Sarcopenia, a Risk Predictor of Postoperative Acute Kidney Injury in Elderly Patients after Hip Fracture Surgery: A Retrospective Analysis.

Background and Objectives: Hip fracture surgery, which affects quality of life, can be a major challenge in geriatric populations. Although sarcopenia is known to be associated with postoperative outcomes, there are few studies on the association between sarcopenia and postoperative acute kidney injury (AKI) in this population. We investigated the association between sarcopenia and postoperative AKI in elderly patients following hip fracture surgery. Materials and Methods: We retrospectively reviewed the records of patients who underwent hip fracture surgery at our institution from March 2019 to December 2021. Patients under the age of 65, patients with no preoperative computed tomography (CT) scans and patients with inappropriate cross-sectional images for measurement were excluded. The psoas-lumbar vertebral index (PLVI), which is the ratio of the average area of both psoas muscles to the area of the fourth lumbar vertebral body, was measured from preoperative CT scans. Sarcopenia was defined as a PLVI within the lowest 25% for each sex, and patients were categorized into sarcopenic and nonsarcopenic groups. The occurrence of AKI was determined based on the serum creatinine level within postoperative day 7 using the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Univariate and multivariate logistic regression analyses were performed to evaluate the associations between clinical variables and the occurrence of AKI. Results: Among the 348 enrolled patients, 92 patients were excluded, and 256 patients were analyzed. The PLVI cutoff values for defining sarcopenia lower than 25% for male and female patients were 0.57 and 0.43, respectively. The overall incidence of AKI was 18.4% (47 patients), and AKI occurred more frequently in sarcopenic patients than in nonsarcopenic patients (29.7% vs. 14.6%, p = 0.007). According to the multivariate logistic regression, which included all variables with a p value < 0.05 in the univariate analysis and adjusted for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) physical status, sarcopenia was revealed to be an independent predictor of postoperative AKI (odds ratio = 5.10, 95% confidence interval = 1.77-14.77; p = 0.003). Conclusions: Preoperative sarcopenia, which corresponds to the lowest quartile of PLVI values, is associated with postoperative AKI among elderly patients who underwent hip fracture surgery.

GS Hip Nail versus Affixus Hip Fracture Nail for the Intramedullary Nailing of Intertrochanteric Fractures.

BACKGROUND: Intertrochanteric fractures are a global health concern, especially in aging populations like the Republic of Korea. Surgical treatments like intramedullary nailing are preferred for their benefit. Various hip nails are used worldwide, each with unique features and challenges. This study aims to compare the GS hip nail with the Affixus hip fracture nail for the treatment of intertrochanteric fractures. MATERIAL AND METHODS: This retrospective study, conducted at a single center, included 179 patients who underwent intramedullary nailing for intertrochanteric fractures using the GS hip nail or the Affixus hip fracture nail. Excluding specific cases, 43 patients in the GS group and 46 in the Affixus group met the minimum 6-month follow-up criteria. RESULT: The GS group exhibited a significantly shorter mean operation time (43.26 min) compared to the Affixus group (51.11 min). Radiographically, both groups showed no significant differences in their reduction quality, tip, and apex distance (TAD), or Cleveland index in the immediate postoperative window. However, the GS group achieved a greater valgus reduction based on the contralateral femoral neck shaft angle (NSA). At 6 months post-operation, there were no significant differences in TAD or advancement and sliding distances. Complication rates were similar between the two groups, with no implant breakages. Clinical outcomes, as measured via mHHS and EQ-5D-5L, showed no significant differences. Despite a slightly higher implant cost, the GS group had a lower total hospital cost than the Affixus group, but this was not statistically significant. CONCLUSIONS: This study highlights the efficiency of the GS hip nail in reducing the operation time compared to the Affixus hip fracture nail with comparable radiologic and clinical outcomes. Further research with long-term follow-up and larger patient studies are needed to fully assess its effectiveness in improving patient outcomes in hip fracture treatment.

A review of robotic-assisted total hip arthroplasty.

Total hip arthroplasty (THA) is a successful surgical method for hip replacement but still poses challenges and risks. Robotic-assisted THA (rTHA) using new generation robotic systems has emerged to improve surgical precision and outcomes. The purpose of this paper is to review the literature on rTHA, with a focus on its advantages, such as individualized preoperative planning, intraoperative assistance, and improved accuracy in implantation, especially in complex cases. Additionally, it aims to explore the disadvantages associated with the use of rTHA, including high costs, the learning curve, and prolonged operation time compared to manual THA (mTHA), which are critical drawbacks that require careful consideration and efforts for minimization. Some financial analyses suggest that rTHA may offer cost-effectiveness and reduced postoperative costs compared to mTHA. While technological advancements are expected to reduce technical complications, there are still debates surrounding long-term outcomes. Practical limitations, such as limited availability and accessibility, also warrant attention. Although the development of rTHA shows promise, it is still in its early stages, necessitating critical evaluation and further research to ensure optimal patient benefits.

Risk Factors of Proximal Screw Breakage of Locking Plate (ZPLP®) after MIPO for Distal Femur Fractures -Analysis of Patients with Plate Removal after Bony Union.

BACKGROUND: Locking a compression plate is a more favorable surgical technique than intramedullary nailing in the treatment of distal femur fractures. This study analyzed the risk factors of proximal screw breakage retrospectively, which was confirmed in the patients with plate removal after bony union. METHODS: A total of 140 patients who were fixed by MIPO using ZPLP from 2009 to 2019 were identified. A total of 42 patients met the inclusion criteria and were included. The screw breakage group (12 patients) and the non-breakage group (30 patients) were compared. RESULTS: Approximately 12 (28.6%) of 42 plate-removal patients showed proximal screw breakage. The breakage of proximal screws developed at the junction of the screw head and neck. The number of broken proximal screws averaged 1.4 (1~4). The breakage of the proximal screw even after the bony union is more frequent in older patients (p = 0.023), the dominant side (p = 0.025), the use of the cortical screw as the proximal uppermost screw (p = 0.039), and the higher plate-screw density (p = 0.048). CONCLUSIONS: Advanced age, dominant side, use of the cortical screw as the uppermost screw, and higher plate-screw density were related to proximal screw breakage. When the plate is removed after bony union or delayed union is shown in these situations, the possibility of proximal screw breakage should be kept in mind.

Clinical Significance of Discordance between Hip and Spine Bone Mineral Density in Korean Elderly Patients with Hip Fractures.

The clinical significance of BMD discordance has not yet been elucidated. The objective of this study was to evaluate the clinical significance of BMD discordance between the hip and spine for hip fractures. The BMD was measured and related factors were investigated in 109 elderly patients hospitalized for a hip fracture (fracture group) and 109 patients hospitalized without a hip fracture (non-fracture group). BMD discordance of the hip and spine was classified as minor discordance (normal and osteopenia, and osteopenia and osteoporosis) and major discordance (normal and osteoporosis). The risk of hip fracture was calculated according to the type of discordance: no discordance, low hip, and lower spine. There was no significant difference between the general characteristics of the fracture group and the non-fracture group. The rate of BMD discordance and low hip discordance were significantly higher in the fracture group (53.2%, 43.1%) than in the non-fracture group (28.4%, 19.3%). The odds ratio of hip fracture was 2.86 times higher in patients with BMD discordance than in those without discordance and 3.42 times higher in the patients with low hip discordance than in those without no hip discordance. The presence of discordance, particularly when there is low hip discordance, might be related to the hip fractures.

Simultaneous reduction and fixation using an anatomical suprapectineal quadrilateral surface plate through modified Stoppa approach in superomedially displaced acetabular fractures.

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Sixteen consecutive patients (14 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 11 both-column fractures and 5 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d'Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. For comparative analysis, 23 patients who underwent internal fixation with the conventional reconstruction plate through modified ilioinguinal approach between February 2010 and May 2018, were selected. This control group was composed of 18 both-column fractures and 5 anterior-column and posterior hemitransverse fractures. The follow-up period was at least 1 year in all patients. The mean operation time and blood loss was 109 min, and 853 ml, respectively, whereas 236 min, and 1843 ml in control group. Anatomical reduction was achieved in 14 (87.5%) patients, while imperfect reduction was achieved in the remaining 2 patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 14 patients (87.5%), one, and one, respectively. The mean PMA score was 16.1 (range 13-18) and the mean VAS score was 1.0 (range 0-3). No secondary reduction loss or implant loosening was observed. However, 2 patients underwent conversion to total hip arthroplasty (THA) due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. In the comparative analysis, radiological outcome showed a significant relationship with the conversion to THA (p = 0.013). Shorter operation time and less blood loss were significantly observed in the QLS plate fixation group through the modified Stoppa approach compared with the conventional reconstruction plate fixation group through modified ilioinguinal approach (p < 0.001, respectively). Simultaneous reduction and fixation using an anatomical suprapectineal QLS plate through the modified Stoppa approach may be a viable technique in superomedially displaced acetabular fractures along with shorter operation time and less blood loss.

Three-Dimensional Computed Tomography Reconstructions Do Not Improve the Interobserver Reliability of the AO/Orthopaedic Trauma Association and Young and Burgess Pelvic Fracture Classifications.

Purpose: To evaluate the value of three-dimensional (3D) computed tomography (CT) scans on the interobserver and intraobserver reliability of AO/Orthopaedic Trauma Association (OTA) and Young and Burgess (YB) classifications for pelvic ring injuries. Methods: Seven reviewers (four fellowship-trained orthopaedic trauma surgeons and three fellows) independently classified 36 pelvic ring injuries using radiographs and axial two-dimensional (2D) CT scan images and then repeated this process 2 months later with the addition of 3D CT images. Interobserver and intraobserver reliability was assessed. Results: The interobserver reliability of the AO/OTA classification using 2D vs. 3D CT scans was considered fair (k 0.23, CI 0.17-0.29) vs. slight (k 0.16, CI 0.09-0.22), with no observed difference [mean difference (MD) - 0.07, CI 0.16-0.01]. The interobserver reliability of the YB classification using 2D vs. 3D CT scans was considered fair for both (k 0.37, CI 0.32-0.42, vs. 0.37, CI 0.30-0.45), with no observed difference (MD - 0.0005, CI - 0.08 to 0.08). The intraobserver reliability of the AO/OTA vs. YB classifications was considered fair (k 0.35, CI 0.26-0.44) vs. moderate (k 0.49, CI 0.40-0.57), with the YB classification having higher kappa value (MD 0.13, CI 0.01-0.26, p = 0.03). Conclusion: The addition of 3D CT scan reconstructions to radiographs and 2D CT did not improve the interobserver reliability of AO/OTA and YB classifications for pelvic ring injuries.

Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1,2 intertrochanteric fractures treated with cephalomedullary nailing.

PURPOSE: Cephalomedullary nails are used widely today for pertrochanteric fractures, and intraoperative lateral wall fractures can cause adverse effects. Recently, a high incidence of coronal fragments in pertrochanteric fractures was reported when analyzed with 3D CT reconstructions. In this study, we analyzed the association between the type of coronal fragments and perioperative lateral wall fractures. METHODS: Patients diagnosed with pertrochanteric fractures and treated by cephalomedullary nails at three university hospitals from September 2016 to December 2020 were examined. A total of 463 patients were included. We examined the coronal fragments and divided the patients into two groups according to the involvement of the posteromedial cortex. Postoperative X-rays were scanned for fracture lines at the blade entry site. RESULTS: Twenty-two patients among 463 patients had perioperative lateral wall fractures. The AO type A2 fractures, use of provisional pins, existence of coronal fragments, involvement of the posteromedial cortex, and the existence of anterior big neck fragments were significantly relevant to perioperative lateral wall fractures. 11 of 22 lateral wall fracture patients were delayed fracture patients, identified 4 weeks after surgery. A coronal fragment combined by anterior big neck fragments had a 9.24 times higher risk of lateral wall fractures compared to fractures with only coronal fragments. CONCLUSION: Pertrochanteric fractures with large coronal fragments and anterior big neck fragments have a high risk of perioperative lateral wall fractures when treated by cephalomedullary nails. Surgeons should examine the width of the intact lateral wall, and take caution to preserve its integrity.

Clinical results of short external rotators preserving posterolateral approach for hemiarthroplasty after femoral neck fractures in elderly patients.

INTRODUCTION: Even though the dislocation rate is lower in the hemiarthroplasty (HA) than total hip arthroplasty, it has still developed as one of serious complications in elderly patients. We have used short external rotators (SER) preserving posterolateral approach to reduce dislocation after hip arthroplasty, especially in elderly patients. The present study was conducted to introduce SER preserving posterolateral approach and report the dislocation rate after HA via this approach in elderly patients with femoral neck fractures. METHODS: Between January 2015 and July 2019, 307 consecutive elderly patients aged over 70 years who underwent cementless bipolar HA for femoral neck fractures and were followed up for at least one year, were enrolled in this study. All surgeries were performed using the SER preserving posterolateral approach. The demographic and perioperative data were examined and the complications including dislocation were investigated. RESULTS: Mean operation time was 54.3 min, and mean estimated blood loss was 252.4 cc. The mean follow-up time was 22.1 months, HHS was 67.5 points at the final examination Dislocation following HA developed in only one patient (0.3%) with dementia during hospital stay, which was reduced closely with no subsequent recurrence. Periprosthetic femoral fracture occurred in two patients, which was treated with internal fixation in one patient and with stem revision in the other patient. There was no surgical site infection or periprosthetic infection as complications. CONCLUSION: The SER preserving technique in posterolateral approach effectively can be effective for reducing the dislocation after HA in elderly patients with femoral neck fracture. It can be encouraged in posterolateral approach for HA, especially in elderly patients under the risk of dislocation.

Bilateral subtrochanteric stress riser fractures following percutaneous screw fixation of femoral neck stress fractures: a literature review and case report.

Hip and groin pain in patients at-risk for femoral neck stress fracture demand a careful workup including advanced imaging in the setting of normal radiographs. A delay in diagnosis can lead to fracture displacement, which negatively impacts outcomes. Non-displaced tension-sided fractures and displaced fractures warrant operative fixation, while non-displaced compression-side fractures can be managed conservatively. Fixation with a sliding hip screw or cephalomedullary nail is recommended over cannulated screws. In addition, all patients should undergo a metabolic workup to identify correctable parameters. We present a rare case of bilateral compression-sided basicervical femoral neck stress fractures in a non-compliant osteoporotic patient who was treated with cannulated screws. The postoperative course was complicated by bilateral subtrochanteric stress riser fractures requiring revision fixation, which could have been prevented with use of a different implant.

Research Update on Stress Riser Fractures.

Stress fractures are fatigue-induced fractures which are caused by repetitive force, often from overuse. They are well-established and frequently encountered in the field of orthopedics. Stress fractures occur in the bone because of low-bone strength and high chronic mechanical stress placed on the bone. Stress riser fractures are also stress fractures that occur because of the presence of cortical defects (holes), changes in stiffness, sharp corners, and cracks (fracture lines). Periprosthetic or peri-implant fractures are good examples of stress riser fractures that occur in regions where stress forces are higher than those in the surrounding material. Most stress riser fractures are related to technical errors (iatrogenic causes) and are difficult to manage. It is possible and more effective to prevent the creation of stress riser fractures through better surgical techniques. The proper terminology for stress fractures, stress riser fractures, periprosthetic fractures, peri-implant fractures, interprosthetic fractures, and interimplant fractures is discussed. This review of the current state of knowledge, diagnosis, treatment, and prevention of stress riser fractures is based on clinical evidence and recent literature.

The Association of Surgical Timing and Injury Severity With Systemic Complications in Severely Injured Patients With Pelvic Ring Injuries.

OBJECTIVES: To evaluate the relationship between timing of definitive fixation, injury severity, and the development of systemic complications in severely injured patients with pelvic ring injuries. DESIGN: Retrospective review. SETTINGS: Level 1 trauma center. PATIENTS: One hundred eighteen severely injured [Injury Severity Score (ISS) ≥ 16] adult patients with pelvic ring injuries undergoing definitive fixation, excluding patients treated with external fixation for hemodynamic instability. INTERVENTION: Early fixation (≤36 hours) in 37 patients and delayed fixation (>36 hours) in 81 patients. MAIN OUTCOME MEASUREMENTS: Systemic complications (acute respiratory distress syndrome, pulmonary embolism, deep venous thrombosis, sepsis, multi-organ failure, and death). RESULTS: The delayed fixation group had a higher ISS and had more patients with chest injuries. There was no detectable difference in the number of patients with systemic complications between early versus delayed fixation groups [8 (22%) vs. 29 (35%), P = 0.1]. The only difference detected in specific complications was a higher incidence of pneumonia with delayed fixation [16 (20%) vs. 0 (0%), P = 0.004] with 11 of the 16 cases being associated with chest injury. Univariate analysis showed an association between complication and time to fixation, ISS, Glasgow Coma Scale, pH, base excess, and injuries to the head, chest, and abdomen. On multivariate analysis, only ISS remained significantly associated with the development of complications [Odds ratio 2.6 per 10 point increase, 95% confidence interval (CI), 1.4-4.4]. CONCLUSIONS: These data suggest that the severity of injury is most highly associated with systemic complications after definitive fixation of pelvic ring injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of standard versus reconstruction proximal interlocking screw configurations for antegrade intramedullary nail fixation of femoral shaft fractures.

BACKGROUND: The standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications. METHODS: A retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications. RESULTS: 130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference -3%, 95% confidence interval (CI) -30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications. CONCLUSIONS: In this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Dual mobility articulation total hip arthroplasty for displaced neck fracture in elderly with neuromuscular disorder.

PURPOSE: Neuromuscular disease is well known to be at increased risk of complications following hip replacement surgeries. This study is prospectively conducted to investigate clinical performance and survivorship of total hip arthroplasty (THA) using dual mobility articulation in femoral neck fractures of elderly with neuromuscular disease. MATERIALS AND METHODS: We prospectively enrolled 162 patients (162 hips) with displaced femoral neck fracture who gave informed consent for dual mobility articulation THA. Of the 162 patients, 35 patients had neuromuscular disease including cerebral palsy, poliomyelitis, hemiplegia, and Parkinson disease (NM group). The other 127 patients had no history of neuromuscular disease (non-NM group). The mean age was 76.5 years (range, 60 - 95) and female ratio was 71.0% (115/162). Clinical outcomes including Harris hip score (HHS), University of California Los Angles activity (UCLA) score were compared between the two groups. Computed tomography and serial radiographs were obtained after surgery. Postoperative complications and reoperation including revision were recorded. RESULTS: Pain-VAS and all clinical scores of the NM group were comparable to those of the non-NM group. The incidence of dislocation in the NM group did not differ from that in Non-NM group (2/35, 5.7% versus 5/127, 3.9%, p = 0.645). Reoperation was performed in 3 hips (3/35, 8.6%) of the NM group and in 4 hips (4/127, 3.1%) of the non-NM group (p = 0.173). Kaplan-Meier survivorship with an end point of revision for any reason was 97.1% (95% confidence interval [CI], 0.92 to 1.03) in the NM group and 98.4% (95% CI, 0.96 to 1.01) in the non-NM group at 7.3 years after surgery. CONCLUSIONS: In elderly with neuromuscular disease, THA with dual mobility articulation is a reasonable option as a treatment for femoral neck fractures.

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

INTRODUCTION: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. METHODS: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. RESULTS: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108). CONCLUSION: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. LEVEL OF EVIDENCE: Level 3, retrospective cohort.

Impact of Dexmedetomidine on Tourniquet-Induced Systemic Effects in Total Knee Arthroplasty under Spinal Anesthesia: a Prospective Randomized, Double-Blinded Study.

BACKGROUND: Clinical studies on the impact of dexmedetomidine on tourniquet-induced systemic effects have been inconsistent. We investigated the impact of dexmedetomidine on tourniquet-induced systemic effects in total knee arthroplasty. METHODS: Eighty patients were randomly assigned to either control (CON) or dexmedetomidine (DEX) group. The DEX group received an intravenous loading dose of 0.5 µg/kg DEX over 10 minutes, followed by a continuous infusion of 0.5 µg/kg/h from 10 minutes before the start of surgery until completion. The CON group received the same calculated volume of normal saline. Pain outcomes and metabolic and coagulative changes after tourniquet application and after tourniquet release were investigated. RESULTS: The frequency of fentanyl administration postoperatively, patient-controlled analgesia (PCA) volume at 24 hours postoperatively, total PCA volume consumed in 48 hours postoperatively, and VAS score for pain at 24 and 48 hours postoperatively were significantly lower in the DEX group than in the CON group. Ten minutes after the tourniquet release, the DEX group showed significantly higher pH and lower lactate level than those in the CON group. Antithrombin III activity and body temperature 10 minutes after tourniquet release were significantly lower in the DEX group than in the CON group. Ca2+, K+, HCO3 -, base excess, and PCO2 levels 10 minutes after tourniquet release were not significantly different between the two groups. CONCLUSION: We showed that DEX attenuated pain and hemodynamic, metabolic, and coagulative effects induced by the tourniquet. However, these metabolic and coagulative changes were within normal limits. Therefore, DEX could be used as an analgesic adjuvant, but should not be considered for routine use to prevent the systemic effects induced by tourniquet use.

Risk Factors Associated with Failure of Cephalomedullary Nail Fixation in the Treatment of Trochanteric Hip Fractures.

BACKGROUND: Intramedullary (IM) nailing is widely performed in elderly patients with trochanteric fractures. Thus, it is important to identify causative factors associated with fixation failure. We investigated fixation failures after IM nailing in elderly patients with trochanteric fractures and compared the failure group with nonfailure group to identify risk factors of fixation failure. METHODS: A total of 396 patients aged 65 years or older underwent IM nailing for trochanteric fractures between January 2012 and August 2016 at our institution. Of those, 194 patients who were followed up for more than 12 months were enrolled in this study; 202 patients were excluded due to death during follow-up, bedridden status before injury, and loss to follow-up. All patients underwent plain radiography and preoperative computed tomography (CT). RESULTS: Fixation failure occurred in 11 patients (5.7%). Seven patients had stable fractures (AO/OTA); eight patients had basicervical fractures (confirmed by CT). Five patients had comminution in the greater trochanter (confirmed by CT). Regarding fracture reduction, eight patients showed discontinuity in the anterior cortex. The position of the lag screw on the lateral view was in the center in six patients and in a posterior area in the other five patients. On the basis of comparison with the 183 patients without fixation failure, risk factors of fixation failure were higher body mass index (BMI; p = 0.003), basicervical type of fracture (p = 0.037), posterior placement of the lag screw on the lateral view (p < 0.001), and inaccurate reduction of the anterior cortex (p = 0.011). CONCLUSIONS: Among the risk factors of fixation failure after IM nailing in elderly patients with trochanteric fractures, discontinuity of the anterior cortex and posterior position of the lag screw are modifiable surgeon factors, whereas higher BMI and basicervical type of fracture are nonmodifiable patient factors. Therefore, care should be taken to avoid fixation failure in IM nailing for patients with a basicervical type of fracture or higher BMI or both.

Posterolateral clamp placement on the pelvic brim provides optimal reduction of transtectal acetabular fractures fixed through the anterior intrapelvic approach.

PURPOSE: To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route. METHODS: Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface. RESULTS: The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7-3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2). CONCLUSIONS: When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

Gamma 3 U-Blade lag screws in patients with trochanteric femur fractures: are rotation control lag screws better than others?

BACKGROUND: Intramedullary hip nails may be classified as blades or screws depending on the type of lag screw used. Recently, a combination of lag screw types with a U-clip insertion has also been used. The purpose of this study was to evaluate the clinical and radiological outcomes of these new screw types. METHODS: A total of 185 patients with trochanteric femoral fractures (age ≥ 65 years) who underwent surgery with intramedullary nails were selected. Surgeries with InterTrochanteric/SubTrochanteric (ITST), Proximal Femoral Nail Antirotation (PFNA), and Gamma 3 U-Blade lag screws were performed between January 2011 and June 2016. The AO/OTA classification, presence of a basicervical fracture type on 3D-CT, BMI, BMD, reduction quality, position of the lag screw, TAD (tip apex distance) of the lag screw, sliding distance of the lag screw, varus change (neck shaft angle), radiological union period, fixation failure and functional outcome as determined by walking ability were analyzed. RESULTS: There were 3/60 (5.0%) cases of fixation failure in the ITST group, all caused by cut-out; 4/57 (7.0%) in the PFNA II group: 3 caused by cut-through and 1 by metal fracture; 1/68 (1.5%) in the Gamma 3 U-Blade lag screw group (P = 0.301). In each group, the sliding distance of the lag screw showed a significant difference (P = 0.017), whereas significant sliding over 10 mm showed no statistically significant results. CONCLUSION: There was only one (1.5%) case of fixation failure in the Gamma 3 U-Blade lag screw group. The sliding distance of the U-Blade was found to be in the middle, between the PFNA II (shorter) and ITST (longer) implants. The new rotational control lag screw seems to be comparable to other screw types.