Nonunion of coronal shear fracture of femoral condyle

Isolated coronal fractures of femoral condyle are rare in adults and nonunion of Hoffa fracture is reported only a few times in the literature. We analyzed six cases of nonunion of Hoffa fractures over a period of three years. Three patients were treated conservatively and three patients had fixation failures. Delay of presentation was 2 months to one year. Treatment protocol consisted of open reduction, excision of pseudoarthrosis, bone grafting and internal fixation along with knee arthrolysis. Union was achieved in all patients at mean 16 weeks. The treatment of nonunion of Hoffa fractures requires careful preoperative planning and meticulous surgical technique. The literature regarding the controversies in fracture management and surgical technique are reviewed.     

Nonunion of coronal shear fracture of femoral condyle

Isolated coronal fractures of femoral condyle are rare in adults and nonunion of Hoffa fracture is reported only a few times in the literature. We analyzed six cases of nonunion of Hoffa fractures over a period of three years. Three patients were treated conservatively and three patients had fixation failures. Delay of presentation was 2 months to one year. Treatment protocol consisted of open reduction, excision of pseudoarthrosis, bone grafting and internal fixation along with knee arthrolysis. Union was achieved in all patients at mean 16 weeks. The treatment of nonunion of Hoffa fractures requires careful preoperative planning and meticulous surgical technique. The literature regarding the controversies in fracture management and surgical technique are reviewed.     

Posterior buttress plate with locking compression plate for Hoffa fracture

BackgroundMany difficulties are associated with treating fractures of the posterior condyle of the femur (Hoffa fractures). Anatomical reduction and internal fixation are optimum for such intra-articular fractures. Some surgeons use anteroposterior screws to achieve direct stability. However, screw fixation is not adequate in some cases. To increase stability, we treat Hoffa fractures with a posterior buttress plate; we use a twisted, 1/3 tubular plate at the posterior surface and a supplementary, locking compression plate (LCP) for additional stability.MethodsPatients who had sustained Hoffa fractures between January 2006 and March 2009 were included in this study. Patients comprised three males and two females with a mean age of 73.6 years at the time of surgery. A 3.5-mm 1/3 tubular plate was twisted and applied to the posterolateral aspect of the distal femur. This was combined with an LCP on the distal femur to achieve a rafting effect.ResultsAll fractures were healed within 15 weeks. There were no instances of nonunion, infection, or implant removal. The mean range of motion was ?3° to 121°. Four patients had no pain in the treated limb and one had mild pain on weight bearing. The average Oxford Knee Score was 44.6 points. All patients achieved satisfactory joint function and regained their walking ability with good clinical results.ConclusionsImproved stability associated with this technique enables patients to begin range-of-motion training and return to their normal activities sooner; this resulted in good outcome.     

A new fixation method for Hoffa fracture

Purpose

To investigate the clinical effect of a new fixation method for Hoffa fractures.

Methods

We treated eleven patients with Hoffa fracture using the new fixation method (fixation with one screw inserted from the femoral intercondylar notch and two screws inserted from the nonarticular lateral (or medial) surface of the fractured condylar fragment; the two sets of screws were crossed).

Results

After an average follow-up period of 24 months (range 5–28 months), all fractures had healed. The average healing time was 11.6 weeks (range 9–14 weeks). On the version of the Knee Society Score modified by Dr. John Insall in 1993, the average score was 174.6 points (range 125–199 points).

Conclusions

The new fixation method for Hoffa fracture is effective, and may provide a new way to treat Hoffa fractures.     

Hoffa骨折的治疗

目的 总结Hoffa骨折的临床特点,探讨其治疗方法及临床疗效.方法对2002年1月至2009年4月收治的20例24髁Hoffa骨折患者资料进行回顾性分析,男14例18髁,女6例6髁;年龄20～70岁,平均43.3岁.股骨内髁骨折15髁,外髁骨折9髁;其中单侧双髁骨折2例,单侧双髁并对侧单髁骨折1例;新鲜骨折20髁,陈旧性骨折内固定失效4髁.骨折按Letenneur分型:Ⅰ型6髁,Ⅱ型4髁,Ⅲ型14髁.15髁使用从前向后方向2～4枚直径3.5或6.5 mm松质骨螺钉或空心螺钉固定,8髁使用从后向前方向螺钉固定,1髁开放性骨折采用2枚3.0 mm克氏针固定.5髁联合使用侧方支持钢板结合螺钉固定,3髁联合使用后方抗滑移钢板结合螺钉固定.结果 20例患者术后获平均14.4个月(6～84个月)随访.所有患者骨折均获骨性愈介,愈合时间为12～44 周,平均18.6周,无骨折不愈合、感染、内固定松动及股骨髁缺血性坏死等并发症发生.参照Letenneur等的Hoffa骨折术后功能评估标准评定疗效:优16髁,良6髁,差2髁,优良率为91.7%.结论 Hoffa骨折临床少见,螺钉固定是Hoffa骨折于术固定方法的金标准,螺钉固定方向、直径及手术切口的选择应视骨折类型和骨折块大小而定.对于不稳定Hoffa骨折,在螺钉固定的基础上应考虑联合应用侧方支持钢板或后方抗滑移钢板固定.

Abstract：

Objective To investigate clinical characteristics and treatment of Hoffa fractures.Methods Twenty patients with Hoffa fracture (24 condyles) were treated from January 2002 to April 2009.They were 14 men (18 condyles) and 6 women (6 condyles), aged from 20 to 70 years (average, 43. 3 years).There were 15 fractures of medial femoral condyle and 9 ones of lateral femoral condyle. Two rare cases were fractures of unilateral bi-condyles and one rare case fractures of unilateral bi-condyles plus contralateral single condyle. Four fractured condyles were old due to implant failure and 20 were fresh. According to the modified Letenneur's classification, there were 6 condyles of type Ⅰ, 4 condyles of type Ⅱ and 14 condyles of type Ⅲ.Fifteen condyles were fixed anteroposteriorly with 2 to 4 cancellous or canulated screws, 8 condyles were fixed posteroanteriorly with 2 to 4 screws, and one condyle was fixed with K wires. Five condyles were fixed with screws plus lateral supporting plates, and 3 condyles with screws plus posterior anti-sliding plates. Results All the patients were followed up for an average of 14. 4 months (6 to 84 months) . All the 24 condyles obtained bony union after an average of 18. 6 weeks (from 12 to 44 weeks). There was no infection, implant failure, nonunion or bone necrosis. According to Letenneur's functional assessment system, 16 condyles were excellent, 6 good and 2 poor, with a good-to-excellent rate of 91. 7%. Conclusions All Hoffa fractures should be treated with screws. Screw diameter, fixation direction and surgical incision should depend on facture type and size of fracture block. Unstable Hoffa fractures should be treated with screws combined with lateral supporting plates or posterior anti-sliding plates.     

Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures

OBJECTIVE: To summarize the surgical experience and clinical results of the first 89 fractures of the proximal tibia treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). DESIGN: Retrospective analysis of prospectively enrolled patients into a database. SETTING: Academic level I trauma center. SUBJECTS/PARTICIPANTS: Eighty-seven consecutive patients with 89 proximal tibia fractures (AO/OTA type 41 and proximal type 42 fractures) treated by 2 surgeons. Seventy-five patients with 77 fractures were followed until union. The mean follow-up was 14 months (range: 3-35 months). There were 55 closed fractures and 22 open fractures. INTERVENTION: Surgical reduction and fixation of fractures, followed by rehabilitation. MAIN OUTCOME MEASUREMENTS: Perioperative and postoperative complications, postoperative alignment, loss of fixation, time to full weight bearing, radiographic union, and range of motion. RESULTS: Seventy of 77 fractures healed without major complications (91%). There were 2 early losses of proximal fixation, 2 nonunions, 2 deep delayed infections, and 1 deep peroneal nerve palsy. Other complications included a superficial wound infection and 3 seromas. Postoperative malalignment occurred in 7 patients with 6 degrees to 10 degrees of angular deformity (6 flexion/extension and 1 varus/valgus malalignments), and an eighth patient had a 15 degrees flexion deformity. In 4 patients, the hardware was removed at an average of 13 months because of irritation (5%). The mean time for allowance of full weight bearing was 12.6 weeks (range: 6-21 weeks), and the mean range of final knee motion was 1 degrees to 122 degrees . CONCLUSIONS: The LISS provides stable fixation (97%), a high rate of union (97%), and a low (4%) rate of infection for proximal tibial fractures. The technique requires the successful use of new and unfamiliar surgical principles to effect an accurate reduction and acceptable rate of malalignment.     

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment.A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively.Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment.Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.     

Surgically treated Hoffa Fractures with poor long-term functional results

IntroductionHoffa fractures are rare injuries and usually involve the lateral condyle. There are few published studies of large series of isolated coronal plane fractures of the femoral condyle. The aim of the study to determine the long-term functional outcomes and complications in surgically treated Hoffa fractures.Patients and methodsA retrospective review was made of 13 consecutive patients who were treated surgically for an isolated coronal plane fracture of the distal femur posterior condyle. The patients were evaluated with physical examination, PA and lateral radiographs and CT at the final follow-up examination. Functional outcome was evaluated with the OXFORD knee scoring system and Knee Society Score (KSS). Pain at rest and in activity was assessed using a Visual Analog Scale (VAS).ResultsThe patients comprised 11 males and 2 females with an average age at surgery of 27.5 years. The mean follow-up period was 93 months (range, 62–134 months). Mean time to fracture healing was 10 weeks (range, 8–12 weeks). The mean ROM was determined as 110°, mean KSS 78,4 and mean Oxford knee score 38,2. The mean KSS was 66,5 for medial Hoffa fracture patients and it was 83,8 for lateral Hoffa fracture patients. The mean Oxford knee score was 33,2 for medial Hoffa fracture patients and it was 40,4 for lateral Hoffa fracture patients. The mean VAS at rest and in activity was 1,1 and 2,9, respectively. Osteoarthritis was seen in 7 (54%) patients and avascular necrosis in 2 (15.4%). Varus instability was determined in 1 patient and valgus instability in 1 patient.ConclusionHoffa fractures may easily be overlooked if the radiological examination is not made carefully. Screw fixation was seen to provide enough biomechanical stability until the fracture healed. Arthrosis is a frequent long-term complication which worsens the functional results. Medial Hoffa fractures tend to have worse functional results than lateral Hoffa fractures.Level of evidence: Therapeutic Level IV retrospective case series.     

Early results of the less invasive stabilization system for mechanically unstable fractures of the distal femur (AO/OTA types A2, A3, C2, and C3)

OBJECTIVES: Historically, mechanically unstable fractures of the distal femur have been difficult to treat. Problems such as varus collapse, malunion, and nonunion frequently resulted before fixed-angle plates and indirect reduction techniques were popularized. More recently, the Less Invasive Stabilization System, or LISS (Synthes, Paoli, PA), has been designed to combine these 2 approaches with the intended goals of achieving adequate stable fixation and early healing. Early clinical results for the femoral Less Invasive Stabilization System have been promising. The purpose of this study is to evaluate the clinical results of patients with high energy, mechanically unstable fractures of the distal femur treated with the Less Invasive Stabilization System. DESIGN: Retrospective analysis of a treatment protocol, consecutive patient series. SETTING: Busy level II trauma center. PATIENTS /PARTICIPANTS: Twenty-six patients with 27 high-energy AO/OTA types A2, A3, C2, and C3 fractures of the distal femur. INTERVENTION: Treatment with indirect fracture reduction and internal distal femoral fixation using the Less Invasive Stabilization System. MAIN OUTCOME MEASUREMENTS: Clinical and radiographic assessment. RESULTS: Twenty-one patients with 22 fractures were available for evaluation at an average 19 months postinjury (range 12-35 months). The mechanism of injury included 12 motor vehicle collisions, 4 high falls, 5 motorcycle crashes, and 1 bicyclist struck by a car. Twenty patients had associated injuries. Six fractures were open. All fractures were comminuted; according to the AO/OTA fracture classification there were 4 A2, 3 A3, 12 C2, and 3 C3 fractures. All fractures healed without secondary surgeries at a mean of 13 weeks (range 7-16 weeks). There were no cases of failed fixation, implant breakage, or infection. Average joint line orientation relative to the femoral shaft axis (valgus) measured 99 degrees on postoperative radiographs and 99 degrees on final radiographs. A comparison of postoperative to healed final radiographs for each femur demonstrated no case with greater than a 3 degrees difference in either varus or valgus. Complications included 1 mal-union where the fracture was fixed in 8 degrees of valgus and 2 cases of external rotation between 10 degrees and 15 degrees. Painful hardware occurred in 4 patients, of which 3 underwent implant removal. The average knee range of motion was 5 degrees to 114 degrees. CONCLUSIONS: The Less Invasive Stabilization System allows for stable fixation and facilitates early healing in mechanically unstable high-energy fractures of the distal femur. There were no patients with fixation failure, varus collapse, or nonunion in this "at-risk" population. This treatment safely allows for immediate postoperative initiation of joint mobility and the progression of weight bearing with early radiographic signs of healing.     

Mennen plate fixation for the treatment of periprosthetic femoral fractures: a multicenter study of thirty-six fractures

BACKGROUND: The management of periprosthetic femoral fractures after total hip and knee replacement remains difficult and controversial. This study was performed to determine the results of Mennen plate fixation for the treatment of periprosthetic femoral fractures. METHODS: This retrospective multicenter study consists of a review of a consecutive series of thirty-five patients in whom a total of thirty-six periprosthetic femoral fractures were treated with Mennen plate fixation. The average duration of follow-up was twenty-seven months (range, eight to forty-six months). RESULTS: Twenty-six fractures (72%) had united at an average of five months (range, three to ten months) after surgery. One of them had varus bending (10 degrees) of the plate. The remaining ten fractures had a nonunion and varus bending (20 degrees to 30 degrees) of the plate, with a fracture of the plate in eight. A revision procedure was successfully performed in the eight patients with nonunion. CONCLUSIONS: The treatment of unstable periprosthetic femoral fractures with Mennen plate fixation was complicated by high rates of mechanical failure (31%) and nonunion (28%). For this reason, we do not recommend the use of the Mennen plate for the treatment of periprosthetic femoral fractures.     

Early healing with locked condylar plating of periprosthetic fractures around the knee

Management of periprosthetic fractures around the knee is often difficult because of poor bone quality, comminution, and constraints imposed by the existing prosthesis. Locked condylar plates may provide more reliable fixation for these fractures than traditional methods of fixation. Eleven patients with periprosthetic fractures around the knee were treated with open reduction and internal fixation using a locked condylar plate. All 9 acute fractures and 1 of 2 periprosthetic nonunions healed at an average of 21 weeks, and no patient required additional surgery. Nine fractures healed in anatomical alignment, whereas 1 healed in 5 degrees valgus. The remaining periprosthetic nonunion developed a persistent nonunion with subsequent hardware failure. The average range of motion was 4 degrees to 92 degrees . Locked plating systems are highly effective for the management of complex periprosthetic fractures around the knee. They result in reliable fracture healing and permit early motion in complex fractures.     

Nonoperative treatment of ipsilateral fractures of the scapula and clavicle

BACKGROUND: Internal fixation of one or both bones is the recommended treatment for floating shoulder injuries (ipsilateral fractures of the scapula and clavicle). Perceived risks of nonoperative treatment include abduction weakness, decreased range of motion, chronic pain, malunion, and nonunion. None of these problems, however, have been confirmed by clinical studies. The purpose of this retrospective study was to analyze the clinical and radiographic results of nonoperative treatment of floating shoulder injuries. METHODS: Twenty patients with a floating shoulder injury were treated with either a sling or a shoulder immobilizer. Eleven clavicular fractures were displaced ten millimeters or more, and five scapular fractures were displaced more than five millimeters. Physical therapy was begun three days to two weeks after the injury. Patients were evaluated with three separate scoring systems: those of Herscovici et al., Rowe, and Constant and Murley. Shoulder abduction and flexion were measured, and abduction strength was evaluated by clinical examination and comparison with the uninjured extremity. The duration of follow-up averaged twenty-eight months (range, nine to seventy-nine months). RESULTS: Nineteen of the twenty pairs of fractures united uneventfully. One clavicular nonunion occurred secondary to segmental bone loss from a gunshot wound. On the basis of the Herscovici rating system, seventeen patients had an excellent result and three had a good result. According to the Rowe system, eighteen patients had an excellent result, one had a good result, and one had a fair result. The average Rowe score was 95. The average Constant score was 96. In all twenty patients, the strength of the injured extremity was equal to that of the uninjured extremity. Eighteen patients had a full, symmetrical range of shoulder motion, one lost 15 degrees of flexion, and one lost 20 degrees of abduction. CONCLUSIONS: Nonoperative treatment of floating shoulder injuries, especially those with less than five millimeters of fracture displacement, can achieve satisfactory results that are probably equal or superior to those reported after operative treatment, without the risk of operative complications.     

Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius

PURPOSE: To review the results of condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. METHODS: Twenty-four patients in whom a minicondylar blade plate was used to repair an unstable fracture of the distal ulna associated with a fracture of the distal radius were reviewed retrospectively an average of 26 months (range, 12-50 months) after injury. According to the Q modifier of the Comprehensive Classification of Fractures, there were 1 simple fracture of the ulnar neck (Q2), 20 comminuted fractures of the ulnar neck (Q3), and 3 fractures of the head and neck (Q5). Subsequent surgeries included repeat fixation and autogenous cancellous bone grafting in 2 patients with nonunion of the distal radius and 1 with nonunion of the distal ulna. Seven patients had a second operation to remove the ulnar plate secondary to discomfort from plate prominence. RESULTS: The final average motion was as follows: degrees of flexion (range, 30 degrees-80 degrees), 52 degrees of extension (range, 40 degrees-90 degrees), 76 degrees of pronation (range, 45 degrees-90 degrees), and 70 degrees of supination (range, 45 degrees-90 degrees). Grip strength averaged 64% of the contralateral, uninjured extremity (range, 35%-100%). Final radiographic measurements included an average palmar tilt of the distal articular surface of the radius of 8 degrees (range, 0 degrees-20 degrees of palmar tilt), ulnar inclination of 21 degrees (range, 15 degrees-25 degrees), and ulnar positive variance of 1 mm (range, 0-4 mm). There were no problems related to the distal radioulnar joint. According to the system of Gartland and Werley as modified by Sarmiento, there were 6 excellent, 15 good, and 4 fair results at final evaluation. CONCLUSION: For unstable fractures of the distal ulna associated with fracture of the distal radius, condylar blade plate fixation can achieve healing with good alignment, satisfactory function, and an acceptable rate of secondary surgery.     

Minimally invasive percutaneous plating of distal femoral fractures using the dynamic condylar screw

BACKGROUND: In distal femoral fractures, conventional open reduction and internal fixation causes complications because of excessive soft-tissue stripping. To prevent this, minimally invasive percutaneous plating was performed in distal femoral fractures. METHODS: Sixteen supracondylar or intercondylar femoral fractures were treated by minimally invasive percutaneous plating with the dynamic condylar screw without bone graft. Five (31%) were open fractures. RESULTS: All fractures healed except one. The average time for fracture healing was 17 weeks (range, 14-22 weeks). Complications included one nonunion related to early full weight bearing. No patient showed malunion or deep infection. Results were evaluated by modified Neer rating, and all patients had excellent or good results. Intra-articular fractures showed less favorable range of motion and clinical scores than extra-articular fractures. CONCLUSION: Minimally invasive percutaneous plating with the dynamic condylar screw can provide favorable results in the treatment of distal femoral fractures.     

Early mobilization of ankle fractures after open reduction and internal fixation

The effect of early mobilization and unrestricted weight bearing on final ankle motion in 51 operatively stabilized ankle fractures was prospectively investigated. Patients were treated with an ankle-foot orthosis (AFO) or a cast. Full weight bearing was unrestricted in both groups. Thirty-two fractures received an AFO and 19 received a cast. The follow-up period ranged from 2.3 to 66 months, with a median of eight months. At the final follow-up examination, the motion in the AFO-treated group was not functionally different from that of the cast-treated group. However, 72% of the patients treated in an AFO compared with 37% of patients treated in a cast had ankle dorsiflexion greater than 15 degrees (p = 0.014). No complications were directly related to the AFO. No loss of reduction occurred in any patient. The results of this series indicate that early motion of a fractured ankle treated operatively does not affect ankle motion. Early motion was not associated with increased morbidity or loss of reduction.     

Primary nonunion of intertrochanteric fractures of femur: An analysis of results of valgization and bone grafting

Background:

Nonunion of intertrochanteric fractures is uncommon because there is excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). There is only one published series that exclusively describes seven primary nonunions of intertrochanteric fractures. The aim of the present study was to analyze the results of internal fixation, valgization with 135° dynamic hip screw (DHS), and bone grafting in patients with primary nonunion of intertrochanteric fractures.

Materials and Methods:

Eighteen patients with primary intertrochanteric nonunion were included in the study; 16 were male and 2 were female. The age range was 30–70 years (mean: 46.9 years). The mean duration since index injury was 8.5 months (range: 4–18 months). As per the AO classification, the fractures were 31A 1.1 (n=1), 1.2 (n=1), 2.2 (n=3), 2.3 (n=9), and 3.3 (n=4). Three patients had hypermobile nonunion and 15 had stiff nonunion. The surgical principle was excision of pseudarthrosis, if present (n=3); freshening of the bone ends; stable fixation with 135° DHS, with good proximal purchase; bone grafting; and valgization.

Results:

Union was achieved in all patients at an average of 5.62 months (range: 4–7 months). The Harris hip score improved from 38 points preoperatively to 86 postoperatively at healing. The average limb shortening improved by 2 cm (range: 1.5 cm–3 cm). There was no infection and pain at the hip at final follow-up in any of the cases. All patients were subjectively satisfied with the outcome. All were capable of full weight bearing on their affected limb.

Conclusion:

Union in primary nonunion of intertrochanteric fractures in physiologically young patients with a well-preserved femoral head and good bone stock can be achieved with internal fixation, valgization, and grafting procedures.     

Dynamic external fixation of comminuted intra-articular fractures of the distal tibia (type C pilon fractures)

We report 26 patients with 28 type C3, distal intraarticular tibial (pilon) fractures treated by dynamic external fixation. Follow-up was at least two years, and the results (subjective and objective) were classified according to the Ovadia system. The mean to fracture union was 14 weeks (range: 12 to 20 weeks). There were three cases with angulation deformity (from 7 degrees to 20 degrees). There were no cases with nonunion or deep infection. Based on these results, this treatment with closed reduction and dynamic external fixation allowing early motion appears as a suitable method for treatment of comminuted intraarticular tibial pilon fractures.     

Atrophic nonunions of the proximal ulna

Ten consecutive patients were treated by one surgeon for an atrophic nonunion of the proximal ulna. There were six men and four women with an average age of 47 years. Nine of the initial injuries were fracture-dislocations (seven posterior Monteggia lesions and two transolecranon fracture-dislocations) and one was a fracture of the proximal ulnar and radial diaphysis. The nonunion was associated with failed operative fixation in nine patients and occurred after treatment in cast in one patient. Three patients had synovial pseudarthroses and eight had bony defects. Debridement of the nonunion, autogenous cancellous bone grafting, and contoured limited-contact plate fixation were done at an average of 36 months after the original injury. The patients were followed up for an average of 39 months. Union was achieved in all 10 patients. The average arc of ulnohumeral motion was 105 degrees and the average arc of forearm rotation was 130 degrees. According to the system of Broberg and Morrey five patients had an excellent result, four had a good result, and one had a fair result. The fair result was attributable to proximal radioulnar synostosis and severe ulnohumeral arthrosis. Atrophic nonunion of fractures of the proximal ulna usually follow a complex injury treated with inadequate fixation. Stable plate fixation and autogenous bone graft predictably lead to union, but the functional result may be limited by associated problems.     

Treatment of distal femoral nonunion and delayed union by using a retrograde intramedullary interlocking nail

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Operative treatment of calcaneal fractures in elderly patients

BACKGROUND: Operative intervention is an accepted treatment for fractures of the calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures of the calcaneus in elderly patients. METHODS: Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. RESULTS: The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38 degrees of plantar flexion, 10 degrees of dorsiflexion, 16 degrees of inversion, and 11 degrees of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. CONCLUSIONS: Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.