Osteosynthesis of unstable pertrochanteric femoral fractures with the compression hip screw

Injuries of unstable pertrochanteric fractures of the upper femur represent a contingent with high multi-morbidity at highest average age. The only successful procedures within biologically set boundaries, would be those of an early and weight-bearing resistive osteo-synthesis. Starting in 1979 till the middle of 1982, we treated 70 unstable pertrochanteric fractures out of 350 proximal femur fractures, with this compression hip screw. Because of its underlying bio-mechanical principle, its advantageous operative handling, as well as high durability of the material used, this version of an osteosynthesis showed few complications. We found neither head penetration and pseudoarthrosis, nor did we find any implant bending and breaking so far. Although averaging almost 80 years, 63% of our patients could be released after hospitalization for an average of 39 days, leaving at full mobility. The set goal of an early weight-bearing with elderly patients was fully achieved by means of this version of osteo-synthesis, since dynamic compression of even comminuted fracture zones permitted a statically sound and unhindered possibility at weight-bearing.     

Follow-up results of osteosynthesis of medial femoral neck fractures with the dynamic hip screw

The operative treatment of subcapital femoral neck fractures of stages Garden III and IV in the young patient is still a problem. The current methods of osteosynthesis show a high rate of avascular necrosis of the femoral head. We controlled 24 patients with subcapital femoral neck fracture, who were treated with a dynamic hip screw (DHS). The average age of these patients is 55 years. They were examined after 30-89 months from the operation. All patients were assessed regarding clinical and radiological parameters. All of the six patients with femoral neck fractures of stages Garden I and II had no pain, their clinical results were good. In one of these patients we found a partial avascular necrosis of the femoral head. Four out of the 18 patients with femoral neck fractures of stages Garden III and IV had painful complications, 3 of them needed a reoperation. Fourteen patients of the group with femoral neck fractures of stages Garden III and IV had no pain and wer satisfied with the result. But in this group we found 7 patients with partial avascular necrosis of the femoral head. These results are discussed and compared with data published elsewhere.     

Crossed screw osteosynthesis of proximal humerus fractures

Between March 1997 and October 1999 thirty-one patients with displaced proximal humeral fractures were treated with crossed screw osteosynthesis. Insertion of the screws was realized by using a deltoideo-pectoral approach placing the screws anteriorly and posteriorly in a crossed manner from the distal fragment into the humeral head. Additionally, in all two-part-fractures a tension band was applied. In all three-part-fractures, the greater tuberosity was reattached by additional screws. In 21 patients (14 female, 7 male, median age 62 years, 18–86) a clinical and radiological follow-up (median 18 months, 10–29) was obtained. Fractures were classified as two-part-fractures in 10 patients and as three-part-fractures in 11 patients. According to the Constant-Score, “excellent” and “good” results were achieved in 15 patients, “moderate” results were found in 3 patients. However, in 3 patients results were only “poor” (1 two-part-, 2 three-part-fractures). The complication rate was 29% (premature hardware removal due to head perforation in 3 cases; humeral head necrosis necessitating prosthetic replacement in 2 patients; secondary displacement in 1 case). Crossed screw osteosynthesis represents an justified alternative in the surgical treatment of displaced proximal humeral fractures permitting early functional therapy.     

Evaluation of cruciate and slot auxiliary screw head design modifications for extracting stripped screw heads

Slotted and cruciate auxiliary screw head design modifications for "salvaging" a stripped hexagonal head screw were studied. Thirty screws were divided into 3 groups: Group 1 = control without modification, Group 2 = auxiliary cruciate design modification and Group 3 = auxiliary slot design modification. Screws were inserted into adhesive filled high-density synthetic bone tunnels using a hexagonal driver. Group 1 screws were removed using a hexagonal driver. Group 2 and group 3 screws were removed using drivers that matched their respective auxiliary design modifications. All group 1 and group 3 screws (100%) were effectively extracted. Three of 10 (30%) group 2 screws could not be effectively extracted. Group 2 screws displayed greater stripping and deformation than the other groups. The auxiliary slot design modification withstood comparable extraction torques as control screws without significant deformation. Screws with a cruciate design modification displayed more frequent failure, greater stripping and deformation.     

Trabecular metal screw implanted for avascular necrosis of the femoral head may complicate subsequent arthroplasty surgery

A trabecular metal screw has been suggested to treat avascular osteonecrosis of the femoral head. Non-surgical management with partial weight bearing can only be selected for early stages and very small lesions. Even in such cases, it has been proven to be ineffective in 80–90 % of patients. Conversely, the results with trabecular metal implants are not always clinically satisfactory, and some patients can show emerging pain and activity limitations that could require conversion to a total hip arthroplasty. Hereby we report the results of 6 patients who underwent this implant and describe the histopathology of the bone at the femoral neck and to speculate on the causes of complications encountered during arthroplasty surgery. The necrosis was stopped in 1 case, and 5 hips showed disease progression. Two protrusions of the screw apex were observed. In one case, rupture of the greater trochanter during prosthesis implant occurred. After trabecular metal implants for avascular osteonecrosis, some patients can require conversion to a total hip arthroplasty. Two patients had an intraoperative fracture with detachment of the greater trochanter that required wiring. Complications related to implant removal can be encountered, and the orthopedic surgeon should be aware of removal techniques.     

Using Naive Bayes Classifier to predict osteonecrosis of the femoral head with cannulated screw fixation

Predictive models permitting personalized prognostication for patients with cannulated screw fixation for the femoral neck fracture before operation are lacking. The objective of this study was to train, test, and cross-validate a Naive Bayes Classifier to predict the occurrence of postoperative osteonecrosis of cannulated screw fixation before the patient underwent the operation. The data for the classifier model were obtained from a ambispective cohort of 120 patients who had undergone closed reduction and cannulated screw fixation from January 2011 to June 2013. Three spatial displaced parameters of femoral neck: displacement of centre of femoral head, displacement of deepest of femoral head foveae and rotational displacement were measured from preoperative CT scans using a 3-dimensional software. The Naive Bayes Classifier was modelled with age, gender, side of fractures, mechanism of injury, preoperative traction, Pauwels angle and the three spatial parameters. After modelling, the ten-fold cross-validation method was used in this study to validate its performance. The ten-fold cross-validation method uses the whole dataset to be trained and tested by the given algorithm. Two of the three spatial parameters of femoral neck (displacement of center of femoral head and rotational displacement) were included successfully in the final Naive Bayes Classifier. The Classifier achieved good performance of the accuracy (74.4%), sensitivity (74.2%), specificity (75%), positive predictive value (92%), negative predictive value (42.9%) and AUC (0.746). We showed that the Naive Bayes Classifier have the potential utility to be used to predict the osteonecrosis of femoral head within 5 years after surgery. Although this study population was restricted to patients treated with cannulated screws fixation, Bayesian-derived models may be developed for application to patients with other surgical procedures at risk of osteonecrosis.     

Subchondral screw fixation of cervical hip fractures: joint congruence studied with combined arthrography and tomography

This study was done to determine whether fixation with the Uppsala internal fixation technique into the subchondral bone of the femoral head in the treatment of cervical hip fractures could lead to elevation of the femoral head cartilage. Combined arthrography and frontal tomography of the hip joint in the plane of the screws was performed. The series consisted of 16 patients. In two of the patients, the tips of the screws had penetrated into the cartilage of the femoral head. In the other 14, the internal fixation was technically correct with the tips of the screws in the subchondral bone. In the two hips with the screws penetrating into the cartilage, the cartilage was slightly elevated. In the hips where the screws were in the correct position, no incongruities or deformity in the cartilage could be detected. Combined arthrography and frontal tomography can, therefore, detect elevation of the cartilage of the femoral head. By placing the screws in the immediate subchondral bone, no elevation of the cartilage of the femoral head surface should occur.     

Migration of the lag screw within the femoral head: a comparison of the intramedullary hip screw and the Gamma Asia-Pacific nail

OBJECTIVES: To study the functional difference in the performances of sliding femoral head screws by comparing the displacement of the screw in relation to the femoral head in hips treated with the Gamma Asia-Pacific nail (GN) and hips treated with the intramedullary hip screw (IMHS). STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Displacement of the femoral head screw in relation to the femoral head was measured in fifty-six elderly patients with intertrochanteric fractures who were treated with an IMHS or GN. Displacement of the femoral head screw was determined by comparing screw position in the immediate postoperative radiograph with a film taken 3 months after surgery. RESULTS: In the GN group, significant displacement of the screw was observed with 3.8 +/- 3.8 percent translation in the horizontal axis (P < 0.005) and 4.3 +/- 5.1 percent displacement in the vertical axis (P < 0.05) in comparison with the diameter of the femoral head. In comparison, displacement of the femoral head screw was not observed with the IMHS (P = 0.48 for horizontal, P = 0.18 for vertical). Total displacement of the femoral head screw in relation to the femoral head in the GN was twice that observed in the IMHS (P < 0.001). CONCLUSION: These results indicate that the displacement of the femoral head screw of the IMHS was less than the lag screw of the GN. However, it is still unknown whether this smaller displacement of the IMHS is clinically significant for reducing the rate of screw cut-out after surgery.     

Intertrochanteric fractures of the hip treated with the hip compression screw: analysis of problems.

Seventy-five patients were treated for intertrochanteric hip fractures with the hip compression screw. There were 4 cases in which the lag screw was inserted twice into the femoral head. Three of these patients had a poor result due to superolateral migration and extrusion of the lag screw. The fact that the lag screw is large in comparison to the femoral head makes double placement dangerous. Satisfactory guide wire placement is essential for a one time, precise insertion of the lag screw into the femoral head. The use of a threaded tip guide wire minimizes the chance of it falling out when withdrawing the reamer or tap. If the position of a lag screw is unacceptable, it seems better to insert a flanged nail rather than a second screw in a second track.     

Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture

Sixteen consecutive patients with cutout of a lag screw of a dynamic hip screw fixation in an intertrochanteric fracture were treated with reinsertion of a lag screw, bone cement supplementation in the neck-trochanter, and subtrochanteric valgus osteotomy. Postoperatively, patients were permitted to ambulate with protected weight-bearing. Fourteen patients were followed-up for at least 1 year (median 2 years; range 1–3 years), and all had a solid union. The union period took a median of 5 months, with a range of 3–7 months. Usually, union of an intertrochanteric fracture was faster than that of subtrochanteric osteotomy (P < 0.01). There were no complications of wound infection, loss of reduction, cutout of a lag screw, or osteonecrosis of the femoral head. From clinical and theoretical considerations, we conclude that despite cutout of a lag screw of a dynamic hip screw fixation being difficult to treat, out technique still can provide an excellent outcome. Therefore, we strongly recommend its wide use. Received: 7 February 1997     

空心钉联合同种异体腓骨内固定治疗中青年股骨颈骨折临床初步观察

目的探讨空心钉联合同种异体腓骨内固定治疗中青年股骨颈骨折的初步疗效。方法采用同种异体腓骨植入股骨头前外侧,并以两枚AO空心钉固定治疗中青年股骨颈骨折。结果经临床应用40例40个髋关节,初步随访24～84个月,平均48．5个月,15例出现坏死症状,5例晚期塌陷,塌陷率12．5％,3例塌陷进展行全髋关节置换,髋关节Harris功能评分,优良率92．5％。结论空心钉联合同种异体腓骨内固定治疗中青年股骨颈骨折具有以下优点：（1）促进股骨颈骨折愈合预防骨不连及股骨颈短缩;（2）增加股骨头负重区软骨下骨的机械支撑,分散传导局部应力,提供有效的头内稳定性,利于坏死修复,尽早预防股骨头坏死后塌陷或塌陷进展;（3）增加固定稳定性,可早期下地活动。该手术方法简单、疗效可靠,尤其适用于中青年股骨颈移位或粉碎性骨质缺损骨折。     

Compression hip screw fixation with bone cement in trochanteric fractures

Internal fixation with compression hip screw (DHS) of trochanteric fractures in osteoporotic patients may be followed by failure of fixation. The most common failure is represented by the "cut-out" of the screw. This complication may occur in 4-10% of unstable trochanteric fractures. In order to avoid such a problem we chose a technical solution that offers a good fixation of the screw in the femoral head. The technique, described by Bartucci, was used in a 78 years old female with unstable trochanteric fracture and severe osteoporosis. The postoperative result was very good and no mechanical complications were noted. We consider that the technique of augmentation of fixation using acrylic bone cement may be a solution in such cases.     

Treatment of subtrochanteric femur fractures using the dynamic condylar screw

Thirty-two consecutive subtrochanteric femur fractures were treated using the 95 degree dynamic condylar screw between 1982 and 1985. All fractures were classified according to the radiographic criteria of Seinsheimer. Twenty-two patients were available for follow-up study, with an average time of 23.8 months. Functional results were rated using a new traumatic hip score rating system. The overall union rate was 77.3% (17/22), with functional results rated as excellent or good in 68% (15/22). All five technical failures were associated with extensive bony comminution. Four of these failures were not bone grafted. There were no cases of screw penetration of the femoral head or neck. The indications for the use of this device include transverse, short, and long oblique subtrochanteric fractures, with or without lesser trochanteric avulsion. When excessive comminution exists, this device should not be employed.     

Subchondral screw fixation for femoral neck fractures

We describe a method of internal fixation for femoral neck fractures which has been newly developed to reduce the frequency of early complications. Two cannulated screws are inserted in the axis of the femoral neck to reach into the subchondral bone of the femoral head. The screws are inserted over guide pins and the tip of the screw is self-tapping and designed to provide good anchorage in the femoral head. We used this method in 44 consecutive patients in a prospective study with no exclusions, followed for a minimum of 24 months. All fractures healed within 12 months, and there were no cases of early loosening or nonunion. In four cases, late segmental collapse had developed during the mean follow-up period of 30 months.     

Ankle arthrodesis using internal screw fixation

Ankle arthrodesis treated by external fixation frequently results in complications from pin tract infections, loss of position, nonunion, and malunion. A method of ankle arthrodesis using 6.5-mm cancellous screws as the primary fixation hardware was developed. The most important screw is placed from the posterior malleolus into the neck and head of the talus, and medial and lateral malleolar screws are added to secure fixation. Near-normal anatomy is maintained with this technique because little or no bone, only cartilage, is removed. Earlier cases were all done through an anterior approach. Later, special techniques were developed for placing screws and strain-relieving bone grafting was added to promote union. Twenty-three cases that were treated by the earlier technique are reviewed. The overall fusion rate was 74%. Three conditions (avascular talus, pyarthrosis, and spasticity) were identified that placed patients at high risk for failure of fusion. Of the patients who were not in a high-risk group, only one had a delayed union. When the high-risk patients were not included in the statistics, the fusion rate was 93%. The evolved technique shows great promise for accurate and trouble-free ankle arthrodesis.     

国产可吸收钉治疗股骨头骨折的实验研究及临床评价

目的: 观察国产可吸收钉关节内植入后对周围组织的影响, 评价其在治疗股骨头骨折中的临床疗效。方法: 新西兰兔 6只于两侧膝关节内分别植入可吸收钉及金属钉; 4、8、12周后取标本, 行大体及组织学观察。临床 45例股骨头骨折患者采用国产可吸收钉固定。结果: 可吸收钉植入组, 仅表现组织对异物的正常反应; 金属钉组见关节软骨有明显的机械性损伤。45例患者, 随访 12~28个月, 优良率为 93%, 未发现不良反应。结论: 国产可吸收钉是治疗股骨头骨折理想的内固定物。     

Clinical experience of the management for the most severely head—injured patients with GCS score of 3

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股骨颈骨折闭合复位内固定疗效分析

目的评估闭合复位空心螺钉内固定治疗股骨颈骨折的临床疗效。方法对41例新鲜股骨颈骨折的患者行闭合复位经皮空心钉内固定术。骨折按Garden分型:Ⅰ型2例,Ⅱ型12例,Ⅲ型20例,Ⅳ型7例。观察术后骨折愈合、髋部功能状态以及术后并发症情况。结果随访12.0～40.0个月,平均26.0个月,38例(92.7%)骨折获骨性愈合,骨折不愈合2例,股骨头坏死1例。结论闭合复位加压空心钉内固定治疗股骨颈骨折操作简单、疗效可靠、不切开关节囊、不暴露骨折端、对股骨头血液循环干扰小。     

钽棒植入治疗成人早期股骨头坏死

目的：探讨一种简单有效治疗成人早期股骨头缺血性坏死的新方法,以避免股骨头进一步塌陷和坏死,改善临床症状。方法：自2009年1月至2010年6月采用钽棒植入治疗9例（10髋）成人早期股骨头坏死,男7例,女2例;年龄29～63岁,平均44.1岁。术前均摄髋关节正侧位X线片,行CT和MRI扫描。按Steinberg分期：Ⅰ期1例1髋,Ⅱa期4例5髋,Ⅱb期4例4髋。手术在C形臂X线机定位下进行,从股骨大转子下钻入导针到股骨头坏死区中心,空心钻沿导针扩髓,刮除坏死区死骨,必要时植骨,选择合适长度的钽棒拧入,支撑坏死区关节面。术后3、6、9个月随访,采用JOA评分标准评价临床疗效,摄髋关节正侧位X线片,观察股骨头变化。结果：手术时间40～60min,平均50min;出血量60～100ml,平均80ml。术后无感染、骨折及下肢深静脉血栓形成等并发症,全部病例获得随访,时间9个月及以上,定期行X线检查未发现股骨头塌陷和坏死加重。JOA评分从术前平均（31.30±19.63）分增加至术后3个月平均（54.10±13.20）分,术后6个月（69.90±15.04）分,术后9个月（87.00±8.83）分。结论：钽棒植入治疗成人早期股骨头坏死手术简单易行,能有效避免坏死区股骨头塌陷,近期疗效满意。     

Ca of the head of the pancreas and the ampulla of Vater (150 cases) (author's transl)]

From 1968 till 1977 we observed 150 patients with carcinoma of the head of the pancreas and the ampulla of Vater. In 29% a radical operation (duodeno-pancreatectomy) could be practiced. The prognosis of carcinoma of the head of the pancreas is much less favourable in comparison to the carcinoma of the ampulla of Vater.