Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates - a propensity score matched retrospective cohort study of 106 patients.

BACKGROUND: Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure. To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs. METHODS: A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs. RESULTS: During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439). CONCLUSION: ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results.

Should nails be locked dynamically or statically in atypical femoral fractures? - A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up.

INTRODUCTION: Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. METHODS: Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. RESULTS: A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82-0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24-10.96 vs 13.0 months; 95% CI = 10.60-15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. CONCLUSIONS: Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.

A Retrospective Review on Atypical Femoral Fracture: Operative Outcomes and the Risk Factors for Failure.

BACKGROUND: Atypical femoral fractures have been demonstrated to have high risks of reoperation and nonunion. The aim of this study is to evaluate whether the quality of reduction following operative fixation of atypical femoral fracture predicts failure. METHODS: This is a 6.5-year retrospective review of atypical femoral fractures from 2 centers in a high-income region. A total of 56 patients with 66 fractures met our inclusion criteria. The quality of reduction was evaluated from postoperative films according to Hoskins' modification of Baumgartner criteria for subtrochanteric fractures. Our primary outcome measure was failure of treatment, defined as either reoperation or nonunion at 12 months. RESULTS: There were a total of 8 reoperations (12% of all fractures) and 8 nonunion (12% of all fractures), affecting a total of 12 fractures (18%) in 12 patients (21%). Closed reduction (P = .04) and poor quality of reduction (P = .0227 Fisher exact test) are statistically significant risk factors for failure. CONCLUSIONS: An aim for anatomical reduction with both <4 mm maximal cortical displacement and <10° angulation can improve the operative outcome of atypical femoral fractures. The addition of open reduction may be beneficial.

Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons: a case report.

We report on a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient had a positive coracoid impingement test for both shoulders. Radiology showed calcific deposits at the insertion of both subscapularis tendons, close to the lesser tuberosities and just posterior to the coracoid tips. The patient underwent sequential arthroscopic coracoplasty and removal of calcific deposits in the subscapularis tendons. The patient returned to work 6 weeks after each surgery. At 2 years, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence.

Propagation of bisphosphonate-related femoral stress fractures despite femoral nailing: a cautionary tale from 2 cases.

We report 2 cases of atypical femoral fracture displacement despite treatment with intramedullary (IM) nailing. Both patients had received more than 3 years of bisphosphonates. One patient had prophylactic fixation of an atypical femur fracture due to intractable pain. The other had undergone nailing previously for a traumatic shaft fracture. The patient then received bisphosphonate later and sustained an atypical fracture with the nail in place. Both femoral nails were slotted, cannulated stainless steel piriformis entry designs. These 2 cases are among the first reported failures of IM fixation in preventing displacement of a bisphosphonate stress fracture. We advice caution when using slotted nails in prophylaxis of atypical femur fractures because of its significantly reduced torsional stiffness compared to modern nonopen sectioned nails.

Nightmare of lumbar diskectomy: aorta laceration.

STUDY DESIGN: Case report. OBJECTIVE: To present a rare case of a patient who during posterior lumbar spinal decompression and diskectomy underwent a laceration of the aorta. The patient survived with prompt treatment. SUMMARY OF BACKGROUND DATA: Intraoperative injuries of the prevertebral and pelvic vessels are infrequent but serious complications of posterior lumbar disc surgery. Injury may cause laceration of the vessel with acute life-threatening retroperitoneal hemorrhage, which is usually massive. The aortic bifurcation is closely approximated to the anterior surface of the L4-L5 disc. METHODS: A 70-year-old gentleman with prolapsed intervertebral disc between fourth and fifth lumbar vertebrae and left-sided radiculopathy of L5 root was operated with L4-L5 laminectomy and L4-L5 diskectomy. During diskectomy, it was noticed by the surgeon that there was one episode of giving way of the pituitary rongeur anteriorly. However, no major bleeding was encountered from the disc space immediately after the event; vital signs were stable hemodynamically and we completed the diskectomy. Five minutes later, we noted the dural sac to have a collapsing pulsation. Prevertebral vessel injury was suspected. Patient became pulseless. RESULTS: We turned the patient supine for cardiopulmonary resuscitation without extubation. Vascular surgeons proceeded with laparotomy. Huge retroperitoneal hematoma and a 1.5 × 1.5 cm laceration at the bifurcation of aorta were noted anterior to the L4-L5 intervertebral disc. The vascular surgeon repaired the aorta by primary repair. The patient was extubated on day 5 and was allowed to ambulate. He was discharged subsequently with a normal neurological and vascular examination. No pseudoaneurysm or arteriovenous fistula formation was detected on magnetic resonance imaging and magnetic resonance angiography at 2 years follow-up. CONCLUSION: Iatrogenic vascular injury during posterior lumbar disc surgery, although rare, should be suspected if signs of circulatory instability or abnormal pulsation of the dural sac are noted, especially if any lapse in the ordinary technique has been observed. In preoperative imaging, note the position of the aorta and prevertebral veins and the depth and integrity of the anterior wall of the disc.

Femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction.

PURPOSE: To evaluate the extent of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation in contrast to bioabsorbable screw fixation augmented with Endopearl. METHODS: 16 patients underwent cross pin femoral fixation and the next 15 underwent bioabsorbable screw fixation augmented with Endopearl. The patients were evaluated radiographically for femoral tunnel widening. Standard posteroanterior radiographs of the knee in full extension were taken at postoperative year 2 and 5. The tunnel width was measured at the opening, the widest and the most proximal parts of the femoral tunnel. RESULTS: In the femoral cross pin and bioabsorbable screw fixations, the mean femoral tunnel sizes were 7.6 and 8.0 mm, respectively. The overall mean tunnel widening at all measured sites were 2.7 and 1.8 mm at the 2-year follow-up and were 2.5 and 1.8 mm at the 5-year follow-up, respectively. The femoral tunnel widening was greater in the cross pin than the bioabsorbable screw group, but only the difference in the most proximal part was significant (p=0.01 at year 2 and p<0.001 at year 5). CONCLUSION: Femoral tunnel widening was greater in femoral cross pin fixation, probably related to the windshield-wiper and bungee-cord effects. It usually occurred in the first 2 years after the operation and remained static thereafter.

Anatomic variations of neurovascular structures of the ankle in relation to arthroscopic portals: a cadaveric study of Chinese subjects.

PURPOSE: To investigate anatomic variations of neurovascular structures in the ankle and the safety margin for arthroscopic portals. METHODS: 11 left and 12 right ankles from 8 female and 15 male fresh cadavers of Chinese ethnicity aged 53 to 88 (mean, 68) years were used. The ankle was standardised in a plantigrade position, zero-degree inversion, and neutral rotation. Four ankle portals, namely anteromedial (AM), anterolateral (AL), posteromedial (PM) and posterolateral (PL), were identified using 23-gauge needles. Skin and subcutaneous fat were dissected from the underlying fascia to visualise neurovascular structures. Distances were measured from: (1) the AM portal to the saphenous vein and nerve and its branches, (2) the AL portal to branches of the superficial peroneal nerves, of which the lateral one was labelled as the intermediate dorsal cutaneous branch and the medial one as the medial dorsal cutaneous branch, (3) the PM portal to the posterior tibial neurovascular bundles, and (4) the PL portal to the sural nerve. RESULTS: The distances from (1) the AM portal to branches of the great saphenous vein and nerve, and (2) the AL portal to the intermediate dorsal cutaneous branch of the superficial peroneal nerve were short and may be an anatomic hazard. Variations were significant among the cadavers in terms of distances of the portals to the neurovascular structures. CONCLUSION: In Chinese cadavers, variations of neurovascular structures are significant. Care must be taken to avoid inadvertent injury during ankle arthroscopy.

Mycotic aortic aneurysm following treatment of pyogenic vertebral osteomyelitis.

Mycotic aortic aneurysm is a surgical emergency. However, its bizarre presentations could delay the golden hour of surgical reconstruction which is the mainstay of treatment. We report a case of mycotic aneurysm of the aortic arch which developed in the postoperative period after surgical treatment of pyogenic vertebral osteomyelitis at the lower thoracic level.