Acute Adductor Muscle Injury: A Systematic Review on Diagnostic Imaging, Treatment, and Prevention

BACKGROUND

Controversies remain regarding the diagnosis, imaging, and treatment of acute adductor injuries in athletes.

PURPOSE

To investigate the diagnostic imaging, treatment, and prevention of acute adductor injuries based on the most recent and relevant scientific evidence.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed and Web of Science databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles studying acute adductor injury in athletes. Inclusion criteria were original publication on acute adductor injury in amateur or professional athletes, level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or the methodological index for non-randomized studies criteria. Articles were grouped as imaging, treatment, prevention focused, or mixed.

RESULTS

A total of 30 studies published between 2001 and 2021 were selected, involving 594 male patients with a mean age 26.2 years (range, 16-68 years). The most frequent sports were soccer (62%), basketball (14%), futsal (6%), American football (3%), and ice hockey and handball (2%). Risk factors for acute adductor injury were previous acute groin injury, adductor weakness compared with the uninjured side, any injury in the previous season, and reduced rotational hip range of motion. The frequency of complete adductor muscle tears on magnetic resonance imaging was 21% to 25%. For complete adductor tears, the average time to return to play was 8.9 weeks in patients treated nonoperatively and 14.2 weeks for patients treated surgically. Greater stump retraction was observed in individuals treated surgically. Partial acute adductor tears were treated nonoperatively with physical therapy in all studies in the present systematic review. The average time to return to play was 1 to 6.9 weeks depending on the injury grade. The efficacy of adductor strengthening on preventing acute adductor tears has controversial results in the literature.

CONCLUSION

Athletes with partial adductor injuries returned to play 1 to 7 weeks after injury with physical therapy treatment. Nonoperative or surgical treatment is an acceptable option for complete adductor longus tendon tear.

Lower extremity kinematic and kinetic factors associated with bat speed at ball contact during the baseball swing

The purpose of this study was to determine which biomechanical variables measured during the baseball swing are associated with linear bat speed at ball contact (bat speed). Twenty collegiate baseball players hit a baseball from a tee into a net. Kinematics were recorded with a motion capture system sampling at 500 Hz and kinetics were measured by force plates under each foot sampling at 1000 Hz. Associations between bat speed, individual joint and segment kinematics, joint moments and ground reaction forces (GRF) were assessed using Pearson correlations and stepwise linear regression. Average bat speed was 30 ± 2 m/s. Lead foot peak vertical (159 ± 29% BW, r = 0.622, P = 0.001), posterior (-57 ± 12% BW, r = -0.574, P = 0.008) and resultant (170 ± 30% BW, r = 0.662, P = 0.001) GRF were all correlated with bat speed. No combination of factors strengthened the relationship to bat speed beyond these individual variables. These results illustrate the role of the lead leg in generating and transferring ground reaction forces through the kinetic chain in order to accelerate the bat. Training to improve bat speed should include both general lower extremity strengthening exercises and sport-specific hitting drills to improve lower extremity force production following lead foot contact.

Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes

» Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.» Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.» Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.» Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology.

Surgical Reattachment of Rare Proximal Adductor Avulsion Injury in a Female Athlete: A Case Report

CASE

A 54-year-old female professional equestrian sustained a traumatic right groin injury with disabling groin pain. Magnetic resonance images indicated a proximal adductor avulsion injury with a 3.2-cm tendon retraction. Surgical reattachment of the fibrocartilage avulsion with suture anchor repair was subsequently performed.

CONCLUSION

Adductor avulsion injuries have been rarely reported in female athletes. Patient-reported outcomes demonstrate a successful return to preinjury levels of daily function and sports performance after surgery for a female athlete. Surgical reattachment should be considered for the management of proximal adductor avulsion injuries in elite female athletes.

Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique

Background:

Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes.

Purpose:

To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed.

Results:

Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin.

Conclusion:

Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.

Conservative Treatment of Avulsion Injuries of the Lesser Trochanter in Adolescent Athletes

BACKGROUND

 Avulsion injuries of the lesser trochanter apophysis are relatively uncommon injuries and there have been no peer-reviewed case series dedicated to the evaluation and treatment of this injury. The purpose of this study is to characterize avulsion injuries of the lesser trochanter apophysis, review treatment protocols, and time to return to sport.  Methods: We reviewed 30 confirmed avulsion fractures of the lesser trochanter. Clinical data were reviewed to evaluate treatment protocols, duration, and time to return to sport. Radiographs were reviewed to confirm lesser trochanter avulsion and fracture displacement.

RESULTS

There were 26 males and 4 females, with the average age at the time of injury being 14.2 years. Treatment modalities consisted of protective weight-bearing, discontinuation of the patient's sport in all cases, and formal physical therapy in 18 cases. The average treatment duration was 30.7 days. The mean follow-up time was 102 days. The radiographic assessment demonstrated an average fracture displacement of 5.1 mm. The average return to sport was 11 weeks.

CONCLUSION

This is the first large case series studying avulsion injuries of the lesser trochanter. We have shown that these athletes can be managed non-surgically and can successfully return back to sport within three months.

Arthroscopic Management of Subspinous Impingement in Borderline Hip Dysplasia and Outcomes Compared With a Matched Cohort With Nondysplastic Femoroacetabular Impingement

BACKGROUND

Arthroscopic management of femoroacetabular impingement (FAI) in the setting of borderline hip dysplasia is controversial. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement.

PURPOSE/HYPOTHESIS

The purpose was to report outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia compared with a matched cohort with nondysplastic FAI. Addressing a prominent subspinous region and cam/pincer lesion in the borderline dysplastic hip may lead to favorable outcomes comparable with those of patients undergoing arthroscopic management of nondysplastic FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with symptomatic hip impingement, borderline dysplasia (lateral center-edge angle [LCEA], 18°-24°), and prominent AIIS (BDSI group) whose nonoperative management failed and who subsequently underwent arthroscopic subspinous decompression were retrospectively identified. Three-dimensional computed tomography imaging was used to categorize AIIS morphology into type 1, 2, or 3 (Hetsroni classification). Patient-reported outcome (PRO) scores consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperatively (range, 23-61 months). Exclusion criteria were Tönnis osteoarthritis grade >1 and a history of previous hip procedures. An age-, sex-, and body mass index-matched cohort of patients without dysplasia (LCEA, >25°) who underwent arthroscopic FAI surgery with a minimum 2-year follow-up were selected to serve as the control group.

RESULTS

Eighteen patients, 19 hips (14 women and 4 men; average age, 28 years) were included. Of the 19 hips in the BDSI group, the average LCEA and alpha angle were 21.8° and 66.2°, respectively; 14 hips were Hestroni type 2, and 5 hips were type 1. There were no postoperative complications or additional procedures performed since the last follow-up. Repeated-measures analysis of variance revealed a significant improvement in all PRO scores from preoperatively to the last follow-up: mHHS, 64.7 to 87.7 (P < .001); HOS-ADL, 62.1 to 92.1 (P < .001); HOS-SSS, 26.5 to 87.1 (P < .001). An analysis of covariance revealed that patients with type 2 AIIS had a significantly higher postoperative mHHS than those with a type 1 morphology (88.3 and 95.6, respectively; P < .01) The BDSI group had a significantly lower preoperative HOS-SSS (26.5; P < .001) in comparison with the control group. However, there was no significant difference in postoperative outcome scores between groups. The BDSI group underwent significantly more microfracture, capsular plication, and ligamentum teres debridement (15.8%; P = .04).

CONCLUSION

Arthroscopic AIIS decompression in patients with coexisting borderline dysplasia and subspinous impingement is a safe and effective method of treatment that produces outcomes comparable with those of a cohort with nondysplastic FAI.

Sports Hernia/Athletic Pubalgia Among Women

Background:

“Athletic pubalgia,” a term that has gained acceptance over “sports hernia,” is more common in men than women; however, it represents a significant source of morbidity for patients of both sexes. Inconsistent terminology surrounding this entity poses a diagnostic challenge and makes studying the populations at risk difficult.

Purpose:

To review a case series of women with athletic pubalgia by analyzing their presentations, concomitant pathologies, and surgical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 2013 and 2016, 197 patients were seen and evaluated for the diagnosis of athletic pubalgia. Eighteen patients seen during this time were women. All patients received “pubalgia protocol” magnetic resonance imaging and subsequent surgical intervention for their pathologies. Outcomes among 17 women were assessed with a patient questionnaire >1 year after surgery.

Results:

Of the 17 women, 9 had rectus aponeurotic plate injury only, or pure athletic pubalgia; the remaining 8 had athletic pubalgia in combination with ≥1 inguinal, obturator, and femoral hernias. Regarding female patients in both groups, 88.2% reported that the surgery was a success at follow-up.

Conclusion:

Surgical repair of athletic pubalgia among women is successful in dramatically reducing pain levels in this important subset of patients.

Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes

Background:

Sports-related groin injuries are common among athletes. However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair.

Purpose:

To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

Prospective data were collected on patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Patient-reported outcomes (Hip Outcome Score–Activities of Daily Living [HOS-ADL] and Hip Outcome Score–Sport Specific [SS] subscales, modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) were collected preoperatively and at a minimum 2-year follow-up.

Results:

The latest follow-up of each patient averaged 33.4 months postoperatively (range, 25-42.5 months). All patients returned to sporting activities, with 1 minor wound complication that resolved. Paired-samples t tests indicated that the mean latest postoperative scores for all patients were significantly better than their mean preoperative scores (HOS-ADL: 99.0 vs 43.2, HOS-SS: 98.9 vs 8.3, and mHHS: 97.1 vs 44.6, respectively; P < .001 for all). Similarly, there was a significant improvement in mean postoperative VAS scores for all patients (from 89.2 to 2.2; P < .001).

Conclusion:

Patient-reported outcomes offer an objective measure of hip function and pain control. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport.

Endoscopic Proximal Adductor Lengthening for Chronic Adductor-Related Groin Pain

Proximal adductor injuries are relatively common groin injuries in athletes. Various tenotomy techniques have been described including open, partial, and percutaneous approaches. Current techniques help most athletes return to sport; however, many develop adductor weakness. Moreover, the procedures lack full visualization of the tendon and do not allow for return to athletes' preinjury level of play. We describe an endoscopic z-lengthening of the proximal adductor tendon with the potential to minimize complications associated with open procedures such as incisional pain and neurovascular injury while affording a more complete tenotomy than current percutaneous techniques. This is a safe and reproducible technique that allows for release of tension as a result of pathologic adductor tendon pathologies.

The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept

PURPOSE

Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.

METHODS

A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.

RESULTS

The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.

CONCLUSION

The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Anchor-induced chondral damage in the hip

The purpose of this study is to investigate the outcomes from anchor-induced chondral damage of the hip, both with and without frank chondral penetration. A multicenter retrospective case series was performed of patients with chondral deformation or penetration during initial hip arthroscopic surgery. Intra-operative findings, post-surgical clinical courses, hip outcome scores and descriptions of arthroscopic treatment in cases requiring revision surgery and anchor removal are reported. Five patients (three females) of mean age 32 years (range, 16–41 years) had documented anchor-induced chondral damage with mean 3.5 years (range, 1.5–6.0 years) follow-up. The 1 o'clock position (four cases) and anterior and mid-anterior portals (two cases each) were most commonly implicated. Two cases of anchor-induced acetabular chondral deformation without frank penetration had successful clinical and radiographic outcomes, while one case progressed from deformation to chondral penetration with clinical worsening. Of the cases that underwent revision hip arthroscopy, all three had confirmed exposed hard anchors which were removed. Two patients have had clinical improvement and one patient underwent early total hip arthroplasty. Anchor-induced chondral deformation without frank chondral penetration may be treated with close clinical and radiographic monitoring with a low threshold for revision surgery and anchor removal. Chondral penetration should be treated with immediate removal of offending hard anchor implants. Preventative measures include distal-based portals, small diameter and short anchors, removable hard anchors, soft suture-based anchors, curved drill and anchor insertion instrumentation and attention to safe trajectories while visualizing the acetabular articular surface.

The incidence of venous thromboembolism (VTE)--after hip arthroscopy

PURPOSE

The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy.

METHODS

Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded.

RESULTS

We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure.

CONCLUSION AND CLINICAL RELEVANCE

In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

Labral tears, extra-articular injuries, and hip arthroscopy in the athlete

Labral tears in athletes can lead to disabling hip pain and affect their athletic performance. Other intra-articular lesions, including chondral injuries, capsular abnormalities, and ligamentum teres tears, commonly coexist with acetabular labral tears. Isolated athletic injury or repetitive traumatic activity can lead to labral tears; however, underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing athletes to labral pathology must be addressed. Recent studies have demonstrated lesions associated with acetabular labral tears, and that labral tears rarely occur as isolated injuries. Return to sport is favorable in athletes who have labral tears if they are properly treated with arthroscopic intervention.

Endoscopic treatment of calcific tendinitis of gluteus medius and minimus

Calcific tendinitis results from deposition of calcium hydroxyapatite crystals in periarticular muscle attachments. Although involvement of tendons around the hip is not uncommon, gluteus medius and minimus tendons are rarely affected. We present endoscopic treatment of calcific tendonitis of gluteus medius and minimus and associated trochanteric bursitis in a patient with 2-year history of lateral hip pain. This is the first reported case treated using an endoscopic approach, which is effective and minimally invasive.

Knee fractures in the athlete

Sports-related fractures of the knee, although uncommon, do occur during athletic participation. The assessment and management of each fracture type have been emphasized in this article to provide a guideline for treating these acute knee injuries to a successful return to sports-specific competition. Anatomic fracture reduction is necessary to have optimal joint function in the knee as well as stability of fracture for early joint motion, promote bone healing, and avoid traumatic arthritis. This is especially crucial to the injured athlete, as residual deficits of the knee can greatly affect performance. Selection of low-profile implants at the time of surgery to prevent soft tissue irritation and possible implant removal must also be considered with the return to athletic activity.

Internal fixation of cervical trauma following corpectomy and reconstruction. The effects of posterior element injury

Although biomechanical data indicates that anterior fixation alone in unstable cervical injuries may not provide adequate stability, reports of clinical series indicate general success with this method of treatment. The specific contribution of posterior column injury to overall stability following reconstruction has not been evaluated. This study examined the biomechanical stability of anterior and/or posterior plate fixation following anterior corpectomy and reconstruction for unstable cervical injuries with varying degrees of posterior element injury. The C4-C6 motion segments of ten fresh frozen bovine cervical spines were used. After mounting, nondestructive mechanical testing in axial compression, torsion, flexion, extension, and lateral bending was done as an intact control. A C5 corpectomy with reconstruction using a synthetic bone graft was performed and the posterior ligaments sectioned at the C5-C6 level. Each specimen was sequentially instrumented with anterior and posterior plating alone and in combination and each construct was mechanically retested. The specimens were then further destabilized by bilateral facetectomies at C5-C6 and again tested with the same instrumentation combinations. In comparison to the controls, the spines with a C5 corpectomy/bone graft and posterior ligament rupture with anterior plating demonstrated significantly increased stiffness in flexion, extension, and lateral bending; posterior plating increased stiffness in only flexion and lateral bending. In axial compression and torsion, anterior or posterior plating demonstrated stiffness similar to the controls. Further destabilization by facetectomy significantly decreased stiffness of the instrumented construct (less than control) in torsion with anterior or posterior plate fixation alone. Combined plating showed increased stability compared to controls in all loading conditions for both patterns of instability. Anterior plating alone was able to restore the stability of the cervical spines with posterior ligamentous injury after corpectomy, but it failed to do so with the addition of bilateral facetectomies. For the unstable cervical spine with significant bilateral loss of posterior bony contact, anterior or posterior plating alone may not provide sufficient stabilization in the absence of any additional external immobilization. Combined plating should be considered, which may obviate the need for external immobilization.

A new technique for complex fibula fracture fixation in the elderly: a clinical and biomechanical evaluation

OBJECTIVE

To determine whether intramedullary fixation could augment plate fixation strength in comminuted and osteopenic fibula fractures.

STUDY DESIGN

Retrospective clinical study and biomechanical laboratory study.

METHODS

Twenty comminuted or osteopenic fibula fractures in twenty patients age fifty years or older were stabilized using plate fixation augmented with intramedullary Kirschner wires. Nineteen patients were available for follow-up which averaged 15.4 months (range, 6-43 months). In conjunction with this clinical series, a biomechanical evaluation was performed comparing fixation of mildly osteopenic fibulas using this technique to plate and screws alone. The fibulas were first tested non destructively in bending, and then destructively in torsion to determine stability and ultimate strength of the fixation.

RESULTS

All nineteen fractures united without loss of reduction: seventeen of nineteen patients (89%) had either no pain, slight or mild pain. Biomechanical testing demonstrated that the resistance to bending of the plated fibulas augmented with Kirschner wires was 81% greater than the fibulas stabilized with a plate alone (p < .05). In torsional testing, the augmented group had twice the resistance to motion than the plate group (p < .002).

CONCLUSION

This clinical series and biomechanical study support the use of plate fixation augmented with intramedullary Kirschner wires for the treatment of comminuted and osteopenic fibula fractures in the elderly.

Distal femoral fixation: a laboratory comparison of the 95 degrees plate, antegrade and retrograde inserted reamed intramedullary nails

A biomechanical cadaver study was performed to compare the stability of three standard distal femoral fixation techniques. Eighteen mildly osteoporotic femurs were selected, based on a dual-energy x-ray absorption scanning bone density of 0.3-0.5 g/cm2 and a Singh index of III-IV. After initial mechanical characterization of these intact femurs, a distal femoral osteotomy was created, reduced, and stabilized under compression using random assignment to one of three methods of fixation: (a) six-hole 95 degrees supracondylar plate, (b) retrograde inserted statically locked supracondylar intramedullary nail, and (c) antegrade inserted statically locked Russell-Taylor nail. The instrumented femurs were mechanically tested, a 1-cm gap created, and the femurs retested. The specimens were finally loaded to failure in A-P three-point bending. The 95 degrees plate provided significantly stiffer fixation than the supracondylar intramedullary nail or Russell-Taylor nail in both a compressed transverse and gap distal femoral osteotomy model. The Russell-Taylor nail provided the least rigid fixation. The 95 degrees plate and Russell-Taylor nail had statistically significant greater loads to failure than the supracondylar intramedullary nail. These results support the use of a 95 degrees plate when maximum rigidity of fixation or maximum compression is desired.