Faculty Bibliography

OBJECTIVE: The objective of our study was to evaluate the diagnostic utility of conventional radiography for diagnosing bisphosphonate-related atypical subtrochanteric femoral fractures. MATERIALS AND METHODS: Retrospective interpretation of 38 radiographs of complete subtrochanteric and diaphyseal femoral fractures in two patient groups-one group being treated with bisphosphonates (19 fractures in 17 patients) and a second group not being treated with bisphosphonates (19 fractures in 19 patients)-was performed by three radiologists. The readers assessed four imaging criteria: focal lateral cortical thickening, transverse fracture, medial femoral spike, and fracture comminution. The odds ratios and the sensitivity, specificity, and accuracy of each imaging criterion as a predictor of bisphosphonate-related fractures were calculated. Similarly, the interobserver agreement and the sensitivity, specificity, and accuracy of diagnosing bisphosphonate-related fractures (i.e., atypical femoral fractures) were determined for the three readers. RESULTS: Among the candidate predictors of bisphosphonate-related fractures, focal lateral cortical thickening and transverse fracture had the highest odds ratios (76.4 and 10.1, respectively). Medial spike and comminution had odd ratios of 3.8 and 0.63, respectively. Focal lateral cortical thickening and transverse fracture were also the most accurate factors for detecting bisphosphonate-related fractures for all readers. The sensitivity, specificity, and overall accuracy for diagnosing bisphosphonate-related fractures were 94.7%, 100%, and 97.4% for reader 1; 94.7%, 68.4%, and 81.6% for reader 2; and 89.5%, 89.5%, and 89.5% for reader 3, respectively. The interobserver agreement was substantial (kappa > 0.61). CONCLUSION: Radiographs are reliable for distinguishing between complete femoral fractures related to bisphosphonate use and those not related to bisphosphonate use. Focal lateral cortical thickening and transverse fracture are the most dependable signs, showing high odds ratios and the highest accuracy for diagnosing these fractures

BACKGROUND: : Open distal humerus fractures are associated with soft tissue and bony injury. This study compares the results of a staged protocol using initial joint spanning external fixation and delayed definitive fixation to acute definitive fixation. METHODS: : Treated open distal humerus fractures were retrospectively reviewed, with patients examined at 2 weeks, 6 weeks, 12 weeks, 26 weeks, and 52 weeks after definitive surgery. Outcomes were determined radiographically by union rate and clinically by range of motion, Short Musculoskeletal Function Assessment, Short Form-36, and Mayo Elbow Performance Index. RESULTS: : Fourteen treated patients with open AO/OTA type 13-C3 distal humerus fractures, with average patient age 52.7 years and average follow-up 98.6 weeks, were identified. All fractures were treated with initial irrigation and debridement emergently and either spanning external fixation in eight patients or primary definitive internal fixation in six patients. All fractures healed, with average time to osseous healing, in 25.7 weeks versus 23.4 weeks (p = 0.7) in staged versus primary definitive treatment, respectively. Elbow range of motion on final follow-up was 73.75 degrees versus 94.17 degrees (p = 0.22). Complications included nonunions, heterotopic ossification, infection, and persistent ulnar nerve deficit. Average functional outcomes scores for staged management versus primary internal fixation were Short Form-36, 50.2 versus 68.2 (p = 0.065); Short Musculoskeletal Function Assessment, 33.5 versus 12.5 (p = 0.078); and Mayo Elbow Performance Index, 55.6 versus 84.2 (p = 0.011), respectively. CONCLUSIONS: : Open distal humerus fractures had poor outcomes relative to normative functional scores; however, this is possibly due to more severe soft tissue injuries that were felt better managed with staged management at the time of presentation

Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced </=2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy

The use of locking technology has expanded significantly over the last decade. This technology has led to improvements in implant design for fixation in osteoporotic bone and allowed more secure and stable constructs. Locking plates and screws have been helpful in surgical repair of metaphyseal fractures and those with significant comminution and in the elderly. Biomechanically, creating a fixed-angle design leads to stronger constructs and potentially decreases failure rates. The use of this technology must be tempered by awareness of the complications associated with both the technique and implants

OBJECTIVES: : The treatment of fractures of the proximal femur has evolved significantly over recent years. The most recent advance is the proximal femoral locking compression plate (PF-LCP; Synthes, West Chester, PA). We present seven failures of the PF-LCP in an attempt to elicit reasons for the failures so that these pitfalls can be avoided in the future. DESIGN: : Retrospective chart review. SETTING: : Level I trauma centers, tertiary referral hospitals. PATIENTS/PARTICIPANTS: : Ten patients at five institutions. INTERVENTION: : Open reduction and internal fixation with a PF-LCP. MAIN OUTCOME MEASUREMENTS: : Failure mode, time until failure, need for further surgery, bony union, or conversion to arthroplasty. RESULTS: : Of the seven cases, two were acute peritrochanteric fractures, one was a periprosthetic fracture at the site of a prior hip fusion, one was an early failure of a compression hip screw, and three were nonunions. The failure mode was implant fracture in four cases and loss of fixation in three cases resulting from varus collapse and implant cutout. Five of seven failures were within the first 3 weeks (average, 12.4 days). The average time to failure for all cases was 37.9 days (range, 5-175 days). The average patient age was 56.7 years (range, 36-72 years). CONCLUSION: : Biomechanical studies have shown the PF-LCP to be stronger or equivalent to other fixation methods for fractures of the femoral neck and subtrochanteric femur fractures. The seven failures in our cases may be partially the result of patient factors as well as technical factors; however, there appears to be a high rate of failure even when surgery is performed by experienced and fellowship-trained traumatologists

Treating intra-articular fractures about the osteoporotic distal humerus poses a significant challenge. The purpose of this retrospective study was to evaluate functional outcomes for distal humeral fractures treated with total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) in a nonarthritic elderly population with osteoporosis. We reviewed the records of all women older than age 60 who had undergone surgical treatment for intraarticular distal humerus fractures (Orthopaedic Trauma Association types 13B and 13C) by 1 of 2 surgeons. Demographic and operative data were obtained, charts were reviewed, and patients were asked to have their outcomes evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). Twenty-two patients (23 elbows) were identified, and 2 of these (3 elbows) were excluded. Of the remaining 20 patients, 9 had undergone cemented, semiconstrained TEA as initial treatment, and 11 had undergone ORIF. These 2 groups were compared. Mean follow-up was 14.8 months (range, 6-38 months). There were no significant differences between the TEA and ORIF groups with respect to demographic factors. Final elbow range of motion was 92 degrees flexion-extension arc (arthroplasty group) and 98 degrees (fixation group). Two patients in the arthroplasty group and 2 in the fixation group died. For the remaining patients, mean DASH scores were 30.2 (arthroplasty) and 32.1 (fixation), and mean MEPI scores were 79 (arthroplasty) and 85 (fixation). These differences were not statistically significant. Four TEAs developed radiographic loosening by a mean of 15 months, and 1 of these underwent revision with good outcome. Ten of the 11 fractures in the fixation group healed radiographically; the 1 nonunion with collapse continued to be asymptomatic. Two patients in the fixation group underwent contracture release after union for limited elbow range of motion. Many factors come into play in the treatment of intra-articular distal humerus fractures in patients with osteoporosis. Implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF

Before proceeding with treatment, it is necessary to recognize that bony injuries are always associated with soft-tissue disruption and damage. A good soft-tissue envelope is essential to fracture healing and overall extremity function. Injury management begins by recognizing and classifying the injury. Wound debridement with irrigation fluid at low pressure and the administration of antibiotics are essential aspects of treatment. Wound treatment starts with applying dressing material using negative suction and can be guided by the tenets of an algorithm modeled on the reconstructive ladder

A mangled extremity is defined as a limb with injury to three of four systems in the extremity. The decision to salvage or amputate the injured limb has generated much controversy in the literature, with studies to support advantages of each approach. Various scoring systems have proved unreliable in predicting the need for amputation or salvage; however, a recurring theme in the literature is that the key to limb viability seems to be the severity of the soft-tissue injury. Factors such as associated injuries, patient age, and comorbidities (such as diabetes) also should be considered. Attempted limb salvage should be considered only if a patient is hemodynamically stable enough to tolerate the necessary surgical procedures and blood loss associated with limb salvage. For persistently hemodynamically unstable patients and those in extremis, life comes before limb. Recently, the Lower Extremity Assessment Project study attempted to answer the question of whether amputation or limb salvage achieves a better outcome. The study also evaluated other factors, including return-to-work status, impact of the level of and bilaterality of the amputation, and economic cost. There appears to be no significant difference in return to work, functional outcomes, or the cost of treatment (including the prosthesis) between the two groups. A team approach with different specialties, including orthopaedics, plastic surgery, vascular surgery and trauma general surgery, is recommended for treating patients with a mangled extremity.