The American Journal of Orthopedics

mi-eye 2™ (https://tricemedical.com/mi-eye/)

Over the past decade, magnetic resonance imaging (MRI) has been the gold standard for identification of intra-articular soft tissue pathology of the knee. Limitations, however, do exist for the use of MRI in diagnosing injuries. Various studies have reported MRI sensitivity and specificity to be 86% and 91% in diagnosis of knee pathology.¹ These numbers can be lower in the setting of previous surgery. Furthermore, some patients cannot have MRIs, while for others, MRIs would be inconclusive. This includes patients who are morbidly obese, claustrophobic, renally impaired, have implanted medical devices, have metal within their bodies, or have had previous surgical intervention to the affected joint.

As an alternative to MRI, in-office needle arthroscopy offers a cost-effective, minimally invasive tool that can provide similar or greater diagnostic accuracy.^2,3 The ability to provide real-time dynamic visualization of the patient’s anatomy allows for more accurate decision making by the physician and can potentially reduce the time from injury to diagnosis to recovery.⁴ It can be performed in a variety of joints, including the knee, shoulder, elbow, and ankle. Indications for use include patients with suspected meniscal tears, anterior cruciate ligament (ACL) tears, loose bodies, rotator cuff tears, and labral tears, as well as pre-arthroplasty evaluations and second-look evaluations of cartilage procedures.

The mi-eye 2™ (Trice Medical) is an in-office diagnostic needle arthroscope that can provide immediate diagnostic capabilities (Figure 1).

mi-eye 2™ (https://tricemedical.com/mi-eye/)

Over the past decade, magnetic resonance imaging (MRI) has been the gold standard for identification of intra-articular soft tissue pathology of the knee. Limitations, however, do exist for the use of MRI in diagnosing injuries. Various studies have reported MRI sensitivity and specificity to be 86% and 91% in diagnosis of knee pathology.¹ These numbers can be lower in the setting of previous surgery. Furthermore, some patients cannot have MRIs, while for others, MRIs would be inconclusive. This includes patients who are morbidly obese, claustrophobic, renally impaired, have implanted medical devices, have metal within their bodies, or have had previous surgical intervention to the affected joint.

As an alternative to MRI, in-office needle arthroscopy offers a cost-effective, minimally invasive tool that can provide similar or greater diagnostic accuracy.^2,3 The ability to provide real-time dynamic visualization of the patient’s anatomy allows for more accurate decision making by the physician and can potentially reduce the time from injury to diagnosis to recovery.⁴ It can be performed in a variety of joints, including the knee, shoulder, elbow, and ankle. Indications for use include patients with suspected meniscal tears, anterior cruciate ligament (ACL) tears, loose bodies, rotator cuff tears, and labral tears, as well as pre-arthroplasty evaluations and second-look evaluations of cartilage procedures.

The mi-eye 2™ (Trice Medical) is an in-office diagnostic needle arthroscope that can provide immediate diagnostic capabilities (Figure 1).

mi-eye 2™ (https://tricemedical.com/mi-eye/)

Over the past decade, magnetic resonance imaging (MRI) has been the gold standard for identification of intra-articular soft tissue pathology of the knee. Limitations, however, do exist for the use of MRI in diagnosing injuries. Various studies have reported MRI sensitivity and specificity to be 86% and 91% in diagnosis of knee pathology.¹ These numbers can be lower in the setting of previous surgery. Furthermore, some patients cannot have MRIs, while for others, MRIs would be inconclusive. This includes patients who are morbidly obese, claustrophobic, renally impaired, have implanted medical devices, have metal within their bodies, or have had previous surgical intervention to the affected joint.

As an alternative to MRI, in-office needle arthroscopy offers a cost-effective, minimally invasive tool that can provide similar or greater diagnostic accuracy.^2,3 The ability to provide real-time dynamic visualization of the patient’s anatomy allows for more accurate decision making by the physician and can potentially reduce the time from injury to diagnosis to recovery.⁴ It can be performed in a variety of joints, including the knee, shoulder, elbow, and ankle. Indications for use include patients with suspected meniscal tears, anterior cruciate ligament (ACL) tears, loose bodies, rotator cuff tears, and labral tears, as well as pre-arthroplasty evaluations and second-look evaluations of cartilage procedures.

The mi-eye 2™ (Trice Medical) is an in-office diagnostic needle arthroscope that can provide immediate diagnostic capabilities (Figure 1).

Matthew J. Matava, MD

Associate Editor for Professional Sports

Dr. Matava is a professor of Orthopedic Surgery and Physical Therapy, Chief of the Sports Medicine Service, and the Head Team Physician for the varsity athletic program at Washington University in St. Louis. He is also a team physician for the National Hockey League’s St. Louis Blues. Formerly, he was the Head Team Physician for the St. Louis Rams, and was President of the National Football League Physicians Society (NFLPS) from 2013-2015. Dr. Matava earned his Medical Degree from the University of Missouri-Kansas City. He completed his internship and orthopedic surgery residency at Emory University in Atlanta, GA, followed by a fellowship in sports medicine and arthroscopic surgery at the Cincinnati Sports Medicine and Orthopedic Center. He is the recipient of several research awards from Emory University, is a member of the Alpha Omega Medical Honor Society, and received the Palma Chironis Award for Excellence in Teaching from the Washington University Department of Orthopedic Surgery in 2012. Dr. Matava has been listed as a “Best Doctor in America” since 2005, and was recently hailed by Orthopedics This Week as one of the top 28 sports knee surgeons in the nation.

Jeffrey Sawyer, MD

Associate Editor for Pediatrics

Dr. Sawyer is a professor of Orthopaedic Surgery and the Pediatric Orthopaedic Fellowship Director at the University of Tennessee-Campbell Clinic. He also serves as a reviewer/editor for the Journal of Pediatric Orthopaedics and Orthopedic Clinics of North America. He graduated from the University of Rochester School of Medicine and completed his residency at the University of Pennsylvania, prior to completing his Pediatric Orthopaedic Fellowship at the University of Tennessee-Campbell Clinic. Dr. Sawyer has held numerous leadership positions in the Pediatric Orthopaedic Society of North America (POSNA). He also was a POSNA Traveling Fellow and won the POSNA Special Achievement Award for his work on the Pediatric Orthopaedic Workforce. He is a national authority on pediatric orthopedic trauma, and is on the Executive Committee of the Children’s Spine Foundation.

Brian K. Vickaryous, MD

Associate Editor for Trauma

Dr. Vickaryous is a specialist in orthopedic traumatology at the Florida Hospital Orthopedic Institute in Orlando, Florida, and has an additional subspecialty board certification in sports medicine. He attended the University of Miami, Florida through the combined degree Medical
Honors Program and completed his residency at the William Beaumont Army Medical Center/Texas Tech University of the Health Sciences. Dr. Vickaryous has also deployed overseas as Commander of the Trauma Unit, the 8th Forward Surgical Team, in Iraq in support of Operation Iraqi Freedom. He currently is a member of the American Academy of Orthopaedic
Surgeons (AAOS) and the Orthopaedic Trauma Association (OTA).

Michael B. Gerhardt, MD

Associate Editor for Sports Medicine

Dr. Gerhardt is a sports medicine specialist at the Kerlan-Jobe Institute and Santa Monica Orthopaedic Group in Los Angeles, CA. He also serves as faculty in the Department of Orthopaedic Surgery at Cedars-Sinai Medical Center. Dr. Gerhardt earned his undergraduate degree from UC San Diego and graduated medical school with honors from the Medical College of Pennsylvania. He received the Leonard Marmur Award for excellence in research and education during his orthopedic residency at the University of Southern California, prior to completing a Sports Medicine Fellowship in 2003. He received further training in hip arthroscopy at the Nashville Orthopaedic Sports Medicine and Orthopaedic Clinic, and maintains a leadership role in the area of sports medicine and hip preservation on a national and international level. Currently, he serves as Team Physician for the US Soccer Men’s National Team, the Los Angeles Galaxy, and Pepperdine University.

Matthew J. Matava, MD

Associate Editor for Professional Sports

Dr. Matava is a professor of Orthopedic Surgery and Physical Therapy, Chief of the Sports Medicine Service, and the Head Team Physician for the varsity athletic program at Washington University in St. Louis. He is also a team physician for the National Hockey League’s St. Louis Blues. Formerly, he was the Head Team Physician for the St. Louis Rams, and was President of the National Football League Physicians Society (NFLPS) from 2013-2015. Dr. Matava earned his Medical Degree from the University of Missouri-Kansas City. He completed his internship and orthopedic surgery residency at Emory University in Atlanta, GA, followed by a fellowship in sports medicine and arthroscopic surgery at the Cincinnati Sports Medicine and Orthopedic Center. He is the recipient of several research awards from Emory University, is a member of the Alpha Omega Medical Honor Society, and received the Palma Chironis Award for Excellence in Teaching from the Washington University Department of Orthopedic Surgery in 2012. Dr. Matava has been listed as a “Best Doctor in America” since 2005, and was recently hailed by Orthopedics This Week as one of the top 28 sports knee surgeons in the nation.

Jeffrey Sawyer, MD

Associate Editor for Pediatrics

Dr. Sawyer is a professor of Orthopaedic Surgery and the Pediatric Orthopaedic Fellowship Director at the University of Tennessee-Campbell Clinic. He also serves as a reviewer/editor for the Journal of Pediatric Orthopaedics and Orthopedic Clinics of North America. He graduated from the University of Rochester School of Medicine and completed his residency at the University of Pennsylvania, prior to completing his Pediatric Orthopaedic Fellowship at the University of Tennessee-Campbell Clinic. Dr. Sawyer has held numerous leadership positions in the Pediatric Orthopaedic Society of North America (POSNA). He also was a POSNA Traveling Fellow and won the POSNA Special Achievement Award for his work on the Pediatric Orthopaedic Workforce. He is a national authority on pediatric orthopedic trauma, and is on the Executive Committee of the Children’s Spine Foundation.

Brian K. Vickaryous, MD

Associate Editor for Trauma

Dr. Vickaryous is a specialist in orthopedic traumatology at the Florida Hospital Orthopedic Institute in Orlando, Florida, and has an additional subspecialty board certification in sports medicine. He attended the University of Miami, Florida through the combined degree Medical
Honors Program and completed his residency at the William Beaumont Army Medical Center/Texas Tech University of the Health Sciences. Dr. Vickaryous has also deployed overseas as Commander of the Trauma Unit, the 8th Forward Surgical Team, in Iraq in support of Operation Iraqi Freedom. He currently is a member of the American Academy of Orthopaedic
Surgeons (AAOS) and the Orthopaedic Trauma Association (OTA).

Michael B. Gerhardt, MD

Associate Editor for Sports Medicine

Dr. Gerhardt is a sports medicine specialist at the Kerlan-Jobe Institute and Santa Monica Orthopaedic Group in Los Angeles, CA. He also serves as faculty in the Department of Orthopaedic Surgery at Cedars-Sinai Medical Center. Dr. Gerhardt earned his undergraduate degree from UC San Diego and graduated medical school with honors from the Medical College of Pennsylvania. He received the Leonard Marmur Award for excellence in research and education during his orthopedic residency at the University of Southern California, prior to completing a Sports Medicine Fellowship in 2003. He received further training in hip arthroscopy at the Nashville Orthopaedic Sports Medicine and Orthopaedic Clinic, and maintains a leadership role in the area of sports medicine and hip preservation on a national and international level. Currently, he serves as Team Physician for the US Soccer Men’s National Team, the Los Angeles Galaxy, and Pepperdine University.

Matthew J. Matava, MD

Associate Editor for Professional Sports

Dr. Matava is a professor of Orthopedic Surgery and Physical Therapy, Chief of the Sports Medicine Service, and the Head Team Physician for the varsity athletic program at Washington University in St. Louis. He is also a team physician for the National Hockey League’s St. Louis Blues. Formerly, he was the Head Team Physician for the St. Louis Rams, and was President of the National Football League Physicians Society (NFLPS) from 2013-2015. Dr. Matava earned his Medical Degree from the University of Missouri-Kansas City. He completed his internship and orthopedic surgery residency at Emory University in Atlanta, GA, followed by a fellowship in sports medicine and arthroscopic surgery at the Cincinnati Sports Medicine and Orthopedic Center. He is the recipient of several research awards from Emory University, is a member of the Alpha Omega Medical Honor Society, and received the Palma Chironis Award for Excellence in Teaching from the Washington University Department of Orthopedic Surgery in 2012. Dr. Matava has been listed as a “Best Doctor in America” since 2005, and was recently hailed by Orthopedics This Week as one of the top 28 sports knee surgeons in the nation.

Jeffrey Sawyer, MD

Associate Editor for Pediatrics

Dr. Sawyer is a professor of Orthopaedic Surgery and the Pediatric Orthopaedic Fellowship Director at the University of Tennessee-Campbell Clinic. He also serves as a reviewer/editor for the Journal of Pediatric Orthopaedics and Orthopedic Clinics of North America. He graduated from the University of Rochester School of Medicine and completed his residency at the University of Pennsylvania, prior to completing his Pediatric Orthopaedic Fellowship at the University of Tennessee-Campbell Clinic. Dr. Sawyer has held numerous leadership positions in the Pediatric Orthopaedic Society of North America (POSNA). He also was a POSNA Traveling Fellow and won the POSNA Special Achievement Award for his work on the Pediatric Orthopaedic Workforce. He is a national authority on pediatric orthopedic trauma, and is on the Executive Committee of the Children’s Spine Foundation.

Brian K. Vickaryous, MD

Associate Editor for Trauma

Dr. Vickaryous is a specialist in orthopedic traumatology at the Florida Hospital Orthopedic Institute in Orlando, Florida, and has an additional subspecialty board certification in sports medicine. He attended the University of Miami, Florida through the combined degree Medical
Honors Program and completed his residency at the William Beaumont Army Medical Center/Texas Tech University of the Health Sciences. Dr. Vickaryous has also deployed overseas as Commander of the Trauma Unit, the 8th Forward Surgical Team, in Iraq in support of Operation Iraqi Freedom. He currently is a member of the American Academy of Orthopaedic
Surgeons (AAOS) and the Orthopaedic Trauma Association (OTA).

Michael B. Gerhardt, MD

Associate Editor for Sports Medicine

Dr. Gerhardt is a sports medicine specialist at the Kerlan-Jobe Institute and Santa Monica Orthopaedic Group in Los Angeles, CA. He also serves as faculty in the Department of Orthopaedic Surgery at Cedars-Sinai Medical Center. Dr. Gerhardt earned his undergraduate degree from UC San Diego and graduated medical school with honors from the Medical College of Pennsylvania. He received the Leonard Marmur Award for excellence in research and education during his orthopedic residency at the University of Southern California, prior to completing a Sports Medicine Fellowship in 2003. He received further training in hip arthroscopy at the Nashville Orthopaedic Sports Medicine and Orthopaedic Clinic, and maintains a leadership role in the area of sports medicine and hip preservation on a national and international level. Currently, he serves as Team Physician for the US Soccer Men’s National Team, the Los Angeles Galaxy, and Pepperdine University.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

Video, Part 1. Femoral Attachment

1. Ultrasound is used to identify femoral and patellar attachments of medial patellofemoral ligament (MPFL).

2. MPFL is followed from patella to its attachment near adductor tubercle.

3. In-plane ultrasound guidance is used to place needle anterior and distal to tubercle.

4. Percutaneous incision is made down to needle tip. Spear is placed at needle tip for anatomical placement of socket.

5. Socket is drilled.

6. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed.

7. Leading edge of torn MPFL is identified.

8. Suture passer (Labral FastPass Scorpion; Arthrex) is used to pass sutures through leading edge of torn MPFL to create horizontal mattress.

9. Sutures are tied.

10. Repair is complete.

Video, Part 2. Patellar Attachment

1. Ultrasound is used to scan patella to identify ideal or exact location of tear. In-plane ultrasound guidance is used to place spinal needle at desired socket location.

2. After spinal needle is positioned, in-line percutaneous incision is made, and needle is palpated at patella.

3. Spear is then placed at spinal needle tip for anatomical positioning of socket.

4. Socket is drilled.

5. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed in socket.

6. Leading edge of torn medial patellofemoral ligament (MPFL) is identified.

7. Suture passer (Labral Past Pass Scorpion; Arthrex) is used to pass suture from anchor in horizontal mattress fashion through leading edge of torn MPFL.

8. Wire with loop (FiberSnare; Arthrex) is used as part of knotless technology to pull suture back through anchor to create knotless fixation.

9. Suture is pulled for appropriate tensioning of tissue.

10. Ultrasound is used to visualize construct to confirm that MPFL tissue abuts anchor and that repair is complete.

Video, Part 1. Femoral Attachment

1. Ultrasound is used to identify femoral and patellar attachments of medial patellofemoral ligament (MPFL).

2. MPFL is followed from patella to its attachment near adductor tubercle.

3. In-plane ultrasound guidance is used to place needle anterior and distal to tubercle.

4. Percutaneous incision is made down to needle tip. Spear is placed at needle tip for anatomical placement of socket.

5. Socket is drilled.

6. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed.

7. Leading edge of torn MPFL is identified.

8. Suture passer (Labral FastPass Scorpion; Arthrex) is used to pass sutures through leading edge of torn MPFL to create horizontal mattress.

9. Sutures are tied.

10. Repair is complete.

Video, Part 2. Patellar Attachment

1. Ultrasound is used to scan patella to identify ideal or exact location of tear. In-plane ultrasound guidance is used to place spinal needle at desired socket location.

2. After spinal needle is positioned, in-line percutaneous incision is made, and needle is palpated at patella.

3. Spear is then placed at spinal needle tip for anatomical positioning of socket.

4. Socket is drilled.

5. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed in socket.

6. Leading edge of torn medial patellofemoral ligament (MPFL) is identified.

7. Suture passer (Labral Past Pass Scorpion; Arthrex) is used to pass suture from anchor in horizontal mattress fashion through leading edge of torn MPFL.

8. Wire with loop (FiberSnare; Arthrex) is used as part of knotless technology to pull suture back through anchor to create knotless fixation.

9. Suture is pulled for appropriate tensioning of tissue.

10. Ultrasound is used to visualize construct to confirm that MPFL tissue abuts anchor and that repair is complete.

Video, Part 1. Femoral Attachment

1. Ultrasound is used to identify femoral and patellar attachments of medial patellofemoral ligament (MPFL).

2. MPFL is followed from patella to its attachment near adductor tubercle.

3. In-plane ultrasound guidance is used to place needle anterior and distal to tubercle.

4. Percutaneous incision is made down to needle tip. Spear is placed at needle tip for anatomical placement of socket.

5. Socket is drilled.

6. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed.

7. Leading edge of torn MPFL is identified.

8. Suture passer (Labral FastPass Scorpion; Arthrex) is used to pass sutures through leading edge of torn MPFL to create horizontal mattress.

9. Sutures are tied.

10. Repair is complete.

Video, Part 2. Patellar Attachment

1. Ultrasound is used to scan patella to identify ideal or exact location of tear. In-plane ultrasound guidance is used to place spinal needle at desired socket location.

2. After spinal needle is positioned, in-line percutaneous incision is made, and needle is palpated at patella.

3. Spear is then placed at spinal needle tip for anatomical positioning of socket.

4. Socket is drilled.

5. 3.0-mm suture anchor (BioComposite Knotless SutureTak; Arthrex) is placed in socket.

6. Leading edge of torn medial patellofemoral ligament (MPFL) is identified.

7. Suture passer (Labral Past Pass Scorpion; Arthrex) is used to pass suture from anchor in horizontal mattress fashion through leading edge of torn MPFL.

8. Wire with loop (FiberSnare; Arthrex) is used as part of knotless technology to pull suture back through anchor to create knotless fixation.

9. Suture is pulled for appropriate tensioning of tissue.

10. Ultrasound is used to visualize construct to confirm that MPFL tissue abuts anchor and that repair is complete.

Take-Home Points

• Both PFN and PFLCP are effective treatments for unstable trochanteric femur fractures.
• PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing.
• Both devices have good long-term functional outcomes.
• Complication rates in unstable trochanteric fractures treated with both implants are comparable.
• Larger randomized controlled multicenter studies are needed to further evaluate and compare both implants in displaced unstable trochanteric femur fractures.

Trochanteric fractures are among the most widely treated orthopedic injuries, occurring mainly as low-energy injuries in elderly patients and high-energy injuries in younger patients.^1,2 About half of these injuries are unstable.³ According to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) system, trochanteric fractures can be classified stable (AO/OTA 31.A1-1 to 31.A2-1) or unstable (AO/OTA 31.A2-2 to 31.A3.3).^4,5 For surgical fixation of trochanteric femur fractures, various internal fixation devices have been used, either extramedullary (EM) or intramedullary (IM).⁶ The dynamic hip screw (DHS) is the implant of choice in the treatment of stable trochanteric femur fractures (AO/OTA 31-A1), as it provides secure fixation and controlled impaction.⁷ Mechanical and technical failures continue to occur in up to 6% to 18% of cases of unstable trochanteric fractures treated with DHS.⁸ Excessive sliding of the lag screw within the plate barrel results in limb shortening and distal fragment medialization, which are the main causes of these failures.^9,10 Dissatisfaction with DHS use in unstable fractures led to the use of IM nails. The various IM devices available are condylocephalic (Ender) nails and cephalomedullary nails, such as gamma nails; IM hip screws; trochanteric antegrade nails; proximal femoral nails (PFNs); and trochanteric fixation nails.^11,12 Unstable trochanteric fractures treated with these IM fixation devices have had good results.^12-14 Because of their central location and shorter lever arm, IM nails decrease the tensile strain on the implant and thereby reduce the risk of implant failure and provide more efficient load transfer while maintaining the advantage of controlled fracture impaction, as in DHS.^15,16 According to some authors, IM nail insertion theoretically requires less operative time and less soft-tissue dissection, potentially resulting in decreased overall morbidity.^15,16 PFN is one of the most effective fixation methods used to treat unstable trochanteric femur fractures.¹⁷ However, it is associated with various technical problems and failures, such as anterior femoral cortex penetration (caused by mismatch of nail curvature and intact femur), lag screw prominence in the lateral thigh, creation of a large hole in the greater trochanter (leading to abductors weakness), and potential for the Z-effect.^18,19 Studies have compared PFN with the Less Invasive Stabilization System-Distal Femur (LISS-DF) in the treatment of proximal femur fracture, and the clinical results are encouraging.^20,21 Recently, the proximal femoral locking compression plate (PFLCP) was introduced as a new implant that allows for angular-stable plating in the treatment of complex comminuted and osteoporotic intertrochanteric fractures.^22,23

To our knowledge, our study is the first to compare functional outcomes and complications of unstable trochanteric fractures treated with PFN and those treated with PFLCP. We hypothesized that both PFN and PFLCP would provide good functional outcomes with acceptable and comparable complications in the treatment of unstable trochanteric fractures.

Materials and Methods

The protocol for this prospective comparative study was approved by the Institutional Review Board at Mayo Institute of Medical Sciences. Informed consent was provided by all patients. A power analysis with power of 90% to detect a Harris Hip Score (HHS) difference of 10 as being significant at the 5% level, and with a 10% to 15% dropout rate, determined that a sample size of 50 patients was needed. Each group (PFN, PFLCP) required at least 25 participants. From April 2009 to June 2011, 74 patients with unilateral closed unstable trochanteric fractures were admitted to our hospital. Of these patients, 48 met our inclusion criteria and were included in the study. A sealed envelope method was used to randomly assign 24 of these patients to PFN treatment and the other 24 to PFLCP treatment. One patient died of causes unrelated to an implant during the study, and 2 were lost to follow-up (telephone numbers changed). The remaining 45 patients (23 PFN, 22 PFLCP) reached 2-year follow-up.

Inclusion criteria were unilateral, closed unstable trochanteric fractures, and age over 18 years. Exclusion criteria were bilateral fractures, polytrauma, pathologic fractures, open fractures (American Society of Anesthesiologists [ASA] grade 4 or 5),²⁴ and associated hip osteoarthritis (Kellgren-Lawrence grade 3 or 4).²⁵ We collected data on demographics, operative time, incision length, intraoperative blood loss (measured by gravimetric method), hospital length of stay (LOS), and time to full weight-bearing. Mean (SD) age was 58.3 (9.3) years for the PFN group (range, 19-82 years) and 60.5 (8.1) years for the PFLCP group (range, 20-84 years).

Results

Intraoperative blood loss (P = .02) and incision length (P = .008) were significantly less in the PFN group than in the PFLCP group. No significant difference was found between the groups in terms of operative time (P = .08), reduction quality (P = .82), radiologic exposure time (P = .18), LOS (P = .32), union rate (P = .42), and time to union (P = .68).

Two PFN patients and 3 PFLCP patients developed a superficial infection (P = .36); all 5 infections were controlled with oral antibiotics. There was 1 nonunion in the PFN group but none in the PFLCP group (P = .28). The nonunion patient, who also had a broken implant without any history of fresh trauma, was treated with implant removal and bipolar hemiarthroplasty.

Discussion

The goal in managing proximal femoral fractures is to achieve near anatomical reduction with stable fracture fixation. Over the years, EM and IM devices have been used to treat trochanteric fractures; each has its merits and demerits.^29,30 However, unstable trochanteric fractures treated with EM devices (eg, DHS, dynamic condylar screw) have high complication rates (6%-18%).^8,31 Excessive sliding of the lag screw within the plate barrel may result in limb shortening and distal fragment medialization. EM devices cannot adequately prevent secondary limb shortening after weight-bearing, owing to medialization of the distal fragment.^32,33 Varus collapse and implant failure (eg, cut-out of the femoral head screw) are also common.²⁹ These complications led to the development of IM hip screw devices, such as PFN, which has several potential advantages, including a shorter lever arm (decreases tensile strain on implant) and efficient load transfer capacity. PFN has been found to have increased fracture stability, with no difference in operative time or intraoperative complication rates, but some studies have reported implant failure and other complications (3%-17%) in PFN-treated unstable trochanteric fractures.^29,34,35

We conducted the present study to compare PFN and PFLCP, new treatment options for unstable and highly comminuted trochanteric fractures. The characteristics of the patients in this study are very different from those in most hip fracture studies. Our PFN and PFLCP groups’ mean ages were lower relative to other studies.^14,15,36 In addition, time from injury to surgery was longer for both our groups than for groups in other studies, though some studies³⁶ have reported comparable times. Moreover, our groups showed no statistically significant differences in operative time, radiologic exposure time, LOS, union rate, or time to union. Our PFN patients had significantly shorter incisions and less time to full weight-bearing.

Wang and colleagues³⁷ compared the clinical outcomes of DHS, IM fixation (IMF), and PFLCP in the treatment of trochanteric fractures in elderly patients. Incision length and operative time were shorter for the IMF group than for DHS and PFLCP, but there were no significant differences between DHS and PFLCP. Intraoperative blood loss, rehabilitation, and time to healing were less for the IMF and PFLCP groups than for DHS, but there were no significant differences between IMF and PFLCP. Functional recovery was better for the IMF and PFLCP groups than for DHS, and there were significant differences among the 3 groups. There were fewer complications in the PFLCP group than in IMF and DHS.

Yao and colleagues³⁸ compared reverse LISS and PFN treatment of intertrochanteric fractures and reported no significant differences in operative time, intraoperative blood loss, or functional outcome. Regarding complications, the PFN group had none, and the LISS group had 3 (1 nonunion with locking screw breakage, 2 varus unions).

Haq and colleagues³⁹ compared PFN and contralateral reverse distal femoral locking compression plate (reverse DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall and reported better intraoperative variables, better functional outcomes, and lower failure rates in the PFN group than in the reverse DFLCP group.

Zha and colleagues²² followed up 110 patients with intertrochanteric and subtrochanteric fractures treated with PFLCP fixation and reported a 100% union rate at 1-year follow-up. Mean operative time was 35.5minutes, and mean bleeding amount was 150mL, which included operative blood loss and wound drainage. Mean radiologic exposure time was 5minutes, and mean incision length was 9cm. There was 1 case of implant breakage.

Strohm and colleagues⁴⁰ reported good results in children with trochanteric fractures treated with conventional locking compression plate.

Brett and colleagues⁴¹ compared blade plate and PFLCP with and without a kickstand screw in a composite femur subtrochanteric fracture gap model. In their biomechanical study, the PFLCP with a kickstand screw provided higher axial but less torsional stiffness than the blade plate. The authors concluded that, though the devices are biomechanically equivalent, PFLCP may allow percutaneous insertion that avoids the potential morbidity associated with the blade plate’s extensile approach.

Our PFN group’s mean (SD) time to healing was 4.2 (1.3) months. In other studies, mean healing time for IMF-treated unstable trochanteric fractures was 3 to 4 months. Some authors have reported even longer healing times, up to 17 months,⁴² for PFN-treated trochanteric fractures. Many of the studies indicated that gradual weight-bearing was allowed around 6 weeks, when callus formation was adequate.⁴³ Our treatment protocol differed in that its protected weight-bearing period was prolonged, and controlled weight-bearing was delayed until around 6 weeks, when callus formation was adequate.

The better PFLCP outcomes in our study, relative to most other studies, can be attributed to the relatively younger age of our PFN and PFLCP groups. In a study of 19 patients with trochanteric fractures treated with open reduction and internal fixation using PFLCP, Wirtz and colleagues⁴⁴ reported 4 cases of secondary varus collapse, 2 cut-outs of the proximal fragment, and 1 implant failure caused by a broken proximal screw. Eight patients experienced persistent trochanteric pain, and 3 underwent hardware removal.

Streubel and colleagues⁴⁵ retrospectively analyzed 29 patients with 30 OTA 31.A3 fractures treated with PFLCP and reported 11 failures (37%) at 20-month follow-up. The most frequent failure mode (5 cases) was varus collapse with screw cut-out. Presence of a kickstand screw and medial cortical reduction were not significantly different between cases that failed and those that did not.

Glassner and Tejwani⁴⁶ retrospectively studied 10 patients with trochanteric fractures treated with open reduction and internal fixation with PFLCP. Failure modes were implant fracture (4 cases) and fixation loss (3 cases) resulting from varus collapse and implant cutout.

One of our PFN patients had a lower neck screw back out by 9-month follow-up. As the fracture had consolidated well, the patient underwent screw removal. Another PFN patient had a broken implant and fracture nonunion at 1-year follow-up. Various complications have been reported in the literature,^13,14,47,48 but none occurred in our study. There were no implant-related complications in our PFLCP group, possibly because of the mechanical advantage of 3-dimensional and angular-stable fixation with PFLCP in unstable trochanteric fractures.

Gadegone and Salphale⁴⁹ analyzed 100 cases of PFN-treated trochanteric fractures and reported femoral head cut-through (4.8%), intraoperative femoral shaft fracture (0.8%), implant breakage (0.8%), wound-healing impairment (9.7%), and false placement of osteosynthesis materials (0.8%). The 19% reoperation rate in their study mainly involved cephalic screw removal for lateral protrusion at the proximal thigh. Our PFN reoperation rate was 8.7%; none of our PFLCP patients required revision surgery.

Tyllianakis and colleagues⁵⁰ analyzed 45 cases of PFN-treated unstable trochanteric fractures and concluded technical or mechanical complications were related more to fracture type, surgical technique, and time to weight-bearing than to the implant itself. Our postoperative wound complication rate was similar to that of other studies.^14,47,51 Regarding functional outcomes, our groups’ HHSs were good and comparable at final follow-up, as were their PPM scores.

This study was limited in that it was a small prospective comparative single-center study with a small number of patients. Larger randomized controlled multicenter studies are needed to evaluate and compare both implants in displaced unstable trochanteric femur fractures.

This study found that both PFN and PFLCP were effective treatments for unstable trochanteric femur fractures. PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing. Both devices can be used in unstable trochanteric fractures, and both have good functional outcomes and acceptable complication rates.

Am J Orthop. 2017;46(2):E116-E123. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Both PFN and PFLCP are effective treatments for unstable trochanteric femur fractures.
• PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing.
• Both devices have good long-term functional outcomes.
• Complication rates in unstable trochanteric fractures treated with both implants are comparable.
• Larger randomized controlled multicenter studies are needed to further evaluate and compare both implants in displaced unstable trochanteric femur fractures.

Trochanteric fractures are among the most widely treated orthopedic injuries, occurring mainly as low-energy injuries in elderly patients and high-energy injuries in younger patients.^1,2 About half of these injuries are unstable.³ According to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) system, trochanteric fractures can be classified stable (AO/OTA 31.A1-1 to 31.A2-1) or unstable (AO/OTA 31.A2-2 to 31.A3.3).^4,5 For surgical fixation of trochanteric femur fractures, various internal fixation devices have been used, either extramedullary (EM) or intramedullary (IM).⁶ The dynamic hip screw (DHS) is the implant of choice in the treatment of stable trochanteric femur fractures (AO/OTA 31-A1), as it provides secure fixation and controlled impaction.⁷ Mechanical and technical failures continue to occur in up to 6% to 18% of cases of unstable trochanteric fractures treated with DHS.⁸ Excessive sliding of the lag screw within the plate barrel results in limb shortening and distal fragment medialization, which are the main causes of these failures.^9,10 Dissatisfaction with DHS use in unstable fractures led to the use of IM nails. The various IM devices available are condylocephalic (Ender) nails and cephalomedullary nails, such as gamma nails; IM hip screws; trochanteric antegrade nails; proximal femoral nails (PFNs); and trochanteric fixation nails.^11,12 Unstable trochanteric fractures treated with these IM fixation devices have had good results.^12-14 Because of their central location and shorter lever arm, IM nails decrease the tensile strain on the implant and thereby reduce the risk of implant failure and provide more efficient load transfer while maintaining the advantage of controlled fracture impaction, as in DHS.^15,16 According to some authors, IM nail insertion theoretically requires less operative time and less soft-tissue dissection, potentially resulting in decreased overall morbidity.^15,16 PFN is one of the most effective fixation methods used to treat unstable trochanteric femur fractures.¹⁷ However, it is associated with various technical problems and failures, such as anterior femoral cortex penetration (caused by mismatch of nail curvature and intact femur), lag screw prominence in the lateral thigh, creation of a large hole in the greater trochanter (leading to abductors weakness), and potential for the Z-effect.^18,19 Studies have compared PFN with the Less Invasive Stabilization System-Distal Femur (LISS-DF) in the treatment of proximal femur fracture, and the clinical results are encouraging.^20,21 Recently, the proximal femoral locking compression plate (PFLCP) was introduced as a new implant that allows for angular-stable plating in the treatment of complex comminuted and osteoporotic intertrochanteric fractures.^22,23

To our knowledge, our study is the first to compare functional outcomes and complications of unstable trochanteric fractures treated with PFN and those treated with PFLCP. We hypothesized that both PFN and PFLCP would provide good functional outcomes with acceptable and comparable complications in the treatment of unstable trochanteric fractures.

Materials and Methods

The protocol for this prospective comparative study was approved by the Institutional Review Board at Mayo Institute of Medical Sciences. Informed consent was provided by all patients. A power analysis with power of 90% to detect a Harris Hip Score (HHS) difference of 10 as being significant at the 5% level, and with a 10% to 15% dropout rate, determined that a sample size of 50 patients was needed. Each group (PFN, PFLCP) required at least 25 participants. From April 2009 to June 2011, 74 patients with unilateral closed unstable trochanteric fractures were admitted to our hospital. Of these patients, 48 met our inclusion criteria and were included in the study. A sealed envelope method was used to randomly assign 24 of these patients to PFN treatment and the other 24 to PFLCP treatment. One patient died of causes unrelated to an implant during the study, and 2 were lost to follow-up (telephone numbers changed). The remaining 45 patients (23 PFN, 22 PFLCP) reached 2-year follow-up.

Inclusion criteria were unilateral, closed unstable trochanteric fractures, and age over 18 years. Exclusion criteria were bilateral fractures, polytrauma, pathologic fractures, open fractures (American Society of Anesthesiologists [ASA] grade 4 or 5),²⁴ and associated hip osteoarthritis (Kellgren-Lawrence grade 3 or 4).²⁵ We collected data on demographics, operative time, incision length, intraoperative blood loss (measured by gravimetric method), hospital length of stay (LOS), and time to full weight-bearing. Mean (SD) age was 58.3 (9.3) years for the PFN group (range, 19-82 years) and 60.5 (8.1) years for the PFLCP group (range, 20-84 years).

Results

Intraoperative blood loss (P = .02) and incision length (P = .008) were significantly less in the PFN group than in the PFLCP group. No significant difference was found between the groups in terms of operative time (P = .08), reduction quality (P = .82), radiologic exposure time (P = .18), LOS (P = .32), union rate (P = .42), and time to union (P = .68).

Two PFN patients and 3 PFLCP patients developed a superficial infection (P = .36); all 5 infections were controlled with oral antibiotics. There was 1 nonunion in the PFN group but none in the PFLCP group (P = .28). The nonunion patient, who also had a broken implant without any history of fresh trauma, was treated with implant removal and bipolar hemiarthroplasty.

Discussion

The goal in managing proximal femoral fractures is to achieve near anatomical reduction with stable fracture fixation. Over the years, EM and IM devices have been used to treat trochanteric fractures; each has its merits and demerits.^29,30 However, unstable trochanteric fractures treated with EM devices (eg, DHS, dynamic condylar screw) have high complication rates (6%-18%).^8,31 Excessive sliding of the lag screw within the plate barrel may result in limb shortening and distal fragment medialization. EM devices cannot adequately prevent secondary limb shortening after weight-bearing, owing to medialization of the distal fragment.^32,33 Varus collapse and implant failure (eg, cut-out of the femoral head screw) are also common.²⁹ These complications led to the development of IM hip screw devices, such as PFN, which has several potential advantages, including a shorter lever arm (decreases tensile strain on implant) and efficient load transfer capacity. PFN has been found to have increased fracture stability, with no difference in operative time or intraoperative complication rates, but some studies have reported implant failure and other complications (3%-17%) in PFN-treated unstable trochanteric fractures.^29,34,35

We conducted the present study to compare PFN and PFLCP, new treatment options for unstable and highly comminuted trochanteric fractures. The characteristics of the patients in this study are very different from those in most hip fracture studies. Our PFN and PFLCP groups’ mean ages were lower relative to other studies.^14,15,36 In addition, time from injury to surgery was longer for both our groups than for groups in other studies, though some studies³⁶ have reported comparable times. Moreover, our groups showed no statistically significant differences in operative time, radiologic exposure time, LOS, union rate, or time to union. Our PFN patients had significantly shorter incisions and less time to full weight-bearing.

Wang and colleagues³⁷ compared the clinical outcomes of DHS, IM fixation (IMF), and PFLCP in the treatment of trochanteric fractures in elderly patients. Incision length and operative time were shorter for the IMF group than for DHS and PFLCP, but there were no significant differences between DHS and PFLCP. Intraoperative blood loss, rehabilitation, and time to healing were less for the IMF and PFLCP groups than for DHS, but there were no significant differences between IMF and PFLCP. Functional recovery was better for the IMF and PFLCP groups than for DHS, and there were significant differences among the 3 groups. There were fewer complications in the PFLCP group than in IMF and DHS.

Yao and colleagues³⁸ compared reverse LISS and PFN treatment of intertrochanteric fractures and reported no significant differences in operative time, intraoperative blood loss, or functional outcome. Regarding complications, the PFN group had none, and the LISS group had 3 (1 nonunion with locking screw breakage, 2 varus unions).

Haq and colleagues³⁹ compared PFN and contralateral reverse distal femoral locking compression plate (reverse DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall and reported better intraoperative variables, better functional outcomes, and lower failure rates in the PFN group than in the reverse DFLCP group.

Zha and colleagues²² followed up 110 patients with intertrochanteric and subtrochanteric fractures treated with PFLCP fixation and reported a 100% union rate at 1-year follow-up. Mean operative time was 35.5minutes, and mean bleeding amount was 150mL, which included operative blood loss and wound drainage. Mean radiologic exposure time was 5minutes, and mean incision length was 9cm. There was 1 case of implant breakage.

Strohm and colleagues⁴⁰ reported good results in children with trochanteric fractures treated with conventional locking compression plate.

Brett and colleagues⁴¹ compared blade plate and PFLCP with and without a kickstand screw in a composite femur subtrochanteric fracture gap model. In their biomechanical study, the PFLCP with a kickstand screw provided higher axial but less torsional stiffness than the blade plate. The authors concluded that, though the devices are biomechanically equivalent, PFLCP may allow percutaneous insertion that avoids the potential morbidity associated with the blade plate’s extensile approach.

Our PFN group’s mean (SD) time to healing was 4.2 (1.3) months. In other studies, mean healing time for IMF-treated unstable trochanteric fractures was 3 to 4 months. Some authors have reported even longer healing times, up to 17 months,⁴² for PFN-treated trochanteric fractures. Many of the studies indicated that gradual weight-bearing was allowed around 6 weeks, when callus formation was adequate.⁴³ Our treatment protocol differed in that its protected weight-bearing period was prolonged, and controlled weight-bearing was delayed until around 6 weeks, when callus formation was adequate.

The better PFLCP outcomes in our study, relative to most other studies, can be attributed to the relatively younger age of our PFN and PFLCP groups. In a study of 19 patients with trochanteric fractures treated with open reduction and internal fixation using PFLCP, Wirtz and colleagues⁴⁴ reported 4 cases of secondary varus collapse, 2 cut-outs of the proximal fragment, and 1 implant failure caused by a broken proximal screw. Eight patients experienced persistent trochanteric pain, and 3 underwent hardware removal.

Streubel and colleagues⁴⁵ retrospectively analyzed 29 patients with 30 OTA 31.A3 fractures treated with PFLCP and reported 11 failures (37%) at 20-month follow-up. The most frequent failure mode (5 cases) was varus collapse with screw cut-out. Presence of a kickstand screw and medial cortical reduction were not significantly different between cases that failed and those that did not.

Glassner and Tejwani⁴⁶ retrospectively studied 10 patients with trochanteric fractures treated with open reduction and internal fixation with PFLCP. Failure modes were implant fracture (4 cases) and fixation loss (3 cases) resulting from varus collapse and implant cutout.

One of our PFN patients had a lower neck screw back out by 9-month follow-up. As the fracture had consolidated well, the patient underwent screw removal. Another PFN patient had a broken implant and fracture nonunion at 1-year follow-up. Various complications have been reported in the literature,^13,14,47,48 but none occurred in our study. There were no implant-related complications in our PFLCP group, possibly because of the mechanical advantage of 3-dimensional and angular-stable fixation with PFLCP in unstable trochanteric fractures.

Gadegone and Salphale⁴⁹ analyzed 100 cases of PFN-treated trochanteric fractures and reported femoral head cut-through (4.8%), intraoperative femoral shaft fracture (0.8%), implant breakage (0.8%), wound-healing impairment (9.7%), and false placement of osteosynthesis materials (0.8%). The 19% reoperation rate in their study mainly involved cephalic screw removal for lateral protrusion at the proximal thigh. Our PFN reoperation rate was 8.7%; none of our PFLCP patients required revision surgery.

Tyllianakis and colleagues⁵⁰ analyzed 45 cases of PFN-treated unstable trochanteric fractures and concluded technical or mechanical complications were related more to fracture type, surgical technique, and time to weight-bearing than to the implant itself. Our postoperative wound complication rate was similar to that of other studies.^14,47,51 Regarding functional outcomes, our groups’ HHSs were good and comparable at final follow-up, as were their PPM scores.

This study was limited in that it was a small prospective comparative single-center study with a small number of patients. Larger randomized controlled multicenter studies are needed to evaluate and compare both implants in displaced unstable trochanteric femur fractures.

This study found that both PFN and PFLCP were effective treatments for unstable trochanteric femur fractures. PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing. Both devices can be used in unstable trochanteric fractures, and both have good functional outcomes and acceptable complication rates.

Am J Orthop. 2017;46(2):E116-E123. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Both PFN and PFLCP are effective treatments for unstable trochanteric femur fractures.
• PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing.
• Both devices have good long-term functional outcomes.
• Complication rates in unstable trochanteric fractures treated with both implants are comparable.
• Larger randomized controlled multicenter studies are needed to further evaluate and compare both implants in displaced unstable trochanteric femur fractures.

Trochanteric fractures are among the most widely treated orthopedic injuries, occurring mainly as low-energy injuries in elderly patients and high-energy injuries in younger patients.^1,2 About half of these injuries are unstable.³ According to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) system, trochanteric fractures can be classified stable (AO/OTA 31.A1-1 to 31.A2-1) or unstable (AO/OTA 31.A2-2 to 31.A3.3).^4,5 For surgical fixation of trochanteric femur fractures, various internal fixation devices have been used, either extramedullary (EM) or intramedullary (IM).⁶ The dynamic hip screw (DHS) is the implant of choice in the treatment of stable trochanteric femur fractures (AO/OTA 31-A1), as it provides secure fixation and controlled impaction.⁷ Mechanical and technical failures continue to occur in up to 6% to 18% of cases of unstable trochanteric fractures treated with DHS.⁸ Excessive sliding of the lag screw within the plate barrel results in limb shortening and distal fragment medialization, which are the main causes of these failures.^9,10 Dissatisfaction with DHS use in unstable fractures led to the use of IM nails. The various IM devices available are condylocephalic (Ender) nails and cephalomedullary nails, such as gamma nails; IM hip screws; trochanteric antegrade nails; proximal femoral nails (PFNs); and trochanteric fixation nails.^11,12 Unstable trochanteric fractures treated with these IM fixation devices have had good results.^12-14 Because of their central location and shorter lever arm, IM nails decrease the tensile strain on the implant and thereby reduce the risk of implant failure and provide more efficient load transfer while maintaining the advantage of controlled fracture impaction, as in DHS.^15,16 According to some authors, IM nail insertion theoretically requires less operative time and less soft-tissue dissection, potentially resulting in decreased overall morbidity.^15,16 PFN is one of the most effective fixation methods used to treat unstable trochanteric femur fractures.¹⁷ However, it is associated with various technical problems and failures, such as anterior femoral cortex penetration (caused by mismatch of nail curvature and intact femur), lag screw prominence in the lateral thigh, creation of a large hole in the greater trochanter (leading to abductors weakness), and potential for the Z-effect.^18,19 Studies have compared PFN with the Less Invasive Stabilization System-Distal Femur (LISS-DF) in the treatment of proximal femur fracture, and the clinical results are encouraging.^20,21 Recently, the proximal femoral locking compression plate (PFLCP) was introduced as a new implant that allows for angular-stable plating in the treatment of complex comminuted and osteoporotic intertrochanteric fractures.^22,23

To our knowledge, our study is the first to compare functional outcomes and complications of unstable trochanteric fractures treated with PFN and those treated with PFLCP. We hypothesized that both PFN and PFLCP would provide good functional outcomes with acceptable and comparable complications in the treatment of unstable trochanteric fractures.

Materials and Methods

The protocol for this prospective comparative study was approved by the Institutional Review Board at Mayo Institute of Medical Sciences. Informed consent was provided by all patients. A power analysis with power of 90% to detect a Harris Hip Score (HHS) difference of 10 as being significant at the 5% level, and with a 10% to 15% dropout rate, determined that a sample size of 50 patients was needed. Each group (PFN, PFLCP) required at least 25 participants. From April 2009 to June 2011, 74 patients with unilateral closed unstable trochanteric fractures were admitted to our hospital. Of these patients, 48 met our inclusion criteria and were included in the study. A sealed envelope method was used to randomly assign 24 of these patients to PFN treatment and the other 24 to PFLCP treatment. One patient died of causes unrelated to an implant during the study, and 2 were lost to follow-up (telephone numbers changed). The remaining 45 patients (23 PFN, 22 PFLCP) reached 2-year follow-up.

Inclusion criteria were unilateral, closed unstable trochanteric fractures, and age over 18 years. Exclusion criteria were bilateral fractures, polytrauma, pathologic fractures, open fractures (American Society of Anesthesiologists [ASA] grade 4 or 5),²⁴ and associated hip osteoarthritis (Kellgren-Lawrence grade 3 or 4).²⁵ We collected data on demographics, operative time, incision length, intraoperative blood loss (measured by gravimetric method), hospital length of stay (LOS), and time to full weight-bearing. Mean (SD) age was 58.3 (9.3) years for the PFN group (range, 19-82 years) and 60.5 (8.1) years for the PFLCP group (range, 20-84 years).

Results

Intraoperative blood loss (P = .02) and incision length (P = .008) were significantly less in the PFN group than in the PFLCP group. No significant difference was found between the groups in terms of operative time (P = .08), reduction quality (P = .82), radiologic exposure time (P = .18), LOS (P = .32), union rate (P = .42), and time to union (P = .68).

Two PFN patients and 3 PFLCP patients developed a superficial infection (P = .36); all 5 infections were controlled with oral antibiotics. There was 1 nonunion in the PFN group but none in the PFLCP group (P = .28). The nonunion patient, who also had a broken implant without any history of fresh trauma, was treated with implant removal and bipolar hemiarthroplasty.

Discussion

The goal in managing proximal femoral fractures is to achieve near anatomical reduction with stable fracture fixation. Over the years, EM and IM devices have been used to treat trochanteric fractures; each has its merits and demerits.^29,30 However, unstable trochanteric fractures treated with EM devices (eg, DHS, dynamic condylar screw) have high complication rates (6%-18%).^8,31 Excessive sliding of the lag screw within the plate barrel may result in limb shortening and distal fragment medialization. EM devices cannot adequately prevent secondary limb shortening after weight-bearing, owing to medialization of the distal fragment.^32,33 Varus collapse and implant failure (eg, cut-out of the femoral head screw) are also common.²⁹ These complications led to the development of IM hip screw devices, such as PFN, which has several potential advantages, including a shorter lever arm (decreases tensile strain on implant) and efficient load transfer capacity. PFN has been found to have increased fracture stability, with no difference in operative time or intraoperative complication rates, but some studies have reported implant failure and other complications (3%-17%) in PFN-treated unstable trochanteric fractures.^29,34,35

We conducted the present study to compare PFN and PFLCP, new treatment options for unstable and highly comminuted trochanteric fractures. The characteristics of the patients in this study are very different from those in most hip fracture studies. Our PFN and PFLCP groups’ mean ages were lower relative to other studies.^14,15,36 In addition, time from injury to surgery was longer for both our groups than for groups in other studies, though some studies³⁶ have reported comparable times. Moreover, our groups showed no statistically significant differences in operative time, radiologic exposure time, LOS, union rate, or time to union. Our PFN patients had significantly shorter incisions and less time to full weight-bearing.

Wang and colleagues³⁷ compared the clinical outcomes of DHS, IM fixation (IMF), and PFLCP in the treatment of trochanteric fractures in elderly patients. Incision length and operative time were shorter for the IMF group than for DHS and PFLCP, but there were no significant differences between DHS and PFLCP. Intraoperative blood loss, rehabilitation, and time to healing were less for the IMF and PFLCP groups than for DHS, but there were no significant differences between IMF and PFLCP. Functional recovery was better for the IMF and PFLCP groups than for DHS, and there were significant differences among the 3 groups. There were fewer complications in the PFLCP group than in IMF and DHS.

Yao and colleagues³⁸ compared reverse LISS and PFN treatment of intertrochanteric fractures and reported no significant differences in operative time, intraoperative blood loss, or functional outcome. Regarding complications, the PFN group had none, and the LISS group had 3 (1 nonunion with locking screw breakage, 2 varus unions).

Haq and colleagues³⁹ compared PFN and contralateral reverse distal femoral locking compression plate (reverse DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall and reported better intraoperative variables, better functional outcomes, and lower failure rates in the PFN group than in the reverse DFLCP group.

Zha and colleagues²² followed up 110 patients with intertrochanteric and subtrochanteric fractures treated with PFLCP fixation and reported a 100% union rate at 1-year follow-up. Mean operative time was 35.5minutes, and mean bleeding amount was 150mL, which included operative blood loss and wound drainage. Mean radiologic exposure time was 5minutes, and mean incision length was 9cm. There was 1 case of implant breakage.

Strohm and colleagues⁴⁰ reported good results in children with trochanteric fractures treated with conventional locking compression plate.

Brett and colleagues⁴¹ compared blade plate and PFLCP with and without a kickstand screw in a composite femur subtrochanteric fracture gap model. In their biomechanical study, the PFLCP with a kickstand screw provided higher axial but less torsional stiffness than the blade plate. The authors concluded that, though the devices are biomechanically equivalent, PFLCP may allow percutaneous insertion that avoids the potential morbidity associated with the blade plate’s extensile approach.

Our PFN group’s mean (SD) time to healing was 4.2 (1.3) months. In other studies, mean healing time for IMF-treated unstable trochanteric fractures was 3 to 4 months. Some authors have reported even longer healing times, up to 17 months,⁴² for PFN-treated trochanteric fractures. Many of the studies indicated that gradual weight-bearing was allowed around 6 weeks, when callus formation was adequate.⁴³ Our treatment protocol differed in that its protected weight-bearing period was prolonged, and controlled weight-bearing was delayed until around 6 weeks, when callus formation was adequate.

The better PFLCP outcomes in our study, relative to most other studies, can be attributed to the relatively younger age of our PFN and PFLCP groups. In a study of 19 patients with trochanteric fractures treated with open reduction and internal fixation using PFLCP, Wirtz and colleagues⁴⁴ reported 4 cases of secondary varus collapse, 2 cut-outs of the proximal fragment, and 1 implant failure caused by a broken proximal screw. Eight patients experienced persistent trochanteric pain, and 3 underwent hardware removal.

Streubel and colleagues⁴⁵ retrospectively analyzed 29 patients with 30 OTA 31.A3 fractures treated with PFLCP and reported 11 failures (37%) at 20-month follow-up. The most frequent failure mode (5 cases) was varus collapse with screw cut-out. Presence of a kickstand screw and medial cortical reduction were not significantly different between cases that failed and those that did not.

Glassner and Tejwani⁴⁶ retrospectively studied 10 patients with trochanteric fractures treated with open reduction and internal fixation with PFLCP. Failure modes were implant fracture (4 cases) and fixation loss (3 cases) resulting from varus collapse and implant cutout.

One of our PFN patients had a lower neck screw back out by 9-month follow-up. As the fracture had consolidated well, the patient underwent screw removal. Another PFN patient had a broken implant and fracture nonunion at 1-year follow-up. Various complications have been reported in the literature,^13,14,47,48 but none occurred in our study. There were no implant-related complications in our PFLCP group, possibly because of the mechanical advantage of 3-dimensional and angular-stable fixation with PFLCP in unstable trochanteric fractures.

Gadegone and Salphale⁴⁹ analyzed 100 cases of PFN-treated trochanteric fractures and reported femoral head cut-through (4.8%), intraoperative femoral shaft fracture (0.8%), implant breakage (0.8%), wound-healing impairment (9.7%), and false placement of osteosynthesis materials (0.8%). The 19% reoperation rate in their study mainly involved cephalic screw removal for lateral protrusion at the proximal thigh. Our PFN reoperation rate was 8.7%; none of our PFLCP patients required revision surgery.

Tyllianakis and colleagues⁵⁰ analyzed 45 cases of PFN-treated unstable trochanteric fractures and concluded technical or mechanical complications were related more to fracture type, surgical technique, and time to weight-bearing than to the implant itself. Our postoperative wound complication rate was similar to that of other studies.^14,47,51 Regarding functional outcomes, our groups’ HHSs were good and comparable at final follow-up, as were their PPM scores.

This study was limited in that it was a small prospective comparative single-center study with a small number of patients. Larger randomized controlled multicenter studies are needed to evaluate and compare both implants in displaced unstable trochanteric femur fractures.

This study found that both PFN and PFLCP were effective treatments for unstable trochanteric femur fractures. PFN is superior to PFLCP only in terms of shorter incisions and shorter time to full weight-bearing. Both devices can be used in unstable trochanteric fractures, and both have good functional outcomes and acceptable complication rates.

Am J Orthop. 2017;46(2):E116-E123. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Importance of on-field management.
• Preseason drilling of spinal injury management.
• Early and rapid intervention.
• Possible benefit of moderate systemic hypothermia as treatment for acute cervical injury.

In 2010, we reported the case of a professional American football player who sustained a complete cervical spinal cord injury (SCI) while tackling an opposing player.¹ He received prompt medical and surgical care based on then-current recommendations, but was also treated with systemic hypothermia soon after his injury. Although systemic hypothermia had been used in the management of other neurologic injuries at that time, it had not been used in humans with acute SCI, except as described in 2 case reports.^2,3 However, Dietrich⁴ described early emerging animal data on the efficacy of systemic hypothermia for acute SCI. We now provide a clinical update on our patient, who provided written informed consent for print and electronic publication of this case report.

Case Report

During a National Football League game, the player sustained a C3–C4 fracture-dislocation after a helmet-to-helmet hit on an opposing player. He fell face down on the ground and did not move. The team’s physician and trainer rushed to the player’s side, immediately assessed him, and initiated the emergency spinal resuscitation protocol.

As per protocol, the assigned team leader took charge of managing the player’s head to maintain in-line traction with the helmet in place until the head was secured in place on a backboard designed to accommodate the helmet.

Conclusion

At the time this player was injured, use of systemic hypothermia with standard therapy for acute SCI was unique and controversial. Since then, smaller randomized human studies have described the tolerable safety profile, efficacy, and potential benefits of this intervention in acute SCI in humans.^8-10 Now, modest systemic hypothermia can be one of many tools considered in the treatment of acute SCI. Before it can become the standard of care, however, additional larger prospective randomized studies need to be completed.

Am J Orthop. 2017;46(2):E79-E82. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Importance of on-field management.
• Preseason drilling of spinal injury management.
• Early and rapid intervention.
• Possible benefit of moderate systemic hypothermia as treatment for acute cervical injury.

In 2010, we reported the case of a professional American football player who sustained a complete cervical spinal cord injury (SCI) while tackling an opposing player.¹ He received prompt medical and surgical care based on then-current recommendations, but was also treated with systemic hypothermia soon after his injury. Although systemic hypothermia had been used in the management of other neurologic injuries at that time, it had not been used in humans with acute SCI, except as described in 2 case reports.^2,3 However, Dietrich⁴ described early emerging animal data on the efficacy of systemic hypothermia for acute SCI. We now provide a clinical update on our patient, who provided written informed consent for print and electronic publication of this case report.

Case Report

During a National Football League game, the player sustained a C3–C4 fracture-dislocation after a helmet-to-helmet hit on an opposing player. He fell face down on the ground and did not move. The team’s physician and trainer rushed to the player’s side, immediately assessed him, and initiated the emergency spinal resuscitation protocol.

As per protocol, the assigned team leader took charge of managing the player’s head to maintain in-line traction with the helmet in place until the head was secured in place on a backboard designed to accommodate the helmet.

Conclusion

At the time this player was injured, use of systemic hypothermia with standard therapy for acute SCI was unique and controversial. Since then, smaller randomized human studies have described the tolerable safety profile, efficacy, and potential benefits of this intervention in acute SCI in humans.^8-10 Now, modest systemic hypothermia can be one of many tools considered in the treatment of acute SCI. Before it can become the standard of care, however, additional larger prospective randomized studies need to be completed.

Am J Orthop. 2017;46(2):E79-E82. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Importance of on-field management.
• Preseason drilling of spinal injury management.
• Early and rapid intervention.
• Possible benefit of moderate systemic hypothermia as treatment for acute cervical injury.

In 2010, we reported the case of a professional American football player who sustained a complete cervical spinal cord injury (SCI) while tackling an opposing player.¹ He received prompt medical and surgical care based on then-current recommendations, but was also treated with systemic hypothermia soon after his injury. Although systemic hypothermia had been used in the management of other neurologic injuries at that time, it had not been used in humans with acute SCI, except as described in 2 case reports.^2,3 However, Dietrich⁴ described early emerging animal data on the efficacy of systemic hypothermia for acute SCI. We now provide a clinical update on our patient, who provided written informed consent for print and electronic publication of this case report.

Case Report

During a National Football League game, the player sustained a C3–C4 fracture-dislocation after a helmet-to-helmet hit on an opposing player. He fell face down on the ground and did not move. The team’s physician and trainer rushed to the player’s side, immediately assessed him, and initiated the emergency spinal resuscitation protocol.

As per protocol, the assigned team leader took charge of managing the player’s head to maintain in-line traction with the helmet in place until the head was secured in place on a backboard designed to accommodate the helmet.

Conclusion

At the time this player was injured, use of systemic hypothermia with standard therapy for acute SCI was unique and controversial. Since then, smaller randomized human studies have described the tolerable safety profile, efficacy, and potential benefits of this intervention in acute SCI in humans.^8-10 Now, modest systemic hypothermia can be one of many tools considered in the treatment of acute SCI. Before it can become the standard of care, however, additional larger prospective randomized studies need to be completed.

Am J Orthop. 2017;46(2):E79-E82. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
• Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
• Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.

Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.¹ Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.² We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.

We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.

Case Report

A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.

Discussion

SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).

Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.³ Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.² This finding, dating to the 19th century, was reported by Willet⁴ when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.⁵

Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).

Take-Home Points

• Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
• Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
• Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.

Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.¹ Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.² We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.

We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.

Case Report

A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.

Discussion

SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).

Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.³ Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.² This finding, dating to the 19th century, was reported by Willet⁴ when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.⁵

Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).

Take-Home Points

• Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
• Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
• Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.

Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.¹ Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.² We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.

We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.

Case Report

A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.

Discussion

SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).

Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.³ Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.² This finding, dating to the 19th century, was reported by Willet⁴ when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.⁵

Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).

Take-Home Points

• According to the orthopedic literature, ST and LTO for a TSA produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.
• Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions.
• ST and LTO approaches for a TSA result in similar Constant scores, pain scores, radiographic outcomes, and complication rates.

During total shoulder arthroplasty (TSA) exposure, the subscapularis muscle must be mobilized; its repair is crucial to the stability of the arthroplasty. The subscapularis is the largest rotator cuff muscle and has a contractile force equal to that of the other 3 muscles combined.^1,2 Traditionally it is mobilized with a tenotomy just medial to the tendon’s insertion onto the lesser tuberosity. Over the past 15 years, however, numerous authors have reported dysfunction after subscapularis tenotomy (ST). In 2003, Miller and colleagues³ reported that, at 2-year follow-up, almost 70% of patients had abnormal belly-press and liftoff tests, surrogate markers of subscapularis function. Other authors have found increased rates of anterior instability after subscapularis rupture.^4,5

In 2005, Gerber and colleagues⁶ introduced a technique for circumventing surgical division of the subscapularis. They described a lesser tuberosity osteotomy (LTO), in which the subscapularis tendon is detached with a bone fragment 5 mm to 10 mm in thickness and 3 cm to 4 cm in length. This approach was based on the premise that bone-to-bone healing is more reliable than tendon-to-tendon healing. Initial studies reported successful osteotomy healing, improved clinical outcome scores, and fewer abnormalities with belly-press and liftoff tests.^2,6 More recent literature, however, has questioned the necessity of LTO.^2,4,7-9We performed a systematic review to evaluate the literature, describe ST and LTO, and summarize the radiographic and clinical outcomes of both techniques. We hypothesized there would be no significant clinical differences between these approaches.

Methods

Search Strategy and Study Selection

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically reviewed the literature.¹⁰ Searches were completed in September 2014 using the PubMed Medline database and the Cochrane Central Register of Clinical Trials. Two reviewers (Dr. Louie, Dr. Levy) independently performed the search and assessed eligibility of all relevant studies based on predetermined inclusion criteria. Disagreements between reviewers were resolved by discussion. Key word selection was designed to capture all English-language studies with clinical and/or radiographic outcomes and level I to IV evidence. We used an electronic search algorithm with key words and a series of NOT phrases to match certain exclusion criteria:

(((((((((((((((((((((((((((((((((((((total[Text Word]) AND shoulder[Title]) AND arthroplasty[Title] AND (English[lang]))) NOT reverse[Title/Abstract]) NOT hemiarthroplasty[Title]) NOT nonoperative[Title]) NOT nonsurgical[Title] AND (English[lang]))) NOT rheumatoid[Title/Abstract]) NOT inflammatory[Title/Abstract]) NOT elbow[Title/Abstract]) NOT wrist[Title/Abstract]) NOT hip[Title/Abstract]) NOT knee[Title/Abstract]) NOT ankle[Title/Abstract] AND (English[lang]))) NOT biomechanic[Title/Abstract]) NOT biomechanics[Title/Abstract]) NOT biomechanical [Title/Abstract]) NOT cadaveric[Title/Abstract]) NOT revision[Title]) NOT resurfacing[Title/Abstract]) NOT surface[Title/Abstract]) NOT interphalangeal[Title/Abstract] AND (English[lang]))) NOT radiostereometric[Title/Abstract] AND (English[lang]))) NOT cmc[Title/Abstract]) NOT carpometacarpal[Title/Abstract]) NOT cervical[Title/Abstract]) NOT histology[Title/Abstract]) NOT histological[Title/Abstract]) NOT collagen[Title/Abstract] AND (English[lang]))) NOT kinematic[Title/Abstract]) NOT kinematics[Title/Abstract] AND (English[lang]))) NOT vitro[Title/Abstract] AND (English[lang]))) NOT inverted[Title/Abstract]) NOT grammont[Title/Abstract]) NOT arthrodesis[Title/Abstract]) NOT fusion[Title/Abstract]) NOT reverse[Title/Abstract] AND (English[lang]))

Study exclusion criteria consisted of cadaveric, biomechanical, histologic, and kinematic results as well as analyses of nonoperative management, hemiarthroplasty, or reverse TSA. Studies were excluded if they did not report clinical and/or radiographic data. Minimum mean follow-up was 2 years. To discount the effect of other TSA technical innovations, we evaluated the same period for the 2 surgical approaches. The first study with clinical outcomes after LTO was published in early 2005,⁶ so all studies published before 2005 were excluded.

We reviewed all references within the studies included by the initial search algorithm: randomized control trials, retrospective and prospective cohort designs, case series, and treatment studies. Technical notes, review papers, letters to the editor, and level V evidence reviews were excluded. To avoid counting patients twice, we compared each study’s authors and data collection period with those of the other studies. If there was overlap in authorship, period, and place, only the study with the longer follow-up or more comprehensive data was included. All trials comparing ST and LTO were included. If the authors of a TSA study did not describe the approach used, that study was excluded from our review.

Data Extraction

We collected details of study design, sample size, and patient demographics (sex, age, hand dominance, primary diagnosis). We also abstracted surgical factors about the glenoid component (cemented vs uncemented; pegged vs keeled; all-polyethylene vs metal-backed) and the humeral component (cemented vs press-fit; stemmed vs stemless). Clinical outcomes included pain scores, functional scores, number of revisions, range of motion (ROM), and subscapularis-specific tests (eg, belly-press, liftoff). As pain scales varied between studies, all values were converted to a 10-point scoring scale (0 = no pain; 10 = maximum pain) for comparisons. Numerous functional outcome scores were reported, but the Constant score was the only one consistently used across studies, making it a good choice for comparisons. One study used Penn Shoulder Scores (PSSs) and directly compared ST and LTO groups, so its data were included. In addition, radiographic data were compiled: radiolucencies around the humeral stem and glenoid component, humeral head subluxation/migration, and osteotomy healing. The only consistent radiographic parameter available for comparisons between groups was the presence of radiolucencies.

The Modified Coleman Methodology Score (MCMS), described by Cowan and colleagues,¹¹ was used to evaluate the methodologic quality of each study. The MCMS is a 15-item instrument that has been used to assess both randomized and nonrandomized trials.^12,13 It has a scaled score ranging from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor). Study quality was not factored into the data synthesis analysis.

Statistical Analysis

Data are reported as weighted means and standard deviations. A mean was calculated for each study reporting on a respective data point and was then weighed according to the study sample size. The result was that the nonweighted means from studies with smaller samples did not carry as much weight as those from studies with larger samples. Student t tests and 2-way analysis of variance were used to compare the ST and LTO groups and assess differences over time (SPSS Version 18; IBM). An α of 0.05 was set as statistically significant.

Results

Twenty studies (1420 shoulders, 1392 patients) were included in the final dataset (Figure).^2,6,8,14-30 

The youngest patients in the ST and LTO groups were 22 years and 19 years of age, respectively.

Discussion

Our goal in this systematic review was to analyze outcomes associated with ST and LTO in a heterogenous TSA population. We hypothesized TSA with ST or LTO would produce similar clinical and radiographic outcomes. There were no significant differences in Constant scores, pain scores, radiolucencies, or complications between the 2 groups. The ST group showed trends toward wider ROM improvements and fewer revisions, but only the change in forward elevation was significant. The components used in the 2 groups were similar with the exception of a lack of keeled glenoids and cemented humeral stems in the LTO group; data stratification controlling for these differences revealed no change in outcomes.

The optimal method of subscapularis mobilization for TSA remains a source of debate. Jackson and colleagues²³ found significant improvements in Neer and DASH scores after ST. However, 7 of 15 patients ruptured the subscapularis after 6 months and had significantly lower DASH scores. In 2005, Gerber and colleagues⁶ first described the LTO technique as an alternative to ST. After a mean of 39 months, 89% of their patients had a negative belly-press test, and 75% had a normal liftoff test. Radiographic evaluation revealed that the osteotomized fragment had healed in an anatomical position in all shoulders. In a large case series, Small and colleagues²⁰ used radiographs and computed tomography to further investigate LTO healing rates and found that 89% of patients had bony union by 6 months and that smoking was a significant risk factor for nonunion.

Biomechanical studies comparing ST and LTO approaches have shown mixed results. Ponce and colleagues² found decreased cyclic displacement and increased maximum load to failure with LTO, but Giuseffi and colleagues³² showed less cyclic displacement with ST and no difference in load to failure. Others authors have found no significant differences in stiffness or maximum load to failure.³³ Van den Berghe and colleagues⁷ reported a higher failure rate in bone-to-bone repairs compared with tendon-to-tendon constructs. Moreover, they found that suture cut-out through bone tunnels is the primary mode of LTO failure, so many LTO surgeons now pass sutures around the humeral stem instead.

Three TSA studies directly compared ST and LTO approaches. Buckley and colleagues¹⁴ analyzed 60 TSAs and found no significant differences in WOOS, DASH, or Constant scores between groups. The authors described an ST subgroup with subscapularis attenuation on ultrasound but did not report the group as having any inferior functional outcome. Scalise and colleagues¹⁵ showed improved strength and PSSs in both groups after 2 years. However, the LTO group had a lower rate of subscapularis tears and significantly higher PSSs. Finally, Jandhyala and colleagues¹⁶ reported more favorable outcomes with LTO, which trended toward wider ROM and significantly higher belly-press test grades. Lapner and colleagues³⁴ conducted a randomized, controlled trial (often referenced) and found no significant differences between the 2 groups in terms of strength or functional outcome at 2-year follow-up. Their study, however, included hemiarthroplasties and did not substratify the TSA population, so we did not include it in our review.

Our systematic review found significantly more forward elevation improvement for the ST group than the LTO group, which may suggest improved ROM with a soft-tissue approach than a bony approach. At the same time, the ST group trended toward better passive external rotation relative to the LTO group. This trend indicates fewer constraints to external rotation in the ST group, possibly attributable to a more attenuated subscapularis after tenotomy. Subscapularis tear or attenuation was more commonly reported in the ST group than in the LTO group, though not significantly so. This may indicate that more ST studies than LTO studies specially emphasized postoperative subscapularis function, but these data also highlight some authors’ concerns regarding subscapularis dysfunction after tenotomy.^6,15,16The study populations’ complication rates were similar, just over 17%. The LTO group trended toward a higher revision rate, but it was not statistically significant. The LTO group also had significantly fewer patients with osteoarthritis and more patients with posttraumatic arthritis, so this group may have had more complex patients predisposed to a higher likelihood of revision surgery. Revisions were most commonly performed for aseptic loosening; theoretically, if osteotomies heal less effectively than tenotomies, the LTO approach could produce component instability and aseptic loosening. However, no prior studies or other clinical findings from this review suggest LTO predisposes to aseptic loosening. Overall, the uneven revision rates represent a clinical concern that should be monitored as larger samples of patients undergo ST and LTO procedures.

Glenoid radiolucencies were the only radiographic parameter consistently reported in the included studies. Twelve ST studies had radiolucency data—compared with only 2 LTO studies. Thus, our ability to compare radiographic outcomes was limited. Our data revealed similar rates of glenoid radiolucencies between the 2 approaches. The clinical relevance of radiolucencies is questioned by some authors, and, indeed, Razmjou and colleagues²⁵ found no correlation of radiolucencies with patient satisfaction. Nevertheless, early presence of radiolucencies may raise concerns about progressive loss of fixation,^35,36 so this should be monitored.

Limitations of this systematic review reflect the studies analyzed. We minimized selection bias by including level I to IV evidence, but most studies were level IV, and only 1 was level I. As such, there was a relative paucity of consistent clinical and radiographic data. For instance, although many ST studies reported patient satisfaction as an outcomes measure, only 1 LTO study commented on it. Perhaps the relative novelty of the LTO approach has prompted some authors to focus more on technical details and less on reporting a variety of outcome measures. As mentioned earlier, the significance of radiolucency data is controversial, and determination of their presence or absence depends on the observer. A radiolucency found in one study may not qualify as one in a study that uses different criteria. However, lucency data were the most frequently and reliably reported radiographic parameter, so we deemed it the most appropriate method for comparing radiographic outcomes. Finally, the baseline differences in diagnosis between the ST and LTO groups complicated comparisons. We stratified the groups by component design because use of keeled or pegged implants or humeral cemented or press-fit stems was usually a uniform feature of each study—enabling removal of certain studies for data stratification. However, we were unable to stratify by original diagnosis because these groups were not stratified within the individual studies.

Conclusion

Our systematic review found similar Constant scores, pain scores, radiographic outcomes, and complication rates for the ST and LTO approaches. Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions. Although not definitive, these data suggest the ST approach may provide more stability over the long term, but additional comprehensive studies are needed to increase the sample size and the power of the trends elucidated in this review. According to the orthopedic literature, both techniques produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.

Am J Orthop. 2017;46(2):E131-E138. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• According to the orthopedic literature, ST and LTO for a TSA produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.
• Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions.
• ST and LTO approaches for a TSA result in similar Constant scores, pain scores, radiographic outcomes, and complication rates.

During total shoulder arthroplasty (TSA) exposure, the subscapularis muscle must be mobilized; its repair is crucial to the stability of the arthroplasty. The subscapularis is the largest rotator cuff muscle and has a contractile force equal to that of the other 3 muscles combined.^1,2 Traditionally it is mobilized with a tenotomy just medial to the tendon’s insertion onto the lesser tuberosity. Over the past 15 years, however, numerous authors have reported dysfunction after subscapularis tenotomy (ST). In 2003, Miller and colleagues³ reported that, at 2-year follow-up, almost 70% of patients had abnormal belly-press and liftoff tests, surrogate markers of subscapularis function. Other authors have found increased rates of anterior instability after subscapularis rupture.^4,5

In 2005, Gerber and colleagues⁶ introduced a technique for circumventing surgical division of the subscapularis. They described a lesser tuberosity osteotomy (LTO), in which the subscapularis tendon is detached with a bone fragment 5 mm to 10 mm in thickness and 3 cm to 4 cm in length. This approach was based on the premise that bone-to-bone healing is more reliable than tendon-to-tendon healing. Initial studies reported successful osteotomy healing, improved clinical outcome scores, and fewer abnormalities with belly-press and liftoff tests.^2,6 More recent literature, however, has questioned the necessity of LTO.^2,4,7-9We performed a systematic review to evaluate the literature, describe ST and LTO, and summarize the radiographic and clinical outcomes of both techniques. We hypothesized there would be no significant clinical differences between these approaches.

Methods

Search Strategy and Study Selection

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically reviewed the literature.¹⁰ Searches were completed in September 2014 using the PubMed Medline database and the Cochrane Central Register of Clinical Trials. Two reviewers (Dr. Louie, Dr. Levy) independently performed the search and assessed eligibility of all relevant studies based on predetermined inclusion criteria. Disagreements between reviewers were resolved by discussion. Key word selection was designed to capture all English-language studies with clinical and/or radiographic outcomes and level I to IV evidence. We used an electronic search algorithm with key words and a series of NOT phrases to match certain exclusion criteria:

(((((((((((((((((((((((((((((((((((((total[Text Word]) AND shoulder[Title]) AND arthroplasty[Title] AND (English[lang]))) NOT reverse[Title/Abstract]) NOT hemiarthroplasty[Title]) NOT nonoperative[Title]) NOT nonsurgical[Title] AND (English[lang]))) NOT rheumatoid[Title/Abstract]) NOT inflammatory[Title/Abstract]) NOT elbow[Title/Abstract]) NOT wrist[Title/Abstract]) NOT hip[Title/Abstract]) NOT knee[Title/Abstract]) NOT ankle[Title/Abstract] AND (English[lang]))) NOT biomechanic[Title/Abstract]) NOT biomechanics[Title/Abstract]) NOT biomechanical [Title/Abstract]) NOT cadaveric[Title/Abstract]) NOT revision[Title]) NOT resurfacing[Title/Abstract]) NOT surface[Title/Abstract]) NOT interphalangeal[Title/Abstract] AND (English[lang]))) NOT radiostereometric[Title/Abstract] AND (English[lang]))) NOT cmc[Title/Abstract]) NOT carpometacarpal[Title/Abstract]) NOT cervical[Title/Abstract]) NOT histology[Title/Abstract]) NOT histological[Title/Abstract]) NOT collagen[Title/Abstract] AND (English[lang]))) NOT kinematic[Title/Abstract]) NOT kinematics[Title/Abstract] AND (English[lang]))) NOT vitro[Title/Abstract] AND (English[lang]))) NOT inverted[Title/Abstract]) NOT grammont[Title/Abstract]) NOT arthrodesis[Title/Abstract]) NOT fusion[Title/Abstract]) NOT reverse[Title/Abstract] AND (English[lang]))

Study exclusion criteria consisted of cadaveric, biomechanical, histologic, and kinematic results as well as analyses of nonoperative management, hemiarthroplasty, or reverse TSA. Studies were excluded if they did not report clinical and/or radiographic data. Minimum mean follow-up was 2 years. To discount the effect of other TSA technical innovations, we evaluated the same period for the 2 surgical approaches. The first study with clinical outcomes after LTO was published in early 2005,⁶ so all studies published before 2005 were excluded.

We reviewed all references within the studies included by the initial search algorithm: randomized control trials, retrospective and prospective cohort designs, case series, and treatment studies. Technical notes, review papers, letters to the editor, and level V evidence reviews were excluded. To avoid counting patients twice, we compared each study’s authors and data collection period with those of the other studies. If there was overlap in authorship, period, and place, only the study with the longer follow-up or more comprehensive data was included. All trials comparing ST and LTO were included. If the authors of a TSA study did not describe the approach used, that study was excluded from our review.

Data Extraction

We collected details of study design, sample size, and patient demographics (sex, age, hand dominance, primary diagnosis). We also abstracted surgical factors about the glenoid component (cemented vs uncemented; pegged vs keeled; all-polyethylene vs metal-backed) and the humeral component (cemented vs press-fit; stemmed vs stemless). Clinical outcomes included pain scores, functional scores, number of revisions, range of motion (ROM), and subscapularis-specific tests (eg, belly-press, liftoff). As pain scales varied between studies, all values were converted to a 10-point scoring scale (0 = no pain; 10 = maximum pain) for comparisons. Numerous functional outcome scores were reported, but the Constant score was the only one consistently used across studies, making it a good choice for comparisons. One study used Penn Shoulder Scores (PSSs) and directly compared ST and LTO groups, so its data were included. In addition, radiographic data were compiled: radiolucencies around the humeral stem and glenoid component, humeral head subluxation/migration, and osteotomy healing. The only consistent radiographic parameter available for comparisons between groups was the presence of radiolucencies.

The Modified Coleman Methodology Score (MCMS), described by Cowan and colleagues,¹¹ was used to evaluate the methodologic quality of each study. The MCMS is a 15-item instrument that has been used to assess both randomized and nonrandomized trials.^12,13 It has a scaled score ranging from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor). Study quality was not factored into the data synthesis analysis.

Statistical Analysis

Data are reported as weighted means and standard deviations. A mean was calculated for each study reporting on a respective data point and was then weighed according to the study sample size. The result was that the nonweighted means from studies with smaller samples did not carry as much weight as those from studies with larger samples. Student t tests and 2-way analysis of variance were used to compare the ST and LTO groups and assess differences over time (SPSS Version 18; IBM). An α of 0.05 was set as statistically significant.

Results

Twenty studies (1420 shoulders, 1392 patients) were included in the final dataset (Figure).^2,6,8,14-30 

The youngest patients in the ST and LTO groups were 22 years and 19 years of age, respectively.

Discussion

Our goal in this systematic review was to analyze outcomes associated with ST and LTO in a heterogenous TSA population. We hypothesized TSA with ST or LTO would produce similar clinical and radiographic outcomes. There were no significant differences in Constant scores, pain scores, radiolucencies, or complications between the 2 groups. The ST group showed trends toward wider ROM improvements and fewer revisions, but only the change in forward elevation was significant. The components used in the 2 groups were similar with the exception of a lack of keeled glenoids and cemented humeral stems in the LTO group; data stratification controlling for these differences revealed no change in outcomes.

The optimal method of subscapularis mobilization for TSA remains a source of debate. Jackson and colleagues²³ found significant improvements in Neer and DASH scores after ST. However, 7 of 15 patients ruptured the subscapularis after 6 months and had significantly lower DASH scores. In 2005, Gerber and colleagues⁶ first described the LTO technique as an alternative to ST. After a mean of 39 months, 89% of their patients had a negative belly-press test, and 75% had a normal liftoff test. Radiographic evaluation revealed that the osteotomized fragment had healed in an anatomical position in all shoulders. In a large case series, Small and colleagues²⁰ used radiographs and computed tomography to further investigate LTO healing rates and found that 89% of patients had bony union by 6 months and that smoking was a significant risk factor for nonunion.

Biomechanical studies comparing ST and LTO approaches have shown mixed results. Ponce and colleagues² found decreased cyclic displacement and increased maximum load to failure with LTO, but Giuseffi and colleagues³² showed less cyclic displacement with ST and no difference in load to failure. Others authors have found no significant differences in stiffness or maximum load to failure.³³ Van den Berghe and colleagues⁷ reported a higher failure rate in bone-to-bone repairs compared with tendon-to-tendon constructs. Moreover, they found that suture cut-out through bone tunnels is the primary mode of LTO failure, so many LTO surgeons now pass sutures around the humeral stem instead.

Three TSA studies directly compared ST and LTO approaches. Buckley and colleagues¹⁴ analyzed 60 TSAs and found no significant differences in WOOS, DASH, or Constant scores between groups. The authors described an ST subgroup with subscapularis attenuation on ultrasound but did not report the group as having any inferior functional outcome. Scalise and colleagues¹⁵ showed improved strength and PSSs in both groups after 2 years. However, the LTO group had a lower rate of subscapularis tears and significantly higher PSSs. Finally, Jandhyala and colleagues¹⁶ reported more favorable outcomes with LTO, which trended toward wider ROM and significantly higher belly-press test grades. Lapner and colleagues³⁴ conducted a randomized, controlled trial (often referenced) and found no significant differences between the 2 groups in terms of strength or functional outcome at 2-year follow-up. Their study, however, included hemiarthroplasties and did not substratify the TSA population, so we did not include it in our review.

Our systematic review found significantly more forward elevation improvement for the ST group than the LTO group, which may suggest improved ROM with a soft-tissue approach than a bony approach. At the same time, the ST group trended toward better passive external rotation relative to the LTO group. This trend indicates fewer constraints to external rotation in the ST group, possibly attributable to a more attenuated subscapularis after tenotomy. Subscapularis tear or attenuation was more commonly reported in the ST group than in the LTO group, though not significantly so. This may indicate that more ST studies than LTO studies specially emphasized postoperative subscapularis function, but these data also highlight some authors’ concerns regarding subscapularis dysfunction after tenotomy.^6,15,16The study populations’ complication rates were similar, just over 17%. The LTO group trended toward a higher revision rate, but it was not statistically significant. The LTO group also had significantly fewer patients with osteoarthritis and more patients with posttraumatic arthritis, so this group may have had more complex patients predisposed to a higher likelihood of revision surgery. Revisions were most commonly performed for aseptic loosening; theoretically, if osteotomies heal less effectively than tenotomies, the LTO approach could produce component instability and aseptic loosening. However, no prior studies or other clinical findings from this review suggest LTO predisposes to aseptic loosening. Overall, the uneven revision rates represent a clinical concern that should be monitored as larger samples of patients undergo ST and LTO procedures.

Glenoid radiolucencies were the only radiographic parameter consistently reported in the included studies. Twelve ST studies had radiolucency data—compared with only 2 LTO studies. Thus, our ability to compare radiographic outcomes was limited. Our data revealed similar rates of glenoid radiolucencies between the 2 approaches. The clinical relevance of radiolucencies is questioned by some authors, and, indeed, Razmjou and colleagues²⁵ found no correlation of radiolucencies with patient satisfaction. Nevertheless, early presence of radiolucencies may raise concerns about progressive loss of fixation,^35,36 so this should be monitored.

Limitations of this systematic review reflect the studies analyzed. We minimized selection bias by including level I to IV evidence, but most studies were level IV, and only 1 was level I. As such, there was a relative paucity of consistent clinical and radiographic data. For instance, although many ST studies reported patient satisfaction as an outcomes measure, only 1 LTO study commented on it. Perhaps the relative novelty of the LTO approach has prompted some authors to focus more on technical details and less on reporting a variety of outcome measures. As mentioned earlier, the significance of radiolucency data is controversial, and determination of their presence or absence depends on the observer. A radiolucency found in one study may not qualify as one in a study that uses different criteria. However, lucency data were the most frequently and reliably reported radiographic parameter, so we deemed it the most appropriate method for comparing radiographic outcomes. Finally, the baseline differences in diagnosis between the ST and LTO groups complicated comparisons. We stratified the groups by component design because use of keeled or pegged implants or humeral cemented or press-fit stems was usually a uniform feature of each study—enabling removal of certain studies for data stratification. However, we were unable to stratify by original diagnosis because these groups were not stratified within the individual studies.

Conclusion

Our systematic review found similar Constant scores, pain scores, radiographic outcomes, and complication rates for the ST and LTO approaches. Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions. Although not definitive, these data suggest the ST approach may provide more stability over the long term, but additional comprehensive studies are needed to increase the sample size and the power of the trends elucidated in this review. According to the orthopedic literature, both techniques produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.

Am J Orthop. 2017;46(2):E131-E138. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• According to the orthopedic literature, ST and LTO for a TSA produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.
• Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions.
• ST and LTO approaches for a TSA result in similar Constant scores, pain scores, radiographic outcomes, and complication rates.

During total shoulder arthroplasty (TSA) exposure, the subscapularis muscle must be mobilized; its repair is crucial to the stability of the arthroplasty. The subscapularis is the largest rotator cuff muscle and has a contractile force equal to that of the other 3 muscles combined.^1,2 Traditionally it is mobilized with a tenotomy just medial to the tendon’s insertion onto the lesser tuberosity. Over the past 15 years, however, numerous authors have reported dysfunction after subscapularis tenotomy (ST). In 2003, Miller and colleagues³ reported that, at 2-year follow-up, almost 70% of patients had abnormal belly-press and liftoff tests, surrogate markers of subscapularis function. Other authors have found increased rates of anterior instability after subscapularis rupture.^4,5

In 2005, Gerber and colleagues⁶ introduced a technique for circumventing surgical division of the subscapularis. They described a lesser tuberosity osteotomy (LTO), in which the subscapularis tendon is detached with a bone fragment 5 mm to 10 mm in thickness and 3 cm to 4 cm in length. This approach was based on the premise that bone-to-bone healing is more reliable than tendon-to-tendon healing. Initial studies reported successful osteotomy healing, improved clinical outcome scores, and fewer abnormalities with belly-press and liftoff tests.^2,6 More recent literature, however, has questioned the necessity of LTO.^2,4,7-9We performed a systematic review to evaluate the literature, describe ST and LTO, and summarize the radiographic and clinical outcomes of both techniques. We hypothesized there would be no significant clinical differences between these approaches.

Methods

Search Strategy and Study Selection

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically reviewed the literature.¹⁰ Searches were completed in September 2014 using the PubMed Medline database and the Cochrane Central Register of Clinical Trials. Two reviewers (Dr. Louie, Dr. Levy) independently performed the search and assessed eligibility of all relevant studies based on predetermined inclusion criteria. Disagreements between reviewers were resolved by discussion. Key word selection was designed to capture all English-language studies with clinical and/or radiographic outcomes and level I to IV evidence. We used an electronic search algorithm with key words and a series of NOT phrases to match certain exclusion criteria:

(((((((((((((((((((((((((((((((((((((total[Text Word]) AND shoulder[Title]) AND arthroplasty[Title] AND (English[lang]))) NOT reverse[Title/Abstract]) NOT hemiarthroplasty[Title]) NOT nonoperative[Title]) NOT nonsurgical[Title] AND (English[lang]))) NOT rheumatoid[Title/Abstract]) NOT inflammatory[Title/Abstract]) NOT elbow[Title/Abstract]) NOT wrist[Title/Abstract]) NOT hip[Title/Abstract]) NOT knee[Title/Abstract]) NOT ankle[Title/Abstract] AND (English[lang]))) NOT biomechanic[Title/Abstract]) NOT biomechanics[Title/Abstract]) NOT biomechanical [Title/Abstract]) NOT cadaveric[Title/Abstract]) NOT revision[Title]) NOT resurfacing[Title/Abstract]) NOT surface[Title/Abstract]) NOT interphalangeal[Title/Abstract] AND (English[lang]))) NOT radiostereometric[Title/Abstract] AND (English[lang]))) NOT cmc[Title/Abstract]) NOT carpometacarpal[Title/Abstract]) NOT cervical[Title/Abstract]) NOT histology[Title/Abstract]) NOT histological[Title/Abstract]) NOT collagen[Title/Abstract] AND (English[lang]))) NOT kinematic[Title/Abstract]) NOT kinematics[Title/Abstract] AND (English[lang]))) NOT vitro[Title/Abstract] AND (English[lang]))) NOT inverted[Title/Abstract]) NOT grammont[Title/Abstract]) NOT arthrodesis[Title/Abstract]) NOT fusion[Title/Abstract]) NOT reverse[Title/Abstract] AND (English[lang]))

Study exclusion criteria consisted of cadaveric, biomechanical, histologic, and kinematic results as well as analyses of nonoperative management, hemiarthroplasty, or reverse TSA. Studies were excluded if they did not report clinical and/or radiographic data. Minimum mean follow-up was 2 years. To discount the effect of other TSA technical innovations, we evaluated the same period for the 2 surgical approaches. The first study with clinical outcomes after LTO was published in early 2005,⁶ so all studies published before 2005 were excluded.

We reviewed all references within the studies included by the initial search algorithm: randomized control trials, retrospective and prospective cohort designs, case series, and treatment studies. Technical notes, review papers, letters to the editor, and level V evidence reviews were excluded. To avoid counting patients twice, we compared each study’s authors and data collection period with those of the other studies. If there was overlap in authorship, period, and place, only the study with the longer follow-up or more comprehensive data was included. All trials comparing ST and LTO were included. If the authors of a TSA study did not describe the approach used, that study was excluded from our review.

Data Extraction

We collected details of study design, sample size, and patient demographics (sex, age, hand dominance, primary diagnosis). We also abstracted surgical factors about the glenoid component (cemented vs uncemented; pegged vs keeled; all-polyethylene vs metal-backed) and the humeral component (cemented vs press-fit; stemmed vs stemless). Clinical outcomes included pain scores, functional scores, number of revisions, range of motion (ROM), and subscapularis-specific tests (eg, belly-press, liftoff). As pain scales varied between studies, all values were converted to a 10-point scoring scale (0 = no pain; 10 = maximum pain) for comparisons. Numerous functional outcome scores were reported, but the Constant score was the only one consistently used across studies, making it a good choice for comparisons. One study used Penn Shoulder Scores (PSSs) and directly compared ST and LTO groups, so its data were included. In addition, radiographic data were compiled: radiolucencies around the humeral stem and glenoid component, humeral head subluxation/migration, and osteotomy healing. The only consistent radiographic parameter available for comparisons between groups was the presence of radiolucencies.

The Modified Coleman Methodology Score (MCMS), described by Cowan and colleagues,¹¹ was used to evaluate the methodologic quality of each study. The MCMS is a 15-item instrument that has been used to assess both randomized and nonrandomized trials.^12,13 It has a scaled score ranging from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor). Study quality was not factored into the data synthesis analysis.

Statistical Analysis

Data are reported as weighted means and standard deviations. A mean was calculated for each study reporting on a respective data point and was then weighed according to the study sample size. The result was that the nonweighted means from studies with smaller samples did not carry as much weight as those from studies with larger samples. Student t tests and 2-way analysis of variance were used to compare the ST and LTO groups and assess differences over time (SPSS Version 18; IBM). An α of 0.05 was set as statistically significant.

Results

Twenty studies (1420 shoulders, 1392 patients) were included in the final dataset (Figure).^2,6,8,14-30 

The youngest patients in the ST and LTO groups were 22 years and 19 years of age, respectively.

Discussion

Our goal in this systematic review was to analyze outcomes associated with ST and LTO in a heterogenous TSA population. We hypothesized TSA with ST or LTO would produce similar clinical and radiographic outcomes. There were no significant differences in Constant scores, pain scores, radiolucencies, or complications between the 2 groups. The ST group showed trends toward wider ROM improvements and fewer revisions, but only the change in forward elevation was significant. The components used in the 2 groups were similar with the exception of a lack of keeled glenoids and cemented humeral stems in the LTO group; data stratification controlling for these differences revealed no change in outcomes.

The optimal method of subscapularis mobilization for TSA remains a source of debate. Jackson and colleagues²³ found significant improvements in Neer and DASH scores after ST. However, 7 of 15 patients ruptured the subscapularis after 6 months and had significantly lower DASH scores. In 2005, Gerber and colleagues⁶ first described the LTO technique as an alternative to ST. After a mean of 39 months, 89% of their patients had a negative belly-press test, and 75% had a normal liftoff test. Radiographic evaluation revealed that the osteotomized fragment had healed in an anatomical position in all shoulders. In a large case series, Small and colleagues²⁰ used radiographs and computed tomography to further investigate LTO healing rates and found that 89% of patients had bony union by 6 months and that smoking was a significant risk factor for nonunion.

Biomechanical studies comparing ST and LTO approaches have shown mixed results. Ponce and colleagues² found decreased cyclic displacement and increased maximum load to failure with LTO, but Giuseffi and colleagues³² showed less cyclic displacement with ST and no difference in load to failure. Others authors have found no significant differences in stiffness or maximum load to failure.³³ Van den Berghe and colleagues⁷ reported a higher failure rate in bone-to-bone repairs compared with tendon-to-tendon constructs. Moreover, they found that suture cut-out through bone tunnels is the primary mode of LTO failure, so many LTO surgeons now pass sutures around the humeral stem instead.

Three TSA studies directly compared ST and LTO approaches. Buckley and colleagues¹⁴ analyzed 60 TSAs and found no significant differences in WOOS, DASH, or Constant scores between groups. The authors described an ST subgroup with subscapularis attenuation on ultrasound but did not report the group as having any inferior functional outcome. Scalise and colleagues¹⁵ showed improved strength and PSSs in both groups after 2 years. However, the LTO group had a lower rate of subscapularis tears and significantly higher PSSs. Finally, Jandhyala and colleagues¹⁶ reported more favorable outcomes with LTO, which trended toward wider ROM and significantly higher belly-press test grades. Lapner and colleagues³⁴ conducted a randomized, controlled trial (often referenced) and found no significant differences between the 2 groups in terms of strength or functional outcome at 2-year follow-up. Their study, however, included hemiarthroplasties and did not substratify the TSA population, so we did not include it in our review.

Our systematic review found significantly more forward elevation improvement for the ST group than the LTO group, which may suggest improved ROM with a soft-tissue approach than a bony approach. At the same time, the ST group trended toward better passive external rotation relative to the LTO group. This trend indicates fewer constraints to external rotation in the ST group, possibly attributable to a more attenuated subscapularis after tenotomy. Subscapularis tear or attenuation was more commonly reported in the ST group than in the LTO group, though not significantly so. This may indicate that more ST studies than LTO studies specially emphasized postoperative subscapularis function, but these data also highlight some authors’ concerns regarding subscapularis dysfunction after tenotomy.^6,15,16The study populations’ complication rates were similar, just over 17%. The LTO group trended toward a higher revision rate, but it was not statistically significant. The LTO group also had significantly fewer patients with osteoarthritis and more patients with posttraumatic arthritis, so this group may have had more complex patients predisposed to a higher likelihood of revision surgery. Revisions were most commonly performed for aseptic loosening; theoretically, if osteotomies heal less effectively than tenotomies, the LTO approach could produce component instability and aseptic loosening. However, no prior studies or other clinical findings from this review suggest LTO predisposes to aseptic loosening. Overall, the uneven revision rates represent a clinical concern that should be monitored as larger samples of patients undergo ST and LTO procedures.

Glenoid radiolucencies were the only radiographic parameter consistently reported in the included studies. Twelve ST studies had radiolucency data—compared with only 2 LTO studies. Thus, our ability to compare radiographic outcomes was limited. Our data revealed similar rates of glenoid radiolucencies between the 2 approaches. The clinical relevance of radiolucencies is questioned by some authors, and, indeed, Razmjou and colleagues²⁵ found no correlation of radiolucencies with patient satisfaction. Nevertheless, early presence of radiolucencies may raise concerns about progressive loss of fixation,^35,36 so this should be monitored.

Limitations of this systematic review reflect the studies analyzed. We minimized selection bias by including level I to IV evidence, but most studies were level IV, and only 1 was level I. As such, there was a relative paucity of consistent clinical and radiographic data. For instance, although many ST studies reported patient satisfaction as an outcomes measure, only 1 LTO study commented on it. Perhaps the relative novelty of the LTO approach has prompted some authors to focus more on technical details and less on reporting a variety of outcome measures. As mentioned earlier, the significance of radiolucency data is controversial, and determination of their presence or absence depends on the observer. A radiolucency found in one study may not qualify as one in a study that uses different criteria. However, lucency data were the most frequently and reliably reported radiographic parameter, so we deemed it the most appropriate method for comparing radiographic outcomes. Finally, the baseline differences in diagnosis between the ST and LTO groups complicated comparisons. We stratified the groups by component design because use of keeled or pegged implants or humeral cemented or press-fit stems was usually a uniform feature of each study—enabling removal of certain studies for data stratification. However, we were unable to stratify by original diagnosis because these groups were not stratified within the individual studies.

Conclusion

Our systematic review found similar Constant scores, pain scores, radiographic outcomes, and complication rates for the ST and LTO approaches. Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions. Although not definitive, these data suggest the ST approach may provide more stability over the long term, but additional comprehensive studies are needed to increase the sample size and the power of the trends elucidated in this review. According to the orthopedic literature, both techniques produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.

Am J Orthop. 2017;46(2):E131-E138. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Nail breakage is a known complication of intramedullary nail (IMN) fixation of tibial fractures.
• Several techniques have been described for broken IMN extraction.

Intramedullary nail (IMN) fixation is reliably used to manage tibial fractures and has become very popular for managing fractures of varying complexity.^1-4 An occasional complication of intramedullary nailing is nail breakage,^5-7 which can result from a fatigue fracture (from excessive fracture site instability caused by inadequate nail diameter, delayed fracture healing, or fracture nonunion) and direct traumatic impact.^5-7 Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from tibias and femurs.^4,8-16 In this article, we describe an efficient technique for extracting broken tibial IMNs—a technique that can be used before attempting more invasive extraction methods. The patient provided written informed consent for print and electronic publication of this case report.

Case Report and Surgical Technique

A 34-year-old male logger presented to our facility (Department of Orthopaedics, Warren Alpert School of Medicine, Brown University) with a new fracture of the left tibia and fibula with an associated broken IMN after a tree fell on his leg at work (Figures 1A, 1B).

The original IMN had been placed through a paramedian incision, with lateral to medial distal locking screws. The tibial shaft fracture and broken nail were displaced in the coronal plane (Figures 1A, 1B). For restoration of the central canal of the nail, closed reduction was performed in the operating room (Figure 2A). Once the fracture was reduced, the more proximal of the 2 distal interlocking screws was partially backed out so the extraction hook could be passed antegrade into the distal segment of the nail (Figure 2A).

Discussion

IMN fixation of tibial fractures is reliable.^1-4 An occasional complication of intramedullary nailing is nail breakage. Several case reports have described unique methods used to facilitate removal of broken hollow and solid IMNs from knees and femurs.^4,8-16

Our patient’s case involved a cannulated tibial IMN that broke secondary to an acute traumatic event. Several techniques have been used to remove the distal segment of broken cannulated tibial IMNs.^8,9,14,17 Abdelgawad and Kanlic⁸ described a technique in which a small distractor hook was introduced past the distal end of the broken distal piece, and a small (~2 in) piece of flexible nail was introduced into the slot of the distal interlocking screw hole. The hook was pulled back and became incarcerated in the nail by the flexible nail piece, allowing the hook to extract the distal segment of the nail.

Charnley and Farrington⁹ used Petelin laparoscopic grasping forceps to extract the distal segment of a broken cannulated tibial IMN under fluoroscopic guidance. This tibial canal was initially reamed before inserting the instrument and removing the distal segment of the nail.

Levine and Georgiadis¹⁴ used a 4.5-mm bit to drill a hole in the distal aspect of the medial malleolus. A smooth Steinmann pin was used to engage the tip of the IMN. The nail was hammered several centimeters up the medullary canal of the tibia. A 3.0-mm ball-tipped guide wire was inserted in the hole in the medial malleolus and advanced through the distal aspect of the nail under fluoroscopic guidance. The guide wire was advanced through the extent of the nail proximally until it emerged through the knee incision. The distal segment of the broken nail was extracted with the guide wire; the end of the guide wire with the ball engaged the distal aspect of the nail.

Our technique allowed us to use a nail extraction device to extract the distal segment of a broken tibial IMN. This device is usually on hand for routine nail extraction. We used the more distal of the 2 distal interlocking screws to push the extraction hook over the distal lip of the nail, allowing for extraction without additional incisions or additional drill holes in bone. Our technique was efficient in this particular situation and avoided more time-consuming extraction methods. In cases in which the extraction hook does not engage the distal aspect of the nail secondary to bone ingrowth, our technique should be used before attempting other extraction methods.

Am J Orthop. 2017;46(2):E112-E115. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.