George J. Haidukewych

Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Background: The reverse obliquity fracture of the proximal part of the femur is a distinct fracture pattern that is mechanically different from most intertrochanteric fractures. The purpose of this retrospective study was to determine the prevalence of these fractures and the results and complications of different types of internal fixation used in their treatment. Methods: Between 1988 and 1998, 2472 consecutive patients with a hip fracture were treated at our Level-One Trauma Center; 1035 of the fractures were classified as intertrochanteric or subtrochanteric. Clinical and radiographic records were retrospectively reviewed, and fifty‐five fractures with a reverse obliquity pattern were identified. Forty‐nine patients were followed until the fracture united or a revision operation was performed. The duration of clinical follow-up averaged eighteen months (range, three to sixty‐seven months), and the duration of radiographic follow-up averaged fifteen months (range, three to sixty months). Fractures were classified with the Orthopaedic Trauma Association scheme. Results were analyzed according to the fracture pattern, type of implant, quality of the reduction, position of the implant, and use of bone graft at the index operation. Function was assessed on the basis of pain, living situation, need for walking aids, need for analgesics, and walking capacity. Results: Thirty‐two (68%) of forty‐seven hips treated with internal fixation healed without an additional operation. Fifteen (32%) of the forty‐seven failed to heal or had a failure of fixation. The failure rate was nine of sixteen for the sliding hip screws, two of fifteen for the blade-plates, three of ten for the dynamic condylar screws, one of three for the cephalomedullary nails, and zero of three for the intramedullary hip screws. Use of the fixed-angle devices (the blade-plate and the dynamic condylar screw) resulted in fewer failures than did use of the sliding hip screw (p = 0.023). Eleven (46%) of twenty‐four nonanatomically reduced fractures and four (17%) of twenty‐three anatomically reduced fractures had a failure of treatment (p = 0.060). Eleven (26%) of forty‐two fractures with an ideally placed implant and four (80%) of five fractures with a non-ideally placed implant had a failure of treatment (p = 0.023). Of the fifteen fractures that failed to heal or had a failure of fixation, five were treated with revision to a calcar-replacement prosthesis, seven were treated with revision open reduction and internal fixation with bone-grafting, and one was treated with bone-grafting without revision of the fixation. Two patients refused additional surgery because they had limited functional demands. The two-year mortality rate was 33%. Functional results were poor, with many patients requiring walking aids and losing the capacity for independent walking and self-care. Conclusions: In this series, reverse obliquity fractures accounted for 2% of all hip fractures and 5% of all intertrochanteric and subtrochanteric fractures. Ninety‐five-degree fixed-angle internal fixation devices performed significantly better than did sliding hip screws. Results were also worse for fractures with poor reduction and those with a poorly placed implant.

Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty

The purpose of this study was to assess the systemic safety and potential adverse effects of using a high-dose antibiotic-impregnated cement spacer after resection arthroplasty of an infected total knee replacement. Between October 2000 and December 2002, 36 knees (34 patients) had a resection arthroplasty of an infected total knee prosthesis with placement of a high-dose antibiotic impregnated cement spacer. There were 24 men and 10 women with a mean age of 66.5 years (range, 48–84 years). All spacers placed contained an average of 3.4 batches of cement with an average total dose of 10.5 g of vancomycin (range, 3–16 g) and 12.5 g of gentamicin (range, 3.6–19.2 g). All patients were followed up postoperatively until reimplantation for evidence of renal failure. The preoperative creatinine ranged from 0.7 to 1.8 mg/dL. All patients were concomitantly treated with 6 weeks of intravenous organism-specific antibiotics. One patient with normal preoperative renal function (Cr 0.7 mg/dL) had a perioperative 1-day transient rise in serum creatinine (1.7 mg/dL) postoperatively that subsequently normalized. No patients showed any clinical evidence of acute renal insufficiency, failure, or other systemic side effects of the antibiotics. Treatment of patients with an infected total knee arthroplasty with high-dose vancomycin and gentamicin antibiotic spacers seems to be clinically safe.

Open Reduction and Stable Fixation of Isolated, Displaced Talar Neck and Body Fractures

BACKGROUND The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. METHODS The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). RESULTS The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures. CONCLUSIONS Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.

Motor Nerve Palsy Following Primary Total Hip Arthroplasty

BACKGROUND Nerve palsy is a potentially devastating complication following total hip arthroplasty. The purpose of this study was to retrospectively identify risk factors for, and the prognosis associated with, a motor nerve palsy following primary total hip arthroplasty. METHODS Between 1970 and 2000, 27,004 primary total hip arthroplasties were performed at our institution. Forty-seven patients (0.17%) with postoperative motor nerve dysfunction were identified by a review of the complications log of a total joint database. The medical record of each patient provided the data for this study. The average age of the patients was fifty-seven years at the time of surgery. The patients had serial clinical examinations for a minimum of two years, or until neurologic recovery or death. The nerve palsies were classified as complete or incomplete, and only patients with objective motor weakness were included in the study. The limb lengths were measured on preoperative and postoperative radiographs, and those data were then compared with the limb lengths in a matched cohort of patients who had not sustained a nerve injury after a primary total hip arthroplasty. The extent of neurologic recovery, the need for braces or walking aids, and the use of medications for neurogenic pain were evaluated. RESULTS There were twenty-nine complete motor nerve palsies (sixteen peroneal, eleven sciatic, and two femoral) and eighteen incomplete motor nerve palsies (fourteen peroneal, three sciatic, and one femoral). A preoperative diagnosis of developmental dysplasia of the hip (p = 0.0004) or posttraumatic arthritis (p = 0.01), the use of a posterior approach (p = 0.032), lengthening of the extremity (p < 0.01), and cementless femoral fixation (p = 0.03) were associated with a significantly increased odds ratio for the development of a postoperative motor nerve palsy. Of the twenty-eight patients with a complete palsy who were available for follow-up, only ten (36%) had complete recovery of motor strength, which took an average of 21.1 months. Seven of the eighteen patients with an incomplete palsy fully recovered their preoperative strength. Twenty-one patients required walking aids, and fifteen required permanent use of an ankle-foot orthosis. Five patients required daily medication for chronic neurogenic pain. CONCLUSIONS Motor nerve palsy is uncommon following primary total hip arthroplasty. A preoperative diagnosis of developmental dysplasia of the hip or posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and use of an uncemented femoral implant increased the odds ratio of sustaining a motor nerve palsy. The majority of the motor nerve deficits in our series, whether complete or incomplete, did not fully resolve.

Fatal Sepsis in a Patient With Rheumatoid Arthritis Treated With Etanercept

Patients with long-standing, severe, erosive rheumatoid arthritis who have extra-articular manifestations and have undergone joint replacement surgery are at increased risk for serious infection and premature mortality. New therapies, including cytokine antagonists, hold great promise for improving the course of rheumatoid arthritis. However, they have powerful anti-inflammatory effects that may mask symptoms of serious infection. We report a case of fatal pneumococcal sepsis occurring in a 37-year-old woman with rheumatoid arthritis treated with the tumor necrosis factor antagonist etanercept and suggest management strategies for early detection and management of this complication.

Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures.

Background: Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Treatment with repeated attempts to gain union and to preserve the host femoral head usually is preferred for young patients, but salvage treatment with hip arthroplasty may be considered for selected older patients with poor bone quality, bone loss, or articular cartilage damage. The purpose of the present study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Methods: Between 1985 and 1997, sixty patients (forty-nine women and eleven men) with a mean age of seventy-eight years were treated at our institution with hip arthroplasty after the failed treatment of an intertrochanteric fracture. Thirty-two patients had a total hip arthroplasty with a cemented cup (twenty-four patients) or an uncemented cup (eight patients), twenty-seven had a bipolar hemiarthroplasty, and one had a unipolar hemiarthroplasty. A calcar-replacement design, extended-neck stem, or long-stem implant was used in fifty-one of the sixty hips. Results: Ten patients died within two years (all with the implant intact), and six were lost to follow-up. The remaining forty-four patients were followed for a mean of five years (range, two to fifteen years). At the time of the last follow-up, thirty-nine patients had no or mild pain and five had moderate or severe pain; in all of these patients, the pain was in the region of the greater trochanter. Forty patients were able to walk, twenty-six with one-arm support or less. Twelve patients had a total of thirteen medical complications postoperatively. A total of five reoperations were performed: two patients had a revision, one had a rewiring procedure because of trochanteric avulsion, one had late removal of trochanteric hardware, and one had débridement of fat necrosis. One patient had two dislocations, both of which were treated with closed reduction. Kaplan-Meier survivorship analysis with revision of the implant for any reason as the end point revealed a survival rate of 100% at seven years and 87.5% (95% confidence interval, 67.3% to 100%) at ten years. Conclusions: Hip arthroplasty is an effective salvage procedure after the failed treatment of an intertrochanteric fracture in an older patient. Most patients have good pain relief and functional improvement. Calcar-replacement and long-stem implants often are required. Despite the operative challenges, surprisingly few serious orthopaedic complications were associated with this procedure in the present study. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis.

Background: Concerns about the Gamma nail have largely been fueled by early randomized trials and meta-analyses suggesting an increased risk of subsequent femoral shaft fractures when compared with compression hip screws. Whereas meta-analyses favor compression hip screws over first-generation Gamma nails, little is known as to whether the newer Gamma nail designs and the improved learning curve associated with the implants have reduced the risk of femoral shaft fracture. The current meta-analysis aimed to explore the effects of time and Gamma Nail design on the risks of femoral shaft fracture after treatment of extracapsular hip fractures. Methods: We searched computerized databases (Medline, Cochrane, and SciSearch) for published randomized clinical trials from 1969 to 2002, and we identified additional studies through hand searches of major orthopedic journals, bibliographies of major orthopedic texts, and personal files. Two investigators independently graded study quality and abstracted relevant data. We abstracted information on subsequent femoral shaft fracture rates from studies. We pooled data using a random-effects model and tested for heterogeneity using the I2 test. We conducted sensitivity analyses by date and by generation of the Gamma nail. We further conducted a cumulative meta-analysis to explore the treatment effect over time. Results: We identified 25 relevant randomized trials from 1991 to 2005. In earlier studies (N = 1585 patients), Gamma nails increased the risk of femoral shaft fracture 4.5 times compared with a compression hip screw (95% confidence interval: 1.78-11.36, P = 0.0014, I2 = 0%). However, among the most recent studies (2000-2005), Gamma nails did not significantly increase femoral shaft fracture risk (relative risk = 1.65, 95% confidence interval: 0.50-5.44, P = 0.41, I2 = 0%). The most recent study (2005) found no difference in femoral fracture rates (relative risk = 1.03, 95% confidence interval = 0.06-16.2, P = 0.99). Conclusions: Our meta-analysis of randomized trials suggests that previous concerns about increased femoral shaft fracture risk with Gamma nails have been resolved with improved implant design and improved learning curves with the device. Earlier meta-analyses and randomized trials should be interpreted with caution in light of more recent evidence.

Intramedullary nailing of femoral shaft fractures: current concepts.

&NA; Intramedullary nailing is the preferred method for treating fractures of the femoral shaft. The piriformis fossa and greater trochanter are viable starting points for antegrade nailing. Alternatively, retrograde nailing may be performed. Each option has relative advantages, disadvantages, and indications. Patient positioning can affect the relative ease of intramedullary nailing and the incidence of malalignment. The timing of femoral intramedullary nailing as well as the use of reaming must be tailored to each patient to avoid systemic complications. Associated comorbidities, the body habitus, and associated injuries should be considered when determining the starting point, optimal patient positioning for nailing, whether to use reduction aids as well as which to use, and any modifications of standard technique. Intramedullary nailing of diaphyseal femur fractures provides a stable fixation construct that can be applied using indirect reduction techniques. This method yields high union rates and low complication rates when vigilance is maintained during preoperative planning, the surgical procedure, and the postoperative period.

Hospital cost of dislocation after primary total hip arthroplasty.

BACKGROUND The treatment of dislocation following primary total hip arthroplasty usually requires the use of expensive hospital resources and sometimes requires revision surgery. The hospital costs associated with treating this complication have not been previously analyzed, to our knowledge. The purpose of this study was to assess the financial impact of treating dislocations at our institution. METHODS Between 1997 and 2001, 3671 patients underwent a total of 4054 consecutive primary total hip arthroplasties at our institution. The patients were prospectively followed at regular intervals, and their follow-up data were recorded in an institutional total joint registry. Ninety-nine hips (2.4%) in ninety-nine patients dislocated. The costs to our institution to treat these dislocations were evaluated by determining the cost of each treatment episode required to reestablish hip stability and were expressed as the percent increase in cost compared with that of an uncomplicated primary total hip replacement. RESULTS Of the ninety-nine hips that dislocated, sixty-two (63%) remained stable after one or more closed reductions and thirty-seven (37%) ultimately required revision surgery. The hospital cost of each closed reduction episode represented 19% of the hospital cost of an uncomplicated total hip replacement. When revision surgery was eventually needed, the average hospital costs of one or more closed reductions and the subsequent revisions represented 148% of the hospital cost of an uncomplicated primary total hip replacement. CONCLUSIONS Dislocation after primary hip replacement continues to be a prevalent and costly complication that diminishes the cost-effectiveness of an otherwise very successful surgical procedure.

Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck.

Cemented bipolar hemiarthroplasty commonly is used to treat displaced fractures of the femoral neck in elderly patients. The purpose of the current study was to review the results and survivorship of 212 bipolar hemiarthroplasties done in 205 patients for acute femoral neck fracture between 1976 and 1985. The mean age of the patients at the time of surgery was 79 years (range, 61–100 years). The mean followup for the patients who were alive was 11.7 years (range, 5.3–16.8 years) and 5.8 years (range, 51 days–19.4 years) for the entire group. Ten hips (4.7%) were revised or removed: five for aseptic femoral component loosening, one for acetabular erosion, one for chronic dislocation, and three for infection. In living patients with surviving implants, 96.2% had no or slight pain. Ten-year survivorship free of reoperation for any reason was 93.6%, free of revision surgery for aseptic femoral loosening or acetabular cartilage wear was 95.9%, free of revision surgery for aseptic femoral loosening was 96.5%, and free of revision surgery for acetabular cartilage wear was 99.4%. Cemented bipolar hemiarthroplasty for acute femoral neck fracture is associated with excellent component survivorship in elderly patients. The rate of complications was low, and the arthroplasty provided satisfactory pain relief for the lifetime of the majority of elderly patients.