Patient Mortality in Geriatric Distal Femur Fractures.

OBJECTIVES: To estimate 1-year mortality rates in elderly patients who undergo operative treatment for distal femur fractures and identify potential risk factors for mortality. DESIGN: Retrospective chart review. SETTING: Level 1 and Level 2 trauma centers. PATIENTS/PARTICIPANTS: Two hundred eighty-three elderly patients (average age 76.0 years ± 9.8) who sustained distal femur fractures between 2002 and 2012. INTERVENTION: Fracture fixation of the distal femur. MAIN OUTCOME MEASURE: Survival up to 1 year after surgery. RESULTS: The 1-year mortality rate for distal femur fractures in elderly patients was 13.4%. There were no statistically significant differences in overall mortality between native bone and periprosthetic fractures, intramedullary nail or open reduction internal fixation, or across Orthopaedic Trauma Association fracture classifications. Overall patient mortality was significantly higher at 30 days (P = 0.036), 6 months (P = 0.019), and 1 year (P = 0.018), when surgery occurred more than 2 days from the injury. Mean Charlson Comorbidity Index scores were significantly lower in survivors versus nonsurvivors at all time intervals (30 days, P = 0.023; 6 months, P = 0.001 and 1 year P ≤ 0.001). A time to surgery of more than 2 days, regardless of baseline illness, did not result in improved survivability at 1 year. CONCLUSIONS: Overall mortality for distal femur fractures was 13.4% in the elderly population. A surgical treatment more than 2 days after injury was associated with increased patient mortality. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects.

INTRODUCTION: This study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10cm in length. METHODS: In a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates. RESULTS: The mean size of the bone defect was 7cm in Group A, and 5.8cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P=0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P=0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P=0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P=0.28). CONCLUSIONS: While both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures. LEVEL OF EVIDENCE: Level III; Retrospective comparative study.

Early prediction of tibial and femoral fracture healing: Are we reliable?

INTRODUCTION: To evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures. MATERIALS AND METHODS: Eight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union. RESULTS: Nine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25-0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330-0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p=0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons' years in clinical practice were not associated with accuracy of predictions. CONCLUSIONS: At 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort.

Modern retrograde intramedullary nails versus periarticular locked plates for supracondylar femur fractures after total knee arthroplasty.

This study purpose is to analyze outcomes of modern intramedullary (IM) nails with a locked distal screw versus periarticular locking plates for peri-prosthetic supracondylar femur fractures in TKA. Ninety-five consecutive fractures in 91 patients were retrospectively reviewed. Fixation included 29 knees with a retrograde IM nail and 66 periarticular locked plates. Six patients died and 4 were lost to follow-up. There were 2 (9%) nonunions in the IM nail group and 12 non-unions/delayed-unions (19%) in the locked plate group (P = 0.34). A mean of 5.0 distal screws was used in locked plates versus 3.8 distal screws in the IM nails (P < 0.001). Despite a greater quantity of screws in the distal fragment, the failure rate of locked plating was twice that of IM nail fixation.

Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series.

Treatment of large segmental defects using conventional autogenous iliac crest bone graft can be limited by volume of cancellous bone and donor site morbidity. The reamer-irrigator-aspirator (RIA) technique allows access to a large volume of cancellous bone graft containing growth factors with potency equal to or greater than autograft material from the iliac crest. The purpose of this study was to evaluate the effectiveness of RIA-harvested autogenous bone graft for treating large segmental defects of long bones.