Treatment of type B periprosthetic femur fractures with curved non-locking plate with eccentric holes: Retrospective study of 43 patients with minimum 1-year follow-up.

INTRODUCTION: Periprosthetic femur fracture (PFF) is a serious complication after total hip arthroplasty that can be treated using different internal fixation devices. However, the outcomes with curved non-locking plates with eccentric holes in this indication have not been reported previously. The objectives of this study were to determine: (1) the union rate; (2) the complication rate; (3) autonomy in a group of patients with a Vancouver type B PFF who were treated with this plate. HYPOTHESIS: Use of this plate results in a high union rate with minimal mechanical complications. MATERIALS AND METHODS: Forty-three patients with a mean age of 79 years±13 (41-98) who had undergone fixation of Vancouver type B PFF with this plate between 2002 and 2007 were included in the study. The time to union and Parker Mobility Score were evaluated. The revision-free survival (all causes) was calculated using Kaplan-Meier analysis. The average follow-up was 42 months±20 (16-90). RESULTS: Union was obtained in all patients in a mean of 2.4 months±0.6 (2-4). One patient had varus malunion of the femur. The Parker Mobility Score decreased from 5.93±1.94 (2-9) to 4.93±1.8 (1-9) (P=0.01). Two patients required a surgical revision: one for an infection after 4.5 years and one for stem loosening. The survival of the femoral stem 5 years after fracture fixation was 83.3%±12.6%. CONCLUSION: Use of a curved plate with eccentric holes for treating type B PFF led to a high union rate and a low number of fixation-related complications. However, PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. LEVEL OF EVIDENCE: Retrospective study, level IV.

Fractures atypiques du fémur: A propos de trois cas cliniques [Atypical fractures of the femur: apropos of 3 clinical cases].

Osteoporosis is an increasing public health problem. The bisphophonates are the most useful treatment used through the world to prevent osteoporotic fractures. Their large prescription revealed an unpredictable side effect: the atypical fracture. These fractures appear in the subtrochanteric or diaphysal femoral proximal site, spontaneously or after a low trauma, and could be bilateral. X-rays shows a transversal or oblique fracture with a spur in the cortex and with a diffuse thickening of the cortical of the proximal femur. Expert's recommendations are current in progress to well understand and managed this problem. Here we report three cases of atypical femur fractures occurred in our Centre of bone diseases with some management and treatment propositions.

Early versus delayed application of Thomas splints in patients with isolated femur shaft fractures: The benefits quantified.

AIMS: To investigate and quantify the clinical benefits of early versus delayed application of Thomas splints in patients with isolated femur shaft fractures. MATERIALS AND METHODS: Level IV retrospective clinical and radiological analysis of patients presenting from January to December 2012 at a Level 1 Trauma Unit. All skeletally mature patients with isolated femur shaft fractures independently of their mechanism of injury were included. Exclusion criteria were: ipsilateral fracture of the lower limb, neck and supracondylar femur fractures, periprosthetic and incomplete fractures. Their clinical records were analysed for blood transfusion requirements, pulmonary complications, surgery time, duration of hospital stay and analgesic requirements. RESULTS: A total of 106 patients met our inclusion criteria. There were 74 males and 32 females. Fifty seven (54%) patients were in the 'early splinted' group and 49 patients (46%) were in the 'delayed splinted' group (P>0.05). The need for blood transfusion was significantly reduced in the 'early splinted' group (P=0.04). There was a significantly higher rate of pulmonary complications in the 'delayed splinted' group (P=0.008). All other parameters were similar between the two groups. CONCLUSION: The early application of Thomas splints for isolated femur fractures in non-polytraumatised patients has a clinically and statistically significant benefit of reducing the need for blood transfusions and the incidence of pulmonary complications.

Six years of denosumab treatment in postmenopausal women with osteoporosis: results from the first three years of the freedom extension

Background/Purpose: Denosumab (DMAb) is an approved therapy for the treatment of postmenopausal women with osteoporosis at increased risk for fracture. A favorable risk/benefit profile was demonstrated in the pivotal, 3-year FREEDOM trial (Cummings et al NEJM 2009). The open-label, active-treatment FREEDOM Extension study is investigating the efficacy and safety of DMAb for up to 10 years. The Extension trial enrolled women who had received DMAb or placebo in FREEDOM and provides an opportunity to evaluate the long-term efficacy and safety of continuous DMAb treatment (long-term group), and to replicate the DMAb findings observed in FREEDOM (cross-over group). Here, we report the results from the first 3 years of the Extension, representing up to 6 continuous years of DMAb exposure.Methods: During the Extension, each woman is scheduled to receive 60 mg DMAb every 6 months and supplemental calcium and vitamin D daily. For the analyses reported here, women from the FREEDOM DMAb group received 3 more years of DMAb for a total of 6 years of exposure (long-term group) and women from the FREEDOM placebo group received 3 years of DMAb exposure (cross-over group).Results: Of the 5928 women eligible for the Extension, 4550 (77%) enrolled (N_2343 long-term; N_2207 cross-over). In the long-term group, further significant mean increases in bone mineral density (BMD) occurred 4044 for cumulative 6-year gains of 15.2% at the lumbar spine and 7.5% at the total hip (Figure). During the first 3 years of DMAb treatment during the Extension, the cross-over group had significant mean gains in BMD at the lumbar spine (9.4%) and total hip (4.8%), similar to those observed in the long-term DMAb group during the first 3 years of FREEDOM (lumbar spine, 10.1%; total hip, 5.7%). Serum CTX was rapidly and similarly reduced after the 1st (cross-over) or 7th (long-term) DMAb dose with the characteristic attenuation observed at the end of the dosing period. In the cross-over group, yearly incidences of new vertebral and nonvertebral fractures were lower than in the FREEDOM placebo group. Fracture incidence remained low in the long-term group. Incidences of adverse events (AEs) and serious AEs did not increase over time with DMAb treatment. There were 2 subjects with AEs adjudicated to ONJ in the cross-over group and 2 in the long-term group. Both cases in the cross-over group healed completely and without further complications; 1 of these subjects continues to receive DMAb. Both women in the long-term group continue to be followed. No atypical femur fractures have been observed to date. Figure. Percent changes in bone mineral density during FREEDOM and the Extension Conclusion: DMAb treatment for 6 continuous years (long-term group) remained well tolerated, maintained reduced bone turnover, and continued to significantly increase BMD. Fracture incidence remained low. DMAb treatment for 3 years in the cross-over group reproduced the original observations in FREEDOM.

Six Years of Denosumab Treatment in Postmenopausal Women with Osteoporosis: Results From the First Three Years of the FREEDOM Extension

Background/Purpose: Denosumab (DMAb) is an approved therapy for the treatment of postmenopausal women with osteoporosis at increased risk for fracture. A favorable risk/benefit profile was demonstrated in the pivotal, 3-year FREEDOM trial (Cummings et al NEJM 2009). The open-label, active-treatment FREEDOM Extension study is investigating the efficacy and safety of DMAb for up to 10 years. The Extension trial enrolled women who had received DMAb or placebo in FREEDOM and provides an opportunity to evaluate the long-term efficacy and safety of continuous DMAb treatment (long-term group), and to replicate the DMAb findings observed in FREEDOM (cross-over group). Here, we report the results from the first 3 years of the Extension, representing up to 6 continuous years of DMAb exposure. Methods: During the Extension, each woman is scheduled to receive 60 mg DMAb every 6 months and supplemental calcium and vitamin D daily. For the analyses reported here, women from the FREEDOM DMAb group received 3 more years of DMAb for a total of 6 years of exposure (long-term group) and women from the FREEDOM placebo group received 3 years of DMAb exposure (cross-over group). Results: Of the 5928 women eligible for the Extension, 4550 (77%) enrolled (N_2343 long-term; N_2207 cross-over). In the long-term group, further significant mean increases in bone mineral density (BMD) occurred 4044 for cumulative 6-year gains of 15.2% at the lumbar spine and 7.5% at the total hip (Figure). During the first 3 years of DMAb treatment during the Extension, the cross-over group had significant mean gains in BMD at the lumbar spine (9.4%) and total hip (4.8%), similar to those observed in the long-term DMAb group during the first 3 years of FREEDOM (lumbar spine, 10.1%; total hip, 5.7%). Serum CTX was rapidly and similarly reduced after the 1st (cross-over) or 7th (long-term) DMAb dose with the characteristic attenuation observed at the end of the dosing period. In the cross-over group, yearly incidences of new vertebral and nonvertebral fractures were lower than in the FREEDOM placebo group. Fracture incidence remained low in the long-term group. Incidences of adverse events (AEs) and serious AEs did not increase over time with DMAb treatment. There were 2 subjects with AEs adjudicated to ONJ in the cross-over group and 2 in the long-term group. Both cases in the cross-over group healed completely and without further complications; 1 of these subjects continues to receive DMAb. Both women in the long-term group continue to be followed. No atypical femur fractures have been observed to date. Figure. Percent changes in bone mineral density during FREEDOM and the Extension Conclusion: DMAb treatment for 6 continuous years (long-term group) remained well tolerated, maintained reduced bone turnover, and continued to significantly increase BMD. Fracture incidence remained low. DMAb treatment for 3 years in the cross-over group reproduced the original observations in FREEDOM

Impact de la prophylaxie hormonale sur les fractures du fémur proximal des femmes postménopausiques: une étude de simulation. [Impact of hormonal prevention on fractures of the proximal femur in postmenopausal women: a simulation study].

A simulation model of the effects of hormone replacement therapy (HRT) on hip fractures and their consequences is based on a population of 100,000 post-menopausal women. This cohort is confronted with literature derived probabilities of cancers (endometrium or breast, which are contra-indications to HRT), hip fracture, disability requiring nursing home or home care, and death. Administration of HRT for life prevents 55,5% of hip fractures, 22,6% of years with home care and 4,4% of years in nursing homes. If HRT is administered for 15 years, these results are 15,5%, 10% and 2,2%, respectively. A slight gain in life expectancy is observed for both durations of HRT. The net financial loss in the simulated population is 222 million Swiss Francs (cost/benefit ratio 1.25) for lifelong administration of HRT, and 153 million Swiss Francs (cost/benefit ratio 1.42) if HRT is administered during 15 years.

Qualité des données fournies par la statistique médicale VESKA: le cas de la fracture du fémur proximal. [Quality of data provided by VESKA medical statistics: the case of the fractured proximal femur].

Within the framework of a retrospective study of the incidence of hip fractures in the canton of Vaud (Switzerland), all cases of hip fracture occurring among the resident population in 1986 and treated in the hospitals of the canton were identified from among five different information sources. Relevant data were then extracted from the medical records. At least two sources of information were used to identify cases in each hospital, among them the statistics of the Swiss Hospital Association (VESKA). These statistics were available for 9 of the 18 hospitals in the canton that participated in the study. The number of cases identified from the VESKA statistics was compared to the total number of cases for each hospital. For the 9 hospitals the number of cases in the VESKA statistics was 407, whereas, after having excluded diagnoses that were actually "status after fracture" and double entries, the total for these hospitals was 392, that is 4% less than the VESKA statistics indicate. It is concluded that the VESKA statistics provide a good approximation of the actual number of cases treated in these hospitals, with a tendency to overestimate this number. In order to use these statistics for calculating incidence figures, however, it is imperative that a greater proportion of all hospitals (50% presently in the canton, 35% nationwide) participate in these statistics.

Prospective evaluation of risk of vertebral fractures using quantitative ultrasound measurements and bone mineral density in a population-based sample of postmenopausal women: results of the Basel Osteoporosis Study.

OBJECTIVE: Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures. METHODS: 432 women aged 60-80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression. RESULTS: QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables. CONCLUSIONS: QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.

Ostéogénèse atypique après séquestrectomies multiples pour fracture ouverte infectée du fémur: un cas [Atypical osteogenesis following multiple sequestrectomies for infected open fracture of the femur: a case]

The authors present the case of an open fracture of femur Cauchoix type II with an infection due to Escherichia coli, Clostridium perfringens, Enterococcus and Aspergillus fumigatus. After several sequestrectomies and five hyperbaric sessions, apyrexia was attained at the end of the third month, the femur having been stabilised with an external fixator. The 15 cm gap due to loss of bone substance, filled at each dressing with an antiseptic iodine based ointment, closed itself finishing as continuous bone five months after the accident, the granulation tissue having been recovered by thin skin grafts. A repeated fracture occurring forty-eight hours after the removal of the Hoffmann frame was treated by fitting an Ilizarov fixator arriving at consolidation in seven months. The authors examine different possibilities of accelerating osteogenesis and highlight the potential role of iodine ointment as inductive to osteogenesis stemming from a periosteal layer seemingly held in place.

Documentation of fracture severity with the AO classification of pediatric long-bone fractures.

BACKGROUND: The AO comprehensive pediatric longbone fracture classification system describes the localization and morphology of fractures, and considers severity in 3 categories: (1) simple, (2) wedge, and (3) complex. We evaluated the reliability and accuracy of surgeons in using this rating system. MATERIAL AND METHODS: In a first validation phase, 5 experienced pediatric (orthopedic) surgeons reviewed radiographs of 267 prospectively collected pediatric fractures (agreement study A). In a second study (B), 70 surgeons of various levels of experience in 15 clinics classified 275 fractures via internet. Simple fractures comprised about 90%, 99% and 100% of diaphyseal (D), metaphyseal (M), and epiphyseal (E) fractures, respectively. RESULTS: Kappa coefficients for severity coding in D fractures were 0.82 and 0.51 in studies A and B, respectively. The median accuracy of surgeons in classifying simple fractures was above 97% in both studies but was lower, 85% (46-100), for wedge or complex D fractures. INTERPRETATION: While reliability and accuracy estimates were satisfactory as a whole, the ratings of some individual surgeons were inadequate. Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures.

Femur fracture in preschool children : experience with flexible intramedullary nailing in 72 children

RESUME Fractures du fémur chez les enfants d'âge préscolaire. Expérience avec l'enclouage centromédullaire élastique stable chez 72 enfants Introduction L'immobilisation plâtrée est le traitement le plus fréquemment utilisé pour traiter les fractures du fémur chez les enfants d'âge préscolaire de moins de 6 ans. L'enclouage centromédullaire élastique stable (ECMES), qui a remplacé les immobilisations plâtrées chez les enfants d'âge scolaire, est une alternative qui n'a jamais été étudiée spécifiquement dans la tranche d'âge préscolaire. Matériel et Méthode Nous avons réalisé une étude rétrospective de tous les cas de fractures du fémur chez l'enfant de moins de 6 ans traitées par ECMES dans le service de chirurgie pédiatrique du Centre Hospitalier Universitaire Vaudois et de l'Hôpital de l'Enfance de Lausanne sur une période de 15 ans. Résultats Parmi les 210 fractures du fémur traitées par ECMES entre le 1.1.1988 et le 31.12.2003, 74 fractures du fémur ont été identifiées chez 73 enfants âgés de 1.5 à 5.9 ans. Ces fractures étaient sous-trochantériennes (n=5), diaphysaires (n=64, dont 5 ouvertes), ou métaphysaires discales (n=4). Le type de fracture était transverse (n=35, dont 2 ouvertes), oblique (n=28, dont 3 ouvertes) au spiroïde (n=11). Quatre fractures étaient comminutives. Le temps opératoire moyen était de 56,9 minutes (limites entre 20 et 155 min.) pour les enfants ne présentant pas d'autre pathologie chirurgicale. Le séjour hospitalier moyen était de 9.1 jours (limites entre 1 et 46 jours) pour tous les enfants n'ayant pas de pathologie associée. Chez les enfants sans lésion ou pathologie associée, la première mise en charge s'est effectuée en moyenne au 14,1 ème jour post-opératoire (limites entre 1 et 42ème jour) alors que la première mobilisation a eu lieu en moyenne dès le 2,7ème jour post-opératoire (limites entre le 1 et le 14ème jour). 64 enfants ont été suivis à long terme avec un recul moyen de. 36,8 mois (limites entre 4 et 124 mois). Nous avons relevés 6 enfants avec une inégalité de longueur de plus d'un centimètre, alors que nous n'avons jamais constaté de défaut de rotation. Durant le 11 premières années de l'étude, 9 enfants ont dû être réopérés pour raccourcissement secondaire de broches extériorisées ou douloureuses sous la peau. Aucun problème de broche n'a été observé après introduction d'une nouvelle pince à couper. 2 réductions de fracture se sont faites à foyer ouvert. Une infection localisée transitoire du point de ponction d'une broche a été notée, sans ostéite associée. Discussion L' ECMES chez le petit enfant est techniquement réalisable sans véritable limite inférieure d'âge. Il favorise la mobilisation et la charge précoces. Les complications sont avant tout en rapport avec la technique et peuvent être évitées. Les résultats sont au moins aussi bons et meilleurs sur certains points que ceux publiés en utilisant les immobilisations. En outre ce traitement évite une longue hospitalisation. Conclusions L'ECMES peut être appliqué aux enfants de moins de 6 ans avec les mêmes bénéfices que ceux observés pour les plus grands, sans en augmenter la morbidité. La limite inférieure d'âge reste à déterminer. Un suivi à long terme s'impose pour vérifier l'absence d'inégalité de longueur des membres inférieurs.

Jaffé-Campanacci syndrome: an extremely rare cause of pathologic fracture of the femur

Introduction: Non-ossifying fibromas are common benign bone tumors of children and young adults. They are usually single, asymptomatic and regress spontaneously in adulthood. Some rare cases of pathologic fractures have been described. Jaffé-Campanacci syndrome is the association of multiple non-ossifying fibromas, "café-au-lait" spots and some degree of type 1 neurofibromatosis. While the relationship between the two entities remains unclear, there seems to be some genetic similarities (partial or complete deletion of the gene NF1). Case Report: A 17 yo female patient with a neurofibromatosis type 1 was referred to our tertiary centre with a pathologic fracture of the distal femur through a non-ossifying fibroma. She had a slight mental retardation and "café-au-lait" spots. Imaging revealed multiple typical non-ossifying fibromas of both distal femurs and proximal tibias. There was no impending fracture of the controlateral side, and no other findings on thoraco-abdominal CT scanner. The fracture was treated by minimal invasive plate osteosynthesis. Histological analysis of tissue samples taken during the intervention confirmed the histologic diagnosis of non-ossifying fibroma. The fracture healed eventless and the patient returned to work after 3 months. At 12 months follow-up, the patient remained pain-free. Imaging revealed remodelling of the lesions. Conclusion: Jaffé-Campanacci syndrome is an extremely rare cause of pathologic femur fracture. These fractures can be treated like any other, and good outcome is expected. There is still no consensus in regards to definition of the disease and its relationship with type 1 neurofibromatosis.

Assessment of volumetric bone mineral density of the femoral neck in postmenopausal women with and without vertebral fractures using quantitative multi-slice CT.

OBJECTIVE: To demonstrate the validity and reliability of volumetric quantitative computed tomography (vQCT) with multi-slice computed tomography (MSCT) and dual energy X-ray absorptiometry (DXA) for hip bone mineral density (BMD) measurements, and to compare the differences between the two techniques in discriminating postmenopausal women with osteoporosis-related vertebral fractures from those without. METHODS: Ninety subjects were enrolled and divided into three groups based on the BMD values of the lumbar spine and/or the femoral neck by DXA. Groups 1 and 2 consisted of postmenopausal women with BMD changes <-2SD, with and without radiographically confirmed vertebral fracture (n=11 and 33, respectively). Group 3 comprised normal controls with BMD changes > or =-1SD (n=46). Post-MSCT (GE, LightSpeed16) scan reconstructed images of the abdominal-pelvic region, 1.25 mm thick per slice, were processed by OsteoCAD software to calculate the following parameters: volumetric BMD values of trabecular bone (TRAB), cortical bone (CORT), and integral bone (INTGL) of the left femoral neck, femoral neck axis length (NAL), and minimum cross-section area (mCSA). DXA BMD measurements of the lumbar spine (AP-SPINE) and the left femoral neck (NECK) also were performed for each subject. RESULTS: The values of all seven parameters were significantly lower in subjects of Groups 1 and 2 than in normal postmenopausal women (P<0.05, respectively). Comparing Groups 1 and 2, 3D-TRAB and 3D-INTGL were significantly lower in postmenopausal women with vertebral fracture(s) [(109.8+/-9.61) and (243.3+/-33.0) mg/cm3, respectively] than in those without [(148.9+/-7.47) and (285.4+/-17.8) mg/cm(3), respectively] (P<0.05, respectively), but no significant differences were evident in AP-SPINE or NECK BMD. CONCLUSION: the femoral neck-derived volumetric BMD parameters using vQCT appeared better than the DXA-derived ones in discriminating osteoporotic postmenopausal women with vertebral fractures from those without. vQCT might be useful to evaluate the effect of osteoporotic vertebral fracture status on changes in bone mass in the femoral neck.

The AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study.

The first AO comprehensive pediatric long-bone fracture classification system has been proposed following a structured path of development and validation with experienced pediatric surgeons. A Web-based multicenter agreement study involving 70 surgeons in 15 clinics and 5 countries was conducted to assess the reliability and accuracy of this classification when used by a wide range of surgeons with various levels of experience. Training was provided at each clinic before the session. Using the Internet, participants could log in at any time and classify 275 supracondylar, radius, and tibia fractures at their own pace. The fracture diagnosis was made following the hierarchy of the classification system using both clinical terminology and codes. kappa coefficients for the single-surgeon diagnosis of epiphyseal, metaphyseal, or diaphyseal fracture type were 0.66, 0.80, and 0.91, respectively. Median accuracy estimates for each bone and type were all greater than 80%. Depending on their experience and specialization, surgeons greatly varied in their ability to classify fractures. Pediatric training and at least 2 years of experience were associated with significant improvement in reliability and accuracy. Kappa coefficients for diagnosis of specific child patterns were 0.51, 0.63, and 0.48 for epiphyseal, metaphyseal, and diaphyseal fractures, respectively. Identified reasons for coding discrepancies were related to different understandings of terminology and definitions, as well as poor quality radiographic images. Results supported some minor adjustments in the coding of fracture type and child patterns. This classification system received wide acceptance and support among the surgeons involved. As long as appropriate training could be performed, the system classification was reliable, especially among surgeons with a minimum of 2 years of clinical experience. We encourage broad-based consultation between surgeons' international societies and the use of this classification system in the context of clinical practice as well as prospectively for clinical studies.

Traitement des fractures de l'enfant par enclouage centro-médullaire élastique stable (ECMES) [Treatment of pediatric fractures by intramedullary stable elastic pinning]

During the past decade several new techniques for the treatment of children's fractures respecting the specificity of the growing bone have been described. The goal of all these techniques was to mechanically stabilise the fracture however to preserve a certain instability of the fracture gap itself inducing early callus formation and subsequent consolidation. The dynamic external fixation as well as the elastic stable intramedullary pinning have become accepted means in the treatment of long bone fractures in the paediatric age group. We report our experience of the last seven years with the intramedullary pinning of 105 fractures. Eighty-four were fractures of the femur, 9 of the humerus, 8 of the forearm, and a further 4 of the tibial shaft. The intramedullary elastic pinning represents a simple technique which supports or even enhances the natural process of fracture healing of the growing bone. The method is not very invasive, is cost effective, and allows short hospitalisation. Early physical activity is guaranteed due to early consolidation of the fracture. Complications are rare and the final orthopedic and cosmetic outcome is excellent.