Osteonecrosis Research Articles

Application of Mirror Image 3D-Printing Technology Bone Cement in Treatment of Stage IIIb Necrosis of the Lunate Bone.

At present, conventional operations are weak for pain relief and restoring the carpal joint function in the treatment of avascular necrosis of the lunate bone. Mirror image 3-dimensional (3D)-printing technology has rarely been reported for the treatment of lunate bone necrosis, The use of mirror 3D-printed lunar bone replacement and bone cement technology in the treatment of stage IIIb lunar bone necrosis has been rarely reported in previous literature. Personalized customized 3D-printed prostheses have become an effective solution for solving many complex cases, and the flexible application of bone cement technology can also achieve satisfactory clinical results. The authors report 3 patients who underwent mirror printing of lunar bone prostheses based on healthy side lunar bone computed tomography data, 3D printing of lunar bone prostheses replacement through small incisions, and intraoperative selection of alternative bone cement technology based on actual conditions. Mirror image 3D printing relieved the pain and resulted in satisfactory functional recovery for stage IIIb lunate bone necrosis.

Long-term result of unicompartmental knee arthroplasty in knee osteoarthritis secondary to chondrodysplasia

Background. In determining the indications for unicondylar endoprosthesis of the knee joint the literature practically does not cover the results of such interventions in knee osteoarthritis in patients with chondrodysplasia. The purpose of our report was to publish our observation of the long-term results of unicondylar endoprosthesis of the knee joint in a patient with knee osteoarthritis due to chondrodysplasia. Material and methods. We operated on a patient with chondrodysplasia who came to the clinic at the age of 28 with complaints of pain in the right knee joint during walking, “clicking” and joint swelling. The radiological and magnetic resonance examination results of the right knee determined the presence of an area of aseptic necrosis of the medial femoral condyle. Considering the concordance of lower limb axis disorders, it was decided to perform unicondylar arthroplasty with preservation of the preoperative varus deformity to maintain the motor stereotype's compensation state. Results. In the postoperative period, there were no complications in wound healing, the rate of recovery of movements corresponded to similar indicators in patients with knee osteoarthritis of other etiologies after similar interventions, and the patient was discharged from the hospital on the sixth day after surgery with the preoperative range of motion in the operated joint. At the examination 10 years after the operation there were no complaints from the operated knee joint, the movements in the operated joint remained in the same range, and the patient moved without additional support with full load on the operated limb. Conclusions. Our results indicate the appropriateness of unicompartmental knee arthroplasty in patients with knee osteoarthritis secondary to.

Talar head replacement for treatment of Müller – Weiss syndrome: three clinical cases

Introduction Müller – Weiss syndrome is a rare condition that is characterized by avascular necrosis of the navicular bone leading to severe foot deformity, pain disturbing activities of daily living. There is no generally accepted treatment for avascular necrosis of the scaphoid, and the available treatments have disadvantages, which necessitates the need for new options.The objective was to present short-term results of three patients with osteonecrosis of the scaphoid and local necrosis of the talar head treated with ceramic talar head prosthesis, plastic surgery, metal osteosynthesis of the scaphoid and related surgical techniques.Material and methods Three patients diagnosed with Müller – Weiss syndrome were treated with ceramic talar head replacement, autologous bone grafting and metal osteosynthesis of the scaphoid bone with accompanying surgical techniques. Severity of pain and the condition of patients were assessed with the VAS and AOFAS AH scores.Results Short-term results showed consolidation at the site of metal osteosynthesis in all patients with no signs of instability of the talus hemiprosthesis. VAS and AOFAS AH scores indicated decrease in the pain and improved condition of the patients.Discussion Hemiarthroplasty of the talar head combined with plastic surgery and restoration of a congruent joint surface of the scaphoid, and associated surgical techniques may become an effective alternative to existing treatments for patients with Müller – Weiss syndrome, with further study.Conclusion The short-term findings showed that hemiarthroplasty was practical for restoration of the talonavicular mobility maintaining stable fixation of the talus.

Short-term functional outcome of total hip arthroplasty for avascular necrosis of femoral head and influence of patient-related factors

Introduction Avascular necrosis of the femoral head (ANFH) is a phenomenon vascular supply disruption lead to death of bone cells around the femoral head. The disease is a severe health issue all over the world. Within 2 years about 80 % to 85 % of symptomatic cases will result in collapse of the femoral head. Recovery of hip function after total hip arthroplasty (THA) may be influenced by many factors that vary among different racial/ethnic groups. Most findings in this field have been from Western developed nations, and not much information from developing Asian countries is available.This study aimed to determine the six-month functional outcome and patient–related factors that predict functional recovery in patients with avascular necrosis of the femoral head (ANFH) undertaking total hip arthroplasty (THA).Methods Between January 2022 and December 2023 there were 143 patients participating in this prospective study. Demographic, medical history and clinical findings were collected from their medical records. The six-month functional outcome was evaluated using the Harris hip score (HHS). The mean age of the participants was 55.90 ± 11.49 years, and the majority (86.7 %) were male. Most patients had excellent (43.4 %) or good outcome (51.7 %).Discussion Our study had some limitations: the length of the follow-up after surgery is short (6 months), that hospital-related factors like the type and volume of the hospital have not been analyzed. Nonetheless, previous observations suggest that most of the improvement in physical function occurs during the first six months following surgery and remains the same for a long time. However, our sample has typical demographic and clinical characteristics of patients with THA for ANFH, suggesting that determinants of the 6-month functional outcome in the current study could apply to other patients undergoing this surgery.Results The determinants of excellent outcome were a higher preoperative HHS (odds ratio (OR): 4.369, 95 % confidence interval (CI) =1.854 – 10.299; p < 0.001) and absence of comorbidity (OR: 2.440, 95 % CI = 1.071 – 5.557, p = 0.034). No demographic (age, gender, body mass index), medical history (using of steroids, alcohol consumption or smoking), or any other clinical parameter (stage or side of the affected hip, time until surgery) had a significant influence on functional outcome.Conclusion Earlier surgery during functional decline and better management of comorbidity may help improve THA outcomes for patients with avascular necrosis of the femoral head.

Comparison of treatment methods in patients with developmental dysplasia of the hip.

This study aimed to compare the results of Pemberton osteotomy (PO), Salter innominate osteotomy (SO), open reduction (OR), and closed reduction (CR) applied in the treatment of developmental dysplasia of the hip (DDH). Included in the study were 101 hips of 82 patients treated at our orthopedic clinic between 2017 and 2023. The patients were evaluated preoperatively, postoperatively, and at the final follow-up. The results were evaluated based on Barret's clinical and Severin's radiological classifications. Those who developed avascular necrosis (AVN) were evaluated based on Bucholz-Ogden's classification. In terms of the preoperative acetabular angles (AAs), those for hips treated with PO were significantly higher than those of the other three, and those treated with SO were significantly higher than those of the other two (OR and CR) (p < 0.001). There was a significant difference in the final follow-up AAs of those treated with SO and PO compared to those treated with OR and CR (p < 0.001). The best corrections were achieved with PO (average: 27.94 ± 4.89°). There was a significant difference between PO and OR, and PO and CR in terms of the preoperative collodiaphyseal angles (CDAs) (p < 0.05). The greatest decrease was in those treated with PO (average: 22.44 ± 9.45°). AVN developed at various stages in 15 of 79 hips (14.85%) that were treated surgically. While AVN developed at a rate of 22.22% with PO, 18.18% with SO, and 17.85% with OR, no AVN developed in the 22 hips treated with CR. Understanding normal and abnormal values by age is essential for selecting appropriate treatments. Acetabulum-related surgeries should be planned for patients over 1.5 years of age with an AA above 30°. Early diagnosis and CR treatments yield excellent results and low AVN rates. Various DDH treatments in our clinic have shown low AVN rates, indicating safety and efficacy.

A novel radiographic finding for estimation of the cortical-cancellous boundary: A magnetic resonance imaging case series of patients with femoroacetabular impingement

PurposeTo determine if comparing alpha angle measurements of the outer cortical margin (preoperative alpha angle) and the inner cortical margin (theoretical postoperative alpha angle) on magnetic resonance imaging (MRI) can estimate the amount of sclerotic bone that needs to be resected to restore the alpha angle to normative values (<55⁰) in patients with symptomatic femoroacetabular impingement (FAI). MethodsA retrospective review was conducted on patients with FAI undergoing primary hip arthroscopy and CAM osteoplasty from June 2013 to February 2017. Inclusion criteria were radiologist-measured alpha angles >70° on 3T oblique axial MRI, unilateral primary hip arthroscopy, and age ≥18. Exclusions included previous hip surgery, hip trauma, avascular necrosis, advanced osteoarthritis, dysplasia, poor quality images, or missing MRI images. Alpha angles were measured preoperatively using the outer cortical margin and postoperatively using the inner cortical margin of femur. Surgeries were performed by the senior surgeon. Paired t-tests compared preoperative and postoperative alpha angles, and intraclass correlation coefficients (ICC) were used to assess inter-rater and intra-rater reliability. ResultsOne hundred patients (100 hips) were included with an average age of 40.8 years (range, 18.7–64.9), with 75 % being male (n = 75). The average BMI was 24.7 ± 3.9 (range, 17.1–38.8). The average maximum alpha angle at the outer cortical margin was 77.0 ± 4.2° (range, 70.0–90.8), with an ICC for inter-rater reliability of 0.861, indicating excellent agreement. The average inner cortical alpha angle was 46.4 ± 3.4° (range, 36.5–55.4), significantly less than 55° (p<0.001). The mean difference between the outer and inner cortical alpha angles was −30.6 ± 5.1° (p< 0.001). ConclusionsThe difference between outer and inner cortical alpha angles on MRI can accurately estimate the amount of sclerotic bone resection needed to restore the alpha angle to normative values in patients with FAI. This information may be directly applied clinically marker to assess adequacy of CAM resection.

Avascular Necrosis of the Talus: Diagnosis, Treatment, and Modern Reconstructive Options.

Talar avascular necrosis (AVN) is a devastating condition that frequently follows type III and IV talar neck fractures. As 60% of the talus is covered by hyaline cartilage, its vascular supply is limited and prone to trauma, which may eventually lead to AVN development. Early detection of AVN (Hawkins sign, MRI) is crucial, as it may prevent the development of the irreversible stages III and IV of AVN. Alertness is advised regarding non-obvious conditions that may cause this complication (sub chondroplasty, systemic lupus erythematosus, diabetes mellitus). Although, in stages I-II, AVN may be treated with non-surgical procedures (ESWT therapy, non-weight bearing) or joint-sparing techniques (core drilling, bone marrow aspirate injections), stages III-IV require more advanced procedures, such as joint-sacrificing procedures (hindfoot arthrodesis/ankle arthrodesis), or replacement surgery, including total talar replacement (TTR) or combined total ankle replacement (TAR). The advancement of 3D-printing technology and increased access to implant manufacturing are contributing to a rise in the production rates of third-generation total talar prostheses. As a result, there is a growing frequency of alloplasty procedures and combined total ankle replacement (TAR) surgeries. By performing TTR as opposed to deses, the operator avoids (i) delayed union, (ii) a shortening of the limb, (iii) a lack of mobility, and (iv) the stiffening of adjacent joints, which are the main disadvantages of joint-sacrificing procedures. Simultaneously, TTR and combined TAR offer (i) a brief period of weight-bearing restriction, (ii) quick pain relief, and (iii) preservation of the length of the limb. Here, we summarize the most up-to-date knowledge regarding AVN diagnosis and treatment, with a special focus on the role of TTR.

Preliminary study of the role of histone deacetylase (HDAC) in steroid-induced avascular necrosis of the femoral head induced by BMSC adipogenic differentiation

Our previous research revealed a close association between the acetylation of peroxisome proliferator-activated receptor γ (PPARγ) histone H3K27 and the adipogenic differentiation of bone marrow mesenchymal stem cells (BMSCs). We preliminarily explored the epigenetic mechanism of steroid-induced avascular necrosis of the femoral head (SANFH) development, but the specific histone deacetylase (HDAC) involved in this regulatory process remains unknown. In this study, we combined cell, animal, and clinical specimen experiments to screen for specific HDAC genes that could regulate BMSC adipogenic differentiation and to explore their roles. The results showed that dexamethasone (DEX) significantly exacerbated the imbalance between the adipogenic and osteogenic differentiation of BMSCs, and there were differences in HDAC expression in the adipogenic differentiation cell models, with histone deacetylase 10 (HDAC10) showing the most significant decrease in expression. Subsequent use of a chromatin immunoprecipitation assay kit and quantitative polymerase chain reaction (ChIP‒qPCR) revealed a decrease in HDAC10 expression at predicted potential sites within the PPARγ promoter, indicating a significant decrease in HDAC10 enrichment in the PPARγ promoter region of BMSCs, thereby promoting sustained PPARγ expression. Additionally, immunohistochemistry of samples collected from mice and humans with SANFH and normal femoral heads revealed an imbalance between adipogenic and osteogenic differentiation in the necrotic area of femoral heads, with a significant decrease in the relative expression of HDAC10 in the necrotic area of femoral heads with SANFH. In summary, we speculate that HDAC10 affects the progression of SANFH by regulating BMSC adipogenic differentiation, a process possibly related to PPARγ histone acetylation. These findings provide a promising direction for the treatment of SANFH.Graphical abstract

Comparison of third-generation minimally invasive surgery, split-drill osteotomy, and triplanar chevron osteotomy for treating mild to moderate hallux valgus with metatarsalgia in middle-aged women: An observational study.

This retrospective study compared the clinical efficacy of third-generation minimally invasive surgery (3rd-MIS) split-drill osteotomy with soft tissue release to that of triplanar chevron osteotomy (TCO) for treating mild to moderate hallux valgus (HV) with metatarsalgia in middle-aged women. This study compared the efficacy of 3rd-MIS using split-drill osteotomy to that of TCO in treating mild to moderate HV with metatarsalgia in 52 middle-aged women from March 2022 to June 2023. Retrospectively analyzing a total of 52 patients (26 patients per group), we employed 2 distinct surgical methods across 2 groups in this study: the TCO group received a traditional TCO accompanied by soft tissue release, whereas the MIS group underwent a split-drill osteotomy with soft tissue release. The study compared the operation time, onset of weight-bearing, osteotomy healing, blood loss, pre- and postsurgery X-ray measurements, metatarsalgia, and foot function scores. In the TCO group, complications included peri-incisional numbness, elevation of the first metatarsal head with metatarsalgia, and bone hyperplasia with stiffness at the MTPJ in one patient each. In the MIS group, bunions were successfully corrected without significant complications like bone nonunion or avascular necrosis of the metatarsal head, and the metatarsal length was preserved. Significant differences in operation time, weight-bearing onset, healing, and blood loss were detected between groups (P < .05). Preoperatively, there were no significant differences in hallux valgus angle, 1-2 intermetatarsal angle, or distal metatarsal articular angle among the groups (P > .05). Nonetheless, notable postoperative differences were observed (P < .05). Foot function and pain scores, assessed by the American Orthopaedic Foot & Ankle Society and the Visual Analogue Scale, showed significant improvements in both groups following surgery. Both surgical techniques effectively corrected the HV angle without significant changes in the first metatarsal length. The MIS group experienced significantly less pain on the second day postsurgery, as indicated by lower Visual Analogue Scale scores (P < .05). Both techniques were similarly effective in treating metatarsalgia. 3rd-MIS split-drill osteotomy with soft tissue release offers several advantages over TCO techniques for treating mild to moderate HV with metatarsalgia in middle-aged women, such as reduced trauma, quicker healing, smaller scars, and less pain after surgery.

Efficacy study of platelet-rich plasma combined with core decompression and bone grafting in the treatment of early-stage avascular necrosis of the femoral head: a retrospective study

ObjectiveThis study aimed to evaluate the effectiveness of combined core decompression (CD), bone grafting (BG), and platelet-rich plasma (PRP) in treating early-stage avascular necrosis of the femoral head (ANFH).MethodsA retrospective study was conducted on 74 patients (85 hips) with Ficat-Arlet stage I-II ANFH who were treated at our hospital between May 2015 and May 2018. The control group (20 patients, 22 hips) received symptomatic treatments, including weight-bearing reduction and oral analgesics. The CD + BG group (29 patients, 34 hips) underwent CD and β-tricalcium phosphate bone grafting. The PRP combination group (25 patients, 29 hips) received PRP injections in addition to CD and BG. Patients were followed up for five years to assess the necessity for total hip arthroplasty (THA). Data analysis was performed on those from the CD + BG and PRP groups who did not require THA. Clinical outcomes were evaluated using the Visual Analog Scale (VAS), Harris Hip Score (HHS), and the proportion of patients not accepting THA.ResultsAt the five-year follow-up, the rate of THA in the control group was 68.18% (15/22), while in the CD + BG group and the PRP combination group, the rates were 17.65% (6/34) and 10.34% (3/29), respectively. There was no statistically significant difference between the CD + BG group and the PRP combination group (P = 0.441), but both differed significantly from the control group (P < 0.001). Kaplan-Meier survival analysis showed that over time, the proportion of patients in the PRP combination group who did not require THA was consistently higher than that in the CD + BG group. Among patients who did not undergo THA, the proportion of Ficat-Arlet stage I-II patients in the PRP combination group was 88.46% (23/26), which was higher than the 64.29% (18/28) in the CD + BG group, showing a significant difference (P = 0.038). VAS score and HHS were compared between the two groups at 6 months, 12 months, and the last follow-up point, with patients in the PRP combination group showing better scores than those in the CD + BG group (p < 0.05) in both metrics.ConclusionThe combination therapy of CD, BG, and PRP demonstrates significant advantages in improving symptoms and delaying disease progression in early-stage ANFH.

Patellar Resurfacing in Total Knee Arthroplasty: A Contentious Matter.

Orthopaedic surgeons hold differing opinions on replacing the patella during total knee arthroplasty (TKA) for knee osteoarthritis, sparking a continued discussion on the optimal approach. Patellar resurfacing (PR) replaces the patella's surface with a prosthetic component, aiming to enhance joint function and reduce anterior knee pain. However, it has potential complications such as avascular necrosis, fractures, and patellar clunk syndrome. This analysis evaluates the effectiveness of TKA with and without PR, highlighting the variations in outcomes between the two methods. Findings suggest that resurfacing is associated with improved clinical outcomes, activity level, patient satisfaction, and pain relief. Nevertheless, the decision should be individualized based on patient preferences and circumstances. Additional long-term randomised controlled trials incorporating outcome measures specific to patellar function are required to better understand the effects of PR versus non-resurfacing in TKA.

Vascularized medial femoral condyle bone graft for the management of an acute talar neck fracture: A case report

Background Management of talar neck fractures can be challenging due to the high rate of non- or malunion, avascular necrosis and post-traumatic arthritis, which has been attributed to the disruption of the bone’s tenuous blood supply during fracture displacement. Osseous medial femoral condyle (MFC) flaps are increasingly being used in the reconstruction of small bony defects due to recalcitrant non-union and avascular necrosis in the upper and lower limbs. We report a rare case of an MFC flap used in the reconstruction of an acute talar neck fracture. Case Presentation A 38-year-old male presented with multiple injuries following a motor vehicle accident, including an open comminuted talar neck and lateral process fracture, with dislocation of the subtalar and talocrural joints (Hawkins III). Initial exploration and debridement demonstrated a significant defect in the dorsal portion of the talar neck. Temporary stabilisation was achieved with Kirschner wires and the defect was packed with bone cement. Two weeks later, a MFC flap was harvested from the ipsilateral knee and tailored to fit the talar defect. Fixation was achieved with cannulated compression screws. At six weeks post-operative, all wounds had healed, a radiograph demonstrated a positive Hawkins sign and computed tomography showed incorporation of the flap. The patient had no donor site morbidity, and commenced weight bearing at 3 months postoperatively. Conclusion This is the first report demonstrating the viability of MFC flap reconstruction for the management of bony defects in acute talar neck fractures.

Clinical and Radiological Severity of Avascular Necrosis of the Femoral Head in Sickle Cell Disease Patients

Abstract Background: Sickle cell disease (SCD) has a high prevalence in Sub-Saharan Africa. Avascular necrosis (AVN) of the femoral head is a devastating complication of SCD. Early presentation and diagnosis can be treated with hip-preserving procedures, resulting in good outcomes. Late presentations will require more complicated treatment procedures, such as hip replacement. A good knowledge of the clinical presentation and severity of the disease will aid in early detection and clinical management. This study was designed to establish the age and sex distribution, severity, and stages of AVN in SCD patients at Korle-Bu Teaching Hospital. Materials and Methods: This was a cross-sectional study of SCD patients referred to the orthopaedic clinic with AVN of the femoral head. An evaluation form was used to assess the patient’s age, sex, genotype, and clinical symptoms. Hip X-rays were obtained to assess the severity of the disease. Chi-square tests were used to determine the association between demographic variables’ data and AVN. Results: Most patients were in the 31- to 50-year age group and presented with profound and limiting clinical features and advanced features on X-rays (stages 3 and 4 of the disease). There was a statistically significant association between the radiological stage of disease and clinical symptoms (limping, difficulty climbing stairs, and hip abduction). Conclusion: The patients mostly presented with severe disease both clinically and radiologically and will require complex surgical procedures including hip arthroplasties. Clinicians at primary care centres need to look out for early signs so that they can refer them for treatment.

Radiological follow-up of osteonecrosis lesions in children and adolescents with Hodgkin lymphoma.

Osteonecrosis (ON) is a common complication of glucocorticoid-based Hodgkin lymphoma (HL) treatment, but the natural evolution and prognosis of ON lesions remain poorly understood. We describe the radiological evolution of ON lesions identified in a Nordic population-based cohort of paediatric HL patients. Magnetic resonance images of suspected ON lesions were centrally reviewed to confirm ON diagnosis and grade the ON lesions according to the Niinimäki classification. The study included 202 ON lesions in 46 patients, of which 77 were joint lesions. Follow-up images were available for 146/202 lesions, with a mean follow-up time of 28 months. During follow-up, 71% of the lesions remained stable, 26% improved or resolved, and 3% progressed. A higher ON grade at diagnosis was associated with a lower likelihood of spontaneous resolution. The likelihood for resolution of ON decreased by 50% for each year of added patient age, when adjusted for sex, ON location, and symptoms. Hip ON showed less spontaneous improvement compared with other joints, and the risk for surgery was 13-fold in hip ON. Grades 3-4 joint ON has the potential to either progress or resolve, warranting follow-up in patients with severe symptoms. Research on secondary prevention should be directed at grade 3-4 joint ON.

The Effects and Risk Factors of Femoral Neck Shortening after Internal Fixation of Femoral Neck Fractures.

Internal fixation has been established as a treatment of choice in relatively young patients with femoral neck fractures. Due to the characteristics of femoral neck anatomy and blood supply, complications such as malunion, nonunion, avascular necrosis, and femoral neck shortening can occur after internal fixation of femoral neck fractures. Unlike other complications such as avascular necrosis or nonunion, femoral neck shortening has not been relatively well studied. This study aimed to investigate the risk factors and clinical outcomes of femoral neck shortening after internal fixation of femoral neck fractures. From June 2012 to July 2022, among 102 patients who underwent internal fixation of femoral neck fractures, 94 patients who met inclusion and exclusion criteria were retrospectively analyzed. Internal fixation of the femoral neck was done with cannulated compression screws or a femoral neck system. Patients were divided into 2 groups; femoral neck shortening (≥ 5 mm) and no shortening (< 5 mm) according to measurement on follow-up hip anteroposterior (AP) simple radiographs compared with postoperative hip AP simple radiographs. Demographic and radiographic data were compared between the 2 groups. The modified Harris Hip Score (mHHS) and a visual analog scale (VAS) were used to evaluate the clinical outcomes. Among 94 patients, femoral neck shortening was observed in 33 (35.1%). In chi-square test, Pauwels angle, Garden type III or IV (displacement), and cortical comminution were significantly correlated with neck shortening (p < 0.05). In the multifactorial logistic regression test, cortical comminution was significantly correlated with femoral neck shortening (p < 0.01). The shortening group showed significantly lower clinical scores in terms of mHHS and VAS (p < 0.01). The femoral neck shortening group showed significantly lower clinical scores of mHHS and VAS than the no-shortening group. The presence of cortical comminution in preoperative hip computed tomography is a risk factor of femoral neck shortening after internal fixation of femoral neck fractures.

Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options.

Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice. PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design. Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs. The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Dual energy computed tomography in assessment of bone marrow edema in pathologies of the appendicular skeleton

BackgroundBone marrow edema cannot be detected on the conventional computed tomography scan. MRI has excellent diagnostic performance in detecting bone marrow edema but multiple difficulties in the emergency setting makes performing MRI logistically challenging. The aim of the study was to assess dual energy computed tomography accuracy for bone marrow edema in pathologies of the appendicular skeleton. This was based on color-coded maps and quantitative analysis of Hounsfield unit (HU) in subtraction images, compared with MRI. Materials and methodsProspective observational study was performed by including 60 patients who underwent Dual energy CT (DECT) and MRI. Statistical analysis was performed by calculating p-value and ROC curve analysis. The derived cut off value was used to identify bone marrow edema and diagnostic accuracy, sensitivity, specificity, negative predictive value and positive predictive value of DECT was calculated using MRI as gold standard. A further sub-analysis between the traumatic and non-traumatic groups was done. ResultsBone marrow edema on Color coded virtual non-calcium (VNCa) images and Mean HU of bone marrow edematous site was calculated. Attenuation difference between edematous bone marrow and rest of the bone were correlated with MRI, (p-value 0.0001). The sensitivity, specificity, negative predictive, positive predictive value, and diagnostic accuracy were 91.1, 93.3, 97.6, 77.8 and 91.67 % respectively. ConclusionOur results confirmed that Dual energy CT has high overall sensitivity, specificity and diagnostic accuracy in depicting bone marrow edema when compared to MRI, in various etiologies of the appendicular skeleton. This will lead to reduced missed cases by early detection of bone marrow edema secondary to fractures that are not identifiable in conventional CT. Marrow edema in DECT can be used as an indicator for disease activity and progression in conditions such as transient osteoporosis, tumour, arthritis, avascular necrosis and various other etiologies, generally missed in conventional radiography.

Arthroscopic Chondral Nail Fixation for Treating Acetabular Cartilage Delamination Results in Improved Pain Relief at Minimum 2-year Follow-up in Patients with Femoroacetabular Impingement Syndrome: A Propensity-Matched Study

PurposeTo investigate the clinical outcomes following arthroscopic chondral nail fixation for acetabular cartilage delamination (ACD) in patients with femoroacetabular impingement syndrome (FAIS), and the presentation of ACD on MRI at follow-up. MethodsA retrospective review was performed between March 2021 and March 2022 at our institute. Patients undergoing primary hip arthroscopy for FAIS and diagnosed with ACD intraoperatively were included. Exclusion criteria were incomplete data or loss of minimum 2-year follow-up, and concomitant hip conditions including hip osteoarthritis with a Tönnis grade > 1, avascular necrosis, Legg-Calvé-Perthes disease, osteoid osteoma, synovial chondromatosis, pigmented villonodular synovitis, and developmental dysplasia of the hip (DDH). Patients who underwent chondral nail fixation were matched 1:1 with a control cohort of patients who only underwent simple debridement. Preoperative and minimum 2-year postoperative patient-reported outcome (PRO) scores including Visual Analog pain Scale (VAS), modified Harris Hip Score (mHHS), and percentage of achieving minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were collected and compared. MRI was performed preoperatively and at final follow-up to assess ACD. ResultsFifty-eight patients were included in the study (29 patients in each group). Both groups demonstrated improved VAS and mHHS following surgery (all with P < .05). The chondral nail group demonstrated better postoperative VAS (P = .022) compared to the control group, while the postoperative mHHS was comparable between the two groups (P = .852). No significant difference was found in the achievement of MCID between the two groups (all with P > .05). More patients in the chondral nail group achieved PASS of VAS compared to the control group (75.9% vs 48.3%, P = .030). No patient underwent revision surgery or conversion to total hip arthroplasty (THA). The chondral nail group demonstrated significantly higher rate of ACD healing on MRI compared to the control group (P < .001). ConclusionPatients undergoing arthroscopic chondral nail fixation for treating ACD demonstrated significant pain relief, more achievement of PASS of VAS, and higher rate of ACD healing on MRI compared to those undergoing simple debridement. Level of EvidenceLevel III; retrospective cohort study.

Tratamiento quirúrgico de fractura subcapital de cadera no desplazada: Femoral Neck System vs. tornillos canulados. Estudio comparativo

ObjectiveThe objective of this study is to compare the outcomes of using the Femoral Neck System (FNS) (DePuy Synthes®) versus the use of cannulated screws (CS) in the surgical treatment of non-displaced subcapital hip fractures. Materials and methodsA retrospective cohort study was conducted on non-displaced subcapital hip fractures treated with CS or FNS between 2020 and 2023, with a minimum follow-up of one year. A total of 28 patients were included, 14 treated with CS and 14 with FNS. Demographic, radiological, clinical, and functional variables were analyzed. ResultsIn the CS group, 64% were male, with a mean age of 66.5 years (SD 14.9) and an average follow-up of 22 months (range, 12-36 months). In the FNS group, 57% were male, with a median age of 60.8 years (SD 13.78) and an average follow-up of 16 months (range, 12-24 months).Regarding functional outcomes, no significant differences were found between FNS and CS in the Harris scale: 94.21±11.55 for FNS and 96.50±6.9 for CS (p=0.618).The total postoperative complications (FNS/CS) were 7.1% versus 43%, and implant failure with conversion to total hip replacement was 0% versus 43%, both significantly higher in the CS group (p=0.047; p=0.016, respectively). The FNS also presented a lower rate of avascular necrosis (0% versus 11.1%, p=0.391) and nonunion (0% versus 20%, p=0.163), although these differences did not reach statistical significance. ConclusionsAlthough both treatment methods, cannulated screws and the FNS, showed similar short-term functional outcomes in the management of undisplaced subcapital femoral fractures, the FNS demonstrated a significantly lower rate of complications and reoperations. These results suggest that the FNS could be considered a safer and more effective option compared to cannulated screws.

FIJACIÓN DE LAS FRACTURAS DE CUELLO FEMORAL DEL ADULTO: COMPARACIÓN RETROSPECTIVA ENTRE TORNILLOS CANULADOS Y EL SISTEMA DE CUELLO FEMORAL (FNS)

The FNS System DePuy Synthes® (EEUU, 2018) represents a recent alternative treatment for the fixation of femoral neck fractures, providing biomechanical advantages with respect to cannulated screws (3CS). The objective of this study is to compare the clinical results of both fixation methods. A retrospective collection of the 36 subcapital fractures treated with the FNS system was carried out compared with a retrospective search of the last 35 patients treated with 3CS. Age, sex, fracture pattern, delay until the intervention, lenght of intervention, hospital length stay, and haemoglobin loss were analyzed. In addition, the rate of avascular necrosis, nonunion, symptomatic femoral neck shortening, and material protrusion with or without its removal were recorded during a minimum follow-up of 6 months. No significant differences were found in age (p-value 0.32), fracture patterns (p-value 0.77), surgical delay (p-value 0.28), surgical time (p-value 0.226), length of hospital stay (p-value 0.921) and blood loss (p-value 0.086) between the two groups. A significantly higher overall complication rate was observed in the group treated with cannulated screws (p-value 0.004). Analysed separately, a higher rate of avascular necrosis, symptomatic shortening of the femoral neck, protrusion of the osteosynthesis material with or without removal was observed in the group treated with cannulated screws. The FNS system represents a safe and reproductible alternative for the fixation of femoral neck fractures, showing non-inferior outcomes to treatment with cannulated screws.