Antegrade femoral nailing in the lateral decubitus position: a case series, technical tips and review of literature.

BACKGROUND: Femoral intramedullary nailing is traditionally performed with the patient supine on a fracture table. We aimed to describe a case series of femoral intramedullary nailing for fracture in the lateral position, with discussion of the operative technique. METHODS: A retrospective analysis identified 52 patients who underwent femoral intramedullary nailing performed in a lateral position without traction over a 5-year period at a single level 1 trauma center. Medical records were reviewed for demographics, blood loss including need for transfusion, operative duration, complications, length of stay, fracture union, re-operation and death. RESULTS: There were 24 subtrochanteric, 16 peri-trochanteric and 12 diaphyseal femoral fractures. Mean operative time was 136.2 ± 101.4 min with a mean estimated blood loss of 372.5 ± 349.6 ml. Seventeen patients required blood transfusion. Mean length of stay was 10.3 ± 8.1 days. There were 3 (5.8%) surgical (compartment syndrome, infection and retained drain) and 12 (23.1%) medical complications, with a 30-day mortality rate of 3.8% (2). Mean follow-up was 9.9 ± 8.7 months. The union rate was 94.2% (49) and 3.8% (2) patients required revision fixation (hardware exchange for irritation and exchange nailing for non-union). Discharge destination was home, rehabilitation center and specialized nursing facility in 21 (40.4%), 16 (30.8%) and 15 (28.8%) patients, respectively. DISCUSSION AND CONCLUSION: Femoral intramedullary nailing in the lateral decubitus position is a useful technique of managing peri-trochanteric, subtrochanteric and diaphyseal femoral fractures. We describe a known technique with technical tips, which has distinct advantages over traditional supine positioning especially in certain patient and fracture types. In addition, operative times, blood loss, length of stay, revision and outcomes were comparable to the literature.

Pipkin type IV femoral head fractures: a case series and review of literature.

INTRODUCTION: Femoral head fractures with associated acetabular fractures are uncommon injuries usually resulting from high-energy mechanisms such as motor vehicle collisions. Outcomes of Pipkin type IV fractures have been historically poor, with high rates of osteonecrosis, post-traumatic arthritis, and heterotopic ossification. The objective of this study was to define the outcomes of operatively treated Pipkin type IV fractures In addition, we reviewed the available literature of this uncommon injury pattern. METHODS: A retrospective chart review at a single level 1 trauma center from 2007 to 2016 identified 10 patients with Pipkin IV femoral head fractures. Demographic information, fracture type, associated injuries, operative details, and complications were evaluated. Clinical and radiological outcomes were assessed at latest follow-up including conversion to total hip arthroplasty. RESULTS: Six of the seven patients were treated with open reduction and internal fixation of the femoral head fracture and acetabular fracture through a Kocher-Langenbeck approach aided by a trochanteric flip and one had fragment excision. Six patients (87.5%) developed post-traumatic arthritis. Four (57.1%) later underwent conversion to total hip arthroplasty (THA) a mean of 20.5 months after index procedure. CONCLUSION: Our study shows a rate of osteonecrosis and osteoarthritis that is even higher than the previously reported studies. The former may relate to longer-term follow-up and the latter possibly due to associated comminuted posterior wall fracture.

Pre-discharge postoperative radiographs after primary total knee replacement : tradition or science?

Consistent evidence exists on the inutility of immediate postoperative radiographs after a total knee replacement (TKR). We hypothesized that eliminating the pre-discharge film would not have any effect on the postoperative patient outcomes. Retrospective analysis of prospectively collected data was performed on 220 knees. Patients undergoing a simple primary TKR operated by 2 surgeons (Surgeon A and B) from January 2013 to July 2015 were divided into 2 groups (Groups 1 and 2 having 112 and 108 knees respectively). While Surgeon A routinely asked for the second postoperative day pre-discharge radiograph, Surgeon B directly performed weight bearing radiographs 6 weeks postoperatively. Greater knee pain was seen in Group 1 (p = 0.01). No changes in rehabilitation protocols based on pre-discharge radiographs, complications, medico-legal issues or revision surgery could be identified in any patient. The quality of the pre-discharge radiographs was adequate in 65 of the 112 knees (58%). A cost reduction of approximately $220 per patient was observed with the exclusion of the pre-discharge film. Eliminating routine inpatient pre-discharge radio-graphs after simple primary TKR does not alter the rehabilitation protocol, identify any of the standard complication or have any medico-legal implications. On the contrary, these films seem to increase postoperative pain and costs.

Geriatric hip fracture management: keys to providing a successful program.

BACKGROUND: Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program. INTERVENTION: The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital's data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process. CONCLUSION: To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential-those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.

The successful use of vancomycin-impregnated cement beads in a patient with vancomycin systemic toxicity: a case report with review of literature.

We report the use of vancomycin laden antibiotic cement beads in a patient with calcaneal osteomyelitis who had prior acute kidney injury (AKI). The patient experienced non-oliguric renal failure after exposure to intravenous vancomycin and recovered well after antibiotic discontinuation and adequate hydration. We are not aware of any similar case report where vancomycin laden antibiotic cement has been used in a patient with AKI to vancomycin.

Biomechanical effects of hardware configuration after union of proximal femoral and shaft fractures.

OBJECTIVES: The use of two implants to manage concomitant ipsilateral femoral shaft and proximal femoral fractures has been indicated, but no studies address the relationship of dynamic hip screw (DHS) side plate screws and the intramedullary nail where failure might occur after union. This study compares different implant configurations in order to investigate bridging the gap between the distal DHS and tip of the intramedullary nail. METHODS: A total of 29 left synthetic femora were tested in three groups: 1) gapped short nail (GSN); 2) unicortical short nail (USN), differing from GSN by the use of two unicortical bridging screws; and 3) bicortical long nail (BLN), with two angled bicortical and one unicortical bridging screws. With these findings, five matched-pairs of cadaveric femora were tested in two groups: 1) unicortical long nail (ULN), with a longer nail than USN and three bridging unicortical screws; and 2) BLN. Specimens were axially loaded to 22.7 kg (50 lb), and internally rotated 90°/sec until failure. RESULTS: For synthetic femora, a difference was detected between GSN and BLN in energy to failure (p = 0.04) and torque at failure (p = 0.02), but not between USN and other groups for energy to failure (vs GSN, p = 0.71; vs BLN, p = 0.19) and torque at failure (vs GSN, p = 0.55; vs BLN, p = 0.15). For cadaveric femora, ULN and BLN performed similarly because of the improvement provided by the bridging screws. CONCLUSIONS: Our study shows that bicortical angled screws in the DHS side plate are superior to no screws at all in this model and loading scenario, and suggests that adding unicortical screws to a gapped construct is probably beneficial.