Intertrochanteric femur fractures in the elderly treated with either proximal femur nailing or hemiarthroplasty: A prospective randomised clinical study

INTRODUCTION

The purpose of this prospective randomised study is to compare in the elderly the functional results of intertrochanteric femur fractures treated either with closed reduction and internal fixation with proximal femoral nailing or cemented hemiarthroplasty.

MATERIALS AND METHODS

The study included patients above the age of 75 who were diagnosed with intertrochanteric femur fracture and admitted to the Department of Orthopaedics and Traumatology, Ege University Hospital between October 2006 and December 2012. After informed consent was obtained from the patients, they were randomised via sealed opaque envelops into two groups. Patients in Group 1 were internally fixated utilizing proximal femoral nail, whilst the patients in Group 2 were treated with a cemented hemiarthroplasty. Complications were recorded and functional results were evaluated using the Harris Hip score. The mean time of follow up was 31.72 months (min. 18-max. 47, std. dev. ±10.68).

RESULTS

A total of 54 patients were included in the study. 21 of them (38.9%) received a proximal femoral nail whilst 33 (61.1%) were treated with hemiarthroplasty. Average age of the patients was 82.24 (min. 75-max. 97). Average age in Group 1 was 79.57 (min. 75-max. 91), whilst it was 83.94 in Group 2 (min. 75-max. 97). Harris Hip score analysis revealed that the difference between the patients treated with hemiarthroplasty and proximal femoral nailing was statistically significant in favour of the hemiarthroplasty group within the first 3 months. However, this difference diminished at the 6th month time point, and even reversed as of the 12th month postoperatively.

DISCUSSION AND CONCLUSIONS

Although cases with hemiarthroplasty achieved a better level of activity in the beginning, cases with proximal femoral nailing reached a comparable level of activity within a short period of time, faster than those treated with hemiarthroplasty, displaying a better level of activity in the end.

Influence of number and orientation of screws on stability in the internal fixation of unstable femoral neck fractures

OBJECTIVE

The aim of this study was to biomechanically compare 3 different cannulated screw configurations used in internal fixation of unstable femoral neck fractures.

METHODS

The study included 28 synthetic left femurs randomly divided into 4 equal groups. Samples in the first 3 groups were osteotomized in the basicervical region to create Pauwels Type 3 fractures. Fixation was carried out using cannulated screws. In Group 1, four screws were used including 3 in an inverted triangle configuration in parallel with the neck and the fourth screw transversely into the calcar. In Group 2, three screws were used including 2 in parallel with the neck and the third transversely into the calcar. In Group 3, three screws were used in an inverted triangle configuration in parallel with the neck. No osteotomy or fixation was carried out in Group 4. Load test was performed on all the groups and the strength of the screw fixations against axial load and their amount of relocation were measured.

RESULTS

Average maximum strength was 36.1 ± 3.2 N/mm2 in Group 1, 27.3 ± 4.1 N/mm2 in Group 2 and 21.9 ± 3.2 N/mm2 in Group 3. The average relocation in the line of osteotomy in the moment of average maximum stress (21.9 ± 3.2 N/mm2) was 11.5 ± 2.1 mm in Group 3, 6 ± 1.3 mm in Group 2 and 5.8 ± 1.1 mm in Group 1 (p<0.05). It was also observed that while the relocation in the moment of average maximum stress (27.3 ± 4.1 N/mm2) was 9.1 ± 1.7 mm in Group 2, the deformation under the same stress value was 9 ± 1.7 mm in Group 1 (p>0.05).

CONCLUSION

The use of a transverse screw in the calcar in addition to cannulated screws parallel to the neck appear to provide stability benefit in the treatment of unstable femoral neck fractures.

Evaluation of hemostatic changes using n thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery

The effects of Ringer lactate, 6% hydroxyethyl starch (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% hydroxyethyl starch 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.

Clinical and Radiological Outcomes of Trochanteric AO/OTA 31A2 Fractures: Comparison between Helical Blade and Lag Screw - A Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to compare the clinical and radiological outcomes of AO/OTA type 31A2 fractures treated by the use of trochanteric nails either with a blade or a screw.

PATIENTS AND METHODS

This study was designed retrospectively. Between May 2007 and May 2014, a total of 144 patients with trochanteric fractures were admitted to the clinic, and only 65 of them met the inclusion criteria. Thirty-two of them (blade group) were treated with a helical blade and the rest of the 33 patients (screw group) were treated with a screw. The mean ages of the patients were 76.01 and 75.82, respectively (p = 0.905). The mean follow-up time was 27.6 months (blade group: 34.2 ± 19.1 months; screw group: 18.6 ± 7.9 months; p < 0.001). Between these two groups, we evaluated the differences in tip apex distances (TAD), calcar-referenced tip-apex distances (Cal-TAD), implant positions, cut-out rates, and implant failures. Functional outcomes were measured with the help of the Harris Hip Score.

RESULTS

No significant differences were seen between the blade and screw groups by means of cutting out, implant positions, and varus collapse. Cutting out was seen in a total of six patients (blade group n = 2; screw group = 4; p = 0.672) and varus collapse in nine patients (blade group n = 5, screw group n = 4; p = 0.733). Harris Hip Scores were similar between the two groups (blade group: 72.70 ± 18.43; screw group: 80.83 ± 18.75; p = 0.84).

[The modifed Eden-Lange procedure for paralysis of the trapezius muscle]

Trapezius muscle paralysis results from injury to the spinal accessory nerve. Impairment in the trapezius muscle function may destabilize the muscle resulting in winged scapula. A 25-year-old university student who was active in sports had complaints of shoulder drop and pain on abduction. He had a three-year history of fall resulting in a scapular fracture for which he received conservative treatment. Physical examination showed asymmetry and drop of the right shoulder. Lateral scapular winging was apparent particularly above 90 degrees of abduction. Electromyography revealed isolated paralysis of the trapezius muscle. The patient underwent reconstruction with the modified Eden-Lange procedure. After a two-year follow-up, asymmetry in the shoulder decreased, there was no pain on active abduction, and the patient returned to active sports and was fully satisfied with the outcome.

Management of shotgun induced open fractures of the humerus with Ilizarov external fixator

BACKGROUND

Our aim was to evaluate the clinical efficacy of Ilizarov external fixator used for the management of shotgun induced open humeral fractures with special emphasize on neurovascular sequelae.

METHODS

The authors retrospectively reviewed eleven shotgun induced open humeral fractures managed with emergent application of Ilizarov external fixator. No patient had associated neurovascular injury. All fractures were stabilized with Ilizarov external fixator immediately after meticulous debridement and irrigation under emergent conditions.

RESULTS

With Ilizarov fixation technique complete bony union occurred in all patients within 14 to 44 weeks (average, 21 weeks) postoperatively. One patient required a second intervention in order to adjust the external fixator rings. Two patients required a rotational fasciocutaneous flap so as to handle the soft tissue coverage problem. Superficial pin tract infection was present in eight patients, however in none of the patients deep tissue infection or osteomyelitis has been observed. Good to excellent results were achieved in 10 patients with Ilizarov fixation technique according to the rating system proposed by Smith and Cooney.

CONCLUSION

Emergent Ilizarov external fixation is a safe method of obtaining a functional limb in the management of shotgun induced open humeral fractures with severe soft tissue damage.

Which implant is better for the fixation of posterior wall acetabular fractures: A conventional reconstruction plate or a brand-new calcaneal plate?

BACKGROUND

Increased posterior wall acetabular fractures among older adults, require precise treatment to restore stability to the joint, lower the risk of degenerative arthritis, and enhance overall functional recovery. The purpose of this study was to compare the fixation stability and mechanical characteristics of calcaneal buttress plate and conventional reconstruction plate under different loading condition.

METHODS

Typical acetabular posterior wall fractures were created on twenty synthetic hemipelvis models. They were fixed with calcaneus plate and reconstruction plate. Dynamic and static tests were performed. Displacements of fracture line and stiffness were calculated.

FINDINGS

After dynamic loading, calcaneus plate fixation has significantly less displacement than the reconstruction plate on the superior posterior wall. Under static loading condition, the calcaneus plate group has significantly less displacement than the reconstruction plate group on the inferior posterior part of the fracture. The average stiffness values of the calcaneus plate group and the reconstruction plate group were 265.16±53.98 N/mm and 167.48±36.87 N/mm, respectively and a statistically significant difference was found between the two groups.

INTERPRETATION

The calcaneal plate group demonstrated better stability along the fracture line after dynamic and static loading conditions. Especially when the fragment was on the acetabulum's superior posterior, inferior posterior, and inferior rim, Calcaneal buttress plates offer biomechanically effective choices.

Surgical treatment of displaced radial neck fractures in children with Metaizeau technique

BACKGROUND

The treatment of radial neck fractures in children is difficult when the angular displacement exceeds 30 degrees. The authors report their experience with closed reduction of this fracture and intramedullary pinning which was described and popularized by Metaizeau et al. in 1980.

METHODS

Under general anesthesia and guidance of an image intensifier, a 1 cm incision was made on the radial side of distal radial metaphysis. A Kirschner wire was contoured and then the last 3-5 mm were bent approximately 30 degrees. It was introduced into the medullary canal of the radius and by pushing it proximally until its point reaches the inferior aspect of the epiphysis to elevate and rotate to achieve an anatomic reduction. This technique was used in nine patients between 1996 and 2003.

RESULTS

Full functional recoveries with excellent results were observed in all cases but one at the last follow-up. No complication was encountered.

CONCLUSION

We recommend this closed technique as it is relatively simple and associated with encouraging results.

[Giant cell tumor at the wrist: a review of 23 cases]

OBJECTIVES

We evaluated patients who underwent surgical treatment for giant cell tumor of the wrist with regard to recurrence rates, factors influencing tumor recurrence, complications, and postoperative functional and emotional status of the patients.

METHODS

The study included 23 patients (6 males, 17 females; mean age 31.6 years; range 12 to 74 years) who were treated surgically for giant cell tumor of the wrist. Grading, assessment of surgical margins, and functional evaluation were performed according to the Enneking's criteria. The effects of tumor volume, soft tissue extension, and selected surgical therapy on recurrence were investigated. Joint movements and stability, postoperative pain, presence of deformity, muscle strength, limitations in functional activities, and patient satisfaction were evaluated. The mean follow-up period was 6.7 years.

RESULTS

Of all the patients, 69% had stage 2 and 23% had stage 3 tumors. There was no significant correlation between tumor volume and recurrence (p=0.22). Recurrences were observed in three (33%) of nine patients with soft tissue extension and in four (28.6%) of 14 patients without soft tissue extension. Recurrence rates were 33.3% in those who were treated by curettage alone (n=3), 50% with curettage and grafting (n=6), 50% with curettage and bone cement (n=2), and 16% in those who underwent wide excision (n=12).

CONCLUSION

The most important factor influencing recurrence rate in giant cell tumors is the extent of surgical resection. At least marginal resection must be considered in patients with stage 2 and 3 lesions especially in cases with soft tissue extension. Adjunctive therapy should be added if curettage is considered.