Publications by authors named "Kenneth J Koval"

168 Publications

Long-Term Patient-Reported Knee Outcomes After Suprapatellar Intramedullary Tibial Nailing.

Indian J Orthop 2021 Jun 16;55(3):669-672. Epub 2021 Jan 16.

Orlando Health, Orlando, FL USA.

Background: Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing.

Methods: Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4-9 years) follow-up.

Results: The median TLKS was 98 (interquartile range, 85-100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1-65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker's compensation.

Conclusion: At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications.

Level Of Evidence: III, Retrospective cohort study.
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http://dx.doi.org/10.1007/s43465-020-00340-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081801PMC
June 2021

Comparison of standard versus reconstruction proximal interlocking screw configurations for antegrade intramedullary nail fixation of femoral shaft fractures.

J Clin Orthop Trauma 2021 Jun 1;17:94-98. Epub 2021 Mar 1.

Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA.

Background: The standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications.

Methods: A retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications.

Results: 130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference -3%, 95% confidence interval (CI) -30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications.

Conclusions: In this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation.

Level Of Evidence: Level III, Retrospective cohort study.
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http://dx.doi.org/10.1016/j.jcot.2021.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941042PMC
June 2021

Complications after fibula intramedullary nail fixation of pilon versus ankle fractures.

J Clin Orthop Trauma 2021 May 7;16:75-79. Epub 2021 Jan 7.

Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA.

Background: Intramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures.

Methods: A retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed.

Results: There was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups.

Conclusion: Fibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures.

Level Of Evidence: Level III, retrospective cohort.
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http://dx.doi.org/10.1016/j.jcot.2020.12.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920162PMC
May 2021

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

Eur J Orthop Surg Traumatol 2021 May 27;31(4):683-687. Epub 2020 Oct 27.

Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver Health, 777 Bannock St, MC 0188, Denver, CO, USA.

Introduction: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation.

Methods: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded.

Results: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108).

Conclusion: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study.

Level Of Evidence: Level 3, retrospective cohort.
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http://dx.doi.org/10.1007/s00590-020-02820-1DOI Listing
May 2021

Variables Associated With Lag Screw Sliding After Single-Screw Cephalomedullary Nail Fixation of Intertrochanteric Fractures.

J Orthop Trauma 2020 Jul;34(7):356-358

Department of Orthopaedics, Orlando Health, Orlando, FL; and.

Objectives: To evaluate variables associated with lag screw sliding after single-screw cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures.

Design: Retrospective cohort study.

Setting: Level-one trauma center.

Patients/participants: One hundred fifty-eight intertrochanteric fractures in patients older than 65 years with an average follow-up of 22 months.

Intervention: Single-screw CMN fixation.

Main Outcome Measurements: Lag screw sliding and revision surgeries.

Results: The average amount of lag screw sliding was 5 ± 5 mm (range, 0-21 mm). Lag screw sliding was greater with unstable fracture patterns (mean difference 2 mm, 95% confidence interval 0.4-3.5 mm, P = 0.01) and calcar gapping >4 mm (mean difference 3.7 mm, 95% confidence interval 2-5 mm, P < 0.01). No association was found between lag screw sliding and age, female gender, implants, long versus short nails, distal interlock screw use, postoperative neck-shaft angle, or tip-apex distance (P > 0.05). Revision surgeries were performed in 6 (4%) patients. Indications included symptomatic lag screw removal (n = 2), avascular necrosis (n = 1), cutout (n = 1), loss of reduction (n = 1), and perimplant fracture (n = 1).

Conclusions: Unstable fracture patterns are unavoidable; however, careful attention to calcar reduction and selection of dual-screw CMN implants may minimize lag screw sliding and its detrimental effects on outcomes.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001730DOI Listing
July 2020

Early Operative Treatment of Acetabular Fractures Does Not Increase Blood Loss: A Retrospective Review.

J Orthop Trauma 2020 May;34(5):244-247

Department of Orthopaedics, Orlando Health, Orlando, FL.

Objectives: To compare cell salvage (CS) volume, intraoperative blood loss, intraoperative blood transfusions, and operative time for acetabular fractures undergoing early (≤48 hours from admission) versus delayed fixation (>48 hours from admission).

Design: Retrospective.

Setting: Level one trauma center.

Patients: One hundred thirty-one patients with unilateral acetabular fractures involving at least one column.

Intervention: Open reduction and internal fixation performed through the anterior intrapelvic approach or posterior approach.

Main Outcome Measurements: CS volume, estimated blood loss (EBL), intravenous fluids (IVFs), intraoperative packed red blood cells (PRBCs), and operative time.

Results: Early versus delayed fixation through the posterior approach was associated with shorter operative times and less intraoperative PRBCs (140 vs. 301 mL, MD -161 mL, 95% confidence interval -25 to -296 mL) with no differences in CS, EBL, or IVF. Early versus delayed fixation through an anterior intrapelvic approach was more common in less severe fracture patterns with no differences in PRBCs, CS, EBL, or IVF. CS, through either approach, was successful in returning blood to 77% of patients for an average of 267 ± 168 mL (range, 105-900 mL).

Conclusions: Fixation of acetabular fractures within 48 hours of admission did not increase blood loss or intraoperative transfusions. CS was successful in returning an average of one unit of blood to a majority of patients.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001682DOI Listing
May 2020

Caregivers of hip fracture patients: The forgotten victims?

Injury 2019 Dec 20;50(12):2259-2262. Epub 2019 Sep 20.

Memorial Hospital, Gulfport, MS, United States.

Introduction: The burden that family and friends assume when caring for hip fracture patients can negatively impact the caregiver's quality of life, relationships, and the decision to place the patient in a care facility. The purpose of this study was to evaluate the burden of caregiving for intertrochanteric hip fractures to better counsel patients and caregivers in order to prevent delayed admission to a care facility.

Methods: A retrospective analysis of a prospectively gathered elderly hip fracture database identified 29 patients and their caregivers with complete 6 month follow-up. Caregiver burden and depression scales were administered to the primary caregiver in the immediate perioperative period (baseline), at 3 month follow-up, and at 6 month follow-up. At each time point caregivers reported the effects of caregiving on their finances, work hours, relationships, and their willingness to admit the patient to a long-term care facility.

Results: At 6 month follow-up, <30% of caregivers reported negative effects on their finances, relationships, work hours, or intent to place the patient in care facility, while 77% endorsed cherishing their time spent as a caregiver. The number of caregivers with a high caregiver burden remained stable at 20% over the 6 month follow-up; these caregivers were more likely to have a depressed mood (p < 0.01), to consider placement of the patient into a long-term care facility (p < 0.01), and to have negatively affected finances (p = 0.03) and relationships (p < 0.01).

Conclusions: High degrees of burden were experienced by 20% of caregivers of hip fracture patients. Caregivers with high caregiver burdens were more likely to consider placement of the patient into a long-term care facility. Risk factors for high caregiver burdens should be identified to optimize the quality of caregiving after discharge and to prevent delayed admission to a long-term care facility.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.injury.2019.09.030DOI Listing
December 2019

Needlestick and sharps injuries in orthopedic surgery residents and fellows.

Infect Control Hosp Epidemiol 2019 11;40(11):1253-1257

Department of Orthopaedic Surgery, Orlando Health, Orlando, Florida.

Objective: Needlestick and sharps injury (NSSI) is a common occupational hazard of orthopedic surgery training. The purpose of this study was to examine the incidence and surrounding circumstances of intraoperative NSSI in orthopedic surgery residents and fellows and to examine postexposure reporting.

Design: A 35-question cross-sectional survey.

Setting: The study was conducted by orthopedic surgery residents and faculty at a nonprofit regional hospital.

Participants: The questionnaire was distributed to US allopathic orthopedic surgery residency and fellowship programs; 300 orthopedic surgery trainees participated in the survey.

Results: Of 223 trainees who had completed at least 1 year of residency, 172 (77.1%) sustained an NSSI during residency, and 57 of 63 trainees (90.5%) who had completed at least 4 years sustained an NSSI during residency. The most common causes of NSSI were solid needles, followed by solid pins or wires. The surgical activity most associated with NSSI was wound closure, followed by fracture fixation. The type of surgery most frequently associated with NSSI was orthopedic trauma, followed by hip and knee arthroplasty. Of 177 trainees who had sustained a prior NSSI, 99 (55.9%) failed to report all events to their institution's occupational health department.

Conclusions: The incidence of NSSI during residency training is high, with >90% of trainees in their fifth year or later of training having received an injury during their training, with a mean of >4 separate events. Most trainees with an NSSI did not report all of their events, which implies that changes are needed in the incident reporting process universally.
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http://dx.doi.org/10.1017/ice.2019.262DOI Listing
November 2019

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures.

Eur J Orthop Surg Traumatol 2020 Feb 9;30(2):227-230. Epub 2019 Sep 9.

Orlando Health, Orlando, FL, USA.

Introduction: Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels.

Methods: A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk.

Results: None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up.

Conclusions: None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1007/s00590-019-02546-9DOI Listing
February 2020

Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery.

J Orthop Trauma 2019 Apr;33(4):203-213

Department of Orthopedics, Orlando Regional Medical Center, Orlando, FL.

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.
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http://dx.doi.org/10.1097/BOT.0000000000001420DOI Listing
April 2019

The Telescoping Hip Plate for Treatment of Femoral Neck Fracture: Design Rationale, Surgical Technique and Early Results.

Iowa Orthop J 2018 ;38:61-71

Department of Orthopaedics, University of Iowa, Iowa City, IA.

Recent estimates suggest an annual incidence of greater than 125,000 femoral neck fractures. Surgical treatment is indicated for the majority of these fractures, which are estimated to double by the year 2050. Most displaced femoral neck fractures in elderly patients are treated with arthroplasty secondary to high complication rates associated with internal fixation. Traditional implants used for internal fixation, typically in elderly patients with stable fracture morphology and younger patients regardless of morphology, include the sliding hip screw (SHS), with or without a supplemental anti-rotation screw, and multiple cancellous lag screws. Complications have been reported with both of these fixation techniques, especially as they apply to treating displaced femoral neck fractures in the elderly. Yet, complications of nonunion, loss of fixation and osteonecrosis, among others, still frequently occur in stable patterns of femoral neck fracture treated with internal fixation. Accordingly, additional implants have been designed recently to improve outcomes and avoid such complications in this population. The Targon Femoral Neck Plate (Aesculap, Tuttlinger, Germany) has been used in Europe for the treatment of both displaced and nondisplaced femoral neck fractures by combining a side plate and multiple cancellous lag screws. Multiple studies have shown superior rates of both nonunion and osteonecrosis when compared to the SHS and multiple cancellous screws in both displaced and nondisplaced femoral neck fractures. This article details the design rationale, surgical technique and early postoperative results of a new hybrid implant used for the treatment of both displaced and nondisplaced femoral neck fractures.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047398PMC
December 2018

Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis.

Injury 2017 Dec 3;48(12):2705-2708. Epub 2017 Oct 3.

Department of Orthopedics, Orlando Regional Medical Center, United States.

Purpose: Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors.

Materials And Methods: Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis.

Results: 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017).

Conclusions: Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.
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http://dx.doi.org/10.1016/j.injury.2017.09.030DOI Listing
December 2017

What's new in ankle fractures.

Injury 2017 Oct 9;48(10):2035-2041. Epub 2017 Aug 9.

Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJ Barnabas Health, Jersey City, NJ, United States. Electronic address:

The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.
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http://dx.doi.org/10.1016/j.injury.2017.08.016DOI Listing
October 2017

Controversies in Intramedullary Fixation for Intertrochanteric Hip Fractures.

J Orthop Trauma 2016 Dec;30(12):635-641

*Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando Health, Orlando, FL; and†Florida Orthopaedic Institute, Department of Orthopaedic Surgery, University of South Florida, Tampa, FL.

Intertrochanteric hip fractures are common and costly. Intramedullary fixation has gained popularity as a means of stabilizing intertrochanteric hip fractures. This review article presents some of the controversies surrounding the treatment of intertrochanteric fractures using a cephalomedullary nail. These topics include nail length, the need for distal interlocking, proximal screw design, the number of proximal lag screws, and integrated proximal sliding lag screws.

Level Of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000652DOI Listing
December 2016

Analysis of Failure with the Use of Locked Plates for Stabilization of Proximal Humerus Fractures.

Bull Hosp Jt Dis (2013) 2015 Jul;73(3):185-9

Objective: To evaluate factors associated with complications in a series of patients with proximal humerus fractures treated with locked plating.

Design: Retrospective chart review.

Setting: Level 1 Trauma Center.

Patients And Methods: A retrospective review was performed on patients older than 18 years of age treated with a locked plate for a proximal humerus fracture between June 2007 and December 2011 in order to identify any factors associated with failure. Patients had a minimum of 6 months of clinical follow-up.

Results: 78 proximal humerus fractures in 78 patients were stabilized using a locked plate. Twenty-four patients were lost to follow-up, while 54 patients were available for 6-month minimum follow-up and comprised the study group. A healing complication occurred in 20 patients (37%) and consisted of loss of reduction (16), varus malunion (16), avascular necrosis (6) or implant penetration (1). Eleven of 54 patients (20%) required secondary surgery. Factors associated with a healing complication were number of fracture parts (p < 0.029), one or more comorbidities (p <0.016), three or more comorbidities (p < 0.038), and varus malreduction (p < 0.001).

Conclusion: An overall complication rate of 37% was found in patients stabilized using a locked plate after sustaining a proximal humerus fracture. Factors associated with healing complications included increased number of fracture parts, increasing number of comorbidities, and initial varus malreduction. Patient selection for locked plating after proximal humerus fracture should incorporate many factors with meticulous attention to surgical technique.
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July 2015

Manipulation Under Anesthesia: A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee.

J Orthop Trauma 2015 Dec;29(12):e464-8

*Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA; and †Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando, FL.

Objectives: This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis.

Design: Retrospective review.

Setting: Level I trauma center.

Patients/participants: Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months.

Intervention: Closed knee MUA.

Outcome Measurements: Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA.

Results: The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12).

Discussion: MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000395DOI Listing
December 2015

Muscle Viability Revisited: Are We Removing Normal Muscle? A Critical Evaluation of Dogmatic Debridement.

J Orthop Trauma 2016 Jan;30(1):17-21

Departments of *Orthopaedic Surgery, and†Surgical Pathology, Orlando Regional Medical Center, Orlando, FL.

Purpose: Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques.

Methods: After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis.

Results: The surgeon's impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance.

Conclusions: Neither the 4 Cs nor the surgeon's impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeon's gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle.

Level Of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000423DOI Listing
January 2016

Influence of Femoral Component Design on Retrograde Femoral Nail Starting Point.

J Orthop Trauma 2015 Oct;29(10):e380-4

*Orlando Health, Orlando, FL; and †University of Central Florida College of Medicine, Orlando, FL.

Purpose: Our experience with retrograde femoral nailing after periprosthetic distal femur fractures was that femoral components with deep trochlear grooves posteriorly displace the nail entry point resulting in recurvatum deformity. This study evaluated the influence of distal femoral prosthetic design on the starting point.

Methods: One hundred lateral knee images were examined. The distal edge of Blumensaat's line was used to create a ratio of its location compared with the maximum anteroposterior condylar width called the starting point ratio (SPR). Femoral trials from 6 manufacturers were analyzed to determine the location of simulated nail position in the sagittal plane compared with the maximum anteroposterior prosthetic width. These measurements were used to create a ratio, the femoral component ratio (FCR). The FCR was compared with the SPR to determine if a femoral component would be at risk for retrograde nail starting point posterior to the Blumensaat's line.

Results: The mean SPR was 0.392 ± 0.03, and the mean FCR was 0.416 ± 0.05, which was significantly greater (P = 0.003). The mean FCR was 0.444 ± 0.06 for the cruciate retaining (CR) trials and was 0.393 ± 0.04 for the posterior stabilized trials; this difference was significant (P < 0.001).

Conclusions: The FCR for the femoral trials studied was significantly greater than the SPR for native knees and was significantly greater for CR femoral components compared with posterior stabilized components. These findings demonstrate that many total knee prostheses, particularly CR designs, are at risk for a starting point posterior to Blumensaat's line.
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http://dx.doi.org/10.1097/BOT.0000000000000350DOI Listing
October 2015

Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial.

BMJ Open 2015 Feb 13;5(2):e006263. Epub 2015 Feb 13.

Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Introduction: Hip fractures are a leading cause of mortality and disability worldwide, and the number of hip fractures is expected to rise to over 6 million per year by 2050. The optimal approach for the surgical management of displaced femoral neck fractures remains unknown. Current evidence suggests the use of arthroplasty; however, there is lack of evidence regarding whether patients with displaced femoral neck fractures experience better outcomes with total hip arthroplasty (THA) or hemiarthroplasty (HA). The HEALTH trial compares outcomes following THA versus HA in patients 50 years of age or older with displaced femoral neck fractures.

Methods And Analysis: HEALTH is a multicentre, randomised controlled trial where 1434 patients, 50 years of age or older, with displaced femoral neck fractures from international sites are randomised to receive either THA or HA. Exclusion criteria include associated major injuries of the lower extremity, hip infection(s) and a history of frank dementia. The primary outcome is unplanned secondary procedures and the secondary outcomes include functional outcomes, patient quality of life, mortality and hip-related complications-both within 2 years of the initial surgery. We are using minimisation to ensure balance between intervention groups for the following factors: age, prefracture living, prefracture functional status, American Society for Anesthesiologists (ASA) Class and centre number. Data analysts and the HEALTH Steering Committee are blinded to the surgical allocation throughout the trial. Outcome analysis will be performed using a χ(2) test (or Fisher's exact test) and Cox proportional hazards modelling estimate. All results will be presented with 95% CIs.

Ethics And Dissemination: The HEALTH trial has received local and McMaster University Research Ethics Board (REB) approval (REB#: 06-151).

Results: Outcomes from the primary manuscript will be disseminated through publications in academic journals and presentations at relevant orthopaedic conferences. We will communicate trial results to all participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results.

Trial Registration Number: The HEALTH trial is registered with clinicaltrials.gov (NCT00556842).
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http://dx.doi.org/10.1136/bmjopen-2014-006263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330331PMC
February 2015

Femoral neck fractures: current management.

J Orthop Trauma 2015 Mar;29(3):121-9

Level One Orthopedics, Orlando Regional Medical Center, Orlando, FL.

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.
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http://dx.doi.org/10.1097/BOT.0000000000000291DOI Listing
March 2015

Intramedullary nailing of subtrochanteric fractures--does malreduction matter?

Bull Hosp Jt Dis (2013) 2014 ;72(2):159-63

Introduction: Subtrochanteric femur fractures remain challenging injuries to treat. Historically, varus malreduction has been linked to the development of nonunion; however, there is a paucity of literature evaluating the impact of sagittal plane malreduction. The purpose of this study was to evaluate the influence of coronal and sagittal plane malreductions on time to union of subtrochanteric femur fractures treated with an intramedullary device.

Methods: A retrospective study was performed of all sub-trochanteric fractures (AO/OTA type 32) treated at a single institution. Inclusion criteria consisted of: 1. 18 or more years of age, and 2. fracture stabilization using an intramedullary device. All patients included were followed to union or revision surgery. Radiographic evidence of healing was defined as bridging callus on three of four cortices on AP and lateral views. Delayed union was defined as lack of radiographic healing by 4 months postoperatively and nonunion as lack of healing by 6 months. The definition of malreduction was coronal or sagittal plane deformity greater than 10° at the fracture site.

Results: Thirty-five patients met inclusion criteria; 20 men and 15 women with an average age of 55 years (range 19 to 100 years). Mean clinical follow up was 7 months (range 3 to 18 months). Thirty-four of 35 fractures (97%) healed without need for additional surgery. Twenty-one of the 35 fractures (60%) healed within 4 months of surgery. Thirteen fractures (37%) had delayed union, and 1 (2.9%) developed nonunion requiring reoperation. Seven of 35 fractures (20.0%) had a malreduction of greater than 10°, defined as varus (2 fractures), flexion (4 fractures), or both (1 fracture). Of the seven fractures with a malreduction, all (100%) developed a delayed (6) or nonunion (1). Of the 28 fractures without malreduction, 21 (75%) healed within 4 months, 7 (25%) had a delayed union, and none had a nonunion. The presence of a malreduction greater than 10° in any plane resulted in a significantly higher rate of delayed or nonunion (p = 0.0005).

Conclusion: For patients with subtrochanteric fractures treated with an intramedullary device, malreduction in any plane of greater than 10° resulted in a significantly increased rate of delayed or nonunion or both.
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May 2015

Retrograde reamed femoral nailing.

J Orthop Trauma 2014 Aug;28 Suppl 8:S15-24

Orthopedic Trauma Service, Tampa General Hospital, Tampa Florida; *Fracture Service, The Hospital for Joint Diseases, Orthopaedic Institute, New York, New York; †Laboratory for Experimental Research, Davos, Switzerland; and ‡Hospital for Special Surgery, New York, New York, U.S.A.

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) poly trauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122°; only two knees had an extensor lag of >5°. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.
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http://dx.doi.org/10.1097/01.bot.0000452786.80923.a7DOI Listing
August 2014

Minimally displaced clavicle fracture after high-energy injury: are they likely to displace?

Can J Surg 2014 Jun;57(3):169-74

The Orlando Regional Medical Center, Level One Orthopaedics, Orlando, FL.

Background: Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture.

Methods: We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded.

Results: Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission.

Conclusion: Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.
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http://dx.doi.org/10.1503/cjs.003613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035398PMC
June 2014

Efficacy and safety of recombinant human bone morphogenetic protein-2/calcium phosphate matrix for closed tibial diaphyseal fracture: a double-blind, randomized, controlled phase-II/III trial.

J Bone Joint Surg Am 2013 Dec;95(23):2088-96

Department of Trauma Services, Lutheran Medical Center, 150 55th Street, Brooklyn, NY 11220. E-mail address for T. Lyon:

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) applied on an absorbable collagen sponge improves open tibial fracture-healing as an adjunct to unreamed intramedullary nail fixation. We evaluated rhBMP-2 and a new, injectable calcium phosphate matrix (CPM) formulation in acute closed tibial diaphyseal fractures treated with reamed intramedullary nail fixation.

Methods: Patients were randomized (1:2:2:1) to receive standard of care, which consisted of definitive fracture fixation within seventy-two hours of injury with a locked intramedullary nail after reaming; standard of care and injection with 1.0 mg/mL of rhBMP-2/CPM; standard of care and injection with 2.0 mg/mL of rhBMP-2/CPM; or standard of care and injection with buffer/CPM, to evaluate the activity of the CPM delivery matrix and provide for sponsor and investigator blinding. The co-primary end points of the study were the effects of rhBMP-2/CPM on the time to fracture union (based on blinded assessment of radiographs) and the time to return to normal function (based on blinded assessment of the time to full weight-bearing without pain at the fracture site) compared with standard of care alone.

Results: Three hundred and sixty-nine patients were randomized and included in the intent-to-treat population. This study was terminated after an interim analysis (180 patients with six months of follow-up) revealed no shortening in the time to fracture union in the active treatment arms compared with the standard of care control (the SOC group). In the final primary analysis, the median time to radiographic fracture union was not significantly different for the SOC (13.1 weeks), 1.0-mg/mL rhBMP-2/CPM (13.0 weeks), 2.0-mg/mL rhBMP-2/CPM (15.9 weeks), or buffer/CPM (15.4 weeks) treatment groups. The median time to pain-free full weight-bearing was also not significantly different among the SOC (13.4 weeks), 1.0-mg/mL rhBMP-2/CPM (13.4 weeks), 2.0-mg/mL rhBMP-2/CPM (14.3 weeks), and buffer/CPM (16.4 weeks) treatment groups.

Conclusions: In patients with closed tibial fractures treated with reamed intramedullary nailing, the time to fracture union and pain-free full weight-bearing were not significantly reduced by rhBMP-2/CPM compared with standard of care alone. 24306696
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http://dx.doi.org/10.2106/JBJS.L.01545DOI Listing
December 2013

Retained bullet removal in civilian pelvis and extremity gunshot injuries: a systematic review.

Clin Orthop Relat Res 2013 Dec;471(12):3956-60

University of Louisville Hospital, Louisville, KY, USA.

Background: Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances.

Questions/purposes: We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments?

Methods: A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.

Results: No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal.

Conclusions: The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.
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http://dx.doi.org/10.1007/s11999-013-3260-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3825878PMC
December 2013

Silicon: a review of its potential role in the prevention and treatment of postmenopausal osteoporosis.

Int J Endocrinol 2013 15;2013:316783. Epub 2013 May 15.

Orlando Health Department of Orthopedic Surgery, 1222 Orange Avenue, Orlando, FL 32806, USA.

Physicians are aware of the benefits of calcium and vitamin D supplementation. However, additional nutritional components may also be important for bone health. There is a growing body of the scientific literature which recognizes that silicon plays an essential role in bone formation and maintenance. Silicon improves bone matrix quality and facilitates bone mineralization. Increased intake of bioavailable silicon has been associated with increased bone mineral density. Silicon supplementation in animals and humans has been shown to increase bone mineral density and improve bone strength. Dietary sources of bioavailable silicon include whole grains, cereals, beer, and some vegetables such as green beans. Silicon in the form of silica, or silicon dioxide (SiO2), is a common food additive but has limited intestinal absorption. More attention to this important mineral by the academic community may lead to improved nutrition, dietary supplements, and better understanding of the role of silicon in the management of postmenopausal osteoporosis.
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http://dx.doi.org/10.1155/2013/316783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671293PMC
June 2013

Is there a role for intramedullary nails in the treatment of simple pilon fractures? Rationale and preliminary results.

Injury 2013 Aug 6;44(8):1107-11. Epub 2013 Apr 6.

Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, UMDNJ - New Jersey Medical School, Newark, NJ 07101, USA.

Introduction: Certain patients with pilon fractures present with significant soft-tissue swelling or with a poor soft-tissue envelope typically not amenable to definitive fixation in the early time period. The objective of this study was to review the treatment of simple intra-articular fractures of the tibial plafond (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43C1-C2) via intramedullary nailing (IMN) with the assessment of clinical and radiographic results and any associated complications.

Materials And Methods: Retrospective clinical and radiological reviews of 31 patients sustaining AO/OTA type 43C distal tibial fractures treated with IMN were evaluated. Our main outcome measurement included achievable alignment in the immediate postoperative period and at the time of union along with complications or need for secondary procedures within the first year of follow-up.

Results: Seven patients were lost to follow-up. All the remaining patients achieved bony union at a mean union time of 14.1 ± 4.9 weeks with no evidence of malunion or malrotation. All patients were at full-weight-bearing status at 1-year follow-up. Complications were notable for one delayed union, one non-union, one patient with superficial wound drainage, two with deep infection, one with symptomatic hardware and one with deep vein thrombosis.

Conclusion: Simple articular fractures of the tibial plafond (AO/OTA type 43C) treated via IMN can achieve excellent alignment and union rates with proper patient selection and surgical indication. One should not hesitate to use additional bone screws or plating options to help achieve better anatomic reduction. However, larger, prospective randomised trials comparing plating versus nailing, in experienced hands, are needed to completely delineate the utility of this treatment modality.
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http://dx.doi.org/10.1016/j.injury.2013.02.014DOI Listing
August 2013

Cortical encroachment after cephalomedullary nailing of the proximal femur: evaluation of a more anatomic radius of curvature.

J Orthop Trauma 2013 Jun;27(6):303-7

Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY 10003, USA.

Objectives: : A unique complication of using full-length intramedullary nails for pertrochanteric and subtrochanteric femur fractures is nail penetration of the anterior cortex at the distal end of the femur because of a mismatch of the anatomic femoral bow with that of currently available cephalomedullary nails (CMNs). This study was performed to determine the rate of distal femoral cortical penetration after stabilization of the proximal femur in a consecutive series of patients using a long CMN with a curvature of 180 cm and to examine the final location of the nails within the femoral canal.

Design: : Retrospective chart review.

Setting: : Level 1 trauma center with tertiary care.

Patients/participants: : Between June 2005 and September 2008, 271 consecutive proximal femoral fractures or impending fractures were stabilized using a specially designed CMN [pertrochanteric nail (PTN) system; Biomet, Warsaw, IN]. Fifty-seven fractures were excluded because of inadequate lateral radiographs, leaving 214 nails in 212 patients available for analysis.

Intervention: : The proximal femur fractures or impending fractures were stabilized with a full-length CMN with a shaft diameter of 11 mm and a radius of curvature of 180 cm.

Main Outcome Measurements: : Nail position was determined from the lateral radiograph, which included the minimal distance from the nail to the anterior cortex of the distal femur and the relative position of the nail within the medullary canal, at a level within 2 cm proximal to the superior pole of the patella. Based on the nail position within the distal femoral canal, the following were calculated: (1) the overall rate of distal femoral anterior cortical penetration, (2) the distribution of nail distances to the anterior cortex, and (3) the proportion of nails lying in each quarter of the space available for the nail.

Results: : Four surgeries (1.9%) were performed for pathologic fracture and 22 (10.3%) for impending pathologic fracture. The remaining 188 CMNs were used to stabilize OTA Type 31A1 fractures (52 nails, 24.3%), Type 31A2 fractures (62 nails, 29%), Type 31A3 fractures (15 nails, 6.5%), and Type 32 fractures (59 nails, 27.6%). Of the 214 cases available for radiographic analysis, there was 1 case (0.47%) of distal femoral anterior cortical penetration. Of the remaining 213 CMNs, 40% of nails ended up far anterior, 48% anterior, 10% posterior, and 2% far posterior. Sixteen percent (1/6) were within 3 mm of the anterior cortex and half were within 7 mm. The average distance from nail to the anterior cortex was 8.5 mm.

Conclusion: : Use of a CMN with a radius of curvature of 180 cm to stabilize the proximal femur resulted in a very low rate of distal femoral anterior cortical penetration. However, most of the intramedullary nails ended up in the anterior half of the space available for the nail with 16% within 3 mm of the anterior cortex. These results highlight the importance of being aware of the complication of anterior cortical impingement and perforation during CMN insertion.

Level Of Evidence: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0b013e318283f24fDOI Listing
June 2013

Is reconstruction nailing of all femoral shaft fractures cost effective? A decision analysis.

J Orthop Trauma 2012 Nov;26(11):624-32

Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.

Objectives: Femoral shaft fractures are usually treated with anterograde or retrograde nails that typically do not provide femoral neck fixation. Ipsilateral femoral neck fractures occur with 2.5%-10% of femoral shaft fractures; 19%-55% of associated femoral neck fractures are missed with plain films and 5%-22% with computed tomography (CT). This study was performed to determine if routine reconstruction nailing of all femoral shaft fractures with or without occult femoral neck fractures is cost effective.

Methods: A decision tree model examined the cost effectiveness of reconstruction nailing over standard intramedullary nailing for all femoral shaft fractures in which an associated femoral neck fracture was not identified on plain radiographs. As a base model, we assumed that 5% of shaft fractures had an ipsilateral femoral neck fracture, and 37% were missed and required further surgery. We assigned a small morbidity and additional cost ($680) for the use of a reconstruction nail and 2 screws. Model inputs including costs, clinical outcome probabilities, and health utilities were derived from the literature, estimated from institutional data, or assumed by the authors. Sensitivity analyses evaluated the effect of the rate of associated femoral neck fracture, the rate of missed femoral neck fracture, the complication rate of reconstruction screws, the cost of the extra reconstruction screws, and the utilities of each outcome on the incremental cost effectiveness (ICER) of both strategies. Current practice in cost-effectiveness analysis uses a threshold of $100,000 per quality-adjusted life year gained as cost effective. A secondary analysis of the use CT scans to reduce missed femoral neck fractures was also performed.

Results: The base model showed that the placement of reconstruction nails in all isolated femur fractures was not cost effective. Sensitivity analysis demonstrated that the ICER was most sensitive to the cost of the reconstruction nail, hemiarthroplasty, and a missed femoral neck fracture. The ICER was affected by the rate of femoral neck fracture and the rate of missed femoral neck fracture. If the rate of missed femoral neck fractures was >38%, then reconstruction nailing was a cost-effective strategy. If the probability of an ipsilateral femoral neck fracture was >7%, then reconstruction nailing was cost effective. Protocolized CT scans had an ICER >$100,000. If the additional cost of the reconstruction nails was <$650, then it was cost effective to perform reconstruction nailing for all femoral shaft fractures.

Conclusions: Reconstruction nailing of femoral shaft fractures can be a cost-effective method to reduce the risks and morbidity of missed femoral neck fractures if the incremental implant costs are <$650. Routine reconstruction nailing is cost effective if the rate of associated femoral neck fracture is >7% or the rate of missed femoral neck fracture is >38%. CT scans are not a cost-effective strategy to reduce the risk and morbidity of missed femoral neck fractures if the cost is >$243. Weaknesses of this study include the reliance on low-powered studies and on estimations of some utilities and costs. To prevent the morbidity of missed or occult femoral neck fractures, the use of reconstruction nails for femoral shaft fractures is cost effective when the incremental costs of implants are <$650.

Level Of Evidence: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0b013e318246dfd9DOI Listing
November 2012

Does low-intensity pulsed ultrasound reduce time to fracture healing? A meta-analysis.

Am J Orthop (Belle Mead NJ) 2012 Feb;41(2):E12-9

Dartmouth Medical School, Hanover, New Hampshire, USA.

We conducted a meta-analysis of randomized controlled trials to obtain a more precise estimate of the effect of low-intensity pulsed ultrasound (LIPU) versus placebo on the acceleration of fracture healing in skeletally mature persons and to determine if any serious adverse events are associated with LIPU when used to accelerate fracture healing.
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February 2012
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