Far cortical locking constructs for fixation of distal femur fractures in an Asian population: A prospective observational study.

BACKGROUND: The stiffness of locked plates suppresses healing process, prompting the introduction of far cortical locking to address this issue. This study aimed to demonstrate the clinical efficacy of far cortical locking constructs in treating distal femoral fractures in an Asian population. METHODS: This multicenter prospective observational study was conducted at four university hospitals between February 2018 and February 2021. Demographic data, the presence of metaphyseal comminution, and surgical fixation details were recorded. Clinical outcomes, including single-leg standing, EQ-5D, and EQ-VAS scores, and radiologic outcomes, including the RUST score of each cortex, were evaluated and compared according to the presence of metaphyseal comminution. RESULTS: There were 37 patients (14 men and 23 women) with a mean age of 67.3 ± 11.8 years. Twenty-two patients had metaphyseal comminution (59%), and 15 presented simple fractures in metaphyseal areas. Four patients (13%) could stand on one leg >10s at 6 weeks, and 24 patients (92%) at 1 year. EQ-5D increased from 0.022 ± 0.388 to 0.692 ± 0.347, and the mean EQ-VAS 51.1 ± 13.1 to 74.1 ± 24.1 between discharge (n = 37) and post-operative 1 year (n = 33), respectively. RUST score presented increment for time, from 6.2 ± 1.8 at 6 week to 11.6 ± 1.1 at 1 year. Radiological healing demonstrated rapid increase from week 6 (16/28, 43%) to month 3 (27/31, 87%), with no obvious increase was observed in 6 months (23/26, 89%) or 12 months (25/28, 89%). Simple metaphyseal fractures presented significantly higher RUST scores at 6 weeks and 3 months, but there was no difference in RUST scores at 6 months or 1 year according to metaphyseal comminution. CONCLUSIONS: Plate constructs with far cortical locking screws provided safe and effective fixation for distal femoral fractures, with consistent radiological and clinical results, regardless of metaphyseal comminution.

Clinical Outcomes Following Incomplete Arthroscopic Iliotibial Band Release for External Snapping Hip Syndrome: An Observational Study.

OBJECTIVES: Arthroscopic treatment is indicated for external snapping hip (ESH) syndrome in patients refractory to conservative treatment, but snapping does not disappear completely in some case. No previous studies have described the clinical course of ESH syndrome in patients who presented with persistent snapping after an arthroscopic procedure. We demonstrated the clinical outcomes following an incomplete arthroscopic iliotibial band (ITB) release for ESH syndrome. METHODS: This retrospective observational study was performed at two teaching hospitals between October 2015 and December 2021. We reviewed the data of 33 patients (34 hips) aged ≥18 years, diagnosed with ESH syndrome, who were treated with arthroscopic ITB release. Patients who presented with persistent snapping despite sufficient arthroscopic ITB release following systematic order were defined as having an incomplete release. We collected the data for recurrent symptomatic snapping hip as the primary outcome after a minimum 2-year follow-up. The visual analogue scale (VAS) and modified Harris hip (mHHS) scores were measured as secondary outcome. RESULTS: "Incomplete release" was identified in three of the 34 hips (8.9%). Cases of recurrent symptomatic snapping or conversion to open surgery were not observed. The symptoms of residual snapping spontaneously disappeared in all cases following routine postoperative rehabilitation within a 3-month follow-up period. The VAS (4 ± 1) and mHHS (17 ± 6) scores of all the patients improved. CONCLUSION: When refractory ESH syndrome is identified during arthroscopic surgery, appropriate ITB release and removal of the major lesion causing snapping are expected to lead to resolution of residual symptoms without conversion to open surgery.

Posterior deltoid-sparing approach for displaced inferior or posterior glenoid fossa fractures: technical note and case series.

Scapular surgery has usually been performed through the posterior Judet approach. This approach allows access to the entire posterior scapular body, but causes significant soft tissue damage and detaches the deltoid muscle. To date, there has been no clinical study of a deltoid-preserving approach to access the joint for displaced postero-inferior glenoid fractures (Ideberg type II or Ib). We describe an easy and less invasive approach to the postero-inferior glenoid fossa.

Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction.

This study aimed to investigate the outcomes of elderly acetabular fractures according to the reduction of impacted dome fragments. A retrospective cohort study was performed in two institutions. Fifty-four patients aged ≥ 60 years with acetabular fractures were enrolled. Data for dome impaction and postoperative reduction was collected. Patients were divided into the good reduction group (displacement ≤ 3 mm) and poor reduction group (displacement > 3 mm). Postoperative osteoarthritis (OA), Harris hip score (HHS), total hip arthroplasty conversion, good/poor outcomes were compared between the two groups. The good reduction group (N = 45) demonstrated a lower proportion of radiographic OA (18 vs. 77%, P = 0.001), higher HHS (82.1 vs. 68.6, P = 0.022), and higher proportion of good outcomes than the poor reduction group (N = 9) (89 vs. 22%, P < 0.001). In a subgroup analysis of the patients with dome impaction, the good reduction group had a higher proportion of good outcomes (80 vs. 20%, P = 0.031). On comparing within the good reduction group, dome impaction did not influence clinical outcomes. Elderly acetabular fractures demonstrated favorable outcomes when adequate reduction was achieved even with dome impaction. Well-reduced dome impaction could achieve satisfactory outcomes in elderly acetabular fractures.

The Clinical Efficacy of Contouring Periarticular Plates on a 3D Printed Bone Model.

We report our experience of preoperative plate contouring for periarticular fractures using three-dimensional printing (3DP) technology and describe its benefits. We enrolled 34 patients, including 11 with humerus midshaft fractures, 12 with tibia plateau fractures, 2 with pilon fractures, and 9 with acetabulum fractures. The entire process of plate contouring over the 3DP model was videotaped and retrospectively analyzed. The total time and number of trials for the intraoperative positioning of precontoured plates and any further intraoperative contouring events were prospectively recorded. The mismatch between the planned and postoperative plate positions was evaluated. The average plate contouring time was 9.2 min for humerus shaft, 13.8 min for tibia plateau fractures, 8.8 min for pilon fractures, and 11.6 min for acetabular fractures. Most precontoured plates (88%, 30/34) could sit on the planned position without mismatch. In addition, only one patient with humerus shaft fracture required additional intraoperative contouring. Preoperative patient specific periarticular plate contouring using a 3DP model is a simple and efficient method that may alleviate the surgical challenges involved in plate contouring and positioning.

Irreducible Ankle Fracture Dislocation Because of Tibialis Posterior and Flexor Digitorum Longus Tendon Entrapment in the Interosseous Membrane: A Case Report.

CASE: We describe the case of a 63-year-old man with anterior ankle dislocation and fracture confirmed by x-ray. Postreduction x-ray and computed tomography (CT) revealed Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 44C3 and Lauge-Hansen pronation-external rotation-type ankle fractures. CONCLUSION: This was a rare case of ankle fracture dislocation because of entrapment of the tibialis posterior and flexor digitorum longus tendons in the interosseous membrane. Tendon entrapment should be suspected in cases of high-energy injuries, Weber type C fractures, Lauge-Hansen pronation-external rotation fractures, syndesmosis widening, and irreducible fractures using manual closed reduction. Fractures and soft tissues should be evaluated by changing the CT settings.

Is Nail-Canal Diameter Discordance a Risk Factor for the Excessive Sliding of Cephalomedullary Nails in Geriatric Intertrochanteric Fracture Surgery?

Background and Objectives:: There were limited studies which investigated nail diameter as a predictor for cephalomedullary nail (CMN) failure in intertrochanteric fracture (ITF). We aimed to evaluate the surgical outcomes of CMN in fragility ITF following nail-canal (N-C) diameter discordance. Materials and Methods: From November 2010 to March 2022, we retrospectively reviewed 120 consecutive patients who underwent CMN surgeries due to fragility ITF. We included patients with acceptable reduction and a tip-apex distance ≤ 25 mm. The N-C diameter differences both in anterior-posterior (AP) and lateral-view X-rays were measured, and we compared the number of excessive sliding instances and the rate of implant failure between the N-C concordance (≤3 mm) and discordance (>3 mm) group. Simple linear regression was used to determine the strength of the relationship between the N-C difference and sliding distance. Results: The sliding distance showed no differences between the groups in the AP (3.6 vs. 3.3 mm, p = 0.75) and lateral view (3.5 vs. 3.4 mm, p = 0.91). For analyses in the AP view, the AP-concordance and AP-discordance groups had 14 (25%) and 14 patients (22%) with a sliding distance of >5 mm (p = 0.69), while treatment failure occurred in 3 (5%) and 3 (3%) patients, respectively (p = 0.66). For analyses in the lateral view, the lat-concordance and lat-discordance groups had 8 (27%) and 20 patients (22%) with a sliding distance of >5 mm (p = 0.62), while treatment failure occurred in 1 (3%) and 4 (4%) patients, respectively (p = 1.00). Linear regression analyses showed that the N-C difference in either views was not a significant predictor of sliding distance in both the AP (R2 = 0.002, p = 0.60) and lateral views (R2 = 0.007, p = 0.35). Conclusions: If appropriate fracture reduction and fixation are achieved, the N-C discordance of short CMN does not affect treatment outcomes in ITF.

Open reduction versus closed reduction in internal fixation of displaced femoral neck fracture in children: a systematic review and meta-analysis.

BACKGROUND: The quality of reduction is an important factor affecting clinical outcomes for displaced femoral neck fractures (FNFs). However, concerns remain about the invasiveness of open reduction and internal fixation (ORIF) as compared to that of closed reduction and internal fixation (CRIF), and the choice between ORIF and CRIF as an optimal treatment strategy for displaced pediatric FNF remains controversial. MATERIALS AND METHODS: MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to December 22, 2022, that compared ORIF and CRIF techniques for treating FNF in children. Pooled analysis identified differences in surgical outcomes between ORIF and CRIF, especially regarding postoperative complications, such as osteonecrosis of the femoral head (ONFH), nonunion, coxa vara deformity, leg-length discrepancy LLD, and premature physeal closure (PPC). RESULTS: We included 15 studies with 635 pediatric FNF cases in our review. Of these, 324 and 311 were treated with ORIF and CRIF, respectively. The pooled analysis revealed that no significant differences existed between each reduction technique for ONFH (odds ratio [OR] = 0.89; 95% confidence interval [CI] 0.51-1.56; P = 0.69), nonunion (OR = 0.51; 95% CI 0.18-1.47; P = 0.21), coxa vara deformity (OR = 0.58; 95% CI 0.20-1.72; P = 0.33), LLD (OR = 0.57; 95% CI 0.18-1.82; P = 0.35), and PPC (OR = 0.72; 95% CI 0.11-4.92; P = 0.74). CONCLUSIONS: Despite concerns about the invasiveness of ORIF, no differences in complications exist between ORIF and CRIF after FNF in children. Therefore, we believe that ORIF should be performed in FNF when the fracture is irreducible by closed manner.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

Radiographic rotational profiles of the proximal and distal humerus: analysis of 46 computed tomography scans with 3-dimensional simulation.

BACKGROUND: To date, no study has investigated the radiographic rotational profiles (RRPs) of the proximal and distal humerus. However, malrotation after minimally invasive surgery for humeral fracture has been an unsolved problem. Therefore, we aimed to investigate the RRPs of the proximal and distal humerus that linearly correlate with rotational status and show significant differences as the rotational status changes. METHODS: Forty-six computed tomography scans of the humerus were 3-dimensionally reconstructed, and 5 rotational statuses (20° and 10° of internal rotation; neutral; and 10° and 20° of external rotation) were simulated. Seven candidate RRPs of the proximal humerus and 4 candidates of the distal humerus were measured for each rotational status. The overall differences and trends in the RRPs as the rotational status changed were evaluated, and multiple comparisons were performed between the RRPs for each of the 5 rotational statuses. Moreover, the correlations between the RRPs and rotational status with adjustment of retroversion were analyzed. Finally, interobserver and intraobserver reliabilities were evaluated. RESULTS: The following proximal and distal RRPs were linearly correlated with rotational status, differed significantly between the rotational statuses, and showed a relatively low prediction error and excellent interobserver and intraobserver reliabilities: the distance from the tip of the lesser tuberosity to the lateral margin of the proximal humerus (PL1) and the medial margin of the head (PL2), as well as the PL1 to PL2 ratio (PRL), in the proximal humerus; and the distance from the medial margin of the olecranon process to the medial epicondyle (DOP), the widest width of the overlapped olecranon fossa (DOF), and the distance from the lateral margin of the capitellum to the lateral epicondyle (DC) in the distal humerus. CONCLUSION: Our findings suggest that PL1, PL2, and PRL in the proximal humerus and DOP, DOF, and DC in the distal humerus are potentially useful and reproducible RRPs for restoring the intrinsic rotational alignment in humeral fractures.

Outcome of multi-staged induced membrane technique based on post-debridement cultures for the management of critical-sized bone defect following fracture-related infection.

The authors' institution utilizes multi-staged induced membrane technique protocol based on post-debridement culture in treating patients with critical-sized bone defect in lower extremity due to infected nonunion or post-traumatic osteomyelitis. This study aimed to evaluate the success rate of this limb reconstruction method and which risk factors are associated with recurrence of infection. 140 patients were treated with multi-staged induced membrane technique from 2013 to 2018 and followed up more than 24 months after bone grafting. The primary success rate of limb reconstruction was 75% with a mean follow-up of 45.3 months. The mean Lower Extremity Functional Scale in success group improved from 12.1 ± 8.5 to 56.6 ± 9.9 after the treatment. There were 35 cases of recurrence of infection at a mean of 18.5 months after bone grafting. Independent risk factors for recurrence of infection were infected free flap, surprise positive culture, deviation from our surgical protocol, and elevated ESR before final bone graft procedure. In conclusion, this study showed that multi-staged induced membrane technique protocol based on post-debridement culture resulted in 75% success rate and revealed a number of risk factors for recurrence of infection.

Clinical Outcomes following Primary Hip Replacement Arthroplasties in Patients with Solid Organ Transplantation: A Systematic Review and Meta-Analysis.

There is still controversy regarding clinical outcomes following primary hip arthroplasty after solid organ transplantation (SOT). The aim of this study was to determine whether clinical outcomes after hip arthroplasty differ between previous SOT recipients and control subjects with no history of undergoing SOT. We conducted a systematic search of MEDLINE, Embase, and the Cochrane Library for studies comparing the clinical outcomes after hip arthroplasty following SOT published up to January 5, 2022. A comparison of medical and surgery-related complications, as well as the readmission rate and 90-day mortality rate between previous SOT recipients and control subjects was performed. Subgroup analyses of the SOT types, liver transplantation (LT) and kidney transplantation (KT), were also performed. Ten studies that included 3,631,861 cases of primary hip arthroplasty were included; among these, 14,996 patients had previously undergone SOT and 3,616,865 patients had not. Significantly higher incidences of cardiac complications, pneumonia, and acute kidney injury were observed in the SOT group compared with the control group. Regarding surgical complications, a higher transfusion rate was observed in the SOT group. The readmission rate and 90-day mortality rate were also significantly higher in the SOT group. A significantly higher incidence of deep vein thrombosis was observed in the KT subgroup compared with the control group. A higher risk of medical and surgical complications, as well as higher readmission and mortality rates after hip arthroplasty was observed for previous SOT recipients compared to patients with no history of SOT.

Impact of the COVID-19 Pandemic on Mortality Following Hip and Knee Joint Arthroplasty Surgeries: A Systematic Review and Meta-Analysis.

We performed a meta-analysis comparing the mortality rates after hip and knee joint arthroplasty between the coronavirus 2019 (COVID-19) pandemic and pre-pandemic periods. The purpose of present study was to investigate the impact of the COVID-19 pandemic on mortality rates after hip and knee joint arthroplasty. We systematically searched the MEDLINE, Embase, and Cochrane Library databases for studies published up to 28 March 2022. We included studies which directly compared mortality rates after hip and knee joint arthroplasty between the COVID-19 pandemic and pre-pandemic periods. The methodological quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS). We compared the overall mortality rate as the primary outcome. For the subgroup analysis, the mortality rates included were: within 30 days and unrelated to COVID-19; we excluded studies with only elective arthroplasties. Readmission rates following arthroplasties were also compared. We included five studies with 3044 patients, of which 838 patients underwent surgeries during the pandemic period and 2206 patients underwent surgeries in the pre-pandemic period. The mean MINORS score was 15.4/24 (range: 15-16). The overall mortality rate showed no significant differences between the pandemic and pre-pandemic periods (OR, 2.71; 95% CI, 0.78-9.35; p = 0.12; I2 = 19%). No differences were observed in mortality following arthroplasties within 30 days and unrelated to COVID-19 nor in the readmission rates. Mortality, after excluding studies with only elective arthroplasty, presented significant differences between the COVID-19 pandemic and pre-pandemic periods (OR, 3.80; 95% CI, 1.18-12.28; p = 0.03, I2 = 0%). The limitation of the present study was that elective arthroplasty and urgent arthroplasty were not completely differentiated. The overall mortality rate in the COVID-19 pandemic period following hip and knee arthroplasty did not show a significant increase. This finding could help to maintain the practice of elective arthroplasty during a pandemic situation in the future (PROSPERO-CRD42022335471).

The risk factors for subsequent fractures after distal radius fracture.

INTRODUCTION: The purpose of this study was to evaluate the risk factors for subsequent fractures after distal radius fracture (DRF). MATERIALS AND METHODS: We retrospectively reviewed 705 patients with DRF who performed dual-energy X-ray absorptiometry within six months before or after the DRF and followed more than 12 months. We identified patients with subsequent fractures and multivariate logistic regression analyses were conducted with demographic information, underlying disease status, and bone fragility parameters at the time of DRF to evaluate the risk factors for subsequent fractures. RESULTS: Subsequent fractures occurred in 56 patients (7.9% of 705 patients) with 65 fractures at a mean time of 33.5 months after DRF. In multivariate logistic regression analysis, older age (OR 1.032; 95% CI, 1.001-1.064, p = 0.044), diabetes mellitus (DM) (OR 2.663; 95% CI, 1.429-4.963, p = 0.002) and previous fracture history (OR 1.917; 95% CI, 1.019-3.607, p = 0.043), and low total hip BMD (OR 1.410; 95% CI, 1.083-1.836, p = 0.011) were significant risk factors for the occurrence of subsequent fractures. CONCLUSION: This study demonstrated that older age, DM, previous fracture history and low hip BMD are the risk factors for subsequent fractures after DRF. Active glycemic control would have a role in patients with DM and a more aggressive treat-to-target approach may be necessary for patients with low BMDs to prevent subsequent fractures after DRF.

Comparison of olecranon osteotomy and paratricipital approach in distal humerus intra-articular fracture: A systematic review and meta-analysis.

BACKGROUND: Surgical outcomes of the paratricipital approach (PT) and olecranon osteotomy (OO) for the treatment of distal humerus intra-articular fracture have been reported. However, there is no consensus regarding which approach is better in terms of functional outcomes and complications. This study aimed to compare the operation time, functional outcomes, and complications of OO and PT. METHODS: The databases of MEDLINE, Embase, and Cochrane Library were systematically searched for studies published before June 1, 2021. We performed synthetic analysis of the operation time, functional outcomes, and incidence of complication after the conduct of OO group or PT group in patients with distal humerus intra-articular fractures. RESULTS: Five studies were included representing a total of 243 patients who underwent surgery for distal humerus intra-articular fractures. A pooled analysis showed that there was a longer operation time in the OO group compared with the PT group (mean difference [MD] = 13.32, 95% CI: 3.78-22.87; P = .006). There was no significant difference between the functional outcomes of the OO and PT groups (elbow flexion: MD = 2.4, 95% CI: -0.82 to 5.79, P = .14; elbow extension: MD = 0.36, 95% CI: -2.20 to 2.92, P = .78; elbow arc of motion: MD = 0.40, 95% CI: -4.05 to 4.84, P = .86; Mayo Elbow Performance score: MD = -1.37, 95% CI: -4.73 to 1.98, P = .42). The incidence of infection was significantly higher in the OO group compared with that of the PT group (odds ratio [OR] = 3.82, 95% CI: 1.03-14.16, P = .04). There was no significant difference between the 2 groups in terms of the heterotopic ossification and ulnar neuropathy (OR = 1.85, 95% CI: 0.51-6.71, P = .35 and OR = 2.74, 95% CI: 0.60-12.48, P = .19, respectively). CONCLUSIONS: Since the choice of surgical approach does not influence outcomes, surgeons can base their choice of approach on the basis of their own experience and familiarity with the procedure and the need to visualize the entire articular surface in complex intra-articular fracture patterns.

The difference in the corridor of the antegrade posterior column screw according to the presence of pelvic dysmorphism.

INTRODUCTION: Antegrade posterior column screw (aPCS) fixation via the anterior approach has been widely used for separated the posterior columns in acetabular fracture treatment. Although the relationship between pelvic dysmorphism and sacroiliac screws has been widely studied, no studies have reported on the clinical impact of pelvic dysmorphism on acetabular fractures. This study aimed to reveal the difference in the insertion angle and entry point of aPCS between the dysmorphic and normal pelvises. METHODS: Patients diagnosed with unilateral acetabular fractures and who underwent pelvic computed tomography scans between 2013 and 2019 in two institutes were enrolled in this study. Patients were divided into the dysmorphic and control groups according to the sacral dysmorphic score, which predicts the presence of pelvic dysmorphism, and each group enrolled 130 patients. The semitransparent 3D hemipelvis model was reconstructed using a 3D reconstruction program. The sagittal and coronal angles of a virtual cylinder that fill the safe corridor of the column screw the most were measured. The surface area of the safe corridor and distance of the optimal entry point from the anterior border of the sacroiliac joint were analyzed. The measurements were compared between the dysmorphic and control groups. RESULTS: The average sacral dysmorphic score in the normal and dysmorphic pelvis groups was 56.1 and 81.0, respectively. There were no significant differences in demographic data, including age, sex, height, weight, and body mass index, between the dysmorphic and control groups. There was a significant difference in the average sagittal insertion angle of PCs, which was 38.3° in the control group and 27.2° in the dysmorphic group (P < 0.001). The coronal insertion angles were not significantly different. The dysmorphic group presented longer straight distances (25.9 vs 24.8 mm, P = 0.026) and had a smaller aPCS surface area (685 vs 757 mm2, P < 0.001) than the control group. CONCLUSION: The present study describes a difference in the corridor of aPCS between the dysmorphic and normal pelvis. Insertion of aPCS in the dysmorphic pelvis requires a more acute angular trajectory in the sagittal plane than that in the normal pelvis.

Stress fracture after implant removal from the tibia reconstructed by the induced membrane technique: A case report.

Background: The induced membrane technique promotes vascularization and corticalization of the grafted bone and has become one of the mainstays in treatment of segmental bone defects. However, there are clinical concerns regarding the quality of bony consolidation using the induced membrane technique including a thin cortex formation and cortical notching after consolidation. We present the case of a tibial stress fracture in the bone reconstructed by the induced membrane technique after implant removal. Case: A 49-year-old male presented post-traumatic osteomyelitis of the right tibia and was treated with staged segmental bone resection leading to an 11 cm defect which was reconstructed using the induced membrane technique. The patient requested implant removal at 33 months after bony consolidation. Four months after implant removal, he developed acute, atraumatic leg pain due to a tibial stress fracture caused by small notching in the reconstructed tibial segment. His stress fracture treated with intramedullary nailing and later healed uneventfully. Conclusion: Caution is warranted prior to implant removal from bone reconstructed by the induced membrane technique as cortical notching may result in stress fractures.

The effect of antifibrinolytic agents in periacetabular osteotomy: A systematic review and meta-analysis.

BACKGROUND: Periacetabular osteotomy (PAO) is a major hip preservation surgery for developmental dysplasia of the hip. It is inevitably associated with significant blood loss, so it requires frequent transfusions and could be a cause of perioperative morbidity. However, to date, a large number of studies has not evaluated the effect of antifibrinolytic agents in PAO. Therefore we performed a systematic review and meta-analysis to assess if antifibrinolytics would be effective in reducing blood loss and transfusion rate after PAO surgery. METHODS: In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 4, 2020, that investigated the effect of antifibrinolytic agents in PAO. A pooled analysis was designed to identify differences between antifibrinolytic and control groups focusing on blood loss, transfusion, operation time, postoperative venous thromboembolism (VTE), and length of hospital stay. RESULTS: We included five studies involving 507 patients (antifibrinolytic group: 256; control group: 251). The pooled analysis showed that the control group had a greater total estimated blood loss (EBL) than the antifibrinolytic group (mean difference [MD]=-257.60mL, 95% confidence interval [CI] -389.68 to -125.53, p=0.0001), but there were no statistical differences in intraoperative EBL (MD=-46.46mL, 95% CI: -192.57 to 99.64, p=0.53). The allogenic transfusion rate was higher in the control group than in the antifibrinolytic group (odds ratio [OR] 0.21, 95% CI: 0.10-0.43, p<0.0001), but there was no difference in the autogenic transfusion rate (OR 0.35, 95% CI: 0.09-1.43, p=0.14). The pooled result showed no difference in operation time (MD=9.13min, 95% CI: -8.54 to 26.80, p=0.31). For the VTE rate, a pooled analysis was not conducted due to the lack of data. The length of hospital stay showed no differences (MD=-0.51 days, 95% CI: -1.17 to 0.16, p=0.13). CONCLUSIONS: Antifibrinolytic use in PAO has positive effects in terms of reduced total EBL and allogenic transfusion rate. LEVEL OF EVIDENCE: III; meta-analysis.

Aortic Injury After Shoulder Reduction in a Patient with Multiple Rib Fractures: A Case Report.

CASE: A 74-year-old woman presented with multiple rib fractures, hemothorax, spleen rupture, and right shoulder dislocation. Shoulder joint reduction was performed using the traction-countertraction method. An injury to the descending aorta, caused by the seventh rib, was confirmed. CONCLUSION: The authors encountered an aortic injury, a rare complication of shoulder joint reduction, in a patient with a posterior rib fracture. When managing patients with posterior fractures of the fourth to ninth ribs on the left side, the reduction method should be carefully selected depending on the status of the patient to avoid aortic injuries.

Femoral head fracture with large crushed defect in weight-bearing area treated with autologous osteochondral transplantation (repositionplasty): A case report.

RATIONALE: Femoral head fracture is a rare type of fracture commonly associated with hip dislocation. Femoral head fracture treatments include conservative treatment, fragment excision, open reduction, internal fixation, and arthroplasty. In cases of young patients, open reduction and internal fixation are preferred over arthroplasty. Pipkin type 2 fractures are treated with open reduction and internal fixation in most cases because the fracture line extends upward of the fovea and includes the femoral head-acetabular weight-bearing joint surface. However, if the fracture is severely comminuted or crushed, good results are difficult to obtain with open reduction and internal fixation. PATIENT CONCERNS: A 23-years-old male patient presented to the emergency room with right hip pain after 4-m fall. DIAGNOSIS: In initial image work up, he was diagnosed with right posterior hip dislocation and a Pipkin type 2 femoral head fracture with an ipsilateral superior ramus fracture. After manual reduction, simple radiography and computed tomography showed reduction of the hip joint and a large osteochondral defect of approximately 6 cm2 in the weight-bearing area on the superomedial side of the femoral head. INTERVENTIONS: This was treated with a novel surgery named autologous osteochondral transplantation (repositionplasty), devised by the authors. OUTCOMES: The congruent reduction was confirmed by radiography and computed tomography immediately after the surgery. At 5 years postoperatively, the Harris Hip Score was 100 points and no discomfort, femoral head collapse, osteonecrosis, or traumatic arthritis were observed on follow-up radiographs. LESSONS: We think this method "repositionplasty" will be a good treatment method for young patients with a large defect in the weight-bearing part of the femoral head who cannot undergo open reduction and internal fixation.