Charles N. Moon

Surgical Treatment of Three and Four-Part Proximal Humeral Fractures

BACKGROUND Optimal surgical management of three and four-part proximal humeral fractures in osteoporotic patients is controversial, with many advocating prosthetic replacement of the humeral head. Fixed-angle locked plates that maintain angular stability under load have been proposed as an alternative to hemiarthroplasty for the treatment of some osteoporotic fracture types. METHODS The records of 122 consecutive patients who were fifty-five years of age or older and in whom a Neer three or four-part proximal humeral fracture had been treated surgically between January 2002 and November 2005 were studied retrospectively. After exclusions, thirty-eight patients treated with a locked-plate construct were compared with forty-eight patients who had undergone hemiarthroplasty. All patients had radiographic and clinical follow-up at a minimum of twenty-four months and an average of thirty-six months. Reduction and implant placement were evaluated radiographically. Clinical outcomes were measured with use of the Constant-Murley system. RESULTS The mean Constant score (and standard deviation) at the time of final follow-up was significantly better in the locked-plate group (68.6 +/- 9.5 points) than in the hemiarthroplasty group (60.6 +/- 5.9 points) (p < 0.001). The Constant scores for the three-part fractures in the locked-plate and hemiarthroplasty groups were 71.6 and 60.4 points (p < 0.001), respectively, and the scores for the four-part fractures in those groups were 64.7 and 60.1 points (p = 0.19), respectively. Patients with an initial varus extension deformity in the locked-plate group had significantly worse outcomes than those with a valgus impacted pattern (Constant score, 63.8 compared with 74.6 points, respectively; p < 0.001). Complications in the group treated with locked-plate fixation included osteonecrosis in six patients, screw perforation of the humeral head in six patients, loss of fixation in four patients, and wound infection in three patients. Loss of fixation was seen only in patients with >20 degrees of initial varus angulation of the humeral head. Complications in the hemiarthroplasty group included nonunion of the tuberosity in seven patients and wound infection in three patients. CONCLUSIONS In this series, open repair with use of a locked plate resulted in better outcome scores than did hemiarthroplasty in similar patients, especially in those with a three-part fracture, despite a higher overall complication rate. Open reduction and internal fixation of fractures with an initial varus extension pattern should be approached with caution.

Negative pressure dressings as an alternative technique for the treatment of infected wounds.

Coverage of wounds caused by infection and subsequent treatment often are variable because of the location of the wound and wound size. Although much research has been done to expand the indications of negative pressure wound treatment systems, little investigation has been done to quantify the reduction of wound size for vacuum-assisted closure treatment in the presence of infection. In this series, 14 patients who had wounds caused by infections were treated with the vacuum-assisted wound closure system. All wounds were greater than 20 cm2. The duration of treatment averaged 10 days (range, 2–27 days), and the initial wound size averaged 70 cm2 (range, 22.5–288 cm2). After the course of treatment, the final wound size averaged 39 cm2 (range, 10–147 cm2). The average wound size reduction was 43%. This method seems to enhance the rapidity of wound reduction, and because it is a closed system of treatment, it has the added benefit of minimizing exposure of staff and other patients to communicable diseases. Vacuum-assisted wound closure systems add another option in the care of musculoskeletal infections.

Dysplasia epiphysealis hemimelica of the acetabulum: A report of two cases

Dysplasia epiphysealis hemimelica, which is also known as Trevor disease, is a rare developmental lesion that is histologically identical to an osteochondroma. The more common solitary osteochondroma and multiple hereditary osteochondromatosis typically are located on the metaphysis of long bones, occasionally on the diaphysis of long bones, and on flat bones, but never on the epiphysis. The index lesion is intra-articular and characteristically involves only half of the joint (hemimelic). The osseous portions of the lesion distinguish it from synovial chondromatosis, which always consists of multiple lesions usually dispersed throughout the joint. The osteochondroma of dysplasia epiphysealis hemimelica, in addition to being hemimelic, is initially a solitary lesion, although portions may break off, producing multiple pieces17. It is typically found in the joints of the lower extremity, with a predisposition for the medial femoral condyle, the distal aspect of the tibia, and the talus1,2,4,5,7,12,15,21,25. Mouchet and Belot16, in 1926, were the first to report this entity, and they called it tarsomegalie. Trevor25 described ten patients in 1950 and used the term tarso-epiphysial aclasis. In 1956, Fairbank5 reported on fourteen patients and renamed the condition dysplasia epiphysialis hemimelica. We report the cases of two patients who had a subluxation of the hip that was found to be associated with an isolated intra-articular osteochondroma of the acetabulum. These two cases are presented because of the isolated and unique acetabular location of the lesion. CASE 1. A five-year-old girl was referred to one of the authors (H. A. P.) because of a several-month history of bilateral discomfort of the lower limb. The patients father had noted a change in the childs gait a few days before she was seen …

Primary total elbow arthroplasty for distal humeral fractures in elderly patients: a nationwide analysis.

BACKGROUND Displaced intra-articular distal humeral fractures are a challenging injury in elderly patients. High rates of complications have led to the increasing use of total elbow arthroplasty (TEA) for primary treatment. This study presents US nationwide trends in primary TEA for distal humeral fractures in elderly patients (65 years and older) from 2002 to 2012. We hypothesized that there was an increase in the rate of TEA utilization. METHODS Data were obtained from the Nationwide Inpatient Sample for the years 2002 to 2012. All inpatients 65 years and older with distal humeral fractures were identified and were divided into 2 subgroups based on the operation they received: (1) TEA and (2) open reduction-internal fixation (ORIF). RESULTS Between 2002 and 2012, the annual frequency of TEA for elderly patients with distal humeral fractures increased 2.6-fold, with 147 patients in 2002 and 385 in 2012. In 2012, TEA was performed in 13% of operatively treated distal humeral fractures compared with only 5.1% in 2002 (P < .05). Mean hospital charges increased significantly for both the ORIF and TEA groups from 2002 to 2012. The average hospital charge for TEA in 2012 was

Temporising external fixation of calcaneus fractures prior to definitive plate fixation: a case series

85,365, which was

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

16,358 higher than that for patients who underwent ORIF (P < .05). CONCLUSION The national rate of primary TEA for the acute management of distal humeral fractures in elderly patients has increased significantly over the past 10 years. Given the significant complexity, long-term restrictions, and risks associated with TEA, this increasing trend should be analyzed closely.

Biomechanical Analysis of a Novel Buried Fixation Technique Using Headless Compression Screws for the Treatment of Patella Fractures

INTRODUCTION Surgical management of calcaneus fractures is technically demanding and has a high risk of wound complications. These fractures are traditionally managed with splinting until swelling has subsided, which can take weeks and leaves the fracture fragments displaced. We describe a novel protocol for the management of displaced intraarticular calcaneus fractures that utilises a temporising external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique was to enable earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the traditional extensile approach. METHODS The records of patients with displaced calcaneus fractures from 2010-2014 were reviewed retrospectively. A total of nine patients with 10 calcaneus fractures were treated using this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours after injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. RESULTS The average Bohlers angle improved from 13.2 (range -2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight-bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. CONCLUSION Early temporising external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. There were no complications related to the use of the external fixator in this series.

Minimally Invasive Osteosynthes of Periprosthetic Fractures in the Lower Extremity

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was

Locked Plating of 3- and 4-Part Proximal Humerus Fractures in Older Patients: The Effect of Initial Fracture Pattern on Outcome

24,154, which was significantly higher than that for ORIF (

Use of a Trochanteric Flip Osteotomy Improves Outcomes in Pipkin IV Fractures

16,269) or hemiarthroplasty (