Sclerotic bone: a sign of bone reaction in patients with medication related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction associated with antiresorptive drugs such as bisphosphonates and denosumab. When dealing with advanced and/or multiple MRONJ lesions undergoing surgical therapy, the extent of surgery is often a topic of discussion. The aim of this study was to identify the differences in bone density in and around the MRONJ lesion before and after surgical treatment to evaluate the needed surgical extend of the modelling osteotomy. In this retrospective study 26 patients with MRONJ lesions that were surgically treated in our department were observed. Length, width and bone density were measured in panoramic radiograph pre and postoperatively with the Imaging processing software Sidexis and ImageJ (Fiji). The necrotic area, the surrounding sclerotic area as well as the healthy contralateral side were observed. Measurements were performed by two independent observers. Pearson correlation was calculated to determine the interobserver variability. Bone density was significantly reduced in the necrotic bone area compared to the healthy unaffected contralateral reference side. The sclerotic bone area surrounding the necrosis showed increased bone density compared to the contralateral unaffected reference side. The density of the sclerotic bone area was increased in the previously affected MRONJ area in the postoperative panoramic radiograph. The pre and postoperative density showed no significant correlation to healing behaviour. The focus of the modelling osteotomy in surgical treatment of mature MRONJ lesions should be predominantly on the parts that appear necrotic and less dense in the panoramic radiograph as sclerotic areas might be an expression of bone reaction.

Lateral Femoral Condyle Allograft in the Treatment of Elbow Capitellar Avascular Necrosis: A Case Report.

CASE: A 27-year-old woman developed capitellar osteonecrosis after long-term corticosteroid use to treat non-Hodgkin lymphoma. She underwent an osteochondral reconstruction using a lateral femoral condyle (LFC) allograft. This graft was selected because it has a similar radius of curvature to the capitellum. The patient had osseous integration, painless, near full range of motion of her elbow 6 months postoperatively and good shoulder function 1.0 year postoperatively. CONCLUSION: The LFC allograft should be considered a viable option in treating capitellar osteonecrosis.

[Left mandibular osteonecrosis following herpes zoster of the third branch of left trigeminal nerve: A case report].

Herpes zoster of trigeminal nerve was a common skin disease caused by varicella-zoster virus infection. Simple involvement of the third branch of trigeminal nerve was rare, and so were oral complications such as pulpitis, periodontitis, spontaneous tooth loss, bone necrosis, etc. This article presented a case of herpes zoster on the third branch of the left trigeminal nerve complicated with left mandibular osteonecrosis. We reported the case of a 64-year-old man with sudden pain in the left half of the tongue 1 month ago, and then herpes on the left facial skin appeared following with acute pain.The local hospital diagnosed it as herpes zoster and treated it with external medication. A few days later, he developed gum pain in the left mandibular posterior tooth area. He was admitted to Peking University School and Hospital of Stomatology one week ago with loose and dislodged left posterior tooth accompanied by left mandibular bone surface exposure. Clinical examination showed bilateral symmetry and no obvious restriction of mouth opening. Visible herpes zoster pigmentation and scarring on the left side of the face appeared. The left mandibular posterior tooth was missing, the exposed bone surface was about 1.5 cm×0.8 cm, and the surrounding gingiva was red and swollen, painful under pressure, with no discharge of pus. The remaining teeth in the mouth were all Ⅲ degree loosened. Imageological examination showed irregular low-density destruction of the left mandible bone, unclear boundary, and severe resorption of alveolar bone. The patient was diagnosed as left mandibular osteonecrosis. Under general anesthesia, left mandibular lesion exploration and curettage + left mandibular partial resection + adjacent flap transfer repair were performed. The patient was re-exmained 6 months after surgery, there was no redness, swelling or other abnormality in the gums and the herpes pigmentation on the left face was significantly reduced. Unfortunately, the patient had complications of postherpetic neuralgia. This case indicate that clinicians should improve their awareness of jaw necrosis, a serious oral complication of trigeminal zoster, and provide early treatment. After the inflammation was initially controlled, surgical treatment could be considered to remove the necrotic bone, curettage the inflammatory granulation tissue, and extraction of the focal teeth to avoid further deterioration of the disease.

A novel capitate bone Ilizarov external fixator for treating Kienböck's disease: an anatomical and biomechanical study.

This study aims to measure anatomical data of the capitate bone, develop an external fixator for treating late-stage osteonecrosis of lunate through Ilizarov technique, and evaluate its biomechanical performance. We selected eight wrist joint specimens to measure various parameters of the capitate bone, including its length, the distance from the junction of capitate head and body to the proximal end, as well as the width of its proximal head and distal body. Additionally, we measured these same indicators in 107 patients who had undergone wrist X-ray examination. Based on our measurements, we categorized the capitate bone into two groups and designed two types of capitate bone Ilizarov external fixator (CIEF) for it. Then, we compared it with the orthofix external fixator (OEF) through dynamic fatigue biomechanical experiments and pull-out resistance experiments. The results of the measurement revealed two categories of general patterns in the capitate bone. The first type maintains a consistent longitudinal axis between the proximal and distal ends. The second type is characterized by its proximal end being close to the radial side and its distal end being close to the ulnar side. In the dynamic tensile fatigue test, CIEF-A and CIEF-B had smaller maximum displacement values compared to the OEF (P < 0.05). In the anti-pull-out experiment, both CIEF-A and CIEF-B exhibited higher maximum pull-out force than the OEF (P < 0.05). CIFE is a treatment for advanced osteonecrosis of the lunate bone. It is specifically designed to align with the anatomical characteristics of the capitate bone, providing excellent biomechanical properties and a simple clinical procedure. However, additional clinical experiments are needed to confirm its effectiveness in the future.

Sequestration and Involucrum: Understanding Bone Necrosis and Revascularization in Pediatric Orthopedics.

Sequestration, a condition where a section of bone becomes necrotic due to a loss of vascularity or thrombosis, can be a challenging complication of osteomyelitis. This review explores the pathophysiology of sequestration, highlighting the role of the periosteum in forming involucrum and creeping substitution which facilitate revascularization and bone formation. The authors also discuss the induced membrane technique, a two-stage surgical procedure for cases of failed healing of sequestration. Future directions include the potential use of prophylactic anticoagulation and novel drugs targeting immunocoagulopathy, as well as the development of advanced imaging techniques and single-stage surgical procedures.

Sphenoid Sinus Mucosal Flap after Transsphenoidal Surgery-A Systematic Review.

Background and Objectives: Skull base reconstruction is a crucial step during transsphenoidal surgery. Sphenoid mucosa is a mucosal membrane located in the sphenoid sinus. Preservation and lateral shifting of sphenoid mucosa as sphenoid mucosal flap (SMF) during the transsphenoidal exposure of the sella may be important for later closure. This is the first systematic review to evaluate the utility of sphenoid mucosal flap for sellar reconstruction after transsphenoidal surgery. Materials and Methods: A systematic literature search was performed in January 2023: Cochrane, EMBASE, PubMed, Scopus, and Web of Science. The following keywords and their combinations were used: "sphenoid mucosa", "sphenoid sinus mucosa", "sphenoid mucosal flap", "sphenoid sinus mucosal flap". From a total number of 749 records, 10 articles involving 1671 patients were included in our systematic review. Results: Sphenoid sinus mucosa used to be applied for sellar reconstruction as either a vascularized pedicled flap or as a free flap. Three different types of mucosal flaps, an intersinus septal flap, a superiorly based flap and an inferiorly based flap, were described in the literature. Total SMF covering compared to partial or no SMF covering in sellar floor reconstruction resulted in fewer postoperative CSF leaks (p = 0.008) and a shorter duration of the postoperative lumbar drain (p = 0.003), if applied. Total or partial SMF resulted in fewer local complications (p = 0.012), such as fat graft necrosis, bone graft necrosis, sinusitis or fungal infection, in contrast to no SMF implementation. Conclusions: SMF seems to be an effective technique for skull base reconstruction after transsphenoidal surgery, as it can reduce the usage of avascular grafts such as fat along with the incidence of local complications, such as fat graft necrosis, bone graft necrosis, sinusitis and fungal infection, or it may improve the sinonasal quality of life by maintaining favorable wound healing through vascular flap and promote the normalization of the sphenoid sinus posterior wall. Further clinical studies evaluating sphenoid mucosal flap preservation and application in combination with other techniques, particularly for higher-grade CSF leaks, are required.

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study.

BACKGROUND: Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction. METHODS: Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up. RESULTS: No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees. CONCLUSION: In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common. LEVEL OF EVIDENCE: Level III, prospective study.

Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

High-energy Femoral Neck Fractures in Young Patients.

Femoral neck fractures in physiologically young patients typically occur from high-energy axial loading forces through the thigh with the hip in an abducted position. These fractures have a high rate of associated head, chest, abdominal, and musculoskeletal injuries. High-energy hip fractures differ from traditional geriatric hip fractures regarding incidence, mechanism, management algorithms, and complications. After adequate resuscitation, goals of treatment include anatomic reduction and stable fixation while maintaining vascularity of the femoral head, which can be achieved through a variety of different techniques. Prompt recognition and treatment of these fractures is crucial to achieve a successful outcome because these injuries are often associated with complications such as osteonecrosis, fixation failure, and nonunion.

Comparison of the efficacy of Oxford unicondylar replacement for the treatment of spontaneous osteonecrosis of the knee versus medial knee osteoarthritis: a meta-analysis.

OBJECTIVE: Meta-analysis of the comparative efficacy of Oxford unicompartmental knee arthroplasty (OUKA) for the treatment of spontaneous osteonecrosis of the knee (SONK) and medial knee osteoarthritis (MKOA). METHODS: A computerized search was conducted for literature related to OUKA treatments of SONK and MKOA across various databases, including the China National Knowledge Infrastructure, WAN FANG, VIP, SinoMed, Cochrane Library, PubMed, Embase, and Web of Science, covering the period from each database's inception to September 2023. Literature screening, quality assessment and data extraction were performed according to the inclusion and exclusion criteria. After extracting the literature data, RevMan 5.4 software was applied to analyse the postoperative knee function score, postoperative knee mobility, postoperative pain, bearing dislocation rate, aseptic loosening, postoperative progression of posterolateral arthritis, and revision rate. RESULT: A total of 9 studies were included, including 6 cohort studies and 3 matched case‒control studies. A total of 1544 knees were included, including 183 in the SONK group and 1361 in the MKOA group. The meta-analysis results showed that the SONK and MKOA groups showed a significant difference in postoperative knee function scores [MD = 0.16, 95% CI (- 1.20, 1.51), P = 0.82], postoperative knee mobility [MD = - 0.05, 95% CI (- 1.99. 1.89), P = 0.96], postoperative pain [OR = 0.89, 95% CI (0.23, 3.45), P = 0.87], rate of bearing dislocation [OR = 1.28, 95% CI (0.34, 4.81), P = 0.71], aseptic loosening [OR = 2.22, 95% CI (0.56, 8.82), P = 0.26], postoperative posterolateral arthritis progression [OR = 2.14, 95% CI (0.47, 9.86), P = 0.33], and revision rate [OR = 1.28, 95% CI (0.53, 3.04), P = 0.58] were not statistically significant. CONCLUSION: OUKA treatment with SONK and MKOA can achieve similar satisfactory clinical results.

Outcomes following total ankle total talus replacement: A systematic review.

BACKGROUND: Prosthetic substitution of the talus presents a significant challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis and eventual talar collapse. The purpose of this systematic review is to evaluate whether total ankle total talus replacement (TATTR) leads to improved clinical and radiographic outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. METHODS: We searched the concepts of talus, prosthesis, and arthroplasty in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through March 9, 2023. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 6) inflammatory arthropathy to tibiotalar joint. Patients less than 18 years of age and manuscripts in non-English languages were excluded. RESULTS: Of the 7625 references, 16 studies met the inclusion criteria, yielding data from 136 patients (139 ankles). The studies varied in design, with case reports and retrospective case series being predominant. The overall weighted average modified Coleman Methodology Score (mCMS) was 70.4 out of 100, indicating moderate flaws in study design that may be subject to various forms of bias and possible confounders. Demographics showed a diverse range of etiologies, with alumina ceramic being the primary prosthesis material. Functional scores demonstrated improvements in dorsiflexion and plantarflexion, although patient-reported outcome measures (PROs) were inconsistently reported. Complications included fractures, heterotopic ossification, prolonged wound healing, and infections. Revision details were sparsely reported. CONCLUSION: TATTR is a promising treatment modality for improving short-term functional outcomes for patients with avascular necrosis or trauma-related issues. However, this systematic review underscores the need for standardized reporting, longer-term follow-ups, and further research to establish the procedure's efficacy and safety, particularly in comparison to other treatment modalities. LEVEL OF EVIDENCE: III, Systematic Review of Level IV Studies.

Is there still an indication for the Birmingham Hip Resurfacing in femoral head osteonecrosis?

PURPOSE: Osteonecrosis of the femoral head (ONFH) is a progressive hip disease. Hip resurfacing arthroplasty (HRA) is a preferred surgical procedure among hip arthroplasty performed in young patients. The aim of this study is to show the long-term clinical and radiological results of HRA procedures performed for patients suffering from ONFH. METHODS: Forty-five patients who underwent hip resurfacing with the diagnosis of femoral head osteonecrosis were included in the study. The Harris Hip Score (HHS) was used for clinical scoring of the patients. The blood chromium, cobalt, white blood cell (WBC) count, and CRP levels of patients were checked. Ultrasonography (USG) was performed for all patients at mid-term control checked for pseudo-tumours. For the radiological evaluation, acetabular inclination, stem shaft angle, prothesis-to-neck ratio, osteolysis zones, and heterotopic ossification were used. RESULTS: The mean age of the patients was 46.6 ± 9.3 years, and the mean follow-up period was 11.83 ± 2.9 years. The mean HHS was 90.3 ± 12.8 for final follow-up. The mean WBC value was 8.2 109/L, mean CRP value was 6.3 mg/L, mean chromium value was 4.9 µg/L, and mean cobalt value was 1.8 µg/L. Inclination changing 0.2°(p = 0.788), stem shaft angle changing 0.7°(p = 0.424), and neck-to-prosthesis ratio changing 0.01°(p = 0.075). No pseudo-tumours were detected in any patients in USG examination. CONCLUSION: HRA provides long-term implant survival and excellent clinical outcomes for end-stage ONFH patients with low complication rates.

Modified osteochondral autograft transplantation for steroid-induced osteonecrosis of femoral head in idiopathic thrombocytopenic purpura: a case report and literature.

Osteochondral autograft transplantation (OAT) has been commonly applied in the knee and ankle while the technique has not yet been a popularity in the femoral head. In this article, we present a 28-year-old female patient, who has a history of 1-year-use of glucocorticoid in the treatment of idiopathic thrombocytopenic purpura, with steroid-induced osteonecrosis of the femoral head (SONFH). She underwent surgical hip dislocation, osteochondroplasty, OAT, and internal fixation. Her Harris Hip Score improved from 64 to 82 in 36 months to follow-up. The case is valuable considering that a single, instead of several, 1.5 cm autograft was harvested from the non-bearing part of the same femoral head. This modification dispensed with the need of surgery for harvesting autograft from knee or ankle and reduced the structural vulnerability brought by the multihole donor part of the femoral head.

A chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to reconstruct partial necrosis of talar body: A case report.

Total talar extrusion is a rare complication of high-energy traumas. A consequence of this injury can be avascular necrosis (AVN) of the talus. Patients are confronted with pain, limited range of motion and post-traumatic arthritis. As AVN progresses the talus is gradually destroyed. This report presents the use of a chimeric medial femoral condyle chondro-osseus flap with two thin periosteal flaps to increase vascular supply to the traumatized area, accelerate bone formation, flap integration, and restore articular surfaces in a patient with partial necrosis of talar body. The patient was a 26-year-old female with open left lateral talar extrusion after a motor-vehicle accident that developed a partial avascular necrosis, at the level of the subtalar and ankle joint with altered talar dome surface with partial depression of 2 cm. The patient was in pain and not able to walk. The medial femoral condyle chondro-osseus portion was placed in the talar dome depression to restore the subtalar joint, the periosteal flaps were placed on top to reconstruct the ankle joint restoring the articular surfaces and the correct weight-bearing distribution. No complications or morbidity of donor site were observed. One year after the operation, the patient walks free, without pain. Post-operatory x-ray performed, evidenced progressive bone healing and reduction of the AVN. In the intent of performing a joint-saving procedure, the presented chimeric flap might be effective in the short-term with excellent clinical and radiographic outcomes.

CT-based five-segment classification in Freiberg's infarction: Evaluation of its intraobserver and interobserver reliability.

BACKGROUND: According to the location and frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn for Freiberg's infarction. The objective of the current study is to develop a new computed tomography-based Five-Segment classification system for Freiberg's infarction and testify if it has good intra- and interobserver reliability or not. METHODS: According to the location and its frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn. According to the distribution of osteonecrosis zones of metatarsal heads, we proposed the Five-Segment classification system. Four evaluators evaluated each radiography and computed tomography (CT) twice at 8-week intervals. To test the reproducibility of the Five-Segment classification system, the interobserver and intraobserver reliability of this classification system comparing with that of the Smillie classification by four observers using the kappa statistic. RESULTS: The 80 cases were classified into five reproducible types by using Five-Segment classification system: type Ⅰ, two (2.5%) cases; type Ⅱ, ten (12.5%) cases; type Ⅲ, 42 (52.5) cases; type Ⅳ, 24 (30.0%) cases; type Ⅴ, two (2.5%) cases. The mean kappa value for interobserver reliability using Smillie classification systems was 0.562 (95% CI: 0.531-0.585), whereas the mean kappa value was 0.828 (95% CI: 0.801-0.852), by using Five-Segment classification; the mean kappa values for intraobserver reliability by using Smillie classification and Five-Segment classification were 0.777 (95% CI: 0.762-0.792) and 0.860 (95% CI: 0.843-0.895), respectively. CONCLUSIONS: The new Five-Segment classification system demonstrated perfect interobserver and intraobserver agreement between evaluators in the management of Freiberg's infarction. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice. LEVEL OF EVIDENCE: Level IV, retrospective.

Management of chondral and osteochondral lesions of the hip : A comprehensive review.

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis.

BACKGROUND: Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH. METHODS: Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias. RESULTS: 45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias. CONCLUSIONS: The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Intermediate to Long-Term Results Following Traumatic Hip Dislocation: Characteristics, CT-Based Analysis, and Patient-Reported Outcome Measures.

BACKGROUND: Traumatic hip dislocation is a rare yet severe injury. As the long-term morbidity, subsequent complications, and clinical outcomes are nearly unknown, we aimed to analyze traumatic hip dislocations and identify specific factors that may predict the clinical outcome. METHODS: Data on injury-related characteristics and computed tomographic (CT) scans for all consecutive adult patients who had been managed for traumatic hip dislocation between 2009 and 2021 were analyzed. At the time of follow-up, the patients were assessed with regard to osteonecrosis, posttraumatic osteoarthritis (OA), further operations and complications, return to sports and work, and patient-reported outcome measures (PROMs), including the Tegner Activity Scale and modified Harris hip score. RESULTS: One hundred and twelve patients (mean age [and standard deviation], 43.12 ± 16.6 years) were included. Associated acetabular rim and femoral head fractures (Pipkin Type I to IV) were observed in 44% and 40% of patients, respectively. Concomitant injuries occurred in 67% of the patients, most commonly involving the knee (29% of patients). Sixty-nine patients (61.6%) were available for follow-up; the mean duration of follow-up was 6.02 ± 3.76 years. The rates of osteonecrosis and posttraumatic OA were 13% and 31.9%, respectively, and were independent of the timing of hip reduction, leading to subsequent total hip arthroplasty (THA) in 19% of patients. Sciatic nerve injury occurred in 27.5% of the patients who were available for follow-up. Both THA and sciatic nerve injury were associated with posterior acetabular rim or Pipkin Type-IV fractures (p < 0.001). Only 33.3% of the patients returned to their pre-injury level of sports, 24.6% did not return to work, and 27.5% reported having sexual dysfunction. PROMs (Tegner Activity Scale, modified Harris hip score) were significantly worse in patients with osteonecrosis, posttraumatic OA, or residual sciatic nerve injury (p < 0.05). CONCLUSIONS: Traumatic hip dislocations are predominantly associated with Pipkin and acetabular rim fractures, leading to overall limitations of activities of daily living, sports, and sexual function at intermediate to long-term follow-up. Patients with associated acetabular rim or Pipkin Type-IV fractures are most likely to require THA for the treatment of osteonecrosis or posttraumatic OA and are at greater risk for sustaining sciatic nerve injury. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Valgus-impacted subcapital neck of femur fractures: a systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management.

BACKGROUND: The management of the valgus-impacted neck of femur fracture (AO/OTA 31-B1) remains contentious. The objective of this study was to determine whether operative intervention is cost-effective. METHODS: We conducted a systematic review using electronic databases (Medline, Embase, Cochrane, Ebsco, Scholar) identifying studies published in the English language concerning valgus-impacted neck of femur fractures until June 2022. Additional studies were identified through hand searches of major orthopaedic journals, and bibliographies of major orthopaedic textbooks. MeSH terms (hip fracture and femoral neck fracture) and keywords (undisplaced, valgus-impacted, valgus, subcapital, Garden) connected by the Boolean operators "AND" and "OR" were used to identify studies. 2 reviewers independently extracted the data using standardised forms and recording spreadsheet. Methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument. Meta-analysis was undertaken. Outcome measures were rate of displacement, avascular necrosis, non-union, mortality and requirement of further operative intervention. A cost utility analysis was then conducted to compare the 2 groups on the basis of the cost of initial treatment and the potential requirement of secondary intervention to hemiarthroplasty. RESULTS: 47 studies met the inclusion criteria. Meta-analysis data demonstrated a significant difference in the displacement rate of 22.8% and 2.8% between the nonoperative and internal fixation groups respectively (p = 0.05). The overall incidence of further operative intervention for each group was 23% and 10% respectively. There was no significant difference with respect to avascular necrosis, mortality or union rates. The cost utility analysis revealed nonoperative management to be approximately 60% more costly than initial internal fixation when the costs of subsequent surgery were included. CONCLUSIONS: This meta-analysis of the existing literature concludes that whilst nonoperative management is possible for valgus impacted neck of femur fractures, it is associated with higher complication rates and greater expense than management by internal fixation.