Clinical and radiographic results of locking plate with medial support screw in Proximal Humerus fracture - the more, the better?

BACKGROUND: The calcar of the proximal humerus is a fundamental structure for medial humeral column support. This study aimed to assess the outcome of osteosynthesis across cases of unstable proximal humerus fractures (PHFs) with medial calcar comminution, following treatment with a PHILOS locking plate and medial support screw (MSS). METHODS: Between January 2010 and December 2018, we retrospectively analyzed the outcomes of 121 cases of osteosynthesis for PHFs with medial column disruption. For the medial support, at least one oblique screw was inserted within 5 mm of the subchondral bone in the inferomedial quadrant of the humeral head. All patients were categorized into two groups: 26 patients in the single MSS group, and 95 in the multiple MSS group. Follow-up after at least an year involved clinical and radiographic outcome evaluations, and correspondingly measuring the Constant-Murley score, University of California, Los Angeles (UCLA) shoulder scale, pain visual analogue scale (VAS), major complications, neck-shaft angle (NSA), humeral head height (HHH), and the eventual time to bone union. Risk factors for the major complications were assessed by multivariate logistic regression analyses. RESULTS: The cohort's mean age was 64.4 ± 15.4 years, and the mean follow-up duration was 19.5 ± 7.6 months. At the final follow-up, between the single MSS and multiple MSS groups, no significant differences in the Constant-Murley score (p = 0.367), UCLA score (p = 0.558), VAS (p = 0.571), time to bone union (p = 0.621), NSA loss (p = 0.424), and HHH loss (p = 0.364) were observed. The incidence of complications (p = 0.446) based on the number of MSS were not significantly different. The initial insufficient reduction after surgery (of NSA < 125°) was found to be a significant risk factor for post-surgical complications. CONCLUSIONS: To treat unstable PHFs, the use of at least one MSS along with a locking plate system is sufficient to achieve satisfactory outcomes. Successful operative treatment using a locking plate for PHF treatment is inherent in anatomical fracture reduction, coupled with medial column support.

Novel Use of a Fibular Strut Allograft with Fibular Head in an Elderly Patient with Proximal Humeral Fracture and Severe Metaphyseal Comminution: An Alternative to Shoulder Arthroplasty.

Treatment of a comminuted proximal humerus fracture (PHF) in elderly patients with severe osteoporosis is challenging, often leading to arthroplasty (such as hemiarthroplasty or reverse shoulder arthroplasty) as the treatment of choice. However, arthroplasty does not always guarantee favorable outcomes. In contrast, the use of intramedullary fibular strut allografts provides additional reduction stability during locking plate fixation; however, to our knowledge, there is limited literature on the use of fibular strut allografts, including the fibular head. Here we aim to report the advantages of using a fibular strut containing the fibular head in severe osteoporotic PHFs. We present the case of an 88-year-old female patient with severe osteoporosis diagnosed with a left PHF accompanied by severe metaphyseal comminution following a fall from a chair. Rather than shoulder arthroplasty, we performed osteosynthesis using a fibular strut allograft containing the fibular head. At the one-year follow-up after surgery, we observed excellent bony union and a favorable functional outcome without major complications, such as reduction loss. The novel use of a fibular strut allograft containing the fibular head could be promising for PHFs with severe metaphyseal comminution, potentially avoiding the need for arthroplasty.

Does the coronoid fracture in terrible triad injury always need to be fixed?

BACKGROUND: The ideal treatment of terrble triad injuries and whether fixation of coronoid process fractures is needed or not are still debated. Therefore, we aimed to investigate if terrible triad injuries necessitate coronoid fracture fixation and evaluate if non-fixation treatments have similar efficacies and outcomes as fixation-treatments in cases of terrible triad injuries. METHODS: From August 2011 to July 2020, 23 patients with acute terrible triad injuries without involvement of the anteromedial facet of the coronoid process were included to evaluate the postoperative clinical and radiological outcomes (minimum follow-up of 20 months). According to the preoperative height loss evaluation of the coronoid process and an intraoperative elbow stability test, seven patients underwent coronoid fracture fixation, and the other eight patients were treated conservatively. The elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and modified Broberg-Morrey score were evaluated at the last follow-up. In addition, plain radiographs were reviewed to evaluate joint congruency, fracture union, heterotopic ossification, and the development of arthritic changes. RESULTS: At the last follow-up, the mean arcs of flexion-extension and supination-pronation values were 118.2° and 146.8° in the fixation group and 122.5° and 151.3° in the non-fixation group, respectively. The mean MEPSs were 96.4 in the fixation group (excellent, nine cases; good, tow cases) and 96.7 in the non-fixation group (excellent, ten cases; good, two cases). The mean modified Broberg-Morrey scores were 94.0 in the fixation group (excellent, sevev cases; good, four cases) and 94.0 in the non-fixation group (excellent, ten cases; good, tow cases). No statistically significant differences in clinical scores and ROM were identified between the two groups. However, the non-fixation group showed a significantly lower height loss of the coronoid process than the fixation group (36.3% versus 54.5%). CONCLUSIONS: There were no significant differences in clinical outcomes between the fixation and non-fixation groups in terrible triad injuries.

Outcome Prediction Model Following Proximal Femoral Osteotomy in Legg-Calvé-Perthes Disease Using Machine Learning Algorithms.

BACKGROUND: The purpose of the current study was (1) to analyze various factors that may be associated with the outcomes of Legg-Calvé-Perthes disease (LCPD), and (2) to develop and internally validate machine learning algorithms capable of providing patient-specific predictions of which patients with LCPD will achieve relevant improvement in radiologic outcomes after proximal femoral varus osteotomy (PFVO). We examined several variables, previously identified as factors, that may influence the outcome of LCPD and developed a machine learning algorithm based on them. METHODS: In this retrospective study, we analyzed patients aged older than  6 years at the time of LCPD diagnosis who underwent PFVO at our institution between 1979 and 2015. Univariate and multivariate logistic regression analyses were used to examine the effects of variables on the sphericity of the femoral head at skeletal maturity, including age at onset, sex, stage at operation, extent of epiphyseal involvement and collapse, presence of specific epiphyseal, metaphyseal, and acetabular changes, and postoperative neck shaft angle (NSA). Recursive feature selection was used to identify the combination of variables from an initial pool of 13 features that optimized the model performance. Five machine learning algorithms [extreme gradient boosting (XGBoost), multilayer perception, support vector machine, elastic-net penalized logistic regression, and random forest) were trained using 5-fold cross-validation 3 times and applied to an independent testing set of patients. RESULTS: Ninety patients with LCPD who underwent PFVO were included in this study. The mean age at diagnosis was 7.93 (range, 6.0 to 12.33) years. The average follow-up period was 10.11 (range, 5.25 to 22.92) years. A combination of 8 variables, optimized algorithm performance, and specific cutoffs were found to decrease the likelihood of achieving the 1 or 2 Stulberg classification: age at onset ≤ 8.06, lateral classification ≤ B, 12.40 < preoperative migration percentage (MP) ≤ 22.85, Catterall classification ≤ 2, 117.4 < postoperative NSA ≤ 122.90, -10.8 < postoperative MP ≤ 6.5, 139.65 < preoperative NSA ≤ 144.67, and operation at stage 1. The XGBoost model demonstrated the best performance (F1 score: 0.78; area under the curve: 0.84). CONCLUSIONS: The XGBoost machine learning algorithm achieved the best performance in predicting the postoperative radiologic outcomes in patients with LCPD who underwent PFVO. In our population, age at onset ≤ 8.06, lateral classification ≤ B, 12.40 < preoperative MP ≤ 22.85, Catterall classification ≤ 2, 117.4 < postoperative NSA ≤ 122.90, -10.8 < postoperative MP ≤ 6.5, 139.65 < preoperative NSA ≤ 144.67, and operation at an early stage had the likelihood of achieving the spherical femoral head for the patients with LCPD that underwent PFVO. After external validation, the online application of this model may enhance shared decision-making. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Treatment of bilateral congenital extensor tendon dislocation on multiple digits with only one sagittal band reconstruction: a case report.

Bilateral congenital dislocation of the extensor tendon in the metacarpophalangeal joint is an exceedingly rare disease and often involves multiple fingers. Surgical treatment of multiple congenital extensor tendon dislocations in both hands has been reported; however, no report has clearly stated whether all fingers should be surgically treated in patients with multiple finger involvement. We report a case in which we successfully treated bilateral congenital extensor tendon dislocation on multiple digits with only one single-loop reconstruction of the sagittal band instead of operating on all involved fingers.

Relationship between Slip Severity and BMI in Patients with Slipped Capital Femoral Epiphysis Treated with In Situ Screw Fixation.

Background: Slipped capital femoral epiphysis (SCFE) is a hip disorder that occurs in adolescence before epiphyseal plate closure, causing anatomical changes in the femoral head. Obesity is known to be the single most important risk factor for idiopathic slipped capital femoral epiphysis (SCFE), which is highly related to mechanical factors. Meanwhile, as increased slip angle increases major complications in patients with SCFE, slip severity is an important factor to evaluate prognosis. In obese patients with SCFE, higher shear stress is loaded on the joint, which increases the likelihood of slip. The study aim was to assess the patients with SCFE treated with in situ screw fixation according to the degree of the obesity and to find any factors affecting the severity of slip. Methods: Overall, 68 patients (74 hips) with SCFE who were treated with in situ fixation screw fixation were included (mean age 11.38, range: 6-16) years. There were 53 males (77.9%) and 15 females (22.1%). Patients were categorized underweight, normal weight, overweight, and obese depending on BMI percentile for age. We determined slip severity of patients using the Southwick angle. The slip severity was defined as mild if the angle difference was less than 30 degrees, moderate if the angle difference was between 30 and 50 degrees, and severe if the angle difference was greater than 50 degrees. To examine the effects of several variables on slip severity, we used a univariable and multivariate regression analysis. The following data were analyzed: age at surgery, sex, BMI, symptom duration before diagnosis (acute, chronic, and acute on chronic), stability, and ability to ambulate at the time of the hospital visit. Results: The mean BMI was 25.18 (range: 14.7-33.4) kg/m2. There were more patients with overweight and obese than those with normal weight in SCFE (81.1% vs. 18.9%). We did not find significant differences between overall slip severity and degree of obesity or in any subgroup analysis. Conclusions: We did not find a relationship between slip severity and degree of obesity. A prospective study related to the mechanical factors affecting the slip severity according to the degree of obesity is needed.

Higher survival rate in total knee arthroplasty after high tibial osteotomy than that after unicompartmental knee arthroplasty.

PURPOSE: The objective of this study was to evaluate the survival rates and complications in TKA after UKA and HTO as compared with primary TKA using national health data. It was hypothesized that survival and complication rates would be worse in patients with a history of UKA or HTO compared to primary TKA. METHODS: Based on a list of patients who underwent TKA from Korean National Health Insurance database, 315,071 underwent primary TKA (group A); 2177 TKA after HTO (group B); and 1284 TKA after UKA (group C). Revision rates were compared between the groups using log-rank tests and adjusted hazard ratios (HR) of groups B and C were compared with those of the reference group (group A). A total of 1000 TKA matched patients were assigned to groups B and C according to propensity score for comparing revision rates after TKA and perioperative complication rates between TKA after HTO and UKA. RESULTS: The overall revision rate was 2.1% in group A, 2.0% in group B, and 4.2% in group C. The revision rate until 10 years after TKA was significantly higher in group B (p = 0.03) or C (p < 0.0001) than in group A. The hazard ratios for revision was significantly higher in group A than in groups B and C at 10 years after index TKA (1.4 in group B and 3.7 in group C). The result of the comparison using PSM between TKA after HTO and UKA showed that TKA after HTO had lower risk of revision than TKA after UKA (HR: 0.41 at 10 years). However, no statistically significant differences in the perioperative complication rate between the two groups were found. (NS, not significant) CONCLUSIONS: TKA after UKA or HTO showed a significantly higher risk of revision than primary TKA. While TKA after HTO showed lower risk of revision than TKA after UKA, no significant differences in complications between TKA after UKA and HTO were found. Thus, surgeons must be aware of the low survival rate in TKA after UKA or HTO, especially in TKA after UKA. LEVEL OF EVIDENCE: III (Retrospective cohort study).

Quantification method to objectively evaluate the fibrous structural status of tendons based on polarization-sensitive OCT.

Histological analysis is widely used to evaluate injured tendons; however, it has the limitation of being semi-quantitative. Hence, we developed a quantification method to objectively evaluate the fibrous structure of tendons, exhibiting the optical property of birefringence, using polarization-sensitive optical coherence tomography (PS-OCT). We used a partial-rupture rat model in which the middle 0.75 cm of the Achilles tendon was cut with a blade. Rats were sacrificed at 2, 4 or 6 weeks after the injury, and PS-OCT and histological analyzes were performed. The PS-OCT phase retardation images and score well represented the structural changes of the injured tendon according to the wound healing state. Therefore, the proposed novel quantification method using PS-OCT can be used to evaluate the fibrous structural status of tendons.

Results of Early Proximal Femoral Osteotomy at Skeletal Maturity in Legg-Calvé-Perthes Disease: Implication for the Bypass of Fragmentation Stage.

BACKGROUND: The aim was to assess the long-term radiographic outcomes of patients with Legg-Calvé-Perthes disease following an early proximal femoral osteotomy (PFO) performed in avascular necrosis stage or early fragmentation stage. METHODS: In this retrospective study, we analyzed data of 65 patients aged above 6 years at the time of diagnosis with unilateral Legg-Calvé-Perthes disease, following early PFO performed at our institution between 1979 and 2013. We observed the presence of bypassing fragmentation stage, which was classified into complete and incomplete. We compared radiographic outcomes between patients with bypass of fragmentation stage (26 hips) and those without (31 hips). Regarding skeletal maturity, the hips were graded according to the femoral head shapes: spherical, ovoid, or flat. RESULTS: The mean age at diagnosis was 7.9 years (range: 6.0 to 11.9 y). The average follow-up period was 11.8 years (range: 5.9 to 22.9 y). Fragmentation bypass occurred in 40.5% (26/65) of patients, with 8 (12.3%) "undetermined" cases. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016). The femoral head was also significantly more spherical in patients with bypass (P=0.024). CONCLUSIONS: Our results show that 40.5% of patients who underwent early PFO bypassed the fragmentation stage. The degree of lateral pillar collapse was lower in patients with bypass. In addition, there were significantly more patients with more spherical femoral head in the bypass group. LEVEL OF EVIDENCE: Level IV-case series.

Long-term outcomes of cementless femoral stem revision with the Wagner cone prosthesis.

BACKGROUND: The procedure of femoral stem revision is challenging, and bone conservation with less stress shielding is a mandatory effort in these cases. Although there are several reports of stem revision with stems designed for primary total hip arthroplasty (THA), there is no report on stem revision with the Wagner cone prosthesis. METHODS: Between 1996 and 2008, 41 hips of 41 consecutive patients were subjected to femoral revision THA using the Wagner cone prosthesis. The mean age during revision surgery was 56.1 years, and the mean follow-up period was 14.8 years. The clinical results were evaluated, and the femoral component was assessed radiologically. RESULTS: The results showed that the average period from the first operation to revision THA was 8.0 years. Additionally, the mean Harris hip score improved from 52 points preoperatively to 83 points at the final follow-up. All stems showed bone integration in the radiological evaluation. A subsidence of more than 5 mm was observed in 3 out of 28 (10.7%) femoral stems. Two patients needed an acetabular revision for acetabular cup loosening during the follow-up period. Furthermore, one patient had recurrent dislocation and had to undergo revision surgery for soft tissue augmentation. CONCLUSIONS: We achieved favorable clinical and radiological long-term outcomes in femoral stem revision using the Wagner cone prosthesis. This cementless femoral stem could be an option for femoral stem revision in cases with relatively good bone stock.

No difference of survival between cruciate retaining and substitution designs in high flexion total knee arthroplasty.

The aim of this study was to compare the long-term implant survival and outcomes in patients with high-flexion cruciate-retaining (CR) or high-flexion posterior cruciate-substituting (PS) knee implants. A total of 253 knees (CR group: 159 vs. PS group: 94) were available for examination over a mean follow-up of 10 years. Clinical outcomes were assessed including the Hospital for Special Surgery score, Knee Society score and Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up. Radiologic measurements were also assessed including the hip-knee-ankle angle and radiolucent lines according to the KSS system at the final follow-up. The survival rate was analyzed using the Kaplan-Meier method. At the final follow-up, the mean total HSS scores were similar between the two groups (p = 0.970). The mean hip-knee-ankle angle at the final follow-up was similar between groups (p = 0.601). The 10- and 15-year survival rates were 95.4% and 93.3% in the CR group and 92.7% and 90.9% in the PS group, respectively, with no significant difference. Similar clinical and radiographic outcomes could be achieved with both the high-flexion CR and high-flexion PS total knee designs without a difference in survival rate after a 10-year follow-up.

Characteristics of hip impingement syndrome in patients with multiple hereditary exostoses.

BACKGROUNDS: This study aimed to investigate the characteristic deformities of the hip in multiple hereditary exostoses patients (MHE) and its association with the hip impingement syndrome. MATERIALS AND METHODS: Between 2001 and 2019, total 51 patients (102 hips) were evaluated in this study. Patients with MHE were classified to femoro-acetabular impingement (FAI) symptom group, ischio-femoral impingement (IFI) symptom group and non-impingement symptom group by comparing the symptoms, clinical signs and imaging studies. To assess the morphometry of the hip in patients with MHE, the femoral neck-shaft angle, Sharp's acetabular angle and center-edge (CE) angle were evaluated. Alpha angle was further evaluated to investigate the FAI using radiographs, and the minimum ischio-femoral distance was further measured to investigate the IFI using computed-tomographic (CT) study. RESULTS: On hip impingement symptom analysis, FAI symptom and IFI symptom were confirmed in 14 hip joints and 18 hip joints, respectively. Unlike general population, the number of the hip with IFI-symptom was higher than those with FAI symptom in this study. In morphometric evaluation of MHE hips, coxa valga was most prominent deformity with occasional tendency of mild acetabular dysplasia. In a comparison of morphometric study between the impingement symptom group and non-symptom group, the FAI symptom showed significant differences of morphometric measure values than those of the non-symptom group (FAI symptom group vs. Non-FAI symptom group; Femoral neck-shaft angle (153.9 vs 142.6), Sharp's angle (45.0 vs 41.5), CE angle (21.1 vs 28.8) and alpha angle (76.7 vs 57.9)). Similarly, the IFI symptom group also showed significant differences of morphometric measure values than those of the non-symptom group (IFI-symptom vs. Non-IFI symptom; Femoral neck-shaft angle (150.9 vs 142.7), Sharp's angle (44.7 vs 41.4), CE angle (21.1 vs 29.3) and alpha angle (73.3 vs 56.8)). In addition, the minimum ischio-femoral distance measured using CT was significantly decreased in the IFI symptom group (IFI symptom group: 6.6, Non-IFI symptom group: 16.4). CONCLUSION: The results suggest that the characteristic deformities represented by coxa valga in the MHE hip act as an offset for FAI symptoms, on the contrary, act as a trigger for IFI symptoms. LEVEL OF EVIDENCE: Level III.