Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing.

BACKGROUND: The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience. METHODS: In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience. RESULTS: In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04). CONCLUSIONS: Significant variations exist in surgeons' selection of entry points for proximal femoral nailing, underscoring the task's complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes. TRIAL REGISTRATION NUMBER: DRKS00032465.

The Trochlear Paradox in Native Knees and Its Potential Impact on Total Knee Arthroplasty: An MRI-Based Correlation Study Investigating the Effect of Varying Posterior Femoral Condyle Angles on the Patellofemoral Joint.

BACKGROUND: Since the beginning of total knee arthroplasty, implant alignment has been a central point of discussion. As diverse as the discussed alignment theories are, as uniform is the implant design, which is supposed to be based on the "average knee." Steady upgrades in prosthesis design and modern alignment theories have achieved improvements. However, knee arthroplasty continues to be burdened by a significant percentage of dissatisfied patients. In current knee arthroplasty, femoral implant alignment is referenced by the dorsal and distal condylar axes. The patellofemoral joint variance is not sufficiently considered. Predominantly dorsal and distal referencing at the femoral condyle determines the postoperative shape of the anterior knee joint. The present study investigated a possible relationship between dorsal and distal joint parameters and the patellofemoral joint. METHODS: In this explorative retrospective monocentric study, MRI cross-sectional images of 100 native knee joints were evaluated. By determining parametric correlations according to Pearson, the study investigates whether the independent variables "posterior femoral condyle angle" and "lateral distal femoral angle" are related to "lateral trochlear inclination", "patella tilt", and "bisect offset". RESULTS: The posterior condylar angle significantly correlates with lateral trochlear inclination, patella tilt, and bisect offset. There is a positive correlation with patella tilt and bisect offset but a negative correlation with lateral trochlear inclination. The lateral distal femoral angle did not correlate with the studied parameters. CONCLUSION: The lateral trochlear inclination decreases with an increased posterior femoral condylar angle. The posterior referencing of the femoral component in total knee arthroplasty simultaneously establishes the shape of the anterior knee joint. Our results indicate that increasing posterior condyle angles significantly correlate with flattened lateral trochlear inclinations in native knees and suggest a systematic biomechanical conflict in total knee arthroplasty.

A comprehensive analysis of intraoperative factors associated with acute-on-chronic kidney injury in elderly trauma patients: blood loss as a key predictor.

BACKGROUND: Postoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI. METHODS: A retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed. RESULTS: Postoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL). CONCLUSION: In geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population.

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial.

PURPOSE: Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS: 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS: Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION: Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE: II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER: DRKS00030075.

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study.

INTRODUCTION: An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors-identifiable in conventional X-rays-are predictive. METHODS: Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. RESULTS: Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher's exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. CONCLUSION: In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. LEVEL OF EVIDENCE: III, retrospective cohort study. TRAIL REGISTRATION NUMBER: DRKS00024536.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up.

BACKGROUND: Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up. METHODS: Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters. RESULTS: Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5-5.4)) and PPFF (3.5 (95% CI: 1.2-5.8)) but not for RF (1.5 (95% CI: 0.4-2.6)) and AJ (2.0 (95% CI: 0.0-4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0-27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0-61.5% of cases. DISCUSSION: This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years. CONCLUSION: Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.