Comparison of modern locked plating and antiglide plating for fixation of osteoporotic distal fibular fractures.

BACKGROUND: Fractures in osteoporotic patients can be difficult to treat because of poor bone quality and inability to gain screw purchase. The purpose of this study is to compare modern lateral periarticular distal fibula locked plating to antiglide plating in the setting of an osteoporotic, unstable distal fibula fracture. METHODS: AO/OTA 44-B2 distal fibula fractures were created in sixteen paired fresh frozen cadaveric ankles and fixed with a lateral locking plate and an independent lag screw or an antiglide plate with a lag screw through the plate. The specimens underwent stiffness, cyclic loading, and load to failure testing. The energy absorbed until failure, torque to failure, construct stiffness, angle at failure, and energy at failure was recorded. RESULTS: The lateral locking construct had a higher torque to failure (p=0.02) and construct stiffness (p=0.04). The locking construct showed a trend toward increased angle at failure, but did not reach statistical significance (p=0.07). Seven of the eight lateral locking plate specimens failed through the distal locking screws, while the antiglide plating construct failed with pullout of the distal screws and displacement of the fracture in six of the eight specimens. CONCLUSION: In our study, the newly designed distal fibula periarticular locking plate with increased distal fixation is biomechanically stronger than a non-locking one third tubular plate applied in antiglide fashion for the treatment of AO/OTA 44-B2 osteoporotic distal fibula fractures. LEVEL OF EVIDENCE: V: This is an ex-vivo study performed on cadavers and is not a study performed on live patients. Therefore, this is considered Level V evidence.

A treatment algorithm for primary patellar dislocations.

CONTEXT: Primary patellar dislocation continues to be a common problem facing clinicians today. These injuries are associated with significant morbidity and a substantial recurrence rate. Myriad operative and nonoperative options have been described to treat these injuries, although the evidence-based literature is sparse. EVIDENCE ACQUISITION: PubMed was searched from 1970-2010 to identify publications on patellar dislocations, including clinical presentation, natural history, radiographic workup, and treatment. RESULTS: The initial workup of a patella dislocation includes a history, physical examination, and radiographs. If there is evidence of a displaced osteochondral fragment or hemarthrosis, then magnetic resonance imaging should be obtained. The treatment of first-time patella dislocators has been controversial, and no study has demonstrated a clear benefit to early operative intervention. CONCLUSION: First-time patellar dislocations should be treated conservatively unless there is evidence of a displaced osteochondral fragment.

A retrospective analysis of locally advanced esophageal cancer patients treated with neoadjuvant chemoradiation therapy followed by surgery or surgery alone.

BACKGROUND: We conducted an institutional review of patients with locally advanced esophageal cancer who had complete pretreatment and surgical staging to identify variables predictive of outcome. METHODS: From 1993 through 2002, 286 patients presented for surgical therapy of esophageal cancer. Of these, 176 patients met criteria for review including pretreatment endoscopic ultrasound stages IIA through IVA and a transthoracic surgical approach with "two-field" lymph node dissection. This cohort was primarily male (84.7%, n = 149) with adenocarcinoma (88.6%, n = 156), and 101 patients (57.3%) demonstrated endoscopic ultrasound stage III or IVA. RESULTS: Eighty-five (48.3%) patients presented to surgery after receiving neoadjuvant chemoradiation therapy, and 91 (51.7%) underwent surgery alone. Both groups were well matched with respect to comorbidities and pretreatment stage. Patients receiving neoadjuvant chemoradiation demonstrated a nonsignificant trend toward increased operative mortality and nonfatal morbidity. The overall median survival was 16.8 months, and there was no survival difference comparing patients treated with neoadjuvant chemoradiation followed by surgery or surgery alone (p = 0.82). The subset of 25 patients (29.4%) demonstrating a complete pathologic response after neoadjuvant chemoradiation therapy however had superior survival (median survival = 57.6 months, p < 0.01) as compared with neoadjuvant chemoradiation patients demonstrating partial downstaging (n = 36, 42.3%), no downstaging (n = 24, 28.2%), and surgery alone patients. Multivariate analysis identified a complete pathologic response, endoscopic ultrasound stage, and number of pathologically positive lymph nodes as independent predictors of survival. CONCLUSIONS: These data support the use of neoadjuvant chemoradiation for locally advanced esophageal cancer as the subset of patients who demonstrate a complete pathologic response experienced significantly better survival.