Cory Collinge

Results of Internal Fixation of Pauwels Type-3 Vertical Femoral Neck Fractures

BACKGROUND It has been postulated that femoral neck fractures with a more vertical fracture line (i.e., a high Pauwels angle) may experience more shear forces and therefore may be predisposed to nonunion or loss of fixation. Although there is controversy regarding which fixation method is ideal, we are aware of no large clinical series in which the treatment outcomes of these fractures were evaluated. The purpose of this multicenter study was to evaluate a large consecutive series of high shear angle (>70 degrees) femoral neck fractures to learn more about the outcomes, complications, and performance of various internal fixation strategies. METHODS Between January 1993 and January 2005, seventy-six Pauwels type-3 (Orthopaedic Trauma Association [OTA] type-31B2.3) femoral neck fractures were treated in seventy-five patients with a mean age of forty-two years. Fourteen patients were lost to follow-up. Sixty-two fractures in sixty-one patients were followed to union or revision surgery, with a mean duration of follow-up of twenty-four months. Thirty-seven fractures were treated with cannulated screws and twenty-five, with a fixed-angle device. The reduction quality, accuracy of implant placement, time to surgery, influence of capsular decompression, and rates of nonunion and osteonecrosis were evaluated. RESULTS Fifty-nine (95%) of the fractures had good-to-excellent reduction, and three had a fair reduction. There was a nonunion of eight (14%) of the fifty-nine fractures with a good-to-excellent reduction and two of the three with a fair reduction. There was a septic nonunion of one fracture treated with a dynamic hip screw. There was an aseptic nonunion of seven (19%) of the thirty-seven fractures treated with screw fixation alone as compared with two (8%) of the twenty-five fractures treated with a fixed-angle device. Osteonecrosis occurred after treatment of seven (11%) of the sixty-two fractures. CONCLUSIONS Despite timely, excellent reduction and accurate implant placement in the vast majority of cases, the nonunion rate was 19% for fractures treated with cannulated screws alone and 8% for those treated with a fixed-angle device. Although these failure rates are not significantly different, we believe that this study documents the challenging nature of this fracture pattern and the ideal fixation device remains undefined.

Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle.

Objective: Results of surgical treatment for clavicle injuries using standard approaches have shown relatively high complication rates including loss of fixation, persistent nonunion, implant related problems, and the need for subsequent surgeries are common. The purpose of this study is to evaluate the clinical results of patients treated for clavicle fractures and painful clavicular nonunions with anterior-inferior plating using a 3.5 mm plate. Design: Consecutive clinical series. Setting: 3 tertiary care academic trauma centers (Level 1 and 2). Patients: Eighty consecutive patients with a middle-third fracture or painful nonunion of the clavicle. Intervention: Open reduction and internal fixation using an anterior-inferior plating technique with a precontoured 3.5 mm plate and lag screw(s). Nonunions received autologous bone grafts. Main Outcome Measurements: Patients were evaluated using physical and radiographic examination, the American Shoulder and Elbow Surgeons Shoulder Assessment (ASES), and the Short Form-36 (SF-36) outcomes questionnaire. Results: Fifty-eight patients had sufficient records and follow-up of at least 24 months (mean 49 months). Clinical and radiographic union was present at a mean of 9.5 weeks for patients treated for acute fracture and 10.5 weeks those treated for nonunion. Complications included 1 failure of fixation, 1 nonunion, and 3 infections. Two patients underwent implant removal for bothersome hardware. Shoulder motion was good or excellent in all patients except those with neurologic injury. Functional results (ASES and SF-36) were good or excellent for the vast majority of patients, except those with neurologic injury. Conclusions: Anterior-inferior plating of acute middle-third fractures of the clavicle and clavicular nonunions using a plate and lag screws typically results in early healing, few complications and an excellent return of function. Advantages of this technique include stable bony fixation with instrumentation directed away from potentially dangerous infraclavicular structures and a minimal incidence of implant prominence problems.

Treatment of complex tibial periarticular fractures using percutaneous techniques.

Open reduction and internal fixation typically is reserved for the treatment of patients with articular or periarticular tibia fractures, or other tibial injuries that are treated inadequately with intramedullary nailing. This approach can result in extensive dissection and tissue devitalization. By modifying the method of fixation, the plating of tibial fractures has been expanded using a percutaneous technique. Using this approach, the fracture is reduced indirectly and plates are placed through subcutaneous or submuscular tunnels through limited incisions. Between 1992 and 1998, 17 patients with tibial shaft fractures and associated severe soft tissue injury, were treated using a percutaneous plating technique. Followup was available in 14 patients. Six patients required bone grafting procedures for delayed union or nonunion, although four of these patients had significant bone loss related to their injury. There were no malunions. Three patients had superficial infections related to external fixator pin sites and one patient had osteomyelitis develop. Percutaneous plating of the tibia offers an alternative method for stabilizing complex fractures with severely compromised soft tissues, especially those injuries with periarticular extension. This technique is thought to cause no increase in the risk of infection or soft tissue damage and permits rapid mobilization of the limb and patient. When using this treatment for patients with significant bone loss, bone grafting should be considered.

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° on postoperative radiographs and 99° on final radiographs. A comparison of postoperative to healed final radiographs for each femur demonstrated no case with greater than a 3° difference in either varus or valgus. Complications included 1 mal-union where the fracture was fixed in 8° of valgus and 2 cases of external rotation between 10° and 15°. Painful hardware occurred in 4 patients, of which 3 underwent implant removal. The average knee range of motion was 5° to 114°. 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.

Minimally invasive plating of high-energy metaphyseal distal tibia fractures.

Objective: The purpose of this study is to evaluate clinical results and outcomes of a strict cohort of high-energy injuries of the metaphyseal distal tibia with minimal or no intraarticular involvement treated using the minimally invasive plating concept. Setting: Level II trauma center. Design: Retrospective analysis of a consecutive case series with limb-specific and whole-person outcomes measures. Intervention: Minimally invasive medial plating for high-energy metaphyseal fractures of the distal tibia with little or no intraarticular involvement. Main Outcome Measurement: Clinical and radiographic results were assessed at a minimum of 1 year, and outcomes measures were applied at final follow-up at a minimum of 2 years. Limbs were assessed with the American Orthopaedic Foot and Ankle Surgeons (AOFAS) ankle-hindfoot instrument and the method of Olerud and Molander. Patient outcomes were evaluated with the Short Form-36 (SF-36) and the Musculoskeletal Functional Assessment (MFA). Results: Twenty-six patients were followed until healed at an average of 36 months (12-56 months). Mean fracture healing time was 35 weeks (12-112 weeks) with acceptable alignment restored (angulation ≤5 degrees or shortening ≤1 cm) in all but 1 case. Two patients (7%) had loss of fixation and 9 (35%) underwent secondary surgeries to achieve union. Risk factors for healing problems included high grades of fracture comminution, bone loss, and high-grade open injuries (P < 0.05). SF-36 outcomes scores in 21 patients at >2 years were comparable to normative data of patients with uninjured limbs, whereas MFA results showed functional deficits in 4 of 10 subsections. Conclusions: Minimally invasive medial plating will restore limb alignment and yield successful clinical outcomes for high-energy metaphyseal fractures of the distal tibia. Despite the significant reoperation rate and prolonged time to union, most patients can expect a predictable return of function. Strong consideration should be given to adjunctive measures in at-risk patients, including those with highly comminuted fracture patterns, bone loss, or Type II or III open fractures.

Risk factors for failure of locked plate fixation of distal femur fractures: an analysis of 335 cases.

Objectives: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. Design: Retrospective review. Setting: Three level I or II trauma centers. Patients/participants: Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17–97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers. Intervention: All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment. Main Outcome Measurements: Risk factors for reoperation to promote union, deep infection, and implant failure. Results: After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. Conclusions: The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure. Level of Evidence: Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Outcomes of Minimally Invasive Plate Osteosynthesis for Metaphyseal Distal Tibia Fractures

Objective: Evaluation of clinical results and outcomes of low metaphyseal distal tibia fractures with minimal or no intra-articular involvement. These were treated using the minimally invasive plate osteosynthesis concept with a 3.5-mm locked medial tibial plafond plate and hybrid (locking and nonlocking) screw construct. Setting: Level II regional trauma center. Design: Consecutive case series of clinical outcomes using limb-specific and whole-person measures. Intervention: Minimally invasive medial plating using hybrid locking and nonlocking techniques. Main Outcome Measurement: The following were applied at a minimum of 2 years: limb assessment-Olerud and Molanders ankle rating scale and the American Orthopaedic Foot and Ankle Surgeons (AOFAS) ankle-hindfoot instrument, whole-person assessment-the Short Form 36 (SF-36). Results: Thirty-eight patients were followed an average of 32 months (range, 12-48 months). Mean fracture healing time was 21 weeks (range, 9-60 weeks). Acceptable alignment and length were restored (angulation ≤5° or shortening ≤1 cm) in all but one case. One patient (3%) had loss of fixation and two (5%) underwent secondary surgeries to achieve union. In 30 patients at >2 years, the AOFAS and the Olerud and Molander ankles scores averaged good-excellent. SF-36 outcomes scores were lower than that of normative data in patients with uninjured limbs but only significantly diminished in physical function. Conclusions: Minimally invasive medial plating using a hybrid locking plate technique in metaphyseal fractures of the distal tibia predictably restored limb alignment with a 5% reoperation rate and yielded mostly good-excellent ankle scores. There were residual impairments seen on whole-body outcomes measures.

Standard Multiplanar Fluoroscopy Versus a Fluoroscopically Based Navigation System for the Percutaneous Insertion of Iliosacral Screws: A Cadaver Model

Objectives: To compare the safety and efficiency of standard multiplanar fluoroscopy (StdFluoro) and virtual fluoroscopy (VirtualFluoro) for use in the percutaneous insertion of iliosacral screws. Design: Human cadaver study comparing 2 imaging modalities during iliosacral screw insertion; imaging randomized from side to side. Setting: Bioskills laboratory in a medical school. Participants: Twenty-nine embalmed whole human cadavers without prior hip or pelvic surgery. Intervention: Iliosacral screws were inserted into the S1 bodies using a percutaneous insertion technique. Screws were inserted on one side using StdFluoro, and on the other side, screws were placed using VirtualFluoro. Main Outcome Measurements: Time necessary for imaging preparation, screw insertion, and actual fluoroscopy were recorded. Accuracy and safety of screw placement was assessed using computed tomography and an anatomic dissection of the pelvis. Results: Fifty-six of 58 iliosacral screws were placed within the desired bony corridor of the posterior pelvis. One screw placed using each method was inserted erroneously, but both were relatively minor deviations. There were no obvious injuries to major vessels or nerve roots. The total surgical time required for preparation of imaging and screw insertion averaged 7.3 minutes using StdFluoro and 6.7 minutes using VirtualFluoro (P = 0.4). Although the time necessary for screw insertion using VirtualFluoro averaged only 3.5 minutes, compared to 7.0 minutes for StdFluoro (P < 0.05), this time savings was offset by that required for application and calibration of tracking devices when using VirtualFluoro. The average fluoroscopy time using StdFluoro method was 26 seconds, whereas that for the VirtualFluoro was only 6 seconds (P < 0.01). Conclusions: Most of the percutaneous iliosacral screws were safely inserted using StdFluoro and VirtualFluoro, and total surgical times were similar using both methods. As VirtualFluoro continues to evolve, improved efficiency in operative times may be expected. Currently, the most beneficial aspect of using VirtualFluoro during the insertion of percutaneous iliosacral screws appears to be significantly decreased use of fluoroscopy when compared to StdFluoro.

The posterolateral approach to the tibia for displaced posterior malleolar injuries.

Fractures involving the posterior malleolus of the tibia can be difficult to manage. Failure to address these fractures can lead to posterior ankle instability and altered ankle reaction forces. The posterolateral approach to the posterior ankle provides access to both the lateral and posterior malleoli. Displaced fractures of the posterior malleolus can be reduced and fixed under direct visualization through a posterolateral incision. We have had excellent results using this technique for management of displaced posterior malleolar fractures with few complications. Surgeons should be aware of the effectiveness of this technique for managing displaced fractures of the posterior malleolus.

The effects of clopidogrel (Plavix) and other oral anticoagulants on early hip fracture surgery.

Objective: Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants. Design: Study design is a retrospective cohort analysis using data extracted from hospital records and state death records. Setting: Regional medical center (level II trauma). Methods: Data for 1118 patients ≥60 years of age who had surgical treatment for a hip fracture between 2004 and 2008 were reviewed. Eighty-two patients undergoing late surgery (>3 days after admission) were excluded. Patients taking clopidogrel were compared against those not taking clopidogrel. In addition, patients taking clopidogrel only were compared against cohorts of patients taking both clopidogrel and aspirin, aspirin only, warfarin only, or no anticoagulant. Results: Seventy-four of 1036 patients (7%) were taking clopidogrel, although control groups included 253 patients on aspirin alone, 90 patients on warfarin, and 619 taking no anticoagulants. No significant differences were noted between patients taking clopidogrel and those not taking clopidogrel in estimated blood loss, transfusion requirement, final blood count, hematoma evacuation, hospital length of stay (LOS), or mortality while in hospital or at 1 year. A higher American Society of Anesthesiologists score was seen in the clopidogrel and warfarin groups (P = 0.05 each), increased LOS in the clopidogrel group (P = 0.05), and higher rate of deep vein thrombosis seen in those patients taking warfarin (P = 0.05). Clopidogrel only versus aspirin versus both aspirin and clopidogrel, versus no anticoagulant versus warfarin showed no significant differences in estimated blood loss, transfusion requirement, final blood count, bleeding or perioperative complications, or mortality. Conclusions: Patients undergoing early hip fracture surgery who are taking clopidogrel, aspirin, or warfarin (with regulated international normalized ratio) are not at substantially increased risk for bleeding, bleeding complications, or mortality. Comorbidities and American Society of Anesthesiologists scores were significantly higher in the clopidogrel group, which may have resulted in the increased postoperative LOS in this group. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.