Does the femoral neck system provide better outcomes compared to cannulated screws fixation for the management of femoral neck fracture in young adults? A systematic review of literature and meta-analysis.

Background: Management of neck of femur fractures depend upon the age of presentation and it ranges from internal fixation to arthroplasty. In a relatively young population, anatomical reduction with stable internal fixation is the preferred treatment modality; the choice of implants available are multiple cannulated cancellous screws, dynamic hip screws, and the newly devised femoral neck system. The fracture configuration and pattern dictate the ideal implant to be utilized, with the femoral neck system documented to be apt for all the fracture types, while the cannulated screws are deemed better for stable fractures. Methods: A primary electronic search was conducted on databases of Medline, Scopus, Scopus, Cochrane Library, and Embase, to look for articles published between 1st January 2010 to 22nd November 2021. Studies including adults with femoral neck fractures treated with internal fixation with femoral neck system and comparing them with internal fixation with cannulated cancellous screws in terms of variables like mean surgical duration, loss of blood, length of incision, fluoroscopy time, duration of hospital stay and outcomes like union time, complications, functional outcomes, Visual Analogue Score, and femoral neck shortening, were included. Results: 6 retrospective studies with 371 patients (224 males,147 females) (164: FNS; 207: CCS) were included. Our analysis demonstrated no statistically significant difference in terms of duration of surgery, incision length, and length of hospital stay, there was more blood loss in FNS, but less fluoroscopy time. The fracture union time was lesser for the FNS group and also the femoral shortening was lesser in it. There was no difference in terms of complications, pain relief, and functional outcomes. Conclusion: Femoral neck system is a new and effective implant for femoral neck fractures in the young with faster union rates and lesser neck shortening through an incision similar to the conventional multiple cancellous screws. It has additional advantages of lesser fluoroscopy exposure to the patient and the OT personnel. However, the rates of complications like implant failure, non-unions, and avascular necrosis are similar to the cannulated screws and either of the implants do not offer any advantage in the final functional status and pain relief to the patient over each other.

Association of Specific Genetic Polymorphisms with Atraumatic Osteonecrosis of the Femoral Head: A Narrative Review.

Introduction: Atraumatic ONFH is one of the leading cause of hip morbidity in the working-age group. It is a multi-factorial disease whose root cause can be attributed to single-nucleotide polymorphism. Identifying such polymorphisms could pave the way for new modalities of treatment for ONFH. Methodology: Two databases were electronically searched for relevant articles. The articles were screened through titles, abstract and full texts to include the relevant studies. A secondary search was done through the reference list of selected articles. Results: A total of 52 studies were included among the 181 hits. All 181 were case-control studies. Summary of these studies identifies multiple SNPs which can cause ONFH. There were 117 SNPs in all 181 studies, of which 92 were associated with the causation of ONFH and 25 were protective against ONFH. Conclusion: SNPs play an essential role in causing atraumatic ONFH. Identification of SNP that contribute to causing ONFH may help reduce the disease burden by early identification, diagnosis and treatment, including targeted gene therapy.

Is early intramedullary interlocked nailing an effective treatment option for open grade III femoral shaft fractures: a systematic review of literature and pooled analysis of 176 cases.

BACKGROUND: Open Grade 3 femoral fractures are high-velocity injuries, often associated with other co-morbid injuries and are highly prone to infections; these fractures are commonly treated by staged procedures to minimize the complications. Early definitive fixation by intramedullary (IM) interlocking nails (ILN) has advantages like early mobility and better outcomes. STUDY QUESTION: Are early definitive fixations of grade III shaft femur fractures with debridement & IM ILN effective in union and infection rates? MATERIALS AND METHODS: Using relevant keywords, a total of 3357 articles were screened from the PubMed, Scopus and Embase database. 6 studies that evaluated at least 10 cases of grade III open femoral shaft fractures treated with early IM ILN during the index surgery were included in this review. RESULTS: Out of the 6 studies, only 1 was prospective, and the remaining 5 were retrospective in design. Out of 176 Grade III fractures, there were 8 non-unions, 3 malunions and 1 case of delayed union. Pooled analysis showed union rates of 94.8% for these fractures (4 studies). Infection was the most common complication. Pooled analysis showed that the mean rate of infection in these grade III fractures was 6.7%. Other complications included limb length discrepancy and stiff knee. CONCLUSION: Intramedullary nailing in grade 3 femoral fractures as an early method of definitive fixation is an effective option. In such cases, optimizing controllable variables like surgical expertise and adequate antibiotic prophylaxis can improve outcomes.

The effectiveness of arthroscopy assisted fixation of Schatzker types I-III tibial plateau fractures: our experience at a tertiary centre.

BACKGROUND: Tibial condyle fractures are high energy injuries which require anatomical reduction and stable fixation for early mobilisation of the knee joint. Arthroscopy assisted fixation of these fractures provide additional benefits of minimal dissection, accurate visualisation of the articular surface and faster rehabilitation. The present study describes our experience with this technique. MATERIALS & METHODS: Patients in the age group 15-65 years, presenting with closed tibial plateau fractures (Schatzker types I, II, III) at the advanced trauma centre of our institute within 3 weeks of injury, were recruited for this prospective case series. Open fractures, fractures of types IV, V and VI, fractures with associated knee dislocation, fractures presenting after 3 weeks and polytrauma patients with head injuries and/or blunt trauma to chest/abdomen, were excluded. Patients were evaluated according to Rasmussen numerical subjective evaluation chart at a minimum follow up of 6 months. RESULTS: There were 5 fractures of Schatzker type I, 8 of type II and 2 of type III, which were scoped and fixed percutaneously. The mean age of the 15 patients was 34.2 years with male to female ratio of 4:1. Diagnostic arthroscopy detected co existent lateral meniscal tears (peripheral) in 2 cases, while 1 case had a contused anterior cruciate ligament. Fixation of the fractures were done by 1 or 2 percutaneous screws in 9/15 cases; buttress plating in 4/15 cases and combination of plate and screw in 2/15 cases. The average overall Rasmussen score was 28.2/30 (range 22-30) and there were 1 patient each with postoperative stiffness and screw prominence while 3 cases had extensor lags. CONCLUSION: The aim of this combination procedure is stable fixation by minimally invasive methods; this reduces surgical insult, improves articular surface visualisation, allows management of concomitant ligament injuries, and patients can be rapidly mobilised. Case selection is extremely important for good results.

Bilateral crescent fracture-dislocation of the sacroiliac joint: a case-based discussion and review of literature.

BACKGROUND: Crescent fractures are a subset of lateral compression injuries associated with high energy trauma and are rotationally unstable. These fractures are rare bilaterally, and we present one such rare case of a bilateral crescent fracture. CASE DESCRIPTION: A 56-year-old male presented with run-over injury and was diagnosed with bilateral crescent fracture-dislocation of the Sacroiliac joint. He was stabilized hemodynamically and then operated with iliosacral screws and reconstruction plates. The fracture united, and the patient is doing his daily activities without discomfort at follow up of 1 year after fracture fixation. CONCLUSION: Bilateral pelvic crescent fractures are rare and need optimization and fixation for improved functional outcomes. It is necessary to evaluate associated injuries.

Prominent Resident's Ridge as a Potential Cause of Anterior Cruciate Ligament Impingement: A Case Report.

BACKGROUND: The resident's ridge is an arthroscopic landmark that is consistent with the anterior border of the anterior cruciate ligament (ACL) femoral attachment. The identification of the landmark allows for accurate graft placement. CASE REPORT: We report a case of a 30-year athletic individual with an ACL-deficient knee, who had an abnormally large resident's ridge, abutting the midsubstance of the torn ACL; the residual femoral attachment was behind the ridge. Resection and burring of this ridge were needed to expose the posterior aspect of the intercondylar notch; even after bone-patellar tendon-bone graft placement, some additional removal of bone had to be done to reduce graft impingement on this area in extension. CONCLUSION: Abnormal resident's ridge may be misleading about the anatomy of the lateral femoral condyle area. Appropriate resection of abnormal bone is the key to the identification of femoral footprint and graft placement. We speculate that this bony projection may even have contributed to the ACL injury, and extra bone had to be removed to minimize subsequent impingement.

Bilateral sub-trochanteric femur fragility fractures in a patient on antiretroviral therapy: a case based discussion and review of literature.

BACKGROUND: The burden of HIV/AIDS is ever increasing, affecting populations all over the world. Along with the disease, its effects and consequences on bone health are also on a rise. A commonly used drug in managing HIV, "Tenofovir" has been shown to affect bone health, specifically on prolonged usage. Osteomalacia and osteoporosis secondary to drug induced Fanconi syndrome and the disease itself, could lead to pathological/fragility fractures with trivial trauma. CASE DESCRIPTION: A 45 year old female on antiretroviral drugs (ART) for HIV, presented with right hip pain and inability to bear weight. She has had similar symptoms previously in the left hip which resolved after 6 weeks of limited weight bearing. Anteroposterior and lateral radiographs of pelvis with hips showed bilateral sub-trochanteric fractures; healed on the left side and displaced on the right side. The patient was managed with cessation of tenofovir and right side proximal femoral nail anti-rotation (PFNA). Patient was lost to follow up but had started to ambulate independently with a cane, by the end of 6 weeks, before she succumbed to systemic complications. CONCLUSION: Patients receiving antiretrovirals especially tenofovir should be regularly investigated for their renal impairment and bone health. Fixation of pathological fractures and early mobilization are important to prevent prolonged bed immobilization and associated complications in these immunocompromised patients.

An Unusual Complex Posterolateral Osteoligamentous Injury of the Knee in an Adolescent.

We present an unusual and complex case of a 16-year-old adolescent male who injured his right knee and sustained combined avulsion injuries of posterior cruciate ligament (PCL) at the tibial insertion site, iliotibial band at lateral tibial condyle, and lateral collateral ligament (LCL) at femoral insertion site akin to osteoligamentous posterolateral corner injury. Anatomical reduction of the femoral LCL avulsion fragment was performed and fixed with a two 4-mm partially threaded cancellous screw. Iliotibial band avulsion was buttressed using Ellis t-plate and fixed with two 4-mm partially threaded cancellous screws. PCL avulsion fracture was conservatively treated owing to minimal displacement. At one-year follow-up, the patient was pain free with a range of motion of 0 to 150 degrees of flexion and had a pain free knee with no instability. Posterolateral corner injury in the patient was very significant as it involved LCL avulsion and iliotibial band avulsion, both of which are part of the posterolateral structures of the knee and also involve the growth plate. Fixation of the avulsion of Gerdy's tubercle with the buttress plate helps to provide additional stability to counteract the deforming forces of the iliotibial band. LCL is also the major stabilizer against varus forces, and hence fixation is required for stability while preventing growth disturbance. PCL avulsion can be treated conservatively in those patients where the fragment is undisplaced or minimally displaced. A good outcome can be achieved in skeletally immature patients who have osteoligamentous posterolateral corner injuries with associated avulsion fractures by using appropriate anatomical reduction and surgical fixation.

Complex Multiplanar Fracture of the Distal Femur with an Undescribed Pattern: A Case Report and Review of the Literature.

Distal femur fractures in younger age groups are associated with high-impact injury leading to severe comminution and soft tissue injuries. Most of the intra-articular distal femur fractures occur as a result of axial loading accompanied by a variable amount of flexion. An 18-year-old male patient who had met with a road traffic accident was brought to the trauma center. Radiographic examination revealed a fracture of the distal femur, predominantly involving the lateral condyle without any evidence of metaphyseal comminution, and lateral view showed a complete separation of both the condyles from the proximal shaft. This type of fracture pattern did not fit into any of the current classification systems of distal femoral fractures. The medial and lateral approaches were carried out simultaneously instead of the anterior midline approach, owing to the poor skin condition over the anterior aspect of the knee. These fractures are difficult to treat due to high articular involvement and present a tedious task for the surgeon. Anatomical reduction with preserved articular cartilage is the key to a good outcome in such complex fractures. Atypical fracture types are not uncommon, and they can be incorporated into existing or future classification systems, which may contribute to a better understanding and management of these fractures.