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The etiology of maxillofacial fractures (MFFs) varies according to the geographical location and density of the population. This study aimed to analyze the etiology, pattern, and treatment of MFFs. Epidemiological characteristics and treatment modalities of MFFs have never been evaluated in Somalia. The study included 45 patients who were operated on for MFFs at a tertiary care hospital in Somalia (2018-2019). Patient demographics, fracture causes, types, associated non-facial injuries, treatment modalities, and hospitalization-time were evaluated. The most common etiological factors of the MFFs were explosion (24.4%) and assault (24.4%), followed by gunshot (22.2%), sports accident (15.6%), motor vehicle accident (11.1%), and fall from height (2.2%) patients, respectively. The main site of injury was the mandible bone (64.4%) followed by nasal bone, maxilla, zygomatic, and orbital region. The most common non-facial injuries of the MFFs were soft tissue laceration (37.8%) followed by femoral fracture (6.7%), clavicle fracture (4.4%), and femoral fracture with chest injuries (2.2%). The most applied treatment was open reduction microplate +/- intermaxillary fixation (77.8%). Due to the size of the mandible fractures, an iliac autograft (6.7%) was performed. The mean length of the hospital stay was 11.8 ± 8.4 days (range, 1-45 days), and some patients (15.6%) needed intensive care due to severe injuries. This will be the first study aiming to analyze the etiology, pattern, and treatment of MFFs in Somalia. This study deals with the social aspects of Somalia, and it shows that MFFs develop as a result of highly interpersonal violence in a young man.

BACKGROUND Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures. METHODS We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed. RESULTS Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P

Background Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems. Methods Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software. Results The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was -1.95 (range, -4.1 to -0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant. Conclusions Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. Clinical relevance These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.

Acetabular articular impaction may well accompany acetabular fractures. Anatomic restoration of acetabular congruence is imperative to achieve longevity of the hip joint. Combination of incarcerated acetabular impaction with osteochondral femoral fracture is a true challenge for the pelvic surgeon to address. We describe a technique to treat a posterior column acetabular fracture in association with incarcerated articular impaction and concomitant osteochondral femoral fracture. Posterior wall osteotomy combined with surgical hip dislocation facilitates the restoration of femoral head anatomy and acetabular surface integrity. This technique should be considered when dealing with this difficult scenario.

BACKGROUND Distal femoral replacement (DFR) is a salvage option for complex primary and revision total knee arthroplasty (TKA). Although excellent immediate fixation and weight-bearing are achieved, there is a paucity of data on long-term outcomes of TKA with DFR. The purpose of the present study was to determine implant survivorship, clinical outcomes, and radiographic results of TKAs with contemporary DFR components in a large series. METHODS We identified 144 consecutive TKAs performed with DFR for non-oncologic indications from 2000 to 2015 at a single academic institution. Indications for the index DFR included 66 (46%) for native (n = 11) or periprosthetic (n = 55) femoral fracture, 40 (28%) for staged treatment of periprosthetic joint infection, 28 (19%) for aseptic TKA loosening, and 10 (7%) for other indications. Porous metal cones were used to augment femoral fixation in 28 patients (19%) and tibial fixation in 38 patients (26%). Outcomes included cumulative incidence of revision and reoperation (utilizing a competing risk model), Knee Society scores, and radiographic results. The mean age at the time of index DFR was 72 years, and 65% of patients were female. The mean follow-up was 5 years (range, 2 to 13 years) for the 111 patients who did not undergo revision, had not died, and were not lost to follow-up. RESULTS The 10-year cumulative incidences of revision for aseptic loosening, all-cause revision, and any reoperation were 17.0%, 27.5%, and 46.3%, respectively. There was an increased risk of reoperation in patients who underwent index DFR for aseptic TKA loosening (hazard ratio [HR], 2.30; p = 0.026) or periprosthetic joint infection (HR, 2.18; p = 0.022) compared with periprosthetic or native femoral fractures. However, there was no difference in risk of revision for aseptic loosening or all-cause revision based on the original operative indication. The mean Knee Society score increased from 45 preoperatively to 71 at the time of the latest follow-up (p < 0.001). Radiographic loosening was observed in 8 unrevised DFRs (7%). There were 7 above-the-knee amputations performed at the time of the final follow-up, all for intractable periprosthetic joint infection. CONCLUSIONS TKAs with contemporary DFR had high 10-year cumulative incidences of both revision and reoperation, underscoring the salvage nature of this procedure as a final reconstructive option. Most patients experienced substantial clinical improvements with this end-stage revision procedure. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Isolated femoral and tibial fractures are 2 of the top 5 causes of pediatric orthopaedic hospital admission, yet their simultaneous ipsilateral presentation, the "floating knee" injury, remains rare. Historically, treatment consisted of traction and cast immobilization, which resulted in prolonged periods of immobilization, lengthy hospitalizations, and high rates of malunion. As such, previous authors have recommended fixation of at least 1 bone in the setting of a floating knee injury. This strategy, however, has never been evaluated and the outcomes of modern treatment are unknown. Methods We performed a multicenter retrospective review of the records of pediatric patients with ipsilateral femoral and tibial fractures that had been treated at 11 tertiary care level-I pediatric trauma centers from 2004 to 2014. Outcomes and treatment strategies were assessed with standardized means. Results Over the study period, 130 floating knees in 129 patients met the inclusion criteria for evaluation. The average patient age was 10.2 years, and 63.1% were male. One-third of the patients presented with open injuries, and 83.8% of injuries were related to vehicular trauma. Simple diaphyseal fractures (OTA/AO 32-A and B femoral fractures and OTA/AO 42-A and B tibial fractures) were most common. Intramedullary fixation (rigid or flexible) was the most common treatment strategy for femoral fractures (69.2%). Tibial fractures were treated most commonly with casting (27.7%), followed by flexible intramedullary nailing (24.6%). The mean duration of hospitalization was 9.7 days. Outcomes were excellent in 66.6% of cases and good in 26.4% of cases. Conclusions Previous literature on pediatric floating knee injuries consisted of small case series that were published prior to the introduction of flexible intramedullary nailing to North America. This multicenter study of a large cohort demonstrates a change in practice pattern from a largely nonoperative treatment strategy to operative fixation of at least the femoral fracture. In the present study, this approach led to good or excellent results in 93.1% of cases and was associated with a short duration of hospitalization. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Recently, many studies have suggested that timely surgery to treat proximal femoral fractures can benefit patients in many respects. However, both the short- and long-term outcomes, and the perioperative complications, of early surgery remain controversial. In addition, the optimal cut-off time for early surgery remains unclear. Thus, we performed a meta-analysis to compare and evaluate the benefits of early versus delayed surgery in terms of the clinical outcomes of patients with proximal femoral fractures. Methods We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases to February 1, 2018 and retrieved original studies comparing the efficacy of early versus delayed surgery for proximal femoral fractures. We calculated risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (CIs) and compared the outcomes of early and delayed surgery. We performed subgroup analyses to explore mortality and perioperative complications associated with different cut-off times for surgery, for various periods. Two reviewers assessed the quality of the included studies and independently extracted the data. We followed the suggestions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. All statistical analyses were performed using the standard statistical procedures of Review Manager 5.2. Results A total of 27 studies (N = 33,727 participants) were included in the present analysis. Compared to delayed surgery, early surgery significantly reduced mortality and complications. The mortality rates of patients who underwent surgery within 48 and 24 h of fracture were 28 and 23% less than those of patients operated upon after 48 h (RR = 0.72; 95% CI: 0.71–0.73) and 24 h (RR = 0.77; 95% CI: 0.65–0.93). In addition, early surgery was associated with fewer perioperative complications than delayed surgery (OR = 0.52; 95% CI: 0.35–0.76), especially in terms of postoperative pressure ulcers (OR = 0.55; 95% CI: 0.45–0.68), urinary tract infections (OR = 0.57; 95% CI: 0.49–0.67), and thromboembolic events (OR = 0.61; 95% CI: 0.39–0.96). Conclusions Early surgery reduces mortality associated with proximal femoral fractures and the frequency of serious perioperative complications when comparing with delayed surgery.

Background This study aimed to identify the risk factors and complications associated with mortality in elderly patients with femoral fracture after a fall from the ground level. Methods This retrospective study reviewed data pertaining to elderly patients aged ≥65 years who were admitted into a Level I trauma center, between January 1, 2009 and December 31, 2017. Multivariate logistic regression analysis was performed to identify independent effects of univariate predictive variables on the occurrence of mortality. Results Of 2407 enrolled elderly patients, there were 42 mortal and 2365 survival patients. A greater percentage of fatal patients than survival patients had a head injury with abbreviated injury scale (AIS) score ≥ 2 in the head/neck region (4.8% vs. 0.7%, respectively; p = 0.042). Multivariate logistic regression analysis revealed that the age (odds ration [OR] 1.1, 95% confident interval [CI] 1.0–1.1, p Conclusions This study identified age, pre-existence of ESRD, and SAH as significant independent risk factors for mortality in elderly patients with femoral fracture in a fall. However, ESRD and SAH only contribute to the mortality in a small group of patients. In contrast, respiratory complications contributed greatly to mortality. Thus aggressive chest-protective measures are encouraged to decrease the respiratory complications associated with femoral fracture in elderly patients.

Background Femoral osteotomies have been widely used to treat a wide range of developmental and degenerative hip diseases. For this purpose, different types of proximal femur osteotomies were developed: at the neck as well as at the trochanteric, intertrochanteric, or subtrochanteric levels. Few studies have evaluated the impact of a previous femoral osteotomy on a THA; thus, whether and how a previous femoral osteotomy affects the outcome of THA remains controversial. Questions/purposes In this systematic review, we asked: (1) What are the most common complications after THA in patients who have undergone femoral osteotomy, and how frequently do those complications occur? (2) What is the survival of THA after previous femoral osteotomy? (3) Is the timing of hardware removal associated with THA complications and survivorship? Methods A systematic review was carried out on PubMed, the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: "THA", "total hip arthroplasty", and "total hip replacement" combined with at least one of "femoral osteotomy" or "intertrochanteric osteotomy" to achieve the maximum sensitivity of the search strategy. Identified studies were included if they met the following criteria: (1) reported data on THAs performed after femoral osteotomy; (2) recorded THA followup; (3) patients who underwent THA after femoral osteotomy constituted either the experimental group or a control group; (4) described the surgical and clinical complications and survivorship of the THA. The database search retrieved 383 studies, on which we performed a primary evaluation. After removing duplicates and completing a full-text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in the final review. Specific information was retrieved from each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The mean MINORS score for the historically controlled studies was 14 of 24 (range, 10-17), whereas for the case series, it was 8.1 of 16 (range, 5-10). Results The proportion of patients who experienced intraoperative complications during THA ranged from 0% to 17%. The most common intraoperative complication was femoral fracture; other intraoperative complications were difficulties in hardware removal and nerve palsy; 15 studies reported on complications. The survivorship of THA after femoral osteotomy in the 13 studies that answered this question ranged from 43.7% to 100% in studies that had a range of followup from 2 to 20 years. The timing of hardware removal was described in five studies, three of which detailed more complications with hardware removal at the time of THA. Conclusions This systematic review demonstrated that THA after femoral osteotomy is technically more demanding and may carry a higher risk of complications than one might expect after straightforward THA. Staged hardware removal may reduce the higher risk of intraoperative fracture and infection, but there is no clear evidence in support of this contention. Although survivorship of THA after femoral osteotomy was generally high, the studies that evaluated it were generally retrospective case series, with substantial biases, including selection bias and transfer bias (loss to followup), and so it is possible that survivorship of THA in the setting of prior femoral osteotomy may be lower than reported. Level of evidence Level III, therapeutic study.

Background Power tools are an integral part of orthopaedic surgery but have the capacity to cause iatrogenic injury. With this systematic review, we aimed to investigate the prevalence of iatrogenic injury due to the use of power tools in orthopaedic surgery and to discuss the current methods that can be used to reduce injury. Methods We performed a systematic review of English-language studies related to power tools and iatrogenic injuries using a keyword search in MEDLINE, Embase, PubMed, and Scopus databases. Exclusion criteria included injuries related to cast-saw use, temperature-induced damage, and complications not clearly related to power-tool use. Results A total of 3,694 abstracts were retrieved, and 88 studies were included in the final analysis. Few studies and individual case reports looked directly at the prevalence of injury due to power tools. These included 2 studies looking at the frequency of vascular injury during femoral fracture fixation (0.49% and 0.2%), 2 studies investigating the frequency of vertebral artery injury during spinal surgery (0.5% and 0.08%), and 4 studies investigating vascular injury during total joint arthroplasty (1 study involving 138 vascular injuries in 124 patients, 2 studies noting 0.13% and 0.1% incidence, and 1 questionnaire sent electronically to surgeons). There are multiple methods for preventing damage during power-tool use. These include the use of robotics and simulation, specific drill settings, and real-time feedback techniques such as spectroscopy and electromyography. Conclusions Power tools have the potential to cause iatrogenic injury to surrounding structures during orthopaedic surgery. Fortunately, the published literature suggests that the frequency of iatrogenic injury using orthopaedic power tools is low. There are multiple technologies available to reduce damage using power tools. In high-risk operations, the use of advanced technologies to reduce the chance of iatrogenic injury should be considered. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Flexible intramedullary nailing is performed for femoral fractures in pediatric patients who may be too large for spica cast immobilization but who have substantial growth remaining and who are not a candidate for rigid intramedullary nailing. Flexible nailing allows the surgeon to obtain correct alignment of the femur fracture so as to allow for healing without a lower extremity deformity. Description The patient is positioned on a radiolucent table, flexible nails are chosen according to the diameter of the medullary canal, medial and lateral incisions are made along the distal aspect of the thigh, and access to the canal is obtained with use of a drill-bit of the appropriate size. Flexible nails are contoured to place the apex at the location of the fracture site and then passed 1 at a time up to the fracture through the medial and lateral corticotomies. Fracture reduction is obtained, and the nails are passed across the fracture 1 at a time. Leave a small amount of nail prominent at the entry site; the nails are then cut and advanced with a tamp. Alternatives Spica cast immobilization, rigid intramedullary nailing, external fixation, and submuscular plating. Rationale Flexible nailing provides relative stability of a femoral fracture similar to external fixation, submuscular plating, and rigid nailing; however, external fixators come with pin-track complications and infections, as well as a bulky device external to the thigh. Submuscular plating is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult. In an older child with growth remaining, a rigid femoral nail is an option with similar outcomes to flexible nailing; however, the implant is harder to remove. Flexible nailing provides a cosmetic incision with reliable relative fixation in length-stable fractures, and easy removal of implants with equal or even improved outcomes compared with other surgical techniques. Expected outcomes The outcomes of this procedure are excellent. Most pediatric femoral fractures treated with flexible nailing heal well with few complications. Angulation at the fracture site is the most common complication and is more common in fractures of the proximal or distal third of the femur1. Worse outcomes occur in older children and children who are heavier1. Outcomes are improved when flexible nailing is done in length-stable fractures; however, postoperative immobilization in a single-leg spica cast or knee immobilizer can augment fixation in fractures that are not stable. Implant irritation can occur at the insertion site; however, the implants are easy to remove once the fracture has healed. There is a substantially lower rate of malunion when stainless-steel nails (6%) are utilized compared with titanium nails (23%). Consideration should therefore be given to the use of stainless-steel nails for pediatric femoral fractures2. Important tips Use a radiolucent table with either a post or a sheet for counter-traction aids during reductionUse stainless-steel nailsPass the easier nail firstAdvance into the femoral neck or trochanteric apophysisDo not wrap rods around each otherCut off the machined tip of the nail and custom-contour the nail in patients with poor bone quality.

OBJECTIVE Traction achieved using an intraoperative femoral fracture reduction device (IFFRD) was compared with that observed using a traction table (TT) for closed reduction of trochanteric fractures and cephalomedullary nail fixation. DESIGN Prospective cohort study. SETTING Level 1 trauma center. PATIENTS One hundred forty-one eligible patients with 141 fractures (Orthopaedic Trauma Association type 31-A1, n = 28; A2, n = 75; and A3, n = 38 cases) were randomized to the IFFRD (n = 73) or TT (n = 68) group. INTERVENTION The IFFRD was used while the patient was placed on a normal radiolucent operation table with 25-30 degrees elevation of the injured side to allow for antero-posterior and lateral fluoroscopic examination and facilitate entry-point guide wire insertion. MAIN OUTCOME MEASURES Patient demographics, operative and fluoroscopy duration, quality of fracture reduction, and radiological bone union time were recorded. RESULTS Patient demographics were similar between groups. Duration of patient positioning was longer in the TT group (P < 0.05); duration of fluoroscopy, fracture reduction, and time to union were comparable. CONCLUSIONS An IFFRD used with a normal radiolucent operation table decreased patient positioning time, with efficacy comparable to the TT approach for closed reduction of trochanteric fractures. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anti-nerve growth factor (anti-NGF) therapy has shown significant promise in attenuating several types of skeletal pain. However, whether anti-NGF therapy changes the level of physical activity in individuals with or without skeletal pain is largely unknown. Here, automated day/night activity boxes monitored the effects of anti-NGF treatment on physical activity in normal young (3 months old) and aging (18-23 months old) mice and mice with bone fracture pain. Although aging mice were clearly less active and showed loss of bone mass compared with young mice, anti-NGF treatment had no effect on any measure of day/night activity in either the young or aging mice. By contrast, in mice with femoral fracture pain, anti-NGF treatment produced a clear increase (10%-27%) in horizontal activity, vertical rearing, and velocity of travel compared with the Fracture + Vehicle group. These results suggest, just as in humans, mice titrate their level of physical activity to their level of skeletal pain. The level of skeletal pain may in part be determined by the level of free NGF that seems to rise after injury but not normal aging of the skeleton. In terms of bone healing, animals that received anti-NGF showed an increase in the size of calcified callus but no increase in the number of displaced fractures or time to cortical union. As physical activity is the best nondrug treatment for many patients with skeletal pain, anti-NGF may be useful in reducing pain and promoting activity in these patients.

REVIEW OBJECTIVE The objective of this review is to identify the effectiveness of operative interventions for individuals who have undergone a hemi or total hip arthroplasty who sustain a Vancouver type B2 peri-prosthetic femoral fracture or equivalent. Specifically, this review will investigate open reduction and internal fixation and femoral revision arthroplasty with or without internal fixation.

BACKGROUND Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P

We present a case of a 10-year-old girl shot in the thigh by a stray bullet who had a favorable outcome when treated with a multidisciplinary approach at the nearest nonpediatric level II trauma center. Point-of-care thromboelastography facilitated effective resuscitation based on her coagulation profile, minimized blood product use, and allowed for damage-control surgery to stabilize and revascularize her complex femur fracture.

The aim of this study was to evaluate the risk factors related to osteosynthesis failure in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction; unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct. Patients over the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level one medical center between 2003 and 2019 were included. Treatment modalities included single construct with/without an antirotational screw for the neck and dual constructs. Radiographic outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher exact test was used to analyze categorical variables. The presence of avascular necrosis of the femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture, and loss of reduction were identified as factors related to treatment failure. A total of 22 patients were included in this study. The average age was 58.5 years, and the majority was male (68.2%). The minimum radiographic follow-up duration was 12 months, and the median follow-up time was 12 (interquartile range 12–24) months. Femoral neck osteosynthesis failed in 3 patients, whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct cohort in 16 infra-isthmus femoral fracture cases (P = .034). In ipsilateral femoral neck and infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate implants (dual constructs). In a dual-construct cohort, separate plate fixation of the femoral shaft achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union rate: 4/8 vs 0/2).

BACKGROUND In the United States intertrochanteric and pertrochanteric fractures occur at a rate of more than 150,000 cases annually. Current standard of care for these fractures includes fixation with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). The purpose of this study was to compare failure and medical complications of intertrochanteric femoral fractures repaired by CMN or SHS. METHODS This study is a retrospective cohort study that included 249 patients with AO/OTA 31 A1.1-3, 31 A2.1-3 nonpathological fractures of the femur, of which 137 received CMN and 112 received SHS. Analysis was stratified by fracture type as stable (AO 31A1.1-2.1) or unstable (AO 31A2.2-3). RESULTS The tip-apex distance in stable fractures fixed with CMN was 17.3 ± 5.9 compared to 26.2 ± 7.9 in the stable SHS group (p 0.05). Among patients with unstable fractures CMN had significantly less collapse (P < 0.001) and failure (P = 0.046) but no difference in complications (P = 0.126) or mortality (P = 0.586). CONCLUSIONS There were no significant differences in failure or complication rates when comparing the CMN to the SHS in stable intertrochanteric fractures. CMN demonstrated significantly reduced failure and collapse rates in unstable intertrochanteric fractures when compared to SHS; however, this study had a relatively small sample size of unstable fractures and all results must be interpreted within this context.

BACKGROUND The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012. METHODS From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. RESULTS A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P

Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age).A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables.Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p0.001), were heavier (mean, 21.5 versus 18.0 kg; p0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p0.001), primarily for elective implant removal.Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.

Background Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. Objectives The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. Patients and methods Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. Results Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75–85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). Conclusions Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.

Periprosthetic distal femoral fracture after total knee arthroplasty carries substantial morbidity and mortality regardless of fixation technique. Surgical treatment is favored in most patients compared with conservative therapy because of high rates of nonunion, malunion, and reoperation after casting or bracing. Internal fixation techniques including retrograde intramedullary nailing and locked plating are favored for surgical treatment in most fractures when bone stock in the distal fragment allows for appropriate fixation. In the setting of deficient distal femoral bone stock or femoral component loosening, revision arthroplasty with distal femoral replacement is the favored technique. Further studies with regard to the use of intramedullary nailing, locked plating, and distal femoral replacement are necessary to refine the indications for each technique and to define the use of combinations of these fixation techniques.

Ventilators, masks, and tests are in short supply Background: From February 20 to April 2020, the coronavirus SARS (severe acute respiratory syndrome)-CoV-2 spread in northern Italy, drastically challenging the care capacities of the national health care system Unprepared for this emergency, hospitals have quickly reformulated paths of assistance in an effort to guarantee treatment for infected patients Orthopaedic departments have been focused on elderly traumatology, especially the treatment of femoral neck fractures in patients with coronavirus disease-2019 (COVID-19) The purpose of the present study was to evaluate the orthopaedic management strategy for femoral fragility fractures in COVID-19-positive patients with the hypothesis that operative treatment may contribute to the overall stability of the patient Methods: Sixteen patients affected by proximal femoral fracture and a recent history of fever, shortness of breath, and desaturation were admitted to the emergency room Thoracic computed tomography (CT) and oropharyngeal swabs confirmed that they were positive for COVID-19, requiring hospitalization and prophylaxis with low-molecular-weight heparin Results: Three patients died before surgery because of severe respiratory insufficiency and multiple-organ-failure syndrome Ten patients underwent surgery on the day after admission, whereas 3 patients had suspended their use of direct thrombin inhibitors and needed surgery to be delayed until the third day after admission In all patients except 1, we noted an improvement in terms of O2 saturation and assisted respiration In 9 patients, hemodynamic and respiratory stability was observed at an average of 7 days postoperatively Four patients who underwent surgical treatment died of respiratory failure on the first day after surgery (1 patient), the third day after surgery (2 patients), or the seventh day after surgery (1 patient) Conclusions: We noted a stabilization of respiratory parameters in 12 COVID-19-positive patients who underwent surgery treatment of proximal femoral fractures We believe that in elderly patients with COVID-19 who have proximal femoral fractures, surgery may contribute to the overall stability of the patient, seated mobilization, improvement in physiological ventilation, and general patient comfort in bed Level of Evidence: Prognostic Level IV See Instructions for Authors for a complete description of levels of evidence Email address for F Catellani: francesco catellani@gavazzeni it Email address for A Coscione: andrea coscione@gavazzeni it Email address for R D’Ambrosi: riccardo dambrosi@hotmail it Email address for L Usai: luca usai@gavazzeni it Email address for C Roscitano: claudio roscitano@gavazzeni it Email address for G Fiorentino: gennaro fiorentino@gavazzeni it Investigation performed at Humanitas Gavazzeni, Bergamo, Italy Disclosure: The authors indicated that no external funding was received for any aspect of this work The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links lww com/JBJS/F867) Copyright 2020 by The Journal of Bone and Joint Surgery, Incorporated

CASE A 33-year-old man presented with acute abdominal and left hip pain after being struck by a motor vehicle. Radiographs revealed a comminuted left subtrochanteric femoral fracture. Computed tomography demonstrated a large pelvic hematoma and a radiopaque mass in the abdomen. Laparoscopy revealed the mass to be a large bone fragment lying within the greater omentum. The bone fragment, which seemed to be a femoral fracture fragment, was removed, and the fracture was repaired with a short cephalomedullary nail. CONCLUSION Rarely, subtrochanteric fracture fragments can penetrate the pelvis or abdomen because of high-energy trauma. Recognizing this possibility is important to assure a correct diagnosis and subsequent treatment.

Background: Clinical practice guidelines are being developed for a number of topics in medicine to decrease practice variability and to improve evidenced-based care. Within orthopaedic surgery, the American Academy of Orthopaedic Surgeons (AAOS) has a dedicated committee that produces these clinical practice guidelines on a variety of issues. One such issue was the treatment of pediatric diaphyseal femoral fractures, with the clinical practice guideline being published in 2009. We performed a retrospective review of the treatment of pediatric diaphyseal femoral fractures at a single institution from 2007 to 2012 to assess the clinical impact of this clinical practice guideline on the treatment of this condition. Methods: A retrospective review of all patients treated at a single pediatric hospital between 2007 and 2012 for a pediatric diaphyseal femoral fracture was conducted. The 2009 AAOS clinical practice guideline on the treatment of this condition was assessed and each patient record was analyzed to determine if the clinical practice guideline was followed, based on the age-specific recommendations. The percentage of treatment rendered adhering to the clinical practice guideline recommendations was compared in the pre-guideline group (prior to June 2009) and the post-guideline group (after June 2009). Results: A total of 361 patients were treated for a diaphyseal femoral fracture during this time frame and were included in this study. Overall, little change in treatment was found following the publication of this clinical practice guideline. The only significant change noted over this time period was a decrease (p = 0.03) in the percentage of patients between the ages of five and eleven years who were treated with flexible nails, at odds with this specific clinical practice guideline recommendation. Conclusions: We found little direct clinical impact of the recently published AAOS clinical practice guideline on the treatment of pediatric diaphyseal femoral fractures. This analysis suggests an important role for clinical assessment after guideline publication to identify areas of potentially important future clinical research and to assess the utility of this guideline.

PURPOSE Subtrochanteric femoral shaft fractures after little or no trauma have been reported in long-term users of bisphosphonates, but risks relative to hip fracture protective effects and among men are not clear. We examined associations between bisphosphonate use and nontraumatic subtrochanteric (NTST) femoral fractures and hip fractures in the Veterans Health Administration. METHODS This retrospective cohort study was conducted using 1998-2007 Veterans Health Administration electronic medical records data on 78,155 individuals who had a fragility fracture at age 45 years or older. Time-to-event analysis examined associations of bisphosphonates with risk of NTST femoral fracture and, separately, hip fracture, controlling for sociodemographics, medications, and comorbid medical conditions. RESULTS The cohort had a mean age 66.5 years (32.5% were ≥75 years old) at the time of their first fracture, and 69.3% were observed for 6 or more years; only 11.8% were prescribed bisphosphonates during observation. During follow-up, 408 had an NTST femoral second fracture, and 1584 had a hip second fracture. Compared with those never on bisphosphonates, the adjusted hazard ratio for NTST femoral second fracture among patients on 4 years of therapy or longer was 0.40 (95% confidence interval, 0.16-0.97) and for hip second fracture was 0.38 (95% confidence interval, 0.24-0.61). CONCLUSIONS Bisphosphonate treatment in this high-risk cohort was infrequent with few long-term users, limiting power to assess long-term effects. Nontraumatic subtrochanteric femoral fractures were uncommon, and longer bisphosphonate use was associated with lower (not higher) risk. In men, risks of NTST femoral fractures associated with bisphosphonate treatment may be low in contrast to substantial protective benefits for hip fracture.

Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures.The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment.Thirty-three patients with 41 atypical, low-energy femur fractures associated with ≥ 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation.Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation.Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Spiral fractures of long bones have long been cited as indications of non-accidental trauma (NAT) in children; however, fracture types are only loosely defined in the literature, and intraobserver and interobserver variability in defining femoral fracture patterns is rarely mentioned. We sought to determine reliability in classifying femoral fractures in young children using a standard series of radiographs shown to physicians with varied backgrounds and training and to determine if a quantitative approach based on objective measurements made on plain radiographs could improve definition of these fractures. Methods On 50 radiographs, the fracture ratio--fracture length divided by bone diameter--was determined and radiographs were reviewed by 14 observers, including pediatric orthopaedic surgeons, emergency room physicians, and musculoskeletal radiologists, who classified the fractures as transverse, oblique, or spiral. A second review of the images in a different order was carried out at least 10 days after the first. Results Overall, intraobserver agreement was strong, whereas interobserver reliability was moderate. Experience level did not correlate with either result. Complete agreement among all observers occurred for only 5 fractures: 3 transverse and 2 spiral. An average fracture ratio near 1.0 appeared to be predictive of a transverse fracture and a ratio of >3.0, a spiral fracture; ratios between these 2 values resulted in essentially random classification. Conclusions The ability to reproducibly classify femoral fractures in young children is highly variable among physicians of different specialties. These results support the belief that fracture morphology has little predictive value in NAT because of the wide variability in what observers classify as a spiral fracture of the femur. Caution should be used in the use of descriptive terms such as spiral, oblique, or transverse when classifying femoral fractures, as well as when evaluating children for possible NAT, because of the variability in classification. Level of evidence Level III-diagnostic study.

Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important.In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup.We present followup at a median of 5 years after surgery (range, 56-65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup.Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9-17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16-74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82-1.7).Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures.Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background Distal femoral physeal fractures have a high incidence of physeal arrest. Several factors have been postulated to contribute to this high incidence, including fracture type, displacement, the undulating nature of the physis, and fracture reduction/fixation. The purpose of this study was to determine whether the position of percutaneous smooth pins across the physis contributes to physeal bar formation. Methods The previously validated New Zealand white rabbit model was used. Power analysis determined that 30 animals were required. All animals had a constant 0.045 smooth Kirschner (K) wire placed under fluoroscopic guidance from the distal lateral femur across the physis centrally. A second 0.045 K-wire was placed in a cross-pin configuration from the medial side in one of 2 positions: zone 1--crossing the physis centrally or zone 2--crossing the physis peripherally. Pins were removed after 4 weeks and micro computed tomography was performed at 8 weeks to assess for physeal bar formation. Histologic analysis was performed to confirm bar formation. Results Two physeal bars (7%) were seen after removal of the constant (lateral pin). The peripheral pin resulted in bar formation in 2 animals (13%) and the central pin in 1 animal (7%). A χ² test was performed; there was no statistically significant difference between zones in terms of bar formation (P=0.5428). Conclusions Injury to the growth plate after distal femoral fracture may be unavoidable. Treatment is aimed to minimize further injury to the physis. Cross-pinning with smooth K-wires results in a low rate of physeal injury. Pins that cross the physis both centrally and peripherally appear to have the same risk for physeal bar formation. Clinical relevance This study reveals that physeal bar formation can be seen with smaller than previously reported cross-sectional damage to the distal femoral physis. This study highlights the need to carefully select and perform fixation of the distal femoral physis with as little additional trauma to the physis as possible.

Case We report a rare case of desmoplastic fibroma (DF) of the midshaft femur presenting as a pathological fracture. This rare benign bone tumor was treated with an acute en bloc excision and femoral shortening over an intramedullary nail. Once union of the acute shortening had been achieved, further surgery was undertaken to lengthen the femur with the use of Intramedullary Skeletal Kinetic Distractors. At 3 years after fracture, our patient had achieved equal leg lengths, had normal knee function, and was disease free. Conclusions DF resulting in pathological fracture of the midshaft femur is extremely rare and has not been reported to occur in the femoral diaphysis. This location is important as preservation of the joint above and below is preferable and en bloc excision is recommended. Restoration of bone stock after en bloc excision is difficult and recurrence needs to be monitored.

CASE A 35-year-old woman, who lived in an endemic area for echinococcosis, developed a periprosthetic fracture with loosening of a total hip arthroplasty that had been performed 9 years earlier for hydatidosis of the right proximal femur with a pathological femoral neck fracture. At that time, the patient did not have any signs of liver or lung involvement. She was successfully managed by a cemented revision hip arthroplasty without any signs of recurrence at the last follow-up of 5 years. CONCLUSIONS Total hip arthroplasty can offer effective management of proximal femur hydatidosis, despite the high rate of recurrence and mechanic failure.

Background: Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) is expensive and may cause local side effects. A small synthetic molecule, SVAK-12, has recently been shown in vitro to potentiate rhBMP-2-induced transdifferentiation of myoblasts into the osteoblastic phenotype. The aims of this study were to test the ability of SVAK-12 to enhance bone formation in a rodent ectopic model and to test whether a single percutaneous injection of SVAK-12 can accelerate callus formation in a rodent femoral fracture model. Methods: Collagen disks with rhBMP-2 alone or with rhBMP-2 and SVAK-12 were implanted in a standard athymic rat chest ectopic model, and radiographic analysis was performed at four weeks. In a second set of rats (Sprague-Dawley), SVAK-12 was percutaneously injected into the site of a closed femoral fracture. The fractures were analyzed radiographically and biomechanically (with torsional testing) five weeks after surgery. Results: In the ectopic model, there was dose-dependent enhancement of rhBMP-2 activity with use of SVAK-12 at doses of 100 to 500 μg. In the fracture model, the SVAK-12-treated group had significantly higher radiographic healing scores than the untreated group (p = 0.028). Biomechanical testing revealed that the fractured femora in the 200 to 250-μg SVAK-12 group were 43% stronger (p = 0.008) and 93% stiffer (p = 0.014) than those in the control group. In summary, at five weeks the femoral fracture group injected with SVAK-12 showed significantly improved radiographic and biomechanical evidence of healing compared with the controls. Conclusions: A single local dose of a low-molecular-weight compound, SVAK-12, enhanced bone-healing in the presence of low-dose exogenous rhBMP-2 (in the ectopic model) and endogenous rhBMPs (in the femoral fracture model). Clinical Relevance: This study demonstrates that rhBMP-2 responsiveness can be enhanced by a novel small molecule, SVAK-12. Local application of anabolic small molecules has the potential for potentiating and accelerating fracture-healing. Use of this small molecule to lower required doses of rhBMPs might both decrease their cost and improve their safety profile.

OBJECTIVES Supracondylar femoral fracture is a complex complication after total knee arthroplasty (TKA). One potential complication of retrograde locked nailing is malunion in extension of the femoral prosthetic component--produced by an overly posterior nail entry point in the intercondylar notch. The aim of this study was to determine the repercussion of this deformity on the midterm radiological and functional outcomes of TKA. DESIGN Retrospective review. METHODS From 2001 to 2006, 30 patients were treated for supracondylar femoral fracture above TKA with a retrograde locked nail. In 7 patients (6 women and 1 man) with a mean age of 78.8 years (range, 74-84 years), more than 10 degrees of hyperextension (mean of 18.5 degrees) of the femoral component on the sagittal plane was observed without any significant misalignment on the coronal plane. Functional outcomes were assessed using the Knee Society Score. RESULTS After a mean follow-up of 68.5 months (range, 48-111 months), all patients' fractures with a hyperextension of the femoral component had consolidated with no clinical or radiological signs of TKA loosening. These patients presented "good" functional outcomes at final follow-up. CONCLUSIONS These results should be interpreted with caution. However, isolated hyperextension of the femoral component of a TKA after placing a retrograde nail for a periprosthetic fracture does not seem to significantly affect the functional or radiological outcomes at ∼6-years follow-up. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Locking compression plates (LCPs) are being increasingly utilized in fixation of fractures and osteotomies in the pediatric population. However, plate insertion or removal may pose a risk of femoral fractures or refractures. The goal of this study was to analyze failure patterns associated with LCPs and identify possible contributing factors. Methods The sample included all patients who underwent fixation of femoral fractures or osteotomies utilizing straight LCPs at a tertiary pediatric medical center from 2004 to 2009. All were followed up until fracture union. The charts and radiographs were reviewed, and data on demographics, indications, surgical technique, and timing of plate removal were summarized. In cases of failure, the timing, circumstances, fracture location, and refixation method were recorded. Results Thirty-seven patients underwent 41 straight LCP fixations during the study period. The indication for surgery was acute femoral fracture in 25 procedures (25 patients) and elective osteotomy or limb lengthening in 16 procedures (12 patients). Thirty-five plates were removed after complete clinical and radiographic union. The time from plate fixation to removal averaged 13 months (range, 5 to 34 mo) in the fracture group and 17.6 months (range, 7.5 to 28 mo) in the osteotomy group. Five procedures (12%) were complicated by femoral fractures or refractures: 2 occurred after the index surgery-1 at the proximal screw and 1 through the original fracture site, with plate breakage. Three patients sustained refractures after plate removal, all at the original fracture or regenerate site: 1 after a fall and 2 spontaneously. The average time from plate removal to refracture was 18 days (range, 10 to 30). There were no differences in demographics, timing, or technique between patients with and without complications. Conclusions Although LCPs are considered flexible fixators, they may carry the risk of overstiffness, similar to external fixators. Further clinical and biomechanical studies are needed to evaluate risk factors for fractures or refractures, particularly in children. There seems to be an increase in risk of refracture immediately after plate removal. Caution should be taken in the first weeks after plate removal. Level of evidence Level IV.

OBJECTIVE To examine the impact of number and position of locking screws in the diaphyseal portion of an osteoporotic distal femoral fracture model with hybrid fixation. METHODS Four groups containing 5 osteoporotic bone models were used with varying combinations of diaphyseal screw fixation: 4 nonlocking screws (control); 1 locking screw adjacent to the osteotomy and 3 nonlocking screws; 1 locking screw in the most proximal screw hole of the plate and 3 nonlocking screws; and 2 locking screws at opposite ends of the diaphyseal fixation with 2 nonlocking screws in between. Fixation in the distal articular segment was identical in all constructs. Testing was performed for 50,000 cycles at 2 Hz using simultaneous axial compression (700 N) and bidirectional torque (±5 Nm) applied along the long axis of the bone. All screws were inserted with 4 Nm of torque. RESULTS The extraction torque for nonlocking screws in those specimens that had a locking screw nearest the osteotomy was significantly greater than those that did not (P = 0.037). In addition, the 10 constructs with a locking screw nearest the osteotomy had no failures compared with 5 of 10 failures in those without a locking screw in this position (P = 0.033). CONCLUSIONS The placement of a locking screw adjacent to the osteotomy was more beneficial in protecting against failure and maintaining the extraction torque of neighboring proximal nonlocking screws. No benefit in adjacent screw extraction torque was seen with a locking screw proximal in the diaphysis. Two locking screws at opposite ends of the diaphyseal fixation were not superior to a single locking screw adjacent to the osteotomy in failure rates or screw extraction torque.

Background: At many centers, double-leg spica casting is the treatment of choice for diaphyseal femoral fractures in children two to six years old. We hypothesized that such patients can be effectively treated with single-leg spica casting and that such treatment would result in easier care and better patient function during treatment. Methods: In a prospective, randomized controlled study, fifty-two patients two to six years old with a diaphyseal femoral fracture were randomly assigned to be treated immediately (after consent was obtained) with a single-leg (twenty-four patients) or double-leg (twenty-eight patients) spica cast. Serial radiographs were evaluated for maintenance of fracture reduction with respect to limb length, varus/valgus angulation, and procurvatum/recurvatum angulation. After cast removal, the performance version of the Activities Scale for Kids questionnaire and a custom-written survey were administered to the parents so that they could evaluate the ease of care and function of the children during treatment. Means were compared between treatment groups with use of Student t tests. P values of

To compare the biomechanical performance of a cephalomedullary nail (CMN), a proximal femoral locking plate, and a 95° angled blade plate in a comminuted subtrochanteric fracture model.A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 pairs of human cadaveric femora confirmed to be nonosteoporotic. The femora were randomized to treatment with one of the previously mentioned 3 devices. Each was tested under incrementally increasing cyclic load up to 90,000 cycles from 50% to 250% of body weight to simulate progressive weight bearing during 3 months of an average 700-N (approximately, 70 kg or 150 lb) person. Force, number of cycles, and total load sustained to reach 10 mm of displacement were compared. Failure modes were also noted.The CMN construct withstood significantly more cycles, failed at a significantly higher force, and withstood a significantly greater load than either of the plate constructs (P0.001). Varus collapse was significantly lower in the CMN construct (P0.0001). Modes of failure differed among implant-bone constructs with damage to the femoral head through implant cutout in 5 of 10 blade plate specimens and 2 of 10 CMN specimens, whereas no damage to the femoral head bone was observed in any of the locking plate constructs.The CMN construct was biomechanically superior to either the locking plate or 95° blade plate constructs. The locking plate construct was biomechanically equivalent to the blade plate construct.

Background: As the population ages, the number of proximal femoral fractures seen each year is expected to increase. Subsequent contralateral hip fractures have been reported to occur in as many as 11.8% of patients after surgical fixation of the initial fracture, but it is unknown if this rate is similar among patients managed with different surgical procedures. Methods: A retrospective comparative study was performed at a single institution at which electronic medical records and digital radiographs were reviewed for 1177 patients who underwent closed reduction and percutaneous pinning or arthroplasty for the treatment of a proximal femoral fracture. For the primary outcome of subsequent fracture, logistic regression analysis was applied. Results: Four hundred and ninety-five patients were managed with closed reduction and percutaneous pinning, and 682 were managed with arthroplasty. Patients who underwent closed reduction and percutaneous pinning were two times morelikelytohaveasubsequentcontralateral femoralfractureincomparisonwith thosewhounderwentarthroplasty,with contralateral fracture rates of 10.10% for the closed reduction and percutaneous pinning group and 5.57% for the arthroplasty group (p = 0.0035). Conclusions: Patients undergoing closed reduction and percutaneous pinning as the initial treatment for a hip fracture had an increased risk of a subsequent contralateral hip fracture in comparison with those undergoing arthroplasty, after controlling for patient characteristics. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The optimal surgical treatment of patients with an unstable extracapsular proximal femoral fracture is yet to be found. From the biomechanical point of view, the use of an intramedullary device in combination with a dynamic femoral head/neck stabilization implant seems an optimal technique. One of these intramedullary devices, the Proximal Femoral Nail (PFN), has several drawbacks in practice. The Proximal Femur Nail Antirotation (PFNA) has been designed to address these. We hypothesized that the placement of one femoral head/neck fixation device in the PFNA would improve positioning of the implant in the femoral head compared with the PFN and reduce the number of reoperations in both short and long term.We followed 157 consecutive patients with unstable trochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen classification 31.A.2 and A.3) treated with a PFN or a PFNA for 1 year. The radiologic position of the implant was evaluated, and the postoperative local and systemic complications were registered.The position of the femoral head/neck stabilization implant was "good" in 39 (44.8%) patients in the PFN group and 23 (32.9%) patients in the PFNA group; the position was "acceptable" in 30 (34.5%) versus 33 (47.1%) patients, and in 18 (20.7%) versus 14 (20%) patients, the position was "poor" (p = 0.277). Because of implant-related complications, three patients in the PFN group and four patients in the PFNA group needed an early reoperation (p = 0.136). A late reoperation because of implant-related complications was performed in 13 patients in the PFN group and in three in the PFNA group (p = 0.016).This study shows that osteosynthesis with the PFNA does not improve the position of the implant in the femoral head compared with the PFN. However, the risk of a secondary complication and the necessity of a late reoperation are significantly higher in patients treated with a PFN compared with patients treated with a PFNA.