Secondary Subtrochanteric Fracture After Atypical Femoral Shaft Fracture Treated With Intramedullary Nail.

Intramedullary (IM) nail fixation is widely used for the treatment of atypical fractures of the femoral shaft. The configuration and location of proximal interlocking screws are unique to each nailing system and maybe transverse or oblique in direction. The authors experienced two cases of incomplete secondary fractures at the subtrochanteric region after IM nail fixation for atypical femoral shaft fractures. The proximal screw fixation of the two cases was different from one another. One was fixed with a spiral blade plus transverse screw and the other was fixed using an oblique direction screw from the greater trochanter to the femoral neck base. Based on our experience, we recommend only using a proximal locking screw toward the head when using an IM nail for the treatment of atypical femoral diaphyseal fractures. An 82-year-old female patient who had been fixed with an IM nail for the treatment of atypical femoral shaft fracture 13 months ago visited the outpatient clinic with pain in the right hip joint for one month. Local hot uptake was observed at the proximal interlocking screw insertion site around the subtrochanteric region on bone scan. A simple removal of the proximal locking screw was enough to treat the incomplete fracture. A 79-year-old woman visited the emergency room for pain in the right hip joint. On the radiograph, the right femur was found to be fixed with an IM nail, and an incomplete fracture line around the lower border of the lesser trochanter was observed. This patient was treated by replacing the IM nail with a reconstruction nail. When using an IM nail for the treatment of atypical femoral shaft fractures, it is appropriate to insert only the screw toward the femoral head for proximal fixation to prevent secondary subtrochanteric fracture.

Osteoperiosteal Decortication and Autogenous Cancellous Bone Graft Combined with Bridge Plating for Non-hypertrophic Diaphyseal Nonunion.

BACKGROUD: The aim of this study was to evaluate results of osteoperiosteal decortication and autogenous cancellous bone graft combined with a bridge plating technique in atrophic and oligotrophic femoral and tibial diaphyseal nonunion. METHODS: We retrospectively reviewed 31 patients with atrophic or oligotrophic femoral and tibial diaphyseal nonunion treated with osteoperiosteal decortication and autogenous cancellous bone graft between January 2008 and December 2018. Patients with hypertrophic nonunion, infected nonunion, and nonunion treated with autogenous cancellous bone graft alone were excluded. The nonunion site was exposed by using the Judet technique of osteoperiosteal decortication. Nonunion with a lack of stability was stabilized with a new plate using a bridge plating technique or augmented by supplemental fixation with a plate. Nonunion with malalignment was stabilized with a new plate after deformity correction. Autogenous cancellous bone graft was harvested from the posterior iliac crest and placed within the area of decortication. A basic demographic survey was conducted, and the type of existing implants, mechanical stability of the implants, the type of implants used for stabilization, the operation time, the time to bone union, and postoperative complications were investigated. RESULTS: The average follow-up period was 33.3 months (range, 8-108 months). The operation time was 207 minutes (range, 100-351 minutes). All but 1 nonunion (96.7%) were healed at an average of 4.2 months (range, 3-8 months). In 1 patient, bone union failed due to implant loosening with absorbed bone graft, and solid union was achieved by an additional surgery for stable fixation with a new plate, osteoperiosteal decortication, and autogenous cancellous bone graft. There were no other major complications such as neurovascular injuries, infection, loss of fixation, and malunion. CONCLUSIONS: Osteoperiosteal decortication and autogenous cancellous bone graft combined with stable fixation by bridge plating showed reliable outcomes in atrophic and oligotrophic diaphyseal nonunion. This treatment modality can be effective for treating atrophic and oligotrophic diaphyseal nonunion because it is very helpful stimulating bone union.

Retained Foreign Body Which Should be Suspected as a Cause of Retractable Chronic Hand Inflammation and Diagnostic Capacity of Ultrasonography.

Background: Foreign bodies in the hand are common but easily and often missed in the initial evaluation of injury. Diagnosing retained foreign bodies is difficult due to radiolucent foreign bodies. Purpose of this study is to emphasize the need of consideration of foreign bodies in patients with chronic synovitis in hand. Methods: Twenty-five patients who had retained foreign body in soft tissue of hand with chronic inflammation symptoms were included. Ultrasonography was conducted in all of the patients. Patient age, sex, localization of foreign body, duration of symptom, history of injury, follow up period, complication, and biopsy results were recorded and reviewed. Also, patients' demographics and clinical results were retrospectively reviewed. Results: Nine of the 25 patients diagnosed with a foreign body in the hand did not remember the initial presentation of injury. The average symptom duration (from injury to hospitalization) was 10.5 months (range 1-96 months). The middle finger and the proximal interphalangeal joint were the most common site of a retained foreign body (10 patients). All patients were diagnosed via ultrasonography and underwent surgery. Biopsy results showed mainly chronic inflammation, fibrosis, granuloma, and foreign bodies. Conclusions: Patient with symptoms of cellulitis, osteomyelitis, and palpable mass in hand for over a month without a diagnosis should be suspected of retained FBs.

Effectiveness of Gelatin-Thrombin Matrix Sealants (Floseal®) on Postoperative Spinal Epidural Hematoma during Single-Level Lumbar Decompression Using Biportal Endoscopic Spine Surgery: Clinical and Magnetic Resonance Image Study.

BACKGROUND: Symptomatic postoperative spinal epidural hematoma (PSEH) is a devastating complication that could develop after lumbar decompression surgery. PSEH can also develop after biportal endoscopic spine surgery (BESS), one of the recently introduced minimally invasive spine surgery techniques. Gelatin-thrombin matrix sealant (GTMS) is commonly used to prevent PSEH. This study aimed at analyzing the clinical and radiological effects of GTMS use during BESS. METHODS: A total of 206 patients with spinal stenosis who underwent decompression by BESS through a posterior interlaminar approach from October 2015 to September 2018 were enrolled in this study. Postoperative magnetic resonance imaging (MRI) was performed in all patients for evaluation of PSEH. Patients in whom GTMS was not used during surgery were assigned to Group A, and those in whom GTMS was used were classified as Group B. In the clinical evaluation, the visual analog scale (VAS) of the leg and back, Oswestry Disability Index (ODI), and modified MacNab criteria were used. The incidence rate and degree of dural compression of PSEH on postoperative MRI were measured. RESULTS: The average age of the patients was 68.1 ± 11.2 (42-89) years. The overall incidence rate of PSEH was 20.9% (43/206). The incidence rates in Groups A and B were 26.4% and 13.6%, respectively, showing a significant difference (p = 0.023). The VAS-leg and ODI improvement was significantly different depending on the intraoperative use of GTMS. However, there was no statistically significant difference between the two groups in terms of the VAS-back improvement. Groups A and B showed "good" and "excellent" rates according to the modified MacNab criteria in 79.4% and 87.6% of patients, respectively, showing statistically significant difference (p = 0.049). In Group A, two patients underwent revision surgery due to PSEH, while none in Group B had such event. CONCLUSION: Intraoperative use of GTMS during BESS may be related to reduction in the occurrence rate of PSEH. Specifically, patients with GTMS appliance showed marked decrease in the occurrence of PSEH and had better clinical outcomes.