Early Complications of a Novel Retrograde Intramedullary Femoral Nail in the Treatment of Femur Fractures.

OBJECTIVES: To determine the early implant failure rate of a novel retrograde intramedullary femoral nail. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS SELECTION CRITERIA: Patients aged 18 years and older with an acute OTA/AO 32-A, 32-B, 32-C, and 33-A fractures or periprosthetic distal femur fracture from April 2018 to April 2022 were included in the study. The 2 interventions compared were the Synthes Expert retrograde/antegrade femoral nail (or control implant) versus the next-generation retrograde femoral nail (RFN)-advanced retrograde femoral nail (RFNA or experimental implant) (Synthes, West Chester, PA). OUTCOME MEASURES AND COMPARISONS: Early implant-related complications between the experimental and control implants were assessed including locking screw back out, screw breakage, intramedullary nail failure, need for secondary surgery, and loss of fracture reduction. RESULTS: Three hundred fourteen patients were identified with a mean age of 31.0 years, and 62.4% of the patients being male. Open fractures occurred in 32.5% of patients with 3.8% of injuries being distal femur periprosthetic fractures. Fifty-six patients were in the experimental group and 258 patients in the control group. Mean follow-up was 46.8 weeks for the control cohort and 21.0 weeks for the experimental cohort. Distal interlocking screw back out occurred in 23.2% (13 of 56) of the experimental group patients and 1.9% (5 of 258) of the control group patients ( P < 0.0001). Initial diagnosis of interlocking screw back out occurred at an average of 3.2 weeks postoperatively (range, 2-12 weeks). Fifty-four percent of patients who sustained screw back out underwent a secondary operation to remove the symptomatic screws (12.5% of all patients treated with the experimental implant required an unplanned secondary operation due to screw back out). A logistic regression model was used to predict screw back out and found the experimental implant group was 4.3 times as likely to experience distal locking screw back out compared with the control group ( P = 0.01). CONCLUSIONS: The retrograde femoral nail-advanced implant was associated with a significantly higher rate of screw back out with a substantial number of unplanned secondary surgeries compared with the previous generation of this implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety of Prepping the External Fixator In Situ During Staged Internal Fixation of Pilon Fractures: A Retrospective Comparative Cohort Study.

OBJECTIVE: (1) To assess the rate of fracture-related infection (FRI) and unplanned reoperation of disinfecting and prepping in the external fixator (Ex-Fix) instrument during definitive open reduction and internal fixation (ORIF) of pilon fractures treated by a staged protocol and (2) to determine whether the amount of time from external fixation to ORIF influences the risk of FRI. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: One hundred thirty-three patients who underwent operative treatment for pilon fracture between 2010 and 2020. INTERVENTION: External fixation and ORIF with or without the Ex-Fix prepped in situ during definitive fixation. MAIN OUTCOME MEASUREMENTS: FRI and unplanned reoperation rates. RESULTS: 133 patients were enrolled, of which 47 (35.3%) had Ex-Fix elements prepped in situ. There was an overall infection rate of 23.3% and unplanned reoperation rate of 11.3%, and there was no significant difference in rates between the 2 cohorts. Patients with Ex-Fix elements prepped in situ who developed an FRI had a higher rate of MRSA and MSSA . Diabetes ( P = 0.0019), open fracture ( P = 0.0014), and longer (≥30 days) interval to ORIF ( P = 0.0001) were associated with postoperative FRI. CONCLUSIONS: Prepping elements of the Ex-Fix in situ did not lead to an increase in rates of FRI or unplanned reoperation. Although diabetes and open fracture were associated with FRI risk, a stronger association was a longer interval of Ex-Fix utilization before definitive internal fixation, specifically 30 days or greater. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds.

Introduction Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6-20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2-4). Mean wound size was 189 cm 2 with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.

Risk Factors for Infection and Subsequent Adverse Clinical Results in the Setting of Operatively Treated Pilon Fractures.

OBJECTIVE: To determine patient-specific and injury-specific factors that may predict infection and other adverse clinical results in the setting of tibial pilon fractures. DESIGN: Retrospective chart review. SETTING: Level 1 academic trauma center. PATIENTS: Two hundred forty-eight patients who underwent operative treatment for tibial pilon fractures between 2010 and 2020. INTERVENTION: External fixation and/or open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Fracture-related infection rates and specific bacteriology, risk factors associated with development of a fracture-related infection, and predictors of adverse clinical results. RESULTS: Two hundred forty-eight patients were enrolled. There was an infection rate of 21%. The 3 most common pathogens cultured were methicillin-resistant Staphylococcus aureus (20.3%), Enterobacter cloacae (16.7%), and methicillin-resistant Staphylococcus aureus (15.5%). There was no significant difference in age, sex, race, body mass index, or smoking status between those who developed an infection and those who did not. Patients with diabetes mellitus ( P = 0.0001), open fractures ( P = 0.0043), and comminuted fractures (OTA/AO 43C2 and 43C3) ( P = 0.0065) were more likely to develop a fracture-related infection. The presence of a polymicrobial infection was positively associated with adverse clinical results ( P = 0.006). History of diabetes was also positively associated with adverse results ( P = 0.019). CONCLUSIONS: History of diabetes and severe fractures, such as those that were open or comminuted fractures, were positively associated with developing a fracture-related infection after the operative fixation of tibial pilon fractures. History of diabetes and presence of a polymicrobial infection were independently associated with adverse clinical results. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes.

OBJECTIVES: To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities. DATA SOURCES: MEDLINE; EMBASE. STUDY SELECTION: A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded. DATA EXTRACTION AND SYNTHESIS: A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate. RESULTS: Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%. CONCLUSIONS: Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comminuted Fibular Head Fractures With Posterolateral Knee Instability: A Novel Repair Technique Using a Tension-Slide Device.

SUMMARY: Comminuted proximal fibula fractures or arcuate fractures (OTA/AO 4F1B fractures) can defunction the posterolateral corner (PLC) and result in posterolateral knee instability. Ongoing posterolateral knee instability can limit function, cause significant pain, and lead to early knee arthrosis. The anatomy of the PLC and proximal fibula limits the options for repair of this injury. The ideal method for osteosynthesis of these injuries has not been established. The goals of treatment include reconstitution of posterolateral stability, restoration of the anatomic relationship of PLC structures, and restoration of bone stock that would permit future reconstruction. This article characterizes the injury pattern, outlines the technique, and provides the clinical and radiographic outcomes of osteosynthesis of comminuted fibular head fractures using a novel application of the tension-slide technique.

The Influence of Sagittal Proximal Tibial Anatomy in Tibial Intramedullary Nailing.

OBJECTIVES: To quantify anatomic variation in sagittal proximal tibial anatomy and determine if anatomy or nail insertion method influences the radiographic nail position. DESIGN: Retrospective cohort of prospectively collected data. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-five patients with 46 tibia fractures (OTA/AO 41A, 42, and 43) treated with infrapatellar (IP) or suprapatellar (SP) nailing. The average patient age was 40.6 years (range 19-62 years). INTERVENTION: Patients received IP or SP nailing. Cohorts were analyzed based on the nailing technique and proximal tibial anatomy. MAIN OUTCOME MEASUREMENTS: Proximal tibial radiographic anatomy was quantified using novel measurements [anterior tubercle angle (ATA) and entry point position (EPP)]. Nail entry point, entry point displacement after reaming, nail position, and quality of reduction was measured and compared between groups. RESULTS: ATA was highly variable between patients. ATA was strongly correlated with EPP with a higher ATA associated with EPP more colinear with the intramedullary canal. Patients with low ATA treated with IP nailing had significantly longer operative times (60.0 vs. 45.7 minutes). Low ATA tibias had a higher incidence of entry point displacement due to eccentric reaming compared with high ATA tibias (70% vs. 38%) with the highest incidence of entry point displacement and absolute displacement in low ATA tibias treated with IP nailing (86%, 2.8 mm). SP nailing demonstrated shorter operative times relative to IP nailing (45.5 vs. 55.6 minutes). CONCLUSIONS: There is considerable variability in proximal tibial anatomy and these features influences the nail position within the tibia. These differences in anatomy should be considered to potentially reduce operative times, entry point displacement and anteriorization of tibial nails. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis of the distal tibia after pilon fractures.

BACKGROUND: Pilon fractures are devastating injuries with high complication rates. Osteonecrosis has been previously described after Weber C fracture-dislocations but has not been reported following fixation of pilon fractures. METHODS: All AO/OTA 43-C pilon fractures from 2007 to 2018 were reviewed. Injury factors and demographics were recorded. Computed tomography (CT) scans of the fracture pattern were analyzed to determine risk factors for ON. RESULTS: 71 pilon fractures in 69 patients were included. Mean follow-up was 21.6 months. 18 patients demonstrated ON at a mean 7.3 months' post-injury. Regression analysis demonstrated no differences between cohorts with respect to smoking status, open injury, or diabetic status. ON was associated with small anterolateral fragment less than 2.0cm2 (OR=19.47, p=0.012), higher comminution (OR=3.00, p=0.005), use of calcium phosphate bone substitute (OR=20.72, p=0.013). CONCLUSIONS: ON of the distal tibia was not associated with patient factors but was associated with fracture characteristics.

Plate-Assisted Intramedullary Nailing of Proximal Third Tibia Fractures.

OBJECTIVES: To report on the safety of unicortical plate stabilization in conjunction with intramedullary nailing (IMN) of proximal third tibia fractures. DESIGN: Retrospective cohort. SETTING: A Level I trauma center. PATIENTS/PARTICIPANTS: All Orthopaedic Trauma Association 41A and 42A/B/C proximal tibia fractures treated with IMN from January 2011 to May 2018 were reviewed. Fifty-three proximal tibia fractures in 50 patients were included in the study. Twenty-four patients were treated with plate-assisted reduction and IMN, and 29 were treated with IMN alone. The plate-assisted IMN cohort was subdivided into patients with plate retention and those that had the plate removed. INTERVENTION: Plate-assisted IMN and IMN only. MAIN OUTCOME MEASUREMENTS: Patients were followed up for evidence of nonunion, reduction quality, postoperative infection, and rate of implant removal. RESULTS: There were no statistically significant differences between plate-assisted IMN and IMN only for age, fracture type, mechanism of injury, quality of reduction, or implant removal rate. Open fractures were treated more often with plate-assisted IMN (88%) compared with the number of open fractures treated with IMN only (12%). There were no differences in nonunion rate or rate of postoperative infection between the 2 groups. CONCLUSIONS: Plate-assisted IMN of proximal third tibia fractures can safely be performed even in open tibia fractures with similar rates of nonunion, infection, and implant removal rates to patients treated with IMN only. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.