Is immediate weight bearing safe for subtrochanteric femur fractures in elderly patients treated by cephalomedullary nailing? A multicentric study in one hundred eighty-two patients.

PURPOSE: Biomechanical superiority of intramedullary nails over extramedullary implants has been proved for subtrochanteric fractures. Nevertheless, postoperative management of these patients has not changed, with high rates of protected weight-bearing after intramedullary nailing. The purpose of this study is to determine the mechanical complications of immediate postoperative full weigh-bearing for subtrochanteric femur fractures in elderly patients treated with a cephalomedullary nail. METHODS: We performed a retrospective case series study from patients treated with a cephalomedullary nail for subtrochanteric fractures (AO/OTA 31A.3 and 32A-32C) over a nine-year period. Patients in the immediate full weight-bearing (IFWB) group received orders for immediate full weight bear as tolerated on postoperative 48 h. Patients in the non- or limited- weight-bearing (NLWB) group received orders not to full weight bear in the immediate postoperative. RESULTS: There were five (2.7%) cases of implant failure including four cutouts and one nail breakage that needed a reoperation. Of them, one (2.2%) followed the NLWB protocol and four (2.9%) followed the IFWB protocol. Mean length of stay was 7.9 days (median 8, range 3-21) in the NLWB group and 10.7 days (median 8, range 2-60) in the IWBAT group. The NLWB group observed a 2.8-day shorter postoperative length of stay when compared to the IFWB, but the median remained equal. CONCLUSION: This study suggests that geriatric patients with subtrochanteric fractures treated by intramedullary nailing and in which a good fracture reduction was achieved, may be able to tolerate immediate postoperative full weight-bearing, not increasing reoperation rates due to implant failure.

AO/OTA type C3 distal humeral fractures in patients aged 75 years and older: Is ORIF with double precontoured anatomical locking plates a reliable treatment?

INTRODUCTION: The incidence of osteoporotic distal humeral fractures (DHF) is on the rise. Their operative management is demanding. Fixation with non-locking reconstruction plates was associate with a high number of complications. Elbow arthroplasty (total or hemi) has been proposed as an alternative treatment, in spite of lifetime activity restrictions, and risk of complications, unknown implant survival and problematic revision surgery. Precontoured anatomical locking plates have increased the strength of the fixation in complex fractures. HYPOTHESIS: double plating ORIF with precontoured anatomical locking plates is a safe and reliable treatment option for the management of AO/OTA type C3 DHF in patients aged 75 and older. PATIENTS AND METHODS: A retrospective case series study of patients aged 75 years old and older with an AO/OTA type C3 DHF treated with ORIF with double precontoured anatomical locking plates between 2007 and 2021. Pathologic fractures were excluded. Patients' demographic, surgical, clinical, and radiological data were reviewed. RESULTS: A total of 27 women and 3 men, mean age of 80.1 years (range 75-93 years), were included. Mean Charlson index was 5 (range 3-8). Out of 30 patients, 19 had already died. Mean survival time after the surgical treatment was 72.3 months. Mean Mayo elbow performance score was 88.9 (range 60-100); 23 patients scored excellent or good. All fractures healed with no cases of delay union or non-union, hardware failure or loss of reduction. No patient needed a revision surgery to arthroplasty. The total number of complications was 12 (40%), mainly ulnar neuropathy (5) and cerclage removal (4). CONCLUSION: ORIF with double pre-contoured locking plates may be a safe and reliable treatment for type C3 DHF in patients aged 75 years and older, with a good functional outcome. Complications are expected but not related to loss of reduction, fixation failure or revision to elbow arthroplasty.

Fluoroscopic landmarks to recognize iatrogenic varus displacement (wedge effect) during cephalomedullary nailing of intertrochanteric fractures.

AIMS: Iatrogenic varus malreduction after intramedullary nailing of intertrochanteric fractures (wedge effect) may be more common than previously reported. The aim of study is to determine its incidence and to define easy fluoroscopic landmarks to recognize it intraoperatively. PATIENTS AND METHODS: We included surgical procedures with residual varus malreduction and sufficient intraoperative fluoroscopy images to assess an intraoperative anatomical reduction at the beginning of the procedure. Two intraoperative fluoroscopic landmarks were defined to assess varus in the anteroposterior view: the position of the greater trochanter (GT) related to the femoral shaft (medialized GT sign), and the position (superior, centre or inferior) of the guide wire in both the neck and the head of the femur (cross wire sign). We describe our current method of treatment to avoid this complication. RESULTS: A total of 369 extracapsular hip fractures were treated using PFNA and Gamma 3 systems. We found 55 (14.9%) fractures with a varus malreduction. Six were underreduced and fixed in varus. Thirty-five (9.48%) were well reduced by closed reduction but suffered a iatrogenic varus displacement when introducing the nail. 31 were female; mean age was 86.6 (range 70-97). Mean postoperative head-shaft angle was 119,2° range (113°-123°). Mean TAD was 24,37 range (14-36 mm). CONCLUSION: Wedge effect (iatrogenic varus displacement of a well reduced intertrochanteric fracture when introducing the nail) could occur in at least 10% of intertrochanteric fractures. The medialized GT and the "crossing wire sign" seem to be good predictors of iatrogenic varus malalignement.

Minimally invasive clamp-assisted reduction and cephalomedullary nailing without cerclage cables for subtrochanteric femur fractures in the elderly: Surgical technique and results.

INTRODUCTION: The treatment of subtrochanteric fractures in the elderly remains technically challenging, due to instability and osteoporosis, with high reoperation rates. Even if intramedullary nailing is the most reliable treatment, reduction is difficult and cerclage wiring remains controversial. The purpose of this study was to evaluate 26 consecutive subtrochanteric fractures in elderly patients treated with a minimally invasive clamp-assisted reduction and cephalomedullary nailing without cerclage wiring. PATIENTS AND METHODS: A retrospective analysis was conducted between January 2010 and September 2013. Data obtained from the medical records included patient's age, sex, classification of the fracture, the quality of reduction after surgery, and the presence of postoperative complications, especially fracture displacement and delayed union or nonunion. RESULTS: Twenty-six patients had adequate radiographic and clinical follow-up. Mean age was 84.4 (range 75-96) years. The mean duration of follow-up was 7.6 months (6-14 months). Mean surgical time was 74.42 min (range 45-115 min). Twenty-four (92.3%) showed acceptable varus/valgus alignment, and no sagittal plane malunions were noted. The tip-apex distance was <25 mm in all cases. Distraction at the fracture was <10mm in 21 fractures. Three patients had limb length discrepancy of 1cm. All fractures healed uneventfully. DISCUSSION: Reducing the fracture before nailing is mandatory to achieve good results. Minimally invasive clamp reduction without cerclage wires, even if challenging, has proven to be a safe, reproducible, and effective surgical technique, with at least the same results as other series.

Comparative study of the second and third generation of gamma nail for trochanteric fractures: review of 218 cases.

OBJECTIVES: The aim of this study was to compare the complications of the trochanteric gamma nail (TGN) and the Gamma3 Nail (G3), focusing on cutout failure. DESIGN: Retrospective comparative cohort analysis. SETTING: Level II Teaching Trauma Center academic trauma center. PATIENTS/METHODS: Two hundred eighteen trochanteric fractures with a mean follow-up of 15 months were included in the study. They were treated either with the TGN or the G3 between January 2005 and December 2010. Bivariate, stratified, and logistic regression analysis was conducted to determine the association between cutout and the independent variables. INTERVENTION: Proximal anterograde nailing with either the TGN or the G3. MAIN OUTCOME MEASUREMENTS: Patient age, sex, type of intramedullary device, stability fracture pattern, tip-apex distance (TAD), distraction at the fracture site, cervical angle, and cutout. RESULTS: The relative risk (RR) of cutout was 4.71 times higher in the group treated with G3 (P < 0.01). RR of cutout for unstable fractures compared with stable fractures was 3.07 (1.01-9.35). In unstable fractures, the RR of cutout was 8.78 times higher in patients with G3 (P < 0.01). RR of cutout was 1.54 times higher with TAD >25 mm (P = 0.4). DISCUSSION: We have not found any relationship between cutout rate and TAD. Only the fracture pattern and the type of implant have shown to be associated with cutout risk. In our study, Gamma3 Nail has higher cutout rates than TGN in unstable fractures. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Triplane fracture of distal radius treated surgically: case report and review of the literature.

Only four cases of triplane distal radius fracture have been described in the literature. We report the first that has been treated with open reduction and internal fixation. A 15-year-old boy sustained a triplane fracture of the distal radius. After an unsuccessful attempt at closed reduction, open reduction and internal fixation were performed. Six months after injury, the patient is asymptomatic, but radiographs show a partial growth arrest. The goal of treatment is to achieve anatomic reduction of the articular surface. In this case interposed periosteum prevented anatomic reduction, requiring open reduction and internal fixation. Because of the patient's advanced age the partial physeal arrest should advance to complete arrest before length impairment or occurrence of angular deformity.

Tourniquet-related iatrogenic femoral nerve palsy after knee surgery: case report and review of the literature.

Purpose. Tourniquet-induced nerve injuries have been reported in the literature, but even if electromyography abnormalities in knee surgery are frequent, only two cases of permanent femoral nerve palsies have been reported, both after prolonged tourniquet time. We report a case of tourniquet-related permanent femoral nerve palsy after knee surgery. Case Report. We report a case of a 58-year-old woman who underwent surgical treatment of a patella fracture. Tourniquet was inflated to 310 mmHg for 45 minutes. After surgery, patient complained about paralysis of the quadriceps femoris with inability to extend the knee. Electromyography and nerve conduction study showed a severe axonal neuropathy of the left femoral nerve, without clinical remission after several months. Discussion. Even if complications are not rare, safe duration and pressure for tourniquet use remain a controversy. Nevertheless, subtle clinical lesions of the femoral nerve or even subclinical lesions only detectable by nerve conduction and EMG activity are frequent, so persistent neurologic dysfunction, even if rare, may be an underreported complication of tourniquet application. Elderly persons with muscle atrophy and flaccid, loose skin might be in risk for iatrogenic nerve injury secondary to tourniquet.

Ankle fractures with posterior malleolar fragment: management and results.

Trimalleolar ankle fractures can be difficult to manage and convey a high risk of long-term morbidity. The question of whether internal fixation of the posterior malleolar fragment is warranted remains open. We conducted a retrospective cohort study involving 45 patients who underwent surgical repair of a trimalleolar fracture. Our goal was to study the effect of the size of the posterior fragment on outcomes. We defined small posterior malleolar fragments as being ≤ 25% of the distal tibial articular surface as viewed on the lateral radiograph. Outcome measures included the radiographic appearance of the reduction, as well as Olerud and Molander (O&M) scores and AOFAS scores. Overall better outcomes were obtained in patients whose fractures involved ≤ 25% of the articular surface, and the difference in outcomes was statistically significant in regard to the AOFAS scores (P = .05), although not statistically significant in regard to Olerud and Molander scores and the radiographic appearance of the reduction (P = .14 and P = .45, respectively). Anatomic reduction was achieved in 73.3% of patients, but they did not have better clinical results than nonanatomic reduction patients: AOFAS (P = .14), O&M (P = .38), radiographic appearance (P = .74).