Yuan, Brandon

Background: Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B 2 and B 3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B 2 and B 3 periprosthetic femoral fractures treated with MFT stems in a large series of patients. Methods: We identified 171 Vancouver B 2 (109) and B 3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m 2 . The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years. Results: The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B 1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71). Conclusions: In this large series of 171 Vancouver B 2 and B 3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Abstract: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Case: The patient sustained a pathologic fracture through chronic osteomyelitis of the tibia. Treatment involved resection of bone and soft tissue, leaving a 15-cm diaphyseal tibial defect. We designed a construct to allow for trifocal bone transport using a magnetic intramedullary lengthening nail connected to cables. This technique uses cables secured to the proximal tibia, the nail, and the transport segments. Conclusion: This case details the successful use of trifocal cable-assisted bone transport through a magnetic lengthening intramedullary nail. This technique can successfully be used to reconstruct diaphyseal bone defects that are longer than the stroke length of the magnetic nail.

Background: Distal femoral replacement (DFR) is a salvage option for complex primary and revision total knee arthroplasty (TKA). Although excellent immediate fixation and weight-bearing are achieved, there is a paucity of data on long-term outcomes of TKA with DFR. The purpose of the present study was to determine implant survivorship, clinical outcomes, and radiographic results of TKAs with contemporary DFR components in a large series. Methods: We identified 144 consecutive TKAs performed with DFR for non-oncologic indications from 2000 to 2015 at a single academic institution. Indications for the index DFR included 66 (46%) for native (n = 11) or periprosthetic (n = 55) femoral fracture, 40 (28%) for staged treatment of periprosthetic joint infection, 28 (19%) for aseptic TKA loosening, and 10 (7%) for other indications. Porous metal cones were used to augment femoral fixation in 28 patients (19%) and tibial fixation in 38 patients (26%). Outcomes included cumulative incidence of revision and reoperation (utilizing a competing risk model), Knee Society scores, and radiographic results. The mean age at the time of index DFR was 72 years, and 65% of patients were female. The mean follow-up was 5 years (range, 2 to 13 years) for the 111 patients who did not undergo revision, had not died, and were not lost to follow-up. Results: The 10-year cumulative incidences of revision for aseptic loosening, all-cause revision, and any reoperation were 17.0%, 27.5%, and 46.3%, respectively. There was an increased risk of reoperation in patients who underwent index DFR for aseptic TKA loosening (hazard ratio [HR], 2.30; p = 0.026) or periprosthetic joint infection (HR, 2.18; p = 0.022) compared with periprosthetic or native femoral fractures. However, there was no difference in risk of revision for aseptic loosening or all-cause revision based on the original operative indication. The mean Knee Society score increased from 45 preoperatively to 71 at the time of the latest follow-up (p < 0.001). Radiographic loosening was observed in 8 unrevised DFRs (7%). There were 7 above-the-knee amputations performed at the time of the final follow-up, all for intractable periprosthetic joint infection. Conclusions: TKAs with contemporary DFR had high 10-year cumulative incidences of both revision and reoperation, underscoring the salvage nature of this procedure as a final reconstructive option. Most patients experienced substantial clinical improvements with this end-stage revision procedure. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.