Intramedullary Stabilization of Periprosthetic Fractures of the Femur Taking Special Account of Bone Defects

Abstract Objective:  Healing of the periprosthetic fracture and area of defective bone by the bone healing mechanisms of intramedullary stabilization. Reconstruction of the correct length, axial alignment, and rotation of the fractured femoral shaft by anchoring a revision stem in the intact femoral diaphysis. Indications:  Periprosthetic femoral shaft fracture in the region of the prosthetic stem combined with preexistent loosening and/or defect in the periprosthetic bone bed (Vancouver classification type B2 and B3). Contraindications: General contraindications, local infection. Surgical Technique:  Lateral transmuscular approach to the femoral shaft. Longitudinal osteotomy of the proximal femur taking the geometry of the fracture into account. Opening of an anterior “bone shell”. Removal of the loose prosthetic stem and cement. Debridement. Preparation of the femoral diaphysis and insertion of a distally anchored revision stem. Distal locking. Repositioning of the “bone shell”, reduction of the fracture, and retention with cerclage wires. Postoperative Management:  Bed rest for approximately 1 week, mobilization with 20 kg partial weight bearing for 12 weeks, gradual increase in weight bearing with radiologic checks on progress, removal of the distal locking bolts after 12–24 months at the earliest. Results:  21 patients (13 women, eight men) aged between 43 and 86 years (mean age: 71.2 years) with periprosthetic fracture of the femur, additional loosening of the stem in eight cases (Vancouver B2) and additional bone loss in 13 cases (Vancouver B3). Postoperative complications: two fractures following another fall (repeat operations: one replacement, one plate), four revisions due to subsidence of the stem (three replacements involving change to a standard stem with healed proximal femur, one replacement with another interlocked revision stem). Bone healing occurred for all fractures after a mean 5.6 months (3–11 months). Follow- up examination after a mean 4.5 years: all patients were able to walk, average Harris Score 70.5 points (29– 95 points). The following is a reprint from Operat Orthop Traumatol 2006;18:341–63 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Operat Orthop Traumatol 2006;18:341–63 DOI 10.1007/s00064-006-1182-2     

Warfarinized Patients with Proximal Femoral Fractures: Survey of UK Clinical Practice

Abstract Introduction:   In an aging population, anticoagulation in patients with musculoskeletal injuries is increasingly prevalent. The North American literature indicates an absence of consensus concerning the most appropriate management for this group. We aim to test the hypothesis that there is a lack of consensus in the UK regarding the perioperative management of patients with hip fractures on long-term warfarin therapy. Materials and Methods:   A representative group of 400 consultant orthopedic surgeons was surveyed by postal questionnaire regarding their policy on the reversal of anticoagulation in warfarinized patients with hip fractures. The consultants contacted were selected to represent a geographical spread throughout the UK. Results:   There were 159 respondents (40% response rate), of which 79% (126) had a trauma commitment. 95 (75%) of these had a protocol for the reversal of anticoagulation prior to surgery. The commonest method used was to simply withhold warfarin and wait (70%). Other methods included FFP (16%), and low-dose (23%) and high-dose (14%) vitamin K. Some respondents used more than onemethod. Although nearly all respondents preferred an INR < 2.0 prior to surgery, 55% preferred an INR < 1.5. Discussion:   Hip fracture in the presence of long-term warfarin use is associated with significantly increased morbidity. This problem is likely to increase. Our results demonstrate variation in approach throughout the UK with regard to warfarin reversal and the acceptable INR at which to operate in this group of patients. We propose that low-dose vitamin K is considered more widely as a safe and effective method of warfarin reversal in this group.     

Stress Fracture of the Femoral Neck in a Young Female Athlete

Abstract   Stress fractures have been reported to occur in association with running. They typically involve the lower extremity. Although relatively rare, unrecognized or untreated femoral neck fractures carry a much higher morbidity rate than other stress fractures. Stress fractures of the femoral neck should even be considered in young amateur athletes with hip pain. If X-ray is inconclusive, radionuclide bone imaging and MRI can be useful in diagnosing these fractures. This rare diagnosis, as well as classification and treatment options, will be discussed.     

Minimal Invasive Fixation of Hamate Hook Fractures Through a Dorsal Percutaneous Approach Using a Mini Compression Screw: An Experimental Feasibility Study

Abstract Purpose:   Isolated fractures of the hamate hook can be treated by conservative or surgical means. Because nonoperative treatment is associated with high nonunion rates, surgical treatment with open reduction and internal fixation through a palmar approach is often preferred. The aim of this study was to refine surgical treatment of hamate hook fractures using a cannulated mini compression screw through a dorsal percutaneous approach. Methods:   Artificial fractures of the hamate hook were created in five male cadaver hands under fluoroscopy. Using an ulnar approach, the hamate hook was fractured at the base (n = 3) and middle third (n = 2) of the hook using an osteotome. Each fracture was visualized by X-ray and computed tomography. Under fluoroscopy, the fracture was stabilized with a 1.1 mm K wire through a dorsal percutaneous approach which guided the introduction of a 3 mm diameter cannulated mini compression screw. The screw position was then controlled by X-ray and computed tomography. Results:   Percutaneous fixation of the fractured hook through the dorsal approach was achieved in all cases. Regardless of the fracture location, all fragments were adapted into anatomically correct positions. No displacement or disruption of the cortex of the hook was observed with central screw positioning. Conclusion:   Minimal invasive repair of isolated hamate hook fractures through a dorsal percutaneous approach is feasible. The special properties of the cannulated mini compression screw allow optimal screw positioning and stable fixation without risk of diplacement or disruption of the hook fragment.     

A New Injectable Brushite Cement: First Results in Distal Radius and Proximal Tibia Fractures

Abstract Objective:   The restoration of metaphyseal defects remains a challenge for the treating surgeon. Although injectable brushite cements may help to refill bone defects stabilized with internal fixation, human data remains unavailable. The main goal of this prospective multicenter study was to observe the performance of this material in a clinical setting. Patients and Methods:   The study conducted in seven trauma units included closed metaphyseal distal radius and proximal tibia fractures with bone defects, stabilized with internal fixation and subsequent filling with brushite cement. At 6- and 12-month follow-ups, patient satisfaction (visual analog scale [VAS]) was recorded, as well as complications. Results:   Thirty-eight proximal tibia fractures and 37 patients with distal radius fractures were included. Overall patient satisfaction with the treatment was high (mean VAS = 92 and 91 for proximal tibia and distal radius, respectively), despite the loss of reduction being described in 11% of proximal tibia and 24% of distal radius fractures; the majority of them included severe fracture types. Radiological evaluation showed postoperative cement leakage in 20 cases, where the majority occurred at the distal radius (n = 15). In 13 distal radius fractures, the leakage was resorbed by the final examination. Conclusion:   The tested material showed good outcome in the majority of patients and adequate resorption characteristics, even in the case of extravasation. Stable internal fixation, sufficient bone quality, and no contact between the cement and joint are essential requirements for chronOS Inject, which can be considered as an alternative to existing augmentation materials.     

Clinical Risk Factors for Hip Fracture in Young Adults Under 50 Years Old

Abstract Background:   Established risk factors for hip fracture exist for older individuals. Young adults (less than 50 years old) presenting with hip fractures have received little attention. Methods:   The records of all adults, presenting over a 5-year period (1999–2004), to a large inner city teaching hospital, with a diagnosis of hip fracture, were reviewed. Of the 2,778 subjects, 196 involved people less than 65 years of age, limiting this to those less than 50 years old left 42 subjects [30 F/12 M, median (IQR) age 43 (37–47) years old]. Stepwise logistic regression analysis was performed to examine for clinical risk factors. Results:   In this cohort regression analysis revealed a history of high impact trauma (β = 0.219, p = 0.002) and intravenous drug abuse (β = 0.206, p = 0.003) as predictors for risk of hip fracture. Conclusions:   Our data suggest that intravenous drug abusers under 50 are a particular group that we should be targeting for intervention strategies.     

Outcomes of Endoprosthetic Replacement for Salvage of Failed Fixation of Malignant Pathologic Proximal Femur Fractures

Background

Internal fixation is often used to treat pathologic proximal femur fractures. However, nonunion and/or tumor progression may lead to hardware failure. In such cases, endoprosthetic replacement may be considered. The purpose of this study is to analyze the outcome of patients undergoing conversion to an endoprosthetic replacement following failed fixation of a pathological proximal femur fracture.

Proximal Splenic Artery Embolization In Blunt Splenic Trauma

Abstract Background:   Proximal embolization of the splenic artery (PSAE) has recently been reported for traumatic splenic injury. The suggested mechanism of action entails a decrease in the splenic blood pressure without ischemia due to collateral blood supply. The main complications of selective embolization are continuous bleeding, splenic infarcts and splenic abscesses. The main complications of observation alone are continuous bleeding and formation of splenic pseudoaneurysms. Our aim was to assess the efficacy of PSAE in the cessation of bleeding without formation of pseudoaneurysms, and the outcome of the spleen after such intervention. Methods:   A prospective observational study of all patients undergoing PSAE for traumatic splenic injury in our institution over a 33-month period. Clinical and Doppler sonographic examinations were performed to assess cessation of bleeding, splenic blood flow, and formation of splenic pseudoaneurysms, infarcts or abscesses. Results:   During 33 months, 11 patients with blunt abdominal trauma and tomographic evidence of either high grade or actively bleeding splenic injuries were treated by PSAE. During follow-up, no patient underwent surgery or repeated embolization. Preserved blood flow was found on Doppler sonography in 82% of the patients and no pseudoaneurysms were demonstrated. A perisplenic collection was found in one patient and responded well to percutaneous drainage. Conclusions:   Proximal embolization of the splenic artery for severe splenic injury is highly successful in cessation of bleeding while preserving splenic architecture. There were minimal complications in this series demonstrated by clinical and Doppler examinations.     

Functional Outcome after Operative Treatment of Displaced Fractures of the Acetabulum: A 12-month to 5-year Follow-up Investigation

Abstract Purpose:  To review our experience with 82 surgically treated displaced acetabular fractures over a 4-year period. Patients and Methods:  Ninety-three consecutive displaced acetabular fractures were consecutively operated on at Level I Trauma Center from January 1, 2000 through December 31, 2003, and 82 were available for review with a minimum of 12-month follow-up. Clinical (Merle D'Aubigné modified by Matta et al.) and radiographic (Matta) outcomes were evaluated. Complications and secondary operative procedures were documented. Results:  Anatomical reduction was achieved in 89% of the patients. At follow-up examination 12–60 months postoperatively (mean 32 months), clinical results were satisfactory in 65 patients (79.2% of the cases), with 14 excellent and 51 good results, and roentgenographic results were satisfactory in 70 patients (85.4% of the cases). Complications included a 12.2% incidence of sciatic nerve palsy (10 patients, two postoperative and eight posttraumatic), a 2.4% incidence of intraoperative vascular lesion (one external iliac artery and one external iliac vein), a 1.2% incidence of postoperative loss of reduction, a 1.2% incidence of infection, a 1.2% incidence of Brooker et al. class IV heterotopic ossification, a 2.4% incidence of posttraumatic osteoarthritis, and a 2.4% incidence of osteonecrosis of the femoral head. Conclusions:  Operative treatment is an effective method for the management of displaced acetabular fractures. Clinical and roentgenographic results correlate closely with an anatomic reduction. Low complication rate can be expected if adequate preoperative assessment and planning is performed. Strategies to minimize the risk of thromboembolism and heterotopic ossification on the basis of mechanical pneumatic compression and antiinflammatory nonsteroidal drugs, respectively, are reliable techniques for these injuries.     

Endovascular Treatment of an Axillary Pseudoaneurysm Following a Traumatic Shoulder Dislocation

Abstract   A pseudoaneurysm following a shoulder dislocation is considered rare. We report here a case of an 82-yearold man who suffered from vascular and neurological injury due to an axillary pseudoaneurysm following anterior dislocation of the left shoulder. An emerging swelling in the shoulder region was caused by a hematoma and a slowly bleeding pseudoaneurysm in combination with reactive swelling of the soft tissues. Neurological damage occurred due to local compression. A minimally invasive technique was used to treat the pseudoaneurysm. Embolization was initially attempted, but this treatment failed. A stent was subsequently inserted to eliminate the axillary pseudoaneurysm from the circulation. Early imaging and an aggressive endovascular treatment should be considered in all patients suffering from an axillary artery (pseudo)aneurysm.     

Pneumocephalus Following Severe Head Trauma

Abstract   It is important to be alert to the possibility of pneumocephalus in patients with head injury. Pneumocephalus is a potentially lethal complication in patients with craniofacial fractures following severe head trauma. A patient presented with intracranial air after he fell down from a height of 4 m. The patient recovered without any neurological deficits after conservative treatment. A time sequence of cerebral CT scans shows how the pneumocephalus developed and finally resolved without surgical intervention. The etiology, diagnosis, treatment and possible complications of this injury are discussed briefly.     

Minimally Invasive Anterior Plate Osteosynthesis in Humeral Shaft Fractures

Abstract   Twelve patients with shaft fractures of the humerus were treated with percutaneous anterior plate osteosynthesis using a deltoid-pectoral respectively brachialis splitting approach without exposure of the radial nerve. The implants used were PHILOS plates, locking compression plates 3.5 and 4.5, and a tibial metaphyseal plate (all by Synthes). There were no intraoperative complications, no infections and no iatrogenic injuries of the radial or axillary nerve. Nine fractures healed entirely. There was one pseudarthrosis caused by a plate that was too short; another fracture probably healed but the distal screws broke; and one patient was lost to follow-up. Minimally invasive anterior plate osteosynthesis in humeral shaft fractures is an operative alternative which may be indicated not only in delayed healing or complex shaft fractures.     

Historical Treatment Results of Pelvic Ring Fractures: A 12-year Cohort Study

Abstract Background:   Since the Academic Medical Center Amsterdam was appointed as a level-1 trauma center in July 1997, the number of polytrauma patients who were presented has increased. This stimulated us to perform a retrospective analysis on the treatment results of patients with a pelvic ring fracture and to evaluate our treatment strategies. Materials and Methods:   A chart review of all patients with a partially stable fracture (Tile/AO type B) or an unstable fracture (Tile/AO type C) was performed. All patients presented between 1 January 1990 and 31 December 2001 were included. Two historical groups (1990–1997 and 1998–2001) were formed. General demographics, treatment method, complications, re-operations, length of hospital stay and anatomic results were recorded for all patients. Results:   Fifty-two patients were included in group 1 and 65 patients in group 2. There was a lower mortality in group 2. The B-fractures were treated either conservatively (group 1 83.3% vs. group 2 73.8%), by external fixation (16.7 vs. 9.5%) or by ORIF (0 vs. 16.7%). C-fractures were treated by ORIF in 32.1 versus 82.6%, by external fixation in 28.6 versus 4.4% and conservatively 39.3 versus 13.0%, respectively. Fracture healing with less than 10 mm displacement was achieved in 58.3 versus 78.6% for the B-fractures, while this was achieved in 42.9 versus 73.9% in the C-fractures. Group 2 showed significantly fewer complications. Conclusion:   Evaluating two consecutive patient groups shows an increase in the number of fractures. A more aggressive surgical treatment has lead to lower mortality, improved anatomical reduction, and lower rate of complications.     

Femoral Neck Fractures in Children: A Follow-Up Study of 19 Cases

Abstract   We studied 20 fractures of the neck of femur in 19 patients under the age of 16 years that were treated in the period from 1998 to 2004. There were nine boys and ten girls with an average age of 11 years. There was one case of Delbet type I (transepiphyseal separation). Thirteen cases were of Delbet type II (transcervical) fractures, four cases were of type III (cervicotrochanteric), and two patients had old fractures (one Delbet type II and one type III). Fourteen fractures were displaced. In our study group, 11 patients were treated surgically by internal fixation while the remaining were treated conservatively by traction followed by hip spica cast application. Mean follow-up was 24 months (range 1–5 years). Avascular necrosis occurred in nine cases (45%). Other complications included coxa vara in two, nonunion in two, postoperative infection in one, and refracture in one. The amount of displacement of the fracture and the quality of reduction and fixation influenced the occurrence of complications such as avascular necrosis and nonunion.     

Injury to the Thoracic Aorta Following Fatal Blunt Trauma: An Autopsy Study

Abstract Background:   Transection of the thoracic aorta (TTA) remains a leading cause of death after blunt trauma. In this autopsy study, the natural history of this injury is reviewed. Patients and Methods:   All blunt trauma deaths that occurred in the Milano urban area over a period of one year were collected. Autopsies were available in all cases. Incidence, mechanisms, anatomical locations of TTA, deaths due to TTA or coexisting injuries, and times of death were reviewed. Cause of death was established. Death was attributed to TTA if its abbreviated injury score was six (hemorrhage not confined to the mediastinum). Results:   199 cases of fatal blunt trauma were included, 72% of which were males; mean age 53 ± 21. A TTA was observed in 53 subjects (27%), with a significantly higher incidence between the ages of 45 and 64 years and after falls from height. The aorta was transected at the isthmus in 36% of cases. Victims with TTA had a higher pre-hospital mortality and more injuries to chest organs, the chest wall and pelvis. In victims with TTA, injury to the aorta was the cause of death in 58%. Only five patients with TTA survived more than 1 h, reaching the hospital alive; four of these died due to the rupture of a mediastinal hematoma during the first hours of in-hospital care. Conclusions:   This study demonstrates that TTA is a frequent cause of immediate deaths among blunt trauma victims. Patients with risk factors for TTA who reach the hospital alive need to be promptly investigated with a contrast CT scan. Evidence of mediastinal hematoma is suggestive for possible rapid evolution.     

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis

Abstract  In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.     

Treating Displaced Distal Forearm Fractures in Children

Abstract Purpose:  Distal forearm fractures are among the most common fractures in children. In the past few years the option of percutaneous pinning has gained more attention in the treatment of unstable fractures. However, it remains unclear in which cases a fracture or its reduction should be considered unstable. Study Design:  In order to evaluate which type of fractures profit most from additional pinning after closed reduction, we performed a retrospective analysis of 225 consecutive cases using the recently published AO pediatric classification of long bone fractures. Results:  After closed reduction, position in the cast was lost in 23% of the cases. The proportion of unstable reductions was much higher in completely displaced fractures. The amount of dislocation was more important than the type of fracture according to the AO classification proposal. Conclusions:  Fully displaced fractures should always be reduced in a setting with pins immediately available. If anatomical reduction cannot be achieved, pinning is advocated. The AO proposal for pediatric long bone fracture classification could be a useful tool to render the diverse studies more comparable. However, the important feature of complete versus subtotal displacement is lacking.     

Is the Wave Plate Still a Salvage Procedure for Femoral Non-union? Results of 75 Cases Treated with a Locked Wave Plate

Abstract Objective:   To analyse the results of the treatment of aseptic femoral non-unions using a singular locked implant. Design:   Consecutive case series. Setting:   A level-1 trauma center with a high number of specialist referrals. Patients:   The study is based on a consecutive series of patients with prospective data evaluation. From 1993 to 2003, 75 patients were treated with a wave plate. All patients had persistent non-union of the femoral shaft without clinical or laboratory signs of infection and previous unsuccessful attempts to treat the non-union. Intervention:   The method of treatment was standardized and included a lateral approach, cancellous bone hip grafting, osteosynthesis with a wave-shaped plate (PPF) and polyaxial locking screws as well as the application of a gentamicin-PMMA chain. Main Outcome Measurements:   Time to achieve union, rate of implant failure and number of remaining nonunions after treatment. A total of 75 patients had full follow-up and were included in the study. Results:   The union of the fracture was found in 64 patients after the initial procedure. In eight cases a second procedure was performed to achieve union in the form of a second bone graft because of a delay in callus formation. The mean time to union was 7.3 months with a range from 3 to 19 months. The implant failed in three cases accounting for 4% of the total. Conclusion:   The locked wave plate offers a further reliable treatment for complex aseptic femoral non-unions.     

Simultaneous, Bilateral Pathological Displaced Intracapsular Hip Fractures Occurring Spontaneously Secondary to Osteomalacia of Hypomagnesemic Origin: A Case Report and Review of the Literature

Abstract   Spontaneous fractures involving both of the femoral necks simultaneously are exceedingly rare events. We report a case of an elderly female who presented after breaking both femoral necks following a trivial fall, initially diagnosed as age-related osteoporosis. Both the hips were treated by hemiarthroplasty. The diagnosis was revised to vitamin D-resistant osteomalacia secondary to hypomagnesemia after histopathological confirmation and further investigations. We examine the different etiological factors and mechanisms operating in the causation of this rare injury and explore the possible role of magnesium in the pathogenesis of osteomalacia. Fractures may remain occult until late, leading to increased morbidity and mortality. The value of an early MRI is recapitulated, with emphasis placed on prevention and early fixation.     

Reconstruction of Large Diaphyseal Defects of the Femur and the Tibia with Autologous Bone

Abstract   Post-traumatic segmental bone defects of the femur and the tibia above the critical size require special attention because conventional bone grafts result in high rates of nonunion. The biological and biomechanical aspects of this challenging surgery, as well as ongoing refinements to achieve mechanically stable bone healing with correct bone alignment are reviewed. Choosing the best appropriate method is mainly dependent on both the location and etiology of the bone defect. Three patients with successful bone reconstruction using two-stage reconstruction with cancellous bone graft, double-barrel free vascularized fibula transfer and distraction osteogenesis are described. Advantages and disadvantages of these methods are discussed in accordance with recent literature.