Traumatic Floating Total Hip Arthroplasty: A Case Report.

CASE: A 58-year-old woman with medical history of a left total hip arthroplasty performed by the direct anterior (DA) approach 2 years prior presented with left hip pain. She was found to have sustained a transverse Vancouver C periprosthetic femur fracture and an unstable periprosthetic pelvic fracture. CONCLUSIONS: This patient's case represents a previously not reported injury about a total hip arthroplasty-with disruption distal to the femoral implant and proximal to the acetabular implant, with the implant-to-bone interface unaffected. This case may guide future treatment of similar injuries.

Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management.

BACKGROUND Hoffa fractures are an uncommon form of coronal fracture that impact the femoral condyle. As a result, they are not very prevalent. It is necessary to perform anatomical reduction and rigorous fixation on these fractures; however, there is no consensus among medical professionals on the surgical procedure and implant that would be the most successful in treating these fractures. CASE REPORT A 50-year-old woman who had poliomyelitis in her right lower limb presented with a displaced medial Hoffa fracture of her left knee. She had fallen and was suffering from poliomyelitis. The trauma that caused this fracture had a modest energy level. Open reduction and internal fixation with 2 retrograde cannulated screws were included in her surgical procedure. An approach known as the medial parapatellar route was used for this treatment. As part of her postoperative rehabilitation, she participated in physiotherapy, exercises that did not require weight bearing, exercises that used passive and active assistance, activities that involved partial and full weight bearing, and exercises that involved complete weight bearing. At the 2-year follow-up, the patient's left knee continued to be painless and stable, and it had unrestricted range of motion across the whole extremity. It was determined via radiographs that the fracture had healed without any problems or arthritic changes developing. She was able to walk without help and carry out her daily tasks since she was able to walk with the use of a cane. CONCLUSIONS Retrograde cannulated screws can be a reliable and successful choice for treatment of medial Hoffa fractures, with positive results according to both clinical and radiographic characteristics. Further research is needed to analyze the outcomes over a longer period of time and make comparisons between this technique and others.

Tumour-induced osteomalacia: the long road to diagnosis and recovery.

Tumour-induced osteomalacia is caused by tumorous production of fibroblast growth factor 23 (FGF23) leading to urinary phosphate wasting, hypophosphataemia and decreased vitamin D activation. The resulting osteomalacia presents with muscle weakness and bone pain but progresses to multiple pathological fractures. Patients often remain undiagnosed for years with severe physical, psychological and economic ramifications. A young woman presented with multiple spontaneous fractures including bilateral femoral fractures. Laboratory tests revealed severe hypophosphataemia, elevated bone turnover markers and low to normal calcium and 25-hydroxy-vitamin D levels. Treatment with phosphate, alfalcalcidol, calcium and magnesium was initiated. 68Gallium-DOTATOC positron emission tomography imaging revealed a mass in the right foot and venous sampling of FGF23 from all extremities confirmed this tumour as the culprit. Biopsy and histology were consistent with a phosphaturic mesenchymal tumour, which was surgically resected. Phosphate levels quickly normalised postoperatively but a long convalescence with hungry bone syndrome, fracture healing and physical therapy followed.

Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging' revisited: a case-report.

BACKGROUND: People with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature. CASE PRESENTATION: In this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient's unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach. CONCLUSIONS: The limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing.

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Sildenafil delays bone remodeling of fractured femora in aged mice by reducing the number and activity of osteoclasts within the callus tissue.

The elderly exhibit a reduced healing capacity after fracture, which is often associated with delayed or failed bone healing. This is due to a plethora of factors, such as an impaired bone vascular system and delayed angiogenesis. The phosphodiesterase-5 (PDE-5) inhibitor sildenafil exerts pro-angiogenic and pro-osteogenic effects. Hence, we herein investigated in aged mice whether sildenafil can improve fracture healing. For this purpose, 40 aged CD-1 mice (16-18 months) were daily treated with 5 mg/kg body weight sildenafil (n = 20) or vehicle (control, n = 20) by oral gavage. The callus tissue of their femora was analyzed at 2 and 5 weeks after fracture by X-ray, biomechanics, micro-computed tomography (µCT), histology, immunohistochemistry as well as Western blotting. These analyses revealed a significantly increased bone volume and higher ratio of callus to femoral bone diameter in sildenafil-treated mice at 5 weeks after fracture when compared to controls. This was associated with a reduced number and activity of osteoclasts at 2 weeks after fracture, most likely caused by an increased expression of osteoprotegerin (OPG). Taken together, these findings indicate that sildenafil does not improve fracture healing in the elderly but delays the process of bone remodeling most likely by reducing the number and activity of osteoclasts within the callus tissue.

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures.

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

Development and validation of a novel overhead method for anteroposterior radiographs of fractured rat femurs.

We aimed to establish a new method of obtaining femur anteroposterior radiographs from live rats. We used five adult male Sprague-Dawley rats and created a femoral fracture model with an 8 mm segmental fragment. After the surgery, we obtained two femoral anteroposterior radiographs, a novel overhead method, and a traditional craniocaudal view. We obtained the overhead method three times, craniocaudal view once, and anteroposterior radiograph of the isolated femoral bone after euthanasia. We compared the overhead method and craniocaudal view with an isolated femoral anteroposterior view. We used a two-sample t-test and intraclass correlation coefficient (ICC) to estimate the intra-observer reliability. The overhead method had significantly smaller differences than the craniocaudal view for nail length (1.53 ± 1.26 vs. 11.4 ± 3.45, p < 0.001, ICC 0.96) and neck shaft angle (5.82 ± 3.8 vs. 37.8 ± 5.7, p < 0.001, ICC 0.96). No significant differences existed for intertrochanteric length/femoral head diameter (0.23 ± 0.13 vs. 0.23 ± 0.13, p = 0.96, ICC 0.98) or lateral condyle/medial condyle width (0.15 ± 0.16 vs. 0.13 ± 0.08, p = 0.82, ICC 0.99). A fragment displacement was within 0.11 mm (2.4%). The overhead method was closer to the isolated femoral anteroposterior view and had higher reliability.

Differences in bone histomorphometry between White postmenopausal women with and without atypical femoral fracture after long-term bisphosphonate therapy.

Bone histomorphometric endpoints in transilial biopsies may be associated with an increased risk of atypical femoral fracture (AFF) in patients with osteoporosis who take antiresorptives, including bisphosphonates (BPs). One way to test this hypothesis is to evaluate bone histomorphometric endpoints in age-, gender-, and treatment time-matched patients who either had AFF or did not have AFF. In this study, we performed transiliac bone biopsies in 52 White postmenopausal women with (n = 20) and without (n = 32) AFFs, all of whom had been treated for osteoporosis continuously with alendronate for 4-17 yr. Despite the matched range of treatment duration (4-17 yr), AFF patients received alendronate for significantly longer time (10.7 yr) than non-AFF patients (8.0 yr) (P = .014). Bone histomorphometric endpoints reflecting microstructure and turnover were assessed in cancellous, intracortical, and endocortical envelopes from transilial biopsy specimens obtained from BP-treated patients 3-6 mo after AFF and from non-AFF patients with similar age-, gender-, and range of BP treatment duration. However, in both cancellous and intracortical envelopes, AFF patients had significantly lower wall thickness (W.Th) and higher osteoclast surface (Oc.S/BS) than non-AFF patients. In addition, AFF patients had significantly higher eroded surface (ES/BS) only in the intracortical envelope. None of the dynamic variables related to bone formation and turnover differed significantly between the groups. In conclusion, in the ilium of BP-treated patients with osteoporosis, AFF patients have lower thickness of superficial bone (lower W.Th) of the cancellous and cortical envelopes than non-AFF patients. AFF and non-AFF patients have a similar bone turnover rate in the ilium. Furthermore, in this population, as in previous work, AFF is more likely to occur in BP-treated patients with longer treatment duration.

Bisphosphonates (BPs) are widely used to prevent osteoporotic fracture and treat osteoporosis. However, prolonged use of BPs may increase the risk of atypical femoral fracture (AFF), and their pathogenesis remains unclear. This study compared the bone histomorphometric findings in cancellous and cortical bones between White osteoporotic women with (n = 20) and without AFF (n = 32), who had received BP treatment for a matched duration of 4­17 yr. The BP-treated patients with AFF had significantly lower wall thickness (W.Th) in both cancellous and cortical bones compared to BP-treated patients without AFF. There were no significant differences in bone formation, turnover, or mineral apposition rate between BP-treated AFF and non-AFF patients. In conclusion, our study results suggest that AFF risk is increased in BP-treated patients with smaller young and healthy superficial bone areas (indicated by lower W.Th). Surprisingly, we also discovered that patients with and without AFF have similar bone turnover rates, which contradicts previous beliefs. Our findings provide valuable insights into the potential factors contributing to AFF in BP-treated patients.

Biomechanical analysis of combi-hole locking compression plate during fracture healing: A numerical study of screw configuration.

Locking compression plates (LCPs) have become a widely used option for treating femur bone fractures. However, the optimal screw configuration with combi-holes remains a subject of debate. The study aims to create a time-dependent finite element (FE) model to assess the impacts of different screw configurations on LCP fixation stiffness and healing efficiency across four healing stages during a complete fracture healing process. To simulate the healing process, we integrated a time-dependent callus formation mechanism into a FE model of the LCP with combi-holes. Three screw configuration parameters, namely working length, screw number, and screw position, were investigated. Increasing the working length negatively affected axial stiffness and healing efficiency (p < 0.001), while screw number or position had no significant impact (p > 0.01). The time-dependent model displayed a moderate correlation with the conventional time-independent model for axial stiffness and healing efficiency (ρ ≥ 0.733, p ≤ 0.025). The highest healing efficiency (95.2%) was observed in screw configuration C125 during the 4-8-week period. The results provide insights into managing fractures using LCPs with combi-holes over an extended duration. Under axial compressive loading conditions, the use of the C125 screw configuration can enhance callus formation during the 4-12-week period for transverse fractures. When employing the C12345 configuration, it becomes crucial to avoid overconstraint during the 4-8-week period.

Segmental femoral fracture malunion: evidence and prognostic analysis of medical intervention in the third century BC.

We examined the remains of an individual who was unearthed from the Tuchengzi site and was believed to be from the Warring States period in China. The remains exhibited segmental femoral fracture. We aimed to deduce the cause of fracture, medical interventions, healing process, and motion behavior after fracture healing using several techniques, including macroscopic observation, computed tomography (CT), and finite element analysis. Based on the morphology of the long bones, it appeared that the individual was male. The fractures resulted in an adduction angle of 5.47° and an anterior flexion angle of 21.34° in the proximal femur, while the femoral neck anteversion angle had been replaced by a retroversion angle of 10.74°. Additionally, the distal femur formed an abnormal anterior convex angle of 144.60°. CT revealed mature callus formation and visible trabecular bundles. The finite element analysis indicated that the maximum von Mises stress in the femur was 17.44 MPa during standing and 96.46 MPa during walking. We suggest that medical practitioners in the Warring States period possessed a good knowledge of thigh anatomy, enabling them to perform fracture reduction and fixation. Reasonable medical intervention facilitated fracture healing and load recovery. Satisfactory fracture healing ensured that the individual could engage in normal standing and walking activities after rehabilitation.

The influence of femoral lytic tumors segmentation on autonomous finite element analysis.

BACKGROUND: The validated CT-based autonomous finite element system Simfini (Yosibash et al., 2020) is used in clinical practice to assist orthopedic oncologists in determining the risk of pathological femoral fractures due to metastatic tumors. The finite element models are created automatically from CT-scans, assigning to lytic tumors a relatively low stiffness as if these were a low-density bone tissue because the tumors could not be automatically identified. METHODS: The newly developed automatic deep learning algorithm which segments lytic tumors in femurs, presented in (Rachmil et al., 2023), was integrated into Simfini. Finite element models of twenty femurs from ten CT-scans of patients with femoral lytic tumors were analyzed three times using: the original methodology without tumor segmentation, manual segmentation of the lytic tumors, and the new automatic segmentation deep learning algorithm to identify lytic tumors. The influence of explicitly incorporating tumors in the autonomous finite element analysis on computed principal strains is quantified. These serve as an indicator of femoral fracture and are therefore of clinical significance. FINDINGS: Autonomous finite element models with segmented lytic tumors had generally larger strains in regions affected by the tumor. The deep learning and manual segmentation of tumors resulted in similar average principal strains in 19 regions out of the 23 regions within 15 femurs with lytic tumors. A high dice similarity score of the automatic deep learning tumor segmentation did not necessarily correspond to minor differences compared to manual segmentation. INTERPRETATION: Automatic tumor segmentation by deep learning allows their incorporation into an autonomous finite element system, resulting generally in elevated averaged principal strains that may better predict pathological femoral fractures.

Accuracy of the Lesser Trochanter Profile as a Marker of Femoral Rotation: Computed Tomography-Based Study of 1,722 Femora.

BACKGROUND: The lesser trochanter (LT) profile is an often-used marker for proximal femoral rotation, particularly during the operative fixation of femoral fractures. Previous studies have come to conflicting conclusions about its reliability for this purpose. METHODS: The SOMA (Stryker Orthopaedic Modeling and Analytics) database (Stryker) was used to identify 1,722 computed tomographic (CT) scans of whole femora. Each femur was taken through an 80° rotational arc in 2.5° increments, and the LT profile was constructed for each position. These 56,826 LT profile measurements were then correlated with the femoral rotation. RESULTS: Across the arc of motion studied, the LT correlated weakly with proximal femoral rotation (R 2 = 0.32). There was a 35° arc, between 10° and 45° relative external rotation of the proximal femur, within which the LT profile only changed by 1 mm. The mean overall femoral anteversion was 21.2°, and women tended to have more femoral anteversion (23.9°) than men (19.2°). On average, men had a 1.6-mm more prominent LT than women. Side-to-side differences in femoral anteversion as well as LT position and size were not significant or were clinically unimportant. CONCLUSIONS: A large-scale, CT-based study shows that the LT profile is a less reliable marker of proximal femoral rotation than previously thought. This is true particularly if there is relative external rotation of the proximal femur, where the proximal femur can undergo up to 35° of rotation before 1 mm of change in the LT profile occurs. Care must be taken to check other markers of rotation such as by clinical examination during fixation of femoral fractures and not rely solely on the LT profile. CLINICAL RELEVANCE: In the largest study of its kind, this CT-based study of 56,826 LT profile measurements found that when the proximal femur is externally rotated, the LT profile becomes an unreliable marker of rotation, which can lead to excessive internal rotation of the distal fracture fragment. The LT profile should be used with caution, and confirmation of rotation by other means is recommended.

Characteristics of Femoral Shaft Fractures That Predict Ipsilateral Femoral Neck Fractures.

INTRODUCTION: This study aims to characterize radiographic features and fracture characteristics in femoral shaft fractures with associated femoral neck fractures, with the goal of establishing predictive indicators for the presence of ipsilateral femoral neck fractures (IFNFs). METHODS: A retrospective cohort was collected from the electronic medical record of three level I trauma centers over a 5-year period (2017 to 2022) by current procedural terminology (CPT) codes. Current CPT codes for combined femoral shaft and IFNFs were identified to generate our study group. CPT codes for isolated femur fractures were identified to generate a control group. RESULTS: One hundred forty patients comprised our IFNF cohort, and 280 comprised the control cohort. On univariate, there were significant differences in mechanism of injury (P < 0.001), Orthopedic Trauma Association (OTA)/Arbeitsgemeinshaft fur Osteosynthesefragen (AO) classification (P = 0.002), and fracture location (P < 0.001) between cohorts. On multivariate, motor vehicle crashes were more commonly associated with IFNFs compared with other mechanism of injuries. OTA/AO 32A fractures were more commonly associated with IFNFs when compared with OTA/AO 32B fractures (adjusted odds ratio = 0.36, P < 0.001). Fractures through the isthmus were significantly more commonly associated with IFNFs than fractures more proximal (adjusted odds ratio = 2.52, P = 0.011). DISCUSSION: Detecting IFNFs in femoral shaft fractures is challenging. Motor vehicle crashes and motorcycle collisions, OTA/AO type 32A fractures, and isthmus fractures are predictive of IFNFs.

Immediate weightbearing is safe after revision total hip arthroplasty for Vancouver B2/B3 periprosthetic femur fractures.

INTRODUCTION: Modular fluted, tapered stems provide a reliable treatment for Vancouver B2/B3 fractures. Historically, these patients had weightbearing restrictions postoperatively. Although full immediate postoperative weightbearing may provide benefits in this patient population, stem subsidence is a concern. QUESTIONS/PURPOSES: The objective of this study was to investigate the effect of post-operative weight-bearing status on stem subsidence in patients treated with modular tapered stems for Vancouver B2 and B3 periprosthetic fractures. We sought to answer two questions: (1) Does full immediate postoperative weightbearing after revision total hip arthroplasty for periprosthetic femur fracture lead to increased stem subsidence compared to protected weightbearing? (2) Is there a mortality difference between these two groups of patients with different weightbearing restrictions? METHODS: From 2009 to 2015 all patients who underwent revision for Vancouver B2/B3 fractures were made non-weightbearing (NWB) for six weeks postoperatively. After 2015, immediate weightbearing as tolerated (WBAT) was allowed postoperatively. We compared stem subsidence between immediate postoperative and final radiographs. Additionally, we performed a Kaplan-Meijer analysis with one-year mortality as an endpoint. RESULTS: The final cohort included forty-seven patients with an average follow-up of 254 days. The average stem subsidence was 1.0 mm (95 % CI, 0.5-1.5 mm) in the NWB cohort and 0.3 mm (95 % CI, 0-0.7 mm) in the WBAT cohort (P = 0.10). In our survivorship analysis, we noted no deaths in the WBAT cohort compared to 17 % mortality in the NWB cohort at the one-year timepoint. CONCLUSION: Allowing patients to weight bear immediately after revision does not increase stem subsidence. Further studies are needed to determine whether early weightbearing provides a mortality benefit.

Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients.

INTRODUCTION: Our primary aim of the study was to assess the results of a treatment protocol for aseptic femoral shaft nonunion treated by three techniques - Exchange Nailing (EN), Plate Augmentation (PA), and Exchange Nailing combined with Plate augmentation (NP). The secondary objective was to assess the radiological outcome, duration of surgery (DOS) and need for blood transfusion (BT) in all the three groups. MATERIALS AND METHODS: We analyzed 330 patients treated for AFNU between Jan 2007 and Dec 2019. Using a simple treatment algorithm, EN, PA and NP were performed in 24,183 and 123 patients respectively. Patients in all the three groups were assessed for radiological-union (union rate and time to union), DOS and BT. RESULTS: Of these 330 patients, 327 (99 %) patients achieved radiological union at a mean duration of 6.07 months. Union rate is highest with NP followed by PA and EN. The union rate in patients with NP, PA and EN were 100 %, 99.5 % and 91.7 % respectively (p < 0.01). Time to union was lowest for NP followed by PA and EN (p < 0.001).The mean time to union for NP, PA and EN were 3.76, 7.2and 9.21 months respectively (p < 0.001). The mean DOS in minutes for NP, EN and PA was 107, 94 and 82 respectively (p < 0.01). The mean need for BT in the form of packed red blood cells for NP, PA and EN were 1.95, 1.87 and 1.38 units respectively (p < 0.01). CONCLUSION: Following a simple algorithm to decide treatment protocol on a case-to case basis helps to achieve good results in an optimal time period. When compared with EN and PA, NP is associated with 100 % union rate with least time to union making NP a reasonably effective procedure with a very high success rate. LEVEL OF EVIDENCE: IV.

Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study.

Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ±â€…2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ±â€…2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.

The effect of screw orientation on internal fixation of Letenneur type II Hoffa fractures: a biomechanics study.

BACKGROUND: To investigate the biomechanical effects of screw orientation and fracture block size on the internal fixation system for Letenneur type II Hoffa fractures. METHODS: The fracture models were randomly divided into six groups according to the fracture subtypes and the direction of nail placement, and a plumb line of the posterior condylar tangent was made across the base of the posterior femoral condyle. The fracture blocks of the three types of fracture were calculated and recorded in the sagittal position, and the biomechanical performance of the six groups was evaluated by biomechanical tests. The axial load on the fracture block at a displacement of 2 mm was set as the failure load, a gradually increasing axial load was applied to each fracture model using a customized indenter at a load of 250-750 N, and the displacements and failure loads of the six groups were recorded at different axial loads. RESULTS: Biomechanical test results showed that the larger the fracture block, the greater was the stability when nailing from front to back, and the smaller the fracture block, the greater was the strength when nailing from back to front (p < 0.001). As the fracture block became larger, the biomechanical advantage of nailing from posterior to anterior decreased.The displacement under 250 N load were 1.351 ± 0.113 mm, 1.465 ± 0.073 mm for Group IIa AP and Group IIa PA. The displacement under 500 N load were 2.596 ± 0.125 mm, 2.344 ± 0.099 mm for Group IIa AP and Group IIa PA. The displacement under 750 N load were 3.997 ± 0.164, 3.386 ± 0.125 mm for Group IIa AP and Group IIa PA. The failure loads were 384 ± 14 N, 415 ± 19 N for Group IIa AP and Group IIa PA. In the type IIa fracture group, the difference was no longer significant (p > 0.001). Therefore, there is a mechanical threshold that ranges from 38.36 to 52.33% between type IIa and type IIb fractures. CONCLUSIONS: The effect of the nailing direction on the strength of fixation has a fracture-block critical point, which is consistent overall with the trend that the larger the fracture block is, the greater the stability when nailing from anterior to posterior, and the smaller the fracture block is, the greater the strength when nailing from posterior to anterior.