The outcome of patients sustaining a proximal femur fracture who suffer from alcohol dependency

There are many negative health consequences associated with alcohol dependency. Fractures of the proximal femur carry significant morbidity and mortality. This study examines the outcomes in patients with alcohol dependency, who sustain a fracture of the proximal femur. Twenty-eight consecutive alcohol dependent patients who suffered a fracture of the proximal femur were identified over a three year period. Data were collected on demographics, co-morbidity, surgical factors, mobility and mortality. The median age of patients was 61 years. The median weekly alcohol intake was 158 units. Thirteen patients sustained an extra-capsular fracture and 15 an intra-capsular proximal femoral fracture. Twenty-two fractures were treated with internal fixation and six with arthroplasty. The overall mortality rate was 29% at a median of 15 months post fracture. The failure rate of intra-capsular fractures fixed with cannulated screws was 56% at a median time of 43 days. All patients had a reduction in mobility compared to their pre-operative function. The reduction in mobility was greatest in patients with intra-capsular fractures treated with cannulated screw fixation. Alcohol dependent patients sustaining a fracture of the proximal femur are significantly younger than non-alcohol dependent patients sustaining the same injury. Despite the younger age at presentation the one year mortality rate of this group was high (29%). The high rate of complications with fracture fixation and high one year mortality suggest that hemiarthroplasty may be the best treatment option for intra-capsular fractures in this patient group.

Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases

INTRODUCTION

Intramedullary fixation of displaced surgical neck fractures of the humerus can be performed either by retrograde pinning or anterograde nailing. The goal of the current study was to compare the postoperative reduction and stability obtained with these two techniques.

HYPOTHESIS

Intramedullary nailing will provide the best reduction and stabilization of these fractures.

PATIENTS AND METHODS

This was a multicenter retrospective study that included patients with sub-tuberosity fractures with or without greater tuberosity fragment. These patients were treated either by retrograde Hackethal type pinning (group 1) or Telegraph anterograde nailing (group 2). To be included, patients needed to have A/P and lateral X-rays that had been taken before the surgery, immediately post-operative, between four and six weeks post-operative, and at the last follow-up. The outcomes were head angulation, translation and greater tuberosity position.

RESULTS

One hundred and five patients (40 retrograde pinning and 65 anterograde nailing) with an average age of 69 years (18-97 years) were included. The pre-operative fracture displacement was similar between the two groups. After the surgery, the A/P head angulation had been corrected in 72.5% of patients in group 1 and 84% in group 2 (no significant difference). Translation was still present in 17.5% of patients in group 1 and 1.5% in group 2 (P<0.05). At the last follow-up, union was achieved without residual angulation on lateral X-rays in 71% of patients in group 1 and 88% in group 2 (P<0.05). The fractures had healed with residual translation is 19.5% of patients in group 1 and 3% in group 2 (P<0.05).

DISCUSSION AND CONCLUSION

In cases of displaced surgical neck fractures with or without a greater tuberosity fragment, anterograde nailing provides better reduction and stability than retrograde pinning. However, fixation of the greater tuberosity fragment must be improved.

LEVEL OF EVIDENCE

IV (retrospective comparative study).

Surgical management for avulsion fracture of the calcaneal tuberosity

OBJECTIVE

To discuss the operative methods and curative effect of calcaneal tuberosity fracture.

METHODS

A retrospective study was done to analyze 15 patients with calcaneal tuberosity fracture who received surgical management between January 2008 and June 2011. There were nine males and six females, with the age ranging from 31 to 68 years (average, 51.4 years). All the patients had unilateral acute injury, with the left foot in 7 cases and the right foot in 8 cases. According to the Beavis classification, there were three cases in type I and 12 cases in type II. All the cases in type I and 10 cases in type II were treated with open reduction and screw fixation. The other two cases in type II with larger fragment involving a portion of the subtalar joint were treated with plate and screw fixation. The effect of the treatment was assessed according to the ankle and hindfoot score system of American Orthopaedic Foot and Ankle Society (AOFAS) after the operation.

RESULTS

Ten patients were followed up for 12 to 36 months (average, 20 months). The healing time in these patients ranged from 8 to 25 weeks (average, 12 weeks). The postoperative score ranged from 47 to 100 points (average, 91.1 points). Seven cases were rated as excellent, two as good, and one as poor. The rate of excellent and good was 90%. Necrosis of skin and soft tissue and exposure of the plate happened in one patient, who eventually healed after 3 weeks by debridement with plate preserved and peroneal artery perforator flap transplantation. Loss of reduction happened to another patient, who was treated with revision surgery by open reduction and screw fixation again.

CONCLUSION

To patients with obvious fracture displacement, whose soft tissues are irritated severely, emergency open reduction and internal fixation operation should be offered to prevent the necrosis of the flaps as far as possible. To patients with small fractures, it is advisable to choose open reduction and large diameter screw fixation, while plate and screw fixation may be better for the patients with large fragments, especially for those with the fracture line extending to the subtalar joint.

A retrospective cohort investigation of active range of motion within one week of open reduction and internal fixation of distal radius fractures

Distal radius fractures stabilized by open reduction internal fixation (ORIF) have become increasingly common. There is currently no consensus on the optimal time to commence range of motion (ROM) exercises post-ORIF. A retrospective cohort review was conducted over a five-year period to compare wrist and forearm range of motion outcomes and number of therapy sessions between patients who commenced active ROM exercises within the first seven days and from day eight onward following ORIF of distal radius fractures. One hundred and twenty-one patient cases were identified. Clinical data, active ROM at initial and discharge therapy assessments, fracture type, surgical approaches, and number of therapy sessions attended were recorded. One hundred and seven (88.4%) cases had complete datasets. The early active ROM group (n = 37) commenced ROM a mean (SD) of 4.27 (1.8) days post-ORIF. The comparator group (n = 70) commenced ROM exercises 24.3 (13.6) days post-ORIF. No significant differences were identified between groups in ROM at initial or discharge assessments, or therapy sessions attended. The results from this study indicate that patients who commenced active ROM exercises an average of 24 days after surgery achieved comparable ROM outcomes with similar number of therapy sessions to those who commenced ROM exercises within the first week.

LEVEL OF EVIDENCE

2B, retrospective cohort.

Osteotomy and fracture fixation in children and teenagers

Significant changes have occurred recently in fixation methods following fracture or osteotomy in children and teenagers. Children have benefited the most from these advances. A child's growth is anatomically and physiologically ensured by the growth plate and periosteum. The need to keep the periosteum intact during trauma cases has led to the introduction of flexible intramedullary nailing. We will review the basic principles of this safe, universally adopted technique, and also describe available material, length and diameter options. The problems and the limitations of this method will be discussed extensively. In orthopedics, the desire to preserve the periosteum has led to the use of locking compression plates. Because of their low profile and high stability, they allow the micromovements essential for bone union. These new methods reduce the immobilization period and allow autonomy to be regained more quickly, which is especially important in children with neurological impairment. The need to preserve the growth plate, which is well known in pediatric surgery, is reviewed with the goal of summarizing current experimental data on standard fracture and osteotomy fixation methods. Adjustable block stop wires provide better control over compression. These provide an alternate means of fixation between K-wires and screws (now cannulated) and have contributed to the development of minimally invasive surgical techniques. The aim of this lecture is to provide a rationale for the distinct technical features of pediatric surgery, while emphasizing the close relationship between the physiology of growth, bone healing and technical advances.

Complications related to fracture treatment in HIV patients: a case report

We present the case report of a 40-year-old woman who was HIV-positive in Highly Active Anti-Retroviral Therapy (HAART) and affected by femural pertrochanteric fracture, which was treated by endomedullary nailing. Two years after the surgical operation, the woman developed an aseptic symptomatic osteolysis around the implant. Hardware removal was resolutive. Aseptic and septic hardware mobilization, hardware removal, and implant decision in HIV patients with pertrochanteric fractures is discussed. The authors suggest close follow-up and prompt hardware removal, as soon as X-rays demonstrate healing signs, in HIV patients with fracture fixation, if general condition allows.

Open reduction and internal fixation of mandibular fracture in an 11-month-old infant: a case report

Mandibular fractures in infants are rare. This case report describes management of a mandibular fracture in an 11-month-old infant using a microplate and screws with open reduction. The surgical treatment was successful. Because the bone fragments were displaced and only the primary incisors had erupted, conservative treatment, such as an acrylic splint and circummandibular wiring, was not recommended. Nine weeks after surgery, the microplate was removed. The results showed complete clinical and radiological bone healing with normal eruption of deciduous teeth.

Comprehension and reproducibility of the Judet and Letournel classification

OBJECTIVE

To evaluate the effectiveness of the method of radiographic interpretation of acetabular fractures, according to the classification of Judet and Letournel, used by a group of residents of Orthopedics at a university hospital.

METHODS

We selected ten orthopedic residents, who were divided into two groups; one group received training in a methodology for the classification of acetabular fractures, which involves transposing the radiographic images to a graphic two-dimensional representation. We classified fifty cases of acetabular fracture on two separate occasions, and determined the intraobserver and interobserver agreement.

RESULT

The success rate was 16.2% (10-26%) for the trained group and 22.8% (10-36%) for the untrained group. The mean kappa coefficients for interobserver and intraobserver agreement in the trained group were 0.08 and 0.12, respectively, and for the untrained group, 0.14 and 0.29.

CONCLUSION

Training in the method of radiographic interpretation of acetabular fractures was not effective for assisting in the classification of acetabular fractures. Level of evidence I, Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing: 29 patients' clinical and functional evaluation

Objective

To evaluate clinically and functionally the pos-operative results of patients submitted to tibiotalocalcaneal arthrodesis for the treatment of traumatic arthropathy and neuropathy.

Methods

Retrospective study of 29 patients undergoing ankle arthrodesis with intramedullary retrograde nail. All patients were evaluated for fusion time, AOFAS and VAS scores, satisfaction, and complications of surgery. The mean follow-up was 36 months (range 6–60 months).

Results

The union rate was 82%, and the consolidation occurred on average at 16 weeks (10–24 weeks). The pos-operative AOFAS score improved in 65.5% (average of 57.7 on neurological cases and 75.7 on cases pos-traumatic) and VAS score improved 94.1% (average of 2.3 on neurological cases and 4,2 on post-traumatic cases), and 86% of patients were satisfied with the procedure performed. Complications occurred in 11 patients (38%), including pseudoarthrosis (17.24%), infection (17.24%), material failure (13.8%) and fracture (13.8%).

Conclusion

Tibiotalocalcaneal arthrodesis with retrograde intramedullary nail proved to be a good option for saving the ankle joint, with improvement of clinical and functional scores (AOFAS = 65.5% and VAS = 94.1%).

Primary stability of an intramedullary calcaneal nail and an angular stable calcaneal plate in a biomechanical testing model of intraarticular calcaneal fracture

BACKGROUND

Nowadays, open anatomic reduction and internal fixation can be considered as a valuable treatment for displaced intra-articular fractures of the calcaneus. However, the application of a calcaneal plate via an extensile lateral approach is at risk for a substantial rate of complications including delayed healing, skin necrosis, or infection. There is some evidence that a limited exposure might contribute to a decreased soft tissue complication rate bearing in mind that most minimally invasive techniques have to accept a reduced primary stability compared with the open application of an angular stable plate. Recently, an intrafocal minimal invasive reduction technique has been established employing an intramedullary nail for fracture stabilisation and support of the subtalar joint. The aim of this study was to compare the primary biomechanical performance of the new device versus lateral angular stable plating.

MATERIAL AND METHODS

Biomechanical testings were performed on 14 human cadaveric feet (7 pairs). Dry calcaneal bones were fractured resulting in a Sanders type IIB fracture pattern and fixed by either a calcaneal locking plate or an intramedullary calcaneal nail. Compressive testing via the corresponding talus was employed at a constant loading velocity until failure with an universal testing machine and a specific mounting device to avoid any shear forces. Apart from the data of the load deformation diagram the relative motion of the fracture elements during loading was recorded by 8 extensometric transducers. After failure the specimens were carefully examined to check the failure patterns.

RESULTS

The displacement of the subtalar joint fragment was substantially lower in specimens fixed with the nail. Stiffness and load to failure were significantly higher after fixation with the intramedullary nail than after application of the angular stable plate. Failure with both fixation modes generally occurred at the anterior calcaneal process fragment.

CONCLUSIONS

The primary stability of an intramedullary nail appeared to be superior to an angular stable plate representing the present standard technique in open reconstruction of the fractured calcaneus. The results from the experimental model speak in favour of the clinical use of the intramedullary calcaneal nail.

Surgical treatment of clavicular fractures in Finland - A register based study between 1987 and 2010

BACKGROUND

Clavicle fractures are among the most common upper extremity injuries. Traditionally most clavicle fractures have been treated non-surgically, but during recent decades the surgical treatment of clavicle fractures has increased. The purpose of this study was to assess the numbers and trends of surgically treated clavicle fractures in Finland between 1987 and 2010.

METHODS

The study covered the entire adult (>18 years) population of Finland over the study period. Data on surgically treated clavicle fractures was collected from the Finnish National Hospital Discharge Register. We assessed the number and incidence of surgically treated clavicle fractures annually.

RESULTS

A total of 7073 surgically treated clavicle fractures were identified in the register over the study period. Three-fourths of the surgically treated patients were men and one-fourth was women. The incidence of surgical treatment increased nearly ninefold from 1.3 per 100,000 person years in 1987 to 10.8 per 100,000 person years in 2010. The increase in the rate of surgical treatment was especially notable in men.

CONCLUSIONS

A striking increase in incidence of surgically treated clavicle fractures was seen from 1987 to 2010. Although the actual incidence of clavicle fractures is not known, we assume that the proportion of patients receiving surgical treatment has increased markedly without high-quality evidence. Since recent reports have suggested similar functional results between operative and conservative treatment critical evaluation of the treatment policy of clavicle fractures is warranted.

Plating of metacarpal fractures with locked or nonlocked screws, a biomechanical study: how many cortices are really necessary?

BACKGROUND

Dorsal plate and screw fixation is a popular choice for metacarpal stabilization. The balance between construct stability and soft tissue dissection remains a surgical dilemma. Historically, six cortices of bone fixation on either side of a fracture were deemed necessary. This study aims to elucidate whether four cortices of locked fixation on either side of the fracture is equivalent to the current gold standard of six cortices of nonlocked fixation on either side of the fracture. If so, less dissection to insert shorter plates with fewer screws could be used to stably fix these fractures.

METHODS

With biomechanical testing-grade composite Sawbones, a comminuted metacarpal fracture model was used to test two fixation constructs consisting of a standard dorsal plate and either six bicortical nonlocking screws (three screws per segment) or four bicortical locking screws (two screws per segment). Thirty specimens were tested to failure in cantilever bending and torsion.

RESULTS

There was statistical equivalence between the locking and nonlocking constructs in cantilever bending stiffness, torsional stiffness, maximum bending load, and maximum torque.

CONCLUSION

The tested metacarpal fracture model had equivalent biomechanical properties when fixed with a standard dorsal plate and either six bicortical nonlocking screws or four bicortical locking screws. By utilizing fewer cortices of fixation, there will be less dissection and less soft tissue stripping during fixation of metacarpal fractures. This will also be of benefit in very proximal or distal fractures as multiple cortices of fixation are often difficult to obtain during stabilization of these challenging fractures.

Treatment of pediatric open femoral fractures with external fixator versus flexible intramedullary nails

BACKGROUND

In children, inappropriate treatment of open femoral fractures may induce several complications. A few studies have compared the external fixator with flexible intramedullary nails in high-grade open femoral fractures of children. The present study aims at comparing results of these two treatment methods in open femoral fractures.

METHODS

In this descriptive analytical study, 27 patients with open femoral fractures, who were treated using either the external fixator (n=14) or TEN nails (n=13) method from 2006-2011, were studied. Some patients were treated with a combination method of TEN and pin. The results were evaluated considering infection, union, malunion, and refracture and the patients were followed up for two years.

RESULTSS

Mean time required for fracture union was 3.89 (range: 2-5.8) and 3.61 (range: 2-5.6) months for the external fixator and TEN groups, respectively. The difference was not statistically significant and there was not any significant difference between the two groups considering infection of the fractured area. Osteomyelitis was not observed in any group. There was an infection surrounding the external fixator pin in 4 cases (28.5%) and so this required changing the location of the pin. In the TEN group, one case (7.6%) of painful bursitis was observed at the entry point of TEN and so the pin was removed earlier than usual. There were two cases (14.2%) of femoral refracture in the external fixator group. Malunion requiring correction was not observed in any of the groups. There were no complications observed in five patients treated with a combined method of pin and flexible intramedullary nails.

CONCLUSION

Both external fixator and intramedullary nail methods are effective ways in treating high grade open femoral fractures in children and final treatment results are similar. Combining pins and flexible intramedullary nails is effective in developing more stability and is not associated with more complications.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study

BACKGROUND

Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach.

PATIENTS AND METHODS

All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score.

RESULTS

Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach.

CONCLUSION

This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

Sacroiliac secure corridor: analysis for safe insertion of iliosacral screws

Objective

Posterior pelvic lesions, especially of the sacral-iliac joint, have high mortality and morbidity risks. Definitive fixation is necessary for the joint stabilization, and one option is the sacral percutaneous pinning with screws. Proximity to important structures to this region brings risks to the fixation procedure; therefore, it is important to know the tridimensional anatomy of the pelvis posterior region. Deviations of the surgeon's hand of four degrees may target the screws to those structures; dimorphisms of the upper sacrum and a poor lesion reduction may redound in a screw malpositioning. This study is aimed to evaluate the dimensions of a safe surgical corridor for safe sacroiliac screw insertion and relations with age and sex of the patients.

Method

One hundred randomly selected pelvis CTs of patients with no pelvic diseases, seen at a tertiary care teaching Hospital. Measurements were made by computer and the safest area for screw insertion was calculated by two methods. The results were expressed in mm (not in degrees), in order to be a further surgical reference.

Results

There was a significant size difference in the analyzed sacral vertebra, differing on a wider size in men than in women. There was no significant statistical difference between vertebral size and age. By both methods, a safe area for screw insertion could be defined.

Conclusion

Age does not influence the width of the surgical corridor. The surgeon has a safe corridor considered narrower when inserting screws in a female pelvis than when in a male one. However, as the smallest vertebra found (feminine) was considered for statics, it was concluded that this corridor is 20 mm wide in any direction, taking as a reference the centrum of the vertebra.

Delayed pharyngeal extrusion of an anterior odontoid screw

A 27-year-old woman with a type II odontoid fracture was treated by anterior odontoid screw fixation. Radiographic union at the fracture site was obtained 3 months after surgery. Nearly 3 years after surgery, she presented at a local Ear, Nose, and Throat (ENT) clinic with a 2-month history of dysphagia. Laryngoscopy identified the head of the odontoid lag screw. Plain radiography showed that the head of the screw had migrated into the pharyngeal soft tissue. The atlantoaxial joint was stable, and computed tomography (CT) scans confirmed odontoid fracture fusion. The screw was found to be movable during endoscopy. The screw could be removed by using a transpharyngeal endoscopic approach under general anesthesia. The failure of the screw was considered to be due in part to malpositioning of the screw and in part to local infection. A transoropharyngeal endoscopic approach to remove the loose anterior odontoid screw was feasible.

Surgical management of a mandible subcondylar fracture

Open reduction and anatomic reduction can create better function for the temporomandibular joint, compared with closed treatment in mandible fracture surgery. Therefore, the double miniplate fixation technique via mini-retromandibular incision was used in order to make the most stable fixation when performing subcondylar fracture surgery. Those approaches provide good visualization of the subcondyle from the posterior edge of the ramus, allow the surgeon to work perpendicularly to the fracture, and enable direct fracture management. Understanding the biomechanical load in the fixation of subcondylar fractures is also necessary in order to optimize fixation methods. Therefore, we measured the biomechanical loads of four different plate fixation techniques in the experimental model regarding mandibular subcondylar fractures. It was found that the loads measured in the two-plate fixation group with one dynamic compression plate (DCP) and one adaption plate showed the highest deformation and failure loads among the four fixation groups. The loads measured in the one DCP plate fixation group showed higher deformation and failure loads than the loads measured in the two adaption plate fixation group. Therefore, we conclude that the selection of the high profile plate (DCP) is also important in order to create a stable load in the subcondylar fracture.

Fracture fixation with two locking screws versus three non-locking screws: A biomechanical comparison in a normal and an osteoporotic bone model

Objectives

We aimed to further evaluate the biomechanical characteristics of two locking screws versus three standard bicortical screws in synthetic models of normal and osteoporotic bone.

Methods

Synthetic tubular bone models representing normal bone density and osteoporotic bone density were used. Artificial fracture gaps of 1 cm were created in each specimen before fixation with one of two constructs: 1) two locking screws using a five-hole locking compression plate (LCP) plate; or 2) three non-locking screws with a seven-hole LCP plate across each side of the fracture gap. The stiffness, maximum displacement, mode of failure and number of cycles to failure were recorded under progressive cyclic torsional and eccentric axial loading.

Results

Locking plates in normal bone survived 10% fewer cycles to failure during cyclic axial loading, but there was no significant difference in maximum displacement or failure load. Locking plates in osteoporotic bone showed less displacement (p = 0.02), but no significant difference in number of cycles to failure or failure load during cyclic axial loading (p = 0.46 and p = 0.25, respectively). Locking plates in normal bone had lower stiffness and torque during torsion testing (both p = 0.03), but there was no significant difference in rotation (angular displacement) (p = 0.84). Locking plates in osteoporotic bone showed lower torque and rotation (p = 0.008), but there was no significant difference in stiffness during torsion testing (p = 0.69).

Conclusions

The mechanical performance of locking plate constructs, using only two screws, is comparable to three non-locking screw constructs in osteoporotic bone. Normal bone loaded with either an axial or torsional moment showed slightly better performance with the non-locking construct.

Functional outcome following intramedullary nailing or plate and screw fixation of paediatric diaphyseal forearm fractures: a systematic review

PURPOSE

Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome.

METHODS

A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures.

RESULTS

Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment.

CONCLUSIONS

The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.

Progression of a fracture site impaction as a prognostic indicator of impacted femoral neck fracture treated with multiple pinning

BACKGROUND

We evaluated the clinical and radiologic results of impacted femoral neck fractures treated with multiple pinning and determined the influence of the progression of impaction at the fracture site on clinical outcome.

METHODS

There were 34 patients with a mean age of 65.5 years. The mean follow-up period was 3.4 years. Progression of fracture site impaction was measured using an articulo-trochanteric distance index and the percentage decrease in the articulo-trochanteric distance index between follow-up intervals. The failure of treatment was clarified as non-union and avascular necrosis. Other characteristics of the patients, including mean waiting time for surgery, preoperative Singh index score, and body mass index, were also measured to evaluate the influence on the clinical outcome of surgery.

RESULTS

There were 6 fractures which were not treated successfully (3 non-union, 8.8% and 3 avascular necrosis, 8.8%). The mean percentage decrease of the articulo-trochanteric distance index within the first 6 weeks after surgery was 4.5% in the successful group and 25.1% in the failure group (p < 0.001). There was also a significant mean percentage decrease in the articulo-trochanteric distance index between 6 weeks and 3 months (p < 0.001).

CONCLUSIONS

Primary stabilization with Knowles pins for impacted femoral neck fractures had a reasonable clinical outcome with low morbidity. Despite a significant difference of a mean percentage decrease in the articulo-trochanteric distance index between the successful group and the failure group, we could not verify it as a risk factor for failure of treatment because the odds ratio was not statistically significant.

Delayed treatment of zygomatic tetrapod fracture

Since maxillofacial injury is frequently accompanied by other diseases, its evaluation and treatment are open delayed. When the evaluation is delayed, the surgical treatment can be difficult or impossible. A 21-yr-old man presented with right facial swelling and deformity after injury. We planned immediate surgical repair for his right tetrapod fracture, but the operation was delayed for two months due to severe hyperthyroidism. During the operation, we reducted and fixed the deviated bone after refracture of the zygomatic arch with an osteotome to achieve mobility. The facial deformity and difficulty in mouth opening were improved after the operation. Even in the presence of accompanying fractures, early evaluation and proper management can prevent complications and achieve acceptable cosmetic outcomes in maxillofacial trauma patients. In patients with malunion of fracture sites, fixation after refracture using an osteotome can be a good treatment option for obtaining good mobility.

STUDY OF THE TREATMENT OF FEMORAL HEAD FRACTURES

OBJECTIVE

To establish guidelines for the treatment of femoral head fractures and to determine the best form of access in cases treated surgically.

METHODS

We evaluated the clinical and radiological results from 13 patients (13 fractures) treated surgically, between May 1986 and July 1996, at the Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de Sao Paulo (SCMSP), Fernandinho Simonsen Wing.

RESULTS

Out of six cases of Pipkin 1 fractures, five underwent resection of the fragment, resulting in four excellent and one good result. The good result had fixation of the fragment. Three patients presented Pipkin 2 fractures and all of them had fixation of the fragment, resulting in two excellent and one regular result. Two patients had Pipkin 3 fractures and underwent primary arthroplasty. Among the two patients with Pipkin 4 lesions, one was treated with reduction and osteosynthesis of the acetabular fracture, without addressing the head fragment, which had reduced significantly, resulting in early arthrosis; and the other patient was treated with total arthroplasty as the primary treatment.

CONCLUSION

Upon comparing the literature review and our patients' treatment results, we concluded that femoral head fracture treatment needs to be surgical and that the choice of surgical access depends on the type of fracture.

LOCALIZATION OF THE TIBIAL ENTRY POINT

Objective: To assess the intramedullary nail entry point in the proximal region of the tibia, through a questionnaire. Methods: 230 participants undergoing treatment for tibial fractures were interviewed. The questionnaire was created with three sections that could be answered in a ”Yes” or “No” format and a fourth section that had two figures representing anteroposterior (AP) and lateral view x-rays that could be answered in an “A, “B” or “C” format. Results: The most frequent reason was “ease of access” (67.8%), followed by “better nail insertion access” (60.9%) and, in third place, “to prevent knee pain” (27.4%). The reasons for choosing the access so as to “prevent knee pain” and “avoid tendinitis” had a significant relationship with points “A” and “C” of the schematic AP x-ray figure, especially “C” (medial tibial crest). There were no significant differences between the types of access to the patellar ligament in the schematic AP and lateral x-ray figures between age groups. Conclusion: The greater the age was, the larger the proportion choosing the question “to avoid valgus deformity” was. The reasons from a medical (practical) perspective related to the type of access in the transpatellar ligament, while the reasons from a patient (functional) perspective related to medial parapatellar access. Transpatellar access was chosen by most of the participants (66.5%).

UPPER LIMB TRACTION DEVICE FOR ANTEROGRADE INTRAMEDULLARY LOCKED NAIL OF HUMERAL SHAFT FRACTURES

Diaphyseal fractures of the femur and tibia in adults are mostly treated surgically, usually by means of intramedullary locked-nail osteosynthesis. Some comminuted and/or highly deviated shaft fractures may present a veritable technical challenge. Fracture (or orthopedic) tables, which enable vertical, horizontal and rotational instrumental stabilization of the limb, greatly facilitate reduction and implant placement maneuvers and are widely used by orthopedic surgeons. Humeral shaft fractures are mostly treated nonsurgically. However, some cases with indications that are well defined in the literature require surgical treatment. They can be fixed by means of plates or intramedullary nails, using anterograde or retrograde routes. In the humerus, fracture reduction and limb stabilization maneuvers for implantation of intramedullary nails are done manually, usually by two assistants. Because muscle fatigue may occur, this option may be less efficient. The aim of this paper is to present an external upper-limb traction device for use in anterograde intramedullary locked-nail osteosynthesis of humeral shaft fractures that enables vertical, horizontal and rotational stabilization of the upper limb, in a manner similar to the device used for the lower limbs. The device is portable, of simple construction, and can be installed on any operating table equipped with side rails. It was used for surgical treatment of 29 humeral shaft fractures using an anterograde locked intramedullary nail. Our experience was extremely positive. We did not have any complications relating to its use and we believe that it notably facilitated the surgical procedures.

Surgical treatment of displaced intra-articular calcaneal fracture using a single small lateral approach

The objective of this study was to evaluate the outcome of semi-open reduction and minimal internal fixation through a single small lateral approach as a minimally invasive technique for treatment of displaced intra-articular calcaneal fractures. This prospective study was conducted on eighteen patients (16 men and 2 women). The average age was 37.7 (22-55). The most common cause of injury was a fall from height in fourteen patients. Patients were operated on within a mean time of 4.8 days of admission (1-11 days) and were followed up for an average period of 24.1 months (6-39 months). Patients were evaluated clinically using the Creighton-Nebraska Heath Foundation Assessment score of Crosby and Fitzgibbons (J Bone Joint Surg (Am) 72-A:852-859, 1990). The scoring system proposed by Knirk and Jupiter was used for radiological assessment of the posterior subtalar joint (Knirk and Jupiter in J Bone Joint Surg (Am) 68-A: 647-659, 1986). The skin incision healed in all cases without necrosis, infection, or sural nerve injury. All fractures healed after an average of 8 weeks (7-10 weeks), and patients returned to the routine daily activities after an average time of 4.3 months (3-7 months). In conclusion, semi-open reduction and minimal internal fixation through a small lateral approach is an effective treatment for carefully selected cases of displaced intra-articular calcaneal fractures.