Ori Safran

The outcome of surgically treated femur fractures associated with long-term bisphosphonate use.

INTRODUCTION Bisphosphonates (BPs) evolved as the mainstay for the treatment of osteoporosis, reducing the incidence of fractures. Recently several publications described the occurrence of low-energy subtrochanteric and femoral shaft fractures associated with long-term BP use. The aim of this study was to describe the outcome of surgically treated femur fractures associated with prolonged BP use. PATIENTS Fifteen patients suffering from 17 atypical femoral fragility fractures associated with long-term (>3 years) BP use were located. Data included fracture type, time of BP use, last bone mineral density DEXA scores for the femoral neck and spine, type of surgery, and the need for revision. RESULTS Fourteen female patients and one male patient were identified. The median age was 73 years (range, 51-80 years). The mean BP use was 7.8 years (range, 4-13 years). Fourteen patients had low-energy traumatic femoral shaft (proximal and distal) or low subtrochanteric fractures. The mean lumbar spine (for 13 patients) bone mineral density T-score was -3.0, whereas mean femoral neck T-score was -1.8 with only three patients in the osteoporotic range.Fracture healing after the first procedure for patients treated with nails was 54%, with 46% of patients requiring revision surgery. These included nail dynamization, exchange nailing, and one revision to a blade plate. All of these eventually healed. CONCLUSIONS BP-related fractures are a recently described phenomenon. Despite initial osteoporosis, the DEXA scan may appear outside the osteoporotic range for the femoral neck in these patients. In addition, a much higher failure rate with intramedullary nailing requiring revision surgery may occur with these patients.

Natural History of Nonoperatively Treated Symptomatic Rotator Cuff Tears in Patients 60 Years Old or Younger

Background: Rotator cuff tears are the most frequent tendon injury in the adult population. However, the natural history of nonoperatively treated full-thickness tears is poorly defined. Knowledge of the expected evolution in tear size is important when considering nonoperative versus surgical care, especially in relatively young, active patients. Purpose: To evaluate the size change of nonoperatively treated full-thickness rotator cuff tears over 2 to 3 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: The authors prospectively followed patients 60 years old or younger who had a full-thickness rotator cuff tear equal to or larger than 5 mm, as diagnosed by bilateral shoulder ultrasound, and who were treated nonoperatively. At 2 to 3 years after the index ultrasound examination, a repeat ultrasound examination was performed by the same ultrasonographer. Results of the follow-up ultrasound examinations of both shoulders were compared with those of the index ultrasound examinations for change in rotator cuff tear size. The correlations were examined between these changes and age, sex, history of initial trauma, size of tear on the index ultrasound, and current shoulder symptoms. Results: Fifty-one patients with 61 rotator cuff tears were evaluated. At a follow-up of 25 to 39 months (mean, 29), 49% of the tears (30 tears) increased in size, 43% (26 tears) had not changed, and 8% (5 tears) decreased in size. For 25% (10 shoulders ) of initially intact shoulders (41 shoulders), a new full-thickness rotator cuff tear was diagnosed. No correlation was found between the change in tear size and age of the patient (P = .85), sex (P = .93), existence of a prior trauma (P = .63), size of tear at index ultrasound (P = .62), and bilateral tears (P = 1.00). There was a correlation between the existence of considerable pain at the time of the follow-up ultrasound and a clinically significant increase in tear size (P = .002). Conclusion: Full-thickness rotator cuff tears tend to increase in size in about half of patients aged 60 years or younger. Surgery should be initially considered in these patients to prevent a probable increase in size tear. Patients treated nonoperatively should be routinely monitored for tear size increase, especially if they remain symptomatic.

Femoral neck shortening and varus collapse after navigated fixation of intracapsular femoral neck fractures.

Objective: Assessing femoral neck shortening (FNS) and varus collapse after internal fixation of femoral neck fractures using computerized navigation (CN). Design: Retrospective cohort study. Settings: Academic Level I trauma center. Patients and Methods: Forty-one patients who had healed femoral neck fractures treated with CN between the years 2003 and 2008. Average age was 65 years (range, 14–91 years). Thirty-six patients had nondisplaced fractures and five had displaced fractures. Intervention: Screws were placed using CN in an inverted triangle formation Follow-up films were digitized into a PACS system, calibrated, and analyzed using CAD software. Outcome Measures: The following parameters were recorded: abductor lever arm shortening (termed x), corresponding vertical femur shortening (termed y), and the resultant femoral neck shortening vector (z). Fifteen patients were available for clinical outcome measures by the means of SF-12 survey Results: Significant FNS of the x component (greater than 5 mm) occurred in 30 of 42 (71%) patients with severe shortening (greater than 10 mm) in 25% of the patients. Significant y shortening occurred in 43% of the patients and severe shortening in 17%. Overall (z) femoral neck shortening occurred in 56% of the patients with severe shortening in 22% of patients. Varus collapse (greater than 5°) did not occur in any patient. Screw pullout (greater than 5 mm) occurred in 17 (41%) patients. Seven patients required late (greater than 6 months) arthroplasty postoperatively. FNS did not significantly correlate with fracture type, quality of reduction, age, or neck shaft angle. SF-12 results were negatively correlated with overall FNS. Conclusions: Our results show a high degree of FNS associated with the use of CN for fixation of femoral neck fractures, similar to recently published series using nonnavigated implants. However, no varus collapse occurred in our series. Our preliminary clinical data show a trend toward an adverse effect of FNS on quality-of-life measures.

The floating hip injury: patterns of injury.

OBJECTIVE To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury. DESIGN Historical retrospective. PATIENTS Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur. INTERVENTION Statistical analysis of the correlation between the mechanism of injury and fracture type. RESULTS Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur. CONCLUSIONS This observation explains the biomechanical nature of this injury and has treatment related implications.

Robot-assisted vertebral body augmentation: a radiation reduction tool.

Study Design. Retrospective. Objective. To assess radiation exposure time during robot-guided vertebral body augmentation compared with other published findings. Summary of Background Data. Rising incidence of vertebral compression fractures in the aging population result in widespread use of vertebral body cement augmentation with significant radiation exposure to the surgeon, operating room staff, and patient. Radiation exposure leads to higher cancer rates among orthopedic and spine surgeons and patients. Methods. Thirty-three patients with 60 vertebral compression fractures underwent robot-guided vertebral body augmentation performed by 2 surgeons simultaneously injecting cement at 2 levels under pulsed fluoroscopy. The age of patients was in the range from 29 to 92 (mean, 67 yr). One to 6 vertebrae were augmented per case (average 2). Twenty-five patients had osteoporotic fractures and 8 had pathological fractures. Robotic guidance data included execution rate, accuracy of guidance, total surgical time, and time required for robotic guidance. Radiation-related data included the average preoperative computed tomographic effective dose, radiation time for calibration, registration, placement of Kirschner wires, and total procedure radiation time. Radiation time per level and surgeons exposure were calculated. Results. Kyphoplasty was performed in 15 patients (1 sacroplasty), vertebroplasty in 13, and intravertebral expanding implants in 5. The average preoperative computed tomographic effective dose was 50 mSv (18–81). Average operative time was 118 minutes (49–350). Mean robotic guidance took 36 minutes. Average operative radiation time was 46.1 seconds per level (33–160). Average exposure time of the surgeons and the operating room staff per augmented level was 37.6 seconds. The execution rate was 99%, with an accuracy of 99%. Two complications (hemothorax and superficial wound infection) occurred. Conclusion. The radiation exposure of the surgeon and the operating room staff in a series of robot-assisted vertebral body augmentation was 74% lower than published results on fluoroscopy guidance and approximately 50% lower than the literature on navigated augmentation. Level of Evidence: 4

Outcome of dorsally comminuted versus intact distal radial fracture fixed with volar locking plates

OBJECTIVE Distal radial fractures are common. Modern trends favour operative treatment in many instances, providing stable fixation and early functional recovery. Recent biomechanical evidence suggests that volar locking plates (VLPs) enable adequate stability for dorsally displaced fractures, both in dorsally intact (DI) and in dorsally comminuted (DC) fractures. The aim of the study was to compare the clinical outcome of these two fracture groups treated with a VLP. METHODS Retrospective case-control analysis of 91 distal radial fractures treated surgically using VLP by a single surgeon between the years 2006 and 2008 was carried out. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthes/Orthopaedic Trauma Association (AO/OTA) classification. Based on initial pre-reduction X-rays and computed tomography (CT) scans, fractures were classified into two groups of DI and DC fractures. The patients were re-evaluated at 2 and 6 weeks, 3 and 6 months and 1 year. RESULTS Forty-one fractures (45%) were dorsally comminuted. Patients in the DC group were significantly older (mean 59 vs. 46 years, p<0.01) and included more female patients, as well as significantly more C3 type fractures than the DI group (p<0.04). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year postoperatively was 6.3±2.3 for the DC group, as compared with 6.6±2.02 for the DI group (p=0.64). Average time to return to work was longer in the DC group (81.2 vs. 63.6 days, p=0.05). Range of motion, volar tilt, and radial inclination were within clinically acceptable values and did not differ significantly among the two groups. CONCLUSIONS VLP fixation of DC distal radial fractures results in the maintenance of reduction and comparable functional and radiographical outcome with respect to DI fractures.

Intraoperative 3-dimensional imaging of scaphoid fracture reduction and fixation

INTRODUCTION We examined the clinical benefit of two intraoperative three-dimensional imaging modalities for reduction and fixation of scaphoid fractures. HYPOTHESIS Our hypothesis was that three dimensional imaging will aid in operative care in comparison with standard fluoroscopy. METHODS In 25 consecutive patients treated for fractures, after satisfactory reduction and fixation was obtained with a single Kirschner wire using fluoroscopy, intraoperative three-dimensional visualization was performed. The quality of fracture reduction, wire position and extrusion of the wire were examined. RESULTS In two of the 25 cases, after three-dimensional visualization, malreduction of the fracture was seen and the reduction revised. Artifact and the dependency on technologist performance, limited the use of these modalities to locate the wire accurately. DISCUSSION Diagnosis of malreduction of a scaphoid fracture is possible with 3-dimensional modalities. Utilization of these systems is still limited by technical factors.

Cigarette Smoking Is Associated with a Lower Concentration of CD105(+) Bone Marrow Progenitor Cells.

Cigarette smoking is associated with musculoskeletal degenerative disorders, delayed fracture healing, and nonunion. Bone marrow progenitor cells (BMPCs), known to express CD105, are important in local trophic and immunomodulatory activity and central to musculoskeletal healing/regeneration. We hypothesized that smoking is associated with lower levels of BMPC. Iliac bone marrow samples were collected from individuals aged 18–65 years during the first steps of pelvic surgery, under IRB approval with informed consent. Patients with active infectious or neoplastic disease, a history of cytotoxic or radiation therapy, primary or secondary metabolic bone disease, or bone marrow dysfunction were excluded. Separation process purity and the number of BMPCs recovered were assessed with FACS. BMPC populations in self-reported smokers and nonsmokers were compared using the two-tailed t-test. 13 smokers and 13 nonsmokers of comparable age and gender were included. The average concentration of BMPCs was 3.52 × 105/mL ± 2.45 × 105/mL for nonsmokers versus 1.31 × 105/mL ± 1.61 × 105/mL for smokers (t = 3.2,  P = 0.004). This suggests that cigarette smoking is linked to a significant decrease in the concentration of BMPCs, which may contribute to the reduced regenerative capacity of smokers, with implications for musculoskeletal maintenance and repair.

Bipolar hip hemiarthroplasty in a patient with an above knee amputation: a case report

The treatment of an above knee amputee who has sustained a fracture of femoral neck is a challenge for both the orthopaedic surgeon and the rehabilitation team. We present a case of such a patient and discuss different difficulties in his treatment.

Use of three-dimensional fluoroscopy to determine intra-articular screw penetration in proximal humeral fracture model

BACKGROUND Proximal humeral locking plates have significantly improved the treatment of proximal humeral fractures in recent years; however, they are not devoid of complications. Inadvertent screw penetration into the joint is a well-documented complication. Intraoperative 3-dimensional (3D) imaging may assist in detecting intra-articular implant penetration. This study compared the performance of a standard C-arm fluoroscope with a novel 3D imaging fluoroscope in detecting penetrating implants in a proximal humeral fracture model. METHODS Zinc-sprayed proximal humerus sawbones were affixed with a proximal humeral locking plate. Six different constructs were assembled. In each specimen, 1 screw, 2 screws, or no screws were inserted 2-mm proud of the articular surface. Each specimen was imaged with a conventional fluoroscope and a 3D imaging fluoroscope. Overall, 36 image sets were prepared for each modality. These were evaluated by 2 fellowship-trained surgeons for intraobserver and interobserver reliability as well for the accuracy of detecting prominent implants in the 2 imaging methods. RESULTS Overall accuracy for observer A was 89.9% compared with 100% for C-arm fluoroscopy and 3D imaging fluoroscopy (P < .01) and for observer B was 91.1% and 100% (P = .01), respectively. The κ values were 0.74 with C-arm fluoroscopy and 1.0 for the 3D imaging fluoroscopy for observer A, and 0.93 and 1.0, respectively, for observer B. CONCLUSIONS In a proximal humeral fracture model, C-arm fluoroscopy is a highly accurate imaging modality that can minimize the incidence of penetrating screws into the joint. Further clinical studies are required to establish this modality.