Operative treatment of intertrochanteric hip fractures: an overview of modern advances and techniques

Hip fractures have been one of the most studied injury pattern in adults. The number of hip fractures is increasing exponentially; furthermore, the cost of treatment places great economic strain on society. There have been recent developments in hip-fracture treatment, particularly involving the intertrochanteric region, with emphasis on deformity prevention to try to optimize patient functional outcomes. In this article, we outline some of these developments with an emphasis on changes in implant design.     

Atypical Femur Fractures: A Review

Bisphosphonates are one of the most commonly prescribed medications for the treatment of osteoporosis. Their use has greatly decreased the number of osteoporosis-related vertebral and nonvertebral fractures. Recently, however, a relationship between long-term bisphosphonate use and subtrochanteric and femoral shaft fractures has been elucidated. These low-energy fractures, termed atypical femur fractures, exhibit unique characteristics in their pathophysiology, presentation, and radiographic appearance compared with more traditional high-energy femur fractures. Here we provide a review based on the most recent literature of the pathophysiology, presentation, evaluation, and management of these fractures. Despite an abundance of literature, atypical femur fractures remain difficult to treat, and surgeons must be aware of the tricks and complications associated with their management.     

Bilateral Disruption of Soft Tissue Extensor Mechanism of Knee: Functional Outcome and Comparison to Unilateral Injuries

Background:

Bilateral ruptures of the extensor mechanism are rare.

Questions/Purpose:

The purpose of this study was to compare the clinical outcomes of operatively treated unilateral and bilateral knee soft tissue extensor mechanism injuries and to identify risk factors for bilateral disruption.

Methods:

All patients operatively treated for a knee extensor mechanism injury were entered into a database and prospectively followed. Postoperative protocol was standardized for all patients. Demographic data, baseline characteristics, range of motion, complications, pain, and functional status were assessed. The main patient-reported outcome measures used in this study were the SF-36 Health Survey and the Lysholm Scale.

Results:

Patients who sustained bilateral injuries were more likely to have one or more systemic medical conditions. There was no statistical difference between the groups with regard to mechanism of injury or body mass index. The average follow-up was 29 months (range 6–60 months). Patient-reported outcomes, in the form of the SF-36 Health Survey and Lysholm scores, were not significantly different between the two groups at final follow-up. Range of motion and quadriceps strength was also similar between the two cohorts. At latest follow-up, 88% of patients with unilateral injuries and 83% of patients with bilateral disruption were able to return to their pre-injury employment.

Conclusion:

Operatively treated bilateral knee extensor mechanism disruptions fare similar to unilateral injuries with regard to ultimate functional outcome. The presence of one of more preexisting medical conditions was identified as a risk factor for bilateral tendinous disruption.     

Self-Reported Feelings of Disability Following Lower Extremity Orthopaedic Trauma

BackgroundNearly 20% of Americans consider themselves disabled. A common cause of disability is unexpected orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma, is the following: to assess the prevalence of self-reported feelings of disability following these injuries, to determine if self-reported feelings of disability impact functional outcomes, and to understand patient characteristics associated with self-reported feelings of disability.MethodsThe functional statuses of patients with tibial plateau fractures and ankle fractures were prospectively assessed. Patient reported feelings of disability (acquired from validated functional outcome surveys), which were compared with overall patient-reported functional outcome and emotional status at each follow-up visit. Additionally, patient demographics were analyzed, to assess associations with feelings of disability.ResultsA total of 710 patients were included in our analysis. At short-term follow-up (3 months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.744, P < 0.001). At long-term follow-up (12-months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.741, P < 0.001). Self-reported feelings of disability were associated with increased age at both short-term (P = 0.015) and long-term (P = 0.003) follow-ups. At short-term follow-up, 41% of males and 59% of females self-reported feelings of disability (P < 0.001) No significant differences existed between genders at long-term follow-up (P = 0.252). Self-reported feelings of disability declined at each follow-up visit, from 48.1% at short-term follow-up to 22.1% at long-term follow-up.ConclusionSelf-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes.Level of EvidenceIII.     

Who Is Lost to Followup?: A Study of Patients with Distal Radius Fractures

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient’s return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes.     

Fixation stability of comminuted humeral shaft fractures: locked intramedullary nailing versus plate fixation

BACKGROUND: This study compared the fixation stability of two treatments for humeral shaft fractures with segmental bone loss during cyclic, physiologic loading. METHODS: Six matched pairs of human humeri received either a 10-hole broad dynamic compression plate or a locked antegrade inserted humeral nail applied to a humeral diaphyseal osteotomy with a 1.5-cm gap defect. The bone-implant humeral constructs were axially loaded for 10,000 cycles at 250 N and 500 N, with measurements of gap displacement and calculation of construct stiffness. The specimens were then loaded to failure. RESULTS: Cyclic loading showed no difference between the two groups for average gap displacement or construct stiffness. The intramedullary nail constructs failed by humeral shaft splitting (n = 4) or head cut-out (n = 2) at an average of 958.3 N, whereas the plate constructs failed by humeral shaft splitting and screw pull-out (n = 3) or plate bending (n = 3) at an average of 641.7 N (p < 0.001). CONCLUSION: Although both methods offer similar fixation stability under physiologic loads, the higher load to failure demonstrated by intramedullary nail fixation may have implications for the patient with multiple injuries for whom partial weightbearing on the injured upper extremity may be necessary.     

Open reduction and internal fixation of tibial pilon fractures

Although it is evident that the fracture of the tibial plafond is a complex, often debilitating injury, its management is not clear. These injuries generally fall into one of two categories. The low-energy, rotational type of fracture has been shown to have excellent clinical and functional results with open reduction and internal fixation. The high-energy, compression type of fracture has had uniformly moderate results and historically high complication rates. Some authors think that bridging external fixation with or without limited internal fixation should be employed in high-energy fractures. Others believe that open reduction and internal fixation to avoid articular incongruence and development of axial malalignment is needed for good long-term outcome. The authors believe the latter. Staging the treatment of the patient can minimize development of soft tissue complications. The authors follow the recommendations of Patterson and Sirkin and believe that high-energy pilon fractures should be temporized with an external fixator with or without fibular plating to restore length. Any open would should be addressed at this time. Definitive fixation should be planned for between 10 and 14 days, by which time the soft tissue envelop is likely to be ready to accept the further insult of surgery. The surgical technique should be well planned for and include the use of meticulous soft tissue techniques and indirect reduction methods. With the proper attention to detail, long-term results will be maximized.