股骨颈嵌插型骨折空间移位程度的三维重建研究

  目的 测量股骨颈嵌插型骨折股骨头的空间移位参数, 以重新认识股骨颈嵌插型骨折。 方法收集50 例股骨颈嵌插型骨折患者双侧股骨近端的多层螺旋CT扫描的薄层原始数据, 男17 例, 女33 例。将原始数据(DICOM格式)导入三维重建软件生成双侧股骨近端三维模型。在健侧生成骨折侧 的镜像模型并将其与健侧相配准, 使配准后的骨折侧镜像模型在CT 横截面图像上生成新的蒙罩, 在蒙 罩上进行关键点的标记, 通过软件三维测量技术计算股骨头空间移位参数, 并分析测量数据。 结果 嵌 插型骨折股骨头空间移位角度为17.17°±10.40°, 70%(35/50)的患者股骨头空间移位角度分布于10°~ 35°之间, 30%(15/50)的患者股骨头空间移位>20°;股骨头中心的移位距离为(6.49±3.60)mm, 股骨头小 凹最深点的移位距离为(10.42±5.92)mm。部分股骨颈嵌插型骨折存在很大的空间移位及成角, 将其完 全归类于Garden 玉型骨折存在一定的偏差。 结论 三维重建数字化测量技术能够更加准确、高效地测 量股骨颈骨折的真实空间移位程度。经典的股骨颈骨折Garden 分型对于嵌插型骨折的认识存在一定的 局限性;临床医生需重新认识嵌插型骨折, 从而制定更适宜的诊疗方案。     

围截骨区卫星棒技术在严重脊柱畸形三柱截骨术中的应用

 目的 探讨严重脊柱畸形三柱截骨术中围截骨区卫星棒技术的可行性,并评估其临床应用价值。方法 回顾性分析2012年7月至2014年1月期间应用卫星棒技术行严重脊柱畸形三柱截骨并有完整临床及影像学资料的13例患者,男6例,女7例;年龄12~57岁,平均（30.9±19.1）岁。分别测量患者手术前后及末次随访时侧凸Cobb角、最大后凸Cobb角（global kyphosis,GK）、冠状面平衡（distance between C₇ plumb line and center sacral vertical line,C₇PL-CSVL）和矢状面平衡（sagittal vertical axis,SVA）。患者初诊及每次随访均填写SF-36量表。结果 随访时间平均为（15.8±3.8）个月。术前侧凸Cobb角平均为86.3°±22.6°,术后为45.2°±19.7°,较术前明显改善,平均矫正率为47.7%±19.1%;末次随访为39.9°±19.8°,随访期间未见明显矫正丢失。术前GK为80.9°±18.7°,术后为35.1°±14.5°,平均矫正率为57.8%±13.8%;末次随访时未见明显丢失,平均为36.3°±10.0°。手术前后C₇PL-CSVL分别为（43.7±36.8） mm、（18.8±5.6） mm,术后有明显改善;末次随访时维持良好,平均为（19.2±8.3） mm。SVA由术前平均（55.0±51.5） mm减小至术后（29.3±19.5） mm,末次随访为（34.2±17.5） mm,亦无明显矫正丢失。13例患者术中监测均无信号异常。术后1例患者1枚螺钉位置偏上穿出上终板,1例患者1枚螺钉位置偏外。患者随访期间均无明显矫形丢失及断钉、断棒等内固定并发症。结论 严重脊柱畸形三柱截骨引入卫星棒技术既满足坚强固定需要又起到分散应力作用,术后矫形效果满意,随访期间矫正丢失及内固定失败等并发症少。     

外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。     

全膝关节置换治疗血友病关节炎围手术期处理及短期疗效评价

 目的 探讨血友病关节炎全膝置换围手术期管理、凝血因子调控及早期临床疗效。方法 回顾性分析2009年3月至2014年3月采用全膝关节置换治疗8例（10膝）血友病膝关节炎患者资料,均为男性患者,年龄31~47岁,平均（38.3±5.0）岁;术前活化部分凝血活酶时间为（63.9±4.0） s,凝血因子活性为2.6%±0.9%;膝关节均有屈曲畸形,伸膝-12.0°±5.9°,屈膝-88.0°±11.4°。其中3例（3膝）合并外翻畸形,外翻角平均-3.0°±5.4°;2例（4膝）合并内翻畸形,内翻角平均-4.5°±6.0°。8例患者中,甲型6例,乙型2例,分别补充冻干人凝血八因子和凝血酶原复合物后手术。骨缺损根据AORI分型方法,T1、T2型采用骨水泥充填,T3包容型采用同种异体骨打压植骨、螺钉支撑内固定修复,T3节段型通过自体骨结构性植骨,并加用胫骨延长杆修复。采用美国特种外科医院（hospital for special surgery, HSS）膝关节评分评价膝关节功能。结果 8例患者均获得随访,随访时间9~26个月,平均14.3个月。末次随访时伸膝0°,屈膝98.5°±6.7°;HSS评分由术前（42.3±10.9）分提高到术后（88.3±4.6）分;X线片示植骨存活,假体、螺钉均未见松动、断裂。结论 全膝关节置换治疗血友病关节炎短期疗效满意,术前的预输试验有助于确定凝血因子的补充剂量。     

慢病毒介导的shRNA干扰PTEN表达促皮层神经元轴突再生及脊髓损伤修复

 目的 观察慢病毒介导特异性短发夹RNA（short hairpin RNA,shRNA）干扰第l0号染色体同源丢失性磷酸酶张力蛋白基因（phosphatase and tensin homology deleted on chromosome ten,PTEN）表达对皮层神经元轴突再生及脊髓损伤修复的影响。方法 体内实验和体外实验两部分各分四组：阴性对照组（DMEM）、空载慢病毒组（Lenti��control）、空白载体组（Lenti��scramble）、慢病毒介导shRNA组（Lenti��shRNA）。体外神经元转染72 h后,Western blot检测各组PTEN表达情况,免疫荧光检测神经元轴突再生能力;体内载体注射1周后,Western blot检测各组PTEN表达情况;6周后荧光显微镜观察皮质脊髓束穿越脊髓损伤局部周围增强绿色荧光蛋白荧光强度及突触素表达情况。采用大鼠脊髓损伤评分评价大鼠后肢运动恢复情况。结果 慢病毒介导shRNA组体外转染神经元后PTEN表达水平比阴性对照组下降83.75%±2.85%,与其他组比较具有统计学意义（F=4277,P< 0.05）;轴突长度（249.70±10.70）μm,大于阴性对照组（95.71±20.24） μm、空载慢病毒组（97.00 ± 22.82）μm及空白载体组（87.57±19.34）μm,差异具有统计学意义（F=84.74,P< 0.05）;每个神经元一级突起数量（5.800±0.359）个,大于阴性对照组（2.800±0.678）个、空载慢病毒组（2.900±0.389）个及空白载体组（3.000±0.877）个,其差异具有统计学意义（F=16.47,P< 0.05）;神经元突起穿越硫酸软骨素蛋白多糖基质的百分比20.60%±1.80%,大于阴性对照组6.70%±1.45%、空载慢病毒组5.50%±1.69%、空白载体组5.60%±1.77%,其差异具有统计学意义（F=94.90,P<0.05）。慢病毒介导shRNA注射大脑皮层运动区后,第6周大鼠脊髓损伤评分达（13.29±0.42）分,高于阴性对照组（7.00±1.48）分,空载慢病毒组（6.43±1.43）分,空白载体组（6.29±1.22）分,其差异具有统计学意义（F=44.85,P< 0.05）。皮层组织PTEN表达水平下降84.57%±1.87%,损伤中心尾端见绿色荧光,突触素染色阳性面积明显增大。结论 慢病毒介导shRNA下调PTEN基因表达后可明显提高脊髓损伤后轴突再生能力,促进神经功能修复。     

保留与不保留残端重建前十字韧带的前瞻性随机对照研究

 目的 评估保留与不保留残端对重建前十字韧带（anterior cruciate ligament,ACL）的意义及临床疗效。方法 2010年1月至2012年10月,收治93例残端存留的ACL损伤患者,前瞻性随机将其分为保留组（保留残端）和不保留组（切除残端）。保留组48例,男34例,女14例;平均年龄30.4岁;左侧25例,右侧23例;损伤至手术时间13.5 d;合并内侧半月板损伤7例,外侧半月板损伤16例,内侧副韧带损伤4例。不保留组45例,男33例,女12例;平均年龄28.8岁;左侧22例,右侧23例;损伤至手术时间14.9 d;合并内侧半月板损伤7例,外侧半月板损伤12例,内侧副韧带损伤2例。两组重建ACL移植物均为自体四股腘绳肌腱。术后两组患者分别行膝关节功能评估、稳定性评估、本体感觉功能测量和二次关节镜手术探查。结果 82例患者完成随访,其中保留组42例,随访时间（25.4±1.9）个月;不保留组40例,随访时间（25.2±1.7）个月。IKDC分级：保留组A级32例,B级9例,C级1例;不保留组A级30例,B级8例,C级2例。Lysholm评分：保留组（95.9±5.2）分,不保留组（95.4±1.7）分。Lachman试验：保留组,阴性38例,1度阳性4例;不保留组,阴性36例,1度阳性4例。轴移试验：保留组,阴性37例,1度阳性5例;不保留组,阴性34例,1度阳性6例。KT-1000测量侧-侧差值：保留组（1.1±1.2） mm,不保留组（1.2±0.9） mm。本体感觉测量关节位置觉侧-侧差值：保留组3.6°±1.8°,不保留组3.9°±2.2°。以上指标两组均无明显差异。二次手术探查移植物滑膜覆盖分型,保留组A型11例,B型6例,C型2例,D型2例;不保留组A型10例,B型5例,C型2例,D型2例。结论 保留较不保留残端并使用自体肌腱移植重建ACL对术后膝关节主观功能、稳定性、本体感觉和移植物滑膜覆盖无促进作用。     

非移位型股骨颈骨折发生股骨头后倾角的研究

目的：探讨临床非移位型股骨颈骨折后发生股骨头后倾情况为临床手术和改善疾病预后提供参考依据。方法：回顾性分析2018年1月至2022年6月收治的非移位型GardenⅠ、Ⅱ型股骨颈骨折患者165例临床资料,男48例,女117例;年龄53~89(71.5±8.5)岁;GardenⅠ型97例,Ⅱ型68例。在术前髋关节矢状位或轴位CT片上,将股骨头半径线与股骨颈中线形成的夹角作为股骨头后倾角α,测量股骨头后倾角大小。并将测量数据分成6组:α＜0°、0°＜α＜5°、5° ≤ α＜10°、10° ≤ α＜15°、15° ≤ α＜20°、α ≥ 20°,比较不同范围后倾角的发生情况。分析比较165例患者性别构成比,并将65岁作为分界点,比较不同性别患者的骨折发生情况。根据术前后倾角大小分为后倾角<20°组135例和后倾角 ≥ 20°组30例,分析比较两组患者在性别和年龄上的差异。结果：165例非移位型股骨颈骨折的患者中,发生股骨头后倾143例(86.7%),其中,后倾0°＜α＜5°36例(21.8%),5° ≤ α<10°40例(24.2%);10° ≤ α<15°27例(16.4%),15° ≤ α<20°10例(6.1%),后倾角α ≥ 20°30例(18.2%),其中最大后倾角为42.7°。165例患者中,女性骨折占比高于男性,且相比男性,女性在65岁前更易发生骨折。但性别、年龄和Garden分型(Ⅰ、Ⅱ型)不是股骨颈骨折术前股骨头后倾角＞20°的影响因素(P＞0.05)。结论：非移位型股骨颈骨折发生股骨头后倾的比率较高,其中发生严重后倾,即股骨头后倾角 ≥ 20°可达18.2%。对于行闭合复位内固定的患者,需要尽可能将骨折断端复位以降低发生术后股骨头缺血性坏死的风险。为了预防股骨颈骨折的发生,要特别重视对于女性的抗骨质疏松治疗。对于不同年龄段、不同性别和Garden分型Ⅰ、Ⅱ型患者,术前评估后倾角都至关重要。     

SPECT-CT评价股骨颈骨折后股骨头血供的变化

目的利用SPECT-CT观察不同分型股骨颈骨折后股骨头血供的变化和股骨头不同部位血供的分布情况。方法回顾性分析76例股骨颈骨折后股骨头的SPECT-CT检查资料,股骨颈骨折采用Garden分型,并将股骨头分为外上方（A）、外下方（B）和内下方（C）三个区域,分别计算患/健股骨头核素比值和三个区域与健侧股骨头核素计数比值,比较股骨颈不同类型骨折、同种骨折股骨头不同部位血供的变化。结果 GardenⅠ、Ⅱ、Ⅲ和Ⅳ型患/健比均值分别为：2.6、1.7、0.7和0.4（F=2.34,P〈0.05）。股骨头外上方、外下方和内下方与健侧股骨头的核素比分别为：（GardenⅠ型）1.9、3.2、2.4（F=3.85,P〈0.05）,（GardenⅡ型）1.3、2.3、1.6（F=4.56,P〈0.05）,（GardenⅢ型）0.3、0.9、0.5（F=3.47,P〈0.05）,（GardenⅣ型）0.1、0.6、0.3（F=2.73,P〈0.05）。结论股骨颈骨折移位程度越大,股骨头血供破坏越严重,尤其是股骨头的外上方部位血供下降程度最为明显。     

髂腰内固定治疗创伤性脊柱骨盆分离

 目的 探讨创伤性脊柱骨盆分离的临床特点及后路髂腰内固定治疗该损伤的临床效果。方法 回顾性分析2008年7月至2012年12月收治12例创伤性脊柱骨盆分离患者资料,男8例,女4例;年龄18~50岁,平均（34.6±9.2）岁。致伤原因：坠落伤11例,车祸伤1例。所有骨折均为闭合性损伤,均有不同程度的合并伤。骶骨骨折按形态学分型：U型4例,H型6例,Y型2例。Roy-Camille分型：Ⅱ型6例,Ⅲ型6例。采用髂腰固定对12例患者进行手术治疗,并对6例有明显神经损害表现且有明确手术指征的患者同时行神经减压术。临床疗效评价采用Majeed标准,神经损伤按照Gibbons评价方法进行评定。结果 12例患者均获得随访,随访时间12~36个月,平均（15.5±6.3）个月。9例患者在受伤早期存在误诊或漏诊,12例患者均有不同程度的神经损害表现。术后所有骨折均获得愈合,骨折愈合时间4~8个月,平均（4.8±2.8）个月。根据Majeed标准,优4例、良4例、可2例、差2例,优良率66.7%（8/12）。12例患者术后患肢感觉、运动功能恢复率为91.7%（11/12）。6例行神经减压术的患者术后感觉、运动功能恢复率为83.3%（5/6）。末次随访时,Gibbons神经评分由术前平均（3.25±0.75）分降至术后平均（1.67±0.99）分,差异有统计学意义。结论 创伤性脊柱骨盆分离是一种少见的高能量损伤,其合并伤及神经损害的发生率很高;后路髂腰内固定是一种值得推荐的治疗方式,对有指征的患者早期行神经减压有利于神经功能的恢复。     

闭合复位技术治疗外展嵌插型股骨颈骨折

目的: 探讨C形臂X线监测下闭合复位技术3枚螺钉固定外展嵌插型股骨颈骨折的可行性。方法: 回顾性分析2014年1月至2019年12月接受手术的17例外展嵌插型股骨颈骨折患者,男10例,女7例,年龄21~59(42.09±7.30)岁。根据术前的X线和CT资料,明确股骨头后倾及外展移位角度,2枚直径2 mm克氏针交叉从股骨头外侧和前方轻敲入髋臼顶盖骨质内,将近骨折段固定在髋臼上,在C形臂X线监测下逆骨折移位方向,逐渐内旋内收下肢(远骨折段),使远骨折端对合近骨折端完成解剖复位后3枚空心螺钉内固定。评价Garden指数,观察术后并发症,进行Harris功能评分。结果: 17例外展嵌插型股骨颈骨折均顺利完成闭合复位内固定,手术时间36~68(43.87±7.63) min,术中出血15~50(28.36±5.93) ml。术中Garden指数评价骨折复位质量,解剖复位12例,可接受复位5例,无复位不成功改开放复位病例。17例获得随访,时间3~41(27.5±8.4)个月。无股骨头坏死、骨折不愈合、髋关节撞击征、股骨颈缩短等并发症出现,MRI检查未发现有股骨头坏死及关节软骨损伤表现。术后2年髋关节Harris评分优13例,良4例。结论: 闭合复位3枚螺钉内固定手术技术治疗外展嵌插型股骨颈骨折可获得良好的解剖复位率及治疗效果。     

Factors Associated with Femoral Neck Shortening After Closed or Open Reduction and Screw Fixation

PurposeThis study aimed to evaluate the incidence of femoral neck shortening (FNS) after the treatment of displaced and non-displaced femoral neck fractures with closed or open reduction internal fixation, and determine the independent factors associated with this condition.MethodThe study included 81 patients who underwent internal fixation by closed or open reduction with multiple screws between 2013 and 2018 due to femoral neck fracture (FNF) and were followed up for at least 1 year. Patients were divided into two groups as with and without FNS. The patient, fracture, and surgical parameters compared between the two groups, and the factors affecting development of FNS were investigated.ResultsInternal fixation was applied by closed reduction in 56 patients (69.1%) and open in 25 (30.9%). FNS was detected in 41 patients (50.6%), with the mean shortening 6.3 ± 6.4 mm. Fracture union achieved in 72 patients (89%). The mean time to fracture union was 4.3 ± 2.3 months.No statistically significant relationship found between FNS and the parameters of gender, age, smoking, reduction type, number, type and orientation of screws, Singh index, and Garden fix index (p > 0.05).However, there was significant difference between two groups regarding energy of the fracture, fragmentation, coronal angulation, Garden type, and fixation with medial buttress plate (p < 0.05)ConclusionFNS is an expected condition in FNF fixed by screws. Patients with high-energy traumas and advanced Garden types are more likely to have FNS. The use of medial plate may be effective in preventing FNS.     

Integrity of posterior retinaculum after displaced femoral neck fractures

Introduction

It is widely thought that the posterior retinaculum is intact only in relatively undisplaced intracapsular fractures, and interruption of the arterial flow through the retinacular arteries to the femoral head is the main cause of avascular necrosis after fracture of the neck.

Patients

In order to test the hypothesis that the posterior retinaculum is torn after a displaced femoral neck fracture, 112 patients (45 males and 67 females), 75 years old on average, underwent a hemiarthroplasty for a displaced femoral neck fracture. There were 71 Garden type III and 41 Garden type IV fractures. The integrity of the posterior retinaculum was examined intraoperatively in every patient during the procedure.

Results

The posterior retinaculum was found intact in all of the Garden type III fractures and in 39 Garden type IV fractures. The posterior retinaculum was found torn in two Garden type IV fractures. There was no tearing in any other part of the capsule of the hip joint in any patient.

Conclusions

The posterior retinaculum of the hip joint remains intact after a displaced femoral neck fracture in all of Garden type III fractures and in the great majority of Garden type IV fractures.     

Effect of integrity of the posterior cortex in displaced femoral neck fractures on outcome after surgical fixation in young adults

Aim

To assess whether disruption of the posterior cortex of intracapsular femoral fractures leads to an increased incidence of complications following closed reduction and internal fixation by multiple cannulated screws in young adults.

Methods

A total of 146 consecutive adult patients with 146 femoral neck fractures were treated by closed reduction and internal fixation with parallel cannulated screw in inverted triangle or diamond configurations. All enrolled patients were divided into three groups: those with a non-displaced femoral neck fracture (Garden types I or II), those with a displaced femoral neck fracture (Garden types III or IV) but no posterior cortex disruption and those with a displaced femoral neck fracture (Garden types III or IV) and a disrupted posterior cortex.

Results

Based on an average follow-up of 4.76 years (range, 2-6 years), displaced femoral neck fractures with a disrupted posterior cortex demonstrated an increased risk for avascular necrosis of the femoral head, shortening, redisplacement and conversion of prosthetic replacement as compared with those fractures without posterior cortex disruption (p = 0.002, 0.016, 0.001 and <0.0001, respectively).

Conclusions

As compared with a femoral neck fracture with an intact posterior cortex, a displaced femoral neck fracture with a disrupted posterior cortex increases the risk for avascular necrosis, redisplacement and shortening and raises the likelihood that prosthetic replacement will be needed. Orthopaedic surgeons should be aware of this prognostic factor.     

The Significance of Evaluating the Femoral Head Blood Supply after Femoral Neck Fracture: A New Classification for Femoral Neck Fractures

ObjectiveTo compare a new classification with the Garden classification by exploring their relationships with vascular injury.MethodsThis retrospective study enrolled 73 patients with subcapital femoral neck fracture from July 2015 to November 2018, including 32 males and 41 females with an average age of 47.2 years. All patients were classified by the Garden classification using anteroposterior X‐ray imaging and by a new classification system based on three‐dimensional CT imaging. The blood supply of the affected femoral head in these patients was evaluated based on DSA images. Correlations between the two classifications and the degree of vascular injury were assessed.ResultsThe results of the DSA examination indicated that eight patients had no retinacular vessel injury, 20 patients had one retinacular vessel injury, 35 patients had two retinacular vessel injuries, and 10 patients had three retinacular vessel injuries. The degree of vascular injury was used to match the two fracture classifications. Forty‐nine Garden classifications (Type I‐IV: 8, 12, 23, 6, respectively, 67.12%) and 66 new classifications (Type I‐IV: 8, 20, 32, 6, respectively, 90.41%) corresponded to the degree of vascular injury (p < 0.05). The Garden classification showed moderate reliability, and the new classification showed near perfect agreement (Interobserver agreement of k = 0.564 [0.01] in Garden classification vs. Garden classification k = 0.902 [0.01] for the five observers).ConclusionsThe new classification system can accurately describe the degree of fracture displacement and judge the extent of vascular injury.     

Epidemiology of proximal femoral fractures

IntroductionWith increasing age, the incidence of proximal femoral fractures increases steadily. Although the different treatments are investigated frequently, little is known about the seasonal variation and predisposing factors. The purpose of this study is to investigate the epidemiology, the impact of femoroacetabular impingement, as well as the presence of osteoarthritis.MethodsWe performed a retrospective review of all patients with pertrochanteric, lateral and medial femoral neck fractures between 2012 and 2019. Inclusion criteria consisted of patients older than 18 years old who presented with isolated proximal femoral fractures without any congenital or hereditary deformity. For analysis, we assessed the demographics, season at time of accident, Kellgren-Lawrence score and corner edge (CE) angle.ResultsIn total, 187 patients were identified at a mean age of 75.1 ± 12.9 years old. Females consisted of 54.5% of this cohort. Most commonly, patients tend to present in winter with pertrochanteric fractures whereas no seasonal variation was found for medial femoral neck fractures. Significant correlations between season and age (regression coefficient −0.050 ± 0.021; p < 0.05) were identified. In medial neck fractures, the Gardner score was lower and Kellgren-Lawrence score higher for both female than males (p < 0.05). Patients with lateral neck fractures were significantly younger at 68.6 ± 12.5 years old (p < 0.05). In pertrochanteric fractures, the Kellgren-Lawrence score was significantly higher at 2.1 ± 0.8 (p < 0.05) with higher CE angle at 43.0 ± 7.6° (p = 0.14).ConclusionWith increasing incidences of proximal femoral fractures, it is essential to recognize potential risk factors. This allows for development of new guidelines and algorithm that can aid in diagnosis, prevention, and education for patients.     

Close Reduction Technique for Severely Displaced Radial Neck Fractures in Children

IntroductionRadial neck fractures account for 5–10% of paediatric elbow trauma. Radial neck fractures have been classified by Judet into five types (I–IVb). There is a global agreement to reduce radial neck fractures with angulation more than 30° (Type III, IVa and IVb). Various maneuvers have been described but none of them uniformly achieved complete reduction in severely displaced radial neck fractures (Type IVa and Type IVb Judet). In this case series, we are presenting our experience with close reduction of ten severely displaced paediatric radial neck fractures to achieve complete anatomical reduction.MethodsWe attempted close reduction in ten consecutive children with average age of 8.59 ± 1.68 years (range, 6–12 years) who presented with severely displaced radial neck fracture (Type IVa and IVb Judet). There were five girls. All patients had close injuries and presented to us within 24–48 h. One of the patients had associated undisplaced lateral condyle fracture. We have excluded two patients with associated elbow dislocation. Close reduction was performed within 48 h of initial injury.ResultsWe were able to obtain complete anatomical reduction in all of our patients with this technique. None of the patients required fixation of fracture. At 1 year of follow-up, (12 ± 2.07 months, range 9–16 months) all patients demonstrated almost full range of elbow and forearm motion. Final radiographs revealed complete union without any evidence of avascular necrosis.ConclusionThis technique offers an option of close reduction for the most severely displaced radial neck fractures, which were otherwise being treated by surgical intervention.Electronic Supplementary MaterialThe online version of this article (10.1007/s43465-020-00168-6) contains supplementary material, which is available to authorized users.     

Medial Buttress Plate and Allograft Bone‐Assisted Cannulated Screw Fixation for Unstable Femoral Neck Fracture with Posteromedial Comminution: A Retrospective Controlled Study

ObjectiveTo investigate the outcomes of open reduction and internal fixation combined with medial buttress plate (MBP) and allograft bone‐assisted cannulated screw (CS) fixation for patients with unstable femoral neck fracture with comminuted posteromedial cortex.MethodsIn a retrospective study of patients operated on for unstable femoral neck fractures with comminuted posteromedial cortex from March 2016 to August 2020, the clinical and radiographic outcomes of 48 patients treated with CS + MBP were compared with the outcomes of 54 patients treated with CS only. All patients in the CS + MBP group were fixed by three CS and MBP (one‐third tubular plates or reconstructive plates) with bone allografts. The surgery‐related outcomes and complications were evaluated, including operative time, blood loss, union time, femoral head necrosis, femoral neck shortening, and other complications after the operation. The Harris score was evaluated at 12 months after the operation.ResultsAll patients were followed up for 12–40 months. The average age of patients in the CS‐only group (54 cases, 22 females) and CS + MBP group (48 cases, 20 females) was 48.46 ± 7.26 and 48.73 ± 6.38 years, respectively. More intraoperative blood loss was observed in the CS + MBP group than that of patients in CS‐only group (153.45 ± 64.27 vs 21.86 ± 18.19 ml, t = 4.058, P = 0.015). The average operative time for patients in the CS + MBP group (75.35 ± 27.67 min) was almost double than that of patients in the CS‐only group (36.87 ± 15.39 min) (t = 2.455, P < 0.001). The Garden alignment index of patients treated by CS + MBP from type I to type IV was 79%, 19%, 2%, and 0%, respectively. On the contrary, they were 31%, 43%, 24% and 2% for those in the CS‐only group, respectively. The average healing times for the CS‐only and CS + MBP groups were 4.34 ± 1.46 and 3.65 ± 1.85 months (t = 1.650, P = 0.102), respectively. Femoral neck shortening was better in the CS + MBP group (1.40 ± 1.73 mm, 9/19) than that in the CS‐only group (4.33 ± 3.32 mm, 24/44). Significantly higher hip function was found in the CS + MBP group (85.60 ± 4.36 vs 82.47 ± 6.33, t = 1.899, P = 0.06). There was no statistical difference between femoral head necrosis (4% vs 11%, χ ² = 1.695, P = 0.193) and nonunion (6% vs 9%, χ ² = 0.318, P = 0.719).ConclusionFor unstable femoral neck fractures with comminuted posteromedial cortex, additional MBP combined with bone allografts showed better reduction quality and neck length control than CS fixation only, with longer operative time and more blood loss.     

Changes in radiological parameters during reduction of femoral neck fractures: A radiographic evaluation of cadavers

ObjectiveTo investigate changes in the Garden index and other radiological parameters during reduction of femoral neck fractures.MethodsTen healthy, human femoral specimens were obtained. A 2.0 mm diameter Kirschner wire was implanted in the centre of the femoral head. A perpendicular osteotomy was made in the middle of the femoral neck. The distal osteotomy surface was used as the angle of rotation (pronation and supination up to 90° at 10° intervals). Anterior-posterior and lateral view radiographs were taken at different angles. The Garden index and other relevant data were analysed using the picture archiving and communication system. Changes in the area of the femoral head fovea at different rotation angles were measured.ResultsThere were no significant differences in the Garden index between 0–30° of pronation and supination (p > .05). For angles of 40–90°, there were statistically significant differences in the Garden index (p < .05). The area of femoral head fovea decreased with increasing pronation angle, and increased with increasing supination angle.ConclusionsThe Garden index does not change significantly if the angle of fracture rotation is 0–30° (in either pronation or supination) during femoral neck fracture reduction. Therefore, it is impossible to judge the rotation of fracture in this range of angles. The Garden index can detect the rotation of fracture for rotation angles of 40–90° (in either pronation or supination). Changes in the area of the femoral head fovea can help determine the rotation of femoral neck fractures.Level of EvidenceLevel V.     

Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination,multicenter analysis

BackgroundThis study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture.MethodsThe ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed.ResultsIn total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate.ConclusionIpsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.     

Garden type I fractures myth or reality? A prospective study comparing CT scans with X-ray findings in Garden type I femoral neck fractures

The Garden type I femoral neck fracture is defined as an incomplete fracture of the neck of the femur as seen on the antero-posterior (AP) radiograph of the injured hip. The diagnosis of incomplete femoral neck fractures has decreased in recent years with the development of improved radiographic imaging. We hypothesized that incomplete femoral neck fractures seen on radiographs are in fact complete fractures on computed tomography (CT). The study aims to test this hypothesis by comparing CT scan images to X-ray findings in patients diagnosed with Garden type I femoral neck fractures. From January 2008 to October 2010, our management of femoral neck fractures included a CT scan of the injured hip for all Garden type I fractures. CT findings were reported by a musculoskeletal radiologist. A classification of the fracture was performed by an orthopedic surgeon. Eight hundred and twenty five femoral neck fractures were admitted during the study period. Seventeen of these fractures (2.1%) were considered incomplete based on radiographic evaluation. In 17 cases (100%), the CT scan demonstrated a complete fracture extending through the medial cortex. Subsequently, all 17 fractures were fixed with standard cannulated screw technique on a fracture table. Secondary displacement occurred in one patient prior to fixation. All fractures healed well and no avascular necrosis was noted. In summary, our study shows that incomplete femoral neck fractures identified on X-rays are actually complete fractures based on CT scans. If confirmed by a larger study population, our findings can simplify the Garden classification by eliminating an inaccurate subcategory. The clinical implications are that Garden type I fractures should all likely be fixed with cannulated screws and with an effort to prevent displacement during treatment.