Amer Mirza

Classifications of Thoracic and Lumbar Fractures: Rationale and Supporting Data

&NA; Classification systems are generalizations that attempt to identify common attributes within a group to predict behavior or outcome without sacrificing too much detail. Because of the inherent variability of fractures, classifying them can be difficult. To properly apply any of the commonly cited classification schemes for thoracic and lumbar fractures, one must not only know the injury categories described in the original studies but also be familiar with the rationale for developing the classification. Many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation. They were based largely on the insights of experienced surgeons and researchers. Although the ideal classification for thoracic and lumbar fractures does not exist, it would incorporate neurologic as well as structural factors. Standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of these injuries and identification of optimal treatment options.

Anterior pelvic reduction and fixation using a subcutaneous internal fixator.

Acute traumatic pelvic instability mandates reduction and mechanical stabilization to maximize the chance of a good functional outcome. Posterior pelvic fixation is frequently inadequate to stabilize the pelvic ring in isolation. Fixation augmentation with anterior pelvic ring implants can take several forms, including plates, medullary screws, or external fixation. Based on a multitude of patient and injury factors, external fixation may be the definitive anterior pelvic implant of choice. However, many drawbacks exist with this treatment, most notably the high infection rates of the transcutaneous pins, impaired patient mobilization, and suboptimal mechanical properties. We present a technique of a subcutaneous anterior pelvic fixator as an alternative method of anterior pelvic ring reduction and stabilization that avoids many of the drawbacks of traditional anterior pelvic external fixation.

A staged treatment plan for the management of Type II and Type IIIA open calcaneus fractures.

Objective: To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen. Intervention: Patients were treated in a staged fashion with antibiotics, irrigation, débridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation. Main Outcome Measures: Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined. Results: There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had débridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial débridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months. Conclusion: Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent débridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.

Initial management of pelvic and femoral fractures in the multiply injured patient

The management of polytrauma patients is clinically challenging and requires a multi-disciplinary team approach. The immediate and definitive operative care of fractures represents the optimal treatment for polytrauma patients with orthopedic injuries. Early orthopedic intervention in long bone fractures and pelvic ring injuries has been shown to decrease pulmonary complications, improve hemodynamic stability, reduce ventilator time, and facilitate early patient mobilization. These factors decrease mortality and improve outcomes for patients with multiple injuries.

Intramedullary Nailing Versus Locked Plate for Treating Supracondylar Periprosthetic Femur Fractures

The objective of this study was to compare retrograde intramedullary femoral nailing with supracondylar locked screw-plate fixation for the treatment of periprosthetic femur fractures following total knee arthroplasty. Time to union and full weight bearing were the primary study outcomes, with perioperative blood loss, need for transfusion, need for revision surgery, and infection being the secondary outcomes. A retrospective review of 63 patients who sustained Rorabeck Type II periprosthetic femoral fractures was undertaken. Patients were pooled from 3 academic institutions between 2001 and 2009. Patients eligible for the study were identified from the electronic medical record using an IDX query of International Classification of Diseases 9 and Current Procedural Terminology codes for fixation of femur fracture with intramedullary implant or plate and screws. In the series, 35 patients were treated with intramedullary femoral nailing and 28 with a locked screw-plate. The 2 groups were compared for radiographic union at 6, 12, 24, and 36 weeks. At 36 weeks, radiographic union was significantly greater in the locked screw-plate group. Time to full weight bearing was not significantly different. A greater perioperative transfusion rate was observed in the locking plate group, but it also had an overall lower rate of reoperation, for any reason, compared with the intramedullary femoral nailing group. The results support the use of a laterally based locked plate in the treatment of Rorabeck type II distal femur periprosthetic fractures.

Percutaneous Plating of the Distal Tibia and Fibula: Risk of Injury to the Saphenous and Superficial Peroneal Nerves

Objectives: To assess the risk of injury to the superficial peroneal nerve, saphenous nerve, and saphenous vein in percutaneous fixation of the distal fibula and tibia. Methods: Ten adult cadaver lower extremities were instrumented with precontoured periarticular plates for the distal tibia and fibula. Plates were inserted percutaneously along the medial distal tibia and lateral fibula. Smooth wires were inserted percutaneously into each screw hole. Dissection of the superficial peroneal nerve, saphenous nerve, and saphenous vein was performed along their respective course. The position of the neurovascular structures relative to the smooth wires was recorded. Results: The saphenous nerve and vein had a predictable course along the medial aspect of the ankle. Both structures were injured in every specimen. This occurred consistently at 2.0 to 4.7 cm from the tip of the medial malleolus. The superficial peroneal nerve demonstrated large variance in the exit point from the lateral compartment crural fascia, exiting at an average of 11.6 cm from the tip of the lateral malleolus. Injury occurred in a single specimen at 11.5 cm from this point. Conclusions: The superficial peroneal nerve, saphenous nerve, and saphenous vein are at risk during percutaneous submuscular plating of the distal fibula and tibia. Careful dissection proximally for the fibula and distally for the tibia can minimize the risk of damage to these structures.

Salvage Hip Arthroplasty After Failed Fixation of Proximal Femur Fractures

We reviewed 46 patients who underwent salvage hip arthroplasty (SHA) for revision of failed cannulated screws (CS), sliding hip screws (SHS), or intramedullary nails (IMN). The primary objective was to determine differences in operative difficulty. SHA after failed femoral neck fixation was associated with lower intra-operative demands than after failed peri-trochanteric fractures. Similarly, analysis by the index implant found that conversion arthroplasty after failed CSs was associated with lower intra-operative morbidity than failed SHSs or IMNs; differences between SHS and IMN were not as clear. Importantly, intra-operative data in cases of failed SHSs were similar regardless of the original fracture type, showing the device played a larger role than the fracture pattern. Complications and revision surgery rates were similar regardless of fracture type or fixation device. Our results suggest that operative demands and subsequent patient morbidity are more dependent on the index device than the fracture pattern during SHA.

Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a triceps-reflecting technique

BACKGROUND Surgical management of extra-articular distal humerus fractures results in predictable fracture alignment. Open reduction and internal fixation also decrease the soft tissue complications and frequent follow-up required with functional bracing. A triceps-reflecting posterior approach provides excellent exposure to the humerus and minimizes trauma to the triceps. An anatomically precontoured plate on the posterolateral surface of the humerus provides stable fixation of these injuries and is placed directly through the interval developed by the triceps-reflecting approach. METHODS We retrospectively reviewed the trauma databases at 2 level I academic trauma institutions during a 5-year period for all patients with an extra-articular distal humerus fracture treated with a triceps-reflecting approach and an anatomically precontoured posterolateral distal humerus plate. Patient and fracture characteristics were recorded, as were QuickDASH functional scores and visual analog scale scores for pain, function, and quality of life. RESULTS Forty patients were eligible for our study. Average follow-up was 88 weeks. Thirty-eight (95%) patients went on to union. Seven (20%) patients required a secondary procedure. The average QuickDASH score was 17.5 (range, 2.6-56.8). The average visual analog scale scores were 1.9 (range, 0-7) for pain, 2.3 (range, 0-8) for function, and 1.6 (range, 0-5) for quality of life. Thirty-five (87.5%) patients reported satisfaction with the outcome of their surgery. DISCUSSION Surgical fixation of extra-articular distal humerus fractures through a triceps-reflecting approach with an anatomically precontoured posterolateral distal humerus plate results in predictable osseous union and overall excellent functional results for patients with this injury.

Risk of Periprosthetic Fractures With Direct Anterior Primary Total Hip Arthroplasty

BACKGROUND Despite increasing interest in the anterior approach for cementless, primary total hip arthroplasty (THA), studies examining the incidence of periprosthetic fractures with this approach are lacking. The purpose of this study was to (1) investigate the incidence of early periprosthetic fractures associated with primary THA performed through an anterior supine intermuscular (ASI) approach without the use of a specialized table and (2) identify potential risk factors for these fractures. METHODS We identified 2869 primary THAs performed via the ASI approach using a single cementless, tapered titanium femoral component with short and standard length options between February 2007 and April 2014. Fifty-two percent of THAs were in female patients, whereas 48% were in males. Short stems were used in 59% vs standard length in 41%. RESULTS There were 26 (0.9%) early periprosthetic femoral fractures, with 23 requiring revision. When looking at the potential risk factors of age, gender, body mass index, and stem length, the only significant finding was that increased age was associated with increased risk of femoral fracture. Logistic regression analysis revealed a significant age-fracture association for female gender only, which remained when controlled for body mass index, stem length, or both. CONCLUSION The muscle-sparing ASI approach appears to be a safe technique for performing primary THA when used in a suitable patient population. The early periprosthetic femoral fracture rate in our series may warrant consideration of using a different design or different approach in elderly female patients.

The epidemiology of primary and revision total hip arthroplasty in teaching and nonteaching hospitals in the United States

Introduction: The purpose of this study was to examine the epidemiology of primary and revision total hip arthroplasty (THA) in teaching and nonteaching hospitals.Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2006 to 2010 to identify primary and revision THAs at teaching and nonteaching hospitals.Results: A total of 1,336,396 primary and 223,520 revision procedures were identified. Forty-six percent of all primary and 54% of all revision procedures were performed at teaching hospitals. Teaching hospitals performed 17% of their THAs as revisions; nonteaching hospitals performed 12% as revisions. For primary and revision THAs, teaching hospitals had fewer patients aged >65 years, fewer Medicare patients, similar gender rates, more nonwhite patients, and more patients in the highest income quartile compared with nonteaching hospitals. Costs, length of stay, and Charlson Comorbidity Index scores were similar; however, the mortality rate was lower at teaching hospitals.Conclusions: This study found small but significant differences in key epidemiologic and outcome variables in examining primary and revision THA at teaching and nonteaching hospitals.Level of Evidence: Level III