Volume 12-1, Spring 2003

Management of distal-third femoral fractures is challenging, especially in the elderly population, where the associated complication rate has been reported to be as high as 40%. This study reviews the techniques and safety of intramedullary stabilization for displaced and unstable fractures involving the distal third of the femur in patients who were at least 80 years old, with the use of Ender nails. A retrospective study of 12 patients with 14 femur fractures underwent closed fixation of their fracture(s) with Ender nails performed within 24 hours of the injury. There were 10 females and 2 males, whose average age was 88 years (range, 82–103 years). The average length of follow-up was 3 years. Twelve fractures (86%) healed uneventfully. There were two nonunions (14%) with no other major or minor complications. No patients were lost to follow-up evaluation. All patients eventually returned to their preinjury level of function. This technique is particularly applicable to elderly patients with severe osteopenia and preexisting medical problems, as it minimizes blood loss and other associated complications, while providing stability for immediate mobilization. (Journal of the Southern Orthopaedic Association 12(1):3–8, 2003) Key words: elderly, Ender nails, femoral fractures, osteopenia

The occurrence of deep vein thrombosis (DVT) following cases of major trauma, in particular pelvic and hip fracture, has ranged from 36% to 60%, depending on the study quoted and the method of detection. The frequency of fatal pulmonary embolism (PE) has been reported as 0.5%–12.9% of the cases. A retrospective study of 1000 consecutive hip fracture patients in a community hospital setting reveals that 95% received a combination of mechanical and pharmacologic prophylaxis for prevention of DVT. Sixtyone patients were excluded for insufficient data, leaving 939 for analysis. There were 724 female patients with an average age of 83 years and 215 male patients with an average age of 78 years. Fifty-one patients (18.4%) received no prophylaxis in the eligible population. Three hundred eighty-seven patients (41.2%) received only aspirin as the pharmacologic agent for anticoagulation. Four hundred twenty-nine patients (45.6%) were treated with the low-molecular-weight heparin (LMWH), enoxaparin. Ten patients (1.1%) received heparin for anticoagulation and 17 patients (1.8%) were treated with warfarin. A total of 43 patients received a combination of therapies. Four hundred ninety-five of the patients used concomitant intermittent pneumatic compression in addition to pharmacologic prophylaxis. There were 15 perioperative deaths from all causes, including five cases of DVT (two distal and three proximal). One distal DVT occurred prior to surgery. A second distal DVT and one fatal PE occurred in the aspirin group. The rates of minor bleeding complications in the aspirin group, the < 12-hour postoperative dosing of the
enoxaparin group, and the 12 to 24-hour postoperative dosing of the enoxaparin group were 3.1%, 5.7%, and 2.8%, respectively. There were no major bleeds in the aspirin group and 0.9% in the enoxaparin group. The LMWH group also had two proximal DVTs but no PEs. The combination of a relatively short half-life, predictable pharmacokinetics, and favorable safety profile makes enoxaparin an excellent drug for use in hip fracture patients. Additional trials will be necessary to establish an optimal duration of prophylaxis in this population. (Journal of the Southern Orthopaedic Association 12(1):10–17, 2003) Key words: anticoagulation, DVT, hip fracture, thrombosis

Hip fractures are associated with significant morbidity and mortality. Most of these fractures are preventable late manifestations of osteoporosis. The authors examined incidence and medical costs associated with hip fractures among 34,363 veterans by gender and race for fiscal years 1996–2000. Data were obtained from the Patient Treatment File administrative database. The frequencies of seven known risk factors were quantified. White veterans hospitalized for hip fracture were 69% more likely to be given the diagnosis of osteoporosis, when compared to black veterans. Male gender was associated with lower percentage of osteoporosis diagnoses (2.2%) than female gender (11.9%). The authors estimate that hip fractures result in $43 million of excess cost to veterans and the Veterans Health Administration annually. Greater use of diagnostic and preventive measures represents an excellent opportunity for improvement of care, as well as substantial cost savings for at risk populations. (Journal of the Southern Orthopaedic Association 12(1):18–22, 2003) Key words: aged, hip fractures, osteoporosis, risk factors, veterans

The importance of acromial morphology in the pathogenesis of rotator cuff tears remains controversial. Some surgeons place great emphasis on acromial morphology and others feel that acromial shape is a result of cuff tear pathology rather than the cause. The purpose of this study was to determine if there was an association between acromial morphology, age, and rotator cuff tears found by ultrasound in asymptomatic volunteer subjects with no past history of shoulder symptoms. One hundred eighteen outlet x-rays and ultrasound scans were performed in 59 asymptomatic patients in various age groups. Acromial morphology and the age of the patients were then correlated with the ultrasound findings. Older patients were noted to have a high incidence of type II and type III acromions (93% of those over 70). Full- and partial-thickness tears were more commonly seen in patients with type II or type III acromions compared with type I. Patients over 50 years had a high incidence of full-thickness tears (40%), but the incidence did not increase with increasing age past 50. These findings lend credence to the multifactorial etiology of rotator cuff tears. The patient’s age (degeneration) and acromial morphology (impingement) are two of the factors involved in causing rotator cuff tears. The incidence of cuff tears and type III acromions was high in this group of entirely asymptomatic volunteer subjects. Surgeons should interpret radiologically hooked or curved acromions as well as rotator cuff tears diagnosed with ultrasound or other modalities with caution. It may well be that both of these findings should be regarded as part of the natural ageing process. (Journal of the Southern Orthopaedic Association 12(1):23–26, 2003) Key words: acromial morphology, rotator cuff tear, ultrasound

Concomitant nonunion of an operatively treated fracture of the distal humerus and the olecranon osteotomy used for exposure is an unusual and complex situation which compromises ulnohumeral function on both sides of the joint. Operative treatment restored good elbow function in a series of six patients with this problem. An average of 110° of ulnohumeral motion was restored, arthrosis was none (four patients) or mild (two patients) at an average follow-up of 50 months, and outcome measures documented good upper extremity specific (DASH) and general (SF-36) health status. (Journal of the Southern Orthopaedic Association 12(1):27–31, 2003) Key words: elbow, fracture, olecranon osteotomy, ulnohumeral function

A case report is presented of a patient with acetabular protrusio 2 years following hemiresurfacing of the femoral head for osteonecrosis associated with sickle cell disease. Renewed interest in bone-preserving hip arthroplasty has led to increased use of hemiarthroplasty and femoral resurfacing in young patients with arthritis. In cases of osteonecrosis, especially that associated with sickle cell disease, awareness of this potential complication is important. (Journal of the Southern Orthopaedic Association 12(1):32–37, 2003) Key words: arthroplasty, complications, hemiresurfacing, protrusio

A case of anterior inferior iliac spine (AIIS) apophyseal avulsion fracture caused while playing football is reported. A 16-year-old amateur football player felt severe pain in his left groin while kicking the ball during training. There was point tenderness over the anterior inferior iliac spine (AIIS). Avulsion fracture of AIIS was considered clinically. Radiographs confirmed the diagnosis. He was treated with a conservative rehabilitation program. He is still an active football player. Avulsion fractures follow violent or explosive muscular contractions against a fixed resistance, sudden deceleration, or stretching of the involved muscle or as a result of a direct trauma. This injury usually occurs with an extension moment to the hip joint, with the knee flexed, and it is commonly seen in sports that involve kicking. AIIS avulsion fractures should be a diagnostic consideration in patients with pain in the groin who are involved in activities requiring high-level forces of flexion of the hip. (Journal of the Southern Orthopaedic Association 12(1):38–40, 2003) Key words: anterior inferior iliac spine, apophyseal avulsion, football, rehabilitation

An unusual case is presented in which a major peripheral nerve was compressed extrinsically by a schwannoma derived from a minor en passant triceps nerve branch. (Journal of the Southern Orthopaedic Association 12(1):41–42, 2003) Key words: extrinsic compression, nerve sheath tumor