Atypical Presentation of Primary Greater Trochanter Tuberculosis - A Case Report.

Introduction: Tuberculosis (TB) of the greater trochanter constitutes about 2% of musculoskeletal TB cases, often presenting with non-specific symptoms of localized pain, tenderness, and swelling, necessitating differentiation from other conditions like tumors. Bursal involvement results in the formation of a fluctuating mass. This case emphasizes the need for meticulous diagnostic evaluation in these cases due to their uncommon presentation and potential for inadequate assessment. Case Report: A 50-year-old male experienced hip pain and swelling after a trivial fall, leading to surgery for suspected abscess. Despite initial treatment, symptoms persisted which on further imaging suggested TB osteomyelitis that was confirmed on biopsy, prompting 18 months of anti-tubercular therapy. The patient showed significant improvement after a year, highlighting the importance of thorough evaluation and appropriate management in such cases. Conclusion: This case emphasizes the rare occurrence of primary TB in the greater trochanter, advocating for precise diagnosis through advanced imaging. It also underscores the importance of comprehensive TB testing, particularly in extrapulmonary cases which are prevalent in developing nations, to improve treatment outcomes.

[Comparison of the posterior hemipelvectomy of the greater trochanter approach with the standard Kocher-Langenbeck approach in the treatment of posterior acetabulum wall fractures].

OBJECTIVE: To compare the clinical efficacy of the posterior hemipelvectomy of the greater trochanter approach with the standard Kocher-Langenbeck(K-L) approach in the treatment of posterior acetabulum wall fractures and to explore a more optimal approach for the treatment of posterior acetabulum wall fractures. METHODS: Total of 26 patients with posterior acetabulum wall fractures were retrospectively analysed and divided into two groups:the posterior hemipelvectomy of the greater trochanter group (test group) and the standard K-L approach group (control group). In the test group, there were 24 patients including 16 males and 8 females with an average age of (42.00±4.52) years old, the time of injury to surgery was (6.75±1.15) d. In the control group, there were 23 patients including 16 males and 7 females with an average age of (41.00±5.82) years old, the time of injury to surgery was (7.09±1.20) days. The total hospital stay, length of incision, operation time, intraoperative bleeding, postoperative drainage, discharge, fracture reduction quality (Matta criteria), hip abduction muscle strength, hip function (Merle d'Aubigne-Postel score), postoperative complications and the incidence of ectopic ossification were compared. RESULTS: All cases were followed up for 6 months. There was no significant difference in incision length, intraoperative bleeding and postoperative drainage between two groups(P>0.05). However, the operation time of the test group was shorter than that of the control group (P<0.05). There was no statistically significant difference in fracture reduction and hip function between two groups (P>0.05). The hip abduction muscle strength of test group was better than that of control group(P<0.05). In addition, there was no significant difference in the incidence of postoperative complications and heterotopic ossification between two groups(P>0.05). CONCLUSION: Compared with the standard K-L approach, the posterior hemipelvectomy of the greater trochanter approach can shorten the operative time, has better recovery of the postoperative hip abduction muscle strength, exposes the view of the fracture involving the more comminuted posterior acetabulum wall or the fracture of the roof of the socket, improved the rate of fracture anatomical repositioning, provides a new idea for the clinical treatment of posterior acetabulum wall fractures, and allows patients to perform functional exercises at an early stage.

Cement Filling Technique to Prevent Greater Trochanter Displacement in Hip Arthroplasty for Femoral Intertrochanteric Fracture: A Technical Note.

With the increasing use of primary hip arthroplasty for management of intertrochanteric fractures, firm fixation and union of the greater trochanteric (GT) fragment are required during hip arthroplasty for management of intertrochanteric fractures. Various methods have been suggested to address this issue. However, displacement of the GT is a frequent occurrence. We have introduced a cement-filling technique for performance of hip arthroplasty of the proximal femur for achievement of immediate firm fixation of the GT. Cement filling during performance of hip arthroplasty for management of femoral intertrochanteric fractures is a valuable technique for preventing displacement of the GT and to encourage early mobilization.

US-Guided Interventional Procedures for Total Hip Arthroplasty.

In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.

Lesser Trochanter Apophyseal Avulsion Fracture: A Case Report and Review of the Literature.

Pediatric and adolescent apophyseal avulsion injuries are rare but important to recognize. This case report presents a 15-year-old male sprinter with a lesser trochanter apophyseal avulsion fracture who was treated nonoperatively. After 12 months of follow-up, conservative management resulted in significant healing and consolidation, with no pain or functional limitations at final follow-up. Conservative management of apophyseal avulsion injuries leads to positive outcomes in adolescents, while surgical intervention may be necessary for certain cases. Precise diagnosis and management are essential for successful outcomes, and in adults, a more extensive workup is recommended to rule out underlying malignancy.

Effectiveness of Proximal Femur Nail in the Management of Unstable Per-Trochanteric Fractures: A Retrospective Cohort Study.

Background  Intertrochanteric (IT) fractures in the elderly demand surgical intervention for optimal recovery. While dynamic hip screw (DHS) is standard for stable fractures, its use in unstable cases is debated. Proximal femur nail (PFN) addresses unstable per-trochanteric fractures, boasting biomechanical advantages. Many studies favor PFN over DHS, despite concerns like screw migration. In resource-constrained developing nations, the choice of implant is pivotal. This research assesses proximal femur nailing outcomes for unstable fractures, providing insights for regional orthopedic protocols and contributing to tailored treatment guidelines in contexts with limited resources. Objective To assess the clinical and radiological outcomes in patients undergoing proximal femur nailing for unstable per-trochanteric fractures. Material and Methods This retrospective single-arm cohort study was conducted from January 2020 to July 2022. All the consecutive patients who underwent PFN for unstable per-trochanteric fractures were included in this study. Harris Hip Score (HHS) and ambulation status were recorded to evaluate functional outcomes. In contrast, the radiological outcome was assessed by calculating Radiographic Union Score for Hip (RUSH) scores at six weeks, three months, and six months post-operatively. Results  A total of 48 patients were included in this study with equal gender distribution and a mean age of 66 years. The functional outcome was recorded with 2.1% (1), 33.3% (16), and 50% (24) of patients achieving full weight bearing (FWB) without pain at six weeks, three months, and six months respectively while 14.6% (7) of the patients never achieved FWB. The radiological outcome was assessed by calculating RUSH score with 6.3% (3), 43.8% (21), and 50% (24) of the patients achieving complete union at the end of six weeks, three months, and six months respectively. One patient (2.1%) experienced malunion. Conclusion PFN remains an optimal treatment modality for the fixation of unstable per-trochanteric fractures yielding promising functional and radiological outcomes.

The role of the greater trochanter pain syndrome in lumbar degenerative disc disease surgery.

PURPOSE: Greater trochanter pain syndrome (GTPS) is highly discussed during spine surgeons, accompanies lumbar pain and complicates differential diagnosis. The aim is to raise awareness among physicians and demonstrate the lumbar spine degenerative diseases (LSDD) association with GTPS. METHODS: A retro-prospective analysis enrolled 172 patients with LSDD with GTPS signs. Group I - retrospective (n = 112), group II - prospective (n = 60). Patients of group II with the confirmed diagnosis clinically and by the ultrasound recieved a GCS injection (Betamethasone 2 mg\ml + 5 mg\ml - 1.0). Also the VAS, X-ray and SPSS Statistics package were used. RESULTS: 112 patients in group I, 89 (79.5%) had increased pain in the hip early postOp to 7.8 points by VAS. All patients required trigger point injections of GCS and 68 (77%) received a repeat injection. 76 from 112 patients were tracked for long-term results, and recurrence of GTPS was detected in five people who treated conservatively for three months without dynamics. They were identified GTPS by ultrasound. During the injection, 39 from 43 (90%) patients noted pain reduction to 2.1 by VAS, but symptoms of radiculopathy or spinal stenosis persisted. Two patients (5%) did not note any changes. Two patients (5%) noted complete pain regression and refused the surgery. CONCLUSION: Timely detection of GTPS among spinal surgeons influences tactics and, in some cases, allows one to avoid unnecessary surgical interventions. In turn, ignoring the symptoms of GTPS in the preoperative period can lead to pain intensification in the greater trochanter after surgery for degenerative diseases of the spine.

Choice of Entry Point Does Not Affect Clinical and Radiological Outcomes in Antegrade Intra-medullary Nailing in Patients with Shaft of Femur Fracture: A Prospective Randomized Controlled Trial.

Purpose: The choice of entry point, Greater trochanter (GT), or Piriformis entry (PE) for antegrade intramedullary nailing (IMN) of the femur is crucial. This study was performed to compare these two entry points in the patients with shaft of femur fractures regarding intra-operative parameters, radiological and functional outcomes. Materials and Methods: Twenty-four patients underwent GT entry nailing, while 25 patients underwent PE nailing. Surgical time, Intra-operative blood units transfused, Intra-operative fluoroscopy exposure by number of C-arm shots taken, mean drop in hemoglobin, and incidence of iatrogenic fracture were recorded. Patients were followed up at 4 weeks, 6 weeks, and 6 months to look for radiological healing and improvements in functional outcome using Modified Harris Hip Score (MHHS). MRI of bilateral hips with pelvis was done in 25 patients at 6 months of follow-up to detect any preliminary signs of AVN. Results: The mean drop in hemoglobin in the GT group was significantly lesser than the PE group (p = 0.02). Mean MHHS at 4 weeks post-op was also significantly higher in the GT group (p = 0.01). There was no significant difference between both the groups regarding surgical duration, fluoroscopy exposure, radiological and functional outcomes in the long term. None of the patients who underwent MRI displayed any preliminary sign of AVN. Conclusion: GT entry nails lead to lesser surgical time, fluoroscopy exposure, and intra-operative blood loss. Both the nailing systems achieve excellent fracture unions and comparable functional outcomes in the long term, and there is a minuscule risk of AVN in adult patients undergoing IMN.

Bone metastasis manifested 52 years after resection of an apparently benign paraganglioma: A case report.

Paraganglioma is derived from the paraganglia tissue in the neck, along the sympathetic trunk, and in the pelvis. Paraganglioma has malignant potential and can metastasize to remote organs such as the liver, lungs, and bones. Most metachronous metastases occur within several years after the initial diagnosis of paraganglioma. Here, we report the case of a 71-year-old male patient who developed bony metastasis 52 years after the resection of a large paraganglioma at the aortic bifurcation. The biopsy-proven paraganglioma metastasis to the lesser trochanter of left femur presented as an avulsion fracture. His normetanephrine level was elevated. DOTATATE PET (positron emission tomography) did not find any other metastatic lesions. The bony metastasis was treated with radiation therapy. We believe that the patient had one of the longest gaps ever reported, 52 years, between the initial diagnosis and metastasis of paraganglioma. This case highlights the importance of long-term surveillance of patients with paraganglioma for metastasis.

Stress Fracture after Arthroscopic Lesser Trochanter Resection: Diagnosis and Therapy.

We report on the case of a 52-year-old female who presented with a stress fracture after undergoing an endoscopic resection of the lesser trochanter in ischiofemoral impingement, which was resistant to maximal conservative treatment. To the best of our knowledge, this complication has not been previously described. Non-weight-bearing and intravenous alendronic acid were prescribed for management. No additional surgery was required. The patient was pain free with the ability to perform sports on the same level as before and had no complaints.

Alternative Models for Pelvic Marker Occlusion in Cycling.

Bike fitting aims to optimize riders' positions to improve their performance and reduce the risk of injury. To calculate joint angles, the location of the joint centers of the lower limbs needs to be identified. However, one of the greatest difficulties is the location of the hip joint center due to the frequent occlusion of the anterior superior iliac spine markers. Therefore, the objective of this study was to validate a biomechanical model adapted to cycling (modified pelvic model, MPM), based on the traditional pelvic model (TPM) with an additional lateral technical marker placed on the iliac crests. MPM was also compared with a widely used model in cycling, trochanter model (TM). Thirty-one recreational cyclists pedaled on a roller bike while the movement was captured with a 7-camera VICON system. The position of the hip joint center and knee angle were calculated and compared with the TPM continuously (along 10 pedaling cycles) and discreetly at 90° and 180° crank positions. No significant differences were found in the position of the hip joint center or in the knee flexion/extension angle between the TPM and the MPM. However, there are differences between TPM and TM (variations between 4.1° and 6.9° in favor of the TM at 90° and 180°; P < .001). Bland-Altman graphs comparing the models show an average difference or bias close to 0° (limits of agreement [0.2 to -8.5]) between TPM and MPM in both lower limbs and a mean difference of between -4° and -7° (limits of agreement [-0.6 to -13.2]) when comparing TPM and TM. Given the results, the new cycling pelvic model has proven to be valid compared with the TPM when performing bike fitting studies, with the advantage that the occluded markers are avoided. Despite its simplicity, the TM presents measurement errors that may be relevant when making diagnoses, which makes its usefulness questionable.

Assessment in location of sciatic nerve between the ischial tuberosity and the greater trochanter of the femur: A cadaveric study.

Background: The location description of the sciatic nerve (SN) of adult between the ischial tuberosity (IT) and the greater trochanter of the femur (GT) is inconsistent in publications, this impels us to investigate and measure the distance relationship with SN between IT and GT. Methods: Thirty-one adult cadavers were dissected to investigate the distance relationship of SN with the posterior prominent position of the ischial tuberosity (ppIT), the medial edge of IT (mIT) and the lateral prominent position of GT (lGT). Results: SN passed through the point of the junction of medial one-third and middle one-third of a length from ppIT to lGT, and the midpoint of a length from mIT to lGT from the average data of the total studied cadavers. From average data of female and male, the left SN passed through the point of the junction of the medial two-fifths and the lateral three-fifths of the length between mIT and lGT. Between ppIT and lGT, SN located in a range of proportions from 0.1 to 0.6 from medial to lateral. Between mIT and lGT, SN located in a range of proportions from 0.2 to 0.7 from medial to lateral and all SN passed through the middle third of the length. Conclusions: Different bony landmarks draw different location descriptions of anatomic structure. In anatomic study and clinical practice, the utilized bony landmark should be clearly and accurately identified the reference point, inaccurate bony landmark can result in erroneous localization of the interested anatomic structure and lead to operation failure or iatrogenic injury.

A self-locking mechanism of the frog-legged beetle Sagra femorata.

Insect legs play a crucial role in various modes of locomotion, including walking, jumping, swimming, and other forms of movement. The flexibility of their leg joints is critical in enabling various modes of locomotion. The frog-legged leaf beetle Sagra femorata possesses remarkably enlarged hind legs, which are considered to be a critical adaptation that enables the species to withstand external pressures. When confronted with external threats, S. femorata initiates a stress response by rapidly rotating its hind legs backward and upward to a specific angle, thereby potentially intimidating potential assailants. Based on video analysis, we identified 4 distinct phases of the hind leg rotation process in S. femorata, which were determined by the range of rotation angles (0°-168.77°). Utilizing micro-computed tomography (micro-CT) technology, we performed a 3-dimensional (3D) reconstruction and conducted relative positioning and volumetric analysis of the metacoxa and metatrochanter of S. femorata. Our analysis revealed that the metacoxa-trochanter joint is a "screw-nut" structure connected by 4 muscles, which regulate the rotation of the legs. Further testing using a 3D-printed model of the metacoxa-trochanter joint demonstrated its possession of a self-locking mechanism capable of securing the legs in specific positions to prevent excessive rotation and dislocation. It can be envisioned that this self-locking mechanism holds potential for application in bio-inspired robotics.

Muscle forces acting on the greater trochanter lead to a dorsal warping of the apophyseal growth plate.

The apophyseal growth plate of the greater trochanter, unlike most other growth plates of the human body, exhibits a curved morphology that results in a divergent pattern resembling an open crocodile mouth on plain antero-posterior radiographs. To quantify the angular alignment of the growth plate and to draw conclusions about the function of the muscles surrounding it, we analyzed 57 MRI images of 51 children and adolescents aged 3-17 years and of six adults aged 18-52 years. We measured the angulation of the plate relative to the horizontal plane (AY angle) and the trajectories of the muscles attaching to the greater trochanter of the proximal femur. From anterior to posterior, the AY angle shows a decrease of 33.44°. In the anterior third, the cartilage is angled at a mean of 51.64°, and in the posterior third, the mean angulation is 18.6°. This indicates that the cartilage in the anterior region of the greater trochanteric apophysis is subject to more vertically oriented force vectors compared to the posterior region, as the growth plates align perpendicular to the force vectors acting on them. Combining the measured muscle trajectories with the physiological cross-sectional areas (PCSA) available from the literature revealed that, in addition to the known internal and external lateral traction ligament systems, a third, dorsally located traction ligament system exists that may be responsible for the dorsal deformation of the AY angle.

Unrepaired Trochanteric Bursae as a Risk Factor for Deep Gluteal Syndrome After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial.

BACKGROUND: The trochanteric bursae are often left unrepaired after total hip arthroplasty (THA) and they retract posteriorly over the muscle belly of the piriformis. Deep gluteal syndrome (DGS) is a multifactorial condition presenting as buttock pain and is attributed to nondiscogenic sciatic nerve irritation or impingement causes. The purpose of this study was to investigate the relationship between bursal repair and incidence of DGS in patients undergoing THA. METHODS: This prospective randomized trial included patients treated with a THA between January and December 2022 for a diagnosis of primary osteoarthritis. Patients were randomized into 2 groups: group 1 underwent a routine bursal repair, while group 2 did not, leaving the bursae unrepaired. Follow-up was performed on the 15th, 30th, and 90th day postoperatively with clinical scores, physical examinations, and laboratory tests. In this cohort of 104 patients, mean age was 55 years (range, 26 to 88). Demographic variables as well as range of motion and overall clinical results showed no significant difference between the groups. RESULTS: DGS rates were significantly more common in the patients who had an unrepaired bursa (group 2) both on the 30th and 90th postoperative days, while comparison of lateral trochanteric pain on palpation showed similar results between the groups. CONCLUSIONS: DGS is common in individuals who have unrepaired trochanteric bursal tissue following a THA. Despite its higher frequency, these symptoms did not have a substantial impact on the overall clinical scores, which remained consistent across the study groups.

Lesser trochanter reconstruction in artificial femoral head replacement for elderly patients with Evans-Ⅲ femoral intertrochanteric fracture / 中国组织工程研究

BACKGROUND:Artificial femoral head replacement is an effective method for the treatment of elderly unstable intertrochanteric fractures.However,the effect of lesser trochanter reconstruction in femoral head replacement for Evans-Ⅲ femoral intertrochanteric fractures has not been reported. OBJECTIVE:To analyze the effect of lesser trochanter reconstruction on the outcome of artificial femoral head replacement with long stem in elderly patients with Evans-Ⅲ femoral intertrochanteric fracture. METHODS:A retrospective analysis was performed on medical records of 45 elderly patients who underwent bipolar long-stem artificial femoral head replacement due to Evans-Ⅲ femoral intertrochanteric fractures in the Department of Bone and Joint Surgery,Second Affiliated Hospital of Xi'an Jiaotong University from June 2017 to May 2021.According to whether the small trochanter was reconstructed during surgery(reduction and fixation),they were divided into the reconstruction group(n=25)and the non-reconstruction group(n=20).The operation time,bleeding volume,time of getting out of bed,hospital stay time,Harris scores at 3 and 6 months postoperatively,and the incidence of complications during follow-up were compared between the two groups. RESULTS AND CONCLUSION:(1)The operation time of the reconstruction group was longer(99.72±13.41 minutes)than that of the non-reconstruction group(88.90±16.53 minutes)(t=2.369,P=0.023),and there were no significant differences in bleeding volume,time of getting out of bed or hospital stay time between the two groups(P＞0.05).(2)The Harris score of the reconstruction group(69.06±5.64 points)was higher than that of the non-reconstruction group(63.35±5.93 points)at 3 months postoperatively(t=2.982,P=0.005).At 6 months postoperatively,the Harris score of the reconstruction group(86.67±4.49 points)was higher than that of the non-reconstruction group(82.34±5.68 points)(t=2.782,P=0.009).(3)In addition,no significant difference existed in the incidence of complications between the reconstruction and non-reconstruction groups(χ2=0.008,P=0.927).(4)It is concluded that in elderly patients with Evans-Ⅲ femoral intertrochanteric fractures,lesser trochanter reconstruction in the artificial femoral head replacement significantly improved postoperative hip function despite increased operative time,demonstrating the importance of the lesser trochanter reconstruction in the artificial femoral head replacement for Evans-Ⅲ intertrochanteric fractures in the elderly people.

Should the diameter of the proximal femoral nail be large enough to fill the canal in the treatment of intertrochanteric femoral fracture in patients over fifty?

PURPOSE: Many studies have been conducted to evaluate the effects of nail shape, design, or length on the treatment of intertrochanteric fractures. However, the clinical implications of the nail diameter remain unclear. METHODS: This study was conducted with 191 patients aged ≥ 50 years with unilateral intertrochanteric fractures treated with the same type of short cephalomedullary nail and followed for at least one year. We recorded the reduction type, tip-apex distance, cortical contact of the nail, and nail/canal diameter ratio (NCR) just distal to the locking screw. The effects of nail diameter on the clinical results were evaluated. RESULTS: The average NCR was 68.7. The average union time was 4.78 months. Delayed union or nonunion was seen in 17 patients. Eight patients underwent additional surgery. The mean change in the modified Koval activity score was -0.84. The NCR did not significantly affect the clinical results. Comparisons of cases with NCRs above and below the average and the average - 1 standard deviation revealed no significant difference. The clinical outcome was not related to any variable associated with the nail diameter. CONCLUSION: With this specific proximal femoral nail, a small diameter relative to that of the femoral canal had no adverse effect on the union of osteoporotic intertrochanteric fractures, even in patients with unstable fractures and those who had unsatisfactory reductions.

Colgajo DIEP pediculado para reconstrucción de úlceras isquiáticas y trocantéricas sin opción a colgajo local / DIEP pedicled flap for reconstruction of ischial and trochanteric ulcers without local flap option

Introducción y objetivo: El colgajo DIEP pediculado ofrece una alternativa reproducible en el manejo de úlceras isquiáticas y trocantéricas en las que no hay tejido sano periférico disponible para la realización de un colgajo local. Describimos la técnica quirúrgica y presentamos 2 casos clínicos en los que empleamos este procedimiento. Material y método: Previo rastreo con ultrasonido doppler de las arterias perforantes periumbilicales, trazamos una isla cutánea vertical de 10 x15 cm, disecamos el pedículo hasta la unión con la arteria epigástrica inferior profunda que disecamos lo más proximal posible. Realizamos un túnel subcutáneo hasta el área a tratar para el paso sin tensión del pedículo vascular y colocamos el colgajo en su área receptora, suturándolo en dos planos. Resultados: Describimos 2 casos en los que obtuvimos excelentes resultados funcionales con baja morbilidad del área donadora. Conclusiones: En nuestra experiencia, el colgajo DIEP pediculado fue una adecuada opción reconstructiva en pacientes con úlceras isquiáticas y trocantéricas en quienes los tejidos periféricos no permitían reconstrucción con colgajos locales, ya que presenta una baja morbilidad en la zona donadora y un pedículo relativamente largo que le permite alcanzar la zona del defecto.(AU)

Background and objective: The pedicled DIEP flap offers a reproducible alternative in the management of ischial and trochanteric ulcers where healthy peripheral tissue is not available for the realization of a local flap. We describe the surgical technique and present 2 clinical cases in which this procedure has been used, offering a reproducible alternative in the treatment of these conditions. Methods: A doppler ultrasound scan of the periumbilical perforating arteries is carried out, tracing a 10 x 15 cm vertical skin island. The pedicle is dissected down to the junction with the deep inferior epigastric artery, which is dissected as proximal as possible. A subcutaneous tunnel is made to the area to be treated for the passage without tension of the vascular pedicle and the flap is placed in its receiving area, suturing it in two planes. Results: We present 2 clinical cases in which we obtained excellent functional results and low morbidity in the donor area. Conclusions: In our experience, the pedicled DIEP flap was an adequate reconstructive option in patients with ischial and trochanteric ulcers in whom peripheral tissues do not allow reconstruction with local flaps, since it has low morbidity in the donor area and a relatively long pedicle that allows it to reach the defect area.(AU)

Measurement of combined flap thickness for reconstruction of decubitus ulcer using computed tomography.

BACKGROUND: Various reconstruction options have been introduced to treat decubitus ulcers. A combined flap that takes advantage of the fasciocutaneous and muscle flaps has been proven to be effective in reconstructing decubitus ulcers in previous studies. However, no studies have measured combined flap thickness. This is the first study to demonstrate the superiority of the combined flap by measuring its thickness using enhanced abdominopelvic computed tomography (APCT). AIM: To evaluate combined flap modality as a useful reconstruction option for decubitus ulcers using measurements obtained through APCT. METHODS: Fifteen patients with paraplegia who underwent combined flap surgery for reconstruction of decubitus ulcers between March 2020 and December 2021 were included. The defects in the skin and muscle components were reconstructed separately. The inner gluteus muscle flap was split and manipulated to obliterate dead space. The outer fasciocutaneous flap was transposed to cover the muscle flap and opening of the decubitus ulcer. Subsequently, we performed enhanced APCT at 3 wk and 6 mo postoperatively to measure the flap thickness. RESULTS: The mean flap thickness was 32.85 ± 8.89 mm at 3 wk postoperatively and 29.27 ± 8.22 mm at 6 mo postoperatively. The flap thickness was maintained without any major complications such as contour deformities or recurrence. CONCLUSION: Although there was a significant decrease in flap thickness as measured by APCT, the combined flap provided sufficient padding and maintained its thickness even at 6 mo after reconstruction, suggesting that the combined flap modality may be a useful reconstruction option for patients with paraplegic decubitus ulcers.

Surgical and Functional Outcomes of the Results of Conventional Two-Screw Proximal Femoral Nail (PFN) Versus Helical-Blade Anti-rotation Proximal Femoral Nail (PFNA2).

Introduction An intertrochanteric (IT) femur fracture is an extra-capsular fracture between greater and lesser trochanters. Unstable IT fractures are those where there is poor contact between fracture fragments (especially medial and posterior cortices), comminution, and fracture pattern, such that the weight-bearing forces tend to displace the fracture further or a reverse oblique type. Proximal femoral nailing (PFN) is one of the modalities for proximal femoral fractures. A newer modality for proximal femoral fracture is PFNA2, i.e., PFN anti-rotation, which makes use of a helical blade for a better compaction of bone. Both nail designs (PFN and PFNA2) are available in short and long sizes (so a total of four variants). Only a few studies have compared the treatment of IT femur fracture concerning fracture geometry, design, and length using either of the two nail types. In our study, we assessed the surgical and functional outcomes of PFN and PFNA2. Materials and methods This prospective observational study was carried out on 30 patients who had sustained IT fractures of the femur. All cases of IT femur fractures more than 18 years of age, closed injuries, and the patients who consented to participate in this program were included in the study. All open injuries, the patients who refused to participate in this program, patients who have associated injuries, patients with a subtrochanteric femur fracture, and patients with less than six months of follow-up were excluded. The patients were randomized into two types of implant groups. All patients were operated with a standard protocol. The study was conducted for 18 months from February 2021 to August 2022. The results were analyzed (of all four variants) by comparing patient demographics, implant size, implant type, locking methods, union time, and other parameters. Results Most of the patients were operated on with a 10 mm nail diameter (17/30 patients), 380 mm length (long-nail group) (five/11 patients), and 250 mm length (short-nail group). With the use of PFNA2, the overall duration of hospital stay was less. The overall operative time (incision to wound closure) with the use of the short PFNA2 was lesser than that with the use of other designs due to the use of the zig for distal screws. The use of a distal dynamic locking screw in a majority of the patients can get better compression at the fracture site once the patient starts weight bearing and decrease the chances of the Z-effect, reverse Z-effect, screw back-out, and screw cut-out. The union time was nearly the same in the majority of the patients, with an early union seen with the use of PFNA2 nails. The overall modified Harris hip score (HHS) at the final follow-up was nearly the same with slightly better results with the use of PFNA2. Conclusions PFNA2 is the implant of choice in elderly patients with osteoporotic bone. It has less operative time, which is required in such patients with medical comorbidities; hence, it has marginal superiority over PFN. Short-nail design results in less operative time and less blood loss.