Posterior-only fixation in pelvic fractures: Is it sufficient in lateral compression injuries?

PURPOSE: Lateral compression (LC) injuries account for more than two-thirds of all pelvic fractures. The goal of surgical treatment is to provide adequate stability and early mobilization. The consensus on posterior fixation of such injuries is strong in the literature; however, the necessity of anterior ring fixation is not clear. Therefore, this study was formulated to determine the practicability of posterior-only fixation in LC injuries. METHODS: Between March 2015 and May 2020, all patients with LC type pelvic ring fractures who were admitted and operated upon in a single level 1 trauma center were included in this cross-sectional observational study. Demographic data, co-morbidities, treatment, types of surgical fixation, concomitant injuries and surgeries, surgical complications, length of hospital stay, injury to weight bearing duration, and follow-up period were documented. Functional outcome and quality of life were assessed using Majeed score and SF-36 questionnaire. Non-normally distributed data were presented as median (Q1, Q3) and normally distributed data were presented as mean ± SD. Spearman's rank correlation coefficient was used for correlation analysis. RESULTS: A total of 25 patients were included, with a mean age of 29.8 years. All patients were managed operatively with posterior-only fixation. The median Majeed score was 90 (76, 95). The median physical component summary score was 69.37 (38.75, 85.62). The median mental component summary score was 63.95 (39.25, 87.87). There was no significant difference compared to population norms of both physical component summary and mental component summary. Injury to weight bearing time correlated significantly (p = 0.002) with Majeed score as well as SF-36 score (p = 0.044). No other variable had a significant association with outcomes. CONCLUSION: Posterior-only fixation is sufficient for fixing LC injuries with up to 80% of cases having good to excellent functional outcomes. However, comparative studies with larger sample sizes are needed for further validation.

A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: a systematic review and meta-analysis.

PURPOSE: A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar. METHODS: An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1. RESULTS: A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis. CONCLUSION: This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.

Core decompression combined with intralesional autologous bone marrow derived cell therapies for osteonecrosis of the femoral head in adults: A systematic review and meta-analysis.

BACKGROUND: Core decompression (CD) is beneficial in the early stage of osteonecrosis of the femoral head (ONFH). Adjunctive bone marrow derived cell therapies (BMDCT) have been advocated which potentially aid the regenerative process. QUESTION/PURPOSE: This study was conducted to determine potential benefit of CD + BMDCT in ONFH, in terms of disease progression, conversion to arthroplasty (primary outcomes), and functional outcomes and complication rates (secondary outcomes). METHODS: A systematic review of literature was performed on 3 databases. Studies reporting CD + BMDCT (intralesional instillation) in ONFH, with a minimum follow up of 1 year and reporting the pre-defined outcome measures were included in the review. Meta-analysis consisted of two different arms: a comparative arm, to compare CD + BMDCT to CD alone, and a non-comparative meta-analysis arm, to determine pooled rates of disease progression, conversion to arthroplasty and complication rates. RESULTS: A total of 18 studies were included in the systematic review. CD + BMDCT had lower rates of disease progression (OR 0.19 [95% CI, 0.09, 0.40]) and conversion to arthroplasty (OR 0.20 [95% CI, 0.11, 0.40]) as compared to CD alone. Functional score (MD = -7.07 [95% CI, -12.28, -1.86]) and visual analog scale also showed better improvement with the use of CD + BMAC (MD = -10.39 [95% CI, -12.87, -7.90]). Increasing age and post-collapse stage at presentation were noted to have an adverse effect on the outcomes. CONCLUSION: CD + BMDCT was found to decrease disease progression and conversion to arthroplasty, and was noted to have better functional outcome scores as compared to CD alone.

Ilioinguinal versus modified Stoppa approach for open reduction and internal fixation of displaced acetabular fractures: a systematic review and meta-analysis of 717 patients across ten studies.

BACKGROUND: Acetabulum fracture is one of the most challenging fractures to manage and operate for orthopaedic surgeons; anatomical reduction of fractures and reconstruction of the joint is of utmost importance. These factors in turn are dependent on the appropriate surgical approach used to improve the clinical outcomes and reduce associated complications. Hence, this meta-analysis aims to compare the outcomes of ilioinguinal versus modified Stoppa approach for open reduction and internal fixation (ORIF) of displaced acetabular fractures. METHODS: Medline (PubMed), Embase, Scopus, and Cochrane Library databases were searched from their inception to 10th of June 2021 for both randomized clinical trials (RCTs) and or non-randomized studies comparing the outcomes of ilioinguinal approach and modified Stoppa approach for the ORIF of acetabular fractures. The estimates of treatment effects were described by mean difference (MD) for continuous variables and odds ratio (OR) for dichotomous variables with corresponding 95% confidence (95% CI) intervals. The risk of bias was assessed by MINORS tool for the non-randomized, and the Cochrane Collaboration's risk of bias tool for RCTs. RESULT: A total of ten studies (717 patients), three RCTs and seven retrospective studies, were included. Modified Stoppa approach showed shorter mean duration of surgery (MD 47.13, 95% CI: 27.30-66.96), lesser number of overall complications (OR 2.14, 95% CI: 1.46-3.13), less intraoperative blood loss (MD 259.65, 95% CI: 152.66-366.64), and lower rates of infection (OR 2.17, 95% CI: 1.14-4.15). However, ilioinguinal approach showed a better quality of fracture reduction (OR 0.59, 95% CI: 0.42-0.82). Results were equivocal in terms of vascular injuries (OR 1.88 (95% CI: 0.86-4.09), nerve injuries (OR 1.77, 95% CI: 0.99-3.17), heterotopic ossification (OR1.74, 95% CI: 0.63-4.82), and clinical outcome (OR 0.81, 95% CI: 0.45-1.47) between the two groups. CONCLUSION: Modified Stoppa approach carries a lesser duration of surgery, lesser intraoperative blood loss, fewer overall complications, and lesser postoperative infection rates compared to ilioinguinal approach. Although a better anatomical reduction is achieved by ilioinguinal approach, however, this does not translate into better clinic functional outcomes which remain comparable between the two approaches. So overall, modified Stoppa approach seems a better alternative for managing these fractures.

Complications and mid to long term outcomes for hip resurfacing versus total hip replacement: a systematic review and meta-analysis.

INTRODUCTION: The long-term results of total hip replacement (THR) are excellent; however, it has higher failure rates in young and active patients. Hip resurfacing arthroplasty (HRA) is an alternative in such patients and gaining popularity. This review was done to compare complications and outcomes between HRA and THA by assessing the latest level 1 studies comparing the two from the past 10 years. METHOD: A systematic review and meta-analysis was conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the complications between THR and HRA in medium to long term follow up. The primary outcome of interest included the complication and revision rate between the two techniques. Functional outcomes and ionic levels at follow up were also compared as secondary outcomes. Risk of bias assessment was done using the Cochrane risk of bias tool. RESULT: The present review included 6 level 1 studies. These included 308 THR and 304 HRA. On meta-analysis, overall complications rates were significantly lower in HRA compared to the THA group with an Odds ratio (OR) of 2.17 (95% CI 1.21, 3.88; p = 0.009). No difference was seen between the two groups in terms of revision rate (OR 1.06 95% CI 0.57, 1.99; p = 0.85). Functional outcomes in both the groups were satisfactory but the Harris Hip Score was found to be significantly better in the resurfacing group (MD 2.99 95% CI - 4.01, - 1.96, p < 0.00001). There were increased cobalt and chromium ions in the resurfacing group but no detrimental effect was seen in terms of reported poisoning. CONCLUSION: Despite similar function and revision rates, HRA was seen to have lesser associated complications and ionic levels may not be a detrimental issue. Hip resurfacing provides relative ease during revisions, especially in younger patients and it may be an alternative to THR in the younger population.

Artificial intelligence and synthetic biology approaches for human gut microbiome.

The gut microbiome comprises a variety of microorganisms whose genes encode proteins to carry out crucial metabolic functions that are responsible for the majority of health-related issues in human beings. The advent of the technological revolution in artificial intelligence (AI) assisted synthetic biology (SB) approaches will play a vital role in the modulating the therapeutic and nutritive potential of probiotics. This can turn human gut as a reservoir of beneficial bacterial colonies having an immense role in immunity, digestion, brain function, and other health benefits. Hence, in the present review, we have discussed the role of several gene editing tools and approaches in synthetic biology that have equipped us with novel tools like Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR-Cas) systems to precisely engineer probiotics for diagnostic, therapeutic and nutritive value. A brief discussion over the AI techniques to understand the metagenomic data from the healthy and diseased gut microbiome is also presented. Further, the role of AI in potentially impacting the pace of developments in SB and its current challenges is also discussed. The review also describes the health benefits conferred by engineered microbes through the production of biochemicals, nutraceuticals, drugs or biotherapeutics molecules etc. Finally, the review concludes with the challenges and regulatory concerns in adopting synthetic biology engineered microbes for clinical applications. Thus, the review presents a synergistic approach of AI and SB toward human gut microbiome for better health which will provide interesting clues to researchers working in the area of rapidly evolving food and nutrition science.

Long-term survival of CLS Spotorno femoral stem: a systematic review of literature.

BACKGROUND: CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems. RESEARCH QUESTION: Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes? METHODOLOGY: Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done. RESULTS: All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3-27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08-91.23, p < 0.01). The improvement in scores from preoperative values (of 43.9 points) were comparable to Corail (43.8) and Exeter (45) stems. Thigh pain was seen in only 41 cases out of 1097 hips. CONCLUSION: Despite the limitations due to high heterogeneity of the cumulative data, the review suggests that CLS Spotorno femoral stems provides excellent long-term survival and good hip function. These outcomes are comparable to other commonly utilized femoral stems like the Corail and Exeter. LEVEL OF EVIDENCE: IV.

Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis.

INTRODUCTION: Unstable intertrochanteric femoral fractures in the elderly require either fixation or joint sacrificing surgery; proximal femoral nail (PFN) and bipolar hemiarthroplasties (BPH) are the most common interventions. PFN is considered to be the ideal construct for these fractures; however, the usage of hemiarthroplasties to facilitate earlier mobilization has been on a rise. Currently there is no consensus on the superiority of one of these two techniques over the other and the present review was done to determine this. RESEARCH QUESTION: Is PFN a better alternative to BPH for unstable intertrochanteric femur fractures in the elderly? OBJECTIVE: The present systematic review and meta-analysis was conducted to determine the superiority of PFN over BPH by comparing the primary outcomes like mortality, Harris Hip scores (HHS), complications, and re-operations. Additionally, secondary outcomes like blood loss, duration of surgery, and period of hospital stays were also compared. METHODOLOGY: Three databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles that directly compared PFN and BPH in unstable intertrochanteric femur fractures in the elderly. RESULTS: We analyzed a total of seven studies published between the years 2005 to 2017. There were four retrospective and three prospective randomized controlled studies. The number of patients in these studies ranged from 53 to 303. PRIMARY OUTCOMES: There was a significant difference in HHS between two groups with standard mean difference of - 0.51 (range - 0.67 to -0.36), favouring the PFN group. The rate of mortality was higher in the BPH group with odds ratio of 2.07 (range 1.40-3.08). Implant-related complications like fractures and subsidence were more in BPH group but this was not significant. SECONDARY OUTCOMES: Mean surgical time (standard mean difference 2.19) and blood loss (3.75) were significantly less in the PFN group. The duration of hospital stay was also found to be significantly less in the PFN group (2.66). CONCLUSION: Proximal femoral nails are superior to bipolar hemiarthroplasties for unstable intertrochanteric femoral fractures in the elderly. PFN imparts better functional outcomes and has lower rates of overall mortality. Additionally it is faster surgery, with lesser blood loss contributing to better results.

Epidemiology of pelvic fractures in adults: Our experience at a tertiary hospital.

PURPOSE: Pelvic fractures are severe injuries and are often associated with multiple system injuries, exacerbating the overall outcome. In India, the incidence of pelvic fractures is on a rise due to suboptimal roads and traffics but related literature regarding the overall epidemiology of these injuries is scarce and scanty. Our aim was to study the epidemiology of patients admitted with pelvic fractures at a level 1 trauma centre in India. METHODS: A 16-month (between September 2015 and December 2016) prospective observational study was carried out on trauma patients with pelvic fractures at a level 1 trauma centre of a tertiary care hospital. Demography of patients, mechanism of injuries and complications were recorded prospectively. RESULTS: We observed 75 patients who presented with pelvic fractures, where 56 were males and 19 were females. Mean age of the study population was 37.57 years. Road traffic accidents were the most common mode of injuries. Lateral compression injuries were the most common pattern. Associated injuries frequently encountered were lower extremities and acetabulum fractures, blunt abdominal trauma, urogenital injuries and head injuries. Out of the 75 patients, 52 were treated surgically and 23 were managed by conservative methods. Associated injuries of the extremities, head, abdomen and urogenital system indicated a longer hospital stay. CONCLUSION: Pelvic fractures, although belong to a relatively rare trauma subset, cause a high morbidity and mortality with considerable burden on the economy. Proper road safety training and driving etiquettes along with its strict implementation in true sense and spirit are the need of the hour.

Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

BACKGROUND: Management of fractures of neck of femur in the elderly is largely joint sacrificing, with hemiarthroplasties being the most common entity used. Cemented and uncemented, both the techniques, are universally accepted; however, the former has been more time tested, despite its theoretical disadvantage in the form of cement embolism leading to intra-operative complications. Uncemented stems have been ever evolving with newer designs to increase incorporation, stability and durability. They have their own reported sets of disadvantages like subsidence and fractures. However, overall there is no established gold standard out of the two. OBJECTIVE: The present systematic review and meta-analysis of current literature was conducted, so as to determine the superiority of one technique over the other by comparing the primary outcomes like hip function, residual pain, local and general complications and mortality. Additionally secondary outcomes like duration of surgery, blood loss and re-operations were analysed as well. METHODOLOGY: Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles of last 10 years that directly compare uncemented and cemented hemiarthroplasties, and based on our inclusion and exclusion criteria, article selection was done. RESULTS: We analysed a total of six randomised controlled studies dated from 2008 to 2017. PRIMARY OUTCOMES: There was a significant difference in post-operative ability to ambulate at 1 year, between 2 groups with odds ratio 0.45 (95% CI 0.29-0.67, p = 0.0001) favouring cemented hemiarthroplasty. Prosthesis-related complications like fractures and subsidence and general complications like lung complications were more in uncemented group. Mortality at 1 year was more in cemented group. SECONDARY OUTCOMES: Mean surgical time was lesser in uncemented cases. There was no difference in blood loss and re-operation rates. CONCLUSION: Cementing techniques are here to stay, until a better, durable and more stable uncemented stem evolves, that could lessen the complications related to uncemented surgeries and match the cemented implants in pain relief and ambulation.

Correction to: Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

The original version of this article unfortunately contained a mistake. The correct information is given below. In abstract, the last sentence of the "Primary outcomes" section should read as: Mortality at 1 year was the same in both the groups.

Quality of life following total hip arthroplasty in patients with acetabular fractures, previously managed by open reduction and internal fixation.

PURPOSE: Total hip replacement (THR) is one of the most successful and cost-effective surgical procedures and remains the treatment of choice for long-term pain relief and restoration of function for patients with diseased or damaged hips. Acetabular fractures managed either conservatively or operatively by fixation tend to present later with secondary joint changes that require THR. In this study we evaluated the functional outcome and quality of life achieved by such patients. METHODS: Our study was carried out as a retrospective trial by recruiting patients who underwent THR from June 2006 to May 2012. A total of 32 patients were included with a mean age of 46.08 years ranging from (25-65) years. We evaluated the quality of life in the patients using scoring techniques of Short Musculoskeletal Functional Assessment (SMFA) and the 12-Item Short Form Health Survey (SF-12). Functional outcome was assessed using Harris Hip Score (HHS). RESULTS: The mean HHS of the patients was 84.3 with a range from 56 to 100. The SMFA averaged 13.3. The SF-12 score averaged 49.1. The correlation of the HHS with SF-12 was positive (p =0.001) while with SMFA there was a negative correlation (p =0.001). CONCLUSION: From this study it is inferred that the functional outcome of THR and quality of life in patients who had acetabular fractures and were initially managed by open reduction and internal fixation is good.

Microfluidic Point-of-Care Diagnostics for Multi-Disease Detection Using Optical Techniques: A Review.

The lifestyle of modern society is a major contributing factor for the majority of patients suffering from more than one disease. To Screen and diagnose each of those diseases, there is a great need for portable, and economical diagnostic tools, which are highly stipulated to yield rapid and accurate results using a small volume of the samples such as blood, saliva, sweat, etc. Point-of-care Testing (POCT) is one of the approaches to harvest prompt diagnosis of numerous diseases. The Majority of Point-of-Care Devices (POCD) are developed to diagnose one disease within the specimen. On the other hand, multi-disease detection capabilities in the same point-of-care devices are considered to be an efficient candidate to execute the state-of-the-art platform for multi-disease detection. Most of the literature reviews in this field focus on Point-of-Care (POC) devices, their underlying principles of operation, and their potential applications. It is evident from a perusal of the scholarly works that no review articles have been written on multi-disease detection POC devices. A review study analyzing the current level and functionality of multi-disease detection POC devices would be of great use to future researchers and device manufacturers. This review paper is addressing the above gap by focusing on various optical techniques like fluorescence, Absorbance, and Surface Plasmon Resonance (SPR) for multi-disease detection by harnessing the microfluidic-based POC device.

Irreducible Complex Posterior Elbow Dislocation with Varus Posteromedial Rotary Instability - A Case Report.

Introduction: Elbow dislocations, particularly those associated with varus posteromedial rotary instability, are relatively uncommon. We present the case of a 25-year-old male initially managed nonoperatively for a posterior elbow dislocation, who subsequently experienced irreducible re-dislocation with characteristic fractures of the anteromedial facet and tip of the coronoid, indicative of varus posteromedial rotary instability. Case Report: Following an unsuccessful attempt at closed reduction under general anesthesia, open reduction was performed, revealing the interposition of the posterior capsule of the humero-ulnar joint as the cause of irreducibility. Fixation of the coronoid fracture was undertaken, and the patient exhibited excellent functional outcomes at a 4.5-year follow-up. Conclusion: This case underscores the rarity of irreducible elbow dislocation in the context of varus posteromedial rotary instability and highlights the crucial role of capsular interposition in such cases. Successful open reduction, coronoid fixation, and attentive postoperative care contributed to the patient's favorable long-term functional outcome.

Choice of Entry Point Does Not Affect Clinical and Radiological Outcomes in Antegrade Intra-medullary Nailing in Patients with Shaft of Femur Fracture: A Prospective Randomized Controlled Trial.

Purpose: The choice of entry point, Greater trochanter (GT), or Piriformis entry (PE) for antegrade intramedullary nailing (IMN) of the femur is crucial. This study was performed to compare these two entry points in the patients with shaft of femur fractures regarding intra-operative parameters, radiological and functional outcomes. Materials and Methods: Twenty-four patients underwent GT entry nailing, while 25 patients underwent PE nailing. Surgical time, Intra-operative blood units transfused, Intra-operative fluoroscopy exposure by number of C-arm shots taken, mean drop in hemoglobin, and incidence of iatrogenic fracture were recorded. Patients were followed up at 4 weeks, 6 weeks, and 6 months to look for radiological healing and improvements in functional outcome using Modified Harris Hip Score (MHHS). MRI of bilateral hips with pelvis was done in 25 patients at 6 months of follow-up to detect any preliminary signs of AVN. Results: The mean drop in hemoglobin in the GT group was significantly lesser than the PE group (p = 0.02). Mean MHHS at 4 weeks post-op was also significantly higher in the GT group (p = 0.01). There was no significant difference between both the groups regarding surgical duration, fluoroscopy exposure, radiological and functional outcomes in the long term. None of the patients who underwent MRI displayed any preliminary sign of AVN. Conclusion: GT entry nails lead to lesser surgical time, fluoroscopy exposure, and intra-operative blood loss. Both the nailing systems achieve excellent fracture unions and comparable functional outcomes in the long term, and there is a minuscule risk of AVN in adult patients undergoing IMN.

Femoral neck fracture fixation in rhombic versus inverted triangle configuration in young adults: A systematic review.

Objective: This review evaluated the outcomes of rhombic versus inverted triangle configuration fixation of femoral neck fractures. Methods: Six databases, PubMed, Embase, Scopus, Web of Science, Cochrane Library databases, and China National Knowledge Infrastructure (CNKI), were comprehensibly searched for the comparative studies of two configurations (rhombic versus inverted triangle) of neck femur fracture fixation. Ultimately seven studies were included in this systematic review for qualitative and quantitative analysis. A meta-analysis was performed with the software RevMan 5.4.1. Results: Fewer nonunion (OR 0.46 with 95 % CI 0.23, 0.94; p = 0.03), and early full weight bearing (MD -3.09 with 95 % CI -5.41, -0.77; p = 0.009) were seen in the rhombic than in the inverted configuration; however, a better hip function (MD 3.72 with 95 % CI 0.99, 6.44; p = 0.008), and lesser less blood loss (MD 3.84 with 95 % CI 1.19, 6.49; p = 0.004) during surgery were found in the inverted triangle configuration. There was no difference between the two fixation configurations regarding the duration of surgery, fracture union time, overall complications, femoral neck shortening, length of hospital stay, fluoroscopy times, and incision size. Conclusion: The rhomboid configuration showed fewer non-union, early weight bearing, better hip function and comparable complications rate than the inverted triangle configuration; however, there was more blood loss intraoperatively than inverted triangle configuration. Hence, the addition of a fourth screw in the rhombic configuration have an added advantage over the inverted triangle configuration in femoral neck fracture.