Far cortical locking constructs for fixation of distal femur fractures in an Asian population: A prospective observational study.

BACKGROUND: The stiffness of locked plates suppresses healing process, prompting the introduction of far cortical locking to address this issue. This study aimed to demonstrate the clinical efficacy of far cortical locking constructs in treating distal femoral fractures in an Asian population. METHODS: This multicenter prospective observational study was conducted at four university hospitals between February 2018 and February 2021. Demographic data, the presence of metaphyseal comminution, and surgical fixation details were recorded. Clinical outcomes, including single-leg standing, EQ-5D, and EQ-VAS scores, and radiologic outcomes, including the RUST score of each cortex, were evaluated and compared according to the presence of metaphyseal comminution. RESULTS: There were 37 patients (14 men and 23 women) with a mean age of 67.3 ± 11.8 years. Twenty-two patients had metaphyseal comminution (59%), and 15 presented simple fractures in metaphyseal areas. Four patients (13%) could stand on one leg >10s at 6 weeks, and 24 patients (92%) at 1 year. EQ-5D increased from 0.022 ± 0.388 to 0.692 ± 0.347, and the mean EQ-VAS 51.1 ± 13.1 to 74.1 ± 24.1 between discharge (n = 37) and post-operative 1 year (n = 33), respectively. RUST score presented increment for time, from 6.2 ± 1.8 at 6 week to 11.6 ± 1.1 at 1 year. Radiological healing demonstrated rapid increase from week 6 (16/28, 43%) to month 3 (27/31, 87%), with no obvious increase was observed in 6 months (23/26, 89%) or 12 months (25/28, 89%). Simple metaphyseal fractures presented significantly higher RUST scores at 6 weeks and 3 months, but there was no difference in RUST scores at 6 months or 1 year according to metaphyseal comminution. CONCLUSIONS: Plate constructs with far cortical locking screws provided safe and effective fixation for distal femoral fractures, with consistent radiological and clinical results, regardless of metaphyseal comminution.

Induced membrane technique with plate fixation has a lower complication rate than bone transport over a plate for segmental tibial defects larger than 5 cm.

INTRODUCTION: The treatment of segmental tibial bone defects remains a surgical challenge. While Bone Transport (BT) and Induced Membrane Technique (IMT) are effective strategies for regenerating bone, there are few comparative studies between them. This investigation undertakes a comparative analysis of BT and IMT for large segmental tibial defects stabilised through plate fixation. MATERIALS AND METHODS: Patients with segmental tibial defects exceeding 5 cm were prospectively enrolled from 2008 to 2021 in a single institution, with a minimum follow-up duration of two years. All patients underwent either BT or IMT with plate fixation of the tibia. Procedural success, primary union as well as bone and functional outcome scores were compared. Complications, including non-unions, joint contractures and deep infections requiring surgical intervention, were also compared. RESULTS: 41 patients were recruited in total. 28 patients underwent Bone Transport Over a Plate (BTOP), while 13 patients underwent IMT with Plate fixation (IMTP). The procedural success rate trended higher in IMTP compared to BTOP (100% vs. 85.7%). The primary union rate also trended higher in IMTP compared to BTOP (92.3% vs. 79.2%). BTOP and IMTP achieved similar rates of satisfactory bone outcome scores (78.6% vs. 84.6%) and functional outcome scores (75% vs. 76.5%). There was no statistical difference between procedural success, primary union, bone and functional outcome scores. The complication rate in BTOP was 78.6% (22 of 28), including five docking site or regenerate non-unions, eight deep infections and nine joint contractures. IMTP had a 38.5% (5 of 13) complication rate, including one non-union, two deep infections and two joint contractures. The complication rate was 2.04 times higher in BTOP compared to IMTP (p = 0.0117). CONCLUSIONS: BTOP and IMTP are both equally effective techniques for regenerating bone in large tibial bone defects. However, IMTP may be a safer procedure than BTOP, with a lower probability of requiring additional procedures to address complications.

Biomechanical Comparison of Fixation Methods for Posterior Wall Fractures of the Acetabulum: Conventional Reconstruction Plate vs. Spring Plate vs. Variable Angle Locking Compression Plate.

Background and Objectives: Acetabular fractures, though infrequent, present considerable challenges in treatment due to their association with high-energy trauma and poor prognoses. Posterior wall fractures, the most common type among them, typically have a more favorable prognosis compared to other types. Anatomical reduction and stable fixation of the posterior wall are crucial for optimal treatment outcomes. This study aimed to biomechanically compare three commonly used fixation methods for posterior wall fractures of the acetabulum-a conventional reconstruction plate, a spring plate, and a 2.7 mm variable angle locking compression plate (VA-LCP). Materials and Methods: The study utilized 6 fresh-frozen cadavers, yielding 12 hemipelvises free from prior trauma or surgery. Three fixation methods were compared using a simple acetabulum posterior wall fracture model. Fixation was performed by an orthopedic specialist, with prebending of plates to minimize errors. Hemipelvises were subjected to quasi-static and cyclic loading tests, measuring fracture gap, stiffness, and displacement under load. Results: It showed no significant differences in fracture gap among the three fixation methods under cyclic loading conditions simulating walking. However, the conventional reconstruction plate exhibited a greater stiffness compared to the spring and variable angle plates. Fatigue analysis revealed no significant differences among the plates, indicating a similar stability throughout cyclic loading. Despite differences in stiffness, all three fixation methods demonstrated adequate stability under loading conditions. Conclusions: While the conventional reconstruction plate demonstrated a superior stiffness, all three fixation methods provided sufficient stability under cyclic loading conditions similar to walking. This suggests that postoperative limitations are unlikely with any of the three methods, provided excessive activities are avoided. Furthermore, the variable angle plate-like the spring plate-offers an appropriate stability for fragment-specific fixation, supporting its use in surgical applications. These findings contribute to understanding the biomechanical performance of different fixation methods for acetabular fractures, facilitating improved surgical outcomes in challenging cases.

Radiographic rotational profiles of the proximal and distal humerus: analysis of 46 computed tomography scans with 3-dimensional simulation.

BACKGROUND: To date, no study has investigated the radiographic rotational profiles (RRPs) of the proximal and distal humerus. However, malrotation after minimally invasive surgery for humeral fracture has been an unsolved problem. Therefore, we aimed to investigate the RRPs of the proximal and distal humerus that linearly correlate with rotational status and show significant differences as the rotational status changes. METHODS: Forty-six computed tomography scans of the humerus were 3-dimensionally reconstructed, and 5 rotational statuses (20° and 10° of internal rotation; neutral; and 10° and 20° of external rotation) were simulated. Seven candidate RRPs of the proximal humerus and 4 candidates of the distal humerus were measured for each rotational status. The overall differences and trends in the RRPs as the rotational status changed were evaluated, and multiple comparisons were performed between the RRPs for each of the 5 rotational statuses. Moreover, the correlations between the RRPs and rotational status with adjustment of retroversion were analyzed. Finally, interobserver and intraobserver reliabilities were evaluated. RESULTS: The following proximal and distal RRPs were linearly correlated with rotational status, differed significantly between the rotational statuses, and showed a relatively low prediction error and excellent interobserver and intraobserver reliabilities: the distance from the tip of the lesser tuberosity to the lateral margin of the proximal humerus (PL1) and the medial margin of the head (PL2), as well as the PL1 to PL2 ratio (PRL), in the proximal humerus; and the distance from the medial margin of the olecranon process to the medial epicondyle (DOP), the widest width of the overlapped olecranon fossa (DOF), and the distance from the lateral margin of the capitellum to the lateral epicondyle (DC) in the distal humerus. CONCLUSION: Our findings suggest that PL1, PL2, and PRL in the proximal humerus and DOP, DOF, and DC in the distal humerus are potentially useful and reproducible RRPs for restoring the intrinsic rotational alignment in humeral fractures.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

The role of an augmentative plating in the management of femoral subtrochanteric nonunion.

INTRODUCTION: Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation. MATERIALS AND METHODS: Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months. RESULTS: Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed. CONCLUSIONS: Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.

Peri-implant atypical femoral fracture after nail or plate osteosynthesis.

BACKGROUND: A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS: We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS: The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS: PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.

Outcomes of embedded rafting k-wire technique for intermediate articular fragment fixation in comminuted olecranon fractures.

BACKGROUND: Severely comminuted olecranon fractures are challenging injuries. Commonly used tension band wiring exerts excessive compressive forces causing olecranon shortening and joint incongruity. This study aimed to introduce the embedded rafting k-wire technique with the bridging technique for intermediate articular fragment fixation in comminuted olecranon fractures and evaluate its clinical and radiological outcomes. MATERIALS AND METHODS: A total of 34 patients with comminuted olecranon fractures were treated with rafting k-wire fixation combined with a locking plate. Time to union, the number of rafting k-wires in the intermediate articular fragment, quality of joint reduction, and secondary reduction loss were analyzed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up. RESULTS: Fracture union was obtained in all patients. The mean number of intermediate articular fragments was 2.4 ± 0.7, and the average number of rafting k-wires was 3.0 ± 1.2. There were mild and moderate degree early posttraumatic osteoarthritis in 6 cases (17.6%) at the mean 20.8 months of follow-up. At the final follow-up, the mean range of elbow motion was 4.6° of flexion contracture and 133.5° of further flexion. The average MEPS was 97.1 (range, 75-100). Two patients had heterotrophic ossification without functional impairment. CONCLUSION: The embedded rafting k-wire technique with bridging plates in comminuted olecranon fractures exhibited satisfactory outcomes. This method might serve as an alternative when considering the ability to restore articular congruency and stability in severely comminuted olecranon fragments. LEVEL OF EVIDENCE: Level IV, therapeutic.

The importance of reconstruction nailing for diaphyseal atypical femoral fractures: a comparative study with standard nailing.

INTRODUCTION: Subtrochanteric atypical femoral fractures (AFFs) usually require long cephalomedullary or reconstruction nailing to achieve satisfactory healing. Recently, this type of nailing has also been recommended to fix diaphyseal AFFs and prevent fragility fractures around the proximal femur, although standard antegrade nailing seems sufficient from a biomechanical perspective. This study aimed to compare treatment outcomes and complications between reconstruction and standard nailing for diaphyseal AFFs. MATERIALS AND METHODS: A retrospective comparative study of 48 female patients with diaphyseal AFFs who underwent surgical treatment with either reconstruction or standard nailing was conducted. The reconstruction nailing group comprised 23 patients with a mean age of 74.4 years and included 16 complete and 7 incomplete AFFs. The mean follow-up period was 30 months. The standard nailing group comprised 25 patients with a mean age of 71.1 years and included 16 complete and 9 incomplete AFFs. The mean follow-up period was 57.8 months. The healing rate, time to union, and complications were analyzed and compared between the two groups. RESULTS: Bony union was achieved in all 23 cases (100%) of the reconstruction nailing group by a mean of 19.3 weeks postoperative. In the standard nailing group, 23 of 25 cases healed (92%) by a mean of 16 weeks postoperative. The standard nailing group included two delayed fragility fractures of the femoral neck (5 and 10 years after the initial surgery), four cases of newly developed subtrochanteric AFFs at the distal screw of the proximal interlocking screws of the nail (one complete and three incomplete fractures), and two cases of nonunion. Complications only occurred in the standard nailing group (p = 0.01, Fisher's exact test). CONCLUSIONS: In diaphyseal AFFs, reconstruction nailing may achieve a satisfactory outcome and can also decrease delayed peri-implant fragility fractures of the hip, newly developed subtrochanteric AFFs, and nonunion.

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design.

BACKGROUND: Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF's. METHODS: This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. DISCUSSION: Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03598530 .

Morphological characteristics of fractures of the anteromedial facet of the coronoid in posteromedial rotatory instability of the elbow: a three-dimensional CT remodeling study.

BACKGROUND: Fractures of the anteromedial facet of the coronoid in posteromedial rotatory instability of the elbow are classified into 3 subtypes based on their location. The purpose of this study was to analyze the fracture morphology of anteromedial facet fractures in their 3 subtypes (anteromedial rim, anteromedial rim + tip, and anteromedial rim + sublime tubercle [±tip]). METHODS: Three-dimensional computed tomography remodeling was used to evaluate anteromedial facet fractures in a consecutive series of 40 patients, all of whom were affected by posteromedial rotatory instability of the elbow. Characteristics of the fractures, including the number of fragments, size of fragments, plane of the fracture line, and involvement of the sublime tubercle and radial notch, were measured for each subtype of the anteromedial facet fractures. RESULTS: Each subtype had a typical fracture pattern and distinct size. The fracture subtype 1 showed a single-fragment fracture, subtype 2 showed either a single- or dual-fragment fracture, and subtype 3 showed either a dual- or triple-fragment fracture. The angle between the fracture line and the coronal plane was greatest in subtype 3 fractures. The surface area of the fragment was largest in subtype 3 fractures. The percentages of articular involvement of the sublime tubercle were 0% in subtype 1, 47% in subtype 2, and 79% in subtype 3. The percentages of articular involvement of the radial notch were 0% in subtype 1, 7% in subtype 2, and 8% in subtype 3. CONCLUSION: Analysis with quantitative 3-dimensional computed tomography showed the characteristic morphology of each subtype of anteromedial facet fracture. Subtype 1 comprised 1 fragment with the smallest fragment size. Subtype 2 was a single- or dual-fragment fracture, the size of which should be considered in the treatment plan. Subtype 3 was a large fragment comprising the sublime tubercle. Our findings are significant because they highlight unique fracture morphology that may help surgeons to distinguish one fracture subtype from another in clinical practice.

Biomechanical comparison of proximal interlocking screw constructs in different subtrochanteric fracture models.

BACKGROUND: Depending on the size of the proximal bone segment, either a standard locking construct or a recon locking construct can be used in intramedullary nailing for a subtrochanteric fracture. However, the most appropriate construct for a given size of proximal bone segment has not yet been determined. Therefore, this study aimed to identify the appropriate construct using biomechanical testing. METHODS: Fourteen intramedullary nails for each locking construct (standard and recon) were inserted into 28 synthetic femurs. Fourteen subtrochanteric fracture models were developed by creating parallel defects (2 cm in size) 2 cm distal to the lower edge of the lesser trochanter (low fracture group), and 14 fracture models were developed with identical defects situated 1 cm distal to the lower edge of the lesser trochanter (high fracture group). An axial load experiment was conducted to measure the stiffness and failure load for each proximal interlocking screw construct. RESULTS: There were no statistically significant differences in the stiffness and failure load between the locking constructs in the low fracture group. However, the stiffness and failure load were significantly greater for the recon locking construct than for the standard locking construct in the high fracture group. CONCLUSION: The standard locking system allows for sufficient fixation strength when performing intramedullary nailing for subtrochanteric fractures located 2 cm distal to the lower edge of the lesser trochanter.

Clinical outcome of staged surgery after primary amputation for mangled extremity.

INTRODUCTION: Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation. MATERIALS AND METHODS: This study included 47 patients (38 men, 9 women; average age, 52.4 years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed. RESULTS: No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1 year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation. CONCLUSION: Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.

"Reverse miss-a-nail technique" of reconstruction nailing for successful fixation of the ipsilateral femoral neck and shaft fracture.

INTRODUCTION: Although reconstruction nails have an advantage of single-construct fixation in ipsilateral femoral neck and shaft fractures, they have not been used widely due to the technical challenges associated with their placement. Reduction is particularly demanding in patients with displaced neck fractures after nailing of the shaft fracture, and can be resulted in nonunion, malunion, and osteonecrosis. We report a new technique of reconstruction nailing after the provisional reduction and fixation of a neck fracture to achieve successful healing of this injury. MATERIALS AND METHODS: Osteosynthesis using a reconstruction nail was performed in ten consecutive patients with displaced femoral neck and shaft fracture. After closed reduction of the displaced neck fracture, the femoral neck was provisionally fixed with pins in an anterolateral-to-medial direction. While maintaining reduction of the neck fracture, a nail was inserted and passed into the medullary canal posterior to the provisionally fixed pins with indirect reduction of the shaft fracture. After two reconstruction locking screws were fixed for proximal interlocking, the provisional pins were removed once distal interlocking was achieved. The radiologic outcomes included quality of reduction, healing rate, and time to the union were appraised, and the functional outcomes were assessed with Friedman and Wyman's criteria. RESULTS: This novel technique provided satisfactory reduction of both the femoral neck and shaft fractures with no malunion. All fractures achieved primary union, except for one case of nonunion of femoral shaft. Eight of ten patients experienced good results in functional outcome, whereas the remaining two patients reported moderate limitations in activities of daily living. At the latest follow-up, all patients had excellent range of motion in hip and knee joints. CONCLUSIONS: Provisional fixation after reduction of a femoral neck fracture may facilitate successful reconstruction nailing in the ipsilateral fractures of the femoral neck and shaft. This "Reverse Miss-a-Nail Technique" may minimize complications and maximize the radiologic and functional outcomes of patients who experience this injury.

Excellent outcomes after double-locked plating in very low periprosthetic distal femoral fractures.

INTRODUCTION: Very low periprosthetic distal femur fractures (PPDFFs) are rare injuries and often have a relatively high failure rate after single lateral locked plating. The double plating technique yields good outcomes in osteoporotic fractures of the distal femur. To date, there is limited information on double-locked plate fixation of very low PPDFFs. This study aimed to evaluate the outcomes and complications of surgically treated very low PPDFFs using double-locked plate fixation. MATERIALS AND METHODS: Between January 2013 and December 2018, sixty-one consecutive patients with PPDFFs have been conducted. Only Su type III PPDFFs with double-locked plate fixation through a lateral minimally invasive approach and a medial subvastus approach to the distal femur were analyzed. Patients were encouraged to perform straight leg raising exercises and active knee motion on the second postoperative day. Assisted weight bearing from the early postoperative days was supported, and full weight-bearing was allowed after healing the fracture site. All patients were evaluated according to the time to union, limb alignment, range of knee motion, Knee Society Score, and presence of complications. RESULTS: Twenty one patients (17 females and 4 males, mean age 76 years, range 56-90) were included in the study. There were 10 of 33-A1, 6 of 33-A2 and 5 of 33 A3 fractures, according to the AO classification. Of 21 patients, 20 achieved union at an average of 14 weeks postoperatively. Postoperative limb alignment was satisfactory in all cases, with an average mechanical distal lateral femur angle of 89° and average mechanical posterior distal femur angle of 86°. All patients recovered the knee joint motion similar to that of the contralateral side, and daily life pre-injury. The average knee and function scores were 94 and 89, respectively. There were one case of non-union and three cases of superficial wound infection, which resolved after intravenous antibiotic therapy. CONCLUSIONS: Double locked plating showed excellent radiographic and functional outcomes with few complications in patients with very low PPDFFs. Based on these promising results, we propose the consideration of double-locked plate fixation in the treatment of very low PPDFFs.

Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus.

BACKGROUND: We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. METHODS: Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. RESULTS: The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. CONCLUSIONS: The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.

An intuitive and simple technique for accurate insertion point selection and precise Poller (blocking) screw insertion.

Although indirect reduction with intramedullary (IM) nailing is the gold standard for long bone fractures, IM nailing in meta-diaphyseal fractures often results in malalignment. Placement of Poller (blocking) screws is an attractive and useful technique in these situations; however, the selection of accurate placement points and the placement process itself are often complicated. This paper proposes an intuitive, simple, and clear technique for selecting the location of Poller screw placement that can be used in either the anteroposterior or lateral view regardless of the fracture type and discusses techniques for Poller screw placement that enable displacement correction.

Significance of orthopedic trauma specialists in trauma centers in Korea.

INTRODUCTION: In 2012, the Korean central government selected trauma centers to provide effective treatment and reduce preventable mortality in severe trauma patients. General surgeons, thoracic surgeons, orthopedists, and neurosurgeons play pivotal roles in trauma centers, as most trauma patients require orthopedic procedures. This study aimed to underscore the importance of trauma orthopedic specialists (TOSs) by comparing treatment outcomes between a TOS and general orthopedists. PATIENTS AND METHODS: Orthopedic trauma patients with injury severity scores > 15 points, admitted to level 1 trauma centers between March 2015 and December 2016, were divided into the TOS group (treated by 1 orthopedic trauma specialist who treats trauma patients with no limitation in the joint of specialization) and the general orthopedist group (GOG; treated by several general orthopedists who manage both trauma and disease but are each specialized in a certain joint). Emergency room response time, triage time, surgical preparation time, number of surgeries per patient, intensive care unit (ICU) duration, complications, and mortality were retrospectively analyzed. RESULTS: Among 272 patients, 52 were treated by a TOS and 220 were treated by several general orthopedists. For the TOS group and the GOG, the average emergency room response time was 8 and 32 min; average triage time, 27 and 162 min; average surgical preparation time, 141 and 350 min; average number of surgeries per patient, 1.9 and 2.7; and average ICU duration, 8.5 and 12.2 days, respectively. The TOS group saved $2700 per patient. No statistical differences were found in complications and mortality between the 2 groups. CONCLUSIONS: TOSs can provide rapid treatment to trauma patients and systemically participate in collaborative treatment with other specialists in a trauma center. As treatment provided by a TOS can also reduce the ICU duration, TOSs can play an important role in rapid rehabilitation and cost reduction for trauma patients.

Fragment specific fixation technique using 2.7 mm VA LCP for comminuted posterior wall acetabular fractures: a novel surgical technique.

PURPOSE: The purposes of the study were to introduce surgical technique of fragment-specific fixation technique using multiple 2.7-mm variable-angle locking compression plates (VA LCPs) in comminuted posterior wall acetabular fractures and reported its clinical results. PATIENTS AND METHODS: Among the 68 patients, 23 with comminuted posterior wall factures with ≥ 3 fragments in the CT scan and no column involvement with a minimum follow-up duration of 12 months were enrolled in this study. We evaluated the clinical results after the treatment of comminuted posterior wall acetabular fractures via the fragment-specific fixation technique using 2.7-mm variable-angle locking compression plates (VA LCPs) retrospectively. RESULTS: The average duration of follow-up was 26.8 months. Anatomical reduction was achieved in eighteen patients. Imperfect reduction was achieved in five patients. 22 patients achieved fracture union and one patient underwent revision surgery owing to acute postoperative infection. There were no complications, including loss of reduction, fixative failures, sciatic nerve palsy, heterotopic ossification, and early posttraumatic arthritis among 22 patients. The average functional outcome was measured as 'very good'. CONCLUSION: Fragment-specific fixation technique using 2.7-mm VA LCPs for comminuted posterior wall acetabular fractures could be an acceptable alternative means of surgical fixation.

Increased Serum Ion Levels After Ceramic-on-Metal Bearing Total Hip Arthroplasty: Influence of an Asian Lifestyle.

BACKGROUND: Recent clinical studies have suggested that systemic metal ion levels are significantly elevated at midterm follow-up in patients with ceramic-on-metal (COM) bearing. However, it is not clear whether there is a correlation between patient-related factors including the lifestyle and elevated levels of serum metal ions following COM total hip arthroplasty (THA). METHODS: Serum metal levels were measured in 201 patients (234 hips) including 121 COM patients (140 hips) and 80 non-COM patients (94 hips). The Harris Hip Score, University of California, Los Angeles activity scale score, and Western Ontario and McMaster Universities Osteoarthritis Index score were measured and radiographs were obtained for the analysis. RESULTS: Significantly higher levels of cobalt (Co) and chromium (Cr) were detected in the serum of the COM THA group (Co: 1.86 ± 4.0 µg/L; Cr: 1.81 ± 2.87 µg/L) than those of the non-COM THA group (Co: 0.27 ± 0.14 µg/L; Cr: 0.19 ± 0.25 µg/L; P < .001). The serum metal levels of patients who achieved the squatting position and the kneeling position were significantly higher than those of patients who could not squat (Co: P = .033; Cr: P = .074) and kneel (Co: P = .049; Cr: P = .031). The metal ion levels of the COM THA group correlated with the total range of motion (Co: P = .0293; Cr: P = .0399). CONCLUSION: Patients who underwent a 36-mm COM THA showed high serum metal levels although good clinical outcomes at the midterm follow-up. We found that COM THA patients who were capable of greater range of motion, squatting, and kneeling are at risk of metal ion-related problems.