Debra L. Sietsema

Outcome of periprosthetic distal femoral fractures following knee arthroplasty.

INTRODUCTIONnThe majority of periprosthetic fractures around the knee occur at the supracondylar region of the distal femur. Fixation of distal femoral fractures in osteoporotic bone with short segment remains a challenge, especially after total knee arthroplasty (TKA). Internal fixation of these fractures using locking plates has become popular. The purpose of this study was to evaluate a consecutive series of periprosthetic supracondylar femoral fractures treated with locked periarticular plate fixation with regard to surgical procedure, complications and clinical outcome.nnnMATERIALS AND METHODSnFrom two academic trauma centres, 55 consecutive periprosthetic distal femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association, AO/OTA 33) were retrospectively identified as having been treated with locked plate fixation. Of these, 36 fractures in 35 patients (86.1% female) met the inclusion criteria. Patients had an average age of 73.2 years (range 54-95 years). Fixation constructs for plate length and working length were delineated. Nonunion, infection and implant failure were used as complication variables. Demographics were assessed. Outcome was addressed radiographically and clinically according to Kristensen et al.(1) by range of motion and pain.nnnRESULTSnTwenty-five of 36 fractures (69.4%) healed after the index procedure. Eight of 36 fractures (22.2%) developed a nonunion with three fractures (8.3%) leading to hardware failure. Nine of the 36 patients (25%) were radiographically diagnosed with notching of the anterior femoral cortex. Regarding technical aspects, distance from the anterior flange of the femoral component to fracture was significantly shorter in patients with compared to without anterior notching (t=3.68, p=0.02). Patients who underwent submuscular plate insertion compared to an extensive lateral approach had a reduced nonunion risk (χ(2)=0.05). No difference in infection rate was found for submuscular procedures compared with open procedures (χ(2)=0.85). Range of motion was reduced in most of the patients and 13.5% had a persistent loss of extension of 5°. More than 77% of the patients reported no or only mild pain during the last office visit. Range of motion loss did not influence pain. Successful treatment according to Cain et al.(2) was achieved in 83%. Using Kristensens(1) criteria, 56% of the knees had acceptable flexion.nnnCONCLUSIONnOperative fixation of periprosthetic distal femoral fractures after TKA continues to be challenging. Notching of the anterior femoral cortex should be avoided. Loss of reduction and high failure rates still occur with locked plating and may be related to underlying factors. Indirect reduction and submuscular plate insertion technique reduce nonunion risk.

Analysis of operative versus nonoperative treatment of displaced scapular fractures.

BackgroundOperative indications for displaced scapular fractures have been controversial and inconsistent. Surgeons have been dissuaded to operate on these uncommon fractures because of the complex anatomy, approaches, and fracture patterns. It is unclear whether return to work, pain, or complications differ in patients with scapular fractures treated nonoperatively or operatively.Questions/PurposesWe therefore assessed differences in rates of union, range of motion, ability to return to work, pain, and complications between operatively and nonoperatively treated scapular body and neck fractures.Patients and MethodsWe retrospectively reviewed 182 patients with 182 scapular fractures treated between 2002 and 2005. Of the 182 fractures, 31 were treated with open reduction internal fixation and matched by age, occupation, and gender to 31 patients treated nonoperatively. The proportions of AO/OTA fracture types were similar in the two groups. The mean displacement, shortening, and angulation were greater in the operative group as compared with the nonoperative group. All patients were followed until healing or discharge from care (average, 1.5xa0years; range, 14–32xa0months). We assessed complications, return to work, and radiographic healing.ResultsAll fractures healed. We found no differences in return to work, pain, or complications.ConclusionsOur observations suggest operative treatment of displaced scapula fractures results in similar healing, return to work, pain, and complications as nonoperative treatment. We do not recommend operating on any scapular neck or body fractures displaced less than 20xa0mm.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort

PurposeLocked plating (LP) of distal femoral fractures has become very popular. Despite technique suggestions from anecdotal and some early reports, knowledge about risk factors for failure, nonunion (NU), and revision is limited. The purpose of this study was to analyze the complications and clinical outcomes of LP treatment for distal femoral fractures.Materials and methodsFrom two trauma centers, 243 consecutive surgically treated distal femoral fractures (AO/OTA 33) were retrospectively identified. Of these, 111 fractures in 106 patients (53.8% female) underwent locked plate fixation. They had an average age of 54 years (range 18 to 95 years): 34.2% were obese, 18.9% were smokers, and 18.9% were diabetic. Open fractures were present in 40.5% with 79.5% Gustilo type III. Fixation constructs for plate length, working length, and screw concentration were delineated. Nonunion and/or infection, and implant failure were used as outcome complication variables. Outcome was based on surgical method and addressed according to Pritchett for reduction, range of motion, and pain.ResultsEighty-three (74.8%) of the fractures healed after the index procedure. Twenty (18.0%) of the patients developed a NU. Four of 20 (20%) resulted in a recalcitrant NU. Length of comminution did not correlate to NU (pu2009=u20090.180). Closed injuries had a higher tendency to heal after the index procedure than open injuries (pu2009=u20090.057). Closed and minimally open (Gustilo/Anderson types I and II) fractures healed at a significantly higher rate after the index procedure compared to type III open fractures (80.0% versus 61.3%, pu2009=u20090.041). Eleven fractures (9.9%) developed hardware failure. Fewer nonunions were found in the submuscular group (10.7%) compared to open reduction (32.0%) (pu2009=u20090.023). Fractures above total knee arthroplasties had a significantly greater rate of failed hardware (pu2009=u20090.040) and worse clinical outcome according to Pritchett (pu2009=u20090.040). Loss of fixation was related to pain (Fu2009=u20093.19, pu2009=u20090.046) and a tendency to worse outcome (Fu2009=u20092.43, pu2009=u20090.071). No relationship was found between nonunion and working length.ConclusionDespite modern fixation techniques, distal femoral fractures often result in persistent disability and worse clinical outcomes. Soft tissue management seems to be important. Submuscular plate insertion reduced the nonunion rate. Preexisting total knee arthroplasty increased the risk of hardware failure. Further studies determining factors that improve outcome are warranted.

Can lumbopelvic fixation salvage unstable complex sacral fractures

BackgroundTraditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.Questions/purposesWe therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.MethodsWe retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12xa0months (mean, 23xa0months; range, 12–41xa0months).ResultsPosterior reduction quality was 11 of 15 with less than 5xa0mm persistent displacement and four of 15 with 5 to 10xa0mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.ConclusionComplex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Locked Plating of Proximal Humeral Fractures: Is Function Affected by Age, Time, and Fracture Patterns?

BackgroundLocking plate fixation of proximal humeral fractures improves biomechanical stability. It has expanded the indications of traditional open reduction internal fixation and become increasingly common for treating unstable, displaced proximal humeral fractures. Despite improved stability it is unclear whether these improve function and if so for which patients.Questions/purposesWe therefore determined patient function after a locked plating technique for the treatment of unstable proximal humeral fractures based on age, time, fracture pattern, and associated injures.Patients and MethodsWe retrospectively reviewed 66 patients with 69 proximal humeral fractures treated with a locked proximal humeral plating technique from 2002–2006 using prospectively gathered data. Function was measured using the Short Musculoskeletal Function Assessment (SMFA), Disability of the Arm, Shoulder, and Hand (DASH), and SF-36 at 6, 12, and 24xa0months. Fracture healing was determined radiographically and complication rates were determined from the medical records.ResultsAt 2xa0years, DASH scores were 26.5 and 37.4 for isolated and polytrauma patients, respectively. For age differences, DASH scores were 33.1 and 28.9 for ages younger than 60 and 60xa0years old or older, respectively. At 2xa0years, SMFA scores were higher (worse) in older compared with younger patients. Function, but not bother continues to improve in younger patients up to 2xa0years. More severe fracture patterns performed worse in all SMFA indices at 2xa0years. Polytrauma patients consistently experienced worse mobility than isolated injury patients at each time interval.ConclusionsWith locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1xa0year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. Long-term functional deficits persist.Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Complications of rhBMP-2 utilization for posterolateral lumbar fusions requiring reoperation: a single practice, retrospective case series report

BACKGROUND CONTEXTnRecombinant human bone morphogenetic protein-2 (rhBMP-2) (INFUSE, Medtronic, Memphis, TN, USA) has been used off-label for posterolateral lumbar fusions for many years.nnnPURPOSEnThe goal of this study was to evaluate the complications requiring reoperation associated with rhBMP-2 application for posterolateral lumbar fusions.nnnSTUDY DESIGN/SETTINGnDuring a 7-year period of time (2002-2009), all patients undergoing lumbar posterolateral fusion using rhBMP-2 (INFUSE) were retrospectively evaluated within a large orthopedic surgery private practice.nnnPATIENT SAMPLEnA total of 1,158 consecutive patients were evaluated with 468 (40.4%) males and 690 (59.6%) females.nnnOUTCOME MEASURESnComplications related to rhBMP were defined as reoperation secondary to symptomatic failed fusion (nonunion), symptomatic seroma formation, symptomatic reformation of foraminal bone, and infection.nnnMETHODSnInclusion criteria were posterolateral fusion with rhBMP-2 implant and age equal to or older than 18 years. Surgical indications and treatment were performed in accordance with the surgeons best knowledge, discretion, and experience. Patients consented to lumbar decompression and arthrodesis using rhBMP-2. All patients were educated and informed of the off-label utilization of rhBMP-2. Patient follow-up was performed at regular intervals of 2 weeks, 6 weeks, 12 weeks, 6 months, 1 year, and later if required or indicated.nnnRESULTSnAverage age was 59.2 years, and body mass index was 30.7 kg/m². Numbers of levels fused were 1 (414, 35.8%), 2 (469, 40.5%), 3 (162, 14.0%), 4 (70, 6.0%), 5 (19, 1.6%), 6 (11, 0.9%), 7 (7, 0.6%), 8 (4, 0.3%), and 9 (2, 0.2%). Patients having complications requiring reoperation were 117 of 1,158 (10.1%): symptomatic nonunion requiring redo fusion and instrumentation 41 (3.5%), seroma with acute neural compression 32 (2.8%), excess bone formation with delayed neural compression 4 (0.3%), and infection requiring debridement 26 (2.2%). Nonunion was related to male sex and previous BMP exposure. Seroma formation was significantly higher in patients with higher doses of rhBMP-2 (p=.050) and with more than 12 mg of rhBMP-2 (χ(2)=0.025). Bone reformation and neural compression at the laminectomy and foraminotomy sites occurred in a delayed fashion. Infection was associated with obesity and respiratory disease. Infections were noted with a greater BMP dose (p<.001), more than 12 mg (χ(2)<0.001), fusion more than three levels (χ(2)<0.001), and reexposed to BMP (χ(2)=0.023).nnnCONCLUSIONSnrhBMP-2 utilization for posterolateral lumbar fusions has a low symptomatic nonunion rate. Prior rhBMP-2 exposure and male sex were related to symptomatic nonunion formation. rhBMP-2-associated neural compression acutely with seroma formation and delayed with foraminal bone formation is concerning and associated with higher rhBMP-2 concentrations.

Mice lacking pten in osteoblasts have improved intramembranous and late endochondral fracture healing.

The failure of an osseous fracture to heal (development of a non-union) is a common and debilitating clinical problem. Mice lacking the tumor suppressor Pten in osteoblasts have dramatic and progressive increases in bone volume and density throughout life. Since fracture healing is a recapitulation of bone development, we investigated the process of fracture healing in mice lacking Pten in osteoblasts (Ocn-cretg/+;Ptenflox/flox). Mid-diaphyseal femoral fractures induced in wild-type and Ocn-cretg/+;Ptenflox/flox mice were studied via micro-computed tomography (µCT) scans, biomechanical testing, histological and histomorphometric analysis, and protein expression analysis. Ocn-cretg/+;Ptenflox/flox mice had significantly stiffer and stronger intact bones relative to controls in all cohorts. They also had significantly stiffer healing bones at day 28 post-fracture (PF) and significantly stronger healing bones at days 14, 21, and 28 PF. At day 7 PF, the proximal and distal ends of the Pten mutant calluses were more ossified. By day 28 PF, Pten mutants had larger and more mineralized calluses. Pten mutants had improved intramembranous bone formation during healing originating from the periosteum. They also had improved endochondral bone formation later in the healing process, after mature osteoblasts are present in the callus. Our results indicate that the inhibition of Pten can improve fracture healing and that the local or short-term use of commercially available Pten-inhibiting agents may have clinical application for enhancing fracture healing.

Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures

Background: Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. Methods: A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. Results: Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). Conclusion: The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. Level of Evidence: Therapeutic level III.

Does plate type influence the clinical outcomes and implant removal in midclavicular fractures fixed with 2.7-mm anteroinferior plates? A retrospective cohort study

BackgroundThe purpose of this study was to evaluate surgical healing rates, implant failure, implant removal, and the need for surgical revision with regards to plate type in midshaft clavicle fractures fixed with 2.7-mm anteroinferior plates utilizing modern plating techniques.MethodsThis retrospective exploratory cohort review took place at a level I teaching trauma center and a single large private practice office. A total of 155 skeletally mature individuals with 156 midshaft clavicle fractures between March 2002 and March 2012 were included in the final results. Fractures were identified by mechanism of injury and classified based on OTA/AO criteria. All fractures were fixed with 2.7-mm anteroinferior plates. Primary outcome measurements included implant failure, malunion, nonunion, and implant removal. Secondary outcome measurements included pain with the visual analog scale and range of motion. Statistically significant testing was set at 0.05, and testing was performed using chi-square, Fisher’s exact, Mann–Whitney U, and Kruskall-Wallis.ResultsImplant failure occurred more often in reconstruction plates as compared to dynamic compression plates (pu2009=u20090.029). Malunions and nonunions occurred more often in fractures fixed with reconstruction plates as compared to dynamic compression plates, but it was not statistically significant. Implant removal attributed to irritation or implant prominence was observed in 14 patients. Statistically significant levels of pain were seen in patients requiring implant removal (pu2009=u20090.001) but were not associated with the plate type.ConclusionsAnteroinferior clavicular fracture fixation with 2.7-mm dynamic compression plates results in excellent healing rates with low removal rates in accordance with the published literature. Given higher rates of failure, 2.7-mm reconstruction plates should be discouraged in comparison to stiffer and more reliable 2.7-mm dynamic compression plates.

Persistent impairment after surgically treated lateral compression pelvic injury.

BackgroundRecently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear.Questions/purposesWe determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain.MethodsWe retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39xa0years with a mean body mass index of 27xa0kg/m2. All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12xa0months (mean, 33xa0months; range, 12–100xa0months).ResultsSMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5xa0mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10xa0mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6xa0months predicted pain and overall SMFA score at last followup.ConclusionsUnstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.