Timothy S. Achor

OBJECTIVES: To assess the outcomes of patients with complete articular distal femur fractures treated with open reduction and retrograde intramedullary nailing. METHODS: Design: Retrospective cohort analysis. Setting: Single-center, Level 1 Academic Trauma Center. Patient Selection Criteria: Patients treated between January 1, 2016, and January 1, 2023, with complete articular distal femur fractures (AO/OTA 33 C1-3)W who underwent independent articular reduction and retrograde intramedullary nailing were included. Patients were included who had a minimum of 3 months of follow-up or until fracture union. Outcome Measures and Comparisons: Patient data pertaining to demographics, surgical details, and radiographic outcomes were systematically collected and analyzed. Coronal and sagittal alignments were evaluated using the anatomic lateral distal femur angle and anatomic posterior distal femoral angle, respectively. Reoperations were stratified into planned and unplanned categories and further classified as major or minor. RESULTS: The study cohort comprised 127 patients (52% males) with 130 complete articular distal femur fractures (3 patients with bilateral fractures) with a mean age of 49.9 years (range: 12–95 years). The mean clinical follow-up was 254.1 days (range: 90–1882 days). Postoperative mean anatomic lateral distal femur angle was 83.4 degrees, and anatomic posterior distal femoral angle was 1.2 degrees apex posterior. Articular reductions were anatomic (0 mm residual displacement, 93.8%) or near anatomic (between 0 and 2 mm residual displacement, 6.2%) in all cases. All reductions were maintained at final follow-up. The reoperation rate was 15.4%, with 3.8% of cases classified as major unplanned operations. Most minor unplanned reoperations (8% of cases) were for implant irritation or knee arthrofibrosis. The rate of osseous union was high, with only 1 case of nonunion observed, yielding an aseptic nonunion rate of 0% and an infected nonunion rate of 0.8%. CONCLUSIONS: Independent articular reduction and retrograde intramedullary nailing of AO/OTA 33C femur fractures resulted in an overall reoperation rate of 15.4%, major unplanned reoperation rate of 3.8%, an osseous union rate of 99%, and maintained articular and metaphyseal reductions at final follow-up. The study's findings support this technique as an effective treatment option for managing these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Case: A 37-year-old woman with a history of depression and polysubstance use disorder presented 3 weeks after developing left hip pain and inability to ambulate. Initial outside radiographs were reportedly negative, delaying diagnosis until a subsequent outside MRI and confirmatory in-house CT demonstrated a displaced AO/OTA 31B2.2 transcervical femoral neck fracture with varus angulation and inferior comminution. She underwent valgus intertrochanteric osteotomy with a fixed-angle blade-plate construct, achieving union and excellent function at 3 years. Conclusion: Valgus-producing osteotomy with blade-plate fixation is a viable joint-preserving option for subacute displaced femoral neck fractures in young adults when arthroplasty is undesirable.

OBJECTIVE: To investigate nonunion rates and risk factors in patients with ipsilateral femoral neck and shaft fractures. METHODS: Design: Retrospective review. Setting: Two Level I trauma centers. Patient Selection Criteria: Two hundred seven patients treated for ipsilateral femoral neck (AO/OTA 31-B) and shaft (AO/OTA 32A-C) fractures from 2013 to 2022. Patients with less than 6 months of follow-up were excluded. Outcome Measures and Comparisons: The primary outcome of this study was femoral shaft nonunion. Risk factors for nonunion were evaluated, including smoking, open fracture, delay to full weight-bearing, blood transfusions, and AO/OTA classification. RESULTS: Two hundred twenty-seven patients were initially identified, but only 154 patients had sufficient follow-up and were included in final analysis. The mean age was 38.9 years (SD = 15.3), and injury severity score was 19.5 (9.7). One hundred ten patients (71%) were male and 69 (45%) required intensive care unit care. Thirty-eight patients (25%) experienced an open fracture, and 44 fractures (29%) were AO/OTA Type C. Thirty patients (20%) underwent initial external fixation, and 88 patients (57%) received a perioperative transfusion. Thirty-four patients (22%) developed a femoral shaft nonunion, and 5 (3%) experienced a surgical site infection. Nonunion was associated with perioperative blood transfusion, AO/OTA Type C fracture, postoperative non-weight-bearing, and delay to full weight-bearing ≥12 weeks. Multivariable regression identified perioperative blood transfusion ≥3 (risk ratio [RR] = 1.91; CI, 1.12–2.72; P = 0.02) and AO/OTA Type C fracture (RR = 2.45; CI, 1.50–3.34; P = 0.001) as independent risk factors. CONCLUSIONS: Ipsilateral femoral neck and shaft fractures remain difficult injuries to treat. Much attention is given to diagnosis and treatment of the femoral neck component. These results suggest that successful treatment of the femoral shaft component presents its own challenges with high nonunion rates. LEVEL OF EVIDENCE: Prognostic Level III.

Case: The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts. Conclusion: Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.

Summary: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.

Background: Despite increased awareness of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures and advanced imaging with thin-cut high-resolution computed tomography (CT), failure of diagnosis remains problematic. The purpose of the present study was to determine if the preoperative diagnosis of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with magnetic resonance imaging (MRI) compared with radiographic and CT imaging. Methods: In response to delayed diagnoses of femoral neck fractures despite thin-cut high-resolution CT, our institutional imaging protocol for acute, high-energy femoral shaft fractures was altered to include rapid limited-sequence MRI to evaluate for occult femoral neck fractures. All patients received standard radiographic imaging as well as thin-cut high-resolution pelvic CT imaging upon presentation. Rapid limited-sequence MRI of the pelvis was obtained to evaluate for an occult femoral neck fracture. Results: Thirty-seven consecutive patients with 39 acute, high-energy femoral shaft fractures resulting from blunt trauma were included. The average age of the patients was 29.1 years (range, 14 to 82 years). Ten (25.6%) of the 39 femoral shaft fractures were open. Two femoral shaft fractures (5.1%) were associated with ipsilateral femoral neck fractures that were detected on radiographs, and no MRI was performed. None of the remaining 37 femoral shaft fractures were associated with a femoral neck fracture that was identified on CT imaging. Thirty-three (89.2%) of 37 patients underwent pelvic MRI to evaluate the ipsilateral femoral neck. Four (12.1%) of those 33 patients were diagnosed with a femoral neck fracture (2 complete, 2 incomplete) that was not identified on thin-cut high-resolution CT or radiographic imaging. Conclusions: Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. Our results suggest that the frequency of femoral neck fractures may be underrepresented on CT imaging; rapid limited-sequence MRI was feasible without delaying definitive treatment even in polytraumatized patients. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Case: We report the case of a 41-year-old man who sustained an open femoral shaft fracture with 10 cm of segmental bone loss in a motorcycle collision. He underwent serial irrigation and debridement procedures and intramedullary nailing of the fracture. He was lost to follow-up, but presented 9 months after the injury with abundant callus formation; at 11 months, the simple hypertrophic nonunion was treated with exchange nailing. Conclusion: Although unusual, secondary union of segmental femoral defects may occur. The mechanism by which this occurs is poorly understood, but is likely related to the biology of the fracture site, the effects of reaming, and the mechanics of the fixation.