Nathaniel Hunter

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.

Background: In the surgical treatment of lower extremity sarcomas, rotationplasty provides a durable biologic reconstruction option. It effectively allows the patient to function with a transtibial amputation, without the burden of a nonbiologically based reconstruction. Despite robust function and durability, rotationplasty may invite its own array of complications. A thorough description of rotationplasty complications and outcomes is lacking in published reports, limiting effective patient and family counseling. Moreover, improving awareness of the potential complications will allow surgeons the opportunity to mitigate their risk of occurrence or detect them early in order to minimize their downstream consequences. Questions/purposes: (1) What are the modes of complication and the proportion at which they occur after oncologic rotationplasty surgery? (2) What is the timing of these complications relative to the index surgical procedure? (3) What proportion of patients ultimately undergo conversion to an amputation, and when, relative to the index rotationplasty, does conversion occur? Methods: We performed a review through the PubMed and Scopus databases for rotationplasty procedures for oncologic indications between 1948 and November of 2024 (both last searched November 15, 2024). This yielded 293 articles; 117 were excluded because they did not include the rotationplasty procedure. We then excluded 15 studies for a nononcologic indication for surgery, 101 studies with cohorts of < 10 patients, 14 for inadequate reporting of postoperative complications, and 20 for duplication of published data by the same study group. We included manuscripts if they had an oncologic indication for the procedure, a lower extremity procedure, a cohort of > 10 patients, and clear reporting of postoperative complications. Ultimately, 26 articles were included in this review. Two different authors screened and extracted clinical metrics, which they recorded in a spreadsheet for collation and evaluation. Risk of bias and methodological quality of the included studies was quantitatively assessed via two methods: the Newcastle-Ottawa Scale (NOS) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Overall risk of bias and methodological quality of the included studies was moderate to poor. Data were pooled for ease of comprehension, but we did not perform a formal meta-analysis of the data. In the papers that reported gender, most patients were boys or men (65% [321 of 491]). The age at time of surgery ranged from 3 to 64 years. Osteosarcoma was the most common diagnosis, accounting for 71% (527 of 746) of diagnoses, and the distal femur was the most common location (56% [419 of 746]). Regarding surgical techniques, for those with reported data concerning vascular management, 65% (309 of 476) utilized an anastomosis construct, whereas 35% (167 of 476) underwent a loop procedure. For osteosynthesis, most reported data demonstrated use of a plate and screw construct (92% [327 of 354]) rather than an intramedullary nail (3% [10 of 354]). Results: There were 746 patients in the included 26 articles, 34% (254) of whom were reported to have had a complication. Twenty-seven patients within our cohort were reported to have had multiple complications, so the total number of reported complications was 281. The most common complications involved the osseous construct (11% [81 of 746]), followed by the vascular system (8% [59 of 746]), then wound healing (7% [55 of 746]). Other less commonly reported complications were neurologic injuries (5% [35 of 746]) and infection (4% [31 of 746]). With regard to timing of postoperative complications, 75% (36 of 48) of osseous construct–related issues arose within the first year, and 94% (31 of 33) of vascular complications occurred within 14 days of surgery. Details of surgical complications were not adequately reported in many series within our cohort. Conclusion: Our review suggests that 34% of all patients with rotationplasty experienced a postoperative complication, the most common being osseous construct–related, followed by vascular and soft tissue complications. These data suggest that rotationplasty is a robust, durable reconstruction option for patients undergoing surgery for a lower extremity bone sarcoma. It carries small yet serious early complication risks; however, this dramatically tapers after osteosynthesis is achieved. A prospective review of multi-institutional perioperative data would allow for a more comprehensive and comparative summary of these procedures to investigate the surgical factors that influence the occurrence of complications and reoperation. Level of Evidence: Level IV, therapeutic study.

This creative engagement essay explores the interaction between a third-year medical student and a patient diagnosed with terminal stomach cancer. The patient's experience is shaped by profound systemic inequities and institutional biases, including his incarcerated status, which significantly delayed and limited his access to medical care. His case highlights the systemic inadequacies within the USA prison healthcare system, where timely and adequate treatment is often unavailable. Beyond the medical aspects of his illness, the patient's emotional journey, particularly his inability to communicate with his family during this critical time, is explored. Through this narrative, the essay underscores the importance of humanism in medicine-bearing witness to each patient's story, recognizing their dignity, and acknowledging the broader sociocultural context that shapes their healthcare experiences.