Ryan G. Miyamoto

Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck Fractures

&NA; During the past 10 years, there has been a worldwide effort in all medical fields to base clinical health care decisions on available evidence as described by thorough reviews of the literature. Hip fractures pose a significant health care problem worldwide, with an annual incidence of approximately 1.7 million. Globally, the mean age of the population is increasing, and the number of hip fractures is expected to triple in the next 50 years. One‐year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. Surgical options for the management of femoral neck fractures are closely linked to individual patient factors and to the location and degree of fracture displacement. Nonsurgical management of intracapsular hip fractures is limited. Based on a critical, evidence‐based review of the current literature, we have found minimal differences between implants used for internal fixation of displaced fractures. Cemented, unipolar hemiarthroplasty remains a good option with reasonable results. In the appropriate patient population, outcomes following total hip arthroplasty are favorable and appear to be superior to those of internal fixation.

Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. II: Intertrochanteric Fractures

&NA; Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence‐based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate‐and‐screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load‐sharing intramedullary implants, this result has not been demonstrated in the current evidencebased literature.

Distal Biceps Tendon Injuries

Distal biceps tendon ruptures present with an initial tearing sensation accompanied by acute pain; weakness may follow. The hook test is very reliable for diagnosing ruptures, and magnetic resonance imaging can provide information about the integrity and any intrasubstance degeneration of the tendon. There are subtle differences between the outcomes of single and modified two-incision operative repairs. With regard to complications, there is a higher prevalence of nerve injuries in association with single-incision techniques and a higher prevalence of heterotopic ossification in association with two-incision techniques. Fixation techniques include the use of bone tunnels, suture anchors, interference screws, and cortical fixation buttons. There is no clinical evidence supporting the use of one fixation method over another, although cortical button fixation has been shown to provide the highest load tolerance and stiffness. Postoperative rehabilitation has become more aggressive as fixation methods have improved.

Treatment of medial collateral ligament injuries.

&NA; The medial collateral ligament is the most frequently injured ligament of the knee. The anatomy and biomechanical role of this ligament and the associated posteromedial structures of the knee continue to be explored. Prophylactic knee bracing has shown promise in preventing injury to the medial collateral ligament, although perhaps at the cost of functional performance. Most isolated injuries are treated nonsurgically. Recent studies have investigated ligament‐healing variables, including modalities such as ultrasound and nonsteroidal anti‐inflammatory drugs. Concomitant damage to the anterior or posterior cruciate ligaments is a common indication to surgically address the high‐grade medial collateral ligament injury. The optimal treatment of multiligamentous knee injuries continues to evolve, and controversy exists surrounding the role of medial collateral ligament repair/reconstruction, with data supporting both conservative and surgical management.

Surgical Treatment of Refractory Tibial Stress Fractures in Elite Dancers A Case Series

Background Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers’ careers. Hypothesis Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing. Study Design Case series; Level of evidence, 4. Methods Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed. Results The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively. Conclusion Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity.

Hoffa fragment associated with a femoral shaft fracture. A case report.

A coronal plane fracture of the femoral condyle (creating a so-called Hoffa fragment) has been well described in association with fractures of the supracondylar-intercondylar region of the distal part of the femur1. This fracture has implications with regard to preoperative planning, the choice of surgical approach, implant selection, and functional outcomes. Coronal plane fractures of the distal part of the femur are markers of high-energy injury mechanisms. Their presence warrants a thorough workup for other injuries associated with high-energy trauma such as fractures of the spine, pelvis, femoral neck, tibial plateau, ankle, and calcaneus. A Hoffa fracture can often be missed on plain radiographs. Nork et al. showed that up to 30% of coronal plane fractures were missed on plain radiographs of distal femoral fractures, often necessitating the use of computerized tomography for identification and preoperative planning2. While the association of a Hoffa fragment with a supracondylar-intercondylar femoral fracture has been well characterized, we are unaware of any previous reports on the isolated occurrence of a coronal plane fracture of a femoral condyle in association with an ipsilateral femoral shaft fracture. We report on a patient who sustained a femoral shaft fracture with an ipsilateral coronal plane fracture of the medial femoral condyle. The patient was informed that data concerning the case would be submitted for publication. A thirty-three-year-old right-hand-dominant man was riding a motorcycle when he was struck by a tractor trailer. He was immediately transported to a level-I trauma center, where he described severe pain in the left leg and arm. Gross deformities of the left arm and thigh were identified on physical examination. Both injuries were closed, and both extremities were neurovascularly intact. A transverse fracture of the left humerus was treated with a coaptation splint. A small effusion was present in the …

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management.

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.