A3 Fractures Research Articles

A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures.

To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). Prospective, randomized, multicenter clinical trial. Five level 1 trauma centers. Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. Computer generated randomization to either IT (n = 123) or SHS (n = 126). The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A Comparative Study to Assess the Preoperative Thickness of Lateral Trochanteric Wall as a Predictor of Postoperative Lateral Wall Fracture in Intertrochanteric Fracture Treated by Dynamic Hip Screw

The aim of this study was to assess the preoperative thickness lateral trochanteric wall as a predictor of postoperative lateral wall fracture in intertrochanteric fracture treated by dynamic hip screw fixation. A Radiograph based Comparative study involved 66 patients with intertrochanteric fracture treated by dynamic hip screw fixation. All patients had an intact lateral wall preoperatively and were AO/OTA 31 A1 and AO/OTA 31 A2 fractures. Mean age of the patients was 75 years. All patients were followed up with x-ray at 1 month and 6 months postoperatively. Age, gender, side of fracture, type of fracture as per AO/OTA classification, the pre-operative thickness of the lateral trochanteric wall, the tip-apex distance and the status of the trochanteric wall after 6 months from surgery were subjected to analysis. Radiographs were retrieved from the Picture Archive and Communication System and thickness of the lateral wall calculated. Measurements were corrected for magnification using the radiological magnification factor. Of the 66 patients, a fracture of the lateral wall occurred in 26 patients (39.39%). The lateral was intact in 40 patients (60.61%). The mean pre-operative thickness of the lateral wall of the 26 patients with a lateral wall fracture was 17.8 mm (SD-6.45) compared to 26.9 mm (SD-6.93) in 40 patients without a lateral wall fracture. The mean thickness of trochanteric wall in 39 patients with A1 fracture was 27.5 mm (SD=7.17) whereas the mean thickness in A2 type fracture (27 cases) was 17.3 mm (SD=4.88).74.07% of patients with A2 type fracture developed a fracture of the lateral wall whereas only 15.38% of A1 type fracture had a fracture of lateral wall after a six months follow-up. Factors like age at the time of operation, gender, side of fracture, tip-apex distance (if less than 25 mm) has no significant relation with development of post-operative lateral wall fracture. In summary, when the lateral wall thickness is less than 20.55 mm there is significantly high chance of lateral wall getting fractured if fixed with a DHS alone.

Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations.

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip. Relevant papers were identified from appropriate clinical databases and a narrative review was undertaken. Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their anatomical and biomechanical characteristics, as do the implants used for their fixation. The optimal choice of implant addresses the stability of the fracture and affects the outcome. The treatment of intertrochanteric fractures of the hip has evolved along with changes in the design of the implants used to fix them, but there remains conflicting evidence to guide the choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all others with an intramedullary device. Cite this article: Bone Joint J 2017;99-B:128-33.

Functional and radiological outcomes of thoracolumbar traumatic spine fractures managed conservatively according to Thoracolumbar Injury Severity Score.

Aim:To study the functional and radiological outcomes in cases managed conservatively for single-level traumatic thoracolumbar spine fractures without neurological deficit.Materials and Methods:In this prospective study design, thirty patients who presented to tertiary care hospital and diagnosed with posttraumatic thoracolumbar vertebral fracture without any neurodeficit were recruited. All the patients were managed conservatively as per the protocol which included bed rest, spinal braces, and physiotherapy. Adequate analgesia was given wherever necessary. The patients were followed at regular intervals up to a maximum of 2 years. Clinically visual analog scale (VAS) score and Roland Morris Disability Questionnaire (RMDQ)-24 were assessed and radiologically local vertebral kyphosis, scoliosis, and loss of body height were noted at each follow-up.Results:The data was statistically analyzed and the results were as follows. Thoracolumbar fractures were more in young adults (<26 years) and more so among the males (80% cases). The most common fracture type in our study was compression fracture. The most common site involved in our study was L1 vertebra (36.7%). There was a significant decrease of VAS score (pain score) in 79% cases with the maximum decrease in type A1 fracture. The mean RMDQ-4 score in our study was 5.53. The overall progression of kyphosis was 1.9°. There was no relation found between the kyphotic deformity and the clinical outcomes (VAS and RMDQ-24 scores). Canal size changes were found to be insignificant at the end of 2 years compared to baseline.Conclusion:Study showed favorable outcomes in terms of return to daily activities, making it a good option in managing Type A1 dorsolumbar fractures. Though there was a progression of kyphosis but no neurological deficit was seen.

Obliged Removal of the Percutaneous Fixation System on the Thoracolumbar Junction in Patients with Idiopathic Scoliosis

Introduction: Minimally invasive percutaneous surgery of the spine is used to treat thoracolumbar junction and lumbar spine fractures by percutaneous fixation. Once fusion has been obtained, it is possible to remove the percutaneous instrumentation after 6 - 12 months. We report the case of an obliged removal of the fixation system at 12 months following operation in a patient with a pre-existing compensated and asymptomatic idiopathic scoliosis. Case Presentation: A 48-year-old patient affected by a compensated asymptomatic idiopathic scoliosis with an L3 type A3 fracture. The patient underwent a percutaneous short fixation L2 - L4. In the following months the patient presented progressive worsening of the low back pain and walking difficulties. The percutaneous fixation system was then removed using the same surgical access. Conclusions: This particular case explains well the importance of biomechanical balance when a spinal fixation should be perform, and demonstrate how an underestimation of this aspect may cause a worsening of symptoms even if the surgical procedure was correctly performed. It is evident that the removal procedure can lead clinical benefit to a patient, in which the fixation system created a decompensation of the curvature of the spine, thus causing biomechanical alterations and generating pain. In these cases, it may be opportune to limit the fracture reduction during the surgical procedure to modify the least possible the pre-existing scoliosis and to increase the patient’s comfort after the operation. The biomechanical behaviour of the spine is specific for each patient so only a careful detection of it could lead to an optimal therapeutic result.

Femoral Medialization, Fixation Failures, and Functional Outcome in Trochanteric Hip Fractures Treated With Either a Sliding Hip Screw or an Intramedullary Nail From Within a Randomized Trial.

The aim of this study was to determine if femoral medialization influences residual pain and mobility and to determine if fixation method or fracture pattern influences the tendency to medialize. This study used data from within a randomized controlled trial. Peterborough City Hospital, UK. Eight hundred forty-four patients presenting with a trochanteric hip fracture were randomized. Five hundred thirty-eight were available for 1-year follow-up. Fractures were classified according to OTA/AO classification as 31 A1, A2, and A3. Randomized to fixation with a Targon proximal femoral nail or sliding hip screw (SHS). Femoral medialization was calculated from follow-up x-rays at a minimum of 28 days post-fixation. Pain and mobility scores were assessed at 1 year by an independent blinded observer. Fixation failure and revision procedures were assessed at a minimum of 1 year from injury. Patients with >50% medialization had worse pain (P = 0.012) and mobility scores (P = 0.013) at 1 year. They also had more fracture healing complications (P = 0.021) and required more revision procedures (P = 0.014). Fractures treated with SHS were more likely to medialize >50% compared with intramedullary nail (P < 0.001). A2 and A3 fractures were more likely to medialize, and A3 fractures were more likely to undergo >50% medialization (P < 0.001). Our study demonstrates the previously theoretical predisposition for unstable hip fractures treated with SHS to undergo femoral medialization and correlates this with worse functional outcomes. It supports the use of intramedullary nails for A3 fractures, which have a significant tendency to medialize. Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

PFNA-II protrusion over the greater trochanter in the Asian population used in proximal femoral fractures.

Background:The treatment of proximal femoral fractures in geriatric osteoporotic patients continues to be a challenge in orthopaedic trauma. Various kinds of cephalomedullary nails, such as gamma nail, InterTan and PFNA were used clinically. The latest generation PFNA II, specially designed for Asian population, is commonly used for geriatric per-/intertrochanteric fractures. The aim of this study was to determine whether the current PFNA-II proximal segment length is suitable for the greater trochanter height, as assessed by postoperative radiograph measurements.Materials and Methods:51 consecutive patients with per-/intertrochanteric fractures treated with the PFNA-II between July 2012 and December 2012 were enrolled in this study. There were 19 males and 32 females, with an average age of 78.6 years (range 66–92 years). According to AO/OTA classification system, there were 4 cases of 31A1 fractures, 35 cases of 31A2 fractures, and 12 cases of 31A3 fractures. The nail protrusion height over the lateral greater trochanter and the Parker ratio of the helical blade tip in the femoral head were measured and compared using pelvic digital anteroposterior radiographs taken within 2 weeks postoperatively. Patients were followed up for a minimum period of 1 year to check whether they had lateral trochanter pain.Results:Postoperative digital anteroposterior (AP) films were used for assessment and any prominence was recorded as positive. Overall, nail protrusion over the greater trochanter occurred in 87.8% of cases. In 60.8% of the cases, protrusion height was >5 mm. The average protrusion height was 6.25 ± 4.27 mm (male average 4.84 ± 4.38 mm, and female average 7.09 ± 4.70 mm). The average Parker ratio of all cases was 51.0 ± 6.9% (male average 49.8 ± 7.5% and female average 51.7 ± 6.5%). Protrusion height was positively correlated (r = 0.394, P = 0.004) with the helical blade position in the femoral head (Parker ratio). Clinically, a total of 42 patients were followed up at an average of 15.0 ± 2.6 months (range 12–24 months) they were able to walk independently or with a stick. There were 13 patients with lateral trochanter pain on the injured side. Protrusion height of these patients was 11.13 ± 3.75 mm, whereas the protrusion height of the remaining 29 patients was 3.87 ± 3.39 mm.Conclusions:There was a morphologic mismatch between the proximal segment length of the PFNA-II and the greater trochanter in the Asian population, which may be the cause of postoperative lateral trochanter pain. A modification to shorten the proximal part of the nail is proposed to avoid protrusion over the greater trochanter.

Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis

BackgroundIn this study we describe the morphology of the posteromedial fragment in pertrochanteric fractures using 3D CT scans and answer two questions 1) Do differences exist between the 3D CT appearances of posteromedial fragments and the depictions made in the AO classification 2) Does the posteromedial fragment affect stability in pertrochanteric fractures, in terms of fracture collapse? MethodsPreoperative CT scans of eight 31-A1 and fifty 31-A2 fractures were analysed. The presence of PM fragment, its fragmentation, greater trochanter (GT) involvement, lesser trochanter (LT) fragment size (in terms of its posterior and medial extent as well as LT length), LT fragment displacement (in terms of medial displacement and rotation) were determined. All fractures were treated with a DHS. Fracture collapse was determined on postoperative radiographs. The relationship between fracture collapse and patient factors including age, gender, fracture type (A1 versus A2), characteristics of the posteromedial fragment, and the presence of a lateral wall fracture were determined. ResultsThree out of eight 31-A1 fractures demonstrated a separate GT fragment (three part fracture). Out of the 50 31-A2 fractures, 12 had a single PM fragment, which included the LT and GT in continuity. The more common four part fractures seem to form by further fragmentation of this basic form. In A2 fractures, the GT was almost always broken and the broken fragment comprised a mean 56% of normal GT. The LT fragment involved an average of 74% of the posterior wall, and an average of 36% of the medial wall of the proximal femur. Larger LT fragments were less displaced as compared to smaller fragments. Univariate regression analyses revealed that fracture collapse was significantly correlated with fracture type (A1 versus A2, p 0.036), GT size (p 0.002) and the presence of a lateral wall fracture (p<0.001). ConclusionsThis study revealed some important differences between the 3D CT appearances and AO classification of pertrochanteric fractures. Further, neither fragmentation of the posteromedial fragment, nor the size of the lesser trochanter fragment was found to predict stability in pertrochanteric fractures. A perioperative lateral wall fracture is the main determinant of stability in these fractures.

Integrated risk scoring model for predicting dynamic hip screw treatment outcome of intertrochanteric fracture

BackgroundDynamic hip screw (DHS) is a common device for treating intertrochanteric fracture (ITF). Various risk factors have been reported to be associated with the operative treatment outcome. However, an integrated risk scoring prediction model is lacking. In this study, we aimed to develop a prediction model for treatment outcome of intertrochanteric fracture. MethodsWe analyzed 442 AO/OTA 31-A1 and A2 fractures which were treated with DHS during the period January 2000 to June 2014 in a level I trauma center. Risk factors including age, gender, injured side, lag screw position, AO/OTA classification, tip-apex distance, postoperative lateral wall fracture, reduction patterns were analyzed to determine their influence on treatment outcome. Integrated risk scores of significant predictors were used to construct a prediction model. ResultsAO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. The failure risk for low- and high-risk groups were significantly different (P<0.001) ConclusionAO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. We developed a model that integrates these factors to predict the treatment outcome, which had excellent prediction accuracy and discriminatory ability. The models may provide useful information for orthopedic doctors to identify patients who need early intervention as well as ITF patients who require more frequent follow-up in the postoperative period.

A Study of Conservative Treatment for Colles’ Fractures Using the Novel Classification by Lateral Radiographic View

Objective: The objective of this study is to elucidate the changes in radiographic parameters over time in conservative treatment of Colles’ fractures. Participants and Methods: The participants were 60 patients with Colles’ fractures (60 wrists) that were treated conservatively. They were l3 males and 47 females with a mean age of 72.5 years (range, 55-96 years). Based on the AO Foundation and Orthopaedic Trauma Association (AO/OTA) fracture and dislocation classification, the numbers of patients with type A2, A3, Cl, C2, and C3 fractures were 33, 5, 5, l2, and 5, respectively. The cause of injury was limited to a fall from eye height, and we excluded patients with a concurrent fracture of the distal ulnar metaphysis and patients with comminution of the palmar cortex. All the patients underwent manipulative reduction immediately after diagnosis. We focused on the palmar cortex in lateral radiographic views to classify the fractures into the intramedullary type, the anatomical type, and the extramedullary type, and measured the palmar tilt (PT), radial inclination (RI), and ulnar variance (UV) at the time of injury, immediately after reduction, and in final observation. Statistical Analysis: We analyzed the correction loss of PT, RI, and UV by Tukey-Kramer after one-way analysis of variance (ANOVA). Results: The fracture types immediately after reduction were the intramedullary type in 11 patients, the anatomical type in 42 patients, and the extramedullary type in 7 patients. The correction loss in PT and in RI was negative in each group, with no significant differences among the 3 groups, whereas UV was positive in each group. The correction loss was significantly greater in the intramedullary group than in the anatomical group and the extramedullary group. Conclusion: We analyzed radiographic parameter changes over time associated with reduced position in the conservative treatment of Colles’ fractures. The correction loss in UV immediately after reduction until the final observation was significantly greater in the intramedullary group than in the anatomical group and the extramedullary group.

A Study of Management of Supracondylar Femur Fractures by Supracondylar Nail

Aims and Objective: To study the incidence and pattern of supracondylar femur fractures according to AO/ASIF classification, to assess the treatment and long-term functional outcome for supracondylar femoral fracture using retrograde nail. Methods: In the present study twenty supracondylar femur shaft fractures were treated by retrograde nail. Of these, four were females and sixteen were males, in the age group of 20 to 70 years. Fractures were classified according to Mullers. 40% were Type A2 fractures, 20% were Type A3, 20% were Type C1, 15% were Type C2 and 5% were Type C3. All the cases were operated with retrograde intramedullary nailing using patellar splitting approach. Results: Most common mechanism of injury was motor vehicles accidents associated with high energy trauma 12 cases (60%). Five were open fractures whereas fifteen were closed. The fractures were comminuted in 30% cases whereas 30% presented with a transverse pattern. 25% were oblique fractures and only one spiral fracture occurred in our series. The average range of knee motion in our series was 92.5 degrees. Knee stiffness occurred in one patient of type C3 fracture. There were two cases of significant shortening, one was 1.8 cms and the other was 3.1 cms, both occurred in type C2 comminuted fractures, it did not cause any morbidity and was corrected by shoe raise. The risk of infection and non-union were low. The incidence and severity of significant malunion was nil. It offers a short hospital stay, early mobilization and predictable healing. Conclusion: Supracondylar nail is an excellent option for management of supracondylar femur fractures even in those with intercondylar extension.

Percutaneous pedicle screw fixation plus kyphoplasty for thoracolumbar fractures A2, A3 and B2.

Retrospective cohort. The aim of this study is to evaluate the effectiveness of percutaneous short fixation (PSFx) plus kyphoplasty (BP) for thoracolumbar fractures. Thirty-six consecutive selected patients, aged 59±17years, with fresh single thoracolumbar A2, A3, and B2 AO-type fracture, received PSFx plus BP. The primary outcomes pain, and vertebral body deformity; and the secondary outcomes screw malposition, facet violation, PMMA leakage, adjacent segment degeneration (ASD) and loss of correction were evaluated. The f/up was 31±7months. Pain and kyphosis decreased and vertebral body heights increased significantly postoperation. PMMA leakage occurred in five cases; 6 (4%) screws were grades III malpositioned in relation to pedicle; facet violation occurred in 8 (5.5%) facets; loss of kyphosis correction was 3.68°; ASD occurred in two cases; interfacet fusion in ten (28%) patients; Three patients were reoperated for different reasons. PSFx plus BP for thoracolumbar fractures reduces significantly spinal deformity and pain with few complications.

Long endomedullary nail in proximal third humeral shaft fractures

IntroductionProximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new “Long” humeral nail for this type of lesion and identify the best distal locking. Materials and methodsForty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four‐part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. ResultsImprovements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. ConclusionsThe results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. Study designretrospective, cohort of cases. Level of evidenceIV.

Which patients risk segmental kyphosis after short segment thoracolumbar fracture fixation with intermediate screws?

IntroductionThe use of intermediate screws in fractured vertebrae has been proposed to decrease the number of fused levels in thoracolumbar fractures and to enable short fixations. The aim of this study was to evaluate the results of this technique and to establish predictive factors involved in loss of segmental kyphosis correction (LKC). MethodsForty-three patients who underwent short-segment spinal fixation with intermediate screws for a thoracolumbar spine fracture in a two-year time period were enrolled in the study. Patients had AO-type A3, A4 and B2 thoracolumbar fractures. Radiological parameters included segmental kyphosis (SK), vertebral wedge angle (VWA) and loss of anterior and posterior vertebral body height. Patients were evaluated up to one-year follow-up. The correlation between LKC and potential risk factors, such as smoking habit, sex, age, neurological status and BMI was evaluated. ResultsMean preoperative SK was 16.5°±6.5°, and it decreased to 3.4°±3.5° postoperatively (P<0.01). At the one-year follow-up mean SK dropped to 5.5°±3.9° (P<0.01). Mean preoperative VWA was 20.0°±8.1°, and significantly improved to 6.3°±3.1° after surgery (P<0.01). There was a mean LKC of 1.8°±2.1°at one year. LKC mildly correlated with body mass index (BMI, r: +0.31), and obese patients (BMI>30) had an increased risk of LKC at the one-year follow-up (P=0.03; odds ratio [OR]=3.2). DiscussionAnalysis of the radiological data at one-year follow-up showed that all the evaluated parameters were associated with a mild loss of correction, with no impact on the clinical outcomes or implant failure. These findings confirm the trends reported in the literature. The correlation between LKC and clinical features, such as BMI, age, sex, smoking habit and preoperative neurological status was investigated. Interestingly, a positive correlation was observed between BMI and LKC, and obese patients with BMI>30 had an increased risk of LKC at one-year follow-up (OR 3.2); to our knowledge this finding has never before been reported. ConclusionShort-segment fixation with intermediate screws is a viable technique with positive clinical and radiological outcomes at one-year follow-up. However, surgeons should be aware that in obese patients (BMI>30) this technique is associated with an increased risk of LKC. Level of evidence3.

Intramedullary nailing for correction of post-traumatic deformity in late-diagnosed distal radius fractures

BackgroundPost-traumatic deformity of the distal radius may lead to multiple sequelae and severe functional impairment. Intramedullary fixation is a novel technique for treatment of distal radius fractures. The present study aimed to evaluate the functional and radiographic outcomes of intramedullary nailing for correction of post-traumatic deformity in late-diagnosed fractures of the distal radius.Materials and methodsFrom July 2009 to February 2011, 16 patients with late-diagnosed displaced fractures of the distal radius were included. Eligible inclusion was extra-articular fracture for more than 4 weeks. Surgical correction and internal fixation with intramedullary nailing was performed for treatment of ten AO type A2 and six AO type A3 fractures. All patients were followed up radiographically and clinically for an average of 20.3 months.ResultsAll fractures achieved bone union without major complications. Functional status and radiographic alignment significantly improved postoperatively. There was no significantly secondary displacement comparing early postoperative and final radiographic parameters. The functional results according to the Mayo wrist scoring system were good or excellent in 94 % of patients. The mean score was 83.8.ConclusionSurgical correction and internal fixation with the intramedullary nail is a feasible and less invasive technique with few complications in the treatment of post-traumatic deformity of the distal radius.Level of evidenceIV.

The epidemiology of thoracolumbar trauma: A meta-analysis

PurposeTo describe the epidemiology of thoracolumbar fractures and associated injuries in blunt trauma patients. MethodsA systematic review and metaanalysis was performed based on a MEDLINE database search using MeSH terms for studies matching our inclusion criteria. The search yielded 21 full-length articles, each sub-grouped according to content. Data extraction and multiple analyses were performed on descriptive data. ResultsThe rate of thoracolumbar fracture in blunt trauma patients was 6.90% (±3.77, 95% CI). The rate of spinal cord injury was 26.56% (±10.70), and non-contiguous cervical spine fracture occurred in 10.49% (±4.17). Associated injury was as follows: abdominal trauma 7.63% (±9.74), thoracic trauma 22.64% (±13.94), pelvic trauma 9.39% (±6.45), extremity trauma 18.26% (±5.95), and head trauma 12.96% (±2.01). Studies that included cervical spine fracture with thoracolumbar fracture had the following rates of associated trauma: 3.78% (±5.94) abdominal trauma, 21.65% (±16.79) thoracic trauma, 3.62% (±1.07) pelvic trauma, 18.36% (±4.94) extremity trauma, and 15.45% (±11.70) head trauma. A subgroup of flexion distraction injuries showed an associated intra-abdominal injury rate of 38.70% (±13.30). The most common vertebra injured was L1 at a rate of 34.40% (±15.90). T7 was the most common non-junctional vertebra injured at 3.90% (±1.09). Burst/AO type A3 fractures were the most common morphology 39.50% (±16.30) followed by 33.60% (±15.10) compression/AO type A1, 14.20% (±8.08) fracture dislocation/AO type C, and 6.96% (±3.50) flexion distraction/AO type B. The most common etiology for a thoracolumbar fracture was motor vehicle collision 36.70% (±5.35), followed by high-energy fall 31.70% (±6.70). ConclusionsHere we report the incidence of thoracolumbar fracture in blunt trauma and the spectrum of associated injuries. To our knowledge, this paper provides the first epidemiological road map for blunt trauma thoracolumbar injuries.

Changing trends in the management of intertrochanteric hip fractures – A single centre experience

With an annual incidence greater than 65,000 in the United Kingdom, hip fractures are a common but debilitating injury predominantly affecting those over 65. Treatment is based on the anatomical location of the fracture relative to the capsule of the hip joint – fractures occurring within it are treated by arthroplasty, while extracapsular fractures are an indication for fixation. Intertrochanteric fractures are further grouped as stable (AO/OTA 31A1/A2) or unstable (31A3) which in turn governs in the current UK guidelines whether this fixation is achieved with a dynamic hip screw or intramedullary device. Anecdotally, some units are tending towards intramedullary devices for 31A2 fractures as well, a practice which from the evidence does not appear to confer benefit and carries an excess cost. We reviewed our data submitted to the National Hip Fracture Database over the last five years and identified all intertrochanteric fractures, from which cohort we identified all patients with 31A2 fractures by review of radiographs. The cohort comprised 370 patients. We then recorded age, gender, ASA grade, abbreviated mental test score, residence from where admitted, length of stay, destination on discharge and whether any further operations were required. There was no significant difference in the demographics of the groups, year-on-year, except gender mix. There was a significant, twenty-fold rise in the use of intramedullary devices between 2011 and 2015. Length of stay, length of overall episode of care, revision rates, mortality and destination on discharge were unchanged. This use is not supported by NICE guidelines and this study offers no evidence to contradict this position. We advocate all centres examine their practice to avoid a costly intervention without clinical benefit.

The Warwick Hip Trauma Evaluation One: a randomised pilot trial comparing the X-Bolt Dynamic Hip Plating System with sliding hip screw fixation in complex extracapsular hip fractures: WHiTE (One).

The aim of this study was to inform a definitive trial which could determine the clinical effectiveness of the X-Bolt Dynamic Hip Plating System compared with the sliding hip screw for patients with complex pertrochanteric fragility fractures of the femur. This was a single centre, participant blinded, randomised, standard-of-care controlled pilot trial. Patients aged 60 years and over with AO/ASIF A2 and A3 type femoral pertrochanteric fractures were eligible. The primary outcome was the EuroQoL 5 Dimension Score (EQ-5D-3L) at one year following index fixation. A total of 100 participants were recruited, and primary outcome data were available for 88 patients following losses to follow-up and withdrawals. The mean difference in EQ-5D was 0.03 (95% confidence interval -0.17, 0.120; p = 0.720.) There were no significant differences in any of the secondary outcomes measures. The recruitment and follow-up rates from this feasibility study were as predicted. A definitive trial with 90% power to find a clinically important difference in EQ-5D would require 964 participants based upon the data from this study. We plan to start recruitment to this trial in Spring 2016. A definitive trial of X-Bolt Dynamic Hip Plating System is feasible and should be conducted now in order to quantify the clinical effectiveness of this novel implant. Cite this article: Bone Joint J 2016;98-B:686-9.

Traction table versus manual traction in the intramedullary nailing of unstable intertrochanteric fractures: A prospective randomized trial

IntroductionThe purpose of this prospective randomized study was to compare traction table with manual traction for the reduction and nailing of unstable intertrochanteric femur fractures. DesignProspective, randomized, two-center trial. Materials and methods72 elderly patients with AO/OTA 31A2 and 31A3 proximal femur fractures were randomized to undergo surgery with either manual traction (MT) or traction table (TT) facilitated intramedullary nailing. The demographics and fracture characteristics, duration of preparation and surgery, total anaesthesia time, fluoroscopy time, blood loss, number of assistants, early post-operative radiological evaluations and 6th month functional and radiological outcomes were evaluated. Data of 64 patients attending 6th month follow-up examination were evaluated statistically. ResultsNo significant differences were observed between groups regarding demographics and fracture characteristics. In the manual traction group, there was a significant time gain in respect of the positioning and preparation period (18.0±1.6min in MT group, 29.0±2.4min in TT group) (p<0.05). In terms of total anaesthesia time (Preparation+surgery) approximately 6min of difference was observed in favor of MT group (72.8±14.0min for MT and 78.6±6.5min for TT, [p<0.05]). Median number of assistants needed was significantly lower in TT group (2 assistants [1–3]) in MT group and (1 assistant [1,2]) in TT group [p<0.05]). There was no significant difference between two groups regarding other surgical and outcome parameters. ConclusionsManual traction reduced the preparation time and total anaesthesia duration, despite an increase in number of surgical assistant. Level of evidenceLevel II.

Results of Ballon Kyphoplasty in Osteoporotic Fractures with Posterior Wall Injury

Introduction Cement augmentation techniques are standard treatment for cases of osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with decreased rates of cement leak. Cases with posterior wall fractures are relative contraindications for both techniques. The aim of this study was to evaluate the results of balloon kyphoplasty in cases of osteoporotic fractures with posterior wall involvement Patients and Methods Forty-eight patients with osteoporotic fractures with injury of the posterior vertebral wall were included. Fractures between T4 and L5 were included. Cases with posterior ligamentous complex injury were excluded. Preoperative evaluation included plain X-rays, CT, MRI, and laboratory diagnosis of osteoporosis. All cases were operated upon with balloon kyphoplasty. Bilateral (bi-pedicular) approach was used in all cases. Injected cement volume and incidence of cement leak were evaluated. The minimum follow-up period was 6 months. Results 18 males and 30 females were operated upon. The average age was 72.4 years. The most common affected vertebra was T12 in 19 patients. The average volume of injected cement was 6.2 ml. Posterior cement leak (in spinal canal) occurred in 2 cases and was asymptomatic. There were no neurologic or embolic complications. Conclusion Balloon kyphoplasty is safe in cases of osteoporotic fractures with posterior wall fractures. Type A3 and A4 fractures (according to AO classification) were not associated with increased incidence of cement leak in spinal canal. The volume of injected cement should not exceed the volume injected to inflate the ballon.