Treatment of non-united femoral neck fracture by a novel subtrochanteric angulation lateral translation valgus osteotomy (SALVA osteotomy).

PURPOSE: The ideal treatment of non-united and neglected fracture neck femur in the young adult still remains unclear and is characterized by many biological and biomechanical challenges. METHODS: Twenty-one patients with non-united or neglected fracture neck femur aged between 19 and 50 years were treated by a novel subtrochanteric valgus osteotomy and were followed up for a mean of 26.7 months. Patients were assessed by radiological parameters, the Harris Hip Score, Oxford Knee Score, and Askin Bryan Criteria to categorize the overall outcome of the patients at 24 months. Other outcome measures included the occurrence of AVN, adductor lever arm, leg length discrepancy, and mechanical implant failure. RESULTS: All patients treated with the SALVA osteotomy consolidated and displayed a marked improvement of functional and radiological outcome measures. Nevertheless, there were 2 mechanical failures in patients with marked osteopenia and three developed AVN. CONCLUSIONS: In patients with un-united/neglected fracture neck femur, SALVA osteotomy appears to be reliable and reproducible. It also restores the abductor lever arm and improves the leg length discrepancy. Technically less demanding conversion to arthroplasty remains still possible prospectively.

Proposal of a modified tip apex distance for prediction of lag screw cut-out in trochanteric hip fractures.

INTRODUCTION: Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries. MATERIALS AND METHODS: A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head. RESULTS: Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker's ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value < 0.001. CONCLUSION: The modified TAD had the highest reliability in the prediction of lag screw cut-out. A value ≤ 25 mm could potentially protect against lag screw cut-out in trochanteric hip fractures.

Repair of spondylolysis using a pedicle screw U-shaped rod construct: A preliminary study of 25 young patients with a mean follow-up of 24 months.

STUDY DESIGN: Prospective case series, therapeutic Level IV. OBJECTIVES: Functional and radiographic outcome evaluation of patients with spondylolysis treated with pars interarticularis defect repair with iliac bone grafting and application of a construct consisting of a pair of polyaxial pedicle screws connected by a U-shaped rod passing beneath the spinous process. METHODS: Twenty-five patients (27 operated lumbar levels) with an average of 20 months of follow-up (range 12-24 m) with spondylolysis who met our inclusion criteria were treated with the above-mentioned technique. Functional assessment was by the Visual Analog Score (VAS) for low back pain (LBP) and Oswestry Disability Index (ODI). Fusion was confirmed with plain x-rays and when indicated with computed tomography scan. Return to activities of daily living (ADL) was also assessed. RESULTS: There were 16 males (64%) and 9 females (36%), with a mean age of 18 ± 3 years at surgery, with a mean operating time of 79 ± 13 min and a mean blood loss of 186 ± 57 ml. ODI significantly improved from a mean of 63 ± 7 preoperatively to 10 ± 4 at 12 months postoperatively (P < 0.001). The mean preoperative LBP VAS score 8 ± 1 showed also a statistically significant decrease of values to 1 ± 1 at 12 months, (P < 0.001). At 12 m, all patients returned to unrestricted ADL. Pars healing was present in 19 patients (76%) at 6 months and in all patients at 12 months. CONCLUSIONS: Polyaxial pedicular screws with a U-shaped rod offer an effective and reproducible treatment for spondylolysis with an appropriate fusion rate, predictable return to daily activities, and good pain relief in young adults.

A Rare Case of Ipsilateral Floating Hip with Femoral Neck Fracture and Contralateral Floating Knee Injury - Proposal for a Management Flowchart and Literature Review.

INTRODUCTION: Femoral neck fractures can complicate by non-union and/or hip avascular necrosis (AVN); moreover, the incidence of AVN remains obscure when it is accompanied by an ipsilateral acetabular fracture. Measures to reduce non-union or hip AVN with this complex injury pattern are not well addressed in the literature. CASE REPORT: We report a case of a young male patient who sustained ipsilateral acetabular, femoral neck, and shaft fractures in addition to a contralateral floating knee injury following a motor vehicle collision. To the best of our knowledge, this is the first report that describes the simultaneous occurrence of these fractures and their management. The patient attained an excellent functional outcome with union of all his fractures. We, therefore, propose a management flowchart for this rare case scenario. CONCLUSION: The acute management of ipsilateral femoral shaft and neck fractures in such cases has to be prioritized. The use of a retrograde nail in addition to dynamic hip screw (DHS) with two cannulated anti-rotation screws and locking the DHS to the nail is likely to increase the healing potential of femoral neck fracture in these cases. Acetabular fixation is better to be performed in a second stage after the hyper-inflammation phase ends. The definitive management for the contralateral floating knee can be delayed to a third stage but should be completed within the 10-day limit of immunosuppression.

Management of unstable pertrochanteric fractures, evaluation of forgotten treatment options.

INTRODUCTION: Unstable trochanteric fractures are challenging with a high rate of implant failure and re-operation. Cephalomedullary nails proved to be a rational management choice for these injuries, yet other management options have not been well assessed. The aim of this study was to compare the use of DHS with trochanteric stabilizing plate (TSP) and proximal femoral locked plate (PFLP) in unstable pertrochanteric fractures. METHODS: This randomized controlled trial (RCT) included 40 patients (22 males, 18 females) with unstable pertrochanteric fractures (AO/OTA 31A2.2/A2.3). The patients were randomized into group 1 managed by DHS with TSP while group 2 was managed by PFLP. All patients were followed up for 1 year. Patients were assessed radiographically and clinically using Harris hip score (HHS) at 3, 6 and 12 months. Operative time, estimated blood loss and time to union were also compared. RESULTS: The difference of intra-operative variables, including operative time and intra-operative blood loss, between both groups was statistically insignificant. Time to bony union was faster in the first group with a statistically significant P value (p = 0.04). Functional outcome per HHS was significantly better in group 1 (p < 0.01) and implant failure in group 1 occurred statistically lesser (p < 0.01). DISCUSSION: DHS with TSP appears to be a good option of management for unstable pertrochanteric fractures. In contrast, the use of PFLP in unstable pertrochanteric fractures in the elderly does not appear to be a good alternative.

Evaluation of infrapatellar tendon plication in spastic cerebral palsy with crouch gait pattern: a pilot study.

OBJECTIVE: In order to substantially improve crouch pattern in cerebral palsy, the existent patella alta needs to be addressed. This pilot study evaluates the effectiveness of a previously described infrapatellar tendon plication for the treatment of patella alta in crouch gait pattern in skeletally immature spastic cerebral palsy patients. METHODS: In 10 skeletally immature patients (20 knees) with spastic diplegia and crouch gait, the previously described technique by Joseph et al. for infrapatellar tendon plication was evaluated within the setting of single event multilevel surgery (SEMLS). Outcome measures included knee extension lag, Koshino's radiological index for patella alta, and the occurrence of complications. Patients were followed-up for a minimum of 12 months. RESULTS: The extensor lag improved and was statistically significant in all cases of the study with no incidence of tibial apophyseal injury at the latest follow-up. Radiographic Koshino index normalized and was maintained all through the follow-up period except in one patient (5%) who was overcorrected. Two patients (4 knees, 20%) showed postoperative knee stiffness due to casting which resolved with physiotherapy within six weeks. One knee (5%) developed a superficial infection which also resolved uneventfully with repeated dressings. CONCLUSION: The described infra-patellar plication technique in skeletally immature spastic diplegics appears effective, safe, and reproducible.