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Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management. [ Orthopedics. 2014; 37(3):151–157.]

Mass spectrometry (MS) is an analytical technique for molecule identification that can be used for investigating protein-metal complex interactions. Once the MS data is collected, the mass spectra are usually interpreted manually to identify the adducts formed as a result of the interactions between proteins and metal-based species. However, with increasing resolution, dataset size, and species complexity, the time required to identify adducts and the error-prone nature of manual assignment have become limiting factors in MS analysis. AdductHunter is a open-source web-based analysis tool that  automates the peak identification process using constraint integer optimization to find feasible combinations of protein and fragments, and dynamic time warping to calculate the dissimilarity between the theoretical isotope pattern of a species and its experimental isotope peak distribution. Empirical evaluation on a collection of 22 unique MS datasetsshows fast and accurate identification of protein-metal complex adducts in deconvoluted mass spectra.

Intramedullary rod fixation is a common technique for treatment of femoral shaft fractures, with both open and closed reduction techniques described. The purpose of this study was to assess union and complication rates among patients treated with open vs closed reduction and intramedullary nailing of closed femoral shaft fractures. A total of 107 patients undergoing intramedullary fixation of nonpathologic femoral shaft fractures (AO/OTA type 32) between January 2012 and June 2017 were retrospectively studied. Those undergoing open reduction prior to intramedullary nailing were compared with those undergoing closed reduction. The primary outcome analyzed was union rate. Secondary outcomes were time to union, complications necessitating return to the operating room, and operative times. Mean follow-up was 14 months in both groups (range, 6–48 months). Of the 107 patients, 34.6% (n=37) underwent open reduction and 65.4% (n=70) underwent closed reduction. Patients in the open reduction group had rates of union (89.1%, 33 of 37) similar to those of patients in the closed reduction group (92.9%, 65 of 70; P =.378). Patients in the open reduction group who had union did so in a mean of 6.2 months (range, 3–12 months) vs a mean of 5.4 months (range, 2–11 months) in the closed reduction group ( P =.13). Six patients (16.2%) in the open reduction group and 6 patients (8.6%) in the closed reduction group had a postoperative complication requiring return to the operating room ( P =.18). Open reduction and intramedullary nailing results in rates of union, time to union, and rates of significant complications similar to those of closed reduction and intramedullary nailing. [ Orthopedics . 2020; 43(2): 103–107.]

ObjectivesA retrograde fibular medullary screw may be utilized in certain fractures about the ankle. The purpose of this study is to investigate the anatomic considerations of a retrograde medullary screw inserted from a lateral starting point to nearby anatomic structures about the distal fibula.MethodsTen fresh-frozen cadaveric lower extremities were utilized. A 1.6-mm Kirschner wire was inserted into the distal fibula from a far-lateral starting point. A 3.2-mm cannulated drill bit was then inserted over the Kirschner wire. After placement of the drill bit, dissection of the lateral ankle was undertaken. The proximity of nearby anatomic structures to the drill bit was measured using calipers. A 4.5-mm cortical screw was then inserted using fluoroscopic guidance. Measurements were then taken again to assess the relationship of the screw head to adjacent structures.ResultsMean distance from drill bit to nearby structures is as follows: Peroneus longus tendon 4.56 mm, peroneus brevis tendon 6.62 mm, sural nerve 4.13 mm, superior peroneal retinaculum 7.52 mm, inferior peroneal retinaculum 6.61 mm, anterior talofibular ligament (ATFL) 6.1 mm, calcaneofibular ligament (CFL) 6.7 mm. Average distance from 4.5-mm screw head to nearby structures is as follows: peroneus longus tendon 6.79 mm, peroneus brevis tendon 6.73 mm, ATFL 4.16 mm, CFL 5.14 mm, lateral talar process 9.41 mm.ConclusionRetrograde medullary fibular screw fixation may be safely carried out through a lateral start point. Anatomic structures about the lateral ankle are nearby but not immediately adjacent to the drill bit.

Purpose To report a novel treatment method for vertebral artery occlusion. Vertebral artery injuries have a high association with specific cervical fractures including atlanto-axial fractures, displaced fracture patterns, and transverse foramen fractures. Optimal medical management of the occluded vertebral artery has yet to be determined; however, there is an extremely high complication rate with systemic anticoagulation in these patients. Furthermore, unlike appendicular skeleton fracture-dislocations with vascular injury, there is no clear consensus as to the optimal acute management of the displaced odontoid fracture with or without vertebral artery injury. Methods We report on a severely displaced odontoid fracture that was found to have a vertebral artery injury. Medical records and imaging were reviewed. Results An 82-year-old female presented to our hospital with a type IIb odontoid fracture after sustaining a ground-level fall. Pertinent physical exam findings were ecchymosis on the left side of her forehead and posterior cervical pain without neurologic deficits. An MRA showed an occluded left vertebral artery. The patient was placed in early cervical traction and the fracture was reduced within 12 h of presentation. Following surgical stabilization, an MR angiogram showed complete reperfusion of the vertebral artery without intimal tear. Conclusion To our knowledge, this is the first report of a displaced odontoid fracture in which cervical traction was used to restore the perfusion of the vertebral artery. Cervical traction may obviate the need for systemic anticoagulation and should be considered in patients who have an identifiable compression of the vertebral artery even if neurologically intact.

A 63-year-old man with a comminuted spiral femoral shaft fracture was treated with closed reduction and internal fixation with a cephalomedullary nail. Two weeks postoperatively, one of the two static distal interlocking bolts began backing out and was removed. The nail ultimately migrated distally and perforated the knee joint at four months postoperatively. The patient was successfully treated with an exchange nail and percutaneous bone graft to the fracture site. A single static distal interlocking bolt may be inadequate to maintain length in a healing comminuted spiral femur shaft. Multiple distal interlocking bolts should be in place until the completion of fracture healing.

Objectives To characterize pelvic-specific functional outcomes in patients with isolated, partially unstable (AO/OTA 61-B), pelvic ring injuries treated with posterior only percutaneous screw fixation of the pelvic ring. Patients and methods Between September 2007 and October 2011, 16 subjects (mean age 42.4 years; range 18–90 years) with isolated, partially unstable pelvic ring injuries (AO/OTA 61-B) were treated with percutaneous, posterior pelvic ring fixation. Subjects underwent an evaluation of pelvic ring function with a modification of Majeed’s pelvic functional outcome assessment tool. Subjects were excluded if they sustained a concomitant long-bone fracture, visceral injury requiring surgery, spinal cord injury, and an injury to the anterior pelvic ring or acetabulum requiring additional fixation. Result Mean follow-up was 30.8 (range 14–55) months. Eleven subjects sustained unilateral posterior ring injuries, and five subjects sustained bilateral posterior ring injuries. All fractures healed uneventfully, and no hardware failures were noted. Average pelvic functional outcome score at final follow-up was 85.3 % (good). All but subjects required assistive walking devices and gait and sitting comfort scored “excellent.” High rates of sexual dysfunction and persistent difficulty with daily activities were noted in this series. Conclusions This series demonstrates that activity-specific dysfunction persists years after definitive percutaneous posterior fixation of isolated pelvic ring injuries. Radiographic outcomes were excellent as were subjects’ ability to ambulate independently and sit comfortably without pain. Many complained of persistent discomfort with both daily activities and sexual activity, suggesting persistent pathology to the non-osseous structures about the pelvis.

The use of humeral nails for femoral subtrochanteric fractures is rarely reported. We present a case in which a humeral nail was employed for a subtrochanteric femur fracture alongside contralateral prophylactic stabilization of the femoral neck and shaft.  A 29-year-old female patient with a history of bilateral varus-producing proximal femoral osteotomies, complicated by symptomatic hardware indicating bilateral removal, sustained a subtrochanteric fracture. Given her 98-degree neck-shaft angle, a humeral nail was selected for right femur fixation. She also underwent prophylactic stabilization of the contralateral proximal femur with a humeral nail. There are limited options for addressing subtrochanteric femur fractures in patients with anatomy variations that preclude using standard femoral nails. This case demonstrates the successful off-label use of a humeral nail for subtrochanteric femur fracture when a traditional femoral nail is impossible.