Percutaneous iliosacral screwing in pelvic ring injury using three-dimensional fluoroscopy.

BACKGROUND: Iliosacral screw fixation is a popular technique for treatment of unstable pelvic injuries involving the posterior ring. However, screw malposition may result in dangerous complications involving injury to adjacent neurovascular structures. This study was conducted in order to evaluate the results and efficacy of using three-dimensional fluoroscopy in the performance of iliosacral screw fixation. METHODS: Twenty-nine patients (31 cases, two bilateral) who suffered injury to the pelvic ring requiring surgical treatment were included in this study. According to the Association for Osteosynthesis-Orthopaedic Trauma Association (AO-OTA) classification, there were 14 patients with type B, 13 patients with type C, and 2 patients with a bilateral sacral fracture. The mean age of patients was 39 years. Once the guide pin had been inserted, its safety was confirmed using three-dimensional fluoroscopy; screw fixation was then performed. Eighteen patients underwent percutaneous iliosacral screw fixation and anterior fixation, while 11 patents underwent screw fixation only. Postoperative computed tomography (CT) was performed for evaluation of the screw position, including any invasion into the sacral foramen or canal and neurovascular injury. The perforation of the screw was divided according to the location (sacral zones I, II, and III) and the degree (grade 0, no perforation; grade 1, perforation <2 mm; grade 2, perforation between 2 and 4 mm; grade 3, perforation >4 mm). RESULTS: The mean operation time was 35.6 min, and the mean radiation exposure time was 85.9 s. For accurate location of the guide pin, one patient underwent three-dimensional reconstruction twice. None of the patients required reoperation or suffered any neurovascular injury. Although seven cases involved perforation, all were less than 2 mm (grade 0: 24 cases, grade 1: 7 cases). CONCLUSIONS: When performing percutaneous iliosacral screw fixation in a patient with an unstable pelvic ring injury, use of three-dimensional fluoroscopy may allow for accurate location of the screw and result in fewer complications.

Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation.

Failure of intertrochanteric fracture fixation often occurs in patients who have poor bone quality, severe osteoporosis, or unstable fracture patterns. The purpose of this study is to compare the results of total hip arthroplasty (THA) with bipolar hemiarthroplasty as the salvage procedures for failed fixation of intertrochanteric fractures of the femur. Eighteen consecutive patients who were treated for failed intertrochanteric fracture fixation were reviewed retrospectively. The patients were divided into 2 groups of salvage procedures: THA (9 patients) and bipolar hemiarthroplasty (9 patients). In the THA group, mean Harris Hip Score (HHS), visual analog scale (VAS) score, and Salvati and Wilson score were 82.1, 0.9, and 31.3, retrospectively. In the bipolar hemiarthroplasty group, mean HHS, VAS score, and Salvati and Wilson score were 68.6, 3.1 and 25.1, retrospectively. Total hip arthroplasty was better than bipolar hemiarthroplasty treatment in HHS (P=.040), VAS score (P=.001), and Salvati and Wilson score (P=.033). There were no significant differences in hospital stay, operating time, and transfusion volume between the 2 groups. Total hip arthroplasty seems to be more reliable salvage procedure for failed intertrochanteric fracture fixation in functional outcome and pain relief.

Factors affecting the results of distal femoral fractures treated by retrograde intramedullary nailing.

OBJECTIVE: To assess the factors that affect the outcome of distal femoral fractures treated by retrograde intramedullary nailing. METHODS: Between November 1999 and June 2006, 30 patients with 31 distal femoral fractures (15 males and 15 females, 1 bilateral) were treated by retrograde nailing. Their ages ranged from 44 to 82 years old (average, 67.2 years old). The causes of injury were slipping downs in 17 patients, traffic accidents in 11, and falling from height in 2. The average interval from injury to operation was 1.8 days. There were 14 cases of A1 fracture, 7 cases of A2, 8 cases of A3, and 2 cases of C1 according to AO/OTA classifications. The mean distance between the most distal line of the fracture and the intercondylar notch was 7.2 cm (range, 0-12 cm). Closed retrograde nailing was done without reaming, and bone grafts were not done. RESULTS: The operation time averaged 76 minutes (range, 45-110 minutes). All patients were followed up for 19-69 months, and the mean follow-up duration was 27 months. Twenty-eight of 31 fractures united on the average of 14.7 weeks (range, 12-22 weeks). Complications occurred in 7 cases. There were 3 nonunions in AO-A3 fractures which were treated by changing implants or bone graft. Two patients suffered screw loosening of distal locking, that were re-fixed. Two patients showed limited knee motion of less than 90 degrees flexion. There were no cases of deep infection, malunion over 10 degrees of angulation or 1 cm of shortening. A satisfactory outcome (excellent and good results) was achieved in 26 of 31 cases (84%), according to Schatzker and Lambert's criteria. Poor results and complications were related to fractures of comminution and located within 5 cm from the intercondylar notch (Pearson Chi-square test, P = 0.03). Other possible factors including age, kinds of nails used, associated injury, and numbers of distal locking screws were not related to the outcome and complication (Pearson Chi-square test, P > 0.05). CONCLUSION: Retrograde nailing may be a useful option for distal femoral fractures, but attention should be paid to comminuted fractures or fractures close to the knee joint.