Outcomes of Angular Stable Locking System in Femoral Diaphyseal Fractures of Elderly Patients: A Multicenter Comparative Study.

Background: The angular stable locking system (ASLS) was developed to provide additional stability to the distal interlocking screw of the intramedullary (IM) nail. Effects of ASLS on the treatment of femoral diaphyseal fractures in the elderly remain unknown. The aim of this study was to compare radiological outcomes of IM nailing using ASLS screws to IM nails with conventional interlocking screws in elderly patients with femoral shaft fractures. Methods: A multicenter retrospective review of 129 patients (average age, 73.5 years; 98 women and 31 men) aged 65 years or older who underwent IM nail fixation for femoral diaphyseal fractures (AO/Orthopaedic Trauma Association [OTA] classification 32) was conducted. Demographic information of patients, fracture site (subtrochanteric or shaft), fracture type (traumatic or atypical), and AO/OTA fracture classification were investigated. Reduction status was evaluated by postoperative plain radiography. Presence of union and time to union were evaluated through serial plain radiograph follow-up. Reoperation due to nonunion or implant failure was also evaluated. Results: ASLS was used in 65 patients (50.3%). A total of 118 patients (91.5%) achieved union without additional surgery and the mean union time was 31.8 ± 13.0 weeks. In terms of reduction status, angulation was greater in the group using ASLS. There were no statistically significant differences of union rate, time to union, and reoperation rate according to the use of ASLS (p > 0.05). There was no difference in the outcomes according to the use of ASLS even when the analysis was divided in terms of fracture site or fracture type (p > 0.05). In further subgroup analysis, only the traumatic subtrochanteric area group showed statistically significantly shorter time to union when ASLS was used (p = 0.038). Conclusions: In geriatric patients with femoral diaphyseal fractures, the use of ASLS was not considered to have a significant effect on fracture healing. Fracture healing seemed to be more affected by surgical techniques such as minimizing the gap and fracture characteristics such as atypical femoral fractures, rather than implants.

A multicenter study of factors affecting nonunion by radiographic analysis after intramedullary nailing in segmental femoral shaft fractures.

The factors affecting the outcomes of segmental femoral shaft fractures are currently unknown. We evaluated the outcomes of intramedullary (IM) nail fixation and investigated factors affecting nonunion of femoral shaft segmental fractures. A total of 38 patients who underwent IM nail fixation for femoral shaft segmental fractures (AO/OTA 32C2) at three university hospitals with a minimum 1-year follow-up period were retrospectively reviewed. The patients were divided into union (n = 32) and nonunion (n = 6) groups. We analyzed smoking status, diabetes mellitus, location of the segmental fragment, segment comminution, filling of the IM nail in the medullary canal, residual gap at the fracture site, use of a cerclage wire or blocking screws as factors that may affect the surgical outcome. In the union group, the average union time was 5.4 months (4-9 months). In the nonunion group, five patients required additional surgery within an average of 7.2 months (5-10 months) postoperatively, whereas one patient remained asymptomatic and did not require further intervention. On comparing the two groups, insufficient canal filling of the IM nail (union, 25.0%; nonunion, 83.3%; p = 0.012) and the presence of a residual gap at the fracture site after reduction (union, 31.3%; nonunion, 83.3%; p = 0.027) were significantly different. In the multivariate analysis, only insufficient canal filling of the IM nail was found to be a factor affecting nonunion, with an odds ratio of 13.3 (p = 0.036). In this study, a relatively high nonunion rate (15.8%) was observed after IM nail fixation. Insufficient IM nail canal filling and a residual gap at the fracture site post reduction were factors affecting segmental femoral shaft fracture nonunion after IM nail fixation.

Mid-term outcomes after the surgical treatment of atypical femoral fractures : minimum three-year follow-up.

AIMS: The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. METHODS: From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. RESULTS: The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85). Delayed union occurred in 41 (27.9%), and nonunion occurred in 13 (8.8%). Contralateral AFF occurred in 79 patients (53.7%), and the use of a bisphosphonate significantly influenced the occurrence of contralateral AFFs (p = 0.019). Peri-implant fractures occurred in a total of 13 patients (8.8%), and a significant increase was observed in cases with plating (p = 0.021) and high grade of postoperative anterolateral bowing (p = 0.044). CONCLUSION: The use of a bisphosphonate was found to be a risk factor for contralateral AFF, and high-grade postoperative anterolateral bowing and plate fixation significantly increased the occurrence of peri-implant fractures. Long-term follow-up studies on the bilaterality of AFFs and peri-implant fractures are warranted. Cite this article: Bone Joint J 2021;103-B(11):1648-1655.

Comparison of the Modified Transtibial Technique, Anteromedial Portal Technique and Outside-in Technique in ACL Reconstruction.

PURPOSE: To compare clinical and radiographic results of anterior cruciate ligament (ACL) reconstruction using modified transtibial technique (mTT), anteromedial (AM) portal technique and outside-in (OI) technique. MATERIALS AND METHODS: From March 2007 to December 2012, ACL reconstruction was performed using the mTT, AM portal technique and OI technique in 20 patients each. Anteroposterior and rotational stability were assessed using the GNRB arthrometer and pivot-shift test. Femoral tunnel obliquity was measured on the anteroposterior and lateral radiographs. RESULTS: Tegner score, Lysholm score, International Knee Documentation Committee score, pivot-shift test were improved at final follow-up in all three groups. However, statistical difference was not shown. Side-to-side difference in GNRB arthrometer was average of 1.4 mm, 1.0 mm and 0.9 mm in mTT, AM and OI group, showing the signicant difference between mTT and AM/OI groups (p<0.001). The mean femoral tunnel obliquity was 56.4° in the mTT group, 39.4° in the AM group and 33.6° in the OI group, showing significant intergroup difference (p<0.001). It showed the significant difference among three groups (p<0.001). CONCLUSIONS: Clinical results were improved in all three groups. Femoral tunnel obliquity in AM and OI were more horizontal on the coronal plane. They are thought to have more benefits in oblique positioning of the grafted ACL in rotational stability; however, there was no significant difference among three techniques in pivot-shift test to assess the rotational stability in this study.

Staged protocol in treatment of open distal tibia fracture: using lateral MIPO.

BACKGROUND: To evaluate the radiological, clinical results in patients with open distal tibia factures, who were treated with a staged treatment protocol using the lateral minimally invasive plate osteosynthesis (MIPO) technique. METHODS: From January 2007 to June 2009, 10 patients with open distal tibia fractures (Gustilo-Anderson classification II, 3; IIIA, 1; IIIB, 6) were treated using a staged treatment protocol. The initial debridement and application of an external fixator were performed within 24 hours and the mean interval from injury to definitive surgical treatment was 15 days (range, 6 to 52 days). Eight weeks later, an additional bone graft was performed in 3 patients. The follow-up duration was more than 1 year. RESULTS: The mean fracture healing time was 21 weeks (range, 17 to 28 weeks), and the average Iowa ankle rating score was 84.5 points. At the last follow-up, there was no non-union, angular deformity > 5°, shortening > 10 mm or infection. In 10 patients, 2 patients had a superficial wound infection, and another 2 patients showed limitation of ankle joint motion. CONCLUSIONS: This staged treatment protocol using a lateral MIPO technique is a useful alternative method for achieving high functional recovery with good healing and low complication rates in patients with an open distal tibia fracture.

Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures.

INTRODUCTION: Although ipsilateral femoral shaft and neck fractures are difficult to treat, there is still no consensus on the optimal treatment of this complex injury. We report the results of treating the 17 fractures with a standard protocol of retrograde nailing for diaphyseal fractures and subsequent screw fixation for the femoral neck fractures. MATERIALS AND METHODS: Seventeen injuries (16 patients) sustained femoral shaft fractures, which were treated with retrograde intramedullary nails and subsequent screw fixation. Femoral neck fracture was noted before the operation in all patients except one. A femoral shaft fracture was always addressed first with unreamed retrograde nailing. Then, the femoral neck fracture was treated by cannulated screws or dynamic hip screw according to the level of fracture. RESULTS: The average time for union of femoral shaft fractures was 27.3 (14-60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of femoral neck fractures was 11 (8-12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman-Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. CONCLUSION: Retrograde nailing of femoral shaft fractures can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.