Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Clinical outcome of interprosthetic femoral fractures treated with polyaxial locking plates

IntroductionTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures in the increasing older population. According to the AAOS, approximately 19,200 Americans are actually living with ipsilateral prosthetic hip and knee leading to 240 interprosthetic fractures annually. Few reviews and case reports give an idea of the obvious problem to achieve consolidation in interprosthetic fractures. Preconfigured plates have been shown to be superior compared with other treatments in patients with stable components. Utilization of internal fixators for interprosthetic fractures might be advantageous.The purpose of this study was to evaluate interprosthetic femoral fractures with polyaxial locking plate treatment in regard to surgical procedure, complications, and clinical outcome.MethodsBetween 2005 and 2012, 143 patients underwent surgical treatment for periprosthetic femur fractures. Thirty-two fractures were identified as interprosthetic fractures. Five patients were excluded. Fractures were classified according to OTA/AO system, Vancouver, Rorabeck, Soenen and Pires. Trauma fellowship trained orthopaedic surgeons performed the surgeries using a NCB-construct (Zimmer Inc., Warshaw, IN). Plate choice was determined according to radiographic classification. Submuscular plate insertion was performed if possible. Complications were recorded concerning infection, union, fixation failure, and revision surgery.ResultsTwenty-seven patients were identified. There were 92.6% females. Follow-up by regular outpatient clinic visits was 24 months. Surface replacements were found in 18 TKA. Nine patients had a stemmed femur component of their TKA. 89% healed after the index procedure. Three patients developed a nonunion with 1 construct leading to hardware failure. Previous revision THA or Pires/modified Vancouver classification did not influence nonunion formation, but all patients with nonunion formation were classified as AO/OTA type B (p = 0.001). These fractures were treated with longer plates (p = 0.015), but with similar working length (p = 0.400). Plate design, additional cerclages, or submuscular insertion did not influence nonunion formation.ConclusionInterprosthetic fracture treatment remains challenging. NCB-locked plating can achieve satisfactory results. Additional soft tissue damage can be prevented by submuscular plate insertion. Treatment of type B fractures resulted in significantly greater nonunion rate. Therefore, consideration of the individual fracture type is essential to determine plate length, plate type, and additional bone grafting or BMP supplementation.     

Effect of dynamic hip system blade on the treatment of femoral neck fractures in elderly patients with osteoporosis

Objective：To discuss the curative effect of the dynamic hip system blade （DHS-blade） on the treatment of femoral neck fractures in elderly patients with osteoporosis.Methods：A retrospective study was conducted to analyse the clinical data of 60 elderly patients with osteoporosis who had been treated for femoral neck fractures with DHS-blade in our department between September 2012 and February 2014.There were 22 males and 38 females with a mean age of （66.8±3.2） years.According to the Singh Index Classification,all the patients＇ Singh index was below level 3.The Harris criterion and function recovery after operation were analysed.Results：All patients were followed up for 12-17 months （mean 14 months）.No femoral head necrosis,femoral neck shortening,internal fixation loosening or backing out of the nails occurred.Bone nonunion was found in one case and he had a good recovery after total hip arthroplasty.The time for fracture healing ranged from 3-6 months （average 3.5 months）.According to Harris criterion,35 cases were rated as excellent,22 good,2 fair and 1 poor.The Harris scale was significantly improved from 28.46±2.35 preoperatively to 91.98±3.26 at 6 months postoperatively （P＜0.05）.Conclusion：DHS-blade,being minimally invasive,allowing earlier postoperative exercise and avoiding the complications elicited by traditional internal fixation,is advisable for treatment of femoral neck fractured patients with osteoporosis.     

Femoral neck shortening in adult patients under the age of 55 years is associated with worse functional outcomes: Analysis of the prospective multi-center study of hip fracture outcomes in China (SHOC)

IntroductionYoung femoral neck fracture patients require surgical fixation to preserve the native hip joint and accommodate increased functional demands. Recent reports have identified a high incidence of fracture shortening and this may have negative functional consequences. We sought to determine if fracture shortening is associated with poor functional outcome in young femoral neck fracture patients.Patients and methodsOne hundred and forty-two patients with femoral neck fractures age 18–55 were recruited in this prospective cohort study across three Level 1 trauma hospitals in Mainland China. Patient-reported and objective functional outcomes were measured with the Harris Hip Score (HHS), Timed Up and Go (TUG), and SF-36 Physical Component Summary (SF-36 PCS) at 12 months. Radiographic fracture shortening was measured along the long axis of the femoral neck and corrected for magnification. Severe shortening was defined as ≥10 mm. The primary analysis measured associations between severe radiographic shortening and HHS at one-year post-fixation.ResultsOne hundred and two patients had complete radiographic and functional outcomes available for analysis at one year. The mean age of participants was 43.7 ± 10.8 years and 53% were male. Fifty-five percent of fractures were displaced and 37% were vertically orientated (Pauwels Type 3). The mean functional outcome scores were: HHS 90.0 ± 10.8, TUG 12.0 ± 5.1 s, and PCS 48.5 ± 8.6. Severe shortening occurred in 13% of patients and was associated with worse functional outcome scores: HHS mean difference 9.9 (p = 0.025), TUG mean difference 3.2 s (p = 0.082), and PCS mean difference 5.4 (p = 0.055).ConclusionsSevere shortening is associated with clinically important decreases in functional outcome as measured by HHS following fixation of young femoral neck fractures, occurring in 13% of patients in this population. The principle of fracture site compression utilized by modern constructs may promote healing; however, excessive shortening is associated with worse patient-reported outcomes and objective functional measures.     

An inception cohort analysis to predict nonunion in tibia and 17 other fracture locations

IntroductionThe epidemiology of fracture nonunion has been characterized so it is potentially possible to predict nonunion using patient-related risk factors. However, prediction models are currently too cumbersome to be useful. We test a hypothesis that nonunion can be predicted with ≤10 variables, retaining the predictive accuracy of a full model with 42 variables.MethodsWe sought to predict nonunion with prospectively-acquired inception cohort data for 18 different bones, using the smallest possible number of variables that did not substantially decrease prediction accuracy. An American nationwide claims database of ∼90.1 million participants was used, which included medical and drug expenses for 2011–2012. Continuous enrollment was required for 12 months after fracture, to allow sufficient time to capture a nonunion diagnosis. Health claims were evaluated for 309,330 fractures. A training dataset used a random subset of 2/3 of these fractures, while the remaining fractures formed a validation dataset. Multivariate logistic regression and stepwise logistic regression were used to identify variables predictive of nonunion. P value and the Akaike Information Criterion (AIC) were used to select variables for reduced models. Area-under-the-curve (AUC) was calculated to characterize the success of prediction.ResultsNonunion rate in 18 fracture locations averaged 4.93%. Algorithms to predict nonunion in 18 locations in the full-model validation set had average AUC = 0.680 (±0.034). In the reduced models, average validation set AUC = 0.680 (±0.033) and the average number of risk factors required for prediction was 7.6. There was agreement across training set, validation set, and reduced set; in tibia, reduced model validation AUC = 0.703, while the full-model validation AUC = 0.709. Certain risk factors were important for predicting nonunion in ≥10 bones, including open fracture, multiple fracture, osteoarthritis, surgical treatment, and use of certain medications, including anticoagulants, anticonvulsants, or analgesics.DiscussionNonunion can be predicted in 18 fracture locations using parsimonious models with <10 patient demography-related risk factors. The model reduction approach used results in simplified models that have nearly the same AUC as the full model. Reduced algorithms can predict nonunion because risk factors important in the full models remain important in the reduced models. This prognostic inception cohort study provides Level I evidence.     

Assessment of trochanteric osteotomy fragment union after acetabular fracture surgery

BackgroundTrochanteric osteotomies are performed in conjunction with standard approaches to improve surgical exposure during open reduction and internal fixation (ORIF) of acetabular fractures. The literature on total hip arthroplasty reports nonunion rates as high as 30% associated with trochanteric osteotomies; however, few data exist regarding the outcomes of trochanteric osteotomies for acetabular fracture surgery. Our hypotheses were 1) patients receiving trochanteric osteotomies during ORIF of acetabular fractures have a low rate of nonunion of the osteotomy fragment, and 2) hip abduction precautions are not necessary with digastric type osteotomies.Patients and methodsA retrospective review was conducted to identify patients with acetabular fractures between July 2002 and June 2010 (n = 734 fractures) who required trochanteric osteotomies (n = 64, 9% of fractures). Forty-seven met inclusion criteria of adequate follow-up (>56 days). No excluded patient experienced a complication. Fractures were classified using the Letournel-Judet classification system.ResultsOnly seven (20%) of 35 patients who received digastric osteotomies had hip abduction precautions applied during the postoperative period. All study patients were shown to have radiographic union at the trochanteric osteotomy site (100% union rate, n = 47). Hip abduction precautions intended to protect the osteotomy site and reduce the risk of nonunion and fixation failure were infrequently applied to patients with digastric osteotomies (20%) in this cohort. Multiple protective factors against nonunion were present in this study population compared with previous arthroplasty studies from other institutions.ConclusionsTrochanteric osteotomies are not associated with a significant nonunion rate, and digastric osteotomies might be safely managed without hip abduction precautions.     

Does femoral offset recover and affect the functional outcome of patients with displaced femoral neck fracture following hemiarthroplasty?

BackgroundRestoring preoperative horizontal femoral offset (FO) promised good functional outcome in patients receiving total hip arthroplasty. However, relatively little was known regarding the clinical relevance of restoring the offset in patients with bipolar hemiarthroplasty to treat displaced femoral neck fracture. Therefore, the objective of this study was to evaluate postoperative FO accurately and verify its relation with functional outcome.MethodsOne hundred elderly patients who received bipolar hemiarthroplasty to treat displaced femoral neck fracture were identified. Preoperative CT scanning of contralateral hip joint and reconstruction of images led to rotation-free FO. By referencing postoperative implant specification and comparing to measured values in Picture Archive and Communication System, rotation-free postoperative FO and the amount of change were acquired. Postoperative Harris Hip Score (HHS) and Modified Barthel Index (MBI) were evaluated to measure functional outcome at 12-month after the surgery. Patients with significant FO change were identified. Multiple regression analysis was conducted to determine if the FO change might independently affect the outcome regardless of confounding factors.ResultsThe mean preoperative offset was 37.4 ± 2.5 increased by 12.7 ± 9.6% after the surgery. Only 25.0% of postoperative offset after hemiarthroplasty was changed within ±5% of preoperative offset. A total of 45.0% of postoperative offset changed within ±10% while 77.0% of postoperative offset changed within ±20%. 23% of patients whose FO changed more than 20% showed significantly worse outcome score than the patients whose FO change remained within ±20% of initial value. Mean MBI and HHS were negatively correlated with FO change. After adjusting for confounding factors, significant correlation remained between modification of FO and MBI, but not between FO change and HHS (B = 4.576; β = 0.235; 95% confidence interval of B: 0.534 to 8.135).ConclusionsFO was not properly restored in 23% of subjects receiving bipolar hemiarthroplasty due to femoral neck fracture. FO restoration independently predicted fair MBI after the surgery. Therefore, surgeons should pay attention to restoring FO with meticulous templating.     

Bone transport for the treatment of infected forearm nonunion

ObjectiveThe objective of this study was to evaluate the effectiveness of the treatment of infected forearm nonunion by bone transport.Materials and methodsWe retrospectively reviewed 16 patients with infected forearm nonunion treated by bone transport. Our study included 10 males and 6 females with a mean of age 38.25 years. The site of bone defects involved 9 radius and 7 ulna. The average length of the bone defects after radical debridement was 3.81 cm (range 2.2–7.5 cm).ResultsThe mean follow-up after removal of the frame was 39.63 months (range 26–55 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 6.19 months (range 3–10 months), and the mean external fixation index was 1.63 months/cm (range 1.14–2.00 months/cm). The mean degrees of wrist flexion were 49.69° (range 45–55°), and the mean degrees of wrist extension were 50.63° (range 40–60°). The mean degrees of elbow flexion were 143.12° (range 135–150°), and the mean degrees of elbow extension were 4.69° (range 0–20°). The mean degrees of forearm pronation were 82.50° (range 70–90°), and the mean degrees of forearm supination were 83.75° (range 75–90°).ConclusionOur study suggested that bone transport in the treatment of infected forearm nonunion acquired satisfied functional results. Radical debridement is the key step to control bone infection.     

Prospective randomized study comparing two cephalomedullary nails for elderly intertrochanteric fractures: Zimmer natural nail versus proximal femoral nail antirotation II

ObjectivesAlthough both clinical and biomechanical studies suggest that cephalomedullary implants have a mechanical advantage over extramedullary implants, a high rate of complications or implant failure remains in elderly patients with osteoporosis. In an attempt to address some of these challenges, new implants with improved designs named proximal femoral nail antirotation II (PFNA II) and Zimmer natural nail (ZNN) were developed for elderly patients. Although the PFNA II reportedly has good clinical outcomes, it is unclear which implant achieves better safety and efficacy for treating intertrochanteric hip fractures. The primary objective of this prospective, randomized trial involved 353 patients was to evaluate Harris Hip Score (HHS). The secondary objective was to compare results associated with clinical outcome such as operation time, fluoroscopy time, lateral hip pain, walking ability, and reoperation rate as well as the incidence of cut-out by using implant position and fracture reduction quality.Methods353 patients with an intertrochanteric fracture amenable to either ZNN implant or PFNA II with a mean age of 77.0 years and a mean follow-up period of 12.3 months were included. We analyzed 353 patients with an intertrochanteric fracture treated using a ZNN implant (n = 172, group I) or a PFNA II (n = 181, group II) between January 2011 and August 2014.ResultsThere were no significant inter-group differences in HHS, walking ability, and reoperation rate were observed. However, operation and fluoroscopy time were significantly different between the two groups as well as group I showed a higher incidence of lateral hip pain than group II. In addition, no significant inter-group differences in cut-out rate determined by implant position and fracture reduction quality. We also found that cut-out was associated with lag screw position in the femoral head measured by Tip-apex distance (TAD) but not with reduction quality.ConclusionsAlthough group I had significant longer operation and fluoroscopy time than group II, both implants are useful tools in the treatment of elderly intertrochanteric fractures as well as only TAD, but not Cleveland zone significantly correlated with lag screw cut-out.     

Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation: A prospective 2-year follow-up study of 182 patients

Background and purposeProspective studies on patient related outcome in patients <70 years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation.Patients and methods182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations.ResultsAt 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5D_index in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p < 0.001).InterpretationTwo thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.     

High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture

PurposeThe purpose was to evaluate the prevalence and location of simultaneous fracture using bone scans in patients with hip fracture and to determine the risk factors associated with simultaneous fracture.Patients and methodsOne hundred eighty two patients with hip fracture were reviewed for this study. Clinical parameters and bone mineral density (BMD) of the lumbar vertebra and femoral neck were investigated. To identify acute simultaneous fracture, a bone scan was performed at 15.4 ± 4.1 days after hip fracture. The prevalence and location of simultaneous fracture were evaluated, and multivariate logistic regression analysis was performed to determine the risk factors.ResultsSimultaneous fracture was observed in 102 of 182 patients, a prevalence of 56.0%. Rib fracture was the most common type of simultaneous fracture followed by rib with vertebral fracture. The BMD of the lumbar vertebra was significantly lower in patients with simultaneous fracture (p = 0.044) and was identified as an independent risk factor (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57).ConclusionsThe prevalence of simultaneous fracture was relatively high among patients with hip fracture, and BMD was significantly lower in patients with simultaneous fracture than in patients without it. Surgeons should be aware of the possibility of simultaneous fracture in patients with hip fracture.     

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures

BackgroundFemoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches.Patients and methodsMedical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model.ResultsThe demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p < 0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ = 368 versus PFN, δ = 65, p < 0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27 g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones.ConclusionsImplementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.     

Early results of minimally invasive,reverse-oblique,distal metaphyseal metatarsal osteotomy (R-DMMO) for arthritis of the lesser tarsometatarsal joints — A retrospective case series

BackgroundArthrodesis is the gold standard for operative management of osteoarthritis of the lesser tarsometatarsal joints (TMTJs) but is not without complications. Our early results of a minimally invasive alternative treatment – the reverse-oblique distal metaphyseal metatarsal osteotomy (R-DMMO) are described.MethodsThis is a single-centre, single-surgeon, retrospective series of patients with isolated, symptomatic lesser TMTJ arthrosis who underwent R-DMMO.ResultsSixteen feet in 15 patients were included. The mean age was 64.7 ± 9.7 years and mean duration of follow-up was 109.4 ± 27.4 weeks. There were no non-unions, infections or wound complications. Two patients developed transfer symptoms to their first metatarsal, one of these patients improved after three months. There was one delayed union which united at 12 months. Two patients developed recurrence of symptoms but felt that they were still improved compared to preoperatively and no patient has required arthrodesis thus far. The mean preoperative VAS was 8.3 ± 1.3 and the mean postoperative VAS was 2.4 ± 2.2 (P < 0.001). The mean postoperative MOxFQ-Walking was 25.2 ± 25.6, MOxFQ-Pain was 24.8 ± 20.5, MOxFQ-Social was 18.4 ± 19.1, and MOxFQ-Index was 23.4 ± 20.6. Eight patients were ‘very satisfied’ and seven were ‘satisfied’ with the procedure.ConclusionsR-DMMO is a minimally invasive and safe procedure for lesser TMTJ arthrosis which can produce good results and prevent, or at least delay, the need for arthrodesis without compromising future operative options. Good to excellent outcomes have been shown with few significant complications in the short term in selected patients.     

The use of interfragmentary positional screw in minimally invasive plate osteosynthesis for simple distal femur fractures in elderly patients: A retrospective,single-centre pilot study

IntroductionMinimally invasive plate osteosynthesis (MIPO) using locking plates has been used in distal femur fractures, but various problems, such as nonunion, malalignment, and implant failure, have been reported. Simple fractures sometimes have poorer outcomes than complex fractures. We studied elderly patients with simple fracture patterns who underwent open reduction followed by placement of a single positional screw to hold the reduced interfragmentary gap, and compared these cases with patients who underwent surgery using conventional MIPO techniques.Patients and methodsA retrospective analysis was conducted on 80 cases of patients with distal femur fractures and simple fracture patterns (33-A1, A2, and C1). The mean age was 74 (60–90) years, and the mean follow-up period was 14 (12–25) months. Group A included 40 patients who underwent conventional MIPO technique while Group B included 40 patients who had surgery using positional screws. Interfragmentary gaps in Group B were reduced using percutaneous reduction clamps, and cortical screws were inserted to sustain the reduction. Then, locking plates were inserted using conventional MIPO techniques.ResultsBony union was achieved in all 80 cases, mean initial callus formation was observed in 11 weeks (8–13 weeks), and radiological union was observed in 27 weeks (15–54 weeks). Time to initial callus formation was not different, but radiologic union was achieved in 30 weeks (18–54 weeks) for Group A and 25 weeks (15–41 weeks) for Group B (p = 0.006). No differences were seen in clinical function at 1 year (p = 0.580). Five cases of malalignment occurred in Group A (p = 0.021). The rate of union during the 1-year period was significantly higher in group B than in group A (p = 0.002).ConclusionsIn a distal femur fracture with a simple fracture pattern, using positional screws to sustain the reduced interfragmentary gap may achieve a more rapid union by reducing fracture gap. Though functional differences were not seen in follow-ups, patients can be expected to return to their normal lives earlier as union is achieved in a shorter time. Performing MIPO using positional screws to sustain the reduced interfragmentary gap after fracture reduction will be helpful in the treatment of simple femoral fracture.     

HLA-B27 homozygosity has no influence on radiographic damage in ankylosing spondylitis: Observation Study of Korean spondyloArthropathy Registry (OSKAR) data

ObjectivesTo evaluate the influence of homozygosity for HLA-B27 on the radiographic damage in ankylosing spondylitis (AS).MethodsA total of 368 AS patients with positive HLA-B27 status from the Observation Study of Korean spondyloArthropathy Registry (OSKAR) cohort were recruited for this study. HLA-B27 positive patients out of all AS patients were assessed for whether they had homozygosity or heterozygosity for HLA-B27. First, all data were stratified in relation to the carrier state of positive HLA-B27 for cross-sectional survey. Then we compared the radiographic damage score between groups. Second, we evaluated collected clinical and radiographic parameters at two different time points. Then we compared radiographic progression between groups. To use the mSASSS, cervical and lumbar spinal radiographs were examined by two experienced bone and joint radiologists (S. Lee, K.B. Joo).ResultsThe agreement between the two readers regarding mSASSS was very good: ICC coefficient 0.70 (95% CI 0.60–0.81). The mean age (SD) of the AS patients was 37.0 (9.2) years, and the mean disease duration (SD) was 15.6 (9.1) years. Of these patients, 34.5% (127 patients) had HLA-B27 homozygosity. The mean mSASSS unit (SEM) was not significantly different between groups (homozygosity 28.57 ± 4.12 vs heterozygosity 23.34 ± 3.44, P = 0.344) on cross-sectional survey. When it comes to radiographic progression between groups over 5 years, there was no significant difference in spite of adjusting for confounding variable (homozygosity 4.98 ± 0.98 vs heterozygosity 4.21 ± 0.82, P = 0.562).ConclusionThe carrier state of positive HLA-B27 plays no role in determining the radiographic progression in AS.     

Treatment of tibial nonunion with posterolateral bone grafting

ObjectivesPosterolateral bone grafting to treat nonunions of the distal two-thirds of the tibia avoids the often traumatized and more tenuous anterior soft-tissue envelope. Few modern reports of its effectiveness are available. We assessed whether posterolateral bone grafting leads to high union and low complication rates.MethodsWe conducted a retrospective review at a Level I trauma center. Our study group was 59 patients with distal two-thirds tibial fractures treated with posterolateral bone grafting. Patients included those with history of deep surgical site infection (SSI) before bone grafting (n = 17), established nonunions (n = 42), and impending nonunions associated with open fractures and bone gaps (n = 17). All patients were followed for a minimum of 12 months unless they achieved union before that time point. Our primary outcome measurement was fracture union. Secondary outcome measurements were any complication associated with the approach and infection requiring return to the operating room.ResultsFracture union was achieved in 44 (75%) of 59 patients without further intervention. The mean interval to union was 9.9 months (range, 3–22). Of 11 infected nonunions treated, nine progressed to union. Seventeen of 23 patients with defects >2 cm, including defects up to 5.4 cm without infection, were successfully treated. Two patients who underwent grafting at least 10 years after initial injury achieved union. No complications were associated with the approach (specifically, no wound breakdown, vascular injury, or tendon injury). Fourteen percent of patients experienced SSI after bone grafting. Seven of eight deep SSI occurred in patients with previous infection or positive intraoperative cultures. Only one (3%) of 36 patients without infection pre- or intraoperatively experienced SSI.ConclusionsEven in this relatively difficult patient cohort that included large bone gaps and history of infection, union was achieved at a relatively high rate with posterolateral bone graft. The approach seems to be safe, considering no known complications specifically associated with the approach occurred, and seems to reduce the risk of SSI in the absence of previous infection.     

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BackgroundThe objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.MethodsFrom May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded.ResultsThe mean follow-up period was 20.9 ± 4.5 months for Group A and 20.0 ± 3.6 months for Group B (P = 0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P = 0.785, P = 0.835, P = 0.803, P = 0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P = 0.001 and P = 0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P = 0.047). When comparing the total complications, no significant difference existed between the groups (P = 0.978).ConclusionsThis study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.     

Clinical results of acetabular fracture management with the Pararectus approach

IntroductionTo present the accuracy of reduction, complications and results two years after open reduction and internal fixation of displaced acetabular fractures involving the anterior column (AC) through the Pararectus approach. Frequencies for conversion to total hip replacement in the early follow up, the clinical outcome in preserved hips, and the need for an extension of the approach (1st window of the ilioinguinal approach) are compared to the literature about the modified Stoppa approach.MethodsForty-eight patients (mean age 62 years, range: 16–98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed. Patients were routinely followed up at eight weeks, 6, 12 and 24 months postoperatively. Failure was defined as the need for total hip arthroplasty. Twenty-four months postoperatively the outcome was rated according to Matta.ResultsIn four patients there were four intraoperative complications (minor vascular damage in two, small perforations of the peritoneum in two) which were managed intraoperatively. Fracture reduction showed statistically significant decreases (mean ± SD, pre- vs. postoperative, in mm) in “step-offs”: 2.6 ± 1.9 vs. 0.1 ± 0.3, p < 0.001 and “gaps”: 11.2 ± 6.8 vs. 0.7 ± 0.9, p < 0.001. Accuracy of reduction was “anatomical” in 45, “imperfect” in three. Five (13%) from 38 available patients required a total hip arthroplasty. Of 33 patients with a preserved hip the clinical outcome was graded as “excellent” in 13 or “good” in 20; radiographically, 27 were graded as “excellent”, four as “good” and two as “fair”. An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%).ConclusionIn the treatment of acetabular fractures involving the anterior column the Pararectus approach allowed for anatomic restoration with minimal access morbidity. Results obtained by means of the Pararectus approach after two years at least parallel those reported after utilisation of the modified Stoppa approach. In contrast to the modified Stoppa approach, a relevant extension of the Pararectus approach was almost not necessary.     

The outcome of super-cutaneous locked plate fixation with percutaneous reduction of displaced intra-articular calcaneal fractures

IntroductionSupercutaneous (external) fixation with locking plate is utilized for fixation of long bone fractures. One retrospective study for open reduction and supercutaneous fixation of the calcaneus is reported. We prospectively evaluated the use of this method of fixation combined with percutaneous reduction.Materials and methodsBetween January 2014 and June 2015, 32 displaced calcaneus fractures in 30 patients were stabilized with percutaneous reduction and super-cutaneous fixation. They were 24 males and six females. The mean age was 37.9 ± 5.7 years (21–55). All cases were closed. The time to surgery, complications, radiographic alignment, and time to radiographic union were recorded. Clinical results at the final follow-up were assessed by evaluating Bohler’s angles for the radiographic alignment, and the system of the American Orthopedic Foot and Ankle Society (AOFAS) for the functional outcome.ResultsAccording to the Sanders’ classification, two cases were type II, 17 cases were type III and 13 cases were type IV. The preoperative average Bohler’s angle was 10.57° ± 4.8. The postoperative X-ray films demonstrated that the average Bohler’s angle improved to 29.07° ± 5.9 (p < 0.001). At the time of radiologic healing (about 3 months), the plates and screws were removed under general anesthesia. The average follow-up was 13.2 months (11–18). Four cases (type IV) showed mal-union and heel pain. According to (AOFAS) rating, the fine score was 87.1 ± 17.1 points.ConclusionSuper-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results.