ORIF of an intertrochanteric fracture proximal to an above-knee amputation using two AO femoral distractors.

We present the case of a patient who sustained a displaced intertrochanteric fracture proximal to an above-the-knee amputation. Reduction was obtained using 2 AO femoral distractors placed anteriorly and laterally, spanning the hip joint. Fracture fixation was achieved using a sliding hip screw and side plate. Intertrochanteric fractures proximal to an above-the-knee amputation are challenging to manage because of the difficulty in obtaining sufficient skin traction on the stump to effect reduction. Using two femoral distractors anteriorly and laterally can help obtain length and alignment in these difficult cases.

Simultaneous Displaced Anterior and Posterior Cruciate Ligament Avulsion Fractures After Fall From a Bicycle: A Case Report.

CASE: We present the case of a 31-year-old man who sustained simultaneous displaced anterior and posterior cruciate ligament (PCL) tibial avulsion fractures after falling from a bicycle. CONCLUSION: Combined avulsion fractures of the anterior and PCLs is an extremely unusual event and has rarely been reported. The displaced fragments pulled proximally by their respective cruciate ligaments required open reduction and internal fixation to prevent impingement and instability. The patient had excellent clinical and radiographic results after open reduction internal fixation of both fractures.

Current Methods for the Evaluation and Surgical Treatment of Periprosthetic Femur Fractures Complicating Hip Arthroplasty.

Over the next decade, orthopedic surgeons will encounter an increasing number of periprosthetic fractures of the femur after hip arthroplasty. This rise is directly related to the increasing numbers of primary and revision hip arthroplasties being performed and the aging of the population. The Vancouver classification is the most widely used classification system for periprosthetic fractures of the femur occurring after hip arthroplasty. This classification considers the location of the fracture in relation to the femoral stem, the stability of the femoral stem, and the availability of femoral bone stock for revision. Most Vancouver AG and AL fractures can be treated nonsurgically, the exceptions being fractures associated with osteolysis and clamshell fractures of the lesser trochanter. B and C type fractures usually require operative intervention. Both Vancouver B1 and C types can be treated with fracture fixation alone, as the femoral implant is stable. Vancouver types B2 and B3 require femoral revision as the implant is loose. Distinguishing between types B1 and B2 can be difficult from radiographs alone and may require computed tomography and intraoperative testing.

Pectoralis Major Muscle Belly Repair in a Young Male Adult: A Case Report.

CASE: A 29-year-old man sustained a near-complete laceration to the left pectoralis major muscle belly. The muscle and epimysium were repaired using the Kragh technique-a combination of running interlocked and Mason-Allen stitches. At the 6-year follow-up, the patient had an excellent outcome as measured by clinical scores (Short Form Survey-36, Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons Score), bench press, cosmesis, and magnetic resonance imaging. CONCLUSIONS: Acute traumatic open pectoralis muscle belly tears may be successfully repaired in select patients using the Kragh technique with excellent postoperative function and cosmesis.

Risk of malnutrition in orthopedic trauma patients with surgical site infections is associated with increased morbidity and mortality - a 3-year follow-up study.

BACKGROUND: Malnutrition is a worldwide problem which can result in prolonged hospitalization from complications such as poor wound healing and increased morbidity. There is increasing evidence of the effect of risk of malnutrition (ROM) on outcomes in orthopedic surgical patients. However, there is little data on the effect of nutritional status on clinical outcomes in orthopedic trauma patients with surgical site infections (SSI). Therefore, our aim was to investigate how malnutrition risk affects clinical outcomes in a prospective cohort of orthopedic trauma patients with SSI. METHODS: The study included 345 patients who underwent surgery due to SSI at a level 1 trauma center. All patients were evaluated on their nutritional status as assessed by the Nutritional Risk Screening in 2014/15 and 2017/18. 238 (69.0%) datasets were available for the follow-up analysis. Twenty patients (8.4%) had died, resulting in 218 patients. Outcomes investigated included comorbidities, medication intake, destination of discharge, degree of mobility, support for procuring food, mortality risk and quality of life. RESULTS: 32.8% were at risk of malnutrition (ROM) at EXAM1. Female patients had a higher ROM than males (p < 0.05). Patients with ROM had more comorbidities (p < 0.001), an increased need for medication intake (p < 0.001), a decreased level of mobility (p < 0.001) and increased need of support in procuring food (p < 0.001). The destination of discharge was independent of the nutritional status (p = 0.641). Twenty (8.4%) of the available 238 patients had died during follow-up time period, resulting in a 6.2-times higher risk of mortality in patients with ROM. EQ-5D revealed that mobility, self-supply and usual activities of daily living were increased in well-nourished patients (p < 0.001). CONCLUSION: ROM in orthopedic trauma patients with SSI is associated with an increased number of comorbidities and need for medication intake, a decrease in mobility and a higher dependency for food acquisition. Patients at ROM exhibited a 6.2-times higher mortality rate than well-nourished patients. EQ-5D evaluation showed better mobility, self-supply, and activity of daily living in well-nourished patients. We therefore strongly recommend supplementing patients with ROM with a specific diet during and after discharge from the hospital in order to reduce postoperative complications and long-term mortality.

Hemiarthroplasty for Femoral Neck Fractures in the Elderly: A Comparison of Cemented and Uncemented Femoral Stems.

The incidence of displaced femoral neck fractures among elderly patients is increasing as the population ages.Historically, the preferred treatment for displaced femoral neck fractures in elderly patients has been hemiarthroplasty with use of cemented fixation of the implant. However, there is evidence that this technique may be associated with fat embolization and subsequent cardiopulmonary arrest in the early postoperative period. Cementing techniques are also associated with increased operative time when compared with cementless techniques.There is increasing evidence that, among elderly patients, the use of uncemented hemiarthroplasty has equivalent functional outcomes and overall mortality rates when compared with the use of hemiarthroplasty with cemented fixation. The main complication associated with uncemented hemiarthroplasty is intraoperative periprosthetic fracture.

Acetabular Fracture Resulting from a Basketball Cutting Movement in a Young Adult Male: A Case Report.

CASE: We present the case of a 26-year-old man who sustained a right transverse-posterior wall acetabular fracture while performing a cutting movement playing basketball. CONCLUSIONS: Acetabular fracture after a relatively low-energy injury in a healthy young adult male is an extremely unusual event. The cutting movement to the right likely forcefully placed the right hip in flexion, adduction, and internal rotation directing the femoral head into the posterior wall. The patient had excellent clinical and radiographic results after acetabular open reduction and internal fixation.

Gastrointestinal stromal tumors: a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. Most GISTs present asymptomatically. They are best identified by computed tomography (CT) scan and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. There have been many risk stratification classifications systems which are calculated based on tumor size, mitotic rate, location, and perforation. The approaches to treating GISTs are to resect primary low-risk tumors, resect high-risk primary or metastatic tumors with imatinib 400 mg daily for 12 months, or if the tumor is unresectable, neoadjuvant imatinib 400 mg daily followed by surgical resection is recommended. Sunitinib is required for KIT exon 9, 13, and 14 mutations, while ponatinib is used for exon 17 mutations and regorafenib for highly refractory tumors. High-risk tumors should be monitored for recurrence with serial abdominal CT scans. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. This report addresses the epidemiology, clinical presentation, diagnostic imaging, histologic diagnosis, classification and risk stratification, staging and grading, surgical treatment, adjuvant treatment, and metastasis of GISTs.

Combined Ipsilateral Humeral Shaft and Galeazzi Fractures Creating a Floating Elbow Variant.

"Floating elbow" injuries of the arm traditionally represent a combination of humeral shaft and forearm fractures which require anatomic rigid open reduction and internal fixation of all fractures to allow for early range of motion exercises of the elbow. There are published variants of the floating elbow injury which include ipsilateral diaphyseal humeral fracture, proximal ulna fracture with proximal radioulnar joint disruption, and ipsilateral diaphyseal humeral fracture with elbow dislocation and both bones forearm fracture. We present the case of a 21-year-old woman whose left arm became caught between the side of a waterslide and adjacent rocks at a park. She sustained a torsional and axial loading injury to her left upper extremity resulting in ipsilateral humeral shaft and Galeazzi fractures. The combination of ipsilateral humeral shaft and Galeazzi fractures resulted in a rare floating elbow variant. Prompt open reduction and internal fixation of both fractures and early range of motion of the elbow and wrist resulted in an excellent clinical and radiographic result. Floating elbow injuries and their variants should be promptly recognized as early anatomic reduction, and rigid internal fixation can allow for good elbow function with minimization of stiffness.

Fracture of the Neck of a Lateral Flare Femoral Implant in Total Hip Arthroplasty.

We present the case of a 38-year-old man who presented 7 years after primary total hip replacement with a fracture of the neck of a lateral flare femoral stem and catastrophic polyethylene wear. The unique design of the lateral flare hip stem has been shown previously to be associated with accelerated polyethylene wear, whereas the stem remains well fixed. The resultant polyethylene wear results in the harder cobalt chrome head abrading the titanium shell generating metallic debris. This may have resulted in proximal migration of the implant neck into the cup with subsequent neck-cup impingement and implant fracture.

Knee Osteoarthritis with Chronic Quadriceps Tendon Rupture Treated with Total Knee Arthroplasty and Extensor Mechanism Allograft Reconstruction: A Case Report.

CASE: A 51-year-old male construction worker with a history of chronic quadriceps tendon rupture presented with no active knee extension and tricompartmental knee osteoarthritis. He underwent simultaneous total knee arthroplasty and extensor mechanism allograft reconstruction. At 4 years postoperatively, the patient had pain-free knee function and active extension. CONCLUSION: The combination of a chronic quadriceps tendon rupture with lack of active knee extension and knee osteoarthritis is a rare and challenging problem. To our knowledge, this combined diagnosis and the treatment described in this case report have not been reported previously in the literature.

Use of the Pelvic C-Clamp to Mitigate Acute Respiratory Distress Syndrome in a Patient with an Unstable Sacral Fracture.

CASE: We present the case of a 21-year-old man who fell from a roof, sustaining a displaced sacral fracture with pelvic instability. He developed acute respiratory distress syndrome (ARDS) within 24 hours of injury. Placement of the pelvic C-clamp resulted in rapid resolution of pulmonary dysfunction, allowing for definitive internal fixation. CONCLUSION: The C-clamp is most commonly used to control hemorrhage in unstable posterior pelvic ring injuries. Our case demonstrates a rare use of the C-clamp to stabilize the posterior pelvis in a patient with an unstable sacral fracture and ARDS, to rapidly improve pulmonary function prior to definitive surgery.

Surgical management of metastatic disease of the proximal part of the femur.

➤ Pathologic fracture of the proximal part of the femur resulting from metastatic disease causes severe pain and an inability to walk. Surgical stabilization can be challenging because of bone loss resulting from the underlying metastatic lesions, the potential for major blood loss, and the poor health of the patient.➤ The goal of surgical treatment is the creation of a stable construct to allow early weight-bearing.➤ Pathologic femoral neck fractures secondary to metastases are best managed with arthroplasty.➤ The treatment of intertrochanteric or subtrochanteric fractures is more controversial. Surgical stabilization may be performed with cephalomedullary nailing or arthroplasty. The choice of implant and operative technique is dependent on careful consideration of multiple factors, including the patient's life span, the type of tumor, the perceived response to other therapies, the need for adjuvant radiation therapy and chemotherapy, the location and number of metastatic lesions, and the degree of bone involvement.➤ While the potential for complications is high, surgical stabilization of the proximal part of the femur decreases pain and improves function.

The axial transsacral approach to interbody fusion at L5-S1.

Lumbosacral interbody fusion may be indicated to treat degenerative disc disease at L5-S1, instability or spondylolisthesis at that level, and severe neural foraminal stenosis resulting from loss of disc space height. In addition, L5-S1 interbody fusion may provide anterior support to a long posterior fusion construct and help offset the stresses experienced by the distal-most screws. There are 3 well-established techniques for L5-S1 interbody fusion: anterior lumbar interbody fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. Each of these has advantages and pitfalls. A more recently described axial transsacral technique, utilizing the presacral corridor, may represent a minimally invasive approach to obtaining lumbosacral interbody arthrodesis. Biomechanical studies demonstrate that the stiffness of the axial rod is comparable to existing fixation devices, suggesting that, biomechanically, it may be a good implant for obtaining lumbosacral interbody fusion. Clinical studies have demonstrated good early results with the use of the axial transsacral approach in obtaining lumbosacral interbody fusion for degenerative disc disease, spondylolisthesis, and below long posterior fusion constructs. The technique is exacting and complications can be major, including rectal perforation and fistula, loss of correction, and pseudarthrosis.