Michael Zlowodzki

Treatment of acute midshaft clavicle fractures Systematic review of 2144 fractures : On behalf of the evidence-based orthopaedic trauma working group

Background: Fractures of the clavicle were reported to represent 2.6% of all fractures1 with an overall incidence of 64 per 100,000 per year (1987, Malmö, Sweden).2 Midshaft fractures account for approximately 69% to 81% of all clavicle fractures.1-4 Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. Objectives: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.

Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures.

Objective: To summarize the complications and early clinical results of 123 distal femur fractures treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). Design: Retrospective analysis of prospectively enrolled patients. Setting: Two academic level I trauma centers. Subjects and Participants: One hundred nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 fractures) treated by 3 surgeons. One hundred three fractures (68 closed fractures and 35 open fractures) in 99 patients were followed up at least until union (mean follow-up = 14 months, range: 3–50 months). Intervention: Surgical reduction and fixation of distal femur fractures. Main Outcome Measurements: Perioperative complications, radiographic union, infection rate, loss of fixation, alignment, and range of motion. Results: Ninety-six (93%) of 103 fractures healed without bone grafting. All fractures eventually healed with secondary procedures, including bone grafting (1 of 68 closed fractures and 6 of 35 open fractures). There were 5 losses of proximal fixation, 2 nonunions, and 3 acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed. Malreductions of the femoral fracture were seen in 6 fractures (6%). The mean range of knee motion was 1° to 109°. Conclusions: Treatment of distal femur fractures with the LISS is associated with high union rates without autogenous bone grafting (93%), a low incidence of infection (3%), and maintenance of distal femoral fixation (100%). No loss of fixation in the distal femoral condyles was observed despite the treatment of 30 patients older than 65 years. The LISS is an acceptable surgical option for treatment of distal femoral fractures.

Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures.

Objective: To evaluate the stability of the retrograde intramedullary nail (IMN), angled blade plate (ABP), and a locked internal fixator (Less Invasive Stabilization System [LISS], Synthes, Paoli, PA) for internal fixation of distal femur fractures. Design: Destructive biomechanical testing of matched pairs of fresh–frozen human cadaveric bone–implant constructs. Setting: Biomechanical laboratory. Methods: A fracture model was created to simulate an AO/OTA33-A3 fracture. Forty-eight matched pairs of specimens were used. Six groups of 8 pairs each were tested to failure: LISS versus ABP and LISS versus IMN (axial, torsional, and cyclical axial). Main Outcome Measurement: Load to failure, mode of failure, energy to failure, displacement at the load to failure, and stiffness. Results: Fixation strength (load/moment to failure) of the LISS constructs was 34% greater in axial loading (P = 0.01) and 32% less in torsional loading (P = 0.05) compared with ABP constructs and 13% greater in axial loading (P = 0.35) and 45% less in torsional loading (P < 0.01) compared with IMN constructs. Loss of distal fixation in axial loading occurred in 1 of 16 cases with the LISS, in 3 of 8 cases with the ABP, and in 8 of 8 cases with the IMN. Cyclical axial loading demonstrated significantly less plastic deformation for the LISS construct compared with ABP constructs (P < 0.01) and similar plastic deformation compared with IMN constructs (P = 0.98). Conclusions: All 3 fixation devices (LISS, ABP, and IMN) offer sufficient torsional stability and sufficient proximal fixation that withstands axial loading without failing. The LISS provides improved distal fixation, especially in osteoporotic bone, at the expense of more displacement at the fracture site.

Treatment of distal tibia fractures without articular involvement : A systematic review of 1125 fractures

The management of unstable distal tibia fractures remains challenging. The mechanism of injury and the prognosis of these fractures are different from pilon fractures, but their proximity to the ankle makes the surgical treatment more complicated than the treatment tibial midshaft fractures. A variety of treatment methods have been suggested for these injuries, including nonoperative treatment, external fixation, intramedullary nailing, and plate fixation. However, each of these treatment options is associated with certain challenges. Nonoperative treatment may be complicated by loss of reduction and subsequent malunion. Similarly, external fixation of distal tibia fractures may result in insufficient reduction, malunion, and pin tract infection. Intramedullary nailing can be considered the “gold standard” for the treatment of tibial midshaft fractures, but there are concerns about their use in distal tibia fractures. This is because of technical difficulties with distal nail fixation, the risk of nail propagation into the ankle joint, and the discrepancy between the diaphyseal and metaphyseal diameter of the intramedullary canal. Open reduction and internal plate fixation results in extensive soft tissue dissection and may be associated with wound complications and infections. The optimal treatment of unstable distal tibia without articular involvement remains controversial. Objectives: This study was designed to review the outcomes of different treatment methods for extra-articular distal tibia fractures. The English literature was systematically reviewed and the rates of malunion, nonunion, infection, fixation failure, and secondary surgical procedures were extracted.

Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials.

BACKGROUND There is currently no consensus on the optimal operative treatment for cubital tunnel syndrome. The objective of this meta-analysis of randomized, controlled trials was to evaluate the efficacy of simple decompression compared with that of anterior transposition of the ulnar nerve in the treatment of this condition. METHODS Multiple databases were searched for randomized, controlled trials on the outcome of operative treatment of cubital tunnel syndrome in patients who had not previously sustained trauma or undergone a surgical procedure involving the elbow. Two reviewers abstracted baseline characteristics, clinical scores, and motor nerve-conduction velocities independently. Data were pooled across studies, standard mean differences in effect sizes weighted by study sample size were calculated, and heterogeneity across studies was assessed. RESULTS We identified four randomized, controlled trials comparing simple decompression with anterior ulnar nerve transposition (two submuscular and two subcutaneous). In three studies that included a total of 261 patients, a clinical scoring system was used as the primary clinical outcome. There were no significant differences between simple decompression and anterior transposition in terms of the clinical scores in those studies (standard mean difference in effect size = -0.04 [95% confidence interval = -0.36 to 0.28], p = 0.81). We did not find significant heterogeneity across these studies (I(2) = 34.2%, p = 0.22). Two reports, on a total of 100 patients, presented postoperative motor nerve-conduction velocities; they showed no significant differences between the procedures (standard mean difference in effect size = 0.24 [95% confidence interval -0.15 to 0.63] in favor of simple decompression, p = 0.23; I(2) = 0%, p = 0.9). CONCLUSIONS The results of this meta-analysis suggest that there is no difference in motor nerve-conduction velocities or clinical outcome scores between simple decompression and ulnar nerve transposition for the treatment of ulnar nerve compression at the elbow in patients with no prior traumatic injuries or surgical procedures involving the affected elbow. Confidence intervals around the points of estimate were narrow, which probably exclude the possibility of clinically meaningful differences. These data suggest that simple decompression of the ulnar nerve is a reasonable alternative to anterior transposition for the surgical management of ulnar nerve compression at the elbow.

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.

The use of calcium phosphate bone cement in fracture treatment: a meta-analysis of randomized trials

BACKGROUND Available options to fill fracture voids include autogenous bone, allograft bone, and synthetic bone materials. The objective of this meta-analysis was to determine whether the use of calcium phosphate bone cement improves clinical and radiographic outcomes and reduces fracture complications as compared with conventional treatment (with or without autogenous bone graft) for the treatment of fractures of the appendicular skeleton in adult patients. METHODS Multiple databases, online registers of randomized controlled trials, and the proceedings of the meetings of major national orthopaedic associations were searched. Published and unpublished randomized controlled trials were included, and data on methodological quality, population, intervention, and outcomes were abstracted in duplicate. Data were pooled across studies, and relative risks for categorical outcomes and weighted mean differences for continuous outcomes, weighted according to study sample size, were calculated. Heterogeneity across studies was determined, and sensitivity analyses were conducted. RESULTS We identified eleven published and three unpublished randomized controlled trials. Of the fourteen studies, six involved distal radial fractures, two involved femoral neck fractures, two involved intertrochanteric femoral fractures, two involved tibial plateau fractures, one involved calcaneal fractures, and one involved multiple types of metaphyseal fractures. All of the studies evaluated the use of calcium phosphate cement for the treatment of metaphyseal fractures occurring primarily through trabecular, cancellous bone. Autogenous bone graft was used in the control group in three studies, and no graft material was used in the remaining studies. Patients managed with calcium phosphate had a significantly lower prevalence of loss of fracture reduction in comparison with patients managed with autograft (relative risk reduction, 68%; 95% confidence interval, 29% to 86%) and had less pain at the fracture site in comparison with controls managed with no graft (relative risk reduction, 56%; 95% confidence interval, 14% to 77%). We were unable to compare pain at the bone-graft donor site between the studies because of methodological reasons. Three studies independently demonstrated improved functional outcomes when the use of calcium phosphate was compared with the use of no grafting material. CONCLUSIONS The use of calcium phosphate bone cement for the treatment of fractures in adult patients is associated with a lower prevalence of pain at the fracture site in comparison with the rate in controls (patients managed with no graft material). Loss of fracture reduction is also decreased in comparison with that in patients managed with autogenous bone graft.

Operative treatment of acute distal femur fractures: Systematic review of 2 comparative studies and 45 case series (1989 to 2005)

Background The incidence of distal femur fractures is approximately 37 per 100,000 person-years.1 Typically, distal femur fractures are caused by a high-energy injury mechanism in young men or a low-energy mechanism in elderly women.2 Managing these fractures can be a challenging task. Most surgeons agree that distal femur fractures need to be treated operatively to achieve optimal patient outcomes. The articular fracture component is usually treated with open reduction and internal lag screw fixation or external tension wire fixation (Illizarov). However, there is no consensus on the type of implant for the fixation of the metaphyseal–diaphyseal fracture component. Objective The aim of this study is to systematically summarize and compare the results of different fixation techniques (traditional compression plating, antegrade nailing, retrograde nailing, submuscular locked internal fixation, and external fixation) in the operative management of acute nonperiprosthetic distal femur fractures (AO/OTA type 33A and C) and the characteristics of the fractures for each treatment (articular/nonarticular and open/closed). Additionally an attempt was made to evaluate the impact of surgical experience on nonunion rate, fixation failure rate, deep infection rate, and secondary surgical procedure rate. In the context of this article compression plating relates to techniques/implants that require compression of the implant to the femoral shaft—it does not relate to interfragmentary compression.

Intramedullary nailing following external fixation in femoral and tibial shaft fractures.

Background: Intramedullary nailing is the standard of care for the definitive management of lower extremity long bone fractures. Occasionally, temporary external fixation is used in fractures with severe open wounds or vascular injury before definitive intramedullary nailing. Secondary intramedullary nailing following external fixation is somewhat controversial, especially with respect to the duration of external fixation that is allowable before the risk of infection following later nailing becomes too great. Several recent studies have provided further insight into this issue. Objective: The primary objective is to evaluate infection and nonunion rates in patients treated with temporary external fixation and secondary intramedullary nailing for lower extremity long bone fractures. The secondary objective is to evaluate whether the duration of external fixation and the interval time (defined as the time from external fixator removal to intramedullary nailing) influence the risk of infection after intramedullary nailing.

The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: A MULTI-CENTRE COHORT STUDY

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5 degrees of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (<5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001).