Operative Techniques in Orthopaedics最新文献

Distal femur fractures in the elderly continue to rise in incidence and there is significant morbidity and mortality associated with these injuries. Geriatric distal femur fractures pose unique problems due to poor bone quality that often can lead to failed fixation and negative outcomes. Nonoperative management has been shown to be inferior to surgical treatment. Multiple treatment options exist including external fixation, open, and minimally invasive locked plate fixation, intramedullary nailing, nail-plate combination constructs, and arthroplasty. Dual implant constructs provide rigid fixation and have been shown to prevent varus collapse and nonunion. The addition of a medial plate has been shown to be biomechanically superior in distal femoral fractures, especially in those in which significant distal fixation is difficult. Indications for dual plate or nail-plate constructs include geriatric femur fractures with osteoporotic bone, low periprosthetic fractures around the knee, and distal femur fractures with extensive metaphyseal loss. Different approaches can be used to accomplish dual plating including both single and double incision techniques. Outcome studies on patients undergoing dual plate fixation demonstrate successful results with similar rates of failure and complication to other operative fixation strategies.

Atypical femur fractures (AFFs) are problematic due to the high incidence of osteoporosis in the growing aging population. There are several factors that lead to increased risk of AFFs including bisphosphonate use, increasing age, female sex, and certain femoral morphologies. The pathogenesis of AFFs involves the combination of altered bone remodeling and unfavorable mechanical environment. AFFs are associated with low energy mechanisms and are diagnosed with clinical history and standard femur radiographs. While the complete management of AFFs always involves medical and endocrinological work-up, most commonly it is also associated with surgical intervention. Evaluation of the contralateral femur is also paramount to optimizing outcomes in patients with incomplete or complete AFFs. The surgeon managing AFFs must be aware of certain fracture-specific issues when treating these fractures, including the risk of nonunion, varus collapse, excessive anterolateral bowing, endosteal thickening at the level of the fracture leading to fracture malreduction with nail passage, and possibility for cortical perforation. This review will outline various surgical techniques helpful in the surgical management of AFFs. Patient should be adequately counseled regarding the high rates of complications including delayed and nonunion.

The ‘terrible triad' (TT) elbow fracture-dislocation is a form of complex elbow instability which includes an elbow dislocation with concomitant radial head and coronoid process fractures. As the name suggests, early attempts at managing this injury complex often resulted in high rates of unsatisfactory outcomes and complications. As our understanding of this injury has grown, modern approaches and surgical treatment protocols have yielded more reliable results. Today, goals of treatment are to obtain a concentric reduction with restoration of joint stability to allow for early-motion rehabilitation. However, many controversies still exist concerning the treatment of this complex injury.

Adult Monteggia fracture-dislocations are a rare occurrence in the adult population. The extent of the injury can vary from a simple proximal ulnar shaft fracture with a radial head dislocation to a complex comminuted fracture with associated injuries. Major factors that contribute to the complexity of the injury include coronoid fracture, radial head comminution, and ulnohumeral instability. Appropriate fixation of the ulna in anatomical alignment is crucial in achieving radial head reduction and limiting complications. While most Monteggia fracture-dislocations have favorable outcomes, it is important to recognize potential poor prognostic factors that can alter the functional outcomes of patients and increase reoperation rates. Knowledge of the relevant anatomy, evaluation, imaging, and management are imperative to improve outcomes and decrease complications for patients with these injuries.

Traumatic injuries involving the elbow can result in soft tissue defects with exposed critical structures including bone, joint, nerve, tendons or implants. Additionally, wounds about the elbow are subject to significant motion and tension, limiting the success of local wound care. In these clinical settings, soft tissue reconstruction is often indicated. The goal of reconstruction is elbow wound coverage with pliable, thin, and durable tissue that allows for repetitive motion without limiting range of motion. In the post-traumatic setting, optimal function is achieved if the soft tissue reconstruction allows for early return to active motion of the elbow joint.

Transolecranon fracture-dislocations are a rare type of olecranon fracture-dislocation of the elbow involving an olecranon fracture with an anterior radiocapitellar dislocation. In these fractures, the relationship between the proximal radioulnar joint is maintained. Principles of surgical fixation involve anatomical articular reduction of the olecranon, reduction of the radiocapitellar joint, and restoring elbow stability to allow early range of motion. With proper recognition of this fracture pattern and application of fixation principles, good outcomes can be expected for the majority of patients after this high-energy injury.