Tibialis anterior and extensor hallucis longus tendon ruptures complicating a closed tibial fracture: A case report.

INTRODUCTION AND IMPORTANCE: Acute rupture of the tibialis anterior tendon and other tendons is an extremely rare injury. It is usually associated with minor trauma in older patients with medical comorbidity. Surgeons must be alert for rupture of these tendons which can complicate a closed tibial fracture. CASE PRESENTATION: A 19-year-old man was transferred to the emergency department with a segmental fracture at the lower third of his tibia. The patient could not actively dorsiflex his right ankle and first toe but was able to dorsiflex other toes actively. The tibialis anterior and extensor hallucis longus tendon were discovered torn at the same point, supposedly by a bone spike. The fracture was reduced and fixed and the tendons were repaired. CLINICAL DISCUSSION: A traumatic rupture of the tibialis anterior and extensor hallucis longus tendons occurs rarely in conjunction with or as a consequence of a bony fracture in closed trauma, with only a few cases documented in the literature. They typically occur as a result of direct blunt or penetrating injury. In three papers, the tibial fracture caused a direct rupture in the tendon. We believe that the tendons rubbing against the fractured edges of the segmental bone of the tibia led to the tendons tearing gradually. CONCLUSION: Further investigation is needed for an evaluation of ankle and first toe dorsiflexion to check for a palpable gap in the soft tissues of a lower third tibial fracture. The tibialis anterior and other tendons can be located between the segment of the tibial fracture and ruptured.

Atraumatic hip fracture due to stiff person syndrome: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Stiff person syndrome (SPS) is a rare autoimmune disorder that affects the central nervous system. Patients with this condition may experience sudden muscle spasms, leading to falls and subsequent fractures. Diagnosis is based on clinical presentation, the presence of anti-GAD antibodies, and electromyography (EMG) findings that show continuous motor unit activity. However, there have been few reports of atraumatic fractures in these patients. CASE PRESENTATION: In this article, we present a case of a patient with stiff person syndrome who sustained an intertrochanteric fracture without any prior history of trauma. Additionally, we review and discuss previous literature on this subject. CLINICAL DISCUSSION: SPS is a rare autoimmune neurological disease with muscle rigidity and spasms predominantly in the trunk and lower limbs. The authors mentioned that SPS diagnosis and managing related fractures could be challenging. They recommended optimizing the patient's status with proper medical treatments before surgical interventions to reduce further complications. CONCLUSION: In conclusion, it appears that stiff person syndrome can lead to recurrent and even atraumatic fractures, and should be considered as an underlying cause. Additionally, uncontrolled spasms in these patients can result in the failure of previous surgical fixations and complicated surgical management. To prevent surgical complications, it is crucial to initiate and maintain appropriate medical treatment to control spasms as soon as the underlying disease is diagnosed.

Catastrophic case of the total knee arthroplasty dislocation: A case report.

INTRODUCTION AND IMPORTANCE: Arterial injury is extremely rare after total knee arthroplasty. CASE PRESENTATION: We describe a 68-year-old woman with dislocation of total knee arthroplasty after falling from a height. She had a popliteal artery injury and a vascular bypass was performed in delay. The patient died of a second myocardial infarction 3.5 months after her first introduction to our center. CLINICAL DISCUSSION: Due to the prominent risk of vascular injuries after dislocation in TKA patients, we recommend performing vascular evaluations using CT angiography for all patients. CONCLUSION: Any untreated vascular compromise in the setting of TKA dislocation may lead to devastating outcomes such as amputation and death.

Terrible Triad of the Elbow with Ipsilateral Complete Triceps Tearing, Distal Radius and Scaphoid Waist Fracture: A Case Report.

Introduction: The terrible triad of the elbow includes an elbow dislocation or subluxation with coronoid and in combination with radial head fractures. Still, none of them are accompanied by rupture of the triceps tendon. Case Report: The article describes a terrible triad injury in a young patient with an additional triceps rupture. The treatment involved lateral and medial approaches for the repair of various ligaments and fractures, but the elbow remained unstable. A posterior approach was used to repair the triceps rupture. Conclusion: Triceps tendon rupture may be accompanied by dribble triad injuries, highlighting the importance of pre-operative evaluation to select the most appropriate surgical approach. The selection of an optimal surgical approach is crucial for the successful treatment and management of these injuries.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Descriptive Epidemiology and Survival Rate of Osteosarcoma: The First National Population-Based Study in the Middle East (2008-2014).

Objectives: The epidemiology of osteosarcoma (OS), the most common primary bone sarcoma, was not evaluated in the Middle East. Therefore, this study aimed to examine the incidence, demographic characteristics, epidemiology, and survival rate of patients with different subtypes of OS, based on data derived from the Iran National Cancer Registry (INCR) to evaluate the influence of ethnicity and race. Methods: All OS patients registered in the INCR between March 20, 2008, and March 20, 2014, were enrolled in this study, and information such as age, gender, cancer location, OS subtype, and survival time were evaluated statistically. Results: The Age-Standardized Incidence Rate (ASIR) for OS was 3.02 per million person-years, with a mean age of 25.6 years and a male-female ratio of 1.54:1. Not Otherwise Specified (NOS) OS, chondroblastic OS, and central OS had the highest frequencies among the subtypes of OS. The overall one-, three-, and five-year survival rates were 87%, 61%, and 49%, respectively, with a mean duration of 6.16 years. Conclusion: The ASIR of OS in our country was similar to that in the US and higher than that in China. The peak frequency was between 15-19 years old. The male-female ratio in our patients was higher than the OS gender ratio in most series. Although it was not statistically significant, older age at the time of diagnosis, axial location, and male gender were the poorest prognosis factors.

Navigation of femoral and popliteal artery around the knee with CT angiography: implications for surgical interventions.

PURPOSE: Uncertainty about the exact position of the femoral and popliteal arteries in the medial thigh and posterior knee might increase vascular complications in surgical procedures. This study aimed to document femoral and popliteal arteries in the medial thigh and around the knee to assist surgeons in developing safer surgical approaches. METHODS: The study included 120 patients-180 lower limbs-who underwent CT angiography (CTA) of the lower extremity. The distance from the femoral artery to the anterior border, midsagittal axis, and posterior border of the femur and the popliteal artery to the medial, lateral, and midpoint posterior cortex of the proximal tibia was measured in two- and three-dimensional CTA images. RESULTS: The femoral artery was found to be on average 236.93 ± 29.61 mm, 195.34 ± 26.12 mm, and 146.28 ± 33.18 mm away from the adductor tubercle at the anterior, midsagittal axis, and posterior borders of the femur, correspondingly. The popliteal artery was to be located on average 5.40 ± 2.50 mm posterior to the midpoint of the plateau tibia at the joint line. CONCLUSION: Considering the mentioned femoral/popliteal artery distances to the femur and proximal tibia would direct surgeons to the safe zones for more accurate surgical approaches in the medial thigh and around the knee when performing osteotomies, knee arthroplasty, arthroscopy, and trauma surgeries, to reduce possible vascular damages. LEVEL OF EVIDENCE: IV.

Job satisfaction, Career Burnout, and Work-Related Well-Being Prevalence among Orthopedic Surgeons: A Nationwide Study.

Background: Burnout is a well-known consequence of chronic stress. Orthopedic surgery is among the most desired specialty among Iranian medical students. The nature of the job, the income, and the ability to deal with stress can all be stressful factors for orthopedic surgeons. Nonetheless, little is known about how these medical doctors work and live in Iran. The present study aimed to assess job satisfaction, engagement, and burnout among Iranian orthopedists. Methods: A nationwide online survey was conducted in Iran. Job satisfaction, engagement, and burnout were evaluated using the job description index (JDI), Utrecht Work Engagement Scale, and Maslach Burnout Scale. They were also asked some additional questions related to career choice. Results: A total of 456 questionnaires (41% response rate) were retrieved. Overall, 56.8% of the participants experienced burnout. The burnout levels significantly differed based on age, years from graduation, working in public hospitals, operating more than 10 patients in a week, monthly income, having less than two children, and being single (P<0.05). They scored higher on work questions on the present job and jobs in general but lower scores on pay and opportunities for promotion. Conclusion: In a national study of orthopedic surgeons, their primary concern in JDI was "pay and promotion." Burnout was substantially associated with respondents' characteristics, such as younger age and having fewer children. This will lead to impaired performance, increased patient complaints, and the tendency to immigrate.

Initial Outcomes of a Novel Modification of Looped Threaded Carpal Tunnel Release Method.

Various surgical techniques are available for the alleviation of symptoms in carpal tunnel syndrome and each of them has its pros and cons. This study was designed and performed to present a novel approach for cutting transverse carpal ligament by the thread looping technique without the use of ultrasonography. The novel modification of looped threaded carpal tunnel release was performed on 10 hands of 10 patients. The disabilities of arm, shoulder, and hand score, visual analog scale, and 2-point discrimination were used for assessing the outcomes. No patients developed pillar pain or scar discomfort after surgery. Complete elimination of paresthesia, pain, and numbness occurred in all patients. There was a significant reduction in the disabilities of arm, shoulder, and hand and visual analog scale scores ( P value<0.05). This technique is safe, available, and effective for carpal tunnel release and minimizes postoperative complications, such as pillar pain, and scar discomfort with avoiding unnecessary injuries to the surrounding soft tissue.

Effects of fixation of clavicle fracture using wide-awake local anesthesia no tourniquet (WALANT) technique on intra-operative bleeding volume, surgical duration, and post-operatively visual analog scale (VAS); A case series study.

Clavicle fractures are common fractures with a rate of 2-5 percent among fractures. Mid-shaft fractures of the clavicle are more common than the other sites of the clavicle. Traditionally, surgical fixation of clavicle fractures has been performed under General Anesthesia (GA). The purpose of this study was to assess the effects of WALANT on intraoperative bleeding, pain control during and after surgery, postoperative complications and patients' function. In the current study, 30 patients with clavicle fractures were surgically fixed using the WALANT technique. The obtained results showed that it could be an effective technique for pain control during the operation and also early postoperative period. Moreover, the WALANT technique could be considered safe in patients who are at risk for GA because of medical comorbidities, cervical spine injuries, or other factors that make intubation difficult.

Clinical Outcomes of Double Mini-Plating Compared with a Single Superior Plating in Midshaft Clavicular Fractures: A Randomized Clinical Trial Study.

Background: In the current study, we aimed to assess the clinical outcomes of the double-plating method using 2.7 mm compression plates compared with the single superior 3.5 mm compression plating method in displaced midshaft fractures of the clavicle. Materials and Methods: Thirty patients with midshaft fractures of the clavicle were randomly assigned into two groups. In group A, 15 patients were fixed by a double-plating technique using two 2.7 mm compression plates on the superior and anteroinferior sides of the bone. The fractures in group B were fixed by a superior plating technique using a single 3.5 mm compression plate. Intraoperative bleeding measurement, length of surgical incision, duration of procedure time, and functional scores were assessed post-surgically through one-year follow-ups. Results: There was no significant difference between groups in terms of surgery time. Device failure was not found among all recruited patients. Incision length and device prominence complaint were significantly different between groups (P value = 0.02, P value = 0.03). Mean ± standard deviation intraoperative bleeding rate was 88.67 ± 29.96 milliliter in the double-plating group and 108.67 ± 41.72 milliliter in the other group, which was not different between these two groups (P value = 0.14). There were no signs of non-union either in radiographies or clinically. Conclusion: Double mini-plating of diaphyseal clavicular fractures could result in a smaller surgical incision and a lower rate of prominence without affecting fixation stability and clinical outcomes in comparison with single superior 3.5 mm plates.

Incidence of primary bone sarcomas in Iranian population (2008-2015): A national population-based study.

Background: Epidemiological characteristics of bone sarcomas are variant in different populations, however, there is no previous study on primary bone sarcomas among Iranian population. This study aimed to evaluate the incidence, age, sex distribution, histologic type, and location of malignant bone sarcomas, based on the Iran National Cancer Registry (INCR). Methods: This was a national population-based study using INCR data from March 20, 2008, to March 20, 2015, on patients who were diagnosed with primary bone sarcomas of the appendicular (C-code:40) and axial skeleton (C-code 41), excluding skull and face bones. Primary bone sarcomas were classified according to the International Classification of Diseases for Oncology (ICD-O-3: C40-C41). Results: A total of 4112 patients (59.5% males and 40.5% females) with a mean age of 36 years were included in the study. 60.38% of patients were between 10 to 44 years old. The overall age-standardized incidence rates (ASIR) was 8.23 (males=9.67 and females=6.80) per million person-years. Osteosarcoma chondrosarcoma and Ewing sarcoma were the three main histology subtypes with the ASIR of 2.36, 1.26, and 1.08 per million person-years. Long bones of the lower limb were the most affected area, with the ASIR of 3.18 (95% CI: 3.02-3.33) per million. We found an increasing trend in the incidence of bone sarcomas in Iran from 8.59 in 2007 to 11.37 per million person-year in 2015. Conclusion: This study provided the epidemiological features of bone sarcomas, including the histological type of sarcoma, tumors' location, and patients' age and gender in the Iranian population for the first time.

Wide-awake local anesthesia for open rotator cuff repair: A case report.

INTRODUCTION AND IMPORTANCE: Improper treatment of rotator cuff tear might result in progression of tear and deterioration of patient function. The rotator cuff tear can be managed conservatively in most cases however surgical treatment is inevitable in persistent patients. PRESENTATION OF CASE: A 45-year-old woman presented to our clinic with shoulder pain and restricted range of motion following a fall from a height three months before the current presentation. Due to the lack of favorable response to conservative treatment and the fact that rotator cuff rupture was traumatic, she became a candidate for rotator cuff repair surgery. Due to financial issues and the patient's refusal of undergoing general anesthesia we considered the WALANT technique. Prior to surgery, we explained the whole procedure to the patient, referring to its pros and cons. CLINICAL DISCUSSION: The WALANT procedure is a relatively recent technique that has become widespread in orthopedic surgery in the past decade. The advantages of the WALANT technique are that it is simple, feasible, and safe and that the analgesic is adequate during the operation and for the first few hours afterward (5). Concerns with this method include patient discomfort and pain during surgery, which can be managed by educating the patient and minute-by-minute explanation during the procedure. CONCLUSION: We advocate open rotator cuff repair with the WALANT approach as an effective, cost-saving, safe, simple, and quick alternative to general and regional anesthesia for certain patients or with limited anesthetic resources. LEVEL OF EVIDENCE: V.

Electric shock sign after digital nerve injury; report of a case and review of literature.

INTRODUCTION AND IMPORTANCE: Digital nerve lacerations are rationally common, especially following penetrating injuries. The majority of patients suffer from numbness as the main complaint. However, electric shock pain is a rare manifestation of partial nerve injury. CASE PRESENTATION: A 65-year-old woman with partial digital nerve injury and an electric shock sign due to a 1 cm laceration on the volar side of the proximal phalanx three weeks earlier. The surgical exploration revealed a neuroma-like mass in the digital nerve; however, the continuity of the nerve was grossly intact. CLINICAL DISCUSSION: Due to the superficiality of digital nerves, penetrating nerve injuries are rationally common in this area. Laceration of the digital nerve could lead to loss of sensation, clumsiness, and even loss of function. Gradually, neuroma formation would add a local pain and electric shock sign to the mentioned symptoms. CONCLUSION: Electric shock sign is characteristic for partial digital nerve injury with unknown mechanism. It seems the symptoms would be progressive and more complicated with neuroma formation. LEVEL OF EVIDENCE: V.

Orthopedic Trauma During Pregnancy; a Narrative Review.

Introduction: Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women, and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomical changes specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma management involves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnancies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approaches to circumvent the resultant challenges. Methods: We reviewed 55 articles, published on orthopedic trauma during pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehicle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury during pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy. Results: According to available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, and even gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrast to elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, should be performed promptly. Conclusion: Based on our investigation, pregnant women with orthopedic injuries that are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes, which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even maternal death.

Soft Tissue Sarcoma of Extremities: Descriptive Epidemiological Analysis According to National Population-based Study.

Background: Soft-Tissue Sarcoma (STS) is a heterogeneous group of neoplasms of mesenchymal origin, occurring in connective tissues. According to previously conducted studies, STS accounts for approximately 1% and 7-%15% of adult and pediatric malignancies, respectively. Almost 50%-60% of sarcomas arise from extremities and usually present as a large painless or rarely painful soft-tissue mass. The present study aimed to describe the epidemiology of soft-tissue sarcomas, especially in the Iranian population. Methods: This epidemiological study of limb soft-tissue sarcoma was conducted based on Iran National Cancer Registry data (INCR) between 2009 and 2014. Patients with soft-tissue sarcoma confirmed by histopathological studies were included, and data were classified based on the International Classification of Diseases for Oncology (first revision-third edition [ICD-O-3]) and analyzed. Descriptive analysis was performed to extract age-standardized and age-specific incidence rates. Results: A total of 2, 593 patients (1,476 males and 1,117 females) were enrolled and assessed in the present study. The age-standardized incidence rate(ASIR) of total soft tissue sarcomas was 6.34 per million person-years. In addition, the highest and lowest ASIR scores stratified by age were observed in patients aged above 65 and under 0 with the value of 19.61 (95% CI:17.91-21.30) and 1.91 (95% CI 1.69, 2.13) per million, respectively. Limb soft tissue sarcomas stratified by gender were dominant in males, and it was statistically significant (P<0.05). The most common extremity soft tissue sarcomas subtypes were mesenchymal tumor (12.26%), spindle cell sarcoma (12.18%), and malignant fibrous histiocytoma (11.45%). Conclusion: As evidenced by the results of the present study, the ASIR of soft tissue sarcoma dramatically increased with age, and the peak ASIR occurred in the age range of above 65 years. The incidence rate of soft tissue sarcomas analyzed by disease site was higher in hip and lower limb than upper limb and pelvis region, and it was detected consistently in all age groups and both genders.

Pilot Study of Additive Effect of "Offloading Ilizarov Frame" To Reduce "Reverse Sural Flap" Surgery Complications: A Clinical Trial.

Background: A reverse sural flap is an available surgical technique because it provides robust axial blood circulation to flaps with a substantially larger surface area. We aimed to assess Ilizarov frames outcome after reverse sural flaps among patients with traumatic injuries to the distal portion of the leg. Methods: Patients with traumatic distal injury of leg in Shoha-e Tajrish Hospital in 2022-2021 were recruited and treated with reverse sural flaps. Interventional group was followed by Ilizarov frames application (group A). For the second group, just conventional dressings and proper positioning were done after surgery (group B). Between the two groups, the duration of surgery, the degree of flap swelling, the time from surgery to discharge and flap failure, surgical site infection, deep vein thrombosis (DVT), and other complications were compared using SPSS 25 software. Results: Of 26 recruited patients, twenty consented to participate in this study. The average time from initial injury to reconstruction surgery, the mean duration of surgery, the mean time from surgery to discharge and the degree of swelling of the flap was compared between these two groups. The results showed better outcome in Ilizarov group, but the flap swelling grade was the only statistically significant factor between groups (P value= 0.03). Conclusions: The use of "offloading Ilizarov frames" to protect reverse sural flaps resulted in a considerable reduction in the flap swelling. It is a safe, quick, easy, and effective technique.

Mobile Spine Osseous Sarcoma: Descriptive Epidemiological Analysis Based on a National Population-Based Study.

BACKGROUND: Primary osseous sarcomas of the mobile spine are rare bony tumors. Ewing sarcoma, chondrosarcoma, chordoma and osteosarcoma constitute the majority of primary bone sarcomas of the spine; however, other rare sarcoma tumors may also affect the spine. In order to perform an epidemiological study of theses tumors, national registries may help to evaluate data for populations with similar characteristics. METHODS: A population-based study was designed based on data from the Iran National Cancer Registry (INCR). All morphology codes (M-Code) of primary osseous sarcomas of the mobile spine (C-code 41.2) were derived and analyzed. RESULTS: Among 186 patients with primary osseous sarcomas of the mobile spine, 67.2% were men and 32.8% were women. The median (IQR) age was 37.0 (20.0-59.0) years and the age-standardized incidence rate (ASIR) was 0.37 per million. The majority of cases of Ewing sarcoma (29.5%) were observed in the age group 20-25 years. Among male patients with chondrosarcoma, the median age was 39.0 (30.0-50.0), while females showed a median age of 56.0 (50.0-59.0). The median age of patients with chordoma was 54.0 (47.0-63.0) years. The crude incidence rate of mobile spine osteosarcoma was 0.04 per million. CONCLUSION: Ewing sarcoma was the most frequent primary osseous sarcoma of the mobile spine. A male predilection was observed among all major sarcomas of the mobile spine. Ewing sarcoma in Iran affects the mobile spine in slightly older ages compared to other studies. Myxoid chondrosarcoma is the most frequent subtype of the mobile spine chondrosarcoma. Chordoma affects male in older ages compared to females. In contrast with other studies which showed a bimodal distribution of osteosarcoma of the spine including young adult and older age groups, 86% of cases in Iran were in the age group of 10-40 years.

How to extract a broken cephalomedullary nail safely? A case presentation and review of the literature.

Application rate of cephalomedullary nails in treatment of pertrochanteric fractures has been increased. Although cephalomedullary nail breakage is rare, the occurrence is catastrophic and removingdistal fragment of the broken nail is always a challenging issue. Many techniques have been described for extracting broken nails, but most of them are used for conventional femoral nails. Furthermore, many of these techniques require specific extraction devices. Herein, we introduce a simple technique to remove the distal fragment of broken cephalomedullary nail with the least equipment requirements.

Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review.

BACKGROUND: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter and the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatment medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be treated surgically, and the complications are considerable. METHODS: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently extracted data from the studies and rated their quality.Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society for Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma, pathological fracture, or malignancy-related fractures were excluded. RESULTS: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years, and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric, respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and the most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the studies did not have a high level of evidence. CONCLUSION: An increase in the rate of atypical femoral fracture with its challenging management makes it an important issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found that extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.