic-acetabular infections. Eighty patients met inclusion criteria for the matched cohort comparison. The median age of those patients with infection was 43 years (range 31-69) and those without infection were 41 years (range 24-71). Both groups were predominantly male (77% and 74% for the 2 groups, respectively). The average BMI and injury severity score of the case (infected) group were significantly higher than that of the control (noninfected) group. Of the variables examined, preoperative leukocytosis, obesity, blood transfusion, and interfacility transfer had a statistical association (P < 0.05) with DPWI after pelvic or acetabular surgery. Preoperative angioembolization reached near statistical significance (P = 0.07). However, determination of PPV and OR suggested that only obesity (OR 8, PPV 33%), obesity plus leukocytosis (OR 12, PPV 39%), and preoperative angioembolization (OR 11, PPV 67%) were strong predictors of postoperative infection. Although the infection rate for combined approaches was twice that of acetabular or pelvic surgery alone, this was not statistically significant.
: Based on the findings of this analysis, patients requiring preoperative angioembolization and having a BMI >30 have a significant increase in their risk of postoperative infection, particularly if associated with leukocytosis. Patients with both pelvic and acetabular fractures that require surgical treatment should be counseled that their risk for infection may be higher.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this OTA-approved pilot study was to compare the clinical and functional outcomes of the knee joint after infrapatellar (IP) versus suprapatellar (SP) tibial nail insertion.
...Prospective, randomized.
Level I trauma center.
After institutional review board approval, skeletally mature patients with OTA 42 tibial shaft fractures were randomized into either an IP or SP nail insertion group after informed consent was obtained. The SP also underwent prenail and postnail insertion patella-femoral (PF) joint arthroscopy. Patients underwent follow-up (6 weeks, 3, 6, and 12 months) with standard radiographs, as well as visual analog score and pain diagram documentation. At the 6-month and 12-month visits, knee function questionnaires (Lysholm knee scale and SF-36) were completed. Magnetic resonance imaging/image (MRI) of the affected knee was obtained at 12 months. Ten patients in each group were required for a power analysis for the anticipated larger randomized control trial, but enrollment in each arm was not limited because of known problems with patient follow-up over a 12-month period.
A total of 41 patients/fractures were enrolled in this study. Of those, only 25 patients/fractures (14 IP, 11 SP) fully complied with and completed 12 months of follow-up. Six of 11 SP presented with articular changes (chondromalacia) in the PF joint during the preinsertion arthroscopy. Three patients displayed a change in the articular cartilage based on postnail insertion arthroscopy. At 12 months, all fractures in both groups had proceeded to union. There were no differences between the affected and unaffected knee with respect to range of motion. Functional visual analog score and Lysholm knee scores showed no significant differences between groups (P > 0.05). The SF-36v2 comparison also revealed no significant differences in the overall score, all 4 mental components, and 3/4 physical components (P > 0.05). The bodily pain component score was superior in the SP group (45 vs. 36, P = 0.035). All 11 SP patients obtained MRIs at 1 year. Five of these patients had evidence of chondromalacia on MRI. These findings did not correlate with either the prenail or postnail insertion arthroscopy. Importantly, no patient in the SP group with postnail insertion arthroscopic changes had PF joint pain at 1 year.
Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up. Based on this pilot study data, larger prospective trial with long-term follow-up is warranted.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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