Impacted Fractures Research Articles

Arthroscopic Knotless Subscapularis Bridge Technique for Reverse Hill-Sachs Lesion With Posterior Shoulder Instability

Posterior shoulder dislocations are an uncommon cause of glenohumeral instability; they are frequently missed and are associated with humeral head defects and capsulolabral lesions. Despite surgical treatment often being mandatory, there is still no standardized treatment for anterior impaction fractures of the humeral head (reverse Hill-Sachs lesions). Arthroscopic surgery is typically indicated, with a tendency toward resorting to knotless techniques in recent years. We present a method for the treatment of posterior shoulder dislocations with engaging reverse Hill-Sachs lesions that achieves full defect coverage using an arthroscopic all-in-the-box knotless subscapularis bridge technique with 2 anchors—with one crossing the subscapularis tendon and the other embracing it—along with posterior capsulolabral complex restoration. This promising technique is a potentially superior alternative for the treatment of these lesions that can also be used in the presence of concomitant partial subscapularis tears.

Irreducible Femur Head Fracture-Dislocation Treatment With Kocher-Langenbeck Approach With Flip Trochanteric Osteotomy: A Novel Approach.

Femoral head fracture-dislocations are rare, and irreducible cases are even less frequent. Truly irreducible fracture-dislocations must be differentiated from incomplete reduction due to incarcerated bone or soft tissue interposition. The Pipkin classification is commonly used to classify femoral head fractures. An urgent reduction is required in traumatic hip dislocations to reduce the risk of avascular necrosis (AVN) of the femoral head. However, in femoral head fractures, the dislocated hip cannot be reduced easily due to incarcerated bone or soft tissue. In an irreducible fracture hip dislocation, It is not advisable to attempt to reduce it repeatedly because sometimes femoral head fracture-dislocation is associated with the impacted fracture of the femoral neck. It may lead to iatrogenic femoral neck fracture. Hence, in such cases, immediate open reduction and internal fixation are recommended. The Kocher-Langenbeck approach can be used for reduction and safe surgical dislocation with flip trochanteric osteotomy for fixation as a novel approach.

The Stieda fracture revisited.

This study aimed to evaluate injury patterns associated with Stieda avulsion fractures of the medial femoral condyle at the attachment of the proximal MCL. Knee radiographs and MRI scans of 11 patients with Stieda fractures were evaluated by two fellowship-trained MSK radiologists for fracture origin, integrity of the deep and superficial components of the MCL, medial retinacular structures, posterior oblique ligament, other ligamentous injuries, meniscal tears, and osteochondral injuries. The mechanism of injury and subsequent clinical management were recorded. Eight Stieda fractures only involved the meniscofemoral fibers of the deep MCL, two larger Stieda fractures related to both superficial and deep layers, and one fracture only involved the superficial layer. Posteromedial retinacular structures and posterior oblique ligament were injured in all cases. Eight had high-grade ACL injuries, but none had high-grade PCL nor FCL injuries. The proximal anterolateral ligament was injured in seven, including two with associated Segond fractures. Other injuries included posterolateral corner injuries in six, meniscal injuries in seven, and additional fractures in nine, most commonly ACL-associated impaction fractures in the lateral tibiofemoral compartment. None had high-grade chondral injury. None of the Stieda fractures were treated surgically, but four underwent subsequent ACL reconstruction. Stieda fractures most commonly involved the deep fibers of the MCL and were accompanied by moderate-to-high-grade injury of other MCL components. There was a high association with other ligamentous injuries, particularly the posterior medial retinacular structures, posterior oblique ligament, and ACL, and many were associated with additional fractures.

Fractures of the Talar Head: A Series of 16 Patients

Category:Hindfoot; TraumaIntroduction/Purpose:Fractures of the talar head are very rare accounting for just 5-10% of talus fractures and fewer than 1% of all fractures. As such, limited clinical literature is available to guide management of these injuries. We present the largest clinical series on talar head fractures to date.Methods:We performed a retrospective review of all patients presenting to three level-1 trauma centers with major fractures of the talus (fractures of the neck, body or head) over a 14-year period. From this cohort of patients, we identified patients presenting with fractures of the talar head with available computed-tomographic (CT) imaging of the foot allow proper fracture evaluation and characterization. In total, 258 patients with major fractures of the talus were identified. Sixteen patients (6.2%) with talar head fractures met inclusion criteria.Results:Most injuries were due to falls from height and only 4 were isolated. The navicular was fractured in 7 patients (43.8%). Six patients (37.5%) exhibited comminuted fracture patterns, while the remaining demonstrated simpler shear or impaction injuries. Four patients underwent fixation of the talar head, 3 were treated with primary stabilization or fusion of the talonavicular joint, and two patients were treated with head fragment excision. The talar head was managed in a closed fashion in the remaining seven patients, five of which presented with comminuted fracture patterns. Eight patients showed radiographic evidence of post- traumatic arthritis (PTA) at mean follow-up of 15.5 months. In all instances of PTA, the patient had sustained a comminuted talar fracture, an associated navicular fracture or both.Conclusion:Talar head fractures are extremely rare injuries with sparse literature to guide clinical management. Simple shearing or impaction fractures may be amenable to surgical fixation with favorable radiographic outcomes. Comminuted fractures and/or concomitant navicular trauma at the time of injury may be associated with increased incidence of talonavicular arthrosis.

Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries.

The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing. We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score. 20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded. Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

Coal bottom ash use in traditional ceramic production: evaluation of engineering properties and indoor air pollution removal ability

Coal bottom ash (CBA) disposed to landfills causes environmental issues. Thus, we used CBA in traditional clay ceramics that had the triple advantage of consuming troublesome waste, adsorbing volatile organics and being decorative indoors, replacing up to 40% by weight of clay with CBA and firing from 700 to 1300 °C. Clay and CBA mixtures were cast, cured at room temperature for 24 h and fired at several temperatures. Firing temperature impacted linear shrinkage, water absorption and fracture toughness, more strongly than CBA mixing proportion. Above 1000 °C, fracture toughness and water absorption resistance was enhanced but shrinkage increased. However, adding CBA lessened the contraction. SEM confirmed complete sintering as clay particles fused as a rigid solid above 1000 °C. X-ray diffraction patterns of ceramics containing CBA showed crystobalite and labradorite, in addition to quartz, due to flux materials in CBA. Leachability tests showed that the CBA ceramics were not ‘toxic’ on the USEPA TCLP regulatory list. Adsorption of gaseous toluene, a representative indoor pollutant, followed a Freundlich model: CBA made the adsorption sites more homogeneous, reduced the interaction mechanisms on the surfaces and thus the Freundlich exponent. Increased CBA increased toluene adsorption by 2–7 times.

Patellar fractures in elderly patients: a multicenter computed tomography-based analysis.

This study aimed to demonstrate the characteristics of patellar fractures and evaluate clinical outcomes in elderly patients. Medical records of patients aged ≥ 60years who presented with patellar fractures were retrospectively reviewed from an institutionally approved multicenter (five institutions) orthopedic database. Patient characteristics and fracture patterns were identified, and the clinical outcomes were investigated. We compared differences according to the injury mechanism (low- vs. high-energy). A total of 202 patients [mean age, 69.4years (range, 60-88years); male, 89, female, 113] were included in this study. The mean follow-up period was 14.8months (range 6-58months), and 75% of the fractures were from low-energy injuries. According to the AO /OTA classification, the most common type was type C (136 cases, 67.3%; 33 cases, C1; 23, C2; and 80, C3), followed by type A (39 cases), type B (26 cases), and unclassified (1 case). The unclassified case was an intra-articular marginal impaction without cortical breakage. Computed tomography (CT) revealed that of the cases, 66.8% had an inferior pole involvement; 80.7%, a comminuted fragment; and 10.4%, an impacted fracture. A total of 166 fractures (82.2%) were treated surgically. The mean union time and range of motion were 13.1weeks and 123.8° (range 30-150°), respectively. The Lysholm score was 82.1 ± 12.0, with 65.7% of the cases having excellent or good function. The complication rate was 12.4% (24 cases), including ten, four, two, and five cases of infection, fixation failure, nonunion, malunion, and pin migration, respectively. The reoperation rate was 26.4%. Patellar fractures in the elderly were mostly from low-energy injuries, and types C3 and A1 were the most common. CT images demonstrated high rates of an inferior pole involvement and comminution. The complication and reoperation rates were relatively high.

Post-operative outcomes associated with posterolateral tibial plateau impaction fractures in the setting of primary ACL tear

Objectives:The primary objective was to assess the effect of impaction fractures of the posterolateral tibial plateau on patient reported post-operative outcomes following primary ACL surgery.Methods:Patients with available MRI images who underwent surgery for primary ACL tears by a single surgeon between April 2010 and September 2017 were identified. A prospectively and consecutively enrolled clinical outcomes database was queried for all patients within this cohort who had 2-year or greater post-operative patient reported outcomes available. Patient reported outcomes included the 12-item Short Form Health Survery (SF-12) Physical Composite Scale (PCS) and Mental Health Composite Scale (MCS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), International Knee Documentation Committee Questionnaire (IKDC), Lysholm Knee Questionnaire, Tegner Activity Scale and patient satisfaction. For patients without existing 2-year outcomes, additional inclusion criteria included English-speaking and current age greater than or equal to 18. Patients meeting these criteria were sent electronic surveys to collect patient reported outcomes. MRI images were reviewed for all patients with denotation of displaced posterolateral tibial impaction fractures. Posterolateral tibial impactions were classified based on morphology using the following classification: (Type I) posterior cortical buckle not involving the articular surface, (Type II) posterior impaction fracture involving the articular surface [(with subtype based on (A) tibial plateau depth bone loss <10% and (B) bone loss >10%)], and (III) displaced osteochondral fragment [(with subtypes for (A) shear or (B) depressed fragment)]. All tibial impaction fractures were measured to determine amount of tibial plateau bone loss in the sagittal plane. Pre-operative and 2-year or greater post-operative patient reported outcome scales were compared based on posterolateral tibial impaction fracture classification using Kruskal-Wallis non-parametric ANOVA with Nemenyi post-hoc test. Pearson’s correlations were used to assess for correlations between post-operative patient reported outcomes and amount of tibial plateau sagittal plane bone loss present.Results:There were 638 knees identified with primary ACL tears who underwent surgery between April 2010 and September 2017. Thirty-nine patients met exclusion criteria, leaving 599 total patients. Of these, 2-year outcomes were available for 416 patients for a 69.4% follow-up rate at a mean time of 158 weeks (range: 90-422). There were statistically significant improvements in all PROs from pre-op to 2-year post-op (p < 0.001). Kruskal-Wallis non-parametric ANOVA showed no difference in all PROs based upon posterolateral impaction fracture classification type, except for Tegner Activity Scale which showed difference in outcomes based on impaction fracture type (p < .002) (Table 1). Specifically, diminished post-operative activity level was observed in patients with type 2B, type 3A, and type 3B fractures. Pearson correlation testing showed weak but statistically significant correlations between tibial plateau impaction fracture sagittal bone loss amount and SF-12 PCS (PCC: -0.156, p = 0.023), WOMAC Total Score (PCC: 0.159, p = 0.02), Lysholm (PCC: -0.203, p = .003), and Tegner Activity Scale (PCC: -0.151, p = 0.032). Independent T-testing showed no difference in any patient reported outcome scores at 2-year follow-up when all posterolateral tibial impaction fractures were grouped together compared to those without impaction fracture.Conclusion:Displaced posterolateral tibial plateau impaction fractures occurring in the setting of ACL tear are associated with diminished 2-year post-operative outcomes after ACL reconstruction. When classified based on fracture morphology, posterolateral tibial plateau impaction fracture types 2B, 3A, and 3B are associated with decreased post-operative activity level as assessed by Tegner Activity Scale. When comparing patients with posterolateral impaction fractures, greater amounts sagittal plane tibial plateau bone loss at the posterior rim showed weak but significant correlations with worse scores on SF-12 PCS, WOMAC, Lysholm, and Tegner patient reported outcome measures.Figure 1.

High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction

Background: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known. Purpose: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present. Results: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; P = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR (P < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = –0.156; P = .023), WOMAC total (PCC = 0.159; P = .02), Lysholm (PCC = –0.203; P = .003), and Tegner scores (PCC = –0.151; P = .032). Conclusion: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.

Knee Injury- A Tragic Tackle In A Weekend Warrior

HISTORY: A 25-year-old male sustained a left knee hyperextension injury while being tackled by a friend in his backyard. He had immediate pain, swelling, and was unable to ambulate. X-Rays in the ED demonstrated an avulsion fracture of unknown origin. Patient was placed in a knee immobilizer and advised to follow up with orthopedics. Three days later, he presented to clinic with pain, swelling, significant instability, numbness and coolness in left foot, and inability to dorsiflex his left ankle. PHYSICAL EXAM: Knee examination revealed significant ecchymosis of the posterior-lateral aspect of the knee and positive effusion. Coolness and decreased sensation to distal one third of left leg. He had a positive foot drop. Difficulty palpating dorsalis pedis pulse. Good capillary refill. Significant laxity to lateral collateral ligament in full extension (0 degrees). Positive Lachman’s as well as laxity with posterior drawer testing. DIFFERENTIAL DIAGNOSIS: 1. Knee dislocation with peroneal neuropraxia and possible popliteal artery injury 2. Multi-ligament left knee injury with peroneal neuropraxia and possible popliteal artery injury TESTS AND RESULTS: CT angiogram- No arterial injury MRI - Edema and nonorganized hematoma involving gastrocnemius, soleus, popliteus, and tibialis anterior. Detached medial and lateral patellar retinaculum, medial and lateral meniscus tears. Partial tear of PCL, MCL strain, ruptured ACL and LCL. Thin but intact peroneal nerve noted. Avulsion fracture of biceps femoris and tear of popliteus tendon. Medial femoral condyle osteochondral impaction fracture. FINAL WORKING DIAGNOSIS: Multi-ligament left knee injury. Avulsion fracture of biceps femoris. Meniscal tears. Peroneal nerve injury without arterial injury. TREATMENT AND OUTCOMES: 1. Surgical repair 2 weeks after injury. 2. Extensive rehabilitation (0-6 weeks post-op: ROM exercises 0-90; 6-12 weeks post-op: strengthening exercises and advancing weight bearing 25% weekly). 3. Functional brace. 4. Continued monitoring for peroneal nerve improvement in motor and sensation. 4. Had discussion with patient regarding limited outcome and primary goal of function. 5. Unlikely to return to sport.

Arthroscopically-assisted reduction and pinning of a radial neck fracture in a child: a case report and review of the literature

BackgroundDisplaced radial neck fractures in children are challenging to treat. The age of the patient and the degree of angulation are the main criteria to consider when managing these fractures in children. Various surgical techniques have been described in the literature for both indirect and direct reduction and for fixation. However, the best treatment is still debated.Case presentationThe case presented is of a 6-year-old Caucasian boy with an impacted and displaced radial neck fracture. With the patient in lateral position, under general anesthesia, elbow arthroscopy was performed to better visualize the articular surface and to assist with reduction and fixation. The fracture was reduced and fixed with a single K-wire under direct arthroscopic visualization. No associated lesions were found. An above-elbow cast was applied after surgery. The cast and K-wire were removed 3 weeks later. At the 3-month follow-up, the patient showed a full recovery with complete range of movement without any postoperative and radiographic complications.ConclusionTraditionally, surgery for displaced radial neck fractures in children is performed by closed reduction with percutaneous pinning or elastic intramedullary nail fixation under fluoroscopic guidance. Direct visualization of the articular surface via an open approach allows better reduction in complex fracture patterns but is related to a higher risk of complications: elbow stiffness, instability, or avascular necrosis. Elbow arthroscopy in children could be a valid alternative to open fixation surgery for displaced radial neck fractures without the complications associated with articular exposure, allowing the direct visualization of the fracture and reducing radiation exposure. Although technically demanding, we believe elbow arthroscopy should be considered an alternative option because it is effective in assisting reduction and fixation and enables the detection of associated joint lesions.

A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model

This study aimed to classify the pathomorphology of impacted proximal humeral fracturesaccording to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making. In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated. From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree. The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.

Functional outcomes following delayed hemi-hamate arthroplasty for proximal interphalangeal joint reconstruction

Palmar lip fractures at the base of the middle phalanx are well-regarded as a difficult condition to treat, with many treatment strategies leading to pain and impairment. Hemi-hamate resurfacing arthroplasty for the proximal interphalangeal joint surface has been described in the literature as a surgical option in the management of this fracture type. This case series aims to describe our institution’s experience with hemi-hamate arthroplasty for this type of fracture. Six patients from a single institution who underwent hemi-hamate arthroplasty for treatment of impacted dorsal fracture dislocations of the base of the middle phalanx between 2014 and 2018 were retrospectively reviewed. Four patients were managed at a time frame greater than 100 days, with a range between 32 and 50% of articular joint involvement. Functional outcomes and pain scores following hemi-hamate arthroplasty in both acute and chronic presentations resulted in adequate range of motion and grip strength, with minimal pain at either fracture or donor site. No cases of non-union were seen in our cohort. Based on our experience, hemi-hamate arthroplasty is a viable option in the management of intra-articular fracture dislocations of the base of the middle phalanx. Level of evidence: Level IV, therapeutic study.

Impaction fractures of the anterior tibial plafond: Outcomes after fractures around the ankle: Is the anterior impaction plafond fracture a problem?

Objectives:To determine whether patients with AO/OTA 43-B anterior impaction tibial plafond fractures have worse clinical outcomes, and an increased risk of progression to ankle arthrodesis.Design:Retrospective cohort study.Setting:Level 1 academic trauma center.Patients:One hundred sixty-eight patients were included in the study, all of whom had tibial plafond fractures.Intervention:Study patients underwent external fixation and/or open reduction internal fixation (ORIF) as indicated by fracture/injury pattern.Main outcome measurements:Arthrodesis rate.Results:AO 43-B Anterior impaction tibial plafond fractures have an increased risk of progression to arthrodesis when compared to AO 43-B nonanterior impaction type fractures (19.4% vs 8%).Conclusions:AO 43-B anterior impaction tibial plafond fractures have a worse clinical outcome compared to AO 43-B nonanterior impaction fractures. These fractures also confer increased risk of progression to arthrodesis.Conflicts of interestThe authors have no conflict of interests to declare.

Conservative vs Surgical Treatment of Impacted Femoral Neck Fracture in Patients 75 Years and Older

To evaluate the safety and effectiveness of conservative treatment (CST), internal fixation (IF), and hemiarthroplasty (HA) in treating patients older than 75 years with impacted femoral neck fracture (IFNF). A randomized clinical trial to compare clinical outcomes of CST, IF, and HA in IFNF patients older than 75 years with a 1:1:1 ratio. Nanjing First Hospital, Nanjing Medical University, Nanjing, China. A total of 154 patients with IFNF aged between 75 and 97 years. Patients with IFNF were allocated to CST, IF, and HA. They all received a 36-month follow-up. All patients were evaluated by Harris hip score (HHS) (primary outcome) for hip function, European Quality of Life-5 Dimensions (EQ-5D) index scores for health-related quality of life, and visual analogue scale score for hip pain. Operation duration, blood loss, mortality, union rate, complications, and reoperation were also recorded. Assessors were blind to the type of treatment. The baseline parameters of the three groups were similar. IF group had much lower blood loss than HA group (P < .05), while no significant difference in operative duration was found between the two groups (P > .05). HHS in HA group was significantly higher at 1, 3, and 6 months (P < .05), but no significant difference in HHS was found between CST and IF groups at any of the time points during the overall follow-up (P > .05). EQ-5D index score was higher in HA group at each follow-up within 1 year (P < .05), but the difference was not significant at 2- and 3-year follow-up (P > .05). There was no significant difference in mortality among the three groups at each follow-up point (P > .05). The nonunion rate was 11.76% (6/51) in CST group and 9.80% (5/51) in IF group and showed no significant difference (P > .05). CST may be a feasible way for IFNF in the older patients. ClinicalTrials.gov Identifier: NCT04219943. J Am Geriatr Soc 68:2214-2221, 2020.

Trampoline-related proximal tibia impaction fractures in children: a population-based approach to epidemiology and radiographic findings between 2006 and 2017.

PurposeProximal tibia impaction fractures are specific injuries, usually caused by trampolining. They may associate with later growth disturbances. There is sparse understanding about their recent epidemiology, in particular the changing incidence. Their typical radiographic findings are not completely known.MethodsAll children, aged < 16 years, who had suffered from proximal tibia fracture in Oulu Arc and Oulu between 2006 and 2017 were enrolled (n = 101). Their annual incidence was determined using the official population-at-risk, obtained from the Statistics Finland. The specific characteristics and risk factors of the patients and their fractures were evaluated. Radiographic findings were analyzed, in particular the anterior tilting of the proximal growth plate, due to impaction.ResultsThe annual incidence increased two-fold from 9.5 per 100 000 children (2006 to 2009) to 22.0 per 100 000 (2014 to 2017) (difference: 12.5; 95% confidence interval 5.1 to 20.3 per 100 000; p = 0.0008). The mean annual incidence of trampoline impaction leg fractures was 15.4 per 100 000 children. In 80% of the cases multiple children had been jumping together on the trampoline. Anterior tilting (mean 7.3°, SD 2.5°, 6.1° to 19.1°) ) of the proximal tibial plate was seen in 68.3% of the patients. Satisfactory bone union was found in 92.7% during follow-up. Isolated patients presented delayed bone healing.ConclusionThe incidence of trampoline leg fractures has increased 130% during the 12 years of the study period. Many of these injuries could have been prevented by avoiding having several jumpers on the trampoline at the same time. Anterior tilting of the growth plate was a common finding and should be recognized in the primary radiographs.Level of evidenceIV

Fate of the lateral femoral notch following early anterior cruciate ligament reconstruction

BackgroundThe goal of this longitudinal study was to investigate the fate of the lateral femoral notch (LFN), which is frequently seen as an impaction fracture of the lateral femoral condyle in patients with anterior cruciate ligament (ACL) tears. MethodsPatients who underwent early ACL reconstruction between 2006 and 2010 were reviewed. If post-injury magnetic resonance images showed an LFN greater than 1.5 mm in depth, patients with untreated LFN were followed. Two blinded observers performed quantitative and qualitative imaging analysis. ResultsSixteen patients (five women, 11 men) were available for follow-up nine years (six to 10 years) post-injury. The median defect area of the LFN significantly decreased from 2.3 cm2 (range: 0.9–3.8 cm2) to 1.6 cm2 (range: 0.4–3.2 cm2) (P < .001). The defect depth did not significantly change from 2.3 mm (range: 2.0–3.6 mm) to 2.5 mm (range: 1.3–3.6 mm) (P > .05). The International Cartilage Repair Society (ICRS) score increased from 1.5 (range: 0–3) post-injury to 2.0 (range: 0–4) at follow-up (P < .01). The Lysholm score was 93 (72–100), the Tegner activity level was 6 (3–9) and the knee injury and osteoarthritis outcome score (KOOS) score was 97 (91–100). ConclusionsThe defect area of the LFN decreased overtime, whereas the depth of the impression remained. Focal cartilage lesions were found in all except two patients post-injury and progressed during follow-up. However, patient-reported outcome scores were satisfying.

Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

Background: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. Purpose: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. Study Design: Case series; Level of evidence 4. Methods: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. Results: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). Conclusion: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.

Morphologic Variants of Posterolateral Tibial Plateau Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

Background: Impaction fractures of the posterolateral tibial plateau commonly occur in the setting of anterior cruciate ligament (ACL) tears, with considerable variability found in fracture size and morphologic features. Purpose: The primary objective was to characterize different morphologic variants of posterolateral tibial plateau impaction fractures. The secondary objective was to investigate the association between these impaction fracture variants and concomitant meniscal and ligamentous injuries. Study Design: Cross-sectional study; Level of evidence 3. Methods: Patients treated for primary ACL tears and having magnetic resonance imaging available were included in this study, and magnetic resonance images were reviewed with denotation of displaced posterolateral tibial impaction fractures. A classification system was created based on morphologic variants of impaction fractures; associations were evaluated through use of independent chi-square testing. Results: There were 825 knees meeting the inclusion criteria, with displaced posterolateral tibial plateau impaction fractures present in 407 knees (49.3%). We observed 3 distinct morphologic variants of lateral tibial plateau impaction fractures: (I) posterior cortical buckle not involving the articular surface; (II) posterior impaction fracture involving the articular surface, with subtypes based on (A) tibial plateau depth bone loss <10% and (B) bone loss >10%; and (III) displaced osteochondral fragment, with subtypes for (A) shear or (B) depressed fragment. Type IIIA impaction fractures were associated with an increased incidence of lateral meniscus posterior root tears (33.3% vs 12.4%; P = .009) and an increased incidence of lateral meniscal tears (83.3% vs 56.7%; P = .024) compared with all knees without type IIIA impaction fracture. An increased incidence of medial collateral ligament (MCL) tears was noted in patients with type IIIA impaction fractures compared with those who had no fracture or had another fracture type (61.1% vs 20.1%; P < .001). Type IIIB impaction fractures were associated with an increased incidence of lateral meniscal tears (80.0% vs 56.2%; P = .005). Conclusion: A high prevalence of displaced posterolateral tibial plateau impaction fractures occur in the setting of ACL tears, and they can be classified into distinct morphologic subtypes. Posterolateral tibial plateau impaction fractures with displaced depressed or shear fragments were both associated with an increased incidence of lateral meniscal tears, whereas impaction fractures with a shear fragment were associated with an increased incidence of lateral meniscus posterior root tears and MCL tears.

Poor results of functional treatment of Garden-1 femoral neck fracture in dependent patients

IntroductionVariable results are reported after functional treatment for Garden-1 femoral neck fracture, with no definite factors for failure, particularly in the absence of selection for risk. It seems well indicated in frail and/or dependent patients with comorbidities, but this has not been specifically assessed, and failure is frequent in this target population. We therefore performed a retrospective study to: (1) assess results of functional treatment for Garden-1 impacted femoral neck fracture in dependent patients, and (2) analyze survival in terms of complications and death, and related factors. HypothesisFunctional treatment for Garden-1 fracture in dependent patients gives poor results, with a high rate of surgical revision. Material and methodsA retrospective analysis was made of Garden-1 femoral neck fracture in dependent patients (Parker score≤5), with a minimum 2 years’ follow-up. One hundred and forty-six patients were included: mean age, 81.3±8.7 years (range, 55.7–99.6 years). The endpoint was survival in terms of complications requiring surgery, secondary displacement requiring surgery, excessive pain requiring surgery, non-union or femoral head osteonecrosis. Secondary endpoints were overall mortality and mortality related to complications. ResultsMean follow-up was 4.2±2.6 years (range, 2.0–10.3 years). Ninety-one of the 146 patients (62.3%) required secondary surgery: 79 (54.1%) early (<3 months post-fracture), with 77 (52.7%) secondary displacements and 2 cases (1.4%) of excessive pain; and 12 (8.2%) late (162.2±132.3 days; range, 90–454 days), with 8 (5.4%) non-unions and 4 (2.7%) osteonecroses. Mean time to onset of secondary displacement was 13.6±11.8 days (range, 0–67.0 days). Two-year survival in terms of revision surgery was 34.1% [95% CI: 26.0–42.4]. At last follow-up, 91 patients (62.3%) had died; 2-year survival in terms of death was 69.9% [95% CI: 62.4–77.3]. Survival analysis in terms of complications revealed greater mortality in absence of complications: 42 of the 55 patients (76.3%) without complications requiring surgery died, versus 49 of the 91 (53.8%) with complications requiring surgery (p=0.012); relative risk of death in absence of complications requiring surgery was 1.42 [95% CI: 1.33–5.77]. DiscussionFunctional treatment for Garden-1 fracture in dependent patients gave poor short- and medium-term results. Surgery is therefore recommended in this specific population; the present findings should improve survival. Level of evidenceIV, retrospective study.