The effect of coronal plane angulation on patient reported outcome measures of operatively treated distal femur fractures: A multi-center prospective evaluation.

OBJECTIVES: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures. DESIGN: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs. RESULTS: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time. CONCLUSIONS: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury.

Reply to Response to Vacuous standards - Subversion of the OSAC standards-development process.

This Letter to the Editor is a reply to Mohammed et al. (2021) https://doi.org/10.1016/j.fsisyn.2021.100145, which in turn is a response to Morrison et al. (2020) "Vacuous standards - subversion of the OSAC standards-development process" https://doi.org/10.1016/j.fsisyn.2020.06.005.

A comment on the PCAST report: Skip the "match"/"non-match" stage.

This letter comments on the report "Forensic science in criminal courts: Ensuring scientific validity of feature-comparison methods" recently released by the President's Council of Advisors on Science and Technology (PCAST). The report advocates a procedure for evaluation of forensic evidence that is a two-stage procedure in which the first stage is "match"/"non-match" and the second stage is empirical assessment of sensitivity (correct acceptance) and false alarm (false acceptance) rates. Almost always, quantitative data from feature-comparison methods are continuously-valued and have within-source variability. We explain why a two-stage procedure is not appropriate for this type of data, and recommend use of statistical procedures which are appropriate.

Effect of flurbiprofen on hind-limb suspension-induced bone loss.

BACKGROUND: Prostaglandins, specifically prostaglandin E2 (PGE2), may be involved in the bone loss that occurs in microgravity. Flurbiprofen (FBP), a nonsteroidal anti-inflammatory drug (NSAID), has been shown to increase periosteal apposition rate in rats, and may inhibit bone loss by decreasing PGE2 concentrations. METHODS: A hind-limb suspension (HLS) technique was used to determine if FBP could attenuate the bone demineralization that occurs with decreased load-bearing activity. Rats were assigned to either the HLS group or the ground-based (control) group. Both of these groups were then divided into drug-treated and control subgroups (n = 10). Rats in the drug group received FBP 2 mg x kg(-1) x d(-1) subcutaneously. Study data were collected at 2 and 4 wk. The left femur of each animal was used for densitometry, and the right tibia was processed for histomorphometry. Mechanical properties of the left femur were assessed by three-point bending. RESULTS: After 2 wk, the FBP-treated rats in both the HLS and ground-based groups had 6% less bone mineral density (BMD) than did controls (p < 0.05). FBP was not effective in protecting bone from the early stages of disuse osteopenia. At 4 wk, BMD in the ground-based group was not significantly different between control and drug animals. However, in the HLS group, BMD was 11% greater in the FBP-treated group than in the control group (p < 0.05). FBP did not significantly affect the mechanical properties of bone at either 2 or 4 wk. CONCLUSION: FBP may not only affect bone demineralization by interacting with existing osteoclasts, but may also interfere with the signaling, activation, and recruitment of osteoclasts that occur after skeletal unloading.

Prospective comparison of retrograde and antegrade femoral intramedullary nailing.

OBJECTIVE: To prospectively compare the results, function, and complications of antegrade and retrograde femoral nailing for femoral shaft fractures. DESIGN: Prospective, randomized. SETTING: Urban Level 1 trauma center. PATIENTS: One hundred consecutive femoral shaft fractures. Fifty-four nails inserted retrograde and forty-six inserted antegrade. INTERVENTION: Ten-millimeter antegrade or retrograde nail inserted for a femoral shaft fracture after reaming. OUTCOME MEASUREMENTS: A comparison of the outcomes after antegrade and retrograde nailing of the femur. Data were collected for analysis on comminution, set-up and starting point times, open grade, location of fracture, injury severity score, body mass index, time to union, knee pain and motion, hip and thigh pain, and nail to intramedullary canal diameter difference. A linear regression model was employed. RESULTS: Knee motion was 120 degrees in all but one knee in each group. The antegrade nailed femurs healed faster than those treated retrograde (A = 14.4, R = 18.1 weeks, p = 0.0496). More patients required dynamization for union in the retrograde insertion group (17 percent versus 5 percent, p = 0.10, NS). In a linear regression model, a nail-to-canal-diameter difference and retrograde nailing had an association with an increased time to union. Knee pain was equal in both groups; however, thigh pain was higher in the antegrade group (p = 0.0108). All of the antegrade nailed femurs healed (100 percent), and 98 percent (one nonunion) of the retrograde femurs healed after secondary procedures. CONCLUSIONS: Both antegrade and retrograde nailing yielded high union rates. Each insertion technique has its own advantages and disadvantages. The two insertion modes appear to be relatively equal for the treatment of femoral shaft fractures.

Retrograde nailing for subtrochanteric femur fractures.

This study reviews the results of subtrochanteric femur fractures treated with a retrograde nail at a level 1 trauma center. Sixteen patients with 17 fractures were followed up until union. The average Injury Severity Score (ISS) was 19, and average knee range of motion was 127 degrees. Four patients required dynamization of their nail, and three healed over a prolonged period of time. Two patients required exchange nailing: one after failure of union after dynamization and one with a broken nail that was revised to an antegrade nailing. The average varus deformity was 5.06 degrees and only 35% of fractures healed in greater than 5 degrees of varus, with an average time to union of 22.4 weeks (range, 6-54 weeks). Antegrade nailing remains the treatment of choice for the vast majority of subtrochanteric femur fractures. However, retrograde femoral nailing may be an effective treatment option for some subtrochanteric fractures in a selected group of patients.

Treatment of floating knee injuries through a single percutaneous approach.

The current study is a review of 20 patients treated by percutaneous stabilization for a floating knee. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. The average Injury Severity Score was 19. Two patients died in the early postoperative period and one patient was lost to followup. The average time to union for the 17 remaining patients with femoral shaft fractures was 14.7 weeks. One patient required dynamization. Four of the 17 patients with tibia fractures required an exchange nailing procedure, one with bone graft, to achieve union. One patient required dynamization and one patient with bone loss required only a bone graft. The average time to union for the tibia fractures was 23 weeks. One patient achieved 115 degrees knee flexion and the remaining 15 patients had full knee motion by 12 weeks, which they were able to maintain. No patient had signs or symptoms of knee pain. This demanding surgical technique using a small incision has yielded good clinical results. Although it is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the mortality and tibial fracture complication rates remain high.

Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation.

OBJECTIVE: To determine the patellofemoral contact areas as well as mean and maximal pressures after retrograde intramedullary nailing in a cadaveric model. STUDY DESIGN: Pressure-sensitive film was used to analyze patellofemoral joint pressures after insertion of a retrograde femoral nail in a cadaveric specimen. METHODS: A retrograde femoral nail was inserted into seven cadaveric knees. Pressure-sensitive film was placed into the patellofemoral joint and physiologic loads (700 newtons) were applied to the knee joint at 90 degrees and 120 degrees of flexion. Testing was performed with the nail three millimeters deep to the cartilage (In), flush with the cartilage (Flush), and one millimeter prominent (Out). The intact knee served as the Control. RESULTS: The mean contact areas showed no statistical differences among the four groups. There was a significant increase in mean pressure at 120 degrees and maximum pressure at 90 degrees and 120 degrees for the Out group when compared with the Control, In, and Flush groups (p < 0.001). CONCLUSIONS: There were no significant differences in mean contact pressure, contact area, or maximum pressure among the Control, three-millimeter insertion depth, or flush insertion groups. There was, however, a significant increase in mean and maximum pressures with the nail one millimeter prominent. These results indicate that placement of a retrograde femoral intramedullary nail is critical, but that proper placement should not significantly influence the biomechanics of the patellofemoral joint.

Office removal of tibial external fixators: an evaluation of cost savings and patient satisfaction.

OBJECTIVES: To evaluate the efficacy and patient satisfaction of office removal of tibial external fixators and to compare the cost of this procedure with the cost of removal of fixators in the operating room. DESIGN: A visual analog scale (VAS) and a questionnaire were answered by all patients after office external fixator removal. The treatment, complications, and costs were compared with those of patients having external fixator removal in the operating suite. SETTING: An urban orthopaedic trauma office with a Level I trauma center. PARTICIPANTS: Two similar groups of patients; thirty fixators removed in the office and twenty-nine fixators removed in the operating room. INTERVENTION: Office or operating room removal of tibial external fixators and application of a sterile dressing. A visual analog scale was answered by those patients who had office removal. MAIN OUTCOME MEASUREMENTS: Patient satisfaction and pain rating (VAS) with office removal of external fixators. Comparison of costs, infections, time in fixator, and surgical interventions between the office and operating room groups. RESULTS: Group I had thirty fixators (twenty-nine half-pin fixators) removed in the office. Group II had twenty-nine fixators removed in the operating room. Duration of time in the frame was not statistically different. Antibiotic usage during the fixator treatment period was 69 percent in both groups. On the visual analog scale, twenty-four members (80 percent) of the office fixator removal group rated the pain during removal as less than 25 percent of maximal, including nine (30 percent) who rated the removal as causing no pain. Cost analysis revealed an average cost of $248 for the office group versus $2,160 for the operating room group (p < 0.001). CONCLUSIONS: Due to the cost savings and patient satisfaction, without compromising clinical care, the office is our preferred location for tibial half-pin external fixator removal.

Retrograde intramedullary nailing of femoral diaphyseal fractures.

OBJECTIVES: To prospectively evaluate the results of retrograde intramedullary nailing of femoral shaft fractures. DESIGN: Prospective, consecutive series. PATIENTS AND SETTING: All patients with a femoral shaft fracture admitted at an urban Level 1 trauma center from December 1995 to December 1996 were treated with a retrograde femoral intramedullary nail. INTERVENTION: Retrograde femoral intramedullary nailing was performed on a radiolucent operating room table. Through a three-centimeter medial parapatellar incision, a reamed ten-millimeter retrograde nail was inserted. METHODS: From the time of injury until union, the following parameters were assessed: operative time, blood loss, extent of comminution, open grade, associated injuries, Injury Severity Score, body mass index, time to union, secondary procedures, range of motion in the knee. and complications. RESULTS: Fifty-seven patients with sixty-one fractures were available for follow-up, which averaged 43.1 weeks. Fifty-two percent of fractures demonstrated Winquist Type 3 or 4 comminution. Twenty-six percent of the fractures were open. Fifty-two fractures healed after the initial nailing, five of seven dynamized nails healed, and one patient with bone loss requiring bone graft united yielding a final union rate of 95 percent. Of the three nonunions (5 percent), two healed with exchange nailing and one remains asymptomatic at seventy-one weeks. One patient developed a late septic knee that resolved with treatment. Excellent range of motion in the knee was obtained by those patients who did not have other ipsilateral limb injuries. CONCLUSIONS: This consecutive series had a 95 percent union rate after nailing and dynamization as necessary. No knee problems were associated with the retrograde femoral intramedullary nailing technique. The one septic knee raises concerns about the use of retrograde nailing in severe open femoral shaft fractures. Retrograde femoral nailing should be given serious consideration as an alternative to antegrade femoral nailing.

A calcaneal fracture with extrusion of the posterior facet.

This is a case report of a 19-year-old woman who sustained multiple fractures including a right calcaneal fracture with extrusion of the posterior facet. The medial soft-tissue injury led to a full thickness skin loss. Despite loss of subtalar motion and decreased toe movement, she is satisfied with her result. The importance of the soft-tissue injuries, especially to the skin and tendons, associated with severely displaced calcaneal fracture dislocations is emphasized by this case report.

A greater trochanteric insertion site for femoral intramedullary nailing in lipomatous patients.

This is a review of the treatment of 12 femoral shaft fractures and three nonunions in lipomatous patients who had a greater trochanteric insertion point for intra medullary nailing. Indications included overweight patients and trochanteric lipodystrophy. Combined with a small proximal extension of the incision, maximal limb adduction, and a slotted intramedullary nail, the greater trochanteric insertion point was effective, and no complications directly related to this procedure were encountered.

Posterior plating of displaced Weber B fibula fractures.

This is a prospective study that examines 32 patients who were treated with posterior plating of a displaced Weber B fibula fracture and had a minimum of 1 year follow-up. The surgical technique included application of an unbent one-third tubular plate to the posterior aspect of the fibula using the antiglide technique. Twenty-seven fractures were classified as supination-eversion IV: 13 with deltoid disruption and 14 with a medial malleolar fracture. Three were classified as pronation-abduction and two as low pronation-eversion fractures at the level of the plafond. A six-hole plate was used most often (18 cases), and 23 patients had a lag screw placed through the plate. There were no nonunions or malunions. No wound complications, screw loosening, loss of fixation, intraarticular screws, or palpable screws were found. Four patients had transient peroneal tendinitis that resolved in 4-8 weeks. Two patients had later plate removal caused by poor technique because of a symptomatic lag screw. Twenty of the 21 patients who returned a questionnaire were satisfied with their result (95%). Posterior fibular plating offers many advantages over lateral plating, including the possibility of no intraarticular or palpable screws and an improved and stronger distal fixation construct. Our favorable results suggest that this technique should be given consideration as a treatment of choice for displaced Weber B fibula fractures.

The surgical anatomy of the radial nerve around the humerus.

Twenty-four cadaveric arms were dissected to determine the position of the radial nerve on the posterior aspect of the humerus relative to the posterior tip of the acromion, the medial and lateral epicondyles, the division between the lateral and long heads of the triceps, and the triceps aponeurosis. The radial nerve passed anterior to the long head of triceps and cross onto the posterior shaft of the humerus an average of 124 mm below the posterior tip of the acromion. It was never closer than 97 mm. The nerve usually lies on the medial head of the triceps as it courses posteriorly around the humerus and then leaves the posterior shaft of the humerus an average of 126 mm above the lateral epicondyle and 131 mm above the medial epicondyle. It was never within 100 mm of either epicondyle. The surgeon can use these landmarks as guidelines to avoid the radial nerve during operative intervention on the humerus.

A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis.

To determine the normal anatomic radiographic land-marks of the ankle syndesmosis, standardized anterior-posterior radiographs of the right ankle were performed on 40 male and 40 female volunteers. The average tibiofibular clear space was 3.8 mm in females, 4.6 mm in males, and 4.2 mm overall. The tibiofibular overlap measured 6.0 mm in females, 9.6 mm in males, and 7.8 mm overall. Due to this variability and the gender differences, we investigated the anatomy of the syndesmosis as ratios of the potentially variable values to fixed landmarks. The ratio of the tibiofibular overlap to the fibular width averaged 54% and the ratio of the tibiofibular clear space to the fibular width averaged 30%, with no statistically significant difference due to gender. Our data show that for 90% prediction intervals, the values are: (1) tibiofibular clear space less than 5.2 mm in women and 6.5 mm in men; (2) tibiofibular overlap of greater than 2.1 mm in females and 5.7 mm in males; (3) tibiofibular overlap:fibular width ratio greater than 24%; (4) tibiofibular clear space:fibular width ratio less than 44%. Additionally, using a linear regression model, a prediction of the tibiofibular overlap can be made when using the distance (in millimeters) from the incisura fibularis to the lateral tibial (LT) border: tibiofibular overlap = 0.862 x lateral tibia - 2.62 (P = .0001). Utilization of these values will help in the determination of posttraumatic disruption of the syndesmosis and postoperative assessment of mortise reduction.