Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

Background: Treatment of scaphoid fractures often requires bone grafting. In such cases, bone graft is traditionally harvested from the iliac crest, but utilizing the distal radius carries less morbidity and is becoming more popular. The purpose of this study is to compare the outcomes of treatment of scaphoid waist fractures with the use of distal radius and iliac crest bone grafts. Methods: A retrospective chart review of patients undergoing repair of a scaphoid waist fracture with bone graft at our institution between 2010 and 2020 was completed. Bone graft was used in patients with nonunion, humpback deformity, or for correction of scaphoid alignment. The primary outcome was rate of union as determined by postoperative X-ray or computed tomography scan. Fisher exact tests, Student t tests, and Mann-Whitney U tests were used as appropriate. Results: Thirty-nine patients were included in the study. Twenty-nine patients were treated with distal radius bone graft, and 10 were treated with an iliac crest graft. There was no statistical difference in union rate between the distal radius and iliac crest cohorts (97% vs 80%, P = .16). There was no significant difference for complication rates, rate of unplanned secondary surgery, time to union, postoperative scapholunate angle, or duration of immobilization. Conclusions: In the fixation of scaphoid waist fractures with bone graft, there is no significant difference in union rate between distal radius and iliac crest grafts. With the well-documented morbidity associated with iliac crest grafts, surgeons should consider using distal radius grafts instead of iliac crest grafts.

Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

Background: The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail. Methods: We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded. Results: There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (P>0.05). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (P<0.05). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (P=0.0004). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing (P>0.05). Conclusion: The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.

Evolution of Surgical Management of Metastatic Disease of the Pelvis.

The surgical management of acetabular and pelvic lesions due to metastatic bone disease is complex in nature. These patients are typically in a frail state, having severe pain, limited mobility, and impaired wound healing. This causes a potential for complications, a high concern for the surgeon. Compounding these issues is limited life span for these patients given the advancement of the disease. Considerations for patients undergoing surgical treatment are achievement of significant pain relief and restoration of ambulation, all while having minimal complications during the postoperative period. Management may also include nonsurgical and interventional methods. A multidisciplinary approach is required for the successful treatment of these patients. Although there have been various surgical methods described, there is still no standardized modality that has been noted. These lesions often require complex decision making, imaging, and surgical reconstruction.

Radiographic Scoring of Humeral Shaft Fractures Helps Identify Patients at Risk of Surgery for Delayed Union.

OBJECTIVES: Assessing external validity and clinical relevance of modified radiographic union score (mRUS) to predict delayed union in closed humeral shaft fractures initially treated with conservative management. DESIGN: Retrospective cohort. SETTING: Single urban academic level 1 trauma center. PATIENTS: Patients undergoing initial nonoperative treatment of a humeral shaft fracture with a minimum of 3 months follow-up and at least one set of follow-up orthogonal x-rays within 12-weeks of injury. MAIN OUTCOME MEASUREMENTS: Interobserver and intraobserver reliability of the (mRUS) system for humeral shaft fractures, and establishing an mRUS threshold at 6 and 12 weeks postinjury to predict surgery for delayed union. RESULTS: mRUS demonstrated substantial interobserver agreement on all assessments. Intraobserver agreement was nearly perfect for all reviewers on repeat assessment. mRUS of ≤7 at 6 ± 1 weeks follow-up was associated with surgery for delayed union with an odds ratio of 4.88 (95% CI, 2.52-9.44, P < 0.01), sensitivity of 0.286, and specificity of 0.924. At 12 ± 1 weeks follow-up, the same threshold demonstrated a stronger association with an odds ratio of 14.7 (95% CI, 4.9-44.1, P < 0.01), sensitivity of 0.225, and specificity of 0.981. CONCLUSIONS: The mRUS for humeral shaft fractures is reliable and reproducible providing an objective way to track subtle changes in radiographs over time. An mRUS of ≤7 at 6 or 12 weeks postinjury is highly specific for delayed union. This can be helpful when counseling patients about the risk of nonunion and potential early surgical intervention. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intra-Articular Osteotomy for Genu Valgum in the Knee with a Lateral Compartment Deficiency.

BACKGROUND: A deficiency of the lateral compartment of the knee, often in the setting of skeletal dysplasia, is an intra-articular deformity resulting in genu valgum. Historically, this abnormality has been treated using an extra-articular approach. Lateral hypoplasia of the femoral condyle can be treated with advancement of the lateral femoral condyle without creating a secondary deformity. The purpose of this study was to present the technique and results of lateral condylar advancement, with or without tibial hemiplateau elevation, in patients with intra-articular valgus deformity secondary to skeletal dysplasia. METHODS: A retrospective review of the cases of five patients, from seven to twenty-one years old, with skeletal dysplasia and unilateral or bilateral severe genu valgum deformity was performed. For all patients, the etiology of the deformity was a deficient lateral compartment of the knee-that is, lateral femoral condylar hypoplasia with or without concomitant lateral hemiplateau depression. Lateral femoral condylar advancement with or without lateral tibial hemiplateau elevation was performed in eight knees. RESULTS: The average tibiofemoral angle was 34.7° of valgus preoperatively and improved to 9.4° of valgus at the most recent follow-up. The average length of follow-up was 2.9 years (range, 1.0 to 5.2 years). The average range of motion at the time of final follow-up was an arc of 108° starting from full extension. All osteotomies healed uneventfully. All five patients were satisfied with both the cosmetic appearance and the function of the involved limb and were able to walk without assistive devices. CONCLUSIONS: In patients with a deficient lateral compartment of the knee, lateral femoral condylar advancement with or without hemiplateau elevation allowed correction of severe genu valgum without the creation of an oblique joint line. This technique allows correction of the overall mechanical axis, restoring both function and the cosmetic appearance of the limb. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.