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Patterson JT, Becerra JA, Duong A, Reddy A, Oakes DA. Drill Bone with Both Hands: Plunge Depth and Accuracy with 4 Bracing Positions. JB JS Open Access 2023; 8:JBJSOA-D-22-00124. [PMID: 36873137 PMCID: PMC9977482 DOI: 10.2106/jbjs.oa.22.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Bone drilling is a critical skill honed during orthopaedic surgical education. How a bone drill is held and operated (bracing position) may influence drilling performance. Methods A prospective study with randomized crossover was conducted to assess the effect of 4 bracing positions on orthopaedic surgical trainee performance in a simulated bone drilling task. Linear mixed effects models considering participant training level, preferred bracing position, height, weight, and drill hole number were used to estimate pairwise and overall comparisons of the effect of each bracing position on 2 primary outcomes of drilling depth and accuracy. Results A total of 42 trainees were screened and 19 were randomized and completed the study. Drill plunge depth with a 1-handed drilling position was significantly greater by pairwise comparison to any of the 3 double handed positions tested: a soft tissue protection sleeve in the other hand (0.41 mm, 95% confidence interval [CI] 0.80-0.03, p = 0.031), a 2-handed position with the contralateral small finger on bone and the thumb on the drill (0.42 mm, 95% CI 0.06-0.79, p = 0.018), and a 2-handed position with the contralateral elbow braced against the table (0.40 mm, 95% CI 0.02-0.78, p = 0.038). No position afforded a significant accuracy advantage (p = 0.227). Interactions of participant height with plunge depth and accuracy as well between drill hole number and plunge depth were observed. Conclusion Orthopaedic surgical educators should discourage trainees from operating a bone drill using only 1 hand to reduce the risk of iatrogenic injury due to drill plunging. Level of Evidence Therapeutic Level II.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jacob A Becerra
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew Duong
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Akhil Reddy
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel A Oakes
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03471-0. [PMID: 36585997 DOI: 10.1007/s00590-022-03471-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023]
Abstract
Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.
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Asano Y, Yamauchi D, Gonoji Y. Evaluation of the positional relationship between femoral arteries and distal screws in the proximal femoral intramedullary nail for preventing iatrogenic vascular injury. Injury 2020; 51:384-388. [PMID: 31668355 DOI: 10.1016/j.injury.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/27/2019] [Accepted: 10/02/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Iatrogenic vascular injury associated with distal screw in the intramedullary nail for femoral trochanteric fracture is a rare but serious complication. This study aimed to investigate the positional relationship between distal screws and superficial (SFA), deep (DFA), and perforating femoral artery (PFA) using computed tomography (CT) angiography and to identify the risk factors of vascular injury. PATIENTS AND METHODS Thirty-eight patients (11 patients who underwent osteosynthesis with proximal femoral intramedullary nail and 27 healthy people) who underwent CT angiography were included. The distance from the great trochanter tip and insertion angle from posterior condylar axis (reference line) of the distal screws were measured, and the presence rates and distances from the femur of each artery within the insertion angle were investigated. RESULTS The distance from the great trochanter tip to the distal screw was 142.5 ± 8.8 mm. The insertion angle from the reference line was 27.3°±15° The measurement points were set at 130, 140, and 150 mm distal from the great trochanter tip, and the assumed insertion angle as 27°±15° Within this angle, the presence rates and distances were 50.8%/34.2 ± 7.0 mm (130 mm), 38.5%/34.3 ± 6.0 mm (140 mm), 30.8%/33.4 ± 6.0 mm (150 mm) in SFA; 12.3%/14.2 ± 3.3 mm (130 mm), 3.1%/13.1 ± 5.9 mm (140 mm), and 0% (150 mm) in DFA; and 0% (130-150 mm) in PFA. The presence rate of DFA increased at the posteromedial area in the thigh, and the distance from the femur became closer. CONCLUSION Within the angle that distal screws were likely to be inserted, the risk of DFA injury was the highest. Therefore, anatomical reduction of the femoral neck anteversion should be performed so that the distal screw will be inserted towards the anteromedial area in the thigh, and great attention should be paid not to over-drill the medial femoral cortex.
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Affiliation(s)
- Yohei Asano
- Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, 7-1, Wadanaka-machi funabashi, Fukui-shi, Fukui, 918-8503, Japan.
| | - Daisuke Yamauchi
- Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, 7-1, Wadanaka-machi funabashi, Fukui-shi, Fukui, 918-8503, Japan.
| | - Yukio Gonoji
- Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, 7-1, Wadanaka-machi funabashi, Fukui-shi, Fukui, 918-8503, Japan.
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Mahmoud SSS, Ahmed B, Hamid K, Milburn S, Baker P. Identification of the medial femoral safe zone for drilling during dynamic hip screw side plate fixation: A CT angiogram tracing of the profunda femoris artery. Injury 2019; 50:720-726. [PMID: 30678872 DOI: 10.1016/j.injury.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/11/2019] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Iatrogenic injury of the Profunda Femoris Artery (PFA) at time of hip fixation surgery can increase morbidity and mortality and prolong the hospital stay. This is an injury that tends to pass unnoticed as a cause of postoperative deterioration despite being frequently reported in the literature. Our study aims to describe the anatomy of the PFA in relation to the medial femoral cortex with specific emphasis on its orientation relative to the position of a sliding hip screw side plate construct. By doing so we are able to present clear guidance to orthopaedic surgeons on how to avoid iatrogenic PFA injury at the time of hip fracture fixation. METHODS Using Computed Tomography Angiographic (CTA) studies, the course of the PFA in relation to the medial femoral cortex was traced in 44 patients (28 males and 16 females) with mean age of 65.6 years. Coronal and axial CT sections were cross-linked to specify the position of the PFA at 1 cm intervals. RESULTS The course of the artery could be divided into three parts relative to a fixed reference point. Proximal and distal parts of the artery were in a safer position in comparison to the middle part of the artery that was found very close to the femoral cortex and along the coronal axis of the femur (mean angle 2.9° from the femoral coronal axis and 13.8 mm from the medial femoral cortex). Using the commercially available side plate constructs, this part of the artery corresponded to the distal part of the plate (third and fourth holes). CONCLUSION Special attention needs to be practiced by the operating surgeon while drilling into the third and fourth holes of the side plate.
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Affiliation(s)
- Samer S S Mahmoud
- MB BCh, MRCS, MSc, SICOT Dip, Specialty registrar of trauma and Orthopaedics, Health Education No rth East, United Kingdom.
| | - Bessam Ahmed
- Specialty registrar of trauma and Orthopaedics, Health Education North East, United Kingdom
| | - Khalid Hamid
- MRCS Edinburgh, Clinical Fellow in general surgery, Queen Elizabeth Hospital, Gateshead, United Kingdom
| | - Simon Milburn
- Consultant radiologist, South Tees Hospital NHS Foundation Trust, United Kingdom
| | - Paul Baker
- DipStat PGCert(Clin Res) FRCS(Trauma and Orthopaedics), Consultant Orthopaedic Surgeon, South Tees Hospitals NHS Foundation Trust, Clinical Research University of York, United Kingdom
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Lee PYF, Rao PVR, Golding DM, Brock J. Delayed Profunda Femoris Artery Bleeding After Intramedullary Nailing of an Unstable Intertrochanteric Fracture: A Case Report. JBJS Case Connect 2018; 7:e60. [PMID: 29252889 DOI: 10.2106/jbjs.cc.16.00217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 75-year-old man underwent intramedullary nailing for an unstable intertrochanteric fracture of the left hip. After surgery and postoperative recovery, he was transferred to a rehabilitation ward. He was able to mobilize at 2 days postoperatively; at 2 weeks postoperatively, he developed the sudden onset of tachycardia, hypotension, and a large hematoma on the left thigh. Following immediate resuscitation, a computed tomography (CT) angiogram demonstrated a bleed from a branch of the profunda femoris artery. The 3-dimensional CT reconstruction implicated the displaced lesser trochanter osseous fragment as the cause of the hemorrhage. CONCLUSION Surgeons should be aware of this rare complication and the possible etiology of fracture displacement as the cause of a delayed-onset bleed after intramedullary nailing, and they should also be cognizant of the subsequent optimal management.
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Affiliation(s)
- Paul Y F Lee
- South Wales Orthopaedic Research Network, Cardiff, South Wales, United Kingdom
| | - Pathi V R Rao
- Princess of Wales Hospital, Bridgend, South Wales, United Kingdom
| | - David M Golding
- South Wales Orthopaedic Research Network, Cardiff, South Wales, United Kingdom
| | - James Brock
- South Wales Orthopaedic Research Network, Cardiff, South Wales, United Kingdom
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Hanson CG, Hanson LF. Non-invasive repair of an iatrogenic tibial artery branch pseudoaneurysm after intramedullary nailing. J Clin Orthop Trauma 2017; 8:S49-S51. [PMID: 29158648 PMCID: PMC5681231 DOI: 10.1016/j.jcot.2017.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022] Open
Abstract
Tibial fractures are a commonly seen injury in orthopedic surgery. Intramedullary nailing is considered the standard of care, as complications are rare. Those of a vascular nature, including iatrogenically induced pseudoaneurysms of the tibial artery have been previously described in the literature, however each reported case has required surgical repair. In the current case, we describe a repair of a tibial artery branch pseudoaneurysm, after direct contact with an interlocking screw from tibial intramedullary nailing, via ultrasound-guided thrombin injection. To the authors' knowledge, this is the first reported case of a tibial artery pseudoaneurysm repaired non-surgically. This adds support to the promising literature on non-invasive repair of orthopedically related pseudoaneurysms.
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Affiliation(s)
- Cameron G. Hanson
- College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO 64106, United States
| | - Logan F. Hanson
- Department of Orthopaedic Surgery, Beaumont Health, Farmington Hills, MI 48336, United States
- Department of Orthopaedics & Sports Medicine, Methodist Hospital & Physicians, Indiana University Health, Indianapolis, IN 46202, United States
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Mavrogenis AF, Panagopoulos GN, Megaloikonomos PD, Igoumenou VG, Galanopoulos I, Vottis CT, Karabinas P, Koulouvaris P, Kontogeorgakos VA, Vlamis J, Papagelopoulos PJ. Complications After Hip Nailing for Fractures. Orthopedics 2016; 39:e108-16. [PMID: 26726984 DOI: 10.3928/01477447-20151222-11] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/15/2015] [Indexed: 02/03/2023]
Abstract
Pertrochanteric fractures in elderly patients represent a major health issue. The available surgical options are fixation with extramedullary devices, intramedullary nailing, and arthroplasty. Intramedullary nailing for hip fractures has become more popular in recent years. Advantages of intramedullary nailing for hip fracture fixation include a more efficient load transfer due to the proximity of the implant to the medial calcar, less implant strain and shorter lever arm because of its closer positioning to the mechanical axis of the femur, significantly less soft tissue disruption and periosteal stripping of the femoral cortex, shorter operative time and hospital stay, fewer blood transfusions, better postoperative walking ability, and lower rates of leg-length discrepancy. Compromise of the posteromedial cortex and/or the lateral cortex, a subtrochanteric extension of the fracture, and a reversed obliquity fracture pattern represent signs of fracture instability, warranting the use of intramedullary nailing. However, the use of intramedullary nailing, with its unique set of clinical implications, has introduced a new set of complications. The reported complications include malalignment, cutout, infection, false drilling, wrong lag screw length and drill bit breakage during the interlocking procedure, external or internal malrotation (≥20°) of the femoral diaphysis, elongation of the femur (2 cm), impaired bone healing, periprosthetic fracture distal to the tip of the nail, fracture collapse, implant failure, lag screw intrapelvic migration, neurovascular injury, secondary varus deviation, complications after implant removal, trochanteric pain, and refracture. Many of these complications are related to technical mistakes. This article reviews intramedullary nailing for the treatment of pertrochanteric femoral fractures, with an emphasis on complications.
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Potenza V, Saputo U, Catellani F, Farsetti P, Caterini R. Laceration of a branch of the profunda femoris artery caused by a spike of the displaced lesser trochanter in an inter-trochanteric femoral fracture. A case report. Int J Surg Case Rep 2016; 24:195-8. [PMID: 27266840 PMCID: PMC4906138 DOI: 10.1016/j.ijscr.2016.05.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/26/2016] [Accepted: 05/27/2016] [Indexed: 11/06/2022] Open
Abstract
Injury of the femoral artery is a rare complication in intertrochanteric fractures. Avulsed lesser trochanter is at risk for femoral vessel injuries. Acute bleeding may cause rapid decrease in the haemoglobin. Meticolous clinical and laboratory monitoring pre- and post-operatively are recommended.
Introduction Injury of femoral vessels is an extremely rare complication in intertrochanteric femoral fractures. In most cases reported, the vascular lesion involves the superficial femoral artery, whereas in very few cases does it involve the profunda femoris artery. Presentation of case: We report a case of acute bleeding due to laceration of a perforating branch of the profunda femoris artery caused by a sharp fragment of the displaced lesser trochanter in an intertrochanteric femoral fracture; the lesion was treated by transcatheter embolization. Discussion The arterial injury may be iatrogenic, occurring during intramedullary internal fixation, or less frequently, the injury may be due to the fracture itself, caused by a sharp bone fragment that damages the profunda femoris artery or one of its perforating branches. Conclusion We believe that intertrochanteric femoral fractures with avulsed lesser trochanter are at risk for femoral vessel injuries caused by the displaced bone spike, and we advise meticulous clinical and laboratory monitoring pre- and post-operatively to prevent serious complications.
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Affiliation(s)
- Vito Potenza
- Department of Orthopaedic Surgery, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy.
| | - Ubaldo Saputo
- Department of Anesthesiology, San Giovanni Addolorata Hospital, Via dell'Amba Aradam 9, 00184 Rome, Italy
| | - Francesco Catellani
- Department of Orthopaedic Surgery, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy.
| | - Pasquale Farsetti
- Department of Orthopaedic Surgery, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Roberto Caterini
- Department of Orthopaedic Surgery, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
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Late laceration of the superficial femoral artery by an intertrochanteric fracture fragment. Hip Int 2016; 21:273-5. [PMID: 21484750 DOI: 10.5301/hip.2011.6512] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2011] [Indexed: 02/04/2023]
Abstract
Injury to the femoral vessels is a rare complication after intertrochanteric fractures, and usually involves the profunda femoris artery. We report the case of a 79-year-old male with an intertrochanteric fracture, treated by closed antegrade intramedullary nailing, which was complicated by late injury to the superficial femoral artery 5 weeks after surgery. The injury was caused by a spike of bone from the anteriorly displaced lesser trochanter fragment. Direct suture of the injured artery was possible without subsequent complications.
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Osagie L, Gallivan S, Pearse Y. Profunda femoris injury following lesser trochanter displacement: complications following intramedullary femoral nailing. Injury 2015; 46:411-3. [PMID: 25458057 DOI: 10.1016/j.injury.2014.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/29/2014] [Indexed: 02/02/2023]
Abstract
Iatrogenic vascular complications following intramedullary nailing of hip fractures is a rare occurrence. We describe a case report of injury to the profunda femoris artery due to a displaced lesser trochanteric fragment following ambulation. We discuss the mechanism of arterial injury and associated signs in addition to possible preventative strategies.
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Affiliation(s)
- Liza Osagie
- Department of Trauma and Orthopaedics, St George's Hospital, London, United Kingdom.
| | - Samantha Gallivan
- Department of Trauma and Orthopaedics, St George's Hospital, London, United Kingdom
| | - Yemi Pearse
- Department of Trauma and Orthopaedics, St George's Hospital, London, United Kingdom
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