Robert P. Dunbar

Purpose Patella fractures are common and may result in significant morbidity. Open patellar fractures are less common, and there are few investigations into their outcomes and complications. This study aimed to determine acute outcomes after operative treatment of open versus closed patella fractures. Methods This study was a retrospective cohort study from a single academic Level One tertiary trauma center. Patients who underwent open reduction internal fixation of open and closed patella fractures with a minimum of 6 months of follow-up from 2013 to 2018 were included. Those who underwent patellectomy or nonoperative treatment were excluded. The main outcome measures assessed for reoperation rates and clinical complications. Results Forty-six patella fractures treated with operative fixation were included. Of them, 25 were open and 21 were closed fractures. The reoperation rate was significantly higher in the open group compared to the closed group, 43% versus 8%, respectively. Knee manipulation for was also significantly more common in the open group at 24% compared to zero in the closed group. On multivariate analysis, compared to closed injuries, open patella fractures were associated with all-cause reoperation (odds ratio 5.2, 95% confidence interval 1.2–34.5, p = 0.048). Patients in the open group also had significantly increased rates of a high-energy mechanism of injury. Nonunion, malunion, and surgical site infection were not statistically different between the groups. Conclusion Reoperation rates are significantly higher in open patella fractures compared to closed fractures. The increased reoperation rate was mainly driven by the need for manipulation under anesthesia.

Introduction Nondisplaced and valgus-impacted femoral neck fractures have traditionally been treated with screw fixation, but reoperation rates remain high. This study reports clinical outcomes following internal fixation of low-energy femoral neck fractures (AO/OTA 31B1.1 and 31B1.2) using a new, fixed-angle sliding device. Methods This was a multi-institutional retrospective review at four academic Level I Trauma Centers, one Level II Trauma Center, and one Level III Trauma Center. Patients with AO/OTA 31B1.1 and 31B1.2 fractures who underwent internal fixation using the Femoral Neck System (“FNS,” DePuy Synthes, West Chester, PA) and had follow-up to radiographic union or reoperation (mean 11.9 months) were included. Fractures with ≥ 20° of posterior tilt were included but distinguished as the “posterolateral” group. Primary outcome was reoperation rate. Secondary outcomes included fixation failure, infection, nonunion, and mortality rates at 3 and 6 months. Results A total of 116 patients met inclusion criteria including 109 “stable” fractures with < 20° of posterior tilt, and seven valgus-impacted fractures with ≥ 20° of posterior tilt (“posterolateral”). All posterolateral fractures underwent a reduction maneuver to reduce posterior tilt prior to fixation. Overall reoperation rate was 10%, including a 5.2% reoperation rate for AVN, with no patients in the posterolateral group requiring reoperation. Nonunion rate was 1.8%, and there was only one case of acute fixation failure (0.9%), which occurred after a repeat fall. Mortality rate was 0.9% at 3 months and 2.2% at 6 months. Conclusions Surgical fixation of nondisplaced and valgus-impacted femoral neck fractures with a femoral neck-specific, fixed-anglescrew-side plate device appears safe and effective. Reoperation rate remained low in the high-risk posterolateral subgroup when reduction maneuvers were performed. Level of evidence III.

Objectives: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. Design: Multicenter, randomized controlled trial. Setting: 16 academic trauma centers. Patients/Participants: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. Intervention: IMN or lateral locked plating. Main Outcome Measurements: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. Results: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. Conclusions: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. Design: Multicenter randomized controlled trial. Setting: Twenty academic trauma centers. Patients/Participants: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. Intervention: Lateral locked plating or retrograde intramedullary nailing. Main Outcome Measurements: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. Results: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. Conclusions: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.