Closed reduction and internal fixation for tillaux fractures, based on pre-operative three-dimensional computed tomography.

OBJECTIVE: This study aimed to propose treatment protocol and identify patterns of tillaux fractures using three-dimensional (3D) computed tomography (CT) analysis and to describe an effective reduction technique. METHODS: Forty-two juvenile patients with tillaux fractures were evaluated with 3D-CT scan for fracture displacement pattern and received surgical treatment. Tillaux fragment was reduced by pushing the superomedial quadrant part of the fragment slightly downward towards the ankle joint from anterolateral to posteromedial through 5-mm skin incisions with mosquito forceps. A 4.0 cannulated screw was subsequently inserted from the anterolateral to the posteromedial side parallel to the ankle joint. We analysed the distance and direction of fracture displacement with 3D-CT before the surgery. Pre-operative and post-operative plain radiographs were evaluated. RESULTS: Pre-operative 3D-CT analysis revealed a common fracture pattern, varus tilt, and external rotation of fragment. We achieved satisfactory reduction with residual fracture gaps less than 2 mm in 42 cases. Two cases had a 13-mm anterior gap that was reduced by mini-open reduction because of periosteal impingement. No significant clinical complications were found. CONCLUSION: The closed reduction technique developed based on the fracture pattern identified by 3D-CT anatomical analysis is safe and effective in treating tillaux fractures.

Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures.

PURPOSE: To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation. MATERIALS AND METHODS: A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated. RESULTS: Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups. CONCLUSION: Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable. LEVEL OF EVIDENCE: Level III.

Risk factors for pubic ramus fracture nonunion after conservative treatment of pelvic ring injuries: a retrospective cohort multicenter study.

PURPOSE: To determine the incidence of nonunion, clinical and radiological outcomes, and risk factors for nonunion in conservatively treated pubic ramus fractures among patients diagnosed with pelvic ring injury. METHODS: A total of 546 patients (192 men, 354 women) diagnosed with pubic ramus fracture, treated conservatively, and who had completed > 1 year follow-up at three level 1 trauma centers between January 2014 and December 2020, were enrolled. Clinical and radiological evaluations were compared between union and nonunion groups. Logistic regression and Kaplan-Meier analyses were used. RESULT: At the final follow-up, 527 (96.5%) and 19 (3.5%) patients had union and nonunion of fractures, respectively. The union and nonunion groups exhibited statistically significant differences in posterior injury (p = 0.040), bilateral ramus fracture (p < 0.001), initial displacement (p < 0.001), and clinical result (p < 0.001). In the multivariate logistic regression analysis, initial displacement (odds ratio, 4.727; p = 0.005) was analyzed as a risk factor for nonunion. According to the Kaplan-Meier analysis, the median initial displacement of nonunion occurrence was 17.9 mm (standard error, 1.211; 95% confidence interval 15.526-20.274), and nonunion patients were included if the displacement was > 15.9 mm (standard error, 1.305) on the 75th percentile. CONCLUSION: Conservative treatment is ineffective in some ramus fracture cases with pelvic ring injury. As ramus nonunion causes functional deterioration, active treatment is required if the displacement is ≥ 16 mm.

Does Serum Vitamin D Influence the Prognosis of Critically Ill Patients with Trauma? A Prospective, Observational Study in a Trauma Center.

Background: Vitamin D concentrations are associated with sepsis, pneumonia, and mortality in critically ill patients. However, the role of vitamin D in critically injured patients with trauma remains unknown. This study investigated the effects of vitamin D concentrations on outcomes in critically injured patients with trauma. Methods: A prospective observational study was conducted by randomly selecting 100 patients among those who visited our trauma center. The serum vitamin D concentration was measured upon arrival at the hospital, and the length of stay in a trauma intensive care unit after admission, duration of mechanical ventilation, number of days spent in the hospital, development of complications, and death were investigated. The association between the surveyed variables and vitamin D concentrations was investigated using regression analysis. Results: Of the 100 patients, 69 were men and 31 were women with an average age of 51.7 years. The average intensive care unit stay length was 18.4 days, and 6 patients (5.9%) died. Univariate regression analysis showed that the factors affecting patient mortality were age (p = 0.02), volume of blood transfused within 24 hours of arrival (p = 0.009), systolic blood pressure measured upon hospital arrival (p = 0.01), and serum lactate concentration measured upon hospital arrival (p = 0.03). Multivariate regression analysis showed that the factors affecting patient mortality were age (p = 0.01), volume of blood transfusion (p = 0.04), and systolic blood pressure measured upon hospital arrival (p = 0.01). Conclusions: There were no statistically significant effects of serum vitamin D concentrations in critically ill patients with trauma on death during hospitalization.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures.

PURPOSE: To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures. MATERIALS AND METHODS: We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated. RESULTS: The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups. CONCLUSION: Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative. LEVEL OF EVIDENCE: Level III.

Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study.

INTRODUCTION: Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. METHODS: We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. RESULTS: Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003). CONCLUSION: A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.

Incomplete Diaphyseal Atypical Femoral Fracture due to Increased Anterolateral Bowing: Treatment with Corrective Osteotomy and Intramedullary Nailing with Augmented Plate Fixation.

BACKGROUND: Increased anterolateral bowing of the femur is associated with atypical femoral fractures among older patients (including both those receiving and those not receiving treatment with bisphosphonates) as well as a greater likelihood of occurring in the diaphyseal versus the subtrochanteric region. Prophylactic intramedullary (IM) nailing is recommended for the treatment of incomplete atypical femoral fractures, which are radiographically evident. However, this bowing deformity is considered to be a major obstacle to IM nailing as it may be associated with postoperative complications. Corrective osteotomy combined with IM nailing straightens the exaggerated curvature of the femur. We hypothesized that this technique may lead to the safe and rapid healing of incomplete diaphyseal atypical femoral fractures, thereby reducing lateral tensile stress. METHODS: From October 2015 through March 2020, 17 female patients (20 femora) with a mean age of 76.1 years (range, 68 to 86 years) underwent a surgical procedure for the treatment of an incomplete diaphyseal atypical femoral fracture associated with anterolateral bowing. The surgical technique consisted of minimally invasive osteotomy and reconstruction with use of IM nailing, with or without an augmentation plate. Preoperative and postoperative radiographic findings (lateral and anterior bowing angles, anterolateral bowing grade, and lateral distal femoral angle [LDFA]) were compared. Primary union, time to union, and complications were evaluated as the outcomes. RESULTS: Primary bone union was achieved in 19 of the 20 femora at a mean of 24.9 weeks (range, 20 to 40 weeks). There were 2 instances of delayed union, which healed at 36 and 40 weeks. The lateral bowing angle, anterior bowing angle, and LDFA significantly improved postoperatively (from 12.0° to 3.3°, from 17.3° to 11.5°, and from 93.5° to 88.8°, respectively) (p < 0.001). There was 1 instance of nonunion, which healed after plate augmentation without a bone graft. CONCLUSIONS: Given the pathophysiology of elevated lateral tensile stress, corrective osteotomy and IM nailing may be an acceptable solution for the treatment of incomplete diaphyseal atypical femoral fractures associated with increased anterolateral bowing. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Efficacy of Staged Surgery in the Treatment of Open Tibial Fractures with Severe Soft Tissue Injury and Bone Defect.

PURPOSE: We aimed to report the clinical and radiological outcomes of staged surgery using the acute induced membrane technique with an antibiotic-impregnated cement spacer (ACS) and soft-tissue reconstructive surgery and to identify factors affecting clinical outcomes. MATERIALS AND METHODS: Thirty-two patients with severe open tibia fractures were treated via staged surgery from January 2014 to December 2019 and followed up for ≥1 year. In the first surgery, an ACS was inserted into the bone defect site along with debridement and irrigation and was temporarily fixed in place with an external fixator. The internal fixator was placed, and flap surgery and cement spacer changes were performed during the next surgery. In the third surgery, an autogenous bone graft was performed. Radiologic and functional results were investigated according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria, and factors affecting the ASAMI score were analyzed. RESULTS: The average bone defect width was 43.9 mm, and the size of soft-tissue defect was 79.3 cm² . Bone union was achieved in all cases except one and required 9.4 months on average. Complications occurred in 10 cases (31.2%). Good or better clinical effects, in terms of ASAMI radiologic and functional scores, were observed in 29 and 24 cases, respectively. Complications and additional surgery were common factors affecting the two scores. CONCLUSION: Staged surgery using the acute induced membrane technique and soft-tissue reconstructive surgery is an efficacious treatment for open tibial fractures with bone defects.

Cephalomedullary Nailing versus Dynamic Hip Screw Fixation in Basicervical Femoral Neck Fracture: A Systematic Review and Meta-Analysis.

PURPOSE: Although many studies have reported the use of dynamic hip screws (DHS) and cephalomedullary nailing (CMN) for basicervical femoral neck fracture (BFNF), no clear treatment protocols have been recommended. The present study aimed to compare the surgical outcomes associated with DHS and CMN to determine the appropriate fixation method for BFNF. MATERIALS AND METHODS: We systematically searched MEDLINE, Embase, and the Cochrane Library for studies published up to January 9, 2021 that compared the treatment outcomes between CMN and DHS in BFNF. The primary outcomes of the present meta-analysis were fracture union time, postoperative cut-out rate, and reoperation rate. RESULTS: We included seven studies involving 353 cases of BFNF in our review. Of these, 206 patients were treated using CMN, and DHS were utilized in 147 patients. In a pooled analysis, the DHS group required a longer time to achieve fracture union compared to the CMN group [mean difference (MD): -0.41; 95% confidence interval (CI): -0.70, -0.12; p=0.006; I²=0%]. However, the cut-out and reoperation rates exhibited no statistically significant differences between the DHS and CMN groups [cut-out odds ratio (OR): 0.54; 95% CI: 0.10, 2.82; p=0.47; I²=24%, reoperation rate OR: 0.65; 95% CI: 0.15, 2.86; p=0.57; I²=19%, respectively]. CONCLUSION: Stable fixation using DHS and CMN does not show a significant clinical or radiographical difference in BFNF, and the implant can be selected based on the surgeon's preference.

Biomechanical Evaluation of Modified ACL Reconstruction with Over-the-Top Augmentation Technique.

Background: Modified ACL reconstruction with over-the-top augmentation technique (OA-ACLR) was designed to allow one-stage revision regardless of tunnel conditions as well as to offer firm stability by hybrid double-fixation. Thus, the purpose of the study is to biomechanically evaluate its effect on knee stability by comparing it with single-bundle ACL reconstruction (SB-ACLR). Methods: Ten porcine knees were sequentially tested using a custom testing system for intact ACL, ACL deficiency, SB-ACLR and OA-ACLR. First, 134-N anterior tibial load was applied, and anterior tibial translation was measured at 30°, 60°, and 90°. Then, anterior tibial translation and relative tibial rotation were measured in a combined rotatory load of 5-Nm of internal tibial torque and 10-Nm of valgus torque. Results: Under anterior tibial load or combined anterior and rotatory loads, SB-ACLR and OA-ACLR resulted in no significant increase in anterior tibial translation at all flexion angles compared with an intact ACL group, and no significant difference was noted in anterior tibial translation between the two ACL reconstruction groups. In combined rotatory load, OA-ACLR resulted in enhanced rotational stability compared with SB-ACLR, and it more closely restored relative tibial internal rotation to the intact ACL group. Conclusions: Our study showed that modified ACL reconstruction with over-the-top augmentation technique resulted in enhanced rotational stability compared to the conventional single-bundle ACL reconstruction, especially at lower flexion angle in a porcine model. Therefore, with several potential advantages as well as biomechanical superiority, our new technique could be clinically applicable in primary and revision ACL reconstruction. Level of Evidence: Experimental.

Safety of surgical hip dislocation in femoral head fracture and dislocation (FHFD) and avascular necrosis risk factor analysis of FHFD: midterm results confirmed by SPECT/CT and MRI.

BACKGROUND: The study aim was to report the treatment outcomes of trochanteric flip osteotomy (TFO) with surgical hip dislocation (SHD) for femoral head fracture and dislocation (FHFD) and to investigate the risk factors for avascular necrosis (AVN) of the femoral head. METHODS: The data of 34 patients (29 men, 5 women; mean age 37.9 years) diagnosed with FHFD and treated with TFO with SHD between May 2009 and February 2018 with an average follow-up period of 5.1 years (range 2.8-10.5 years) were analyzed. Clinical outcomes were evaluated using the Merle d'Aubigné-Postel score and Thompson-Epstein Scale. Radiologic outcomes were classified according to the Matta classification. AVN was confirmed using magnetic resonance imaging or single-photon emission computed tomography/computed tomography. The occurrence of complications was examined, and factors influencing complications, AVN. RESULTS: Regarding the Pipkin's classification, there were 7 patients with type II, 2 patients with type III, and 25 patients with type IV fractures. Posterior wall fractures accompanied all associated acetabular fractures in the patients with Pipkin type IV fractures. Radiologically, the union of acetabular and femoral head fractures was observed within 6.1 months on average (range 4-10 months) in 32 patients, except two patients who developed femoral head AVN. Clinically, the average Merle d'Aubigné-Postel score was 14.4 points (range 8-17 points), and 22 patients had good or excellent results on the Thompson-Epstein Scale. Two patients developed femoral head AVN with both having displaced femoral neck fractures associated with FHFD. AVN was significantly correlated with femoral neck fractures (P = 0.000). CONCLUSION: TFO with SHD is a safe and useful approach for the treatment of FHFD. Particular attention should be paid when treating femoral head fractures associated with displaced femoral neck fractures because of the high risk of AVN development.

Intramedullary nailing of subtrochanteric fractures in elderly patients: Comparative study of helical blade cephalomedullary nail versus reconstruction nail.

INTRODUCTION: Intramedullary nailing (IMN), which is a common method for treating subtrochanteric fractures, is conducted as cephalomedullary (CMN) or reconstruction (RCN) nailing. Numerous studies have reported the effectiveness of CMN, which requires a shorter surgery time and provides stronger fixation strength with blade-type devices. However, the radiographic and clinical outcomes of the use of CMN and RCN in elderly patients aged ≥65 years have not been compared yet. This study aimed to investigate whether CMN offers superior outcomes over RCN in the treatment of subtrochanteric fractures in elderly patients. MATERIALS AND METHODS: This retrospective study included 60 elderly patients (17 men and 43 women; mean age: 74.9 years) diagnosed with subtrochanteric fractures and treated with IMN with helical blade CMN (CMN group: 30 patients) or RCN (RCN group: 30 patients) between January 2013 and December 2018 with at least 1 year of follow-up period. Radiologic outcomes were evaluated based on the postoperative state of alignment and the achievement and timing of bony union at the final follow-up. Clinical outcomes were evaluated using the Merle d'Aubigné-Postel score. Radiologic and clinical outcomes in the two groups were compared and analyzed, and the occurrence of complications was examined. RESULTS: The difference in malalignment between the two groups was not significant; however, the RCN group achieved more effective reduction. At the final follow-up, bony union was achieved within 18.9 weeks, on average, in 28 patients in the CMN group and within 21.6 weeks, on average, in 27 patients in the RCN group. Twenty patients in the CMN group and 26 in the RCN group showed good or better results according to the Merle d'Aubigné-Postel score. No significant differences were found for any of the parameters. CONCLUSIONS: In the treatment of difficult subtrochanteric fractures in elderly patients, RCN can provide excellent reduction and strong fixation similar to CMN and can result in outstanding clinical and radiologic outcomes.

Clinical investigation on acute pyelonephritis without pyuria: a retrospective observational study.

BACKGRUOUND: The current guidelines for the diagnosis of acute pyelonephritis (APN) recommend that APN be diagnosed based on the clinical features and the presence of pyuria. However, we observed that some of the patients who are diagnosed with APN do not have characteristic clinical features or pyuria at the initial examination. We performed this study to investigate the characteristics of APN without pyuria. METHODS: A retrospective, cross-sectional study was conducted on 391 patients diagnosed with APN based on clinical and radiologic findings, between 2015 and 2019. The clinical features, laboratory results, and computed tomography (CT) findings were compared between patients with normal white blood cell (WBC) counts and those with abnormal WBC counts (WBC of 0-5/high power field [HPF] vs. >5/HPF) in urine. RESULTS: More than 50% of patients with APN had no typical urinary tract symptoms and one-third of them had no costovertebral angle (CVA) tenderness. Eighty-eight patients (22.5%) had normal WBC counts (0-5/HPF) on urine microscopy. There was a negative correlation between pyuria (WBC of >5/HPF) and previous antibiotic use (odds ratio, 0.249; 95% confidence interval, 0.140-0.441; p<0.001), and the probability of pyuria was reduced by 75.1% in patients who took antibiotics before visiting the emergency room. CONCLUSION: The diagnosis of APN should not be overlooked even if there are no typical clinical features, or urine microscopic examination is normal. If a patient has already taken antibiotics at the time of diagnosis, imaging studies such as CT should be performed more actively, regardless of the urinalysis results.

Validity of the EOS-determined pelvic parameters and orientation with pelvic positional variation: a phantom study.

The EOS is a medical imaging system that incorporates simultaneous orthogonal images, producing three-dimensional (3D) reconstructions of the whole skeletal system in various functional positions. Despite growing interest in the pelvic 3D position, the validity of the EOS has not yet been well studied. We investigated the trueness and precision of EOS imaging for pelvic parameters and orientation and assessed whether the measurement using the EOS was affected by the pelvic orientation itself. The orientation of the anterior pelvic plane and pelvic parameters of a custom-made pelvic phantom were measured by three raters using the EOS, and the measurements obtained were compared with the true values. The standard deviations of the measurement errors were 3.23°, 0.26°, 0.23°, 2.98°, 0.88°, and 3.22° for flexion, obliquity, rotation, pelvic incidence, spinopelvic tilt, and sacral slope, respectively. The root-mean square averages of the standard deviation of each measurement were 4.05°, 0.41°, 0.28°, 4.80°, 0.99°, and 5.13°, respectively. The measurement errors for sacral slope correlated significantly with geometric means of flexion, obliquity, and rotation (r = 0.364, p = 2.67 × 10-11). The EOS rendered accurate and reliable measurements regarding pelvic 3D position, even with positional variation, but positional variation could affect measurements of sacral slope.

Prevention of Unplanned Surgery Due to Delayed Diagnosis of Occult Ipsilateral Femoral Neck Fractures Associated with Femoral Shaft Fractures: A Study of the CT Capsular Sign with Lipohemarthrosis.

BACKGROUND: The purpose of the present study was to investigate the effectiveness of using the computed tomography (CT) capsular sign with lipohemarthrosis of the hip joint as a selective indicator for preoperative magnetic resonance imaging (MRI) of the hip or prophylactic fixation of the ipsilateral femoral neck for the prevention of unplanned surgery due to delayed diagnosis of occult ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures. METHODS: We evaluated the CT capsular sign with lipohemarthrosis in patients with a high-energy femoral shaft fracture without a preoperative diagnosis of an ipsilateral femoral neck fracture. The CT capsular sign with lipohemarthrosis was considered positive when the side-to-side difference in anterior capsular distension was >1 mm and lipohemarthrosis was seen on soft-tissue-window CT images. A positive CT capsular sign with lipohemarthrosis prompts preoperative hip MRI or prophylactic femoral neck fixation with a reconstruction nail. RESULTS: One hundred and fifty-six consecutive patients were included. Eight patients were preoperatively diagnosed with a displaced or hairline ipsilateral femoral neck fracture, whereas the remaining 148 patients showed no ipsilateral femoral neck fracture on radiographs and bone-window CT images. On soft-tissue-window CT images, 29 (19.6%) of the 148 patients had a positive CT capsular sign with lipohemarthrosis. We performed preoperative MRI for 3 patients; in the remaining 26 patients, prophylactic femoral neck fixation was performed with a reconstruction nail. We identified 5 occult ipsilateral femoral neck fractures among the 29 patients with a positive sign: 2 on preoperative MRI scans, 2 on immediate postoperative radiographs, and 1 on radiographs made 6 weeks postoperatively. In 119 patients with a negative sign, no occult ipsilateral femoral neck fracture was identified. All occult ipsilateral femoral neck fractures healed without further displacement of the femoral neck. Consequently, additional unplanned surgery for delayed diagnosis of occult ipsilateral femoral neck fracture was not required. CONCLUSIONS: The use of the CT capsular sign with lipohemarthrosis as a selective indicator for preoperative hip MRI or prophylactic femoral neck fixation with a reconstruction nail in patients with high-energy femoral shaft fractures is effective for preventing unplanned surgery due to delayed diagnosis of occult ipsilateral femoral neck fractures. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures, multiple fractures and severely injured patients.

INTRODUCTION: Femoral shaft fractures in adults are high-energy fractures typically accompanied by additional fractures of the upper and lower extremities and brain, thoracic, or abdominal injuries. Intramedullary nailing enables early ambulation with a few complications, but rates of non-union remain high. Therefore, we aimed to compare bone union after femoral shaft fractures in adults (20-65 years old) depending on the injury severity and presence of multiple fractures. PATIENTS AND METHODS: This study retrospectively examined 178 patients (145 male and 33 female) who underwent intramedullary nailing for a femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 32 type) between January 2014 and December 2018 and were followed up for at least 1 year. Patients who underwent intramedullary nailing after the preliminary application of an external fixator were excluded. Patients were divided into groups with isolated femoral shaft fractures (IS group), an injury severity score of ≤14, and multiple fractures of the extremities and the pelvic bone (at least three locations), including a femoral shaft fracture (MU group), and severely injured (injury severity score ≥15) with femoral shaft fractures (SE group). Non-union rate by group and risk factors related to bone union and bone union rate according to time to full weight bearing were analyzed. RESULTS: In total, 29, 54, and 95 patients were assigned to the IS group, MU group, and SE group, respectively. Non-union was observed in two patients in the IS group (6.9%), six patients in the MU group (11.1%), and 11 patients in the SE group (11.6%). There were no significant differences in the bone union rate, according to multiple fractures (p=0.515) and injury severity score (p=0.561). Additionally, no differences in the bone union rate were observed according to the time to full weight bearing. Depending on open fracture (p=0.004) and fracture severity (p=0.011), the non-union rate showed a difference of up to four times or greater. CONCLUSIONS: When intramedullary nailing is performed to treat femoral shaft fractures, multiple fractures and severe trauma do not directly affect bone union. However, it should be noted that open fracture and greater fracture severity lead to higher chances of non-union.

The Perimensical Capsule: Potential Supporting Structure Surrounding Meniscus.

This study analyzed the morphological and biomechanical characteristics of perimeniscal capsule in knee joint thus establishing the roles of these tissues. A total of 10 human cadaver knees were used in this study. Medial meniscus and the adjacently surrounding joint capsules were harvested then sectioned both axially and coronally, followed by scanning electron microscopy analysis. The medial meniscus (anterior, middle, posterior) and the adjacent perimeniscal capsules (superior, peripheral) were biomechanically assessed to ascertain the tensile modulus. Among the perimeniscal capsules, the peripherally located capsules were morphologically different from the superiorly located capsules: The peripheral perimeniscal capsule was thicker and showed circumferentially oriented fibers whereas the superior perimeniscal capsule fibers were thinner and arranged in vertical orientation. The peripheral capsule also yielded significantly greater tensile modulus compared with the superior capsule biomechanically. We conclude that depending on its anatomical location, the perimeniscal capsule consists of fibers of varying orientations. This may be important in maintaining the circumferential hoop tension of the meniscus especially in the presence of circumferentially oriented and thick peripheral capsule fibers, which coincidentally have higher tensile modulus.

Posterior pelvic ring injury of straddle fractures: Incidence, fixation methods, and clinical outcomes.

Straddle fracture, a superior and inferior ramus fracture of both sides, is generally treated conservatively. However, posterior pelvic ring injury is often associated with straddle fracture, leading to unstable pelvic bone fracture that requires surgical treatment. The present study reports the clinical and radiological outcomes of straddle fracture with posterior pelvic ring injury. This study included 73 patients (41 men, 32 women) with a straddle fracture injury. The injury mechanism, injury severity score (ISS), accompanying injuries, presence of posterior pelvic ring injury, and fixation methods for the pelvic fracture were analyzed, and outcomes were evaluated functionally and radiologically. Of the 73 patients, 56 (77%) had a posterior pelvic ring injury and 7 died. In 43 patients, the posterior pelvic ring injuries constituted unstable pelvic injury and were treated surgically. The fixation method was determined based on the severity of the posterior pelvic injury. The patients' mean ISS was 24.7 points. Radiological evaluation of surgical outcomes in 43 patients revealed the outcomes as anatomic in 20, nearly anatomic in 14, moderate in 5, and poor in 4, whereas functional evaluation revealed the outcomes as excellent in 21, good in 9, fair in 7, and poor in 6. Posterior pelvic ring fracture can accompany straddle fractures, which may lead to pelvic injury instability. Thus, special attention is required for patients with a straddle fracture.

Triangular Osteosynthesis Using an S1 Pedicle Screw and S2 Alar Iliac Screw for a Unilateral Vertically Displaced Sacral Fracture.

BACKGROUND: Managing unilateral vertically displaced sacral fractures remains a challenge. A triangular osteosynthesis (TOS), which involves fixing the fractured sacrum using unilateral spinopelvic fixation and a supplemental ilio-sacral screw, continues to gain popularity as it facilitates early mobilization and improves the long-term outcome. However, it has limitations, such as destruction of the L5-S1 joint, the need for additional removal surgery, and an increased risk of infection due to the large incision. An S1 pediculoiliac construct was proposed to overcome this limitations. Its use also has complications, however, including a painful hardware prominence due to the traditional iliac screw, excessive soft tissue retraction, and limited reduction capability. CASE DESCRIPTION: A 20-year-old woman fell from a height of 6 meters and sustained a vertical shear type sacral fracture on the left side with substantial vertical displacement. We reduced and fixed the fracture using a TOS using an S1 pedicle screw and an S2 alar iliac screw (S2AIS). The patient was allowed immediate weight-bearing as tolerated. We achieved good reduction and union with a small vertical incision, without the destruction of L5-S1 joints, a symptomatic implant prominence, or wound complications. CONCLUSIONS: For unilateral vertically unstable sacral fractures, TOS using S1 pedicle screws and S2AIS is safe and has the advantage such as maintaining mobility in the lumbar pelvic region, small size wounds, and reduced soft tissue damage, and it may have a potentially low infection rate. Further studies are needed to determine the specific indications and validate the effectiveness of this procedure.

Mechanical effect of different implant caput-collum-diaphyseal angles on the fracture surface after fixation of an unstable intertrochanteric fracture: A finite element analysis.

BACKGROUND/OBJECTIVE: The choice of implant is one of the most easily controllable factors affecting the outcome of intertrochanteric fractures. While most of the caput-collum-diaphysis (CCD) angles of the femur are within the range of 125° and 130°, there is a shortage of data on whether 125° or 130° implants are preferable. Thus, the present finite element analysis (FEA) aimed to compare the biomechanical effects on the fracture surface when using implants with different CCD angles where the anatomical CCD angle of the femur was between 125° and 130°. METHODS: After establishing a finite element model of an unstable intertrochanteric fracture from the femur with a native CCD angle of 127.3°, proximal femoral nail antirotation (PFNA) models with CCD angles of 125° and 130° were virtually implanted to have the same position of screw tip, respectively. RESULTS: In the one-leg stance during walking, when the implant with 130º CCD angle was used, the magnitude of compressive stress (1.61 and 2.12 MPa in the 130° and 125° model, respectively) was lower and the area of the fracture surface under tensile stress (55% and 5% in 130° and 125° model, respectively), the interfragmentary movements (40.9% more movement in 130° model), and the magnitude of bone deformation (23.5% more deformation in 130° model) were more than those of the 125° model. CONCLUSION: The intertrochanteric fracture fixed with PFNA with a 125º CCD angle revealed less interfragmentary movement on the fracture surface when the native CCD was an in-between angle in the FEA.