Size of greater tuberosity fragment: a risk of iatrogenic injury during shoulder dislocation reduction.

PURPOSE: Shoulder dislocation with greater tuberosity fractures (GTF) is becoming increasingly common, as is the number of cases of iatrogenic humeral neck fractures (IHNF) during reduction. This study investigated the relationship between size of greater tuberosity fragment and occurrence of IHNF in patients with shoulder dislocation and GTF. METHODS: A retrospective study was made to identify all patients presenting with shoulder dislocation with GTF between September 2014 and July 2016. There were 74 patients with an average age of 52.4 years (range 18-84 years) representing 76 cases of shoulder dislocation associated with GTF. Patient age, injury mechanism and location, treatment waiting time, and reduction method were noted. Using conventional anterior-posterior view radiographs, three points were identified as A, B, and C. Distance ratios between AC and AB were calculated, then the resulting ratio was compared to a critical value of 0.4. RESULTS: More iatrogenic fractures occurred in cases where the AC/AB ratio exceeded 0.4. Most (13) occurred during emergency Hippocratic manual reduction. Only five of 18 iatrogenic fractures (27.78%) occurred during surgery while under traction. Women ran a higher risk of iatrogenic fracture than men (female/male ratio 8:1). On average, women were older than men at the time of fracture (59.75 years for women vs. 42 years for men). CONCLUSIONS: A statistically significant relationship exists between size of greater tuberosity fragment and occurrence of iatrogenic humeral neck fractures during the reduction of shoulder dislocation. The larger the greater tuberosity fragment, the higher the incidence of iatrogenic humeral neck fractures. For such fracture dislocations, we recommend open reduction with internal fixation directly and using a Kirschner wire in advance to reinforce the proximal humerus before reduction of the shoulder.

A Novel Design of a Plate for Posterolateral Tibial Plateau Fractures Based on Computed Tomography Mapping of the Proximal Tibiofibular Joint.

BACKGROUND We designed a novel plate for the treatment of posterolateral tibial plateau fractures. We first gathered radiological data of the proximal tibiofibular joint to verify the feasibility of the novel plate and provide an anatomical basis. MATERIAL AND METHODS Tomographic images of 98 healthy human tibias were obtained retrospectively. The width of the lateral tibial plateau, width of the posterolateral tibial plateau to the sagittal plane of the tibial plateau and width of the proximal tibiofibular joint to the sagittal plane of tibial plateau were measured. The proximal posterolateral tibial bone cortex angle and posterolateral slope-diaphysis angle were also calculated. Paired sample t-test was used for comparing men and women, and left and right sides. We used 2 variables for Pearson correlation analysis between the width of the lateral tibial plateau and other length indices. RESULTS There were no statistically significant differences between left and right knees (P>0.05). However, there were statistically significant differences of the 3 length indices between men and women (P<0.05). The length indices were all correlated to the width of the lateral tibial plateau (P<0.01). CONCLUSIONS This study of the lateral tibial plateau has a high accuracy in anatomical measurement, and our novel plate design is feasible based on the data. The study provided anatomical basis for the novel plate.

Role of femoral anterior Bow in cephalomedullary nailing: finite element analysis and New index estimation.

BACKGROUND: Cephalomedullary Nail (CMN) is seen as the mainstay of internal fixation in femoral fractures. The purpose of the study was to present an accurate calculation method by simulating diverse anterior bow femoral models with finite element software. We hypothesized that anterior cortical penetration in distal femur would occur in patients whose femoral anterior bow was identified as too large for nailing by preoperative measurement of contralateral X-ray. METHODS: A 31-year healthy male was selected for building 3D bone model through computed tomography (CT) scan of right femoral femur. In Creo Parametric 2.0, the middle section of the femur was twisted gradually to simulate the different femoral anterior bow. Ratio of chord height and half chord length, belonging to the middle section arc, was defined as the tangent value of the femoral anterior bow. The value corresponding to the penetration of the CMN at the distal femur was regarded as critical value, showing the extreme curvature for CMN. RESULT: Three types of right femoral CMNs (ø10, 11, 12 mm × 350 mm; Smith-Nephew Co.) were involved in our study. The CMN passed through distal femur anterior cortex when the tangent value of the femoral anterior bow are 0.140185, 0.133073, 0.092415 respectively, and the corresponding central angle are 21.72°, 20.92°, 16.32°. CONCLUSIONS: The tangent value of the femoral anterior bow would be a precise calculated method, that eliminate the deviation by description of ratio rather than length of radius. An application of this preoperative evaluation can aid surgeons during surgical planning. TRIAL REGISTRATION: Retrospectively registered.

Does integrity of the lesser trochanter influence the surgical outcome of intertrochanteric fracture in elderly patients?

BACKGROUND: Most surgeons do not fix the lesser trochanter when managing femoral intertrochanteric fractures with intramedullary nails. We have not found any published clinical studies on the relationship between the integrity of the lesser trochanter and surgical outcomes of intertrochanteric fractures treated with intramedullary nails. The purpose of this study was to evaluate the impact of the integrity of the lesser trochanter on the surgical outcome of intertrochanteric fractures. METHODS: A retrospective review of 85 patients aged more than 60 years with femoral intertrochanteric fractures from January 2010 to July 2012 was performed. The patients were allocated to two groups: those with (n = 37) and without (n = 48) preoperative integrity of the lesser trochanter. Relevant patient variables and medical comorbidities were collected. Medical comorbidities were evaluated according to the American Society of Anesthesiologists classification and medical records were also reviewed for age, sex, time from injury to operation, intraoperative blood loss, volume of transfusion, operative time, length of stay, time to fracture union, Harris Hip Score 1 year postoperatively, and incidence of postoperative complications. Postoperative complications included deep infection (beneath the fascia lata), congestive heart failure, pulmonary embolus, cerebrovascular accident, pneumonia, cardiac arrhythmia, urinary tract infection, wound hematoma, pressure sores, delirium, and deep venous thrombosis. Variables were statistically compared between the two groups, with statistical significance at P<0.05. RESULTS: Patients with and without preoperative integrity of the lesser trochanter were comparable for all assessed clinical variables except fracture type (P < 0.05). There were no statistically significant differences between these groups in time from injury to operation, volume of transfusion, length of stay, time to fracture union, Harris Hip Score at 1 year postoperatively, and incidence of postoperative complication (P > 0.05). The group with preoperative integrity of the lesser trochanter had significantly less blood loss (107.03 ± 49.21 mL) than those without it (133.96 ± 58.08 mL) (P < 0.05) and the operative time was significantly shorter in the former (0.77 ± 0.07 hours) than the latter (0.84 ± 0.11 hours) group (P < 0.05). CONCLUSIONS: The integrity of the lesser trochanter has no significant influence on the surgical outcome of intramedullary nail internal fixation of femoral intertrochanteric fractures.

Biomechanical comparison of gourd-shaped LCP versus LCP for fixation of comminuted tibial shaft fracture.

The purpose of this study was to compare monotonic biomechanical properties of gourd-shaped LCP fixation with LCP fixation of human tibial shaft in gap fracture mode. Twenty paired fresh cadaveric human tibias were randomly divided into 4 groups (5 pairs each): (1) axial loading single cycle to failure testing, (2) torsion single cycle to failure testing, (3) 4-point bending single cycle to failure testing, and (4) dynamic 4-point bending testing. A 7-hole 4.5 mm gourd-shaped LCP was secured on the anteromedial surface of 1 randomly selected bone from each pair, respectively, using 6 locking screws in the 1st, 2nd, 3rd, 5th, 6th and 7th hole with the middle hole unfilled and just located at the mid-diaphysis of the tibia. A 7-hole 4.5 mm LCP was secured on the other bone with the same method. Standard AO/ASIF techniques were used. After fixation finished, a 10 mm gap in the mid-diaphysis of tibia was created, centrally located at the unfilled hole. The axial, torsional, and bending stiffness and failure strengths were calculated from the collected data in static testings and statistically compared using paired Student's t-test. The 4-point bending fatigue lives of the two constructs were calculated from the dynamic testing data and also statistically compared using paired Student's t-test. Failure modes were recorded and visually analyzed. P<0.05 was considered significant. Results showed that the axial, torsional and bending stiffness of gourd-shaped LCP construct was greater (4%, 19%, 12%, respectively, P<0.05) than that of the LCP construct, and the axial, torsional and bending failure strengths of gourd-shaped LCP construct were stronger (10%, 46%, 29%, respectively, P<0.05) than those of the LCP construct. Both constructs failed as a result of plate plastic torsional deformation. After axial loading and 4-point bending testings, LCP failed in term of an obvious deformation of bent apex just at the unfilled plate hole, while the gourd-shaped LCP failed in term of a deformation of bent arc between the 3rd and 5th holes, which indicated a more consistent stress distribution on gourd-shaped LCP. Fatigue life of gourd-shaped LCP construct was significantly greater than LCP construct (153 836±2 228 vs. 132 471±6 460 cycles, P<0.01). All constructs failed as a result of fracture of the plate through the compression hole of the unfilled combination screw hole. The biomechanical testing showed that gourd-shaped LCP can provide greater stiffness and strength, and longer fatigue life than LCP. The gourd-shaped LCP may be more advantageous mechanically and may reduce the plate breakage rate clinically.

The occurrence rate and clinical application of Osteo-line on the femur neck.

BACKGROUND: This study was done to observe the incidence of Osteo-line on the femur neck and to explore the clinical application of Osteo-line in osteotomy. METHODS: Eighty-nine adult femur specimens were selected to observe the incidence of Osteo-line on the femur neck. From August 2015 to January 2019, a total of 278 patients who completed unilateral hip arthroplasty at the Third Hospital of Hebei Medical University were retrospectively included. Patients who accepted osteotomy via Osteo-line on the femur neck were defined as the experimental group (n = 139), and patients who accepted osteotomy via traditional method (The femoral distance 1.5 cm above the trochanter was retained for osteotomy by visual inspection.) were defined as the control group (n = 139). According to the postoperative pelvic X-ray, Photoshop was used to evaluate the leg length discrepancy (LLD) by the CFR-T-LT method. RESULTS: Among the 89 specimens, the incidence of anterior Osteo-line was 75.28%, and the incidence of posterior Osteo-line was 100%. According to the clinical application results, the incidence of anterior Osteo-line on the femur neck was 80%, and the incidence of posterior Osteo-line was 100%. The Osteo-line was clearer than those on the femoral specimens. Twenty-six cases had LLD greater than 1 cm (9.29%), including 2 cases in the experimental group and 24 cases in the control group. The average postoperative LLD in the experimental group (0.19 ± 0.38 mm) was significantly shorter than in the control group (0.54 ± 0.51 mm)(P = 0.005). CONCLUSION: The incidence of Osteo-line on the femur neck was high, and patients who accepted osteotomy via Osteo-line on the femur neck can achieve shorter postoperative LLD than the control group.

Treatment of the tibial pilon fractures using the antero-medial fibula approach: Ten case series.

Pilon fractures are always results of the high-energy trauma. They are often accompanied with serious soft tissue injury, and tension blisters happened in most cases. For comminuted fractures and poor soft tissue, how to select the incision is challenging. This study aimed to explore the outcomes of the treatment of ten 43-B/C pilon fractures using an anteromedial fibula approach.Ten closed pilon fractures combined with fibula fractures were treated in our hospital from January 2015 to July 2016. Six cases were AO/OTA type 43-B and 4 cases were 43-C, including 9 males and 1 female with a mean age of 36.3 years (range: 20-60 years). When the skin wrinkled, all patients were treated by the senior authors with open reduction and internal fixation using an anteromedial fibula approach. Postoperatively, patients were followed up at 1 month, 3 months, 6 months, 12 months, and 18 months, respectively. The incision healing, the American Orthopedic Foot and Ankle Society scores and fracture healing were recorded to get a comprehensive evaluation of the effect for the incision.All patients were followed from 9 to 18 months (average: 14.1 months). Anatomic reduction was achieved in 7 cases and satisfactory in 3 cases by the Burwell-Charnley radiological criteria evaluation. All patients had complete retention of the dorsal extensor tendon sheath. The most incisions had a good healing without necrosis at 2 weeks after surgery except 1 case. The factures were healed at a range of 12 to 18 weeks (average: 13.7 ±â€Š1.2 weeks). The American Orthopedic Foot and Ankle Society scores were excellent in 7 cases and good in 3 cases at 1 year after surgery (average: 85.6 ±â€Š4.2 points). The satisfactory outcomes were achieved in most patients.The anteromedial fibula approach used for pilon fractures can lead to an effective exposure and allow fixation of tibia and fibula fractures with minimal soft tissue injury. It is a safe, simple, and effective approach that allows for satisfactory functional rehabilitation of the ankle joint. LEVEL OF EVIDENCE:: therapeutic Level IV.

A Novel Method of the Treatment for Posterolateral Tibial Plateau Fractures.

Reduction and fixation of posterolateral tibial plateau fracture via a posterolateral approach is challenging, and the posterolateral approach itself may injure the posterolateral ligament complex of the knee and can result in knee instability. We developed a new curved support plate (CSP) that can pass, via traditional anterolateral approach, through the superior tibiofibular interval and effectively support the posterolateral fragments. The purpose of our study was to determine the biomechanical reliability of the new plate and report the preliminary efficacy of the CSP for posterolateral tibial plateau fracture. In the biomechanical experiment, 40 synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A to D. Vertical displacement of the posterolateral fragments was measured under axial loads of 500 to 1,500 N. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. From June 2016 to August 2017, eight patients with posterolateral tibial plateau fracture underwent treatment with the CSP. Hospital for Special Surgery (HSS) knee score, knee flexion and extension ranges of motion, and complications were recorded to evaluate treatment effects. Eight patients (five men and three women, mean age 44 years [range, 23-66 years]) were enrolled in the study. Mean follow-up time was 13 months (range, 7-19 months). All patients achieved radiographic bone union by 3.3 months (range, 3-4 months) postoperatively. There were no complications of neurovascular injury, deep vein thrombosis, infection, and implant loosening throughout the follow-up period. At final follow-up, mean HSS score was 92.6 (88-96), with a mean knee flexion of 131.25 degrees (120-135 degrees) and a mean knee extension of 1 degree (0-5 degrees). Fixation of posterolateral tibial plateau fracture was easily and successfully achieved using our newly designed CSP, which may provide a new choice for posterolateral tibial plateau fractures.

An innovative method for measuring the femoral arch.

A mismatch between the femoral bow and intramedullary nails causes a series of complications. Previous investigations have sought to determine the curvature of the femur using the radius of the femoral bow. However, the radius of the curvature is affected by femur length. To eliminate the influence of femur length, we instead used an angle to indicate femoral curvatures.Forty patients with intertrochanteric fractures who underwent a surgical procedure at our institution were enrolled in this study. We conducted a lateral X-ray of the contralateral femur before operation. We drew a triangle in the X-ray images using Digimizer software. The tangent values of the acute angle were used to indicate femoral curvature. The tangent values were then compared with the dimensions of currently used nails.The average tangent value of the femurs was 0.0835 ±â€Š0.0147, as measured from the inner cortex and 0.0798 ±â€Š0.0150, as measured from the outer cortex. The tangent values were related to sex, with males having straighter femurs than females, and there was no obvious correlation between tangent values and age or femur length. Tangent value is a reliable method with a high intersurveyor consistency; femur curvatures were significantly greater than the curvatures of currently used nails.

How international are the editorial boards of leading spine journals? A STROBE-compliant study.

Low- and middle-income countries contribute to only a small percentage of publications in multiple medical fields. Editorial bias was reported to be an important reason for this. However, whether this trend exists in leading spine journals remains unclear. This study determined the composition of the editorial boards of leading spine journals and analyzed the international representation of editorial boards.The editorial board members of four leading subspecialty spine journals, including The Spine Journal, Journal of Neurosurgery: Spine, European Spine Journal, and Spine were identified from the journals' websites. The countries of editorial board members were identified and analyzed according to the continent and country income categories classified by the World Bank.A total of 608 editorial board members were identified from the four leading spine journals. The majority (91.4%) of editorial board members were from high-income countries, followed by upper-middle income countries (7.2%), and lower-middle income countries (1.3%). No editorial board members were from low-income countries. Regarding the continent of residence, 46.5% of the editorial board members were from North America, followed by Europe (38.5%), Asia (9.9%), South America (2.8%), Oceania (1.6%), and Africa (0.7%). The editorial board members came from 40 different countries, which were concentrated in North America, Western Europe, and East Asia. The largest number of editorial board members came from the United States (42.3%), followed by Germany (6.9%), the United Kingdom (6.7%), Switzerland (5.8%), and Italy (5.1%).A lack of international representation on editorial boards exists in leading spine journals. Editorial board members from high-income countries are substantially overrepresented, while editorial board members from low- and middle-income countries are severely underrepresented. The United States is the most represented country on the editorial boards of leading spine journals.

A finite element study on posterior short segment fixation combined with unilateral fixation using pedicle screws for stable thoracolumbar fracture.

The objective of this study was to use finite element models to investigate the biomechanics of stable thoracolumbar burst fracture repair using unilateral short-segment fixation and 4 alternate pedicle screw systems.Four posterior pedicle screw systems were compared for unilateral short-segment fixation using finite element models: intermediate bilateral short pedicle screw fixation, intermediate bilateral long pedicle screw fixation, intermediate unilateral short pedicle screw fixation, and intermediate unilateral long pedicle screw fixation. We compared range of motion (ROM), von Mises stresses on the implants, and stress on the intervertebral discs superior and inferior to the injured vertebra during simulated spinal movements.There were no significant differences in ROM, von Mises stress, or intervertebral disc stress among the 4 intermediate pedicle screw fixation techniques for all spinal movements evaluated. In addition, there were no consolidated trends depicting beneficial differences between the short and long screw models, or between the unilateral and bilateral screw models.ROM, von Mises stress, and intervertebral disc stress are the same across the 4, posterior short-segment fixation techniques evaluated using finite element models. The simplest technique-posterior short segment fixation combined with intermediate unilateral short pedicle screw fixation-is a feasible treatment strategy for stable thoracolumbar fracture.