Risk Factors Associated with Intraoperative Iatrogenic Fracture in Patients Undergoing Intramedullary Nailing for Atypical Femoral Fractures with Marked Anterior and Lateral Bowing.

Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49-87 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p < 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3° in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment.

Repair integrity and functional outcomes of arthroscopic repair in chronic anterior shoulder instability: single-loaded versus double-loaded single-row repair.

INTRODUCTION: This study compared the clinical outcome and repair integrity of single-loaded and double-loaded single-row arthroscopic repair of chronic anterior shoulder instability. MATERIALS AND METHODS: Fifty consecutive chronic anterior shoulder instability cases treated by arthroscopic labral repair were included. A single-loaded single-row technique was used in the first 25 consecutive shoulders, and a double-loaded single-row technique was used in the next 25 consecutive shoulders. The number of suture anchors was 4 in the shoulders that underwent single-loaded repair and 3 in the shoulders that underwent double-loaded repair. 42 shoulders (84.0%) followed up clinical outcomes were evaluated a minimum 2 years (mean 28.5 months; range 24-46) postoperatively. The postoperative labral repair integrity was evaluated by MDCT-arthrogram at a minimum 6 months postoperatively. RESULTS: At the final follow-up, the average UCLA, ASES, Constant, Rowe score, VAS pain score, and VAS for instability scores improved significantly, to 33.05, 92.33, 89.05, 94.86, 0.90 and 0.52, respectively, in the single-loaded group and to 32.19, 90.10, 89.05, 94.52, 0.90, and 0.86, respectively, in the double-loaded group. The clinical scores improved in both groups postoperatively (all P < 0.05); however, there was no significant difference between the two groups at final follow-up (P = 0.414, 0.508, 1.000, 0.917, 1.000, and 0.470, respectively). The re-tear rate was 2 (9.5%) in the shoulders that underwent single-loaded repair and 3 (14.3%) in the shoulders that underwent double-loaded repair; this difference was statistically not significant (P = 0.634). CONCLUSION: The double-loaded single-row technique resulted in comparable clinical outcomes, and re-tear rate compared with the single-loaded single-row technique in chronic anterior shoulder instability at short-term follow-up. Number of used suture anchor in double-loaded single-row technique was fewer than that of single-loaded single-row technique. LEVEL OF EVIDENCE: Comparative retrospective study, level III.

Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method.

BACKGROUD: The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications. METHODS: We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion. RESULTS: Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12-20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and Constant-Murley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable. Therefore, second surgery for implant removal is necessary after bone union is achieved.

Relationship between incidence of postoperative radial nerve palsy and surgical experience in the treatment of humeral shaft fractures through a posterior triceps splitting approach: A retrospective study.

OBJECTIVE: The aim of this study was to investigate the incidence of postoperative radial nerve palsy (PORNP) after the surgical treatment of humeral shaft fractures through a posterior triceps splitting approach by a single surgeon's experience in a consecutive case series from a single trauma center. METHODS: In this retrospective study, a total of 118 patients (82male, 36 female;mean age = 48 years, age range = 16 - 80 years)who underwent open reduction and plate fixation through posterior triceps splitting approach due to humeral shaft fractures at a level I trauma center were included. Level of the fractures was categorized as the proximal third, middle third, and distal third of the diaphysis, and then all the fractures were classified according to the AO/OTA classification system. The trend of incidence of PORNP was investigated. All the operations were performed by a single surgeon. The recovery time of PORNP was also recorded. RESULTS: There were 13 cases of proximal third, 67 cases of middle third, and 38 cases of distal third fracture. Based on AO/OTA classification, there were 29 cases of A1-type, 23 cases of A2-type, 42 cases of A3-type, 17 cases of B2-type, 3 cases of B3-type, and 4 cases of C2-type fracture. The overall incidence of PORNP was 11% (13 cases). All the PORNP cases fully recovered within 10.3 ± 10.4 weeks (range = 1 - 44) with conservative treatment. Incidence of PORNP significantly decreased with increase in surgical experience (P = 0.009). The incidence of radial nerve palsy was not significantly related to the level of the fracture (P = 0.199). The incidence of radial nerve palsy was not significantly related with the fracture pattern according to AO/OTA classification (P = 0.659). CONCLUSION: Evidence from this study has shown that the incidence of PORNP following the posterior triceps splitting approach for the treatment of humeral shaft fractures is significantly associated with the surgeon's experience. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

BACKGROUD: The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model. METHODS: Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination. RESULTS: On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage. CONCLUSIONS: The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

Pathological Fracture of the Femoral Neck due to Tophaceous Gout: An Unusual Case of Gout.

A 48-year-old man visited the emergency room with right hip pain that started abruptly while walking out of the bathroom. Computed tomography showed an intraosseous mass in the femoral neck. The patient had a 15-year history of gout and had numerous bilateral tophi in his hands, feet, knees, and elbows. After operation, we diagnosed a pathological fracture due to intraosseous tophi. Patients with hip pain who have many subcutaneous tophi and long-standing gout should be diagnosed carefully. Peri-hip joint pain caused by gout is uncommon, however, if a patient complains of pain, a simple X-ray may be required. If intraosseous tophi are present, appropriate treatment (e.g., strict hyperuricemia control with or without prophylactic internal fixation), may be required before fracture occurs.

Arthroscopic Resection of Osteochondroma of Hip Joint Associated with Internal Snapping: A Case Report.

A 16-year old male patient visited the hospital complaining of inguinal pain and internal snapping of right hip joint. In physical examination, the patient was presumed to be diagnosed femoroacetabular impingement (FAI) and acetabular labral tear. In radiologic evaluation, FAI and acetabular labral tear were identified and bony tumor associated with internal snapping was found on the posteromedial portion of the femoral neck. Despite of conservative treatment, there was no symptomatic improvement. So arthroscopic labral repair, osteoplasty and resection of bony tumor were performed. The tumor was pathologically diagnosed as osteochondroma through biopsy and all symptoms improved after surgery. There was no recurrence, complication or abnormal finding during 1 year follow up. Osteochondroma located at posteromedial portion of femoral neck can be a cause of internal snapping hip and although technical demands are challenging, arthroscopic resection can be a good treatment option.

Repair of the Complete Radial Tear of the Anterior Horn of the Medial Meniscus in Rabbits: A Comparison between Simple Pullout Repair and Pullout Repair with Human Bone Marrow Stem Cell Implantation.

PURPOSE: To evaluate the degree of biological healing response that occurs between the anterior horn of the medial meniscus (MM) and the tibial plateau and investigate the biological healing response after injection of human bone marrow stem cells (hBMSCs) in a rabbit model. MATERIALS AND METHODS: Twenty-five rabbits with a mean body weight of 2.5 kg were chosen for this study. On the left knee, a complete radial tear was made at the anterior tibial attachment site of MM and after removal of tibial cartilage, pullout repair of the torn MM was performed on the tibial plateau. On the right knee, the same procedure was performed, and a scaff old (matrix gel) that contained human bone marrow stem cell was implanted between MM and the tibial plateau. A biopsy was performed at 2 (group 1), 4 (group 2), and 8 (group 3) weeks postoperatively. The authors compared the differences in the degree of biological healing of each group and investigated the degree of biologic healing after hBMSC implantation by comparing the left knee with the right knee. RESULTS: On the biopsy of 40 knees of 20 rabbits that survived after operation, all groups did not show the healing response between the undersurface of MM and the tibial plateau. There was no significant difference in terms of the pathological criteria such as fibroblasts and fibrochondrocytes etc., with and without hBMSC implantation. CONCLUSIONS: There was no attachment between the repaired MM and the tibial plateau after complete radial tear on MM and the authors could not identify the effect of hBMSC.