Treatment of posterolateral tibial plateau fractures: a narrative review and therapeutic strategy.

The posterolateral tibial plateau is crucial for maintaining knee stability during flexion, and fractures in this area often involve ligament and meniscus injuries, necessitating effective management. However, treating posterolateral tibial plateau fractures (PLF) poses significant challenges due to the complex anatomy. Therefore, this review aims to explore contemporary concepts of PLF, from identification to fixation, and proposes a comprehensive treatment strategy. In this article, the authors detail the injury mechanisms, fracture morphology, PLF classification systems, surgical approaches, and techniques for open reduction and internal fixation (ORIF) as well as arthroscopic-assisted internal fixation (ARIF). The findings indicate that PLF is typically caused by flexion-valgus forces, resulting in depression or split-depression patterns. For isolated PLF, the supra-fibular head approach is often preferable, whereas posterior approaches are more suitable for combined fractures. Additionally, innovative plates, particularly the horizontal belt plate, have shown satisfactory outcomes in treating PLF. Currently, the 'bicondylar four-quadrant' concept is widely used for assessing and managing the tibial plateau fractures involving PLF, forming the cornerstone of the comprehensive treatment strategy. Despite challenges in surgical exposure and implant placement, ORIF remains the mainstream treatment for PLF, benefiting significantly from the supra-fibular head approach and the horizontal belt plate. Furthermore, ARIF has proven effective by providing enhanced visualization and surgical precision in managing PLF, emerging as a promising technique.

Anteromedial Cortical Support in Reduction of Trochanteric Hip Fractures: From Definition to Application.

➤ The concept of anteromedial cortical support (AMCS) serves as valuable guidance for the intraoperative reduction of trochanteric hip fractures.➤ Positive medial cortical support (MCS) and positive or neutral anterior cortical support (ACS) are desirable. Some evidence has suggested that positive MCS is potentially superior to neutral MCS.➤ Experimental studies underscore the vital importance of the anteromedial wall and reveal why positive MCS potentially outperforms neutral MCS.➤ Incorporating the AMCS concept, the Chang reduction quality criteria (CRQC) are a reliable alternative approach to evaluate the reduction quality of trochanteric hip fractures.

Importance of the Posterior Plate in Three-Column Tibial Plateau Fractures: A Finite Element Analysis and Clinical Validation.

OBJECTIVE: Dual-plate fixation was thought to be the gold standard for treating complicated bicondylar tibial plateau fractures, yet it was found to be hard to accommodate the posterior column in three-column fractures. Currently, column-specific fixation is becoming more and more recognized, but no comprehensive investigation has been performed to back it up. Therefore, the objective of this study was to validate the importance of posterior column fixation in the three-column tibial fractures by a finite element (FE) analysis and clinical study. METHODS: In FE analysis, three models were developed: the longitudinal triple-plate group (LTPG), the oblique triple-plate group (OTPG), and the dual-plate group (DPG). Three loading scenarios were simulated. The distribution of the displacement and the equivalent von Mises stress (VMS) in each structure was calculated. The comparative measurements including the maximum posterior column collapse (MPCC), the maximum total displacement of the model (MTD), the maximum VMS of cortical posterior column (MPC-VMS), and the maximum VMS located on each group of plates and screws (MPS-VMS). The clinical study evaluated the indicators between the groups with or without the posterior plate, including operation time, blood loss volume, full-weight bearing period, Hospital for Special Surgery Knee Scoring system (HSS), Rasmussen score, and common postoperative complications. RESULTS: In the FE analysis, the MPCC, the MPC-VMS, and the MTD were detected in much lower amounts in LTPG and OTPG than in DPG. In comparison with DPG, the LTPG and OTPG had larger MPS-VMS. In the clinical study, 35 cases were included. In the triple-plate (14) and dual-plate (21) groups, the operation took 115.6 min and 100.5 min (p < 0.05), respectively. Blood loss in both groups was 287.0 mL and 206.6 mL (p < 0.05), and the full-weight bearing period was 14.5 weeks and 16.2 weeks (p < 0.05). At the final follow-up, the HSS score was 85.0 in the triple-plate group and 77.5 in the dual-plate (p < 0.05), the Rasmussen score was 24.1 and 21.6 (p < 0.05), there were two cases with reduction loss (9.5%) in the dual-plate group and one case of superficial incision infection found in the triple-plate group. CONCLUSION: The posterior implant was beneficial in optimizing the biomechanical stability and functional outcomes in the three-column tibial plateau fractures.

Avulsion Fracture of the Tibialis Anterior Tendon Associated with First Metatarsal Base Fracture: A Case Report and Literature Review.

We present a unique case of a 59-year-old shipyard worker who sustained an avulsion fracture of the tibialis anterior tendon, concurrently with a comminuted fracture at the base of the first metatarsal. This is the first reported case highlighting this concomitant presentation, which underlines the possibility of avulsion fractures accompanying comminuted fractures. Importantly, such avulsion fractures could lead to skin tenting and potential necrosis, necessitating early identification and prompt intervention. The patient underwent successful surgical intervention and displayed good functional restoration 15 months postoperatively.

The Impact of Banana-Shaped Fragments on Trochanteric Hip Fractures Treated by PFNA.

Background: Regarding trochanteric hip fractures, one type of posterior coronal fragments was described as the "banana-shaped fragment", while the impact of the banana-shaped fragment on mechanical stability has not been further studied. The current study investigated the association between the banana-shaped fragment and mechanical complications after surgery. Methods: This retrospective cohort study included 273 patients treated by proximal femoral nail antirotation (PFNA) in the full analysis. The age, the sex, the fracture side, the follow-up time, the American Society of Anesthesiologists classification, the operators, the fracture classification, the tip-apex distance, the blade positions, the reduction quality and the bone mineral density were analyzed in relation to mechanical complications, through univariate and multivariate approaches. Results: Mechanical complications happened in 33 patients. The banana-shaped fragment (adjusted odds ratio 5.240, 95% CI 2.172 to 12.641; p < 0.001), the tip-apex distance and the reduction quality showed significant association with mechanical complications in both univariate and multivariate analysis. Moreover, for 118 patients with the banana-shaped fragment, we found that the use of wire cerclage couldn't significantly lower the rates of mechanical complications (p = 0.648). Conclusions: The banana-shaped fragment had a negative impact on mechanical stability of trochanteric hip fractures treated by PFNA. In the perioperative period, the BSF should be carefully evaluated, and its specific handling deserves further study.

Positive medial cortical support versus anatomical reduction for trochanteric hip fractures: Finite element analysis and biomechanical testing.

BACKGROUND AND OBJECTIVES: The anatomical reduction (AR) is usually considered the best option for fractures. Nevertheless, in unstable trochanteric hip fractures (UTHF), previous clinical reports found that the positive medial cortical support (PMCS, an over-reduction technique) attained higher mechanical stability, but this challenging clinical finding still needs experimental validation. METHODS: This study constructed in-silico and biomechanical PMCS and AR models, with the use of the most clinically-representative geometry design of fracture models, the multi-directional design in FE analysis, and the subject-specific (osteoporotic) bone material properties, to make the models better mimic the actual condition in clinical settings. Then multiple performance variables (von-Mises stress, strain, integral axial stiffness, displacement, structural changes, etc.) were assessed to uncover details of integral and regional stability. RESULTS: Among in-silico comparison, PMCS models showed significantly lower maximum displacement than AR models, and the maximum von Mises stress of implants (MVMS-I) was significantly lower in PMCS models than in AR models (highest MVMS-I in -30°-A3-AR of 1055.80 ± 93.37 MPa). Besides, PMCS models had significantly lower maximum von Mises stress along fracture surfaces (MVMS-F) (highest MVMS-F in 30°-A2-AR of 416.40 ± 38.01 MPa). Among biomechanical testing comparison, PMCS models showed significantly lower axial displacement. Significantly lower change of neck-shaft angle (CNSA) was observed in A2-PMCS models. A fair amount of AR models converted into the obvious negative medial cortical support (NMCS) condition, whereas all PMCS models kept the PMCS condition. The results were also validated through comparison to previous clinical data. CONCLUSIONS: The PMCS is superior to the AR in the UTHF surgery. The current study opens up the second thought of the role of over-reduction technique in bone surgery.

Computational evaluation of the axis-blade angle for measurements of implant positions in trochanteric hip fractures: A finite element analysis.

BACKGROUND: Recently, a novel approach axis-blade angle (ABA) was developed to measure implant positions during trochanteric hip fracture surgery. It was defined as the sum of two angles α and ß measured between the femoral neck axis and helical blade axis in anteroposterior and lateral X-ray films, respectively. Although its clinical practicability has been confirmed, the mechanism is yet to be investigated by means of finite element (FE) analysis. METHODS: Computed tomography images of four femurs and dimensions of one implant at three angles were obtained to construct FE models. For each femur, 15 FE models in an arrangement (intramedullary nails at three angles multiplying five blade positions) were established. Under the simulation of normal walking loads, the ABA, von Mises stress (VMS), maximum/minimum principal strain and displacement were analyzed. RESULTS: When the ABA increased, all outcome indicators initially decreased till reaching inferior-middle site and then increased while the blade positions within the femoral head shifted from the superior-anterior quadrant toward the inferior-posterior quadrant, where the ABA were higher. Only the peak VMS of implant models in the inferior-posterior quadrant (particularly the inferior-middle site within) with blades in did not reach the yielding (risky) cut-off. CONCLUSIONS: From the perspective of angles, ABA, this study demonstrated the inferior-posterior quadrant as the relatively stable and safe regions, especially the inferior-middle site within. This was similar but more elaborate compared with previous studies and clinical practice. Therefore, ABA could be employed as a promising approach to anchor the implants into the optimal region.

A new posterosuperior screw placement strategy to avoid in-out-in screws in femoral neck fractures.

Objective: The inverted triangle configuration of the three cannulated screws is the classic fixation method most commonly performed for undisplaced femoral neck fractures in young and geriatric patients. However, the posterosuperior screw has a high incidence of cortical breach, known as an in-out-in (IOI) screw. In this study, we present a novel posterosuperior screw placement strategy to prevent the screw from becoming IOI. Methods: Using computed tomography data and image-processing software, 91 undisplaced femoral neck fractures were reconstructed. The anteroposterior (AP), lateral, and axial radiographs were simulated. To simulate the intraoperative screw placement process, participants used three screw insertion angles (0°, 10°, and 20°) to place the screw on the AP and lateral views of the radiograph according to the three established strategies. On the AP radiograph, a screw was placed abutting (strategy 1), 3.25 mm away from (strategy 2), or 6.5 mm away from (strategy 3) the superior border of the femoral neck. On the lateral radiograph, all the screws were placed abutting the posterior border of the femoral neck. Axial radiographs were used to evaluate the screw position. Results: In strategy 1, all the placed screws were IOI regardless of the screw insertion angle. In strategy 2, 48.3% (44/91) of IOI screws occurred at a 0° screw insertion angle, 41.7% (38/91) of IOI screws occurred at a 10° screw insertion angle, and 42.9% (39/91) of IOI screws occurred at a 20° screw insertion angle situation. In strategy 3, no IOI screw occurred, and the screw insertion angles did not affect the safety and accuracy of screw placement. Conclusions: Screws placed according to strategy 3 are safe. The reliability of this screw placement strategy is unaffected by a screw insertion angle of less than 20 degrees.

Separate vertical wiring plus bilateral anchor girdle suturing fixation for the fractures of the inferior pole of the patella.

BACKGROUND: The fixation of inferior pole fractures of the patella (IPFPs) is still a great challenge for surgeons. MATERIALS AND METHODS: We introduced a new fixation method for IPFP fixation, that is, separate vertical wiring plus bilateral anchor girdle suturing fixation (SVW-BSAG). Three finite element models including the anterior tension band wiring (ATBW) model, separate vertical wiring (SVW) model and SVW-BSAG model, were built to evaluate the fixation strength of different fixation methods. A total of 41 consecutive patients with IPFP injury were enrolled in this retrospective study, including 23 patients in the ATBW group and 18 patients in the SVW-BSAG group. The operation time, radiation exposure, full weight-bearing time, Bostman score, extension lag versus contralateral healthy leg, Insall-Salvati ratio, and radiograph outcomes were employed to assess and compare the ATBW group and SVW-BSAG group. RESULTS: The finite element analysis confirmed that the SVW-BSAG fixation method was as reliable as the ATBW fixation method in terms of fixed strength. Through retrospective analysis, we found that there was no significant difference between the SVW-BSAG and ATBW groups in age, sex, BMI, fracture side, fracture type, or follow-up time. There were no significant differences between the two groups in the Insall-Salvati ratio, 6-month Bostman score, and fixation failure. Compared with the ATBW group, the SVW-BSAG group showed advantages in intraoperative radiation exposure, full weight-bearing time, and extension lag versus the contralateral healthy leg. CONCLUSION: The finite element analysis and clinical results showed that SVW-BSAG fixation methods are a reliable and valuable for IPFP treatment.

Two-Part Intertrochanteric Femur Fractures with Bisection of the Lesser Trochanter: An Irreducible Fracture Pattern.

Objective: To introduce the clinical features of and surgical techniques for a rare type of irreducible pertrochanteric femur fracture pattern with bisection of the lesser trochanter. Methods: From January 2017 to December 2019, 357 patients with per/intertrochanteric femur fractures underwent surgery by closed reduction and internal fixation, of whom 12 patients were identified with rare preoperative imaging features, the lesser trochanter was almost equally bisected. The main fracture pathoanatomy of these cases included: The anterior fracture line passed along the intertrochanteric line to the medial lesser trochanter and bisected it into 2 equal parts from mid-level of the lesser trochanteric protrusion. The proximal part of the lesser trochanter connected to the head-neck fragment and attached by the psoas major tendon, while the distal part of the lesser trochanter connected to the femoral shaft and attached by the tendon of the iliac muscle. These fractures were irreducible by a closed maneuver and were reduced with limited assistance by some devices, and short intramedullary nails were used for fixation of these fractures. Results: All patients were followed up for an average of 14.2 ± 2.1 months. Clinical fracture union occurred at an average of 10.8 ± 1.5 weeks, while radiographic union occurred at an average of 12.7 ± 1.2 weeks. No cut out of the helical blade was visible on radiographs. The average Parker-Palmer score was 6.9 ± 1.3 (range, 5-9) at the last follow up, including 8 cases rated as excellent, 2 as good and 2 as fair. Conclusion: Two-part pertrochanteric femur fractures with bisection of the lesser trochanter have an irreducible fracture pattern with cortical locking and soft tissue incarceration. Soft tissue release and short cephalomedullary nail fixation for this fracture pattern provide stable fixation and allow early exercise. This treatment appears to have excellent outcomes in the short and medium terms.

Ebastine exerts antitumor activity and induces autophagy by activating AMPK/ULK1 signaling in an IPMK-dependent manner in osteosarcoma.

Numerous studies have confirmed that in addition to interfering with the tumor inflammatory environment, anti-inflammatory agents can directly increase apoptosis and sensitivity to conventional therapies and decrease invasion and metastasis, making them useful candidates for cancer therapy. Here, we first used high-throughput screening and had screened one compound candidate, ebastine (a H1-histamine receptor antagonist), for osteosarcoma therapy. Cell viability assays, colony formation assays, wound healing assays, and Transwell assays demonstrated that ebastine elicited antitumor effects in osteosarcoma cells. In addition, ebastine treatment exerted obvious effects on cell cycle arrest, metastasis inhibition, apoptosis and autophagy induction both in vitro and in vivo. Mechanistically, we observed that ebastine treatment triggered proapoptotic autophagy by activating AMPK/ULK1 signaling in osteosarcoma cells. Treatment with the AMPK inhibitor dorsomorphin reversed ebastine-induced apoptosis and autophagy. More importantly, we found that IPMK interacted with AMPK and functioned as a positive regulator of AMPK protein in osteosarcoma cells. A rescue study showed that the induction of autophagy and activation of the AMPK/ULK1 signaling pathway by ebastine treatment were reversed by IPMK knockdown, indicating that the activity of ebastine was IPMK dependent. We provide experimental evidence demonstrating that ebastine has antitumor activity in osteosarcoma and promotes autophagy by activating the AMPK/ULK1 signaling pathway, which is IPMK dependent. Our results provide insight into the clinical application potential of ebastine, which may represent a new potential therapeutic candidate for the treatment of osteosarcoma.

A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images.

Objective: Fracture classification evolves dynamically with new and enhanced imaging modalities. This paper aims to introduce a novel hypothesis of a sophisticated fracture classification system for the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images and accommodate the clinical requirement of the worldwide outbreak of geriatric hip fractures with large amounts of surgical operations. Methods: In the current practice of widely preoperative 3D-CT application and cephalomedullary nailing, we attempt to propose a new comprehensive classification system to describe the fracture characteristics in a more detailed and sophisticated architecture, and pay the most important concern to the parameters that contribute to fracture stability reconstruction in osteosynthesis. Results: The new four-by-four comprehensive classification system, followed the structure of the AO/OTA system, incorporates many fracture characteristics as dividing indexes into multiple grade levels, such as fracture line direction, the number of fragments, the lesser trochanter fragment and its distal extension (>2 cm), the posterior coronal fragment and its anterior expansion (to the entry portal of head-neck implant at the lateral cortex), the lateral wall and anterior cortex fracture, and the anteromedial inferior corner comminution. From a panoramic perspective, there are four types and each type has four subtypes. A1 is simple two-part fractures (20%), A2 is characterized by lesser trochanter fragment and posterior coronal fractures (62.5%), A3 is reverse obliquity and transverse fractures with complete lateral wall broken (15.5%), and A4 is medial wall comminution which further lacks anteromedial cortex transmission of compression force (2%). For subtypes, A2.2 is with a banana-like posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior expansion of the posterior coronal fragment(s) to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region. Conclusion: Classification represents diversity under consistency. The four-by-four sophisticated classification system delineates fracture characteristics in more detail. It is applicable in the time of rapid outbreak of trochanteric fractures in the older population, the large amounts of surgical operations, and incorporates various rare and/or more complicated subtypes which is unclassifiable before.

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures.

BACKGROUND: Maintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails. METHODS: This retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change. RESULTS: Anteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group. CONCLUSIONS: Good reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study.

BACKGROUND: Anteromedial cortical support apposition (positive and/or neutral cortical relations) is crucial for surgical stability reconstruction in the treatment of trochanteric femur fractures. However, the loss of fracture reduction is frequent in follow-ups after cephalomedullary nail fixation. This paper aimed to investigate the possible predictive risk factors for postoperative loss of anteromedial cortex buttress after nail fixation. METHODS: A retrospective analysis of 122 patients with AO/OTA 31A1 and A2 trochanteric femur fractures treated with cephalomedullary nails between January 2017 and December 2019 was performed. The patients were classified into two groups according to the postoperative status of the anteromedial cortical apposition in 3D CT images: Group 1 with contact "yes" (positive or anatomic) and Group 2 with contact "No" (negative, loss of contact). The fracture reduction quality score, tip-apex distance (TAD), calcar-referenced TAD (Cal-TAD), Parker ratio, neck-shaft angle (NSA), and the filling ratio of the distal nail segment to medullary canal diameter in anteroposterior (AP) and lateral fluoroscopies (taken immediately after the operation) were examined in univariate and multivariate analyses. Mechanical complications were measured and compared in follow-up radiographs. RESULTS: According to the postoperative 3D CT, 84 individuals (69%) were categorized into Group 1, and 38 individuals (31%) were classified as Group 2. The multivariate logistic regression analysis showed that the poor fracture reduction quality score (P < 0.001) and decreasing filling ratio in the lateral view (P < 0.001) were significant risk factors for the loss of anteromedial cortical contact. The threshold value for the distal nail filling ratio in lateral fluoroscopy predicting fracture reduction re-displacement was found to be 53%, with 89.3% sensitivity and 78.9% specificity. The mechanical complication (varus and over lateral sliding) rate was higher in Group 2. CONCLUSIONS: The fracture reduction quality score and the decreasing filling ratio of the distal nail to the medullary canal in the lateral view (a novel parameter causing pendulum-like movement of the nail) were possible risk factors for postoperative loss of anteromedial cortical support.

Sub-Classification of AO/OTA-2018 Pertrochanteric Fractures Is Associated With Clinical Outcomes After Fixation of Intramedullary Nails.

BACKGROUND: The new edited AO/OTA-2018 classification of pertrochanteric fractures was revised and no longer based on the status of lesser trochanter. This paper aimed to explore the clinical and technical outcomes among the subgroups (31A1 and 31A2) of the new classification treated with cephalomedullary nails. METHODS: A retrospective research of 154 patients diagnosed with pertrochanteric fractures (AO/OTA-2018 31A1.2/3 and 31A2.1/2/3) treated with intramedullary nails was conducted. The baseline data and outcomes were compared among the subgroups. The outcomes included tip-apex distance (TAD), Cal-TAD, Parker ratio, neck shaft angle (NSA), blood loss, varus displacement, and over lateral sliding rate of the blade. RESULTS: There were 154 cases involving 48 males and 106 females. The average age was higher in the sub-classifications of A2.2 and A2.3 than A1.2. Furthermore, the subgroups of A2.2 and A2.3 presented inferior outcomes with regard to blood loss and reduction quality score than A1.2 and A1.3. The subgroup of A2.3 was further poor with respect to calcar fracture gapping in the anteroposterior view and excessive lateral migration occurrence rate than A1.2. CONCLUSIONS: Complex pertrochanteric fractures indicated inferior outcomes compared to simple sub-classifications, which might lead by the incompetent of lateral wall and instability of the fracture. The newly proposed AO/OTA-2018 classification was conductive to forecast the prognosis.

The Pre-Loaded Set-Screw in InterTAN Nail: Should It Be Tightened or Not Tightened in Pertrochanteric Hip Fractures.

BACKGROUND: InterTAN is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to tighten the preloaded setscrew to allow or not allow secondary sliding in InterTan nail is controversial in clinical practice. METHODS: We retrospectively collected 4 nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further secondary sliding and femoral neck shortening. RESULTS: After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage. CONCLUSIONS: As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in standard-obliquity pertrochanteric hip fractures (AO/OTA-31A1 and A2).

Perforator Detection by Thermographic Imaging Augmented With Tourniquet-Reperfusion: A Modified Approach and Preliminary Report in Distal Lower Leg Reconstruction.

BACKGROUND: Dynamic infrared thermography provides a new imaging method of perforator detection. This study introduces an augmented technique to improve its accuracy by tourniquet-reperfusion and reports its preliminary use in the distal lower leg reconstruction. METHODS: A tourniquet (450 mm Hg) was applied for 3 minutes on proximal thighs. After the tourniquet release, the rewarming rate and pattern of hotspots were observed by thermography to delineate the location and quality of perforators. The results were compared with those detected by computed tomographic angiography. Clinically, the local transferred posterior tibial artery or peroneal artery propeller perforator flap was performed in 9 patients for the distal lower leg reconstruction. RESULTS: There was a 20- to 140-second "perforator observing window" after the tourniquet release. Tourniquet-reperfusion augmented thermal imaging method (TRATIM) had a sensitivity of 90.3% and a positive predictive value of 93.3%. The TRATIM and computed tomographic angiography had an excellent concordance with a kappa index value of 0.839 (P < 0.001). Based on the TRATIM, 9 propeller perforator flaps were successfully designed and raised for the distal lower leg resurfacing. All flaps survived entirely, except one with size of 1.0 cm × 2.0 cm that had terminal necrosis. CONCLUSIONS: The TRATIM is a quick, easy, cheap, and reliable approach for perforator detection in the lower leg. With the aid of TRATIM, a customized propeller perforator flap could be raised efficiently for the distal lower leg reconstruction.