Optimizing the Entry Point for Medullary Hip Screws.

INTRODUCTION: Medullary hip screws (MHSs) are the most common treatment of intertrochanteric hip fractures because they can be used for varied fracture patterns and resist shortening. Identifying the appropriate MHS entry point can be intellectually and technically challenging. We aimed to quantify the variability in the ideal entry point (IEP) for MHSs. METHODS: Standing alignment radiographs of 50 patients were evaluated using TraumaCad (Brainlab). The femoral neck shaft angle and the offset from the tip of the greater trochanter (GT) to the femur's longitudinal axis ('greater trochanter offset') were measured. Five MHS system templates were superimposed on the femur's longitudinal axis, and the distance from the GT tip to MHS's top center was measured. Five independent reviewers each templated 20 images such that all images were measured at least twice. A random sample of five images was selected for all five raters to measure and to calculate an intraclass coefficient Mean IEPs were compared with an independent sample Student t -test. RESULTS: The mean GT offset was 13.5 ± 5.6 mm (range 12.9 to 26.7 mm). The mean neck shaft angle was 129.5 ± 4.0 (range 120 to 139). The mean IEP for nail systems ranged from 5.7 to 7.1 mm medial to the GT tip; there was no notable difference in pairwise comparison of nail systems or in aggregate. Intraclass coefficient for all ratings, measurements, and nail types ranged from moderate to good. Both intra-rater and inter-rater reliability were excellent. DISCUSSION AND CONCLUSION: In a sample with broad variation in femoral anatomy, there is a specific, roughly 1.5 mm wide interval that is 6.4 mm medial to the GT tip that serves as the IEP for the most common MHS systems. No notable difference seems to exist in the IEP among these MHS systems.

Optimizing the Entry Point for Reconstruction Nailing of the Femur.

INTRODUCTION: Varus after antegrade medullary nailing of the proximal femur is associated with worse outcomes. Anecdotally, a more medialized "trochiformis" entry is beneficial to avoid varus with valgus-bend (greater trochanteric entry) femoral nails. However, the optimal entry point remains unknown. The purpose of this study was to define the optimal entry point for reconstruction nailing. METHODS: Using standing alignment radiographs from 51 patients, we templated the ideal entry point for straight and valgus-bend nails from three major manufacturers using TraumaCad software. We measured the distance from the tip of the trochanter to the ideal entry site for each nail. We compared piriformis (PF) with trochanteric (GT) entry for each company and across manufacturers. RESULTS: The mean greater trochanter offset from the femoral axis was 15.2 mm. The mean PF entry was 5.9 to 6.7 mm medial to the mean GT entry for each company's nail and was statistically distinct. No differences were observed in GT and PF entry points across manufacturers. Only 2 of 153 ideal GT entry points were lateral to the tip of the trochanter. An increased neck-shaft angle (NSA) and increased GT offset were correlated with a more medial ideal entry point. DISCUSSION: The ideal entry point for GT nails is similar across manufacturers and is medial to the tip of the greater trochanter; however, PF and GT entry sites remain distinct. During preoperative planning and when executing femoral nailing intraoperatively, it may also be important to consider the NSA and GT offset of a patient before committing to a certain entry point.

Patient preference for trigger finger treatment.

BACKGROUND: Trigger finger is a common disorder of the hand that can cause disabling symptoms. Treatment options range from conservative management with observation and splinting, to surgical release, but there is currently not a consensus on a treatment algorithm. AIM: To determine patient preference for the treatment of trigger finger using an online survey. METHODS: An online crowdsourcing platform, Amazon Mechanical Turk, was used to recruit participants for this study. Participants were led through a scenario in which they were diagnosed with trigger finger. They were then asked to rank their preference of treatment options from the following: Observation, splinting, corticosteroid injection, surgery. The results of the surveys were then analyzed using R software. RESULTS: Of 323 participants completed the survey. 7 participants were excluded because they failed to correctly answer the attention question, leaving 316 participants whose results were included. As a first choice for treatment 117 (37%) of the included participants chose observation, 86 (27%) chose splinting, 61 (19%) chose corticosteroid injection, and 52 (16%) chose surgery. The mean rank for observation was 2.26, for splinting was 2.30, for corticosteroid injection was 2.53, and for surgery was 2.91. The ranking of each treatment option was statistically different (P value < 0.05) from the others except for observation and splinting. CONCLUSION: The practice of shared decision making with patients is imperative to providing the best care possible. The results from this study, especially the preference for less invasive treatment, may help providers better frame discussion around treatment options of trigger fingers. This in turn, may increase patient satisfaction in the treatment of trigger finger.