Comparison of conjoined tendon-preserving posterior approach and conventional posterolateral approach in hemiarthroplasty for femoral neck fracture in the elderly: A multicenter (TRON group) retrospective study.

BACKGROUND: Femoral neck fractures (FNF) are one of the most common traumatic injuries in the elderly. The conjoined tendon-preserving posterior (CPP) approach was developed as a modification of the conventional posterolateral (PL) approach in hemiarthroplasty (HA) for displaced femoral neck fractures (FNF) to reduce postoperative dislocation. We hypothesized that the CPP approach would result in fewer dislocations and similar functional and radiographic outcomes compared to the PL approach. PATIENTS AND METHODS: This was a retrospective multicenter (TRON group) study. We evaluated the rate of complications, and functional and radiographic outcomes for patients aged >65 years who underwent HA via the PL approach or the CPP approach from 2017 to 2019 and followed up for at least 24 months. To adjust for baseline differences between the groups, a propensity score-matching algorithm was used in a 1:1 ratio. RESULTS: We identified 135 patients who underwent HA via the PL approach and 135 patients via the CPP approach. The mean follow-up period was 32.4 ± 14.0 months. The incidence of dislocation was 6 in 135 patients (4.4%) in the PL group and 0 in 135 patients (0%) in the CPP group, and there was significant difference (p = 0.04). Operation time was equivalent between the two groups (73.1 ± 30.4 vs. 71.8 ± 30.0 min; p = 0.72). The rate of varus insertion of stems in the PL group lower than that in the CPP group (19.3% vs. 33.3%; p = 0.01). Postoperative Parker's mobility score was similar between the two groups at 12 months follow-up (6.17 vs. 6.27; p = 0.81). CONCLUSION: The CPP approach showed a significantly lower dislocation rate, similar functional outcome and more varus stem insertions compared with the PL approach in this retrospective study.

Comparing clinical and aesthetic outcomes of cross-finger and homodigital reverse digital artery island flap for fingertip injuries: A single-center retrospective cohort study.

BACKGROUND: Reverse homodigital artery island flap (RHDI) has been reported to have some postoperative complications. Cross-finger reverse digital artery island flap (CRDI), which is harvested from an adjacent intact finger, has been used to decrease these complications. This study aimed to provide a review of the CRDI procedure and compare the clinical outcomes of CRDI with those of RHDI. METHODS: RHDI has been performed for fingertip amputations with deficit of 1.5-2.5 cm before 2018, and CRDI has been performed since 2018. We assessed the functional and aesthetic outcomes, including finger length, nail deformity, finger motion, and Hand20 scores at the final follow-up. RESULTS: We identified 22 patients who underwent RHDI and 10 patients who underwent CRDI. The mean follow-up period was 10.3 ± 5.3 months. The median time required for wound healing were 47.0 days (IQR: 34.3-55.8 days) and 34.5 days (IQR: 29.3-44.3 days) in RHDI and CRDI, respectively. The hook nail deformity occurred significantly more frequently in RHDI compared to that in CRDI (40.9% vs. 0.0%, p = 0.03). Flexion contracture of the proximal interphalangeal joint greater than 15º was found to be significantly more in RHDI than in CRDI (36.4% vs. 0.0%, p = 0.04). The median postoperative total active motion of the donor site in CRDI was 278º (IQR: 260-280º). The median postoperative Hand20 scores were similar between the two groups. CONCLUSION: CRDI was associated with superior clinical outcomes in terms of lower rates of postoperative flexion contracture and hook nail deformity, potentially making it a better option compared to RHDI.

Locked Tension Band Wiring: A Modified Technique for Olecranon Fractures-A Multicenter Study Comparing Clinical Outcomes and Complications with Conventional Methods.

Purpose: Tension band wiring is the standard treatment for olecranon fractures, but it is associated with high rate of implant-related complication. To reduce this high complication rate, we developed a modified technique, locked tension band wiring (LTBW). The aim of this study was to investigate whether LTBW reduces complication and reoperation rates compared to conventional methods (CTBW). Methods: We identified 213 olecranon fractures treated with tension band wiring: 183 were treated with CTBW, and 30 were treated with LTBW, and patients in each group were selected using propensity score matching. We evaluated operation time, intraoperative bleeding, complication and reoperation rates, the amount of Kirschner's wire (K-wire) back-out, and Mayo Elbow Performance Index (MEPI). Complications included nonunion, loss of fracture reduction, implant failure, infection, neurological impairment, heterotopic ossification, and implant irritation. Implant removal included at the patient's request with no symptoms. Results: We finally investigated 29 patients in both groups. The mean operation time was significantly longer in the LTBW (106.7 ± 17.5 vs. 79.7 ± 21.1 min; p < 0.01). Complication rates were significantly lower in the LTBW than the CTBW group (10.3 vs. 37.9%; p = 0.03). The rate of implant irritation was more frequent in the CTBW, but there was no significant difference (3.4 vs. 20.7%; p = 0.10). Removal rate was significantly lower in the LTBW (41.4 vs. 72.4%; p = 0.03). The mean amount of K-wire backout at last follow-up was significantly less in the LTBW (3.79 ± 0.65 mm vs. 8.97 ± 3.54 mm; p < 0.01). There were no significant differences in mean MEPI at all follow-up periods (77.4 ± 9.0 vs. 71.5 ± 14.0; p = 0.07, 87.4 ± 7.2 vs. 85.2 ± 10.3; p = 0.40, 94.6 ± 5.8 vs. 90.4 ± 9.0; p = 0.06, respectively). Conclusion: Our modified TBW significantly increased operation time compared to conventional method, but reduced the complication and removal rate and had equivalent functional outcomes in this retrospective study.

The Results of Hook Plate Fixation for Palmar Fracture Dislocation of the Proximal Interphalangeal Joint.

PURPOSE: This study aimed to present the clinical outcomes of the dorsal plating technique for palmar fracture dislocations of the proximal interphalangeal (PIP) joint. This plating technique minimizes dissection and interference with the finger extensor mechanism. METHODS: We treated seven patients (with a mean age of 39.1 years) with dorsal hook plates for palmar fracture dislocations of the PIP joint between April 2018 and August 2022. The little finger was affected in five patients, and ring finger was affected in two. The mean time to surgery was 5.6 days, and the postoperative follow-up period was seven months. On the second postoperative day, all patients were allowed active motion of both the PIP and the distal interphalangeal (DIP) joints. Simultaneously, DIP blocking exercises were started to prevent adhesion of the extensor mechanism. RESULTS: The mean active flexion and extension of the PIP joint was 105° and -4°, respectively, whereas those of the DIP joint were 65° and 4°. No patient experienced extension lag in the DIP joint. The mean total active motion (TAM) was 273°, and the %TAM was 96%. The grip strength of the affected hand averaged 90% of that of the unaffected hand. The mean numerical rating scale for pain was 0.3 points, and the mean Hand20 score was 5.1 points. No complications were observed; two patients underwent implant removal at their request. CONCLUSIONS: The present study suggests that this hook plate technique, which minimizes interference with the finger extension mechanism, is an effective surgical procedure that allows patients to tolerate early range of motion exercises and obtain satisfactory clinical outcomes in both the PIP and DIP joints. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Comparing Clinical and Aesthetic Outcomes of Digital Artery Flap using Nail Bed Graft for Fingertip Amputation with Replantation.

BACKGROUND: Digital artery flap (DAF) with nail bed graft is a simple method to preserve finger length for fingertip amputations. This study compared the clinical and aesthetic outcomes between replantation and DAF. METHODS: Patients who underwent replantation or DAF for a single fingertip amputation (Ishikawa's subzone II or III) at our hospital from 2013 to 2021 were retrospectively evaluated. The aesthetic and functional outcomes were finger length and nail deformity at the final follow-up, total active motion, grip strength, Semmes-Weinstein monofilament test (S-W), fingertip injuries outcome score (FIOS), and Hand20 scores. RESULTS: Overall, for 74 analyzed cases (40, replantation; 34, DAF), the median operation time and the median length of hospital stay in replantation was longer than that in DAF (188 vs. 126 min, p<0.01; 15 vs. 4 days, p<0.01). The success rates of replantation and DAF were 82.5% and 94.1%, respectively. The rate of finger shortening in replantation was significantly lower than that in DAF (42.5% vs. 82.4%; p<0.01). There were fewer nail deformities in replantation than in DAF (45.0% vs. 67.6%, p=0.06). The proportion of patients who achieved excellent or good FIOS and the median Hand20 scores was not significantly different between the groups (89.5% vs. 85.3%, p=0.61; 8.0 vs. 13.5, p=0.42). The median postoperative S-W values were similar between the groups (3.61 vs. 3.61, p=0.23). CONCLUSIONS: In this retrospective study, DAF for fingertip amputations achieved equivalent postoperative functional outcomes and shorter intraoperative time and hospital stay, but worse aesthetic appearance compared with replantation.

Limiting Levels of Fingertip Replantation Without Venous Anastomosis.

PURPOSE: This study aimed to compare the success rates of fingertip replantation with and without venous anastomosis. METHODS: This retrospective study included 132 patients with 148 fingertip injuries who had undergone fingertip replantation (Ishikawa's classification I‒IV) between 2003 and 2020 at our hospital. Among them, 117 and 15 were men and women respectively, and their mean age was 43 years. There were 53, 44, and 51 fingertips with Ishikawa subzone II, III, and IV amputations respectively, and no cases were classified as Ishikawa subzone I. Venous anastomosis was performed on 64 fingertips (group A). This was not possible in the remaining 84 fingertips; thus, an external bleeding method was used (group B). Our external bleeding protocol consisted of 4-hourly skin pricks of the distal pulp with a 23-gauge needle for the first 5 days. The analyses included survival rates, hemoglobin levels (Hb), and blood transfusions administered. RESULTS: The overall survival rate was 90.5% (134 of 148). In group A, survival was achieved in 92.3%, 100%, and 94.3% of those with subzones II, III, and IV amputations, respectively. In group B, survival was achieved in 100%, 82.1%, and 62.5% of those with subzones II, III, and IV, respectively. Subzone IV in group B showed a significantly lower rate of replantation success. In groups A and B, the preoperative and 7-day postoperative Hb levels were 14.5 g/dL and 14.6 g/dL, and 11.3 g/dL, and 11.6 g/dL, respectively. In addition, blood transfusion was required for five patients (7.9%) in group A and six patients (7.9%) in group B. Thus, the Hb levels and blood transfusion administered were similar between the two groups. CONCLUSIONS: Subzone IV is an important threshold for artery-only replantation. Furthermore, our external bleeding protocol is a safe and effective method. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Locked Tension Band Wiring for Mayo IIA Olecranon Fractures: Modified Surgical Technique and Retrospective Comparative Study of Clinical Outcomes and Cost-effectiveness with Locking Plate.

Background: Tension band wiring (TBW) has traditionally been used for simple olecranon fractures, but due to its many complications, locking plate (LP) is increasingly being employed. To reduce the complications, we developed a modified technique for olecranon fracture repair, locked TBW (LTBW). The study aimed to compare (1) the frequency of complications and re-operations between LP and LTBW techniques, (2) clinical outcomes and the cost efficacy. Methods: We retrospectively evaluated data of 336 patients who underwent surgical treatment for simple and displaced olecranon fractures (Mayo Type ⅡA) in the hospitals of a trauma research group. We excluded open fractures and polytrauma. We investigated complication and re-operation rates as primary outcomes. As secondary outcomes, Mayo Elbow Performance Index (MEPI) and the total cost, including surgery, outpatients and re-operation, were examined between the two groups. Results: We identified 34 patients in the LP group and 29 patients in the LTBW group. The mean follow-up period was 14.2 ± 3.9 months. The complication rate in the LTBW group was comparable to that in the LP group (10.3% vs. 17.6%; p = 0.49). Re-operation and removal rates were not significantly different between the groups (6.9% vs. 8.8%; p = 1.000 and 41.4% vs. 58.8%; p = 1.00, respectively). Mean MEPI at 3 months was significantly lower in the LTBW group (69.7 vs. 82.6; p < 0.01), but mean MEPI at 6 and 12 months were not significantly different (90.6 vs. 85.2; p = 0.06, 93.9 vs. 95.2; p = 0.51, respectively). The mean cost/patient of the total cost in the LTBW group were significantly lower than those in the LP group ($5,249 vs. $6,138; p < 0.001). Conclusions: This study showed that LTBW achieved clinical outcomes equivalent to those of LP and was significantly more cost effective than LP in the retrospective cohort. Level of Evidence: Level III (Therapeutic).

Are the Clinical Results of Locking Plate Fixation for Distal Radius Fractures Inferior in Patients over 80 Years of Age? A Multicentre (TRON Group) Study.

Introduction: With the aging of the population, the proportion of distal radius fracture patients who are > 80 years of age is increasing. In this study, we compared the postoperative clinical and radiographic outcomes between super-elderly patients (age: ≥ 80 years) and middle-elderly (age: 65-79 years) who were treated with volar locking plate (VLP) fixation for distal radius fractures. Patients and Methods: Patients of > 65 years of age with distal radius fractures treated by VLP fixation between 2015 and 2019, and who were followed for at least 6 months after surgery were included in our database (named TRON). Patients with open fractures, multiple-trauma, or who received fixation with implants other than a VLP were excluded. We evaluated postoperative complications, Mayo wrist score (MWS), and radiographic outcomes. Results: We identified 589 patients in this study; 452 were 65-79 years of age (Group A) and 137 were ≥ 80 years of age (Group B). After propensity score matching, we evaluated 309 patients in Group A and 103 patients in Group B. The mean follow-up period was 10.7 ± 4.6 months. Twenty-eight patients (9.1%) in Group A and 5 patients in Group B (4.9%) experienced post-operative complications (non-significant: p = 0.212). The postoperative MWS at 1, 3, and 6 months, respectively, was 65.4 ± 11.7, 75.2 ± 11.0, and 79.6 ± 10.5 in Group A and 67.1 ± 9.61, 75.7 ± 10.7, and 80.6 ± 9.7 in Group B (non-significant: p = 0.418, 0.893, 0.452, respectively). The differences in volar tilt, radial inclination, ulnar variance between the postoperative and last follow-up radiographs did not differ between the two groups to a statistically significant extent (p = 0.053, 0.437, 0.529, respectively). Conclusion: Our study showed that the clinical and radiographic outcomes of distal radius fractures treated with VLP in super-elderly patients were comparable to those in middle-elderly patients.

Low body mass index is a risk factor for increased post-operative mortality and poor functional improvement in distal femur fractures among patients aged over 65: A multicentre (TRON) study.

BACKGROUND: Distal femur fractures have been reported to have a mortality rate comparable to hip fractures, but the risk is still unknown. Recent studies have reported that low body mass index (BMI) is a risk factor for mortality in the elderly. We investigated the efficacy of low BMI for predicting the risk of mortality in distal femur fractures in patients aged over 65 within 18 months after injury and its impact on postoperative clinical outcomes and mortality. METHODS: Data from patients followed for more than six months were obtained from our trauma research group's database. We investigated risk factors for increased mortality using Cox proportional hazards models. We divided the analysed cases into low (<18.5 kg/m2) and high (>18.5 kg/m2) BMI groups. We adjusted the background characteristics of the groups by patient matching, and evaluated the postoperative mortality, complication rate, and knee society score (KSS). RESULTS: We identified 216 patients, including 58 (26.9%) with low BMI values. Low BMI was an independent risk factor for mortality in all models (Hazard Ratio: 2.9, p = 0.011). The overall survival rate of the low BMI group at 18 months was significantly lower than that of the high BMI group (70.7% vs. 89.1%; p = 0.003). The complication rates of the low BMI and high BMI groups were not significantly different (33.3% vs. 22.2%; p = 0.283). The mean KSS values at 3, 6, and 12 months in the low BMI group was significantly worse than that in the high BMI group (78.7 ± 16.2 vs. 84.8 ± 13.1; p = 0.035, 82.2 ± 16.9 vs. 89.7 ± 8.9; p = 0.005, 86.4 ± 13.0 vs. 91.4 ± 8.4; p = 0.020, respectively). CONCLUSIONS: Our study indicated that low BMI was independent associated with increased mortality and impaired postoperative functional recovery in distal femur fractures of the elderly patients.

Total Hip Arthroplasty With Impacted Bone Graft on Acetabulum for Osteoporotic Acetabular Fractures: A Report of 3 Cases.

Osteoporotic acetabular fractures in elderly patients have recently been increasing, but the best treatment remains uncertain due to the difficulty in stabilizing these fractures with osteosynthesis. We performed total hip arthroplasty with an impacted bone graft on the acetabula of 3 elderly patients with comminuted acetabular fractures after confirming acetabular callus formation via radiographic imaging 2 months following the patients' initial injuries. Two of the patients presented in the subacute phase after conservative treatment, and 1 patient had no history of trauma or quadrilateral surface destruction. Two patients achieved good functional results at the 3-year follow-up. Furthermore, no loosening of the prosthesis components or subsidence of the acetabular cemented cup was evident on radiographic imaging in any of the patients.

Early weight bearing versus late weight bearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: A multicenter propensity-matched study.

BACKGROUND: This study aimed to assess differences in implant failure and bone union rates, amount of change in alignment of lower extremities, and walking ability between early weight-bearing (EWB) and late weight-bearing (LWB) groups following retrograde intramedullary nailing (RIMN) for distal femoral fracture (AO/OTA 33) (DFF) at multiple centers using propensity score matching. METHODS: The data of 213 patients who underwent RIMN from 2012 to 2019 in multiple tertiary hospitals were extracted from our database. Cases with the following factors were excluded: age <60, open fracture, AO/OTA-type 33-C3 fracture, preoperative New Mobility Score (NMS) < 3, postoperative follow-up <3 months, and unknown weight-bearing start time. Eighty-four patients were divided into the EWB and LWB groups. EWB group patients were encouraged to perform partial weight-bearing walking at ≤4 weeks after surgery. LWB group patients were not allowed weight bearing for >4 weeks after surgery. After propensity score matching was applied, 26 cases remained in each group. RESULTS: There were no cases of nail failure in either the EWB group or LWB group (P = 1). Screw failure occurred in 0 cases in the EWB group and in 1 case (4.5%) in the LWB group (P = 1.0). Non-union occurred in 5 patients (19.2%) in the EWB group and 4 patients (15.3%) in the LWB group (P = 1). The mean amount of change in lower extremities alignment did not differ between the two groups. The median Knee Society Score was 95.5 (59-100) vs. 93 (72-100) points (P = 0.39). The median NMS was 7 (0-9) vs. 7 (4-9) points (P = 0.82). CONCLUSIONS: There were no significant intergroup differences in the rates of implant failure, bone union at one year after surgery, amount of change in lower extremities alignment, or walking ability. We suggest that early weight bearing after RIMN for DFF may not be harmful in elderly people.

How does intraoperative fracture malalignment affect postoperative function and bone healing following distal femoral fracture? : a retrospective multicentre study.

AIMS: Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes. METHODS: In total, 140 patients were retrospectively identified from data obtained from a database of hospitals participating in a trauma research group. We divided them into two groups according to coronal plane malalignment of more than 5°: 108 had satisfactory fracture alignment (< 5°, group S), and 32 had unsatisfactory alignment (> 5°, group U). Patient characteristics and injury-related factors were recorded. We compared the rates of nonunion, implant failure, and reoperation as healing outcomes and Knee Society Score (KSS) at three, six, and 12 months as functional outcomes. We also performed a sub-analysis to assess the effect of fracture malalignment by plates and nails on postoperative outcomes. RESULTS: The rates of nonunion and reoperation in group U were worse than those in group S (25.0% vs 14.3%; 15.6% vs 5.6%), but the differences were not significant (p = 0.180 and p = 0.126, respectively). Mean KSS in group U at all follow-up periods was significantly worse that in group S (75.7 (SD 18.8) vs 86.0 (SD 8.7); p < 0.001; 78.9 (SD 17.2) vs 89.1 (SD 9.8); p < 0.001; 85.0 (SD 11.9) vs 91.1 (SD 7.2); p = 0.002, respectively). In the sub-analysis of plates, mean KSS was significantly worse in group U at three and six months. In the sub-analysis of nails, the rate of reoperation was significantly higher in group U (28.6% vs 5.8%; p = 0.025), and mean KSS at six and 12 months was significantly worse in Group U. CONCLUSION: To obtain good postoperative functional results, intraoperative alignment of the coronal plane should be accurately restored to less than 5°. Cite this article: Bone Jt Open 2022;3(2):165-172.

Predictive factors for mortality after distal femoral fractures in the elderly: A retrospective multicenter (TRON group) study.

PURPOSE: This retrospective multicenter study aimed to assess the 1-year mortality rate in elderly patients with distal femoral fractures (DFFs) and identify potential risk factors for mortality. METHODS: We analyzed 321 patients aged 65 years and older with DFFs treated surgically between 2012 and 2019 in 13 hospitals. Patient demographics and surgical characteristics were extracted from medical records and radiographs. We used univariable and multivariable Cox regression analyses to identify the factors affecting mortality. RESULTS: The mortality rate for DFFs in elderly patients at 1 year was 9.0%. Multivariable Cox regression analysis revealed older age, male sex, underweight (body mass index [BMI] <18.5 kg/m2), bedridden status, and nursing home residency to be independent predictors for mortality (older age: hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.03-1.11, P<0.001; male sex: HR 3.08, 95% CI 1.23-7.71, P=0.015; underweight: HR 1.93, 95% CI 1.01-3.68, P=0.045; bedridden status: HR 4.59, 95% CI 1.61-13.07, P=0.0042; and nursing home residency: HR 2.63, 95% CI 1.18-5.83, P=0.017). None of the factors associated with surgery including types of fixation, time from initial visit to surgery, blood loss during operation, and operation time was an independent predictor for mortality. CONCLUSION: The 1-year mortality rate in elderly patients with DFFs was relatively low at 9.0%. Older age, lower BMI, and nursing home residency were associated with mortality after surgery for DFFs. Factors associated with the surgical procedure were not significant predictors.

Ulnar Parametacarpal Flap for Small Finger Avulsion Injury.

In difficult cases of replantation following small finger avulsion injury, in which amputation occurs at the proximal interphalangeal joint, the ulnar parametacarpal island flap, rotated 180° (propeller flap), can be used as an alternative method for covering a skin defect of the proximal phalanx. This flap can prevent metacarpophalangeal joint dysfunction and additional finger shortening. We propose the use of an ulnar parametacarpal flap for this purpose and report the outcomes of two successful cases treated with this method and followed up for 12 months.