Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures.

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

Hip Fractures in Centenarians: Functional Outcomes, Mortality, and Risk Factors from a Multicenter Cohort Study.

Background: Increasing longevity has caused the very old population to become the fastest-growing segment. The number of centenarians (over 100 years old) is increasing rapidly. Fractures in the elderly lead to excessive medical costs and decreased quality of life with socioeconomic burdens. However, little research has thoroughly examined the functional outcomes and mortality of hip fractures in centenarians. Methods: This is a retrospective observational study. Sixty-eight centenarian hip fracture patients were admitted to the 10 institutions from February 2004 to December 2019. Fifty-six patients with 1-year follow-up were finally included. The following data were obtained: sex, age, body mass index, Charlson comorbidity index value on the operation day, Koval's classification for ambulatory ability, type of fracture, the time interval from trauma to surgery, American Society of Anesthesiologists grade, surgery-related complications, and duration of hospital stay. Postoperative Koval's classification (at 1 year after surgery) and information about death were also collected. Multivariate analysis was performed to analyze the risk factors affecting mortality 1 year after surgery. Results: Mortality rates were 26.8% at 6 months and 39.3% at 1 year. The 90-day mortality was 19.6%, and one of them (2.1%) died in the hospital. The 1-year mortality rates for the community ambulatory and non-community ambulatory groups were 29% and 52%, respectively. Only 9 (16.1%) were able to walk outdoors 1 year after surgery. The remaining 47 patients (83.9%) had to stay indoors after surgery. Multivariate analysis demonstrated that the pre-injury ambulatory level (adjusted hazard ratio, 2.884; p = 0.034) was associated with the risk of mortality. Conclusions: We report a 1-year mortality rate of 39.3% in centenarian patients with hip fractures. The risk factor for mortality was the pre-injury ambulatory status. This could be an important consideration in the planning of treatment for centenarian hip fracture patients.

Position Statement: Atypical Femoral Fracture from the Korean Society for Bone and Mineral Research in 2023.

As the aging population increases, the number of patients with osteoporosis is gradually rising. Osteoporosis is a metabolic bone disease characterized by low bone mass and the microarchitectural deterioration of bone tissue, resulting in reduced bone strength and an increased risk of low-energy or fragility fractures. Thus, the use of anti-resorptive agents, such as bisphosphonates (BPs), to prevent osteoporotic fractures is growing annually. BPs are effective in reducing hip and other fractures. However, the longer a patient takes BPs, the higher the risk of an atypical femoral fracture (AFF). The exact mechanism by which long-term BP use affects the development of AFFs has not yet been clarified. However, several theories have been suggested to explain the pathogenesis of AFFs, such as suppressed bone remodeling, impaired bone healing, altered bone quality, and femoral morphology. The management of AFFs requires both medical and surgical approaches. BPs therapy should be discontinued immediately, and calcium and vitamin D levels should be evaluated and supplemented if insufficient. Teriparatide can be used for AFFs. Intramedullary nailing is the primary treatment for complete AFFs, and prophylactic femoral nailing is recommended if signs of an impending fracture are detected.

Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique.

Purpose: Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures. Materials and Methods: A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively. Results: Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm. Conclusion: Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.

Midterm Outcomes of Intramedullary Fixation of Intertrochanteric Femoral Fractures Using Compression Hip Nails: Radiologic and Clinical Results.

Background: Various implants are used to treat intertrochanteric fractures. However, the optimal implant to stabilize intertrochanteric femoral fractures is still a matter of debate. The purpose of the present study was to evaluate the midterm outcomes of patients treated using compression hip nails (CHNs). Methods: Between March 2013 and April 2018, 164 patients with intertrochanteric femoral fractures who were treated with internal fixation using CHNs were enrolled in this study. The mean age of the patients was 79.6 years. We retrospectively collected and estimated information such as reduction state, implant position, operation time, blood loss, hospital stay, time to achieve union, clinical scores (Harris hip score [HHS] and EuroQol five-dimensional [EQ-5D]), intraoperative complications (such as lag jamming and drill bit breakage), failure of fixation, avascular necrosis, and surgical site infection. Results: The mean follow-up period was 39.69 months. Eight percent of the patients required an open reduction. The mean operation time was 131 minutes, the mean blood loss was 221.19 mL, the mean hospital stay was 20.66 days, and the average time to union was 18 weeks. Intraoperative complications included 8 cases of breakage of the drill bit while making distal holes. The failure rate was 3.7% and revision surgery was performed in 6 cases (for cut-out in 5 and pull-out of the lag screw in 1). Asymptomatic venous thromboembolism occurred in 2 cases and hematoma requiring intervention occurred in 1 case. There were no other complications such as avascular necrosis, infection, and lateral irritation. At the 2-year follow-up, the averages of HHS and EQ-5D were 71.54 and 0.68, respectively. Conclusions: Among the implants used to treat intertrochanteric femoral fractures, CHNs had a surgical failure of 3.7% and showed good radiologic and clinical results.

General versus Brachial Plexus Block Anesthesia in Pain Management after Internal Fixation in Patients with Distal Radius Fracture: A Randomized Controlled Trial.

Distal radius fractures (DRFs) are very common injuries associated with aging, and the number of fractures is increasing with the increase in the elderly population. General anesthesia or brachial plexus block (BPB) is required for fracture fixation, and acute postoperative pain control is necessary after operation. Early pain control can improve patient satisfaction and functional outcomes. In this study, we report the clinical differences in postoperative pain, according to the method of anesthesia (general anesthesia versus brachial plexus block). Volar plating was used to treat 72 patients older than 60 years who had comminuted DRF. Patients were randomized to either group A (36 patients), who underwent general anesthesia, or group B (36 patients), who underwent BPB. We compared these two groups prospectively for acute postoperative pain using a visual analog scale (VAS) at 2, 4, 6, 12, and 24 h after surgery. The VAS scores of each group were: 6.8 ± 2.5 in general anesthesia and 0.5 ± 2.3 in BPB at 2 h, postoperatively; 6.5 ± 2.4 in general anesthesia and 0.5 ± 2.4 in BPB anesthesia at 4 h, postoperatively; 5.2 ± 2.4 in general anesthesia and 1.5 ± 2.4 in BPB anesthesia at 6 h, postoperatively; 4.5 ± 2.5 in general anesthesia and 3.4 ± 2.7 in BPB anesthesia at 12 h, postoperatively; and 3.5 ± 2.5 in general anesthesia and 3.2 ± 2.7 in BPB anesthesia at 24 h, postoperatively. DRF patients with BPB anesthesia showed a lower VAS score than those subjected to general anesthesia in early postoperative period. As a result, the effect of BPB anesthesia on acute pain management after surgery was excellent, which resulted in a lower pain score compared with general anesthesia in DRF patients undergoing volar plating.

Transfusion Trends of Knee Arthroplasty in Korea: A Nationwide Study Using the Korean National Health Insurance Service Sample Data.

Knee arthroplasties are strongly associated with blood transfusion to compensate for perioperative bleeding. The purpose of this study was to evaluate trends of transfusion associated with knee arthroplasties using nationwide data of the National Health Insurance Service-National Sample Cohort (NHIS-NSC). Using data from the nationwide claims database of the Health Insurance Review Assessment Service managed by the NHIS, 50,553 knee arthroplasties under three categories (total knee replacement arthroplasty, uni-knee replacement arthroplasty, and revision arthroplasty) from 2012 to 2018 were identified. Overall transfusion rate, transfusion count, proportion of each type of transfusion, and cost associated with each type of operation were investigated. Overall transfusion rate was 83.4% (5897/7066) in 2012, 82.7% (5793/7001) in 2013, 79.6% (5557/6978) in 2014, 75.9% (5742/7557) in 2015, 73.1% (6095/8337) in 2016, 68.2% (4187/6139) in 2017, and 64.6% (4271/6613) in 2018. The proportion of each type of transfusion was 1.8% for fresh frozen plasma, 0.5% for platelets, and 97.7% for red blood cells. The average cost of transfusion was $109.1 ($123 in 2012, $124 in 2013, $123.3 in 2014, $110.6 in 2015, $100 in 2016, $92.9 in 2017, and $90.1 in 2018). In this nationally representative study of trends in transfusion associated with knee arthroplasty, we observed significantly high rates of blood transfusion among patients undergoing knee arthroplasties. Although the overall rate of transfusion had declined, the allogeneic transfusion rate was still high from 2012 to 2018 in Korea. Thus, surgeons need to develop various patient blood management plans and minimize the use of allogeneic transfusion when performing knee arthroplasties.

Subtrochanteric Insufficiency Fracture Occurring 5 Years after Surgery at the Steinmann Pin Insertion Site for Fracture Reduction.

Background and Objectives: Steinmann pins are commonly used in orthopedics, with a low rate of complications. However, thermal osteonecrosis may occur when a pin is inserted using a drill. There have been no reports on late-onset fractures at the Steinmann pin insertion site. Materials and Methods: A 32-year-old man who underwent surgery for a femoral shaft fracture 5 years ago complained of proximal thigh pain 1 month after the removal of the internal device. On physical examination, the patient showed a limping gait due to pain, and tenderness was observed on the lateral aspect of the proximal thigh. Magnetic resonance imaging was performed because the symptoms did not improve, despite conservative treatment. A new fracture line was observed in the lateral cortical bone of the proximal femur. It was found that a fracture occurred at the site where the Steinmann pin was inserted for a closed reduction at the time of the first operation. The patient was instructed to limit weight bearing and to use crutches while walking. Parathyroid hormone was additionally administered to promote bone formation. Results: Six months after diagnosis, a complete union was achieved at the subtrochanteric fracture site, and the patient's pain subsided. Conclusions: A fracture that occurs as a late onset at the provisional Steinmann pin insertion site is an extremely rare complication; however, orthopedic surgeons must consider this possibility and make more efforts to lower the occurrence of thermal damage. In addition, if the patient complains of pain in the region where the pin was inserted after surgery, surgeons should spare no effort to determine whether a new fracture has occurred.

Hip Fracture Surgery without Transfusion in Patients with Hemoglobin Less Than 10 g/dL.

BACKGROUD: Hip fracture surgery is associated with blood loss, which may lead to adverse patient outcomes. The hemoglobin level declines gradually in most hip fracture cases involving femoral neck fractures and intertrochanteric fractures. It decreases further after hip fracture surgery due to perioperative bleeding. We developed a protocol, which avoids transfusion in hip fracture surgery, and reviewed the hemodynamic outcomes of patients with hemoglobin less than 10 g/dL without transfusion. METHODS: From 2014 to 2019, we retrospectively recruited 34 patients with hip fractures and a hemoglobin level less than 10 g/dL, who refused to undergo transfusion. There were 19 patients with femoral neck fractures and 15 patients with intertrochanteric fractures. Our patient blood management (PBM) protocol involving 4,000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) was applied to all included patients. Intraoperatively, a cell saver and tranexamic acid were used. Postoperatively, the protocol was maintained until the patients' hemoglobin level reached 10 g/dL. We evaluated the feasibility of our protocol, perioperative complications, and hemodynamic changes. RESULTS: Nineteen patients with femoral neck fractures underwent bipolar hemiarthroplasty and 15 patients with intertrochanteric fractures underwent internal fixation with a cephalomedullary nail. The mean hemoglobin level was 8.9 g/dL (range, 7.3-9.9 g/dL) preoperatively, 7.9 g/dL (range, 6.5-9.3 g/dL) immediately postoperatively, 7.7 g/dL (range, 4.3-9.5 g/dL) on postoperative day 1, 7.4 g/dL (range, 4.2-9.4 g/dL) on postoperative day 3, 8.1 g/dL (range, 4.4-9.7 g/dL) on postoperative day 5, 8.5 g/dL (range, 4.5-9.9 g/dL) on postoperative day 7, and 9.9 g/dL (range, 5.7-11.1 g/dL) on postoperative day 14. The average intraoperative bleeding was 206.2 ± 78.7 mL. There was no case associated with complications of anemia. CONCLUSIONS: Hip fracture surgery in patients with hemoglobin less than 10 g/dL was feasible without the need for transfusion using our PBM protocol in 34 patients. Using this protocol, the operation was conducted safely despite the anemic condition of patients with fractures whose hemoglobin was less than 10 g/dL.

Staged patellar tendon reconstruction using doubled bone-patellar tendon-bone allograft for infected patellar tendon rupture: a rare case report of three years follow-up.

BACKGROUND: Patellar tendon rupture is a relatively rare injury that usually requires surgical treatment. The optimal therapeutic strategy is still controversial, especially when either concomitant patellar tendon infection or soft tissue infection surrounds the patellar tendon. Until recently, most reported reconstruction methods are extensive and difficult to apply because of the poor condition of the soft tissue surrounding the patellar tendon. CASE PRESENTATION: A 19-year-old male patient presented to our clinic three weeks following a motorcycle accident. There was a 5 x 4 cm sized skin defect with soft tissue infection below the inferior pole of patella. We performed a staged patellar tendon reconstruction using a doubled bone-patellar tendon-bone allograft (BPTB) to the infected patellar tendon rupture, following local random fasciocutaneous flap and split-thickness skin graft. Three months following surgery, the patient was able to perform an active knee motion with no extension lag and excellent clinical functional result. DISCUSSION AND CONCLUSIONS: Our technique introduced in this specific case is a relatively simple method to reconstruct chronic patellar tendon defects with limited incision exposing only the patellar tendon areas. We expect it can be less invasively performed on patients who have a soft tissue problem and cannot have extensive surgery.

Arthroscopic treatment of Mycobacterium massiliense septic arthritis outbreak after intra-articular injection: A case-series report and literature review.

ABSTRACT: Non-tuberculous mycobacteria (NTM) comprise mycobacteria, with the exceptions of Mycobacterium (M.) leprae and the M. tuberculosis complex. Septic arthritis caused by NTM is so rare that there is no standardized treatment.Between April and September 2012, 27 patients were infected with M. massiliense in a single clinic following injection of steroid in the knee joint. Clinical data of 9 patients who received arthroscopic treatment in Seoul Hospital of Soonchunhyang University were analyzed retrospectively.Arthroscopic irrigation and debridement were performed average 2.6 times (1-3 times). As 6 out of 9 cases (67%) had joint contracture of the knee joint, arthroscopic adhesiolysis, and brisement were performed. After surgical procedures, Hospital for Special Surgery and Lysholm knee score showed improvement compared before the surgery, but a radiographic result evaluated by Kellgren-Lawrence revealed that 6 cases got deteriorated to stage 4 in the 4-year follow-up.NTM septic arthritis had a higher recurrence and a higher contracture incidence than septic arthritis caused by tuberculous mycobacteria or other bacteria. Treatment was possible with repeated arthroscopic debridement and intravenous antibiotics.

Comparison of medial and lateral tibial tunnel in pullout repair of posterior root tear of medial meniscus: Radiologic, clinical, and arthroscopic outcomes.

PURPOSE: Medial meniscus posterior root tear (MMPRT) should be repaired to the correct position as possible to maintain hoop tension of the meniscus. In this study, we propose a comparison of the outcome between the medial tunnel and the lateral tunnel in the pullout suture technique using the tibial tunnel for anatomical repair of posterior root tear of medial meniscus. METHODS: From April 2010, of patients who underwent pullout suture, 51 cases (24 medial tunnel group (MTG) and 27 lateral tunnel group (LTG)) were able to follow-up with second look arthroscopy. Original Coronal Ratio of Root Attachment (CRORA) was defined as the ratio of the distance from the medial edge of the tibial plateau to the root attach site divided by the entire tibial medial-lateral width on preoperative computed tomography. Error between postoperative CRORA and original CRORA was calculated. We compared this error, clinical outcome, and arthroscopic finding between MTG and LTG. RESULTS: The mean error ratio of postoperative CRORA divided by original CRORA was 0.86 ± 0.11 in MTG, which was significantly (p = 0.001) lower than that (1.02 ± 0.06) in LTG. The mean value of the root attach point in the MTG with a post/original CRORA value of 0.86 ± 0.11 means statistically significant medialization after the operation. There was no statistically significant difference in changes of International Knee Documentation Committee (IKDC) and Lysholom score between MTG and LTG. The difference between the two groups of arthritis progression was not statistically significant. CONCLUSION: In patients with MMPRT, CRORA may provide a basis for coronal assessment of root repair position before and after surgery, and lateral tibial tunnel technique can help anatomical repair by reducing technical error due to guide pin slip medially compared to medial tibial tunnel technique.

Preservation of the Tibial Remnant in Anterior Cruciate Ligament Reconstruction May Improve Postoperative Proprioceptive Function.

The purpose of this study was to retrospectively compare clinical results, including proprioceptive function, after anterior cruciate ligament (ACL) reconstruction between 2 groups using techniques that preserve and eliminate the tibial remnant. Forty-eight patients who were followed for at least 24 months after ACL reconstruction with 4-strand hamstring tendon autografts were enrolled in this study. They were then divided into 2 groups: the remnant-preserving group (group A, 26 patients), in whom more than 7 mm of the remnant tibial stump (approximately 20% of the mean length of the ACL) was preserved; and the remnant-eliminating group (group B, 22 patients), in whom the tibial remnant was eliminated during ACL reconstruction. The average duration of follow-up was 25.5 months. At last follow-up, patients were evaluated using the International Knee Documentation Committee scale, Hospital for Special Surgery score, Lachman test, arthrometer, reproduction of passive positioning (RPP) test, threshold to detection of passive motion (TTDPM) test, one-leg hop test, and single-limb standing test. The clinical results between the 2 groups were statistically compared. Group A showed significantly better results on the RPP test at 15° (P=.040) and 30° (P=.010), one-leg hop test (P=.017), and single-limb standing test (P=.007) compared with group B. The other results showed no significant differences. The remnant-preserving technique in ACL reconstruction yields better proprioceptive and functional outcomes and may help achieve postoperative patient satisfaction. [Orthopedics. 2020;43(4):e231-e236.].

Total hip arthroplasty in hereditary multiple exostoses with secondary osteoarthritis: A case report.

RATIONALE: Hereditary multiple exostoses (HME) is an autosomal dominant disease that causes multiple exostoses throughout the body. It usually occurs around the metaphysis of the long bones, and when it involves the hip, symptoms arise due to deformity and the mass effect. If the lesion does not involve the joint or is not associated with arthritis, symptoms can be relieved by surgical excision of the osteochondroma. However, if secondary osteoarthritis (OA) or subluxation of the joint has progressed, joint replacement arthroplasty should be considered. PATIENT CONCERNS: A 57-year-old woman with HME visited our outpatient department with severe right hip pain. She complained of difficulty walking and severe discomfort during activities of daily living. She was short in stature and had a family history of HME. DIAGNOSIS: A physical examination revealed limited motion in the hip joint and a limb length discrepancy. Plain radiography and a computed tomography scan revealed huge osteochondromas on bilateral proximal femurs and advanced OA with subluxation of the right hip joint. INTERVENTIONS: Cementless total hip arthroplasty of the right hip joint via the modified posterolateral approach was done. OUTCOMES: The patient showed good clinical scores and functional improvement at the 2-year follow-up. LESSONS: Total hip arthroplasty for an anatomically deformed joint is technically difficult, and there are many factors to consider that can make surgeons reluctant to use this modality. However, with careful preparation, arthroplasty is a good surgical option for symptomatic and functional recovery in HME patients with hip joint involvement.

Reliability of measuring lateral bowing angle of the femur in patients with atypical femur fractures.

BACKGROUND: Lateral femoral bowing causes a higher tensile mechanical load on the lateral side of the femur, which plays a critical role in the pathogenesis of atypical femoral fractures (AFFs). There are many ways to measure lateral femoral bowing on plain radiographs, and there are difficulties in finding a correspondence point between measurements among multiple measurers. The purpose of this study is to prove the best method of correspondence between the investigators by analyzing the reliability of various methods for measuring lateral femoral bowing. MATERIALS AND METHODS: We retrospectively collected data from 85 patients (87 femurs) diagnosed with AFF who had plain radiographs of entire femur from October 2013 to March 2018. The femoral bowing was measured in coronal view of femur plain radiographs using five methods (Sasaki, Morin, Jang, Kim, and Yau) by three examiners, respectively. The intra- and interobserver reliability of each method was assessed using intraclass correlation coefficient (ICC) for continuous variables. RESULTS: All methods showed excellent intra- and interobserver reliability with ICC of >0.8. Among five methods, the Yau's method was the highest reliable method (ICC = 0.980, 95% confidence interval = 0.971-0.986). CONCLUSIONS: All methods of measuring lateral femoral bowing in the coronal plane of plain radiographs are reliable. And, we recommend Yau's method, which has a clear reference point for measuring femoral bowing and is highest reproducible.

Atypical incomplete femoral neck fracture in patients taking long-term bisphosphonate: Case report, a report of 2 cases.

RATIONALE: We present 2 cases of lateral incomplete impending fracture of the femoral neck without trauma in elderly patients taking long-term bisphosphonate (BP) treatment, and we defined it as atypical femoral neck fracture (AFNF). To the best of our knowledge, this is the first report on the follow-up results of AFNF. PATIENT CONCERNS: Patients in both cases had been taking BP drugs for a long time with osteoporosis. The duration of BP treatment was 6 years, and there was no history of repeated stresses. DIAGNOSES: All fractures were linear at the lateral aspect of the mid portion of the femoral neck, and the BMD of the femoral neck was -0.9, and -1.8, respectively. INTERVENTIONS: Internal fixation was performed in both cases (73 years, 68 years) using cannulated screws. OUTCOMES: In both patients who underwent screw fixation, the fracture line started to extend distally at 4 weeks and 2 weeks following surgery. In the 3-month follow-up image, the length of the fracture increased by 20.1 mm and 9.9 mm, respectively. There was a problem with active rehabilitation, and the possibility of revision was also found to be a burden in terms of mortality and cost in older patients. LESSONS: In the case of AFNF, guidelines for treatment should be set in consideration of the decreased bone healing, even when the fracture pattern is simple. Arthroplasty based on a wider indication may be worth considering.