Rethinking Conservative Treatment of Humeral Diaphyseal Fractures in Elderly Patients With Dementia.

OBJECTIVES: To assess outcomes and complications of conservatively managed humeral diaphyseal fractures in elderly patients, with an emphasis on the subgroup diagnosed with dementia. DESIGN: Retrospective. SETTING: Upper extremity surgery unit at an academic Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive patients 65 years of age and older who were managed conservatively for humeral diaphyseal fractures between 2007 and 2015. INTERVENTION: Conservatively managed humeral diaphyseal fractures. MAIN OUTCOME MEASUREMENTS: Complications and radiographic outcomes. RESULTS: One-hundred twenty-four patients who were conservatively managed for humeral diaphyseal fractures were identified. Their mean age was 77 (65-92) years, 36 (30%) of them were male and 88 (70%) were female. Fifty-seven (46%) patients experienced complications associated with their treatment, and 33 (27%) patients were eventually treated surgically. Seventeen (14%) patients were diagnosed with dementia. This subgroup had 64% fracture-related complications, and all of them were operated (P-value <0.01 compared with age-matched patients among the other 107 participants in the study). CONCLUSION: Conservative management of humeral diaphyseal fractures seems to be associated with greater morbidity in elderly patients, especially in those diagnosed with dementia. Therefore, early surgical treatment should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of Oral Nutritional Supplements in Patients Undergoing Surgical Intervention for Hip Fracture.

Introduction: Malnutrition is considered a risk factor among geriatric individuals with hip fracture, affecting functional healing and recovery, increasing healthcare spending, and associated with high mortality. In this study, we sought to evaluate the clinical efficacy of oral nutritional supplements in geriatric patients undergoing surgery for hip fracture. Material and Methods: We retrospectively analyzed data of 1625 consecutive patients who underwent fixation or arthroplasty for hip fracture in a tertiary medical center between 2017 and 2020. Patients who had no available albumin or body mass index levels were excluded. The study group is of patients who received an advanced formula in the form of an oral nutritional supplement (ONS), and the control group of patients that received no ONS. Peri- and postoperative complications, readmissions, short-term mortality, and albumin levels were compared between the 2 groups. Results: The final cohort included 1123 patients, 298 in the study group and 825 controls, with a follow-up of at least 1-year. Provision of the advanced enriched formula was not associated with 30-day, 90-day, or 1-year mortality (P = .62, P = .52, and P = .72, respectively) or any perioperative complications, such as 30-day or 90-day readmission (P = .37 and P = .1, respectively), revision surgery of any cause (P = .35), and postoperative infection rates (P = .73). Albumin levels on admission and the minimum albumin levels during hospitalization were similar between the groups, but they were significantly higher in the study group before discharge (33.42 g/L vs. 32.79 g/L, P = .01). Discussion: The use of an ONS was not associated with reduced perioperative complications or mortality, although it did affect nutritional status, as indicated by increased albumin levels, a known marker of nutritional status. Conclusions. While current findings do not support ONS use to minimize major postoperative complication after hip fracture surgery, further long-term study is warranted to evaluate subjective and functional outcomes associated with improved nutritional status.

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures.

BACKGROUND: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN. PATIENTS AND METHODS: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life. RESULTS: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively). CONCLUSIONS: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures. LEVEL OF EVIDENCE: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.

Addressing posterior tilt displacement during surgery to lower failure risk of sub-capital Garden types 1 and 2 femoral fractures.

INTRODUCTION: Sub-capital femoral fractures (SCFF) are impacted or non-displaced in Garden types 1 and 2, respectively. Non-surgical treatment is protected weight-bearing combined with physiotherapy and radiographic follow-up in selected patients. Traditionally, in situ pinning is the surgical treatment of choice. The aim of this study was to estimate whether the valgus deformity in Garden types 1 and 2 (AO classification 31B1.1 and 31B1.2) SCFF is a virtual perception of a posterior tilt deformity and if addressing this deformity improves patients' outcomes. MATERIALS AND METHODS: The records of 96 patients with Garden Types 1 and 2 SCFF treated in tertiary medical center between 1/2014 and 9/2017 were retrospectively reviewed. They all had preoperative hip joint anteroposterior and lateral radiographic views. 75 patients had additional computed tomography (CT) scans. Femoral head displacement was measured on an anteroposterior and axial radiograph projections and were performed before and after surgery. Preoperative 3D reconstructions were performed for a better fracture characterization, and assessment of the imaging was performed by the first author. RESULTS: The average age of the study cohort was 73 years (range 28-96, 68% females). There were 58 right-sided and 38 left-sided fractures. Ninety patients had Type 1 and six patients had Type 2 fractures. The average preoperative posterior tilt was 15 degrees and the average valgus displacement was 10 degrees on plain radiographs compared to 28 degrees and 11 degrees, respectively, on CT scans. Posterior tilt was found with a virtual perception as valgus-impacted fractures. The postoperative posterior tilt was corrected to an average of 3 degrees and the valgus displacement to 5 degrees. CONCLUSION: CT provides an accurate modality for measuring femoral head displacement and fracture extent. The posterior tilt displacement should be addressed during surgery to lower failure risk and the need for additional procedures. IRB APPROVAL: TLV-0292-15. LEVEL OF EVIDENCE: IV.

Early versus delayed surgery for hip fragility fractures in patients treated with direct oral anticoagulants.

BACKGROUND: Delaying surgical treatment for hip fragility fractures increases mortality, but early intervention in patients treated with direct oral anticoagulant (DOAC) may increase the risk of perioperative blood loss due to residual drug activity. This study aimed to evaluate the effect of the timing of hip fragility fractures surgeries in patients treated with DOAC. METHODS: We retrospectively reviewed all records of DOAC-treated patients who underwent surgery for hip fragility fractures between 2011 and 2019. They were divided into three groups according to time to surgery since admission to the emergency room (ER), ≤ 24, 24-48, and ≥ 48 h. Blood loss, peri and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS: Of the 171 suitable patients (59 males and 112 females), 32 (18.7%) were in the ≤ 24 h group, 93 (54.4%) in the 24-48 h group, and 46 (26.9%) in the ≥ 48 h group. Timing of surgery did not affect blood loss, as indicated by changes in pre- and postoperative hemoglobin levels (p = 0.089) and proportion of perioperatively administered packed cells (p = 0.949). There was a trend towards increased 30-day mortality in the ≥ 48 h group compared to the 24-48 h and ≤ 24 h groups (13.0, 4.3 and 3.1%, respectively. p = 0.099), and a trend towards increased 90 day mortality (6.5, 3.2, and 0%, respectively. p = 0.298). CONCLUSIONS: Early surgery did not increase perioperative blood loss. Delayed surgery ≥ 48 h of patients receiving DOAC who underwent surgery for hip fragility fractures showed a trend towards increased 30 day and 90 day mortality.

Adding a First Metatarsal Pin to An Ankle Tubular External Fixator Does Not Reduce the Incidence of Early Reduction Loss.

External fixation with a bilateral frame configuration (delta frame, DF) is a routine approach for treating ankle fractures and dislocations with severe soft tissue damage. The purpose of this study was to evaluate to what extent adding a first metatarsal fixation contributes to the stability of the fixation as evidenced by reduced frequency of early loss of reduction. A retrospective study was performed to compare the rate of early reduction loss in patients treated with a bilateral frame external fixation as part of a 2-stage treatment protocol for periarticular ankle fractures, in a level one trauma center between 2006 and 2016. The cohort was divided into 2 groups according to the frame configuration that had been used: DF only and DF with first metatarsal fixation (DF+1MT). A multivariate analysis assessing risk factors for postoperative loss of reduction was conducted. A total of 67 patients were included in the study, of which 30 underwent fixation by DF and 37 by DF+1MT. Early loss of reduction was recorded in 13 (19.4%) patients, 6 (20%) in the DF group and 7 (18.9%) in the DF+1MT group (p = .576). None of the assessed risk factors reached statistical significance. To conclude, the addition of a first metatarsal pin as an enhancement of external fixation with a delta frame configuration did not reduce the incidence of early loss of reduction. There is no evidence to support the claim that adding this pin contributes to the stability of the fixation in a clinically relevant manner.

Tranexamic acid in hip hemiarthroplasty.

BACKGROUND: Intraoperative use of tranexamic acid (TXA) has been proven to reduce the administration of allogenic blood transfusion in total joint arthroplasty (TJA) patients. Data on TXA efficacy in reducing blood loss in trauma patients undergoing hip hemiarthroplasty are sparse, and its use is not yet well-established. The purpose of this study was to assess the efficacy and safety of intraoperative TXA use in patients undergoing hip hemiarthroplasty as treatment for intracapsular femoral neck fracture. METHODS: This is a historical cohort of patients who underwent hip hemiarthroplasty in a tertiary medical center between 2011 and 2019, with minimum follow-up of one year. The cohort was divided into one group of patients who received intraoperative TXA treatment and another group that did not. Blood loss, peri­ and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS: Of the 1722 consecutive patients (601 males and 1121 females) who underwent hip hemiarthroplasty who were included in this study, 504 were in the "TXA" group and 1218 were in the "non-TXA" group. TXA use significantly reduced 30-day mortality (4.6% vs 7.3%, respectively, p < 0.046) and perioperative blood loss, as indicated by changes in hemoglobin levels before and after surgery (Δ-1.38 gr/dL vs Δ-1.76 gr/dL, p < 0.001), and by administration of allogenic blood transfusions (17.5% vs 44.4%, p < 0.001). CONCLUSIONS: Similar to the known effect of TXA in TJA patients, the use of TXA treatment in patients undergoing hip hemiarthroplasty led to a significant reduction in 30-day mortality, in postoperative blood loss and in the proportion of patients requiring allogenic blood transfusions.

Does hip morphology correlate with proximal femoral fracture type?

PURPOSE: To determine if boney morphology influences the anatomic location of hip fractures in elderly patients. METHODS: All patients with hip fractures between 2008 and 2012 who had hip radiographs taken prior to the fracture were reviewed. Fractures were classified as intracapsular or extracapsular and hip morphology was measured on the pre-fracture x-rays. Hip morphology was determined by alpha angle, lateral central edge angle, acetabular index, neck-shaft angle, hip axis length, femoral neck diameter, Tönnis classification for hip osteoarthritis (OA) and the presence of a crossover sign. RESULTS: 148 subjects (78.4% female, age 83.5 years) with proximal femur fractures were included. 44 patients (29.7%) had intracapsular fractures and 104 (70.3%) had extracapsular fractures. 48% of patients had previous hip fractures on the contralateral side and 74.6% had the same type of fracture bilaterally. The rates of bilateral intracapsular and extracapsular fractures were similar (33.7% vs. 40.9% respectively, p = 0.39). Extracapsular fractures had a statically significant higher neck-shaft angle, a shorter hip axis length, a narrower femoral neck diameter and a higher grade of Tönnis classification of OA (p = 0.04, 0.046, 0.03, 0.02 respectively). Acetabular coverage and the proximal femoral head-neck junction, which were evaluated by lateral centre-edge angle (LCEA), acetabular index and the presence of a crossover sign, did not correlate with fracture type. The alpha angle > 40° had a statistically significant higher likelihood for extracapsular fractures (p = 0.013). CONCLUSIONS: Acetabular coverage and proximal femoral head-neck junction morphology, were found to partially correlate with the location of hip fractures and do not fully elucidate fracture type susceptibility.

Correlation between preoperative imaging parameters and postoperative basic kinematics-based functional outcome in patients with tibial plateau fractures.

BACKGROUND: Functional scores and radiographs are often used to assess function and predict development of osteoarthritis in patients with multi-fragmentary tibial plateau fractures (TPFs). Locomotion, which is the primary goal of fracture treatment, is rarely assessed. The objective of this study was to assess functional ability of patients after TPF fixation using spatio-temporal gait analysis (STGA), and to compare STGA variables with self-reported functional scores and preoperative fracture characteristics. METHODS: Preoperative CT scans of 21 patients with complete articular multi-fragmentary TPFs were evaluated for number of fragments, maximum gap between the fragments and maximum articular depression. All patients underwent STGA (velocity, cadence, step length of the affected and the unaffected leg, single-limb support by the affected and the unaffected leg, and double-leg support) and filled the Knee Society Score and the Short Form-12 questionnaires on average 3 years (SD = 1.56, range, 2-5.8) post-injury. FINDINGS: Step length and single-limb support time of the affected leg were shorter compared to the unaffected leg (p = 0.02 and p = 0.007, respectively). Number of fracture fragments correlated with cadence (R = -0.461, p = 0.04) and velocity (R = -0.447, p = 0.04). INTERPRETATION: Given that both higher fracture comminution and deformity on the one hand and the above gait parameter alterations on the other hand are associated with knee osteoarthritis, STGA may be used for routine postoperative evaluation of patients after TPF fixation.

Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications.

INTRODUCTION: Direct oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral. MATERIALS AND METHODS: This is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients. RESULTS: Patients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015). CONCLUSIONS: DOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

Financial impact and effect on the outcome of preoperative tests for at-risk older hip fracture patients.

AIM: Older patients with proximal femoral fractures often undergo preoperative tests due to coexisting morbidities. Our aim was to evaluate these tests and their impact on patient outcome and medical expenses. METHODS: This retrospective study includes data on head computed tomography, carotid ultrasound, echocardiography and pulmonary functional tests calculated according to the type of surgery (osteosynthesis or hip arthroplasty) carried out on 2798 patients. Time-to-surgery, test repeated postoperatively, American Society of Anesthesiology Physical Status score, additional procedures, hospitalization time, 30-day mortality and associated medical expenses were evaluated. RESULTS: A total of 921 preoperative tests were carried out in 780 (28%) patients, and 375 postoperative tests were carried out in 329 (12%) patients (P < 0.001). A total of 23 procedures were carried out after surgery, none related to the originally carried out tests. Significant group differences were found for American Society of Anesthesiology Physical Status score, days to surgery, hospitalization time (days) and mortality rates. The medical expenses of these tests were 1.3% of the average income per case, and 0.6% of the average study group income. CONCLUSIONS: Non-routine preoperative tests prolong time-to-surgery, increased hospitalization time and contribute to 30-day mortality. No postoperative procedure was related to preoperative test findings. The financial cost for these tests does not burden the medical expenses per procedure. Geriatr Gerontol Int 2018; 18: 937-942.

Functional outcomes after removal of hardware in patellar fracture: are we helping our patients?

PURPOSE: Functional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee pain, limited range of motion and symptomatic hardware. The purpose of this study was to evaluate if removal of hardware is beneficial to symptomatic patients after patellar fracture fixation. METHODS: Patients who presented to our institution between December 2006 and November 2014 with patella fractures treated with ORIF were eligible for inclusion. Patella ORIF was performed using (1) K-wires (KW) with a tension band construct or (2) Cannulated Screws (CS) with a tension band construct. Radiological analyses included (1) AO classification and (2) measurements of prominent hardware length. Patient medical charts were reviewed for demographic and intraoperative data as well as peri/postoperative complications. All patients completed the SF-12 score, visual analog scale, Kujala score, Lysholm score and questionaries' regarding return to previous activity levels. RESULTS: Forty-seven patients met the inclusion criteria. The average time from fracture fixation to removal of hardware was 15.8 (SD ± 14.9) months. The mean follow-up was 43.1 (SD ± 27.1) months. Patella fixation was accomplished using tension band constructs with KW in 28 patients (59.5%) or with CS in 19 patients (40.5%). Patient reported quality of life and pain outcomes improved significantly after removal of hardware (p = 0.001, and p = 0.002 respectively). Functional outcome scores (Kujala and Lysholm) did not improve significantly after hardware removal in the KW or CS groups. Significantly more patients in the KW group returned to pre-injury activity (p = 0.005). CONCLUSIONS: Hardware removal after patella ORIF significantly improves patient reported pain and quality of life outcomes but not functional outcomes. Patients should be counseled regarding the expected outcome of hardware removal following patella ORIF and diabetic patients should be given special consideration before undergoing this procedure.

A double-plating approach to distal femur fracture: A clinical study.

BACKGROUND: Locked plating is one of the latest innovative options for treating supracondylar femur fractures with relatively low failure rates. Single lateral plating was often found to have a relative higher failure rate. No clinical studies of double-plating distal femur fixation have thus far been reported. The aim of this study is to present our clinical experience with this surgical approach. PATIENTS AND METHODS: Thirty-two patients (26 females and 6 males, mean age 76 years, range 44-101) were included in the study. Eight of them patients had a periprosthetic stable implant fracture and two patients were treated for a nonunion. RESULTS: All fractures, excluding one that needed bone grafting and one refracture, healed within 12 weeks. One patient needed bone grafting for delayed union and one patient needed fixation exchange due to femur re-fracture at the site of the most proximal screw. Two patients developed superficial wound infection and one patient required medial plate removal after union due to deep infection. CONCLUSIONS: Based on these promising results, we propose that the double-plating technique should be considered in the surgeon's armamentarium for the treatment of supracondylar femur fractures, particularly in patients with poor bone quality, comminuted fractures and very low periprosthetic fractures.

Corona mortis anastomosis: a three-dimensional computerized tomographic angiographic study.

PURPOSE: We evaluated the corona mortis (CM) anatomy by means of three-dimensional computerized tomography angiographic (CTA). METHODS: Patient demographic, anastomosis incidence, artery diameter, artery distance from the symphysis pubis, and pelvic size (distance between both acetabular upper labrum) parameters were assessed. The 100 patients included 66 males and 34 females (average age of 67.8 years). RESULTS: There were 66 (33%) arterial anastomoses in the 200 evaluated arteries, 30 in the right side and 36 in the left side, 36 unilaterally and 15 bilaterally. No anastomoses were detected in 49 patients. The average diameter was 2.4 mm for the right-sided arteries and 2.24 in the left-sided ones. The distance was 55.2 mm from the right symphysis and 57.2 from the left symphysis (greater for females, 62.2 versus 55.85 mm [p = 0.037] only on the left side). The artery disappears in smaller-sized pelvises. There was a non-occluded arterial pattern in 47 (71%) and a partially occluded one in 19 (29%, all with peripheral vascular disease). CONCLUSION: One-third of the evaluated CTAs revealed competent CMs. CMs were more lateral in females than in males and were absent in small-sized pelvises. It is highly recommended that the radiologist and the surgeon should be familiar with CM existence for decision-making with regard to emergency radiology imaging and intervention as well as when operating in proximity of that anatomic site.

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures.

BACKGROUND: Femoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches. PATIENTS AND METHODS: Medical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model. RESULTS: The demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p<0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ=368 versus PFN, δ=65, p<0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones. CONCLUSIONS: Implementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.

Preoperative Planning of Orthopedic Procedures using Digitalized Software Systems.

The progression from standard celluloid films to digitalized technology led to the development of new software programs to fulfill the needs of preoperative planning. We describe here preoperative digitalized programs and the variety of conditions for which those programs can be used to facilitate preparation for surgery. A PubMed search using the keywords "digitalized software programs," "preoperative planning" and "total joint arthroplasty" was performed for all studies regarding preoperative planning of orthopedic procedures that were published from 1989 to 2014 in English. Digitalized software programs are enabled to import and export all picture archiving communication system (PACS) files (i.e., X-rays, computerized tomograms, magnetic resonance images) from either the local working station or from any remote PACS. Two-dimension (2D) and 3D CT scans were found to be reliable tools with a high preoperative predicting accuracy for implants. The short learning curve, user-friendly features, accurate prediction of implant size, decreased implant stocks and low-cost maintenance makes digitalized software programs an attractive tool in preoperative planning of total joint replacement, fracture fixation, limb deformity repair and pediatric skeletal disorders.

Control of the micromovements of a composite-material nail design: A finite element analysis.

BACKGROUND: Intramedullary nail fixation is the most accepted modality for stabilizing long bone midshaft fractures. The commercially used nails are fabricated from Stainless Steel or Titanium. Composite-materials (CM) mainly carbon-fiber reinforced polymers (CFRP) have been gaining more interest and popularity due to their properties, such as modulus of elasticity close to that of bone, increased fatigue strength, and radio-opacity to irradiation that permits a better visualization of the healing process. The use of CFRP instead of metals allows better control of different directional movements along a fracture site. The purpose of this analysis was to design a CM intramedullary nail to enable micromovements as depicted on a finite element analysis method. METHODS: We designed a three-dimentional femoral nail model. Three CFRP with different laminates arrangements, were included in the analysis. The finite element analysis involved applying vertical and horizontal loads on each of the designed and tested nails. RESULTS: The nails permitted a transverse micromovement of 0.75mm for the 45° lay-up and 1.5mm for the 90° lay-up for the CM, 1.38mm for the Titanium and 0.74mm for the Stainless Steel nails. The recorded axial movements were 0.53mm for the 45° lay-up, 0.87mm for the 90° lay-up, 0.46mm for the unsymmetrical lay-up CM, 0.046 for the Titanium and 0.02 for the Stainless Steel nails. Overall, the simulations showed that nail transverse micromovements can be reduced by using 45° carbon fiber orientations. Similar results were observed with each metal nails. INTERPRETATION: We found that nail micromovements can be controlled by changing the directional stiffness using different lay-up orientations. These results can be useful for predicting nail micromovements under specified loading conditions which are crucial for stimulating callus formation in the early stages of healing.

Dynamic locking plate vs. simple cannulated screws for nondisplaced intracapsular hip fracture: A comparative study.

INTRODUCTION: Intracapsular hip fractures (ICHF) are a common cause of morbidity and mortality and pose a great economic burden on the health care systems. Appropriate surgical treatment requires balancing optimal outcomes with the cost of treatment to the health care system. While in elderly patients with displaced ICHF arthroplasty became the standard of care, the internal fixation method for conserving the femoral head in younger patients or in nondisplaced ICHF is still in debate. We compared a dynamic locking plate with the standard cancellous cannulated screws (CCS) for treatment of nondisplaced ICHF. METHODS: All patients treated with internal fixation for nondisplaced ICHF between July 2009 and December 2012 at our level one trauma center were included in this study. Patients treated with Targon FN (Aesculap) implants and CCS (Synthes) were compared. Charts were reviewed for demographics, intraoperative data and peri/post operative complications retrospectively. Radiographical analysis, pain (VAS), quality of life (SF12) and function (MHHS) data were prospectively gathered. RESULTS: One hundred and fifteen non-displaced ICHFs were treated with internal fixation, 81 with CCS and 34 with Targon FN implant; the mean follow-up was 19 and 28 months, respectively. Group fracture characteristics (Garden/Powel classification), and demographics, excluding age, were not significantly different. Post-operative revision rates of the Targon FN and CCS groups, perioperative complications were not statistically different (p>0.05). Quality of life (SF-12), function (Modified Harris Hip Score) and Visual Analogue Scale (VAS) pain scores were not statistical different. CONCLUSIONS: Complication rates and clinical outcomes for the treatment of nondisplaced ICHF with Targon FN and SCC showed no significant differences. Based on this evidence in consideration of the substantial cost differential between the Targon FN and SCC we suggest SCC for treatment of nondisplaced ICHF. LEVEL OF EVIDENCE: III.

Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy.

PURPOSE: Partial patellectomy (PP) and reattachment of the patellar ligament with transosseous suturing is the mainstay of surgical treatment for distal pole patellar fractures. An anchor suturing (AS) technique has recently been reported as an alternative to PP in such fractures and allows for bone-to-bone interface and possibly superior fracture healing than bone-to-tendon interface with PP. We present our experience with AS and compare it to PP. METHODS: Between 2006 and 2011, 60 patients with distal pole patellar fracture underwent either AS (n = 27) or PP (n = 33). We retrospectively gathered their demographic data and information on fracture type, fixation technique, operation time, postoperative complications and knee range of motion. A telephone survey was performed to grade functional outcomes with standard questionnaires (the SF-12 for quality of life, the Kujala score for patellofemoral function and a visual analog scale [VAS] pain score). RESULTS: AS was equivalent to PP in terms of residual pain and functional outcomes (VAS: 2.45 vs. 2.26, p = 0.83 and Kujala score: 74.3 vs. 69, p = 0.351, respectively) as well as for knee range of motion. Complications included three cases of infection in each group, two cases of early hardware failure and one case of non-union in the AS group. Operation time was significantly shorter for AS compared to PP (68.5 vs. 79.1 min, p = 0.03). CONCLUSIONS: AS is non-inferior to PP for function and pain after distal pole patellar fractures and is superior to PP with regard to operative time. Common complications of this technique are hardware failure and infections. LEVEL OF EVIDENCE: Therapeutic Level III.

Gait characteristics and quality of life perception of patients following tibial plateau fracture.

INTRODUCTION: The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls. MATERIALS AND METHODS: Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life. RESULTS: Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18% compared to the control group (p < 0.001), had slower cadence by 8% compared (p = 0.002) to the control group and had shorter step length in the involved leg by 11% and in the uninvolved leg by 12% compared to the control group (p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12% compared to the uninvolved leg and 5% in the uninvolved leg compared to the control group (p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65% lower compared to healthy controls (p < 0.001), and Mental Health Score of the patients was 40% lower compared to healthy controls (p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns. CONCLUSION: Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as self-reported quality of life.