What Is the Likelihood of Union and Frequency of Complications After Parallel Plating and Supplemental Bone Grafting for Resistant Distal Femoral Nonunions?

BACKGROUND: Management of resistant distal femur nonunions is challenging because patients not only have disability from an unhealed fracture, but also often have a shortened femur, stiff knee, deformities, and bone defects to address during revision surgery. Dual plating of the distal femur in such a setting can maintain stability that allows the nonunion to heal while also addressing bone defects and correcting deformities simultaneously. Dual-plating techniques that have been described lack standardization with regard to the size and type of medial-side implants and configuration of the dual-plate construct. QUESTIONS/PURPOSES: (1) What proportion of patients achieve radiologic evidence of union after parallel plating of resistant distal femoral nonunions? (2) What improvements in function are achieved with this approach, as assessed by improvements in femoral length discrepancy, knee flexion, and patient-reported outcome scores? (3) What complications are associated with the technique? METHODS: Between 2017 and 2020, the senior author of this study treated 38 patients with resistant distal femoral nonunions, defined here as nonunions that persisted for more than 12 months since the injury despite a minimum of two previous internal fixation procedures. During the study period, our preferred technique for treating aseptic, resistant distal femoral nonunions was to use dual plates in a parallel configuration augmented with autografts. Of 38 patients, three patients with active signs of infection who underwent resection and reconstruction using bone transport techniques and two patients older than 65 years with deficient distal femur bone stock who underwent endoprosthetic reconstruction were excluded. Of the 33 included patients, 67% (22 of 33) were male. The median age was 40 years (range 20 to 67 years). Nonunion was articular and metaphyseal in 13 patients and metaphyseal only in 20 patients. Our surgical approach was to remove existing implants, perform intraoperative culturing to rule out infection, debride the nonunion, correct the deformity, perform intra-articular and extra-articular lysis of adhesions with quadriceps release, and apply fixation using medial and lateral fixed-angle anatomic locked implants positioned in a parallel configuration. Every attempt to improve length was undertaken, and the defects were filled with autografts. A total of 97% of patients were followed until union occurred (one of 33 was lost to follow-up before union was documented), and 79% (26 of 33) were assessed for functional outcomes at a minimum of 2 years (median 38 months [range 25 to 60 months]) after excluding patients lost to follow-up and those in whom union did not occur after parallel plating. Union was defined as evidence of central trabecular bridging on AP radiographs and posterior cortical bridging on lateral radiographs. These radiologic criteria were defined to overcome difficulties in assessing radiologic healing in patients with lateral and medial plates. With parallel plating, bridging trabecular bone along the posterior cortex on lateral radiographs and the central region on AP radiographs is visualized and can be appreciated and interpreted as evidence of healing in two orthogonal planes. Preoperative and follow-up clinical assessment of knee ROM, the extent of femoral length correction based on calibrated femoral radiographs before and after surgery, and the evaluation of improvement in lower limb function based on the preoperative and follow-up differences in responses to the lower extremity functional scale (LEFS) were studied (the LEFS is scored from 0 to 80, with higher scores representing better function). Complications and secondary surgical procedures to address them were abstracted from a longitudinally maintained trauma database. RESULTS: Sixty-seven percent (22 of 33) of nonunions showed radiologic healing by 24 weeks, and another 24% (eight of 33) healed by 36 weeks. Six percent (two of 33) did not unite, and one patient was lost to follow-up before union was documented. In the 79% (26 of 33) of patients available for final functional outcome assessment, the median femoral shortening had improved from 2.4 cm (range 0 to 4 cm) to 1.1 cm (range 0 to 2.3 cm; p < 0.001), and the median knee ROM had improved from 70° (range 20° to 110°) to 100° (range 50° to 130°; p = 0.002) after surgery. The median LEFS score improved to 63 (range 41 to 78) compared with 22 (range 15 to 33; p < 0.001) before surgery. Serious complications, including major thromboembolic events, iliac graft site infection, knee stiffness (flexion < 60°), and medial plate impingement necessitating removal, were seen in 30% (10 of 33) of patients. Secondary surgical interventions were performed in 24% (eight of 33) of patients to address procedure-related complications. CONCLUSION: Based on our findings, a high likelihood of union and improvements in knee and lower limb function can be expected with parallel plating of resistant distal femur nonunions using anatomic locked plates. However, the increased frequency of complications observed in our study suggests the need for improvements in dual-plating techniques and to explore possible alternative fixation methods through larger multicenter comparative studies. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Helical Blade or the Integrated Lag Screws: A Matched Pair Analysis of 100 Patients With Unstable Trochanteric Fractures.

OBJECTIVES: To compare the radiological and clinical results with PFNA-II and InterTan in the treatment of unstable trochanteric fractures in the elderly. DESIGN: Retrospective, multicenter, matched pair. SETTING: Three tertiary level trauma centers. PATIENTS: Hundred elderly patients who underwent intramedullary stabilization with either the PFNA-II or the InterTan for osteoporotic unstable trochanteric fractures. INTERVENTIONS: Fifty matched pairs consisting of OTA/AO-A2 and A3 fractures were created from a cohort of 290 patients who underwent internal fixation for unstable trochanteric fractures with the PFNA-II or InterTan nails. OUTCOME MEASUREMENTS: Radiological assessment was performed to compare union rates, varus collapse, medial or lateral screw/blade migration, and cut-out. Functional outcome at 1 year was assessed and compared using Harris hip score, Timed Up and Go test, and the mobility score. RESULTS: Union rates, fracture reduction, neck shaft angle, and tip-apex distance were similar in both groups. The PFNA-II group had a significantly higher degree of lateral sliding of the helical blade (P < 0.001). The InterTan group had a better Harris hip score, mobility score, Timed Up and Go test scores, and abductor strength (P < 0.05) at 1 year. The incidence of varus collapse and medial blade migration were higher in the PFNA-II group (P > 0.05). The need for repeat surgery to address surgery-related complications were significantly high in the PFNA-II group (P = 0.045). CONCLUSIONS: The InterTan may provide superior functional outcome and reduced complications than does the Proximal Femur Nail - Antirotation in elderly patients with unstable trochanteric fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A novel MIS technique for posterior cruciate ligament avulsion fractures.

OBJECTIVE: Open surgical approaches to treat tibial avulsion fractures of the posterior cruciate ligament (PCL) often use large incisions involving extensive muscle dissection and retraction. The objective of this study was to describe a new mini-invasive approach targeting the fractured zone, to minimize surgical dissection and improve recovery and rehabilitation. METHODS: The new approach was used in 15 males and seven females with isolated PCL avulsions. The length of the surgical incision, surgical time, need for conversion to open technique, visual analog scores (VAS) and duration of hospital stay were studied to assess the efficacy, learning curve and advantages of the new technique. Neurovascular complications were recorded. At the two-year follow-up, International Knee Documentation Committee (IKDC) scores were recorded to assess function. RESULTS: Patients were followed up for a mean of 29months (range: 34-41). The mean length of the incision was 4.1cm (range: 3.4 to five) measured at the end of the procedure. None of the patients required conversion to an open technique and no neurovascular complications were recorded. The mean surgical time was 40min (range: 25-50). The mean VAS on discharge was 2.2 (range: one to four) and patients stayed at the hospital for a mean of 2.2days (range: one to three). The mean IKDC score at one-year post surgery was 86.4 (range: 83.9-90.8). CONCLUSIONS: The new mini-invasive targeted approach provides adequate exposure for performing internal fixation of PCL avulsion fractures without the surgical morbidity associated with conventional open surgical approaches. The procedure is safe, fast and does not require a long learning curve.

Delayed Total Hip Arthroplasty for Failed Acetabular Fractures: The Influence of Initial Fracture Management on Outcome After Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) provides a successful salvage option for failed acetabular fractures. The complexity of arthroplasty for a failed acetabular fracture will depend on the fracture pattern and the initial management of the fracture. Our objective was to compare the midterm outcome of THA between patients who presented with failed acetabular fractures following initial surgical or nonsurgical treatment. METHODS: Forty-seven patients underwent cementless THA ± acetabular reconstruction following failed treatment of acetabular fractures. Twenty-seven were initially treated by surgery (group A) and 20 had nonsurgical treatment (group B). Intraoperative measures, preoperative and follow-up clinical, radiological, and functional outcomes were compared between the 2 groups. RESULTS: The mean surgical time, blood loss, and need for blood transfusion were significantly less in group A (P < .05). Acetabular reconstruction to address cavitary or segmental defects was needed in a significantly higher number of patients in group B (P = .006). Significant improvement in modified Merle d'Aubigne and Oxford scores was seen postsurgery in both groups. Acetabular component survival with aseptic loosening as end point was 98%. Overall survival rate with infection, revision, or loosening as end point was 93% at a mean follow-up of 7 years ± 17 months. CONCLUSION: THA for a failed acetabular fracture is greatly facilitated by initial surgical treatment. Although functional results and survivorship were similar in both groups, failed nonsurgical treatment in complex fractures is associated with migrated femoral head and extensive acetabular defects requiring complex acetabular reconstruction.

Second generation locked plating for complex proximal humerus fractures in very elderly patients.

OBJECTIVES: Humeral head sacrificing procedures are more favored in elderly patients with complex proximal humerus fractures because of high incidence of failures and complications with osteosynthesis. The purpose of this study is to assess the outcome of second generation locked plating techniques in 3 and 4 part fractures in active elderly patients >70years with an emphasis on function and complications. MATERIALS AND METHODS: 29 patients with displaced 3 and 4 part proximal humerus fractures were treated using the principles of second-generation proximal humerus locked plating. Fixed angle locked plating (PHILOS) using the anterolateral deltoid spilt approach augmented with traction cuff sutures was performed. Minimum of 7 locking head screws including 2 calcar screws were used. In cases with a comminuted medial calcar, an endosteal fibular strut was used. Subchondral metaphyseal bone voids were filled with injectable calcium phosphate cement. Radiological outcome (union, head - shaft angle, tuberosity reduction), functional outcome assessment (Constant and ASES scores) and complications (loss of reduction, nonunion and osteonecrosis) were assessed. RESULTS: The fracture united in 24 of the 26 patients available for follow up at a mean of 27 months (12-40 months). 3 patients developed complications that required arthroplasty (fixation failure in 2 patients and osteonecrosis in 1 patient). Follow up age adjusted Constant (63.1±11.9) and ASES scores (62.58±7.5) showed the extent of functional improvement post surgery. Patients with fractures having a non-comminuted medial calcar and valgus displacement of the humeral head had better functional scores and fewer complications. CONCLUSION: Osteosynthesis with second generation locked plating techniques provide satisfactory outcome in very elderly patients with complex proximal humerus fractures with minimal complications.

The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study.

OBJECTIVE: To prospectively study the outcome of surgically treated split depression lateral tibial plateau fractures extending into the posterior column using the extended posterolateral approach. METHODS: Twenty-one patients with split depression lateral tibial plateau fractures (AO: 41-B3) with extension into the posterior column were treated with open reduction and internal fixation through an extended posterolateral approach with osteotomy of the fibular neck±Gerdy tubercle. Follow up radiographs was assessed for quality of articular reduction and limb axis. Functional assessment was performed at last follow up using the Tegner-Lysholm score. Complications pertaining to the surgical approach were recorded. RESULTS: The approach was performed in 15 patients with a fibular neck osteotomy alone and 6 patients required a Gerdy's tubercle osteotomy also. All fractures and osteotomies had united. Anatomical articular reduction was achieved in 16 patients. Radiological limb alignment was restored in all patients except for a reversed posterior slope in 1 patient. Arthritic changes were seen in 3 patients. The mean Tegner-Lysholm score was 87.3 (range: 76-95) at last follow up. No specific complications related to the surgical approach like common peroneal nerve injury and lateral instability of the knee was encountered. CONCLUSION: The extended posterolateral approach offers excellent exposure posterior to the fibular head to perform articular reduction and fixation achieving satisfactory radiological and functional results in split depression lateral tibial plateau fractures extending into the posterior column.

Ganz Surgical Dislocation of the Hip Is a Safe Technique for Operative Treatment of Pipkin Fractures. Results of a Prospective Trial.

OBJECTIVES: The primary objective was to study the incidence of femoral head osteonecrosis after Ganz approach for Pipkin fracture dislocations. Clinico-radiological and functional outcomes were also studied. DESIGN: Prospective, nonrandomised. SETTING: Tertiary care trauma center. PATIENTS: Twenty-eight patients with type I/II Pipkin fracture dislocation reduced within 6 hours of injury. INTERVENTION: The displaced head fracture was addressed through safe surgical dislocation after urgent closed reduction of the hip. OUTCOME MEASUREMENTS: Incidence of osteonecrosis using radiographs and functional outcome using modified Merle d'Aubigne and Oxford scores were studied. RESULTS: Twenty-six fractures were fixed, and 2 type I fractures were excised. Twenty-six of 28 patients were followed up for a mean of 36 months. There was no osteonecrosis. All fractures and osteotomies had united. The mean modified Merle d'Aubigne score was 16.5 (14-18), and the mean Oxford score was 42.65 (38-48). CONCLUSIONS: Safe surgical dislocation provides satisfactory results in Pipkin fracture dislocations. The incidence of osteonecrosis is not increased in patients undergoing early joint reduction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Locked plate osteosynthesis of humeral head-splitting fractures in young adults.

BACKGROUND: Humeral head-splitting fractures occur in younger patients and can be associated with poor outcome. We decided to study the functional outcome and complications in simple and complex humeral head-splitting fractures. We hypothesized that simple head-splitting fractures will perform better compared with complex head-splitting fractures. PATIENTS AND METHODS: Records of 16 patients <55 years who underwent locked plating for humeral head-splitting fractures were reviewed. Five fractures were classified as simple (isolated head-splitting fractures) and 11 as complex fractures (associated tuberosity fractures). Union and quality of articular and tuberosity reduction were assessed radiologically. Shoulder and upper limb function was assessed by Constant and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Complications such as osteonecrosis, nonunion, and arthritic changes were also recorded. RESULTS: Of 15 fractures, 13 had united at a mean follow-up of 34 months (25-47 months). No osteonecrosis or nonunion was seen in simple fractures. In complex fractures, osteonecrosis was seen in 4 patients (P = .01), nonunion in 2 patients, and glenohumeral arthritis in 1 patient. The mean Constant score (66.5 [56-77]) and DASH score (21 [7.5-35.8]) showed significantly better outcomes in simple fractures (Constant score, P = .02; DASH score, P = .029). CONCLUSION: Locked plating achieves satisfactory results in simple head-splitting fractures. Complex fractures are associated with higher rates of nonunion, avascular necrosis, and inferior shoulder function.