Comparison of the Outcomes of Plating, Screw Fixation, and Pinning in Sanders Type II Fractures: A Multicenter (TRON) Retrospective Study.

Calcaneus fractures Sanders type II have been historically treated with various modalities. However, few studies compared these procedures directly. The multicenter (TRON group) retrospective study compared the radiographic and clinical outcomes of operative procedures using Kirschner wires (K-wires), cannulated cancellous screws (CCSs) and plates. Between 2014 and 2020, 121 patients with Sanders type II calcaneus fractures were surgically treated in our group using K-wire (Group K: n = 31), CCS (Group C: n = 60) or plate (Group p: n = 30) fixation. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score and infection after operation as clinical outcomes and Böhler's and Preiss' angles as radiographic outcomes. The AOFAS scores of the 3 groups showed a significant difference, with Group P showing significantly inferior scores to Group C at 6 months postoperatively and at the final follow-up examination (p = .015 and p < .001, respectively). The rate of infection did not differ to a statistically significant extent, but the incidence in Group P tended to be higher in comparison to the other groups. Among the three groups, Böhler's angle did not differ to a statistically significant extent immediately after the operation (p = .113) or at the final follow-up examination (p = .383). Postoperatively, Preiss' angle did not differ to a statistically significant extent (p = .251) but was significantly smaller in the Group C at the final follow-up examination (p = .0331). In Sanders type II calcaneus fracture, CCS fixation may obtain the best functional outcomes.

Femoral neck fractures in non-geriatric patients: femoral neck system versus cannulated cancellous screw.

BACKGROUND: The fractures of femoral neck account for 50% among hip fractures with around 3%-10% occurring in younger population of below 65 years. The newly introduced FNS as management approach appears to be a potential alternative to the traditional CCS. The aim of this study was to compare the clinical efficacy and outcome of the femoral neck system (FNS) and the cannulated cancellous screw (CCS) in the treatment of femoral neck fractures in adult below 65 years of age. METHODS: Data of 114 patients between 18-65 years, admitted in our department for femoral neck fracture from January 2019 to March 2021 were retrospectively studied and ranged into two groups based on the surgical methods: FNS group (56 patients) and CCS group (58 patients). The variables of interest including demographic and clinical variables (age, gender, fracture mechanism, injury side and classification), perioperative parameters(operation time, intraoperative bleeding, incision length and hospitalization time), postoperative outcomes and complications (fracture healing time, nonunion rate, femoral neck avascular necrosis, aseptic screw loosening and the Harris Hip Score), were analyzed and compared between the two groups. RESULTS: All 114 patients presented satisfactory reduction and were followed-up for a period of 12 to 36 months (mean 27 ± 2.07 months); there were no significant differences between both groups in terms of age, gender, fracture classification, side of injury, mechanism of injury, the operative time, intraoperative blood loss and the hospital length of stay. However, the fracture healing time between FNS group and CCS group was statistically significant (p < 0.05), respectively 2.86 ± 0.77 and 5.10 ± 0.81 months. The significant differences were also found in terms of numbers of fluoroscopies 8.34 ± 1.38 Vs 17.72 ± 2.19, the HHS 87.80 ± 1.92 Vs 84.28 ± 2.24, postoperative complications 8 (14.28%) Vs 26 (44.82) respectively in FNS and CCS group. CONCLUSION: FNS presented satisfactory outcomes had significantly lower complications rate, therefore, can be one of the alternatives for internal implantation devices in treatment of femoral neck fracture in non-geriatric population.

A less invasive operative method using a medial cannulated cancellous screw and single plate fixation for the treatment of transcondylar fracture of the humerus in elderly patients in multicenter (TRON group) study.

BACKGROUND: Double plate fixation for transcondylar fracture (TCF) tends to be more invasive to the soft tissue, and often carries a higher risk of postoperative complications, including ulnar nerve neuropathy. This study presents the outcomes of TCF of the distal humerus between patients treated with a single plate and cannulated cancellous screw fixation and patients treated with double plate fixation. METHODS: Between 2011 and 2021, 371 cases involving treatment of distal humeral fracture were recorded in our multicenter (named TRON group) database. Patients of ≥ 65 years of age with TCF treated with opeb n reduction and internal fixation were included. Clinical outcomes were assessed by the Mayo elbow performance score, range of motion, and total elbow arc joint. Complications included fracture-related infection (FRI) and ulnar neuropathy. RESULTS: There were significant differences in the average operative time (CCS group vs. Plate group: 119.0 min vs. 186.5 min; p < 0.001) and average tourniquet time (CCS group vs. Plate group: 91.5 min vs. 121.0 min; p < 0.001). FRI occurred as a complication in the Plate group (n = 6). The rates of FRI did not differ to a statistically significant extent (CCS group vs. Plate group: 0% vs. 9.2%; p = 0.477). No patients underwent reoperation. The rate of sensory symptoms in the Plate group was higher than that in the CCS group (CCS group: none [n = 25], numbness [n = 1] vs. Plate group: none [n = 57], numbness [n = 15], sensory depression [n = 2]; p = 0.039). DISCUSSION: Among patients of ≥ 65 years of age with TCF, the clinical outcomes of patients treated with medial CCS and lateral/posterolateral plate did not differ from those of patients who received double plate fixation, and the former treatment was associated with significantly fewer complications, including ulnar nerve palsy. In addition to double plate fixation, this less invasive method of medial CCS and single plate fixation should be considered as a treatment option for TCF in elderly patients.

Outcome of bone marrow instillation at fracture site in intracapsular fracture of femoral neck treated by head preserving surgery.

PURPOSE: The aim of present study is to evaluate the outcome of bone marrow instillation at the fracture site in fracture of intracapsular neck femur treated by head preserving surgery. METHODS: This study included 32 patients of age group 18-50 years with closed fracture of intracapsular neck femur. Patients were randomized into two groups as per the plan generated via www.randomization.com. The two groups were Group A (control), in which the fracture of intracapsular neck femur was treated by closed reduction and cannulated cancellous screw fixation, and Group B (intervention), in which additional percutaneous autologous bone marrow aspirate instillation at fracture site was done along with cannulated cancellous screw fixation. Postoperatively the union at fracture site and avascular necrosis of the femoral head were assessed on serial plain radiographs at final follow-up. Functional outcome was evaluated by Harris hip score. RESULTS: The average follow-up was 19.6 months. Twelve patients in each group had union and 4 patients had signs of nonunion. One patient from each group had avascular necrosis of the femoral head. The average Harris hip score at final follow-up in Group A was 80.50 and in Group B was 75.73, which was found to be not significant. CONCLUSION: There is no significant role of adding on bone marrow aspirate instillation at the fracture site in cases of fresh fracture of intracapsular neck femur treated by head preserving surgery in terms of accelerating the bone healing and reducing the incidence of femoral head necrosis.

Surgical Treatment of Calcaneal Avulsion Fracture in Elderly Patients Using Cannulated Cancellous Screws and Titanium Wire.

Avulsion fractures of the calcaneus are relatively uncommon and are seen most frequently in elderly or osteoporotic patients. A surgical method that avoids displacement of the avulsed fragment after fixation has not been developed. We report the cases of 3 patients (a 73-year-old male, an 85-year-old male, and an 81-year-old female) treated by open reduction and internal fixation using titanium wire and cannulated cancellous screws. The posterior approach was used by way of a vertical midline incision. The fracture was fixed with 2 screws, and then a titanium wire was passed through the holes of the cannulated screws. A small incision on the lateral side of planter was added for the exit and return of the wire. The wire knot was bent inside the proximal Achilles tendon bursa in 2 patients and was directed to the plantar side in 1 to avoid irritation. Bony union was achieved without repeat displacement of the fragment in all 3 patients. Normal ankle function was restored, and the patients recovered the activities of daily living almost to the original level. Although an additional plantar incision is required, this surgical technique provides strong internal fixation.

Isolated talonavicular arthrodesis for talonavicular arthritis: a follow-up study.

We have reviewed a single surgeon's (M.S.) experience of talonavicular arthrodesis in 7 feet in 7 patients with isolated talonavicular arthritis. A standard dorsomedial approach was used to the talonavicular joint. Fixation was performed with 5.5-mm, partially threaded, cancellous screws. The visual analog scale for the foot and ankle (VASFA) was used to measure the preoperative and postoperative results in the categories of pain, function, other complaints, and total score. The follow-up period was 17 to 90 months (mean 48). The overall VASFA score ranged from +19.2 to +57.6 (mean +33.2, p < .01). The VASFA score for pain ranged from +19 to +74.8 (mean +51.3, p < .01). The VASFA score for function ranged from +12.5 to +68.2 (mean +28.3, p < .01). The VASFA score for other problems ranged from +12 to +45.8 (mean +25.5, p < .01). None of the 7 feet required revision, and all 7 patients were satisfied with the outcome and would have the operation again. We have concluded that, taking into account the small power of the present study, talonavicular arthrodesis is a successful treatment for isolated talonavicular arthritis.

Intraoperative avulsion fracture of the intercondylar eminence in Oxford mobile-bearing unicompartmental knee arthroplasty: Case report.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) can provide good postoperative results and long term survival, but there may be complications. We present a rare case of avulsion fracture of the intercondylar eminence during UKA surgery. CASE PRESENTATION: An 88-year-old man had right-knee pain with anteromedial osteoarthritis. Oxford partial knee UKA (Zimmer Biomet, Warsaw, IN) was performed by the senior author by the under-vastus approach using Microplasty instruments. During the final check of the range of motion, an avulsion fracture of the intercondylar eminence occurred at the terminal extension. A 4.0 mm cannulated cancellous screw was inserted into the intercondylar eminence from just in front of the anterior cruciate ligament to the posterior tibial cortex. Six months postoperatively, bony fusion was confirmed by lateral radiography. Two years after the surgery, the patient was fully satisfied. The flexion angle was 125°, but still with an extension limit of 10°. DISCUSSION: Avulsion fracture of the intercondylar eminence can be caused by hyperextension and/or the ACL becoming tighter in full extension of the knee. In this patient, avulsion fracture also probably occurred due to increased tension of the ACL in the fully extended position. After making the horizontal cut, we inserted a thin metal plate to prevent deeper vertical cuts, but an excessive horizontal cut was a possible cause of the fracture. As treatment for avulsion fracture of the intercondylar eminence, fixation of the cannulated cancellous screw resulted in uneventful bone fusion. We recommend having a cannulated cancellous screw at hand for such complications and for other potential intraoperative problems, such as tibial plateau fracture. Further investigation into limited postoperative extension might be needed. CONCLUSION: Our patient had intraoperative avulsion fracture of the intercondylar eminence, a relatively rare complication of Oxford UKA which is probably caused by the extension being tight and/or an excessive horizontal cut. Having a cannulated cancellous screw at hand is advised, and attention should be paid to postoperative limit of extension.

The Functional and Radiological Outcome of Hoffa's Fracture Treated With Cannulated Cancellous Screws.

INTRODUCTION: Distal femur AO type 33 B fractures consist of partial articular fractures subdivided into three types namely sagittal lateral condyle fracture, medial condyle fracture, and coronal split fracture. Coronal plane fractures of the distal femur are less frequent compared to sagittal plane fractures and are known as Hoffa fractures. The mechanism of injury is usually a direct anteroposterior force to the flexed and abducted knee for lateral condylar fractures and a direct impact on the medial side of the knee in flexion for a medial condylar fracture. Various approaches like lateral parapatellar for lateral condylar Hoffa's fixation, with or without posterior approach for open reduction of Hoffa's fracture with screw or buttress plate fixation, medial parapatellar approach for medial condylar Hoffa's fracture screw fixation are used. MATERIALS AND METHODS: This study was conducted at R L Jalappa Hospital and Research Center attached to Sri Devaraj Urs Medical College, Kolar, India, from June 2017 to May 2020 with 17 patients as a sample size. RESULTS: Seventeen patients with Hoffa's fracture were treated with cannulated cancellous screws with lag effect including 12 males and five females with a mean age of 31.1 years. The range of motion ranged from 120 to 135 degrees of flexion with a mean of 125.2 degrees. Three patients had extensor lag ranging from 5 to 10 degrees with an average of 6.3 degrees. Neer scores were excellent in 11, good in four, and fair in two patients. The average fracture union time for the lateral condyle was 16.4 months and for the medial condyle, it was 16.7 months. CONCLUSION: Restoration of articular anatomy and its congruence is of paramount importance for better surgical outcomes. Closed or open reduction and stable fixation with anteroposterior cannulated cancellous screws are essential. A good post-operative rehabilitation program is required for better outcomes.

Outcomes of Displaced, Comminuted, Intracapsular Neck Femur Fracture in Young Adults Managed with Three Screw Inverted Triangle Versus Four Screw Diamond Configuration: A Comparative Pilot Study.

Background: Three cannulated cancellous screws (CCS) inverted triangle configuration is considered to be the gold standard for management of displaced intracapsular neck femur (ICNF) fractures in young adults. However, some authors have recommended four CCS in diamond configuration in the presence of comminution. However, there are no comparative studies to assess the superiority of one over the other. Therefore, the aim of the present study was to compare the radiological and functional outcomes of displaced, comminuted, ICNF fracture in young adults managed with three screw inverted triangle versus four screw diamond configuration CCS fixation. Material and Methods: Twenty-three patients (group I) with displaced comminuted ICNF fractures were managed with three CCS fixation in inverted triangle fashion between October 2014 and October 2015 and were followed up for a mean duration of 33.5 months (range 25-38 months). Twenty-five patients (group II) with the same inclusion and exclusion criteria were managed with four CCS in diamond configuration between October 2013 and October 2014 and followed up for a mean duration of 33.3 months (range 25-38 months). Radiological outcomes of these patients were compared in terms of union rates and avascular necrosis, while functional outcome was measured by Harris Hip Score (HHS) at a minimum of 24 months. Results: Nineteen patients of group I and 20 patients of group II were available for final follow-up. Mean union time in group I was 15 weeks (12-24 weeks), while in group II, it was 14 weeks (12-24 weeks). There was total of four (4/19) cases of non-union in group I, while it was two (2/20) cases in group II. One patient (1/19) developed avascular necrosis in group I, while two (2/20) developed the same in group II. In group I, the mean HHS was 87.3 (range 84-94) points, while in group II, mean HHS was 93.5 (range 78-96) points. Conclusion: There is no difference in the clinical and radiological outcomes following three screw inverted triangle or four screw diamond configuration CCS fixation of displaced comminuted ICNF fracture in young adults. Thus, we conclude that both three screw inverted triangle or four screw diamond configuration CCS fixation are effective treatment modalities for fracture neck femur with comminution and in the absence of larger studies and long-term follow-up the superiority of one over the other cannot be recommended.

Development and initial validation of a novel thread design for nonlocking cancellous screws.

High failure rates have been associated with nonlocking cancellous screws with a typical buttress thread in patients with osteoporotic bone. This study aimed to develop a novel thread design and compare its fixation stability with that of a typical buttress thread. Nonlocking cancellous screws with a novel thread design (proximal flank angle of 120 degrees, a flat crest feature, a tip-facing undercut feature) and nonlocking cancellous screws with a typical buttress thread were manufactured using stainless steel. Fixation stabilities were evaluated individually by the axial pullout and lateral migration tests, and they were evaluated in pairs together with a dynamic compression plate in an osteoporotic bone substitute (10 PCF polyurethane foam per ASTM F1839) under cyclic craniocaudal and torsional loadings. Pullout strength and lateral migration resistance for the individual screw test and the force, torque, and number of cycles required to achieve specific displacement and torsion for the multi-screw test were comparatively analyzed between both screw types. A finite element analysis model was constructed to analyze the stress distributions in the bone tissue adjacent to the threads. The biomechanical test revealed the novel undercut thread had superior axial pullout strength, lateral migration resistance, and superior fixation stability when applied to a dynamic compression plate under cyclic craniocaudal loading and torsional loading than those in the typical buttress thread. The finite element analysis simulation revealed that the novel thread can distribute stress more evenly without high-stress concentration at the adjacent bone tissue when compared to that of a typical buttress thread.

Comparison of Femoral Neck System Versus Cannulated Cancellous Screws for the Fixation of Femoral Neck Fracture in Young Adults: A Systematic Review and Meta-Analysis.

A femoral neck fracture is a very common injury in the elderly. However, its incidence is low among young adults, usually presenting as an emergency. In young adults, implant choice is one of the important factors. This systematic review aims to analyze the femoral neck system (FNS) versus cannulated cancellous (CC) screw for the fixation of femoral neck fractures in young adults through well-defined objectives. A comprehensive search from the electronic database (PubMed, Google Scholar, Web of Science, Cochrane Library) was conducted from the beginning till February 18, 2022. The data regarding study type, authors, year of publication, country, union time, Harris hip score, intraoperative blood loss, operating time, neck shortening, and hospital stay were extracted from the selected articles and analyzed using RevMan 5.4.1 software. For continuous data, e.g., healing time, intraoperative blood loss, operation time, Harris hip score, neck shortening, and hospital stay, the mean difference (MD), either weighted mean difference (WMD) or standardized mean difference (SMD), with a 95% confidence interval (CI) was recorded. A p-value less than 0.05 was taken as statistically significant. The Newcastle Ottawa scale was used for the risk of bias assessment. Six retrospective cohort studies including 427 patients were selected for the meta-analysis. There was significantly less healing time (WMD= -1.10, 95% CI: -1.73 to -0.47), shorter operation duration (WMD=7.70, 95% CI: -0.06 to 15.46), and better Harris hip score (WMD=4.79, 95% CI: 2.12-7.46) in the FNS than CC screw fixation method. However, intraoperative blood loss was significantly less in the CC screw system (WMD=21.27, 95% CI: 8.20-34.35). There was no significant difference between the two approaches in-hospital stay duration and femoral neck shortening. This can be concluded that FNS is better than CC screw fixation for treating neck of femur fractures in adults on the outcome basis of union time, less operation time, and better Harris hip score (HHS) with significant heterogeneity.

A Comparative Study of Dynamic Hip Screw Versus Multiple Cannulated Compression Screw Fixation in Undisplaced Intracapsular Neck of Femur Fractures.

Background Femoral neck fractures are common injuries. Although many studies have compared two-hole dynamic hip screw (DHS) versus multiple cannulated cancellous screw (CCS) fixation for undisplaced intracapsular fractured neck of femurs (NOF), there is no consensus on which surgical technique results in better outcomes. The aim of our study was to compare DHS and CCS for undisplaced NOFs. The primary outcomes were reoperation and mortality rates at one year postoperatively. Methodology A retrospective analysis was performed involving all patients who underwent fixation with DHS/CCS for an undisplaced intracapsular NOF at our hospital between January 2016 and December 2020. All patients had a minimum follow-up time greater than one year. All patients underwent a standardised NOF protocol. Patients either underwent DHS or CCS fixation according to surgeon preference, and there was no randomisation to either group. Results A total of 41 patients underwent fixation with DHS compared to 32 who underwent CCS. The reoperation rate at one year was 9.8% in the DHS group compared to 6.3% in the CCS group. This difference was not statistically significant (p = 0.588). The one-year mortality rate was similar between groups at 22.0% and 21.9% in the DHS group and the CCS group, respectively (p = 0.994). Registrar-level surgeons performed 80.5% of DHS compared to 59.4% of CCS, and consultant surgeons performed 4.9% of DHS compared to 25% of CCS. Conclusions There was no significant difference in revision rates or complications seen between CCS and DHS. A significantly higher percentage of CCS fixations were performed by consultant-grade surgeons at our hospital compared to DHS. This study provides further data on the choice of fixation method for intracapsular fractures. It also reports on the grade of the operating surgeon at our unit, which may be a factor in the quality of fixation and ultimately reoperation rates.

Revising a loosened cancellous screw with a larger screw does not restore original pull-out strength - A biomechanical study.

BACKGROUND: Cancellous screw fixation is often used in fracture fixation. When this screw is over-tightened, damage to the bone and other non-linear processes such as fracture and construct failure would be involved. The objectives of this study were (1) to determine the reduction in pull-out strength when a cancellous screw spins and (2) to determine how much pull-out strength can be restored by revising with a larger diameter screw. METHODS: A biomechanical study using synthetic polyurethane foam (320 kg/m3) was performed to assess (1) the pull-out strength of a 6.5 mm cancellous screw, (2) the pull-out strength of a loosened 6.5 mm cancellous screw and (3) the pull-out strength of a loosened 6.5 mm cancellous screw revised with a 7.3 mm cancellous screw. FINDINGS: The baseline pull-out strength of the 6.5 mm cancellous screw was 2213.91 ± 200.51 N. There was a 79.1% (463.79 ± 99.95 N) reduction in pull-out strength once spinning occurs (p = 0.027). When a spinning 6.5 mm cancellous screw was revised to a 7.3 mm cancellous screw, the pull-out strength increased to 1313.65 ± 93.23 N, 59.3% of the baseline pull-out strength (2213.91 ± 200.51 N) (p = 0.027). INTEPRETATION: A loosened 6.5 mm cancellous screw results in a 79.1% reduction in pull-out strength. Revising a loosened cancellous screw by inserting a larger 7.3 mm diameter screw partially improves the pull-out strength to 59.3% of the baseline. Surgeons should consider the use of "two-finger tight" torque when inserting a screw to avoid stripping.

Surgical Fixation of Subtrochanteric Fracture in Patient with Cancellous Screw Fixation for Neck of Femur Fracture: Surgical Decision-Making and Outcome.

INTRODUCTION: Cannulated screw fixation is a common technique employed for the closed reduction and fixation of minimally or non-displaced neck of femur (NOF) fractures. A rare but potentially devastating complication is a peri-implant subtrochanteric fracture. Given the possibility of dealing with two potentially unstable fractures in close proximity from an incomplete union of the femoral neck, surgical fixation must be carefully planned with the option of retaining the existing cancellous screws to maintain femoral neck stability. The authors describe a case of subtrochanteric fracture in a patient with an existing NOF fracture which was previously fixed with cancellous screw fixation and have provided our approach to such patients. CASE REPORT: The patient is a 73-year-old Chinese male with a previous cancellous screw fixation for an undisplaced NOF fracture 10 months before sustaining another fall resulting in a subtrochanteric fracture. Radiographs and computed tomography imaging revealed a peri-implant subtrochanteric fracture with fracture line originating distal to the inferior screw at the level of the lesser trochanter.The patient subsequently underwent a Trochanteric Fixation Nail-Advanced Proximal Femoral Nailing System (TFNA, Depuy Synthes) fixation of peri-implant subtrochanteric fracture. Two previous cancellous screws (superior-posterior and inferior-central) were first removed to allow the passage of the TFNA nail which just skirted the remaining superior-anterior screw.Postoperatively, the patient was allowed full weight-bearing with the patient managing to ambulate with a roller frame support on the immediate 1stpost-operative day. The subsequent progress was uneventful and at the final follow-up 6-month postoperatively, X-ray showed complete bony union and the patient is pain free and walking independently. CONCLUSION: Peri-implant subtrochanteric fractures following NOF fractures treated with cancellous screws are surgically challenging. A robust system of evaluating such fractures and decision-making aids perioperative planning. An intimate understanding of implant geometries and basic science principles can significantly help in difficult cases and may reduce the likelihood of intraoperative difficulties and complications. Further large-scale studies are required to evaluate the validity of the approach we have proposed.

Radiologic results of additional single screw fixation with lateral locking plate after hybrid closed-wedge high tibial osteotomy.

BACKGROUND: Hybrid closed-wedge high tibial osteotomy (hybrid CWHTO) is an effective surgical treatment for medial compartment osteoarthritis of the knee. Our study investigated whether the combination of a lateral locking plate and a single medial screw promoted bone union after hybrid CWHTO. METHODS: The study cohort consisted of 30 patients (15 men and 15 women) who underwent hybrid CWHTO for medial compartment osteoarthritis or spontaneous osteonecrosis of the knee. Sixteen knees were fixed with a lateral locking plate (LP group), and 17 were fixed with both a lateral locking plate and a cannulated cancellous screw on the medial side of the tibia (LPS group). The times to bone union, radiolucency, and callus formation at the osteotomy site were evaluated radiographically. RESULTS: The mean postoperative time to radiographic confirmation of bone union was 5.5 ± 2.6 months in the LP group and 3.4 ± 1.5 months in the LPS group. Radiolucency at the osteotomy site and excess callus formation on the posterior side of the tibia were lower in the LPS group than in the LP group. CONCLUSIONS: This modified hybrid CWHTO combining a lateral locking plate and a cannulated cancellous screw on the medial side of the tibia improves the stability of the osteotomy site and shortens the period of bone union.

Four Screws Diamond Configuration Fixation for Displaced, Comminuted Intracapsular Fracture Neck Femur in Young Adults.

BACKGROUND: Four cannulated cancellous screws (CCS) in diamond configuration have been recommended by some authors for fixation of intracapsular neck of femur (ICNF) fracture with posterior comminution in adults. This is also supported by biomechanical studies. However, the clinical usefulness of this biomechanical advantage is not known. This study evaluates the outcomes of displaced, comminuted ICNF fracture in young adults managed by four CCS fixation in diamond configuration. MATERIALS AND METHODS: 25 patients who met the inclusion criteria were operated during the study period. Four patients were lost to followup in the first 6 weeks postoperatively, and one patient died in first 6 months of followup unrelated to surgery. Thus, twenty patients were followed up for a mean period of 33.3 months (range 25-38 months). In all patients, fracture fixation was done with four CCS in diamond configuration. Union at fracture site and avascular necrosis (AVN) of femoral head was assessed on serial plain radiographs. Functional outcome was evaluated by Harris hip score. RESULTS: Eighteen patients had union, two patients had nonunion, and two patients had AVN of femoral head. All the sixteen patients who had union without AVN had good or excellent functional outcome. CONCLUSIONS: The present study concludes that four CCS fixation in diamond configuration appears to be a reasonable choice of fixation for displaced fracture ICNF with comminution in young adults. However, further evaluation with better study design and larger patient population is required for definite conclusions.

Management of Neglected Lateral Condyle Fracture of Humerus: A Comparison between Two Modalities of Fixation.

BACKGROUND: Implant for fixation of neglected fracture lateral condyle humerus remains an issue of controversy. This study compares the clinical and radiological outcome of fixation with Kirschner wire (K-wire) and with cancellous screw (CS) in neglected fracture lateral condyle humerus. MATERIALS AND METHODS: 42 patients of neglected lateral condyle humerus fracture, treated either by open reduction and internal fixation (ORIF) with K-wire or ORIF with CS were included in study. The comparisons were made in term of slab immobilization time, union time, improved range of motion (ROM), final achieved carrying angle, and functional outcome measured by Liverpool Elbow Score (LES). RESULTS: There were 22 patients in Group I with mean age 7.8 years and 20 patients in Group II with mean age 7.3 years. Mean delay in presentation was 12.9 versus 15.6 weeks (P > 0.05). Mean followup was 26.9 versus 26.7 months. Mean duration of immobilization was 11.6 versus 9.4 weeks (P < 0.001). Improved carrying angle was 6.8° versus 9.7° (P < 0.05). Mean gain in ROM was 17.7° versus 27.5° (P < 0.05). Mean LES was 8.15 versus 8.18 (P > 0.05). Premature closure of physis was observed in two patients. Pin tract infection was seen in three of Group I (P > 0.05). CONCLUSION: There was no difference in LES, irrespective of implant used. Screw was better in terms of duration of slab, improvement in carrying angle and ROM.

Functional Outcome of Isolated Hoffa Fractures Treated with Cannulated Cancellous Screw.

Introduction: Isolated Hoffa fracture is an infrequent injury and little research has been done on this subject. The purpose of this study was to evaluate the functional outcome and complications of surgically managed Hoffa fractures with cannulated cancellous screw. Materials and Methods: Between 2011 and 2014, eight isolated Hoffa fractures in seven adult patients with mean age 39.8±11.9 years (range 25-60 years) were managed with cannulated cancellous screw of 6.5mm diameter applied in anterior to posterior direction using swashbuckler and medial parapatellar approach for lateral and medial Hoffa fractures respectively. All patients were evaluated using knee evaluation score after two years or longer. Mean follow up was 28±3.8 months (range 24-36 months). Results: All fractures in the eight patients healed clinicoradiologically by the 16th week with excellent result in 87.5% cases and good in 12.5% cases. By the end of union, the range of motion (ROM) of the knee was 0° to 110° except in two patients. One patient had ROM 10°-100° and other had 15°-90°. Mean knee evaluation score was 87.5±10.4. There was no incidence of non-union, infection or avascular changes in the patients or loss of reduction till final follow up. Conclusion: Open reduction and fixation with two 6.5 mm cannulated cancellous screws with early mobilization yielded good functional outcome in isolated Hoffa fractures.

Comparison of compressive forces caused by various cannulated cancellous screws used in arthroscopic ankle arthrodesis.

BACKGROUND: When performing arthroscopic ankle arthrodesis for end-stage ankle arthritis, internal fixation is performed using bone screws after appropriate preparation. However, optimal characteristics of bone screws have not been examined in terms of pressure force. Objective comparisons of bone-screw performance may provide information on procedures for arthroscopic ankle arthrodesis. The study objectives were to determine whether it was possible to measure compressive force changes using the newly developed device and to infer all screw characteristics from measurement results when used in actual surgeries. In addition, we performed experiments on cadavers to verify whether the experimental results could be applied to the joints of living subjects. METHODS: Three types of screws (S1, S2, and S3) were inserted into the unique measurement device, and the changes in pressure were measured for each 45° turn. Changes in pressure and maximum pressure force were recorded after the application of the screws. After reaching the maximum pressure in the simulated bone, further screw rotations were accompanied by a gradual pressure decrease to 0 MPa. We also measured pressure changes in a similar manner by inserting a miniature pressure sensor into the talocrural joints of cadavers. RESULTS: The mean maximum pressure ± standard deviation for S1, S2, and S3 were 0.832 ± 0.164 MPa, 0.434 ± 0.116 MPa, and 0.414 ± 0.127 MPa, respectively. Pressure slopes to the maximum did not significantly differ between the screws in the simulated bone, and a subsequent pressure decrease to 0 MPa was significantly more rapid for S1 than for S2 and S3. Although pressure failure after the overtightening of screws was only observed in the simulated bone, patterns of pressure vs. rotation angle were similar in simulated and cadaveric bones. The pressure profile characteristics of three different screw types were determined. CONCLUSIONS: We were able to measure the compressive force changes using the newly developed device when the screws were inserted. On the basis of the measurement results, we were able to infer the characteristics of all screws when used in actual surgery.

Vertical femoral neck fractures in young adults: a closed fixation strategy using a transverse cancellous lag screw.

Vertical femoral neck fractures (Pauwels type III classification) in young adults generally occur as a consequence of high-energy trauma and are frequently seen in association with multiple injuries. Considering the controversies regarding the optimal fixation for this fracture, our aim was to evaluate the clinical outcome of a closed fixation strategy for vertical femoral neck fractures in young adults using two parallel and one transverse cancellous lag screws. This was a single-surgeon, prospective study including 20 young adults with average age of 38.75 years (range 18-59 years) with a high-energy Pauwels III femoral neck fracture. Closed reduction and internal fixation with three cancellous lag screws were performed. The first screw was inserted crosswise to avoid further shear forces. Second and third parallel screws were placed above the lesser trochanter and centrally on the greater trochanter, respectively. Clinical outcomes were assessed by comparing postoperative and final follow-up radiographs 24 months post-injury. Eleven patients had an isolated vertical femoral neck fracture. Of these, five had further femoral neck comminution. Nine patients had an associated ipsilateral femoral shaft fracture. All fractures were displaced at the time of the first radiological evaluation. Closed reduction quality was considered excellent or good in 15 patients. After 24 months, bone union was achieved in 16 cases. Osteonecrosis of the femoral head developed in association with two fractures, and a nonunion developed in association with two fractures. We conclude that vertical high-energy femoral neck fractures can be treated successfully with internal fixation with two parallel cancellous lag screws positioned above the lesser trochanter and a third screw inserted centrally on the greater trochanter at an angle perpendicular to the fracture line.