Evaluation of the quadrants of femoral neck-head in the cephalomedullary fixation of intertrochanteric fractures with a helical blade: Is inferior posterior quadrant also safe? A clinical study.

OBJECTIVES: This study aims to investigate the positioning of the helical blade to prevent mechanical complications in surgically fixed intertrochanteric fractures (ITFs). PATIENTS AND METHODS: In this retrospective study, 392 patients (158 males, 234 females; mean age: 75.5±13.4; range, 20 to 101) years) with ITFs treated in lateral decubitus position with proximal femoral nail anti-rotation in a single center between January 2009 and January 2017 were evaluated. The fractures were classified according to the Orthopedic Trauma Association classification preoperatively and grouped as stable or unstable. Postoperatively, tip-apex distance (TAD), Baumgaertner reduction criteria, and obtained quadrants were evaluated. Patients with an unstable fracture, proper TAD, and acceptable or good reduction were included in the final evaluation for statistical analysis to investigate the safest quadrant to prevent cut-out complication. RESULTS: Cut-out complications were observed in 19 (4.8%) patients. The scenario; unstable fracture, TAD <25 mm, acceptable or good reduction consisted of 111 patients in total and cut-out complication occurred in four of them (3.6%) (one in center-posterior, one in center-center, one in superior-anterior, and one in superior-center quadrants). There was no statistically significant difference between center-center, inferior-center, and inferior-posterior quadrants (p=0.49). CONCLUSION: Inferior-posterior placement is as safe as central-central or inferior-central placement for blade fixation in the surgical treatment of ITF.

Comparison of Second and Third-Generation Nails in the Treatment of Intertrochanteric Fracture: Screws versus Helical Blades.

OBJECTIVE: The aim of this study was to compare the radiological and functional outcomes of anti-rotation trochanteric nails (ATNs) with proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric femur fractures in elderly patients. MATERIALS AND METHODS: In total, 165 intertrochanteric fractures were treated between January 2007 and January 2010. One hundred forty patients were included. The operation time, amount of blood loss, fluoroscopy screening time, and length of hospitalization were recorded. The radiological position of the implant, quality of fracture reduction, and tip-apex distance were evaluated, and the postoperative complications as well as functional condition of the patients were assessed. RESULTS: There were no significant differences between the ATN and PFNA groups for the presence of general complications, length of hospitalization, and functional capacity. The mean operation time, blood loss amount, and fluoroscopy screening time were more in the ATN group than in the PFNA group. Reoperation was needed for nine and two patients in the ATN and PFNA groups, respectively, because of implant-related complications. CONCLUSION: Both ATNs and PFNA were suitable for the fixation of intertrochanteric fractures, but the risk of complication occurrence and need for reoperation were found to be higher in patients who were treated with ATNs.

Do Patients With Acute Isolated Pubic Ramus Fractures Have To Be Hospitalized?

A total of 129 patients were included in the study. Haemoglobin levels on admission and at 24 hours were evaluated. Radiographs and computed tomography of the pelvis were also evaluated. The patients were divided into subgroups, according to the accompanying occult posterior pelvic injuries, whether they received anticoagulant-antiaggregant treatment, the number of pubic ramus fractures (single or multiple), the level of energy (low or high) and the zone(s) of the fracture(s). The mean haemoglobin decrease was 1.21 g/dL. Forty-six of the patients were under anticoagulant or antiaggregant treatment. Fifty-one of the fractures occurred due to low energy trauma. Posterior ring injuries were observed in 75 of the patients. Haemoglobin level decreases were statistically significant in injuries with high energy trauma aetiology, in patients using antiaggregant or anticoagulant and in fractures of the lateral half of the superior pubic ramus. It is important to follow all pubic ramus fractures closely because, even in low energy trauma, haemoglobin levels could decrease significantly. We recommend hospitalization to monitor this group of patients.

Is surgeons' experience important on intra- and inter-observer reliability of classifications used for adult femoral neck fracture?

PURPOSE: To evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures. MATERIAL AND METHODS: A power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability. RESULTS: Garden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability. CONCLUSION: Both Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation. LEVEL OF EVIDENCE: Level IV, Diagnostic study.

Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients.

INTRODUCTION: Mechanical complications, such as cut-out of the head-neck fixation device, are the most common causes of morbidity after trochanteric femur fracture treatment. The causes of cut-out complications are well defined in patients who are treated with sliding hip screws and biaxial cephalomedullary nails but there are few reports about the patients who are treated with proximal femoral nail antirotation. AIM: The purpose of this study was to evaluate the most important factor about occurance of cutout complication and also to evaluate the risks of the combination of each possible factors. PATIENTS AND METHODS: Overally 298 patients were enrolled in the study. Medical records were reviewed for patients' age, fracture type, gender, anesthesia type and occurance of cut-out complication. Postoperatively taken radiographs were reviewed for tip-apex distance, obtained collo-diaphyseal angle, the quadrant of the helical blade and Ikuta reduction subgroup. The most important factor (s) and also predicted probability of cut-out complication was calculated for each combination of factors. RESULTS: Cut-out complication was observed in 14 patients (4.7 %). The most important factor about occurrence of the cut-out complication was found as varus reduction (p: 0.01), the second important factor was found as implantation of the helical blade in the improper quadrant (p: 0.02). Tip-apex distance was found as third important factor (p: 0.10). The predicted probability of cut-out complication was calculated as 45.6 % when whole of the four surgeon dependent factors were improperly obtained. CONCLUSION: Althought obtaining proper tip-apex distance is important to prevent cutout complication in these fractures, if the fracture is not reduced in varus position and helical blade is inserted in the proper quadrant, possibility of cut-out complication is very low even in the patients with high tip-apex distance.

Nailing or plating for subtrochanteric femoral fractures: a non-randomized comparative study.

BACKGROUND: The aim of the present study was to compare the outcomes of reverse less invasive stabilization system for distal femur (LISS-DF) plates and proximal femoral nail antirotation (PFNA) in the treatment of patients with subtrochanteric fracture. METHODS: Thirty-one patients with 32 fractures were included in this study. The PFNA group consisted of 16 patients, and the reverse LISS-DF plate group consisted of 15 patients. Intraoperative data such as surgical time (min), amount of blood transfusion (units and erythrocyte suspensions) and radiation time (seconds) were noted. Time elapsed until fracture consolidation (weeks), time until full weight bearing (weeks), mean Harris hip score and length of stay (LOS) at hospital (days) were recorded postoperatively. RESULTS: The reverse LISS-DF group had a significantly longer elapsed time until fracture consolidation (p < 0.05). The mean radiation time was significantly longer (p < 0.05), and the Harris hip scores at last control were significantly higher (p < 0.05) compared with the PFNA group. No significant differences were determined in terms of complications and re-operation rates. CONCLUSION: This study demonstrated that in the reverse LISS-DF-treated group, the mean time for bone union was longer and weight bearing was delayed. Considering the surgical technique, minimal surgical approach, reduced amount of blood transfusion and superior functional results following surgery, we concluded that the PFNA system offers advantages over reverse LISS-DF plating in the treatment of subtrochanteric femur fractures.

Fixation of intertrochanteric femur fractures using Proximal Femoral Nail Antirotation (PFNA) in the lateral decubitus position without a traction table.

OBJECTIVE: The aim of this study was to evaluate whether intertrochanteric femur fractures can be reduced and nailed properly in the lateral decubitus position using Proximal Femoral Nail Antirotation (PFNA) as a fixation device without the use of a traction table. METHODS: The study included 207 patients (81 male and 126 female; mean age: 75 years, range: 22 to 95 years). According to the Evans classification, there were 7 Type 1, 40 Type 2, 33 Type 3, 38 Type 4, 61 Type 5 and 28 reverse oblique fractures. Radiographs were used to measure the tip-apex distance (TAD), the quadrant of the helical blade according to Cleveland and Bosworth, Ikuta's reduction subgroup, collodiaphyseal angle and reduction gaps postoperatively. RESULTS: Mean follow-up time was 20.4 (range: 6 to 38) months. According to Ikuta's classification, 176 (85%) reduced fractures were of subtype N, 15 (7.2%) subtype P and 16 (7.7%) subtype A. Good or acceptable reduction according to the Herman criteria was obtained in 99% of fractures. Mean TAD was 29.2 millimeters. Mean operation time was 57.2 minutes. Optimal blade position (center-center or inferior-center) was achieved in 53.5% of patients and was in the superior-posterior quadrants in only 2.4% of patients. Cut-out complication occurred in 9 patients (4.3%). CONCLUSION: While the nailing of intertrochanteric fractures in a lateral decubitus position does not provide ideal quadrant placement and TAD, results are encouraging probably due to the excellent stability that is provided by PFNA.

Posterior fixation of thoracolumbar burst fractures: is it possible to protect one segment in the lumbar region?

BACKGROUND: The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures. METHODS: IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation. RESULTS: The measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)]. CONCLUSIONS: The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.

Retrospective comparison of external fixation versus volar locking plate in the treatment of unstable intra-articular distal radius fractures.

The aim of this study is to compare the radiological and functional outcomes of open reduction and volar locking plates versus external fixation (EF) in the treatment of unstable intra-articular distal radius fractures. In this retrospective comparative study, 69 of 80 patients who underwent an operation for AO/ASIF C1, C2 and C3 distal radius fractures were assessed. Functional evaluation was performed using the Gartland-Werley scoring system and the PRWE scale, and wrist range of motion and grip strength was also measured. For the radiological assessment, radial inclination, volar tilt, radial length, ulnar variance, and articular step-off were compared. The range of movement was better for all parameters in the volar plate group, but only wrist flexion and pronation range differed significantly between the groups (p = 0.037 and p = 0.014, respectively). With the exception of better subjective functional results in the volar plate group, the differences were not significant. With respect to radiological evaluation, all parameters were better in the volar plate group, but only radial inclination and articular step-off were significantly better (p = 0.018 and p = 0.029, respectively). In the volar plate group, two patients had carpal tunnel syndrome and one patient had regional pain syndrome. In the external fixator group, six patients had superficial pin tract infection, two patients had sensory branch injury, and four patients had regional pain syndrome. Volar locking plate fixation appeared as a dependable method for the treatment of intra-articular distal radius, with lower complication rates. On the other hand, EF remains a suitable surgical alternative for these fractures, with easy application and acceptable results.

Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS) for the treatment for unstable peritrochanteric femoral fractures.

PURPOSE: The aim of this study was to compare the results of intramedullary fixation with those of plate-screw fixation for peritrochanteric femoral fracture patients older than 60 years old. METHODS: This article reports on a retrospective review of patients who had peritrochanteric femoral fractures and were treated with a 95° fixed-angle screw plate (DCS) or an intramedullary nailing system (PFNA). Patients with 79 fractures were enrolled in the study; 47 of them were treated with the PFNA system and 37 with the DCS. Followed for at least 1 year, the treatment groups were compared by taking into consideration all demographic and trauma variables. RESULTS: No significant differences were discovered between the two groups with regard to side of injury, mechanism of trauma, associated comorbidities, AO fracture classification, average follow-up duration, mortality, and fracture reduction quality at the 1-year follow-up. The average surgical time was significantly lower in the PFNA group (57 min.) compared to the DCS group (87 min.). Longer operative time was needed in the DCS group, and thus, greater blood loss occurred compared to the PFNA group. The functional results of the PFNA group were found to be significantly better than those of the DCS group. CONCLUSIONS: Owing to some advantages, such as minimal exposure, reduced operative blood loss, and the achievement of biological fixation, PFNA is a better choice for the treatment for unstable peritrochanteric fractures.

Reliability and reproducibility of classifications for distal radius fractures.

OBJECTIVE: The aim of this study was to evaluate the interobserver reliability and intraobserver reproducibility of the Universal, AO, Fernandez and Frykman classifications for distal radius fractures. METHODS: Fifty standard sets of posteroanterior and lateral roentgenograms of displaced distal radius fractures were classified two times by two groups of evaluators at 2-month intervals. The first group consisted of 10 orthopedic surgeons with a minimum of 5 years of experience. The second group consisted of 10 orthopedic residents in their first two years of practice. Interobserver reliability and intraobserver reproducibility were assessed using Cohen's kappa test. RESULTS: None of the classifications achieved good- very good reliability levels. The Fernandez classification had a moderate and the others had a fair interobserver agreement kappa coefficient. All classifications had fair kappa intraobserver agreement although the Frykman and Fernandez classifications had better results. CONCLUSION: None of the classification systems were superior in terms of reliability and reproducibility. The reliability and reproducibility rates of all four classifications were insufficient.

IGF-1 Increases with Hyperbaric Oxygen Therapy and Promotes Wound Healing in Diabetic Foot Ulcers.

Objectives. To investigate insulin-like growth factor I (IGF-1) levels in response to hyperbaric oxygen therapy (HBOT) for diabetic foot ulcers and to determine whether IGF-1 is a predictive indicator of wound healing in patients with diabetic foot ulcers. Design and Methods. We treated 48 consecutive patients with diabetic foot ulcers with HBOT. Alterations of IGF-1 levels in patients whose wound healed with HBOT were compared with those in patients who did not benefit from HBOT. Results. There was no significant difference in initial IGF-1 levels between the two groups (P = 0.399). The mean IGF-1 level increased with HBOT (P < 0.05). In the healed group, the mean IGF-1 increase and the final values were significantly higher (P < 0.05). In the nonhealed group, the mean IGF-1 increase was minus and the final values were not significantly different (P < 0.05). The increase in IGF-1 level with HBOT was significantly higher in the healed group (P < 0.001). Conclusions. IGF-1 increased significantly in the healed group. We believe that HBOT is effective in the treatment of diabetic foot ulcers, with an elevation of IGF-1. This alteration seems to be a predictive factor for wound healing in diabetic foot ulcers treated with HBOT.

Leg length discrepancies in adult femoral shaft fractures treated with intramedullary nailing.

BACKGROUND: To evaluate the leg length discrepancy (LLD) retrospectively in adult femoral shaft fractures treated with intramedullary nailing (IMN). METHODS: Sixty-three patients (58 male, 5 female; mean age 29.9+/-12.4; range 15 to 77 years) were included in the study. Fractures were identified according to the Winquist-Hansen (W) system and AO classification. 16 W0, 18 WI, 16 WII, 7 WIII, and 6 WIV fractures and 35 type A, 22 type B, and 6 type C fractures were repaired. Thirty-one (49.2%) patients had multiple injuries. Fourteen patients sustained an open fracture. LLDs were measured on physical examination and using orthoroentgenography. RESULTS: The mean follow-up was 90.2+/-29.9 (39-193) months. The mean LLD was 12.3+/-15.2 [12-(-60)] mm using orthoroentgenography and 12.9+/-13.7 [10-(-60)] mm according to manual measurement. In seven cases, no LLD was observed. Twenty-seven shortenings and one lengthening were observed in the 28 femurs with a discrepancy greater than 10 mm (44.4%). There was no statistical correlation between LLD and open or closed fracture (r=0.02, p=0.86), polytrauma (r=-0.09, p=0.47), or delayed surgery (p=0.31), but there was a tendency to a greater discrepancy in comminuted fractures (WIII, IV) (r=0.33, p=0.007). CONCLUSION: LLD may be seen in high rates in adult femoral shaft fracture cases treated with IMN. Static IMN following absolute restoration of the length may prevent this problem in femoral diaphysis fractures, especially comminuted WIII and IV types.

Treatment of type I capitellar fractures in adolescents.

BACKGROUND: Because fractures of the capitellum are rare in childhood and the young adolescent period, their treatment is still debatable and there appears to be no established treatment protocol. In the present study, we evaluated the results obtained in adolescents with type 1 capitellar fractures who were treated with open reduction and internal fixation with a 3.5 mm lag screw, directed from posterior to anterior. METHODS: Twelve type I capitellar fractures in adolescents were treated with open reduction and internal fixation with a single 3.5 mm cortical lag screw directed from the posterior to the anterior and the results were evaluated by an objective evaluation score (Broberg and Morrey's functional rating index). Mean age of the patients was 13.5. RESULTS: At final examination (24 to 90 months follow-up), mean Broberg and Morrey's functional rating index was 96.7 points (91 to 100 points). All fractures had healed in anatomic position and no avascular necrosis or heterotrophic ossification was observed. CONCLUSION: Since it is essential to obtain the full range of motion at the elbow, accurate open reduction and stable internal fixation are best to manage displaced type I capitellar fracture in children and adolescents. Single cortical lag screw directed from posterior to the anterior without penetrating the joint surface is suitable for this purpose.

Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

Although hyperbaric oxygen therapy has been used for diabetic foot ulcer since the 1980s, there is little information on its efficacy. The aim of this study is to evaluate whether hyperbaric oxygen can decrease major amputation rates and to determine the predictive factors. A total of 184 consecutive patients were treated with hyperbaric oxygen therapy as an adjunct to standard treatment modalities for their diabetic foot ulcer. Of these patients, 115 were completely healed, 31 showed no improvement and 38 underwent amputation. Of the amputations, nine (4.9%) were major amputations (below knee) and 29 were minor. Major amputations were associated with the Wagner grade (p < 0.0001), with the age of the patients (p = 0.028) and with the age of the wounds (p = 0.018). Hyperbaric oxygen therapy can help to reduce the major amputation rates in diabetic foot ulcer. However, further large, multicentre, randomised controlled studies are needed to make more accurate conclusions.

Congenital clubfoot associated with an accessory soleus muscle.

A 16-month-old male with previously untreated bilateral clubfeet was admitted to S.B. Izmir Tepecik Education and Research Hospital, Izmir, Turkey. Both feet underwent surgical treatment. During surgery, an accessory soleus muscle was detected on the right side. The accessory soleus muscle had a distinct distal insertion at the superior anteromedial border of the calcaneus and also anterior and medial to the Achilles tendon. He was treated by bilateral complete subtalar release with Cincinnati incision, and the accessory soleus was also cut and the distal part resected. At the final follow-up visit, when the patient was 6 years and 9 months old, both feet had a normal appearance and appeared normal on radiograph and magnetic resonance imaging, with no presence of the accessory soleus muscle or its remnant. In our opinion, awareness of the association between an accessory soleus muscle and clubfoot, and sectioning of this muscle during surgery may improve surgical results.

Pedicle screw placement with a free hand technique in thoracolumbar spine: is it safe?

STUDY DESIGN: Computerized tomography (CT) analysis of in vivo pedicle screw placement to determine their exact position in relation to the pedicle in thoracolumbar region (T10-L3). OBJECTIVE: To evaluate the clinical accuracy of the placement of thoracolumbar pedicle screws with a free hand technique after reviewing preoperative imaging. SUMMARY OF BACKGROUND DATA: CT scans have been used in research clinical settings to evaluate pedicle screw placement in thoracolumbar spine. MATERIAL AND METHODS: Ninety-eight consecutive patients who underwent posterior stabilization using 640 transpedicular screws by 1 surgeon from T10 to L3 were analyzed. The mean age was 36.1+/-15.1 (13 to 73) years at the time of surgery. Pedicle screws were inserted using anatomic landmarks; specific entry sites, preoperative anteroposterior/lateral radiographs, and CT imaging were used to guide the surgeon. After preparation of entry point, a pedicle probe was carefully advanced free hand down the pedicle into the body. Careful palpation of all bony borders (flour and 4 pedicle walls) was performed before placement the screw. Postoperative CT scans were used to evaluate the position of all pedicle screws inserted. Screw cortical penetration was graded on the basis of anatomy (the wall penetrated) and distance of the penetration, with 2 mm of interval. RESULTS: The number of screws inserted at each level were as follows: T10 (n=55), T11 (n=124), T12 (n=118), L1 (n=91), L2 (n=146), and L3 (n=106). Analysis of these pedicle screws using postoperative CT scans confirmed 37 (5.8%) violated screws, including 12 medial, 18 lateral, 2 superior, 1 inferior, and 4 anterolateral vertebral body penetrations. No neurologic, vascular, or pleural injuries occurred. No screws required postoperative repositioning. CONCLUSIONS: Pedicle screw placement with a free hand technique after reviewing preoperative imaging seems to be accurate, reliable, and safe adjunct for the placement of thoracolumbar spine screws.

Is radial shortening useful for Litchman stage 3B Kienbock's disease?

Treatment of Litchman stage 3 Kienböck's disease is still controversial. In this study our aim was to evaluate the effectiveness of radial shortening on stage 3B Kienböck's disease in comparison with stage 3A cases. Radial shortening was performed for 23 patients who had stage 3A (group I, n = 13) and 3B (group II, n = 10) Kienböck's disease between 1994 and 2004. The radial osteotomy was performed 4.5 cm proximal to the distal articular surface. The mean shortening was 2.6 mm (range 2 to 4.5). The average follow-up period was 85 months (range 26-147). Based on the modified Nakamura system, the mean clinical points were 14.3 in group I and 13.3 in group II. There was no statistical difference between both groups with regard to clinical points (P = 0.483). The extension-flexion arc showed significant improvement in both groups. Based on the results of this long-term follow-up study, we concluded that radial shortening osteotomy can be performed in the treatment of type 3B Kienböck's disease as reliably as type 3A, despite the lack of evident radiological improvement.