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  • Distal Femur Replacement versus Surgical Fixation for the Treatment of Geriatric Distal Femur Fractures: A Systematic Review. Journal of orthopaedic trauma Salazar, B. P., Babian, A. R., DeBaun, M. R., Githens, M. F., Chavez, G. A., Goodnough, H., Gardner, M. J., Bishop, J. A. 2020

    Abstract

    OBJECTIVES: The management of geriatric distal femur fractures is controversial, and both primary distal femur replacement (DFR) or surgical fixation (SF) are viable treatment options. The purpose of this study was to compare patient outcomes after these treatment strategies.DATA SOURCES: PubMed, Embase, and Cochrane databases were searched for English language papers up to April 24, 2020, identifying 2,129 papers.STUDY SELECTION: Studies evaluating complications in elderly patients treated for distal femur fractures with either immediate DFR or surgical fixation were included. Studies with mean patient age <55 years, nontraumatic indications for DFR, or SF with non-locking plates were excluded.DATA EXTRACTION: Two studies provided Level II or III evidence while the remaining 28 studies provided Level IV evidence. Studies were formally evaluated for methodologic quality using established criteria. Treatment failure between groups was compared using an incidence rate ratio.DATA SYNTHESIS: Treatment failure was defined for both surgical fixation and arthroplasty as complications requiring a major reoperation for reasons such as mechanical failure, nonunion, deep infection, aseptic loosening, or extensor mechanism disruption. There were no significant differences in complication rates or knee range of motion between SF and DFR.CONCLUSION: SF and DFR for the treatment of geriatric distal femur fractures demonstrate similar overall complication rates. Given the available evidence, no strong conclusions on the comparative effectiveness between the two treatments can be definitively made. More rigorous prospective research comparing SF versus DFR to treat acute geriatric distal femur fractures is warranted.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1097/BOT.0000000000001867

    View details for PubMedID 32569072

  • How do pilon fractures heal? An analysis of dual plating and bridging callus formation. Injury Campbell, S. T., Goodnough, L. H., Salazar, B., Lucas, J. F., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    OBJECTIVES: 1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation.DESIGN: Retrospective comparative study.SETTING: Single level one trauma center.PATIENTS: Fifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.INTERVENTION: Internal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation.MAIN OUTCOME MEASUREMENTS: Modified RUST (mRUST) scores at three and six months and reoperation rate.RESULTS: At six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates.CONCLUSIONS: Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable.LEVEL OF EVIDENCE: Three.

    View details for DOI 10.1016/j.injury.2020.04.023

    View details for PubMedID 32434713

  • Hook versus locking plate fixation for Neer type-II and type-V distal clavicle fractures: a retrospective cohort study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Chen, M. J., DeBaun, M. R., Salazar, B. P., Lai, C., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    PURPOSE: This study examined the outcomes and complications after treatment of unstable distal clavicle fractures with hook or locking plate fixation.METHODS: A retrospective search was performed of all acute distal clavicle fractures treated with open reduction and internal fixation from 2009 to 2019 at a Level I trauma center. Patients were separated into hook and locking plate fixation groups. Rates of union, complications, and reoperation, were extracted. QuickDASH (Disabilities of Arm, Shoulder, and Hand) scores were determined.RESULTS: Thirty-one patients met the inclusion criteria and were included in the study. Of these, 12 patients were treated with hook plates and 19 were treated with locking plates. All fractures healed without loss of reduction, regardless of implant selection. There were no immediate or long-term complications in either group. 83% of hook plate patients underwent planned implant removal, while 37% of locking plate patients requested implant removal secondary to irritation. QuickDASH scores were comparable and excellent in both groups.CONCLUSIONS: Hook and locking plate fixation for Neer type-II and type-V distal clavicle fractures have comparably high rates of union. Hook plates were removed routinely per protocol, while locking plates were removed only if symptomatic and occurred significantly less often.

    View details for DOI 10.1007/s00590-020-02658-7

    View details for PubMedID 32221679

  • Safety and efficacy of using 2.4/2.4mm and 2.0/2.4mm dual mini-fragment plate combinations for fixation of displaced diaphyseal clavicle fractures. Injury Chen, M. J., DeBaun, M. R., Salazar, B. P., Lai, C., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    PURPOSE: The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4mm and 2.0/2.4mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures.METHODS: This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal.RESULTS: All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal.CONCLUSION: Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4mm and 2.0/2.4mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.

    View details for DOI 10.1016/j.injury.2020.01.014

    View details for PubMedID 31948781

  • How are peri-implant fractures below short versus long cephalomedullary nails different? European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Salazar, B. P., Furness, J., Feng, J. E., DeBaun, M. R., Campbell, S. T., Lucas, J. F., Cross, W. W., Leucht, P., Grant, K. D., Gardner, M. J., Bishop, J. A. 2020

    Abstract

    Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails.This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups.Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs.Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.

    View details for DOI 10.1007/s00590-020-02785-1

    View details for PubMedID 32909108

  • Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Salazar, B. P., Chen, M. J., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    The need for coracoclavicular (CC) ligament augmentation when performing locking plate fixation of unstable distal clavicle fractures is controversial. The purpose of this study was to compare the results after locking plate fixation for treatment of Neer type-II and type-V distal clavicle fractures with and without suture suspensory augmentation of the CC ligaments.This was a retrospective case series of all Neer type-II and type-V distal clavicle fractures treated with locking plates at a single Level I trauma center. Patients were separated into locking plate-only and locking plate with CC ligament augmentation groups. Postoperative complications and fracture healing rates were recorded. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were recorded as functional outcomes during follow-up phone interviews. Standard descriptive statistics were performed.Sixteen patients were treated with locking plate fixation-only, and seven patients were treated with additional CC ligament augmentation. There was a similar distribution of Neer fracture types with each group. All fractures in both groups went onto union without loss of reduction or implant failure. There were no cases of infection or wound complications in either group. QuickDASH scores were comparable between locking plate-only fixation (mean 4.1 ± 3.9) and additional suspensory suture fixation (mean 4.5 ± 3.6).This comparative study of Neer type-II and type-V distal clavicle fractures demonstrated comparable outcomes after locking plate fixation with and without CC ligament augmentation. CC ligament augmentation may not be necessary when treating unstable distal clavicle fractures if locking plate fixation is used.

    View details for DOI 10.1007/s00590-020-02797-x

    View details for PubMedID 32949271

  • Dual Mini-Fragment Plating is Comparable to Precontoured Small Fragment Plating for Operative Diaphyseal Clavicle Fractures: A Retrospective Cohort Study. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Campbell, S. T., Goodnough, L. H., Lai, C., Salazar, B. P., Bishop, J. A., Gardner, M. J. 2019

    Abstract

    OBJECTIVES: To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation (ORIF) of diaphyseal clavicle fractures.DESIGN: Retrospective Cohort SETTING:: Level 1 Trauma CenterPatients/Participants: A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with ORIF with a minimum of 1 year follow up or until radiographic and clinical union.INTERVENTION: Two patient cohorts were identified: 1) patients treated with orthogonal DmF plate constructs and 2) patients treated with Pc clavicle-specific plates.OUTCOME MEASUREMENTS: Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios (OR), 95% confidence intervals (CI), and p-values (p) were calculated.RESULTS: There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, gender, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, p=0.45) or maintenance of reduction (98.3% DmF; 100% Pc, p=0.45). A total of 8% of DmF patients had symptomatic implant removal compared to 20% of Pc patients (OR 0.36, CI 0.12-1.05, p=0.061).CONCLUSIONS: This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared to Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal.LEVEL OF EVIDENCE: Therapeutic Level III.

    View details for DOI 10.1097/BOT.0000000000001727

    View details for PubMedID 31868765

  • Understanding the Radiographic Anatomy of the Proximal Ulna and Avoiding Inadvertent Intraarticular Screw Placement. Journal of orthopaedic trauma Githens, T. C., Campbell, S. T., Salazar, B., Goodnough, L. H., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2019

    Abstract

    To map the proximal ulnar articular margins and ensure safe extraarticular placement of implants.Ten fresh frozen adult elbow cadaver specimens were obtained. Radio opaque wire was applied to the articular margin of the articular facets and the central trochlear ridge of the proximal ulna. Fluoroscopic images were obtained demonstrating the articular facet margins. Radiographic measurements were performed and used to identify relative safe screw zones.All specimens demonstrated marked extension of the ulnar and radial facets dorsal to the central trochlear ridge. The dorsal extent of the ulnar facets from the central trochlear ridge averaged 9.7 mm (range, 7.9-13 mm; SD, 1.5 mm) and 6.2 mm (range, 3.4-9.4 mm; SD, 1.9 mm) respectively. The average footprint of the posterior ulnar facet occupied 44% (+/-4.9%) of the total ulnar height from the dorsal cortex to the trochlear ridge.The articular margins of the anterior and posterior facets of the proximal ulna are challenging to identify radiographically. A surgical "at risk zone" exists within 9.7 mm from the radiographic margin of the central trochlear ridge. Implants placed within this zone have the potential to violate the articular surface.

    View details for DOI 10.1097/BOT.0000000000001638

    View details for PubMedID 31809415

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