Objectives: To compare, in a systematic review, Krakow transosseous (KT) suturing and separate vertical wiring (VW) fixation methods in inferior pole fractures of the patella and to evaluate whether the supplementary fixation affected bone union.
Methods:
Data sources: The MEDLINE, Embase, and Cochrane databases were searched from inception to January 15, 2023. The keywords were "patella inferior pole fracture", "patella distal pole fracture", "transosseous", "pull-out suture", "reattachment", and "vertical wiring".
Study selection: All clinical studies describing KT or VW techniques for inferior pole fracture of the patella and reporting bone union-related complications were included.
Data extraction: This meta-analysis included 16 studies with 274 patellae. Demographic data, surgical techniques, clinical outcomes, and complication rates were recorded. The Methodological Index for Non-Randomized Studies criteria were used to assess their quality.
Data synthesis: A meta-analysis was performed using random-effects models and meta-regression. The meta-analytic estimate of bone union-related complications was 3.8% (95% CI, 1.6%-6.0%) for either PO or VW techniques in inferior pole fractures of the patella. The bone union-related complication rates did not differ significantly between the two techniques (KT, 5.7%; VW, 3.0%; P = .277). Meanwhile, supplementation fixation was significantly associated with decrease in bone union-related complication rates ( p = .013).
Conclusions: Fixation of inferior pole fractures of the patella using either KT or VW techniques provided satisfactory and similar clinical results with minimal bone union-related complications. Supplementary fixation has a positive impact on reducing bone union-related complications in inferior pole fractures of the patella following KT and VW techniques.
Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To determine the incidence of infection in nonoperative versus operative management of extraperitoneal bladder ruptures in patients with pelvic ring injuries.
Methods:
Design: A retrospective cohort study of 2 prospectively collected trauma registries.
Setting: Two Level 1 trauma centers.
Patient selection criteria: Patients with operative pelvic ring injuries, 68 (6%) had extraperitoneal bladder ruptures.
Outcome measures and comparisons: The primary outcome was the incidence and associated risk factors of deep pelvic infection requiring return to OR for surgical debridement. Secondary outcomes included quality of reduction, other complications, and radiographic union. Comparisons were made based on the status of any associated bladder injury.
Results: Of 1127 patients with operative pelvic ring injuries, 68 patients had extraperitoneal bladder ruptures, 55 had bladder repair and 13 did not. Of those 13 without repair, none had ORIF of the anterior pelvic ring. Patients without bladder repair had an increased odds of infection 17-fold compared to patients who did have a repair performed (OR 16.9, 95% CI 1.75 - 164, P = 0.01). Other associated factors for deep pelvic infection included use of suprapubic catheter ( p < 0.02) and a closed reduction of the anterior ring ( p < 0.01). Patients undergoing anterior ring ORIF and bladder repair had improved reductions and no increased infection risk.
Conclusions: Operative repair of extraperitoneal bladder ruptures decreases risk of infection in patients with pelvic ring injuries. Additionally, ORIF of the anterior pelvic ring does not increase the risk of infection and results in better reductions compared to closed reduction. Treatment algorithms for these combined injuries should consider recommending early bladder repair and anterior pelvic ORIF.
Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange.
Methods:
Design: Retrospective review.
Setting: Eight academic level I trauma centers.
Patient selection criteria: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP.
Outcome measures and comparisons: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP.
Results: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008).
Conclusions: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.
Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objectives: The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology.
Methods: .
Design: Retrospective study, 2015-2021.
Setting: Single, academic, Level 1 trauma center.
Patient selection criteria: Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae.
Outcome measures and comparisons: Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns.
Results: Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous.
Conclusions: The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.
Summary: Cephalomedullary nail fixation of geriatric intertrochanteric femur fractures is, and will continue to be, performed by most orthopaedic surgeons. The influence of technical factors on outcome is clear, and it is imperative that orthopaedic surgeons use contemporary strategies to achieve adequate reduction and fixation. The lateral patient position on a traction table potentially confers several advantages which surgeons can use to achieve quality outcomes even in patients who have challenging body morphology and/or fracture anatomy. A preferred surgical technique for lateral positioning is presented here and a case series comparing supine versus lateral nailing procedures. Lateral positioning was used more frequently in obese patients and by trauma-trained surgeons, and the results equal or exceed those in supine cases with respect to reduction and placement of fixation. Training surgeons in lateral nailing can deliver a reproducible strategy for reduction and fixation in straightforward and complex cases. By mastering the setup and technique on more simple cases, surgeons can be better prepared for the more complex where advantages of lateral nailing are even more apparent.
Objectives: To characterize the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and Gustilo-Anderson classification of open extremity fractures and determine if there is meaningful alignment between these grading systems.
Methods:
Design: Retrospective case series.
Setting: Level I academic trauma center.
Patient selection criteria: Adult patients with at least 1 operatively treated open extremity fracture and surgeon-assigned OTA-OFC and Gustilo-Anderson classification.
Outcome measures and comparisons: Frequency, distribution, and association measures of OTA-OFC category scores and Gustilo-Anderson classification types.
Results: Two thousand twenty-seven patients (mean age, 43.1 ± 17.5 years) with 2215 fractures were included. Gustilo-Anderson type I or II fractures (n = 961; 43%) most frequently had the least severe scores for all OTA-OFC categories. Type IIIA fractures (n = 978; 44%) were most often assigned intermediate scores for OTA-OFC Bone Loss (n = 564; 58%). Type IIIB fractures (n = 204, 9%) were most often assigned intermediate OTA-OFC Skin scores (n = 120; 59%). Type IIIC fractures (n = 72; 3%) were most often assigned the most severe OTA-OFC Arterial score (n = 60; 83%). In the multivariable model, OTA-OFC Contamination scores showed little association (β = 0.05; 95% confidence interval [CI], 0.01-0.09) with Gustilo-Anderson classification severity. Conversely, higher OTA-OFC Arterial (β = 0.50; 95% CI 0.44-0.56) and Skin (β = 0.46; 95% CI, 0.40-0.51) scores were strongly associated with more severe Gustilo-Anderson classifications.
Conclusions: OTA-OFC Contamination scores were weakly associated with Gustilo-Anderson classification severity for open fractures. The study findings suggest that the current Gustilo-Anderson classification does not adequately account for injury contamination, a known predictor of infection.
Level of evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Objectives: The association between labral injuries and acetabular fractures is unknown. This study aimed to identify the frequency and characteristics of labral injuries in operatively treated acetabular fractures that cannot be identified on preoperative imaging.
Methods: .
Design: Prospective observational cohort.
Setting: Level I trauma center.
Patient selection criteria: Adult patients with an acetabular fracture operatively treated through a posterior approach.
Outcome measures and comparisons: The frequency and characteristics of labral injuries.
Results: Fifty-three of 71 acetabular fractures (75%; 95% confidence interval, 63%-83%) demonstrated a labral injury visible via the posterior approach. Posterior labral injuries occurred in 89% of operative acetabular fracture patterns involving the posterior wall and most commonly represent a detachment of the posteroinferior labrum (n = 39, 75%). Fractures with a labral injury were more likely to have gluteus minimus damage (93% vs. 61%, P = 0.02), femoral head lesions (38% vs. 17%, P = 0.03), joint capsule detachment (60% vs. 33%, P = 0.05), and fracture patterns involving the posterior wall (89% vs. 50%, P = 0.05).
Conclusions: This study describes the high rate (89%) of posterior labral injuries in posterior wall fractures, the most common injury pattern being a detachment of the posteroinferior labrum. Labral injuries in acetabular fractures may have important clinical implications and this study is the first to identify the frequency and characteristics of these injuries. Further studies should assess the relationship between labral injuries, treatment strategies, and the progression to post-traumatic osteoarthritis.
Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Objectives: Evaluate whether intraoperatively repaired lateral meniscus injuries impact midterm patient-reported outcomes in those undergoing operative fixation of tibial plateau fracture.
Methods:
Design: Retrospective cohort study.
Setting: Level I trauma center.
Patient selection criteria: All patients (n = 207) who underwent operative fixation of a tibial plateau fracture from 2016 to 2021 with a minimum of 10-month follow-up.
Outcome measures and comparisons: The Patient-Reported Outcomes Measurement Information System Physical Function, Knee Injury and Osteoarthritis Outcome Score, and the PROMIS-Preference health utility score.
Results: Overall, 207 patients were included with average follow-up of 2.9 years. Seventy-three patients (35%) underwent intraoperative lateral meniscus repair. Gender, age, body mass index, Charlson comorbidity index, days to surgery, ligamentous knee injury, open fracture, vascular injury, polytraumatic injuries, Schatzker classification, and Orthopaedic Trauma Association classification were not associated with meniscal repair ( P > 0.05). Rates of reoperation (42% vs. 31%, P = 0.11), infection (8% vs. 10%, P = 0.60), return to work (78% vs. 75%, P = 0.73), and subsequent total knee arthroplasty (8% vs. 5%, P = 0.39) were also similar between those who had a meniscal repair and those without a meniscal injury, respectively. There was no difference in Patient-Reported Outcomes Measurement Information System Physical Function (46.3 vs. 45.8, P = 0.707), PROMIS-Preference (0.51 vs. 0.50, P = 0.729), and all Knee Injury and Osteoarthritis Outcome Score domain scores at the final follow-up between those who had a meniscal repair and those without a meniscal injury, respectively.
Conclusions: In patients with an operatively treated tibial plateau fracture, the presence of a concomitant intraoperatively identified and repaired lateral meniscal tear results in similar midterm PROMs and complication rates when compared with patients without meniscal injury.
Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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