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The OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the ...fracture and the implant. Intramedullary fixation using different types of nails is commonly preferred. The purpose of this study is to evaluate intertrochanteric femoral fractures with intramedullary nail treatment in regard to surgical procedure, complications, and clinical outcomes.
From one level 1 trauma center, 216 consecutive adult intertrochanteric femoral fractures (OTA/AO type 31 A3) were retrospectively identified with intramedullary nail fixation from 2004 through 2013. Of these, 193 patients (58.5% female) met the inclusion criteria. The average age was 70 years (range 19-96 years).
Cephalomedullary nails were utilized in 176 and reconstruction nails in 17 patients. After the index procedure, 86% healed uneventfully. Nonunion development was observed in 6% and 5% had an unscheduled reoperation due to implant or fixation failure. Active smoking was reported in 16.6%. Current smokers had an increased nonunion risk compared to those who do not currently smoke (15.6% vs. 4.3%; p = 0.016). The femoral neck angle averaged 128.0° ± 5°. Fixation failure occurred in 11.1% of patients with a neck-shaft-angle < 125° compared to 2.6% (4/155) of patients with a neck-shaft angle ≥125° (p = 0.021). Patients treated with a reconstruction nail required a second surgical intervention in 23.5%, which was no different compared to 25.0% in the cephalomedullary group (p = 0.893). In the cephalomedullary group, 4.5% developed a nonunion compared to 23.5% in the reconstruction group (p = 0.002). Painful hardware led to hardware removal in 8.8%. All of them were treated with a cephalomedullary device (p = 0.180). During the last office visit, two-thirds of the patients reported no or only mild pain but most patients had reduced hip range of motion.
Intramedullary nailing is a reliable surgical technique when performed with adequate reduction. Varus reduction with a neck-shaft angle < 125° resulted in an increase in fixation failures. Patient and implant factors affected nonunion formation. Smoking increased nonunion formation. Utilization of a cephalomedullary device reduced the nonunion rate, but had higher rates of painful prominent hardware compared to reconstruction nailing.
Ipsilateral femoral neck and shaft fractures typically occur as a result of high-energy trauma in young adults. Up to 9% of femoral shaft fractures will have an associated femoral neck fracture. ...Awareness of this association and the use of a protocolized approach to diagnosis and management can help prevent missed injuries and the associated complications of displacement, nonunion, and osteonecrosis. The femoral neck fracture is often vertically oriented and either nondisplaced or minimally displaced, and thus, these fractures are frequently missed in the initial evaluation. Fixation of these combined injury patterns is challenging, and multiple treatment options exist. Treatment goals should include anatomic reduction and adequate fixation of the femoral neck fracture, as well as restoration of the length, alignment, and rotation of the femoral shaft fracture.
Objective To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed ...tibial fractures.Design A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year.Setting 43 North American academic trauma centers.Participants Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient’s tibial fracture, and tibial fractures that showed <25% cortical contact and >1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled.Interventions Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation.Main outcome measures Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device.Results SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval −0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence interval 0.86 to 1.34; P=0.55). There were no differences in safety outcomes between treatment groups. Patient compliance was moderate; 73% of patients administered ≥50% of all recommended treatments.Conclusions Postoperative use of LIPUS after tibial fracture fixation does not accelerate radiographic healing and fails to improve functional recovery.Study registration ClinicalTrialGov Identifier: NCT00667849
Background
Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, ...U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.
Questions/purposes
We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.
Methods
We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12–41 months).
Results
Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.
Conclusion
Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background
Operative indications for displaced scapular fractures have been controversial and inconsistent. Surgeons have been dissuaded to operate on these uncommon fractures because of the complex ...anatomy, approaches, and fracture patterns. It is unclear whether return to work, pain, or complications differ in patients with scapular fractures treated nonoperatively or operatively.
Questions/Purposes
We therefore assessed differences in rates of union, range of motion, ability to return to work, pain, and complications between operatively and nonoperatively treated scapular body and neck fractures.
Patients and Methods
We retrospectively reviewed 182 patients with 182 scapular fractures treated between 2002 and 2005. Of the 182 fractures, 31 were treated with open reduction internal fixation and matched by age, occupation, and gender to 31 patients treated nonoperatively. The proportions of AO/OTA fracture types were similar in the two groups. The mean displacement, shortening, and angulation were greater in the operative group as compared with the nonoperative group. All patients were followed until healing or discharge from care (average, 1.5 years; range, 14–32 months). We assessed complications, return to work, and radiographic healing.
Results
All fractures healed. We found no differences in return to work, pain, or complications.
Conclusions
Our observations suggest operative treatment of displaced scapula fractures results in similar healing, return to work, pain, and complications as nonoperative treatment. We do not recommend operating on any scapular neck or body fractures displaced less than 20 mm.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
To compare anterior hook plating with established fixation constructs biomechanically and report outcomes and complications in a cohort of patella fractures treated with the technique.
...Laboratory-based biomechanical study and clinical multicenter retrospective cohort study.
2 US Level 1 trauma centers.
51 patients (28 M and 23 F) with 30 simple transverse and 21 comminuted patella fractures. Thirty-six cadaveric patellae were used for the biomechanical study.
Biomechanical-dorsal plating was compared with cerclage wiring and modified tension band cable fixation in a comminuted patella fracture model in 36 cadaveric patellae. Constructs were tested at 0° and 45 degrees of flexion. Clinical-we reviewed a consecutive series of patella fractures in 2 centers for outcome and complications.
Biomechanical-construct stiffness. Clinical-reduction, union, complications, and range of motion.
Stiffness was greatest in dorsal plating at both 0° and 45 degrees. Dorsal plating (976 N, 1643 N) > modified tension band (317 N, 297 N) > cerclage (89.8 N, 150.3 N) at 0 and 45 degrees, respectively. 51 patients with patella fractures had them fixed with dorsal 2.7-mm mini fragment plates including a distal to proximal lag screw through the plate from the nose of the patella. 9 cases were small distal fragments not easily managed with screws and cables. All patients were followed up to union. There were 2 infections (1 superficial and 1 deep with nonunion), and 5 had implant removal (9.8%).
Dorsal plating is biomechanically and clinically superior to modified tension band and cerclage techniques in comminuted patella fractures. This method allows for fixation of small distal pole fractures.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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