The Necessity of Hip Lateral Radiograph for Operative Decision in Two Common Hip Fractures.

Background: Recent studies showed that single hip anterio-posterior (AP) radiograph was adequate for diagnosis of most hip fractures (HF). However, lateral hip radiograph might be necessary to understand the fracture characteristics and to make better decision on surgical management. Material and Method: 100 HF radiographs (50 femoral neck fractures [FNF] and 50 intertrochanteric fractures [ITF]) were consecutively reviewed by five observers. The initial review used only single both hips AP radiograph. One month later, both hips AP and lateral films were reviewed. The diagnosis and operative decision were recorded, and then calculated. Results: The average rate of changing treatment by the assessment of lateral radiographs was 5.0% for all HF, 2.8% for FNF, and 7.2% for ITF. There was no significant difference among those rates between five observers (p<0.05 all). The Intraclass Correlation Coefficients (ICCs) for interobserver agreement regarding the operative decision using only single AP film were 0.787 (95% confidence interval [CI], 0.698 to 0.852) for all HF, 0.818 (95% CI, 0.699 to 0.893) for FNF, and 0.394 (95% CI, 0.130 to 0.606) for ITF. After using both AP and lateral film, the ICCs were changed into 0.792 (95% CI, 0.705 to 0.856) for all HF, 0.795 (95% CI, 0.663 to 0.879) for FNF, and 0.552 (95% CI, 0.323 to 0.720) for ITF. Conclusion: Using single both hips AP radiograph for operative decision is adequate and safe for most hip fractures. However, some of intertrochanteric fractures may require lateral radiograph for better operative decision.

The Impacts of Early Hip Surgery in High-Risk Elderly Taking Antithrombotic Agents and Afflicted with Intertrochanteric Fracture.

OBJECTIVE: To compare the outcome of early hip surgery in intertrochanteric fracture between high surgical risk patients receiving antiplatelet and anticoagulant drugs and those who did not. DESIGN: Retrospective study. MATERIAL AND METHOD: One hundred and four elderly patients with intertrochanteric fracture and having American Society of Anesthesiologist grade III-IV who underwent early hip surgery (within 72 hours after admission) with proximalfemoral nail anti-rotation (PFNA), were recruited and allocated into two group: antiplatelet and anticoagulant (AA-AC) group (n = 65), and no drug group (n = 39). Perioperative and postoperative outcomes were recorded and analyzed. RESULTS: The mean age was 81?8 years. The overall 1-year mortality was 6.7% (7 patients: 5 AA-AC group, and 2 no drug group, p = 0.7). Intra-operative blood loss in AA-AC group and No drug group were 87 ± 70 and 91 ± 65 ml, respectively (p = 0.74). There was no significant difference in blood transfusion, postoperative complications, and 1-year ambulatory status between both groups (p > 0.05 all). However, AA-AC group showed significant longer in duration of hospital stay compared with no drug group (p = 0.02). CONCLUSION: Early hip fracture surgery with PFNA in patients who received antiplatelet and anticoagulant medications is safe and does not significantly increase perioperative blood loss, blood transfusion, and postoperative mortality and morbidity.

Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients.

BACKGROUND: Bone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to (1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS grade 2 or 3: BCIS gr2/3, and (2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HYPOTHESIS: Large wedge-shaped (or "shape-closed") femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. PATIENTS AND METHODS: A total of 128 OFNF patients, who aged over 75years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. RESULTS: The prevalence of overall BCIS and BCIS-gr2/3 was 32.8% (n=42) and 6.2% (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3% and 4.7%, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5% vs. 10.0%, p=0.001). Multivariate analysis showed that age>90years (OR=9.4, 95% CI: 1.4-62.9, p=0.02), preinjury Parker mobility score<4 (OR=48.8; 95% CI: 2.7-897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95% CI: 1.8-204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. CONCLUSION: BCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. LEVEL OF EVIDENCE: III; retrospective case-control study.

Proximal humerus exposure with the inverted-L anterolateral deltoid flip approach, anterolateral deltoid splitting approach, and deltopectoral approach: A comparative cadaveric study.

BACKGROUND: Reduction of the posterior aspect of proximal humerus fracture, such as far-retracted greater tuberosity or posterior articular head split fracture via a deltopectoral or deltoid splitting approach, is difficult and usually needs extensive dissection. The inverted-L anterolateral deltoid flip approach, which is developed from the deltoid splitting approach, accesses the proximal humerus via lateral deltoid flap lifting. This study compared the area and arc of surgical exposure to the proximal humerus of this proposed approach to existing approaches. METHODS: Eleven cadaveric specimens were used. Deltopectoral and deltoid splitting approaches were carried out on the right and left shoulder, respectively. Soft tissue was retracted after completion of a surgical approach to expose the proximal humerus, and dot-to-dot marking pins were placed along the border of exposed area. An additional area with a full shoulder rotation was also marked on the deltopectoral side. An inverted-L deltoid flip approach was further carried out on a deltoid splitting side with a posterior extending incision along the acromion process and the deltoid detachment from the acromion process. The additional area of exposure was subsequently marked. All soft tissue around the proximal humerus was taken down, and the glenohumeral joint was disarticulated. Area of exposure and axial images were taken for further processing and measurement. RESULT: An average distance of the axillary nerve from the acromion process of the deltoid splitting and the deltopectoral approaches were 49.15 mm and 57.35 mm, respectively (P < 0.05). The average area of exposure of the inverted-L deltoid flip, deltoid-splitting, deltopectoral, and deltopectoral with full rotation approaches were 2729.81mm2, 1404.39mm2, 1325.41mm2, and 2354.78mm2, respectively (P < 0.05). Mean arc of exposure lateral to bicipital groove of the inverted-L deltoid flip, deltoid splitting, deltopectoral, and deltopectoral with full rotation approaches were 151.75degrees, 105.02degrees, 61.68°, and 110.64°, respectively (P < 0.05). CONCLUSION: The inverted-L anterolateral deltoid flip approach provides the most posterior access to the proximal humerus. However, it requires more soft tissue dissection and awareness of tension on the axillary nerve. This approach could be an alternative for displaced posterior head splits or far-retracted greater tuberosity proximal humerus fractures.

Predicting Factors for Return to Prefracture Ambulatory Level in High Surgical Risk Elderly Patients Sustained Intertrochanteric Fracture and Treated With Proximal Femoral Nail Antirotation (PFNA) With and Without Cement Augmentation.

INTRODUCTION: Postoperative outcomes in the elderly patients with intertrochanteric fracture were generally poor with a low rate of return to prefracture ambulatory level (RPAL). Recent studies showed that proximal femoral nail antirotation (PFNA) with cement augmentation might be useful for postoperative functional recovery. This study aimed to compare the outcomes in elderly patients with high surgical risk, American Society of Anesthesiologist (ASA) grade 3 or 4, who sustained intertrochanteric fractures and were treated with PFNA with and without cement augmentation, and to correlate perioperative surgical factors with the RPAL. METHODS: A retrospective consecutive series was conducted based on 135 patients with prefracture ambulation classified as independent in community with or without a single cane (68 in augmented group and 67 in control group). Perioperative data and data on the complications within 1-year postsurgery were collected and compared. Predictive factors for RPAL were analyzed via logistic regression analysis. RESULTS: The overall 1-year postoperative mortality rate was 10% (n = 14) with no significant difference between groups (P = .273). The proportion of elderly patients with RPAL in the augmented group was significantly higher than for those in the control group (48% vs 29%, P = .043). Via univariate analysis, ASA grade 4 (P = .077), history of stroke (P = .035), and use of cement augmentation (P = .041) were correlated with RPAL. However, multivariate regression analysis showed that ASA grade 4 (odds ratio [OR] = 0.40, 95% confidence interval [CI]: 0.18-0.90, P = .026) and use of cement augmentation (OR = 2.72, 95% CI: 1.22-6.05, P = .014) were the significant predictors for RPAL. DISCUSSION AND CONCLUSIONS: The results of the present study showed that PFNA with cement augmentation is safe and effectiveness in the intertrochanteric fracture treatment of elderly. Postoperative functional recovery, like RPAL, in elderly patients who sustained intertrochanteric fractures is relatively low, especially in those with ASA grade 4. However, cement augmentation with PFNA might be helpful for increasing the RPAL in high-surgical-risk geriatric patients.

Outcomes after unstable pertrochanteric femur fracture: intermediate versus long cephalomedullary nails.

PURPOSE: Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length. METHODS: We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant. RESULTS: The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05). CONCLUSIONS: We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes. LEVEL OF EVIDENCE: Level IV, Retrospective case series study.

Efficacy of Periarticular Multimodal Drug Injection Without NSAIDs in Elderly Patients With Displaced Femoral Neck Fractures Undergoing Bipolar Hemiarthroplasty: A Prospective Triple-Blinded RCT.

Introduction Recently, periarticular multimodal drug injection (PMDI) has demonstrated the ability to significantly reduce early postoperative pain with hip fractures in the elderly. Nonetheless, data on PMDI without non-steroidal anti-inflammatory drugs (NSAIDs) in these patients are still doubtful. The current study has evaluated the effect of PMDI with NSAIDs in elderly femoral neck fractures (FNFs) underlying bipolar hip arthroplasty (BHA). Materials and methods A prospective triple-blinded randomized controlled trial (RCT) was conducted in 28 elderly FNFs undergoing BHA. They were randomized into two groups: PMDI group (n=14), which received intraoperative PMDI (50-mL solution of 100-mg bupivacaine, 10-mg morphine, 300-mcg epinephrine, and 750-mg cefuroxime), and a placebo group (n=14), which received only saline solution. The primary outcome was a 10-point visual analog scale (VAS). Secondary outcomes were morphine consumption and cumulative ambulatory score (CAS), postoperative complications, and functional outcomes as a timed up-and-go (TUG) test and Harris hip score (HHS) at two, six, and 12 weeks postoperatively. Results The PMDI group demonstrated a significant reduction in the median VAS at the 48th hour postoperatively as compared to the placebo group (P = 0.019), and a non-significant reduction in the median VAS at the 36th and 60th hours (P = 0.058 and 0.110, respectively) and in a median dosage of morphine consumption on the second postoperative day (P = 0.140). There was no significant difference in postoperative ambulation and functional outcome between both groups (P > 0.05, all). Conclusion The PMDI regimen without NSAIDs is effective for postoperative analgesia on the second postoperative day in elderly FNFs undergoing BHA without any significant difference in functional outcome or postoperative complications.

Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery.

BACKGROUND:: The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion. METHODS:: Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format. RESULTS:: Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal. CONCLUSION:: The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study. CLINICAL RELEVANCE:: This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

The distal femur is a reliable guide for tibial plateau fracture reduction: a study of measurements on 3D CT scans in 84 healthy knees.

BACKGROUND: Limited data have been published regarding the typical coronal dimensions of the femur and tibia and how they relate to each other. This can be used to aid in judging optimal operative reduction of tibial plateau fractures. The purpose of the present study was to quantify the width of tibial plateau in relation to the distal femur. METHODS: We reviewed 3D computed tomography (CT) scans taken between 2013 and 2016 of 42 patients (84 knees). We measured positions of the lateral tibial condyle with respect to the lateral femoral condyle (dLC) and the medial tibial condyle with respect to the medial femoral condyle (dMC) in the coronal plane. Positions of the articular edges of the lateral and medial tibia were also measured with respect to the femur (dLA and dMA). RESULTS: The mean (± standard deviation) measurements were as follows: dLC, - 0.1 ± 1.9 mm; dMC, - 4.7 ± 4.1 mm; dLA, 0.9 ± 1.0 mm; and dMA, 0.1 ± 1.5 mm. The mean (± standard deviation) ratio of tibial to femoral condylar width was 0.91 ± 0.03, and the ratio of tibial to femoral articular width was 1.01 ± 0.04. CONCLUSIONS: The articular width of the tibia laterally and medially was slightly wider than the femoral articular width. These small differences and deviations indicate that the femur might be used as a reference to judge tibial plateau width reduction.

Hip muscle power recovery after hip replacement using anterior-based muscle-sparing approach in elderly femoral neck fracture: a prospective study in 40 patients.

INTRODUCTION: The early rehabilitation and mobilization after hip arthroplasty (HA) in elderly femoral neck fracture (FNF) patients significantly reduces the postoperative morbidity and mortality. The direct anterior approach (DAA) without the muscle detachment has been shown to improve the early postoperative functional outcomes in coxarthrosis patients. However, the application of DAA on elderly FNF and the most suitable surgical technique have rarely been investigated. This study aimed to report the short-term outcome after our anterior-based muscle-sparing approach (ABMS) in elderly FNF. MATERIALS AND METHODS: A prospective study, in 40 elderly unilateral FNF patients who underwent HA with ABMS, was conducted. The primary outcomes were hip flexion and abduction power at each follow-up period. The contralateral muscle power, measured at 3 and 6 months, was used as the control value. The perioperative data and complications were recorded. RESULTS: Thirty-two patients underwent bipolar hemiarthroplasty (BHA), while eight other patients received total hip arthroplasty (THA). The hip abduction power returned to control value at 6 weeks (99.0%±6.1%; 95% CI: 86.1-111.8). The hip flexion power returned to control at 3 months (108.5%±5.6%, 95% CI: 96.8-120.2). No iatrogenic nerve injury was found. The intraoperative femoral fracture (IFF) was found in 7 patients (17.5%), and was significantly related to the early period of learning skill (first 11 cases; p<0.01). BHA had nonsignificant higher IFF than THA (8 vs. 0; p=0.31). CONCLUSION: After ABMS, the hip muscle could recover to the baseline value within 3 months without iatrogenic nerve injury. The ABMS-related complication, which was IFF, could be significantly improved with the learning skill. The adequate posterior soft tissue release and gentle manipulation of the hip joint might play important roles for IFF prevention. BHA might relate to higher risk of IFF because of difficult reduction from large femoral head diameter.

A review of the epidemiology and treatment of orthopaedic injuries after earthquakes in developing countries.

BACKGROUND: Earthquakes in developing countries are devastating events. Orthopaedic surgeons play a key role in treating earthquake-related injuries to the extremities. We describe orthopaedic injury epidemiology to help guide response planning for earthquake-related disasters. METHODS: Several databases were searched for articles reporting primary injury after major earthquakes from 1970 to June 2016. We used the following key words: "earthquake" AND "fracture" AND "injury" AND "orthopedic" AND "treatment" AND "epidemiology." The initial search returned 528 articles with 253 excluded duplicates. The remaining 275 articles were screened using inclusion criteria, of which the main one was the description of precise anatomic location of fracture. This yielded 17 articles from which we analyzed the ratio of orthopaedic to nonorthopaedic injuries; orthopaedic injury location, type, and frequency; fracture injury characteristics (open vs. closed, single vs. multiple, and simple vs. comminuted); and first-line treatments. RESULTS: Most injuries requiring treatment after earthquakes (87%) were orthopaedic in nature. Nearly two-thirds of these injuries (65%) were fractures. The most common fracture locations were the tibia/fibula (27%), femur (17%), and foot/ankle (16%). Forty-two percent were multiple fractures, 22% were open, and 16% were comminuted. The most common treatment for orthopaedic injuries in the setting of earthquakes was debridement (33%). CONCLUSIONS: Orthopaedic surgeons play a critical role after earthquake disasters in the developing world. A strong understanding of orthopaedic injury epidemiology and treatment is critical to providing effective preparation and assistance in future earthquake disasters.

Current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the Orthopaedic Trauma Association.

BACKGROUND: The risk of postoperative surgical site infection after long bone fracture fixation can be decreased with appropriate antibiotic use. However, there is no agreement on the superiority of a single- or multiple-dose perioperative regimen of antibiotic prophylaxis. The purpose of this study is to determine the following: 1) What are the current practice patterns of orthopaedic trauma surgeons in using perioperative antibiotics for closed long bone fractures? 2) What is the current knowledge of published antibiotic prophylaxis guidelines among orthopaedic trauma surgeons? 3) Are orthopaedic surgeons willing to change their current practices? METHODS: A questionnaire was distributed via email between September and December 2015 to 955 Orthopaedic Trauma Association members, of whom 297 (31%) responded. RESULTS: Most surgeons (96%) use cefazolin as first-line infection prophylaxis. Fifty-nine percent used a multiple-dose antibiotic regimen, 39% used a single-dose regimen, and 2% varied this decision according to patient factors. Thirty-six percent said they were unfamiliar with Centers for Disease Control and Prevention (CDC) antibiotic prophylaxis guidelines; only 30% were able to select the correct CDC recommendation from a multiple-choice list. However, 44% of surgeons said they followed CDC recommendations. Fifty-six percent answered that a single-dose antibiotic prophylaxis regimen was not inferior to a multiple-dose regimen. If a level-I study comparing a single preoperative dose versus multiple perioperative antibiotic dosing regimen for treatment of closed long bone fractures were published, most respondents (64%) said they would fully follow these guidelines, and 22% said they would partially change their practice to follow these guidelines. CONCLUSION: There is heterogeneity in the use of single- versus multiple-dose antibiotic prophylaxis for surgical repair of closed long bone fractures. Many surgeons were unsure of current evidence-based recommendations regarding perioperative antibiotic use. Most respondents indicated they would be receptive to high-level evidence regarding the single- versus multiple-dose perioperative prophylactic antibiotics for the treatment of closed long bone fractures.

Open versus minimally invasive fixation of a simulated syndesmotic injury in a cadaver model.

BACKGROUND: Malreduction of unstable syndesmotic ankle fractures is common. This study compared the reduction quality of an anterolateral open technique (OT) versus a conventional minimally invasive technique (MIT). METHODS: Fourteen fresh-frozen lower torso specimens with 28 matched lower extremities underwent computed tomography (CT) to measure syndesmosis position before dissection. Reduction was performed using direct visualization and fluoroscopy for the OT group (right-sided specimens) and fluoroscopy only for the MIT group (left-sided specimens). Fixation was achieved with 2 cortical screws. Measurements were repeated with postfixation CT scans. Statistical analysis used a two-tailed t test (α = 0.05). RESULTS: Mean posterior fibula-tibia distance decreased after OT by 0.3 ± 0.5 mm and increased after MIT by 0.7 ± 0.6 mm (P = 0.025 for difference between techniques). Mean anterior fibula-tibia distance decreased after OT by 0.4 ± 0.2 mm (P = 0.007) and did not change significantly after MIT (- 0.01 ± 0.4 mm (P = 0.686). Mean anterior translation after OT was 0.04 ± 0.4 mm (P = 0.856), and mean posterior translation after MIT was 0.3 ± 0.7 mm (P = 0.434). Mean medialization after OT was 0.3 ± 0.4 mm (P = 0.132), and mean lateralization after MIT was 0.2 ± 0.6 mm (P = 0.446). CONCLUSIONS: Both techniques produced near-anatomic reduction of the fibula, with MIT producing significantly more internal rotation malreduction than OT. OT appears to restore near-anatomic fibula position, although this did not differ significantly from the results of MIT. We conditionally recommend OT when closed reduction of the syndesmosis cannot be obtained.

2D versus 3D fluoroscopy-based navigation in posterior pelvic fixation: review of the literature on current technology.

PURPOSE: Percutaneous sacroiliac (SI) fixation of unstable posterior pelvic ring injuries is a widely accepted procedure. The complex sacral anatomy with narrow osseous corridors for SI screw placement makes this procedure technically challenging. Techniques are constantly evolving as a result of better understanding of the posterior pelvic anatomy. Recently developed tools include fluoroscopy-based computer-assisted navigation, which can be two-dimensional (2D) or three-dimensional (3D). Our goal is to determine the relevant technical considerations and clinical outcomes associated with these modalities by reviewing the published research. We hypothesize that 3D fluoroscopy-based navigation is safer and superior to its 2D predecessor with respect to lower radiation dose and more accurate SI screw placement. METHODS: We searched four medical databases to identify English-language studies of 2D and 3D fluoroscopy-based navigation from January 1990 through August 2015. We included articles reporting imaging techniques and outcomes of closed posterior pelvic ring fixation with percutaneous SI screw fixation. Injuries included in the study were sacral fractures (52 patients), sacroiliac fractures (88 patients), lateral compression fractures (20 patients), and anteroposterior compression type pelvic fractures (8 patients). We excluded articles on open reduction of posterior pelvic ring injuries and solely anatomic studies. We then reviewed these studies for technical considerations and outcomes associated with these technologies. RESULTS: Six studies were included in our analysis. Results of these studies indicate that 3D fluoroscopy-based navigation is associated with a lower radiation dose and lower rate of screw malpositioning compared with 2D fluoroscopy-based systems. CONCLUSIONS: It may be advantageous to combine modern imaging modalities such as 3D fluoroscopy with computer-assisted navigation for percutaneous screw fixation in the posterior pelvis.

Medial Knee Approach: An Anatomical Study of Minimally Invasive Plate Osteosynthesis in Medial Femoral Condylar Fracture.

OBJECTIVES: To determine the location of distal medial neurovascular structures, identifying a medial "safe zone" for minimally invasive plate osteosynthesis to treat displaced femoral condylar fractures. METHODS: Eleven uninjured lower-half torsos were dissected on the bilateral medial lower thigh. A longitudinal incision was made at the midsagittal plane of the medial thigh starting 1 cm proximal to the knee joint and extending to the proximal one-third of the femur. Superficial and deep neurovascular structures were dissected. Distances to the medial vastus and adductor compartment were measured. RESULTS: Mean distances were 160 ± 31.4 mm from the adductor tubercle to Hunter canal; 94 ± 18.3 mm from adductor tubercle to adductor hiatus; 31.8 ± 9.21 mm from Hunter canal to the femoral shaft; and 31.7 ± 7.78 mm from adductor hiatus to femoral shaft. All specimens had a descending genicular artery (DGA) with a mean distance to the adductor tubercle of 98.4 ± 16.0 mm. The muscular branch of the DGA crossed the femoral shaft at approximately 50 mm from the adductor tubercle; the osteoarticular branch ran along the adductor magnus tendon. The nerve to the vastus medialis was at the posterior border of the vastus medialis, entering at a mean 143 ± 63.0 mm from the adductor tubercle. CONCLUSIONS: Minor neurovascular branches of the DGA may be vulnerable during medial femoral condyle plating. Careful blunt dissection, proper instrumentation, and plate length within 160 mm allow distal medial femur fixation without additional proximal dissection.

Demineralized Bone Matrix Add-On for Acceleration of Bone Healing in Atypical Subtrochanteric Femoral Fracture: A Consecutive Case-Control Study.

BACKGROUND: Delayed union and nonunion are common complications in atypical femoral fractures (AFFs) despite having good fracture fixation. Demineralized bone matrix (DBM) is a successfully proven method for enhancing fracture healing of the long bone fracture and nonunion and should be used in AFFs. This study aimed to compare the outcome after subtrochanteric AFFs (ST-AFFs) fixation with and without DBM. MATERIALS AND METHODS: A prospective study was conducted on 9 ST-AFFs patients using DBM (DBM group) during 2013-2014 and compared with a retrospective consecutive case series of ST-AFFs patients treated without DBM (2010-2012) (NDBM group, 9 patients). All patients were treated with the same standard guideline and followed up until fractures completely united. Postoperative outcomes were then compared. RESULTS: DBM group showed a significant shorter healing time than NDBM group (28.1 ± 14.4 versus 57.9 ± 36.8 weeks, p = 0.04). Delayed union was found in 4 patients (44%) in DBM group compared with 7 patients (78%) in NDBM group (p > 0.05). No statistical difference of nonunion was demonstrated between both groups (DBM = 1 and NDBM = 2, p > 0.05). Neither postoperative infection nor severe local tissue reaction was found. CONCLUSIONS: DBM is safe and effective for accelerating the fracture healing in ST-AFFx and possibly reduces nonunion after fracture fixation. Trial registration number is TCTR20151021001.

Early Weightbearing After Operatively Treated Ankle Fractures: A Biomechanical Analysis.

BACKGROUND: No consensus exists regarding the timing of weightbearing after surgical fixation of unstable traumatic ankle fractures. We evaluated fracture displacement and timing of displacement with simulated early weightbearing in a cadaveric model. METHODS: Twenty-four fresh-frozen lower extremities were assigned to Group 1, bimalleolar ankle fracture (n=6); Group 2, trimalleolar ankle fracture with unfixed small posterior malleolar fracture (n=9); or Group 3, trimalleolar ankle fracture with fixed large posterior malleolar fracture (n=9) and tested with axial compressive load at 3 Hz from 0 to 1000 N for 250 000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. RESULTS: The average motion at all fracture sites in all groups was significantly less than 1 mm (P < .05). Group 1 displacement of the lateral and medial malleolus fracture was 0.1±0.1 mm and 0.4±0.4 mm, respectively. Group 2 displacement of the lateral, medial, and posterior malleolar fracture was 0.6±0.4 mm, 0.5±0.4 mm, and 0.5±0.6 mm, respectively. Group 3 displacement of the lateral, medial, and posterior malleolar fracture was 0.1±0.1 mm, 0.5±0.7 mm, and 0.5±0.4 mm, respectively. The majority of displacement (64.0% to 92.3%) occurred in the first 50 000 cycles. There was no correlation between fracture displacement and bone mineral density. CONCLUSION: No significant fracture displacement, no hardware failure, and no new fractures occurred in a cadaveric model of early weightbearing in unstable ankle fracture after open reduction and internal fixation. CLINICAL RELEVANCE: This study supports further investigation of early weightbearing postoperative protocols after fixation of unstable ankle fractures.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents.

AIM: To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents. METHODS: Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared. RESULTS: There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all). CONCLUSION: Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Using a reconstruction locking compression plate as external fixator in infected open clavicle fracture.

Open clavicle fracture is an uncommon injury mostly caused by severe direct trauma. It is often associated with multiple organ injuries. Generally, surgical intervention with debridement and fracture repair is always indicated in order to prevent infection, non-union, and malalignment. In situations of bony exposure and significant contamination concomitant with severe soft tissue damage, the external fixation is the treatment of choice because of the possibility it offers of providing stable fixation with minimal local tissue damage resulting in excellent union rates and better soft tissue outcome. Nevertheless, traditional external fixation encountered some potential problems as its bulkiness and sharp edges caused discomfort to the patient. In this study, we present an interesting case of a polytraumatized patient with a gunshot injury with complex open clavicle fracture that was successfully treated with external fixation using reconstruction with a locking compression plate as definitive treatment.