Blocking screw (pin) technique to achieve an acceptable reduction in intramedullary of subtrochanteric femoral fractures: indications, techniques, and clinical outcomes.

INTRODUCTION: Subtrochanteric femur fractures treated with intramedullary nails present biomechanical benefits, early weight-bearing, and reduced soft tissue damage, promoting bone union. However, improper reduction due to muscular forces and fragmented proximal bone increases nonunion risk. This study evaluates the efficacy of the blocking screw technique in preventing malalignment during intramedullary nailing. MATERIAL AND METHODS: In cases of subtrochanteric femoral fractures where malalignment, such as varus and anterior angulation, was anticipated during intramedullary nailing, proper reduction was ensured using blocking screw technique on the proximal bone fragment from the coronal or sagittal plane. A retrospective analysis was conducted on 25 patients (14 males, 11 females; average age 55.12 years) who were followed up for more than 1 year. The postoperative neck-shaft angle, anterior angulation angle, and limb length discrepancy were compared radiologically with those on the healthy side, and the presence and duration of bone union were measured. The Harris hip score was used for functional evaluation, and complications, including infection, were analyzed. RESULTS: At the final follow-up, primary bone union was achieved in 21/25 patients (84%), with an average bone union time of 21.81 weeks (range, 14-42 weeks). Of the four nonunions, bone union was achieved in three cases through bone grafting and supplemental plating and in the other case through intramedullary exchange, supplemental plating, and bone grafting. The femoral neck-shaft angle and anterior angulation showed no statistically significant differences compared with the healthy side, with averages of - 1.15° and - 1.4°, respectively. The limb length discrepancy was an average of - 2.4 mm. Regarding functional outcomes, the Harris hip score averaged 89.52 points (range 82-94 points). CONCLUSIONS: In subtrochanteric femoral fractures, the blocking screw technique effectively prevents malalignment during intramedullary nailing, ensuring not only appropriate reduction but also high bone union rates.

Induced membrane technique with plate fixation has a lower complication rate than bone transport over a plate for segmental tibial defects larger than 5 cm.

INTRODUCTION: The treatment of segmental tibial bone defects remains a surgical challenge. While Bone Transport (BT) and Induced Membrane Technique (IMT) are effective strategies for regenerating bone, there are few comparative studies between them. This investigation undertakes a comparative analysis of BT and IMT for large segmental tibial defects stabilised through plate fixation. MATERIALS AND METHODS: Patients with segmental tibial defects exceeding 5 cm were prospectively enrolled from 2008 to 2021 in a single institution, with a minimum follow-up duration of two years. All patients underwent either BT or IMT with plate fixation of the tibia. Procedural success, primary union as well as bone and functional outcome scores were compared. Complications, including non-unions, joint contractures and deep infections requiring surgical intervention, were also compared. RESULTS: 41 patients were recruited in total. 28 patients underwent Bone Transport Over a Plate (BTOP), while 13 patients underwent IMT with Plate fixation (IMTP). The procedural success rate trended higher in IMTP compared to BTOP (100% vs. 85.7%). The primary union rate also trended higher in IMTP compared to BTOP (92.3% vs. 79.2%). BTOP and IMTP achieved similar rates of satisfactory bone outcome scores (78.6% vs. 84.6%) and functional outcome scores (75% vs. 76.5%). There was no statistical difference between procedural success, primary union, bone and functional outcome scores. The complication rate in BTOP was 78.6% (22 of 28), including five docking site or regenerate non-unions, eight deep infections and nine joint contractures. IMTP had a 38.5% (5 of 13) complication rate, including one non-union, two deep infections and two joint contractures. The complication rate was 2.04 times higher in BTOP compared to IMTP (p = 0.0117). CONCLUSIONS: BTOP and IMTP are both equally effective techniques for regenerating bone in large tibial bone defects. However, IMTP may be a safer procedure than BTOP, with a lower probability of requiring additional procedures to address complications.

Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study.

INTRODUCTION: Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation. MATERIALS AND METHODS: A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation. RESULTS: Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique. CONCLUSIONS: Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion.

Acetabular fractures in elderly.

BACKGROUND: This study aimed to determine characteristics of acetabular fractures in the elderly by evaluating clinical course and computed tomography-based radiological features between low- and high-energy acetabular fractures. METHODS: We reviewed 178 consecutive patients with acetabular fractures aged ≥60 years from six centers. Low-energy fractures (group 1) were identified in 23 (12.9%) patients and high-energy fractures (group 2) in 155 (87.1%) patients. We compared demographics, radiological findings, and clinical course between the groups. RESULTS: Average age (70.6 vs. 67.8 years, p = 0.046) and ratio of females (47.8% vs. 23.2%, p = 0.021) were significantly higher in group 1 than in group 2. The Charlson comorbidity index was also higher in group 1, but no other demographics showed difference. More patients in group 2 than in group 1 underwent surgery (91.6% vs. 73.9%); however, more in group 1 underwent minimally invasive surgery (17.4% vs 4.5%). Anterior column-associated fracture patterns occurred in 91.4% and 38.7% of cases in groups 1 and 2, respectively. Most fractures were displaced (>2 mm); 68% of which were comminuted. Furthermore, 24.2% of the fractures had superior dome impaction, whereas 23.0% were associated with posterior wall impaction. CONCLUSIONS: Patients who sustained low-energy acetabular fractures were mostly women, were older, and had more comorbidities. Radiological findings of low-energy acetabular fractures showed anterior column involvement associated with injury to the quadrilateral surface. Additionally, it was observed to be commonly combined with comminution and impacted fragments.

Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination, multicenter analysis.

BACKGROUND: This study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture. METHODS: The ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed. RESULTS: In total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate. CONCLUSION: Ipsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.

The role of an augmentative plating in the management of femoral subtrochanteric nonunion.

INTRODUCTION: Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation. MATERIALS AND METHODS: Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months. RESULTS: Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed. CONCLUSIONS: Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.

Peri-implant atypical femoral fracture after nail or plate osteosynthesis.

BACKGROUND: A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS: We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS: The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS: PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.

The importance of reconstruction nailing for diaphyseal atypical femoral fractures: a comparative study with standard nailing.

INTRODUCTION: Subtrochanteric atypical femoral fractures (AFFs) usually require long cephalomedullary or reconstruction nailing to achieve satisfactory healing. Recently, this type of nailing has also been recommended to fix diaphyseal AFFs and prevent fragility fractures around the proximal femur, although standard antegrade nailing seems sufficient from a biomechanical perspective. This study aimed to compare treatment outcomes and complications between reconstruction and standard nailing for diaphyseal AFFs. MATERIALS AND METHODS: A retrospective comparative study of 48 female patients with diaphyseal AFFs who underwent surgical treatment with either reconstruction or standard nailing was conducted. The reconstruction nailing group comprised 23 patients with a mean age of 74.4 years and included 16 complete and 7 incomplete AFFs. The mean follow-up period was 30 months. The standard nailing group comprised 25 patients with a mean age of 71.1 years and included 16 complete and 9 incomplete AFFs. The mean follow-up period was 57.8 months. The healing rate, time to union, and complications were analyzed and compared between the two groups. RESULTS: Bony union was achieved in all 23 cases (100%) of the reconstruction nailing group by a mean of 19.3 weeks postoperative. In the standard nailing group, 23 of 25 cases healed (92%) by a mean of 16 weeks postoperative. The standard nailing group included two delayed fragility fractures of the femoral neck (5 and 10 years after the initial surgery), four cases of newly developed subtrochanteric AFFs at the distal screw of the proximal interlocking screws of the nail (one complete and three incomplete fractures), and two cases of nonunion. Complications only occurred in the standard nailing group (p = 0.01, Fisher's exact test). CONCLUSIONS: In diaphyseal AFFs, reconstruction nailing may achieve a satisfactory outcome and can also decrease delayed peri-implant fragility fractures of the hip, newly developed subtrochanteric AFFs, and nonunion.

Biomechanical comparison of proximal interlocking screw constructs in different subtrochanteric fracture models.

BACKGROUND: Depending on the size of the proximal bone segment, either a standard locking construct or a recon locking construct can be used in intramedullary nailing for a subtrochanteric fracture. However, the most appropriate construct for a given size of proximal bone segment has not yet been determined. Therefore, this study aimed to identify the appropriate construct using biomechanical testing. METHODS: Fourteen intramedullary nails for each locking construct (standard and recon) were inserted into 28 synthetic femurs. Fourteen subtrochanteric fracture models were developed by creating parallel defects (2 cm in size) 2 cm distal to the lower edge of the lesser trochanter (low fracture group), and 14 fracture models were developed with identical defects situated 1 cm distal to the lower edge of the lesser trochanter (high fracture group). An axial load experiment was conducted to measure the stiffness and failure load for each proximal interlocking screw construct. RESULTS: There were no statistically significant differences in the stiffness and failure load between the locking constructs in the low fracture group. However, the stiffness and failure load were significantly greater for the recon locking construct than for the standard locking construct in the high fracture group. CONCLUSION: The standard locking system allows for sufficient fixation strength when performing intramedullary nailing for subtrochanteric fractures located 2 cm distal to the lower edge of the lesser trochanter.

Clinical outcome of staged surgery after primary amputation for mangled extremity.

INTRODUCTION: Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation. MATERIALS AND METHODS: This study included 47 patients (38 men, 9 women; average age, 52.4 years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed. RESULTS: No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1 year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation. CONCLUSION: Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.

"Reverse miss-a-nail technique" of reconstruction nailing for successful fixation of the ipsilateral femoral neck and shaft fracture.

INTRODUCTION: Although reconstruction nails have an advantage of single-construct fixation in ipsilateral femoral neck and shaft fractures, they have not been used widely due to the technical challenges associated with their placement. Reduction is particularly demanding in patients with displaced neck fractures after nailing of the shaft fracture, and can be resulted in nonunion, malunion, and osteonecrosis. We report a new technique of reconstruction nailing after the provisional reduction and fixation of a neck fracture to achieve successful healing of this injury. MATERIALS AND METHODS: Osteosynthesis using a reconstruction nail was performed in ten consecutive patients with displaced femoral neck and shaft fracture. After closed reduction of the displaced neck fracture, the femoral neck was provisionally fixed with pins in an anterolateral-to-medial direction. While maintaining reduction of the neck fracture, a nail was inserted and passed into the medullary canal posterior to the provisionally fixed pins with indirect reduction of the shaft fracture. After two reconstruction locking screws were fixed for proximal interlocking, the provisional pins were removed once distal interlocking was achieved. The radiologic outcomes included quality of reduction, healing rate, and time to the union were appraised, and the functional outcomes were assessed with Friedman and Wyman's criteria. RESULTS: This novel technique provided satisfactory reduction of both the femoral neck and shaft fractures with no malunion. All fractures achieved primary union, except for one case of nonunion of femoral shaft. Eight of ten patients experienced good results in functional outcome, whereas the remaining two patients reported moderate limitations in activities of daily living. At the latest follow-up, all patients had excellent range of motion in hip and knee joints. CONCLUSIONS: Provisional fixation after reduction of a femoral neck fracture may facilitate successful reconstruction nailing in the ipsilateral fractures of the femoral neck and shaft. This "Reverse Miss-a-Nail Technique" may minimize complications and maximize the radiologic and functional outcomes of patients who experience this injury.

Excellent outcomes after double-locked plating in very low periprosthetic distal femoral fractures.

INTRODUCTION: Very low periprosthetic distal femur fractures (PPDFFs) are rare injuries and often have a relatively high failure rate after single lateral locked plating. The double plating technique yields good outcomes in osteoporotic fractures of the distal femur. To date, there is limited information on double-locked plate fixation of very low PPDFFs. This study aimed to evaluate the outcomes and complications of surgically treated very low PPDFFs using double-locked plate fixation. MATERIALS AND METHODS: Between January 2013 and December 2018, sixty-one consecutive patients with PPDFFs have been conducted. Only Su type III PPDFFs with double-locked plate fixation through a lateral minimally invasive approach and a medial subvastus approach to the distal femur were analyzed. Patients were encouraged to perform straight leg raising exercises and active knee motion on the second postoperative day. Assisted weight bearing from the early postoperative days was supported, and full weight-bearing was allowed after healing the fracture site. All patients were evaluated according to the time to union, limb alignment, range of knee motion, Knee Society Score, and presence of complications. RESULTS: Twenty one patients (17 females and 4 males, mean age 76 years, range 56-90) were included in the study. There were 10 of 33-A1, 6 of 33-A2 and 5 of 33 A3 fractures, according to the AO classification. Of 21 patients, 20 achieved union at an average of 14 weeks postoperatively. Postoperative limb alignment was satisfactory in all cases, with an average mechanical distal lateral femur angle of 89° and average mechanical posterior distal femur angle of 86°. All patients recovered the knee joint motion similar to that of the contralateral side, and daily life pre-injury. The average knee and function scores were 94 and 89, respectively. There were one case of non-union and three cases of superficial wound infection, which resolved after intravenous antibiotic therapy. CONCLUSIONS: Double locked plating showed excellent radiographic and functional outcomes with few complications in patients with very low PPDFFs. Based on these promising results, we propose the consideration of double-locked plate fixation in the treatment of very low PPDFFs.

An intuitive and simple technique for accurate insertion point selection and precise Poller (blocking) screw insertion.

Although indirect reduction with intramedullary (IM) nailing is the gold standard for long bone fractures, IM nailing in meta-diaphyseal fractures often results in malalignment. Placement of Poller (blocking) screws is an attractive and useful technique in these situations; however, the selection of accurate placement points and the placement process itself are often complicated. This paper proposes an intuitive, simple, and clear technique for selecting the location of Poller screw placement that can be used in either the anteroposterior or lateral view regardless of the fracture type and discusses techniques for Poller screw placement that enable displacement correction.

Significance of orthopedic trauma specialists in trauma centers in Korea.

INTRODUCTION: In 2012, the Korean central government selected trauma centers to provide effective treatment and reduce preventable mortality in severe trauma patients. General surgeons, thoracic surgeons, orthopedists, and neurosurgeons play pivotal roles in trauma centers, as most trauma patients require orthopedic procedures. This study aimed to underscore the importance of trauma orthopedic specialists (TOSs) by comparing treatment outcomes between a TOS and general orthopedists. PATIENTS AND METHODS: Orthopedic trauma patients with injury severity scores > 15 points, admitted to level 1 trauma centers between March 2015 and December 2016, were divided into the TOS group (treated by 1 orthopedic trauma specialist who treats trauma patients with no limitation in the joint of specialization) and the general orthopedist group (GOG; treated by several general orthopedists who manage both trauma and disease but are each specialized in a certain joint). Emergency room response time, triage time, surgical preparation time, number of surgeries per patient, intensive care unit (ICU) duration, complications, and mortality were retrospectively analyzed. RESULTS: Among 272 patients, 52 were treated by a TOS and 220 were treated by several general orthopedists. For the TOS group and the GOG, the average emergency room response time was 8 and 32 min; average triage time, 27 and 162 min; average surgical preparation time, 141 and 350 min; average number of surgeries per patient, 1.9 and 2.7; and average ICU duration, 8.5 and 12.2 days, respectively. The TOS group saved $2700 per patient. No statistical differences were found in complications and mortality between the 2 groups. CONCLUSIONS: TOSs can provide rapid treatment to trauma patients and systemically participate in collaborative treatment with other specialists in a trauma center. As treatment provided by a TOS can also reduce the ICU duration, TOSs can play an important role in rapid rehabilitation and cost reduction for trauma patients.

Fragment specific fixation technique using 2.7 mm VA LCP for comminuted posterior wall acetabular fractures: a novel surgical technique.

PURPOSE: The purposes of the study were to introduce surgical technique of fragment-specific fixation technique using multiple 2.7-mm variable-angle locking compression plates (VA LCPs) in comminuted posterior wall acetabular fractures and reported its clinical results. PATIENTS AND METHODS: Among the 68 patients, 23 with comminuted posterior wall factures with ≥ 3 fragments in the CT scan and no column involvement with a minimum follow-up duration of 12 months were enrolled in this study. We evaluated the clinical results after the treatment of comminuted posterior wall acetabular fractures via the fragment-specific fixation technique using 2.7-mm variable-angle locking compression plates (VA LCPs) retrospectively. RESULTS: The average duration of follow-up was 26.8 months. Anatomical reduction was achieved in eighteen patients. Imperfect reduction was achieved in five patients. 22 patients achieved fracture union and one patient underwent revision surgery owing to acute postoperative infection. There were no complications, including loss of reduction, fixative failures, sciatic nerve palsy, heterotopic ossification, and early posttraumatic arthritis among 22 patients. The average functional outcome was measured as 'very good'. CONCLUSION: Fragment-specific fixation technique using 2.7-mm VA LCPs for comminuted posterior wall acetabular fractures could be an acceptable alternative means of surgical fixation.

Safe zones and a technical guide for cerclage wiring of the femur: a computed topographic angiogram (CTA) study.

INTRODUCTION: Cerclage wiring for reduction of complex femoral shaft fractures can create iatrogenic vascular injury. OBJECTIVE: To describe the anatomical relation of blood vessels to the femur and develop a technical guide for safe passage of cerclage wire. MATERIALS AND METHODS: CT lower-limb angiographs (CTA) of 80 patients were reviewed and analysed to identify the superficial femoral artery (SFA) and the deep femoral artery (DFA) as well as the relation of those arteries to the femoral cortex. The total length of the femur was measured and divided into eight equal segments (seven levels). At each level, the medial half of the femur was divided into eight sectors labelled A through H and the position of the SFA and DFA was recorded. The shortest distance between the femoral cortex and the SFA and DFA at each level was measured. The data was analysed using STATA version 10.0. RESULTS: The average total femoral length from the tip of greater trochanter to lateral joint line was 402.98 ± 26.16 cm. The average distances from the SFA to the femur (d1) for levels 1 through 7 were 37.20 ± 5.0, 32.09 ± 4.74, 27.13 ± 4.19, 27.71 ± 5.46, 23.71 ± 4.40, 13.63 ± 3.59 and 10.08 ± 3.09 mm, respectively. The average distances between the DFA and the femur (d2) for levels 1 through 3 were 26.70 ± 4.13, 14.76 ± 3.27 and 9.58 ± 3.79 mm, respectively. The position of the SFA is located in sectors B through E at levels 1-3 and in sectors E through H at levels 4-7 and the position of the DFA located in sectors B through F at levels 1-3. CONCLUSION: Cerclage wiring should be started from the posterior intermuscular septum at the linea aspera. The safe area is the proximal half (midshaft) of the femur where the SFA and DFA lie at a safe distance from the femur. Between the midshaft and the distal 1/4, insertion of the passer must be done meticulously with the tip kept close to posteromedial cortex. Below the distal 1/4, the tip of the passer should be kept close to the posterior cortex to avoid injury to the SFA and the sciatic nerve.

Exchange nailing with enhanced distal fixation is effective for the treatment of infraisthmal femoral nonunions.

INTRODUCTION: The treatment options for nonunions of infraisthmal femoral shaft fractures after internal fixation are controversial. Methods such as exchanging an existing nail with a nail of a larger size, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. Among those options, exchange nailing seems to be the most popular choice. In this study, a Poller screw, or an additional interlocking screw, was used in conjunction with exchange intramedullary nailing. The purpose of this study was to evaluate the effectiveness of treating femoral shaft nonunions using insertion of a Poller screw or an additional interlocking screw in conjunction with intramedullary nail fixation. MATERIALS AND METHODS: This study included 18 patients who presented with nonunion of femur shaft fractures after internal fixation at the infraisthmal level. These patients included 13 men and 5 women, with a mean age of 46.8 years (range 15-78 years). The mean postsurgical period of nonunion was 7.8 months (range 6-12 months). The patients were classified into two groups: the atrophic nonunion group and the hypertrophic nonunion group. In all patients, nailing was enhanced with a Poller screw or additional interlocking screws. All patients were followed up with plain film examinations and were assessed for their functional recovery status to determine the osseous union conditions. RESULTS: All 18 patients achieved postoperative bony union after a mean time of 7.5 months (range 3-12 months), and all patients were able to walk with full weight-bearing and without pain within 3 months. There were no significant complications, such as broken hardware, implant back-outs, axial or rotational malalignments, or deep infections. CONCLUSION: Poller screws and additional interlocking screws, along with intramedullary nailing exchange, may be an effective and reliable alternative for treating infraisthmal femoral shaft nonunions.

Comminuted inferior pole fracture of patella can be successfully treated with rim-plate-augmented separate vertical wiring.

INTRODUCTION: We present the surgical technique of rim-plate-augmented separate vertical wiring for comminuted inferior pole fracture of the patella and report the clinical outcomes. MATERIALS AND METHODS: Between July 2013 and January 2016, 13 patients (7 male and 6 female) who were diagnosed with comminuted inferior pole fracture of the patella in preoperative computed tomography and underwent a minimum of 1 year of follow-up were enrolled in this study. Mean patient age was 57.7 years (range 28-72 years). All patients underwent open reduction and internal fixation by rim-plate-augmented separate vertical wiring. Bony union, complications, range of motion and Bostman score were the clinical outcomes. RESULTS: Bony union was achieved in all cases at an average of 10 weeks after surgery (range 8-12). There was no loss of reduction and fixative failure during follow-up. The average range of motion was 127° (range 120°-130°). The mean Bostman score at last follow-up was 29.6 points (range 27-30) and graded excellent in 12 patients. CONCLUSION: Rim-plate-augmented separate vertical wiring demonstrated secure fixation and favorable clinical outcomes. This study provides evidence for its effectiveness as a fixation method for treating displaced, comminuted inferior pole fracture of the patella.

Treatment of infra-isthmal femoral fracture with an intramedullary nail: Is retrograde nailing a better option than antegrade nailing?

INTRODUCTION: Antegrade intramedullary (IM) nailing is ideal for femoral shaft fractures, but fixing the fracture distal to the isthmal level may be difficult because of medullary canal widening and the proximity of fracture location from the distal femoral joint line. This study aimed to compare treatment results between antegrade and retrograde nailing for infra-isthmal femoral shaft fracture, and to identify influencing factors of nonunion and malalignment. MATERIALS AND METHODS: Sixty patients with infra-isthmal femoral shaft fractures treated with IM nailing and followed-up for > 1 year were enrolled in this retrospective study, 38 in the antegrade nailing group, and 22 in the retrograde nailing group. The two groups had no significant differences in age, sex, and fracture location (p = 0.297, Mann-Whitney test). Radiological evaluation was performed, and functional result was assessed using the Knee Society scoring system. Complications were analyzed in accordance with fracture location, fracture type, and operative method. RESULTS: According to the AO/OTA classification, 35, 16, and 9 cases were type A (A1: 1, A2: 11, A3: 23), B (B1: 2, B2: 7, B3: 7), and C fractures (C2: 4, C3: 5), respectively. The mean follow-up duration was 29.5 months. In the antegrade and retrograde nailing groups, the primary bony union rates were 73.7% in 20.7 weeks (range 12-41) and 86.4% in 17.4 weeks (range 12-30), respectively. The two groups showed no significant differences in union rate (p = 0.251, Pearson's Chi-square test) and union time (p = 0.897, Mann-Whitney test). No cases of malalignment of > 10° in any plane were found in both groups. The mean Knee Society scores were 92 (range 84-100) and 91 (range 83-95) in the antegrade and retrograde nailing groups, respectively, showing no significant difference (p = 0.297, Pearson's Chi-square test). Although fracture location was not significantly related to union rate (p = 0.584, Mann-Whitney test), patients with an effective working length of the distal segment of < 0.75 were prone to nonunion (p = 0.003, Pearson's Chi-square test). CONCLUSIONS: Although no significant difference was found in IM nail type, the IM nail with a shorter working length distal to the fracture showed a strong relationship with nonunion.

Angular deformity correction by guided growth in growing children: Eight-plate versus 3.5-mm reconstruction plate.

BACKGROUND: Guided growth using the eight-plate (8-plate) is the most commonly used method to correct angular deformities in children; however, implant failure has been reported. Recently, the 3.5-mm reconstruction plate (R-plate) has been used as an alternative option for guided growth; however, hardware prominence has been problematic. This study aimed to compare the coronal angular deformity correction results of guided growth between relatively thin 8-plates with cannulated screws and thick R-plates with solid screws. METHODS: Thirty-nine physes (24 distal femoral, 15 proximal tibial) in 20 patients underwent hemiepiphysiodesis using 8-plates, and 61 physes (40 distal femoral, 21 proximal tibial) in 35 patients underwent hemiepiphysiodesis using R-plates. Coronal angular corrections were measured and compared preoperatively, and after the completion of corrections. Amounts and rates of correction and complications were compared between the groups. RESULTS: Mean body mass index was 18.7 kg/m2 in the 8-plate group, and 22.7 kg/m2 in the R-plate group. Angular correction was achieved in all deformities at a mean of 13.7 months and 19.7 months in the 8-plate and the R-plate group, respectively. The mean corrected mechanical lateral distal femoral angle was 9.0° in the 8-plate group, and 9.9° in the R-plate group (P = 0.55). The mean corrected medial proximal tibial angle was 7.1° in the 8-plate group, and 9.0° in the R-plate group (P = 0.07). The mean rates of angular correction were also not significantly different in the distal femur (1.03°/month vs. 0.77°/month, P = 0.2) and the proximal tibia (0.66°/month vs. 0.63°/month, P = 0.77). There was one superficial infection in each group, and one case of implant failure in the R-plate group. Two rebound deformities were observed and needed repeat hemiepiphysiodesis. Permanent physeal arrest was not observed in this series.