Cases Of Avascular Necrosis Research Articles

Targeted Screening of Hip Dysplasia in Newborns: Experience at a District General Hospital in Scotland.

National Health Service Quality Improvement Scotland (NHS QIS) published a health technology scoping report in 2006 acknowledging that there are serious concerns within Scotland in relation to Developmental Dysplasia of Hip (DDH) as there is no formal screening program in place and there are significant variations between NHS boards leading to confusion for staff and parents. NHS QIS identified need for audit work to improve hip screening in Scotland. The aim of this study is review of current practice of selective screening for DDH. All newborns who had their first hip scan during one year period (2014) were included in this retrospective study and followed up until June 2015 to include any surgical intervention for dysplastic hip. Out of 428 babies (856 hip scans), abnormality was seen in 119 babies/147 hips (134 Graf 2a/2b, 10 hips were 2c and 3 hips were Graf grade 3). Average age when first scan was performed was 5 weeks (range 3 weeks to 22 weeks). Analysis of risk factors in 119 babies with abnormal scan was consistent with literature (83 breech, 12 family history, 12 HBW, 10 instability and 2 twins of breech). Twelve babies (16 hips) required treatment and were successfully treated in Pavlik harness. There was one case of missed/late dislocation, which lived in outside catchment area for 3 years since birth. During this study period there was no case of avascular necrosis or femoral nerve palsy as a result of treatment. In our experience, selective hip screening by ultrasound scan is useful in avoiding overtreatment and minimizing late presentations.

A Study on the Incidence of Avascular Necrosis Following Closed Reduction of the Dislocated Hip in Children with Congenital Dysplasia of the Hip: a Suggestion on Clinical Management

Background: Our district general hospital is one of two providers of elective paediatric orthopaedic services to a rural population with an annual live birth rate of approximately 5000 per year. The preferred practice in our hospital for dislocated hips in cases of congenital dysplasia of the hip (CDH) is to place the child in traction for 2 weeks then perform an arthrogram and closed reduction followed by the application of a hip spica. We wanted to evaluate the incidence of a vascular necrosis (AVN) of the femoral head following closed reduction of the hip. Methods: We have retrospectively reviewed all case notes for patients with congenital dysplastic hips (CDH) that had dislocated hips over a 20 year period from 1993-2013. Data was collected from clinic letters and radiographs. Results: There were 34 children with CDH and dislocated hips. The mean (±S.D) age at closed reduction was 14(±6) months. The mean follow up period was to 6(±3) years. One patient had features of AVN noted on radiographs at age 7 years (2.9%). This patient’s dislocated hip was reduced closed at age 8 months. In our series only 3 patients required open reduction. Of these 2 were followed by femoral derotation osteotomies. All these 3 patients presented with dislocated hips at greater than 15 months of age. Clinically all patients were functioning with no restrictions at last follow up Conclusion: We have treated children with arthrogram and closed reduction of the hip from the age of 4 months to 33 months resulting in one case of AVN in a child treated at 8 months old. This gives an AVN rate of 1 in 34 (2.9%). We would recommend this to be an acceptable method of management with a very low rate of AVN.

Fibular Allograft and Demineralized Bone Matrix for the Treatment of Slipped Capital Femoral Epiphysis.

Previous studies documented the use of fibular allograft in the treatment of slipped capital femoral epiphysis (SCFE) with bone graft epiphysiodesis (BGE). This study describes the results of using a 10-mm diameter premilled fibular allograft packed with demineralized bone matrix placed across the physis in an open surgical approach under image intensification. A review identified 45 cases of BGE using fibular allograft and demineralized bone matrix in 34 patients with a diagnosis of SCFE performed by a single surgeon during an 8-year period. Thirty-four cases (25 patients) had at least 1 year of follow-up and were included in the study. Medical records were reviewed for complications, subsequent surgeries, and time to physeal closure. Of the 34 cases included, there were no cases of acute chondrolysis. Complications included 1 case of bone graft extrusion that required surgical replacement and 1 re-slip requiring surgical stabilization. Five cases of avascular necrosis (AVN) were encountered (1 unstable slip with total head AVN, and 4 stable slips with 3 total head and 1 partial head AVN). In 1 patient, small loose bony fragments were noted on postoperative radiographs that appeared outside of the articular surface of the hip and were asymptomatic. Two patients encountered wound healing issues that resolved with appropriate wound care. In light of the occurrence of AVN in stable cases, BGE with autogenous corticocancellous graft is preferable to BGE with autologous fibular graft for the treatment of SCFE. [Orthopedics. 2016; 39(3):e519-e525.].

Sartorius muscle pedicle iliac bone graft for the treatment of avascular necrosis of femur head.

Avascular necrosis (AVN) of femoral head needs to be addressed early in the course of the disease, to prevent progression to osteoarthritis. A revascularizing procedure which can help preserve the head should be considered in young adults to alleviate the need for total hip arthroplasty. We included 40 cases (53 hips) of AVN of femoral head operated with Sartorius muscle pedicle iliac bone grafting, done by the senior author. Early post-operative rehabilitation was done. The weight bearing was delayed for 6 weeks. All the patients were followed clinically and radiologically at regular intervals. The operated femoral heads, were grouped according to Ficat’s staging: 24 in stage IIA (45.3%), 22 in stage IIB (41.5%) and 07 in stage III (13.2%). The average duration of surgery was 85 min (range: 55–130 min). The total duration of follow-up was average 4.2 years (range: 2.2–15 years).The Harris hip score was excellent (>90) in 18 hips (33.96%), good (80–89) in 24 hips (45.28%), fair (70–79) in 9 hips (17%) and poor (<70) in 2 hips (3.7%). AVN of the femoral head is a painful and disabling condition in young adults. Sartorius muscle pedicle bone graft technique allows adequate decompression, re vascularization and osteogenesis of the femur head in Ficat’s stage IIa, IIb and III, in young adults. This is an effective and easy technique to adopt with excellent to good results in 80% cases and is associated with only minimal complications.

Outcome of surgical treatment of type IV capitellum fractures in adults

ObjectiveFractures of the capitellum and trochlea constitute less than 1% of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported. Type IV capitellum fracture is still controversial in regard to its radiographic appearance, surgical approach and osteosynthesis. We report 10 cases of type IV capitellum fracture with a view to elucidating its clinical features and treatment outcome. MethodsWe treated 10 patients of type IV capitellum fracture with a mean age of 32 years. A uniform surgical approach and postoperative rehabilitation were followed. ResultsNine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter. Double arc sign was absent in 6 cases. Intraopera-tively 6 capitellotrochlear fragments were devoid of soft tissue attachments. By Mayo Elbow Performance Score evaluation, 7 patients got excellent,2 good and 1 fair results. One patient with associated elbow dislocation developed heterotopic ossification. There was no case of avascular necrosis, osteoarthrosis or fixation failures. ConclusionsType IV capitellum fractures are rare and belong to complex articular injuries. A good functional outcome can only be achieved with open reduction and stable internal fixation followed by early mobilization. Preoperative radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants. Good surgical technique and stable internal fixation are the keys to early mobilization and good functional outcome.

Open reduction and internal fixation of three- and four-part proximal humeral fractures by intra-focal distraction: observational study of twenty five cases.

Reduction and fixation of proximal humerus fracture (PHF) by intra-focal distraction with a cemented device is seldom used. A cementless stem called JUST was developed to simplify and standardise reduction and fixation of three- or four-part fractures (3-/4-PFs). This study is designed to evaluate the performances of this device. In addition, we compared the results to those of a previous study based on cemented stems. Twenty-five patients underwent surgery between 2009 and 2011: ten 3-PFs and 15 4-PFs, with a median age of 65.5 and 71years, respectively. The reduction and fixation device comprises a staple placed in the humeral head and a cementless stem impacted in the diaphysis that works like a jack. Median follow-up was 28months. For the ten 3-PFs, the median raw and weighted Constant score were 66.5 and 86, respectively. Only one case presented with secondary displacement. All fractures healed and there was only one case of avascular necrosis. For the 15 4-PFs, the median raw and weighted Constant score were 64 and 76, respectively. Only one case of secondary cephalic displacement was observed and no cases of tuberosity displacement were observed. All fractures healed except for one case of pseudarthrosis of the lesser tuberosity. Five cases of avascular necrosis were observed. This device resolves the mechanical difficulties relating to fixation of 3- and 4-PFs by providing stable fixation but does not prevent the risk of avascular necrosis. The cementless stem is more convenient but does not yield better results than the cemented stem.

Treatment Options in Pipkin Fracture-Dislocation of the Femoral Head: Cases Review

Background: Fractures of the femoral head associated with a hip dislocation are relatively rare and often associated with a poor functional outcome. Materials and methods: In the past two years we had nine cases of femoral head Pipkin fracture-dislocations type I, II and IV. Medical data and radiographs, including computed tomography of the patients were reviewed for analysis. All patients were followed postoperatively for a period of minimum 22 months. Functional outcome was evaluated with the Merle d’Aubigne-Postel score. Results: Of the fractures, four of them were classified as type I Pipkin, of which one was an open type 1 Gustilo- Anderson fracture, two were classified as type II Pipkin, and three were classified as type IV Pipkin. The time from injury to successful closed reduction was 6.7 hours (range 4.5-10 hours). Three type I Pipkin fracture-dislocations were treated by conservative means (no surgery) and one case required excision of intra-articular free bodies. In type II Pipkin fracture-dislocations, open reduction and internal fixation (ORIF) was performed in one case and hemiarthroplasty in the other. In type IV Pipkin lesions, we performed open reduction and internal fixation of the acetabular fracture through posterior Kocher-Langenbeck approach and excision of femoral head intra-articular free bodies The overall outcome was excellent in four cases and good in five cases. Throughout the follow-up period, there was no case of avascular necrosis (AVN) recorded. Heterotopic ossifications (HO) were observed in one case of type I Pipkin, two cases of type II Pipkin and one case of type IV Pipkin fractures. Conclusion: Treatment aim should always be the anatomic reduction of the fragments with minimal soft tissue injury. Sometimes closed reduction is enough, but in the presence of large fragments, the fracture-dislocation is better treated by ORIF. We should not forget that half of these patients will have good outcomes no matter the treatment strategy; this result depends on the general health of the patient, the severity of the injury, associated injuries, associated cartilage injury, and timing of admission to the hospital.

Surgical treatment of proximal humerus fractures using PHILOS plate

ObjectiveTo evaluate functional outcome and complications of open reduction and internal fixation with proximal humeral internal locking system (PHILOS) plate for proximal humerus fractures. MethodsWe reviewed 51 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2007 to 2012. There were 35 men and 16 women with a mean age of 38years (range 24-68). There were 41 patients in the age group of <60years and 10 patients in the age group of >60years. According to Neer classification system, 8, 15 and 23 patients had 2-part, 3-part, and 4-part fractures, respectively and 5 patients had 4-part fracture dislocation. All surgeries were carried out at our tertiary care trauma centre. Functional evaluation of the shoulder at final follow-up was done using Constant-Murley score. ResultsThe mean follow-up period was 30months (range 12-44 months). Two patients were lost to follow-up. Of the remaining 49 patients, all fractures were united clinically and radiologically. The mean time for radiological union was 12weeks (range 8-20 weeks). At the final follow-up the mean Constant-Murley score was 79 (range 50-100). The results were excellent in 25 patients, good in 13 patients, fair in 6 patients and poor in 5 patients. During the follow-up, four cases of varus malunion, one case of subacromial impingement, one case of deep infection, one case of intraarticular screw penetration and one case of failure of fixation were noted. No cases of avascular necrosis, hardware failure, locking screw loosening or nonunion were noted. ConclusionPHILOS provides stable fixation in proximal humerus fractures. To prevent potential complications like avascular necrosis, meticulous surgical dissection to preserve vascularity of humeral head is necessary.

Anterior minimally invasive subcapital osteotomy without hip dislocation for slipped capital femoral epiphysis.

A minimally invasive anterior approach appears to be an attractive alternative to achieve capital realignment without violating femoral head vascular supply and avoiding hip dislocation in slipped capital femoral epiphysis. The aim of this study was to detail the technical steps of subcapital realignment through a minimally invasive anterior approach and to report the preliminary results of this procedure in a prospective cohort of patients with stable slips. Nine patients underwent subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation for moderate or severe stable slips between April 2012 and April 2013. Prophylactic stabilization of the contralateral hip was performed in all cases. A minimum 18months follow-up was available. Clinical course was assessed using the Harris hip score and the hip range of motion. The degree of slippage as proposed by Southwick, the lateral α angle and the epiphyseal-metaphyseal distance allowed radiographic assessment. No patients were lost during follow-up, which was on average 28months. No intraoperative complications occurred; one postoperative transient apraxia of the femoral cutaneous nerve, which completely recovered in sixmonths, was recorded. Southwick angle, lateral α angle and epiphyseal-metaphyseal distance all improved substantially postoperatively. No cases of avascular necrosis were detected. Subcapital cuneiform wedge resection through a minimally invasive anterior approach without hip dislocation can be an easier alternative to restore proximal femoral anatomy in moderate to severe stable slips. Prospective case control studies are required to confirm these preliminary results.

Surgical hip dislocation for treatment of cam femoroacetabular impingement.

Background:Cam femoroacetabular impingement is caused by a misshapen femoral head with a reduced head neck offset, commonly in the anterolateral quadrant. Friction in flexion, adduction and internal rotation causes limitation of the hip movements and pain progressively leading to labral and chondral damage and osteoarthritis. Surgical hip dislocation described by Ganz permits full exposure of the hip without damaging its blood supply. An osteochondroplasty removes the bump at the femoral head neck junction to recreate the offset for impingement free movement.Materials and Methods:Sixteen patients underwent surgery with surgical hip dislocation for the treatment of cam femoroacetabular impingement by open osteochondroplasty over last 6 years. Eight patients suffered from sequelae of avascular necrosis (AVN). Three had a painful dysplastic hip. Two had sequelae of Perthes disease. Three had combined cam and pincer impingement caused by retroversion of acetabulum. All patients were operated by the trochanteric flip osteotomy with attachments of gluteus medius and vastus lateralis, dissection was between the piriformis and gluteus minimus preserving the external rotators. Z-shaped capsular incision and dislocation of the hip was done in external rotation. Three cases also had subtrochanteric osteotomy. Two cases of AVN also had an intraarticular femoral head reshaping osteotomy.Results:Goals of treatment were achieved in all patients. No AVN was detected after a 6 month followup. There were no trochanteric nonunions. Hip range of motion improved in all and Harris hip score improved significantly in 15 of 16 cases. Mean alpha angle reduced from 86.13° (range 66°–108°) to 46.35° (range 39°–58°).Conclusion:Cam femoroacetabular Impingement causing pain and limitation of hip movements was treated by open osteochondroplasty after surgical hip dislocation. This reduced pain, improved hip motion and gave good to excellent results in the short term.

Outcomes of Arthroscopic Hardware Removal Following Locked Plating of Proximal Humerus Fractures: A Prospective Study

the Visual Analog Scale (VAS), DASH questionnaire, American Shoulder and Elbow Surgeons Shoulder score (ASES), as well as the Constant score as outcome measures. Patients were examined by a non-treating physician to determine shoulder motion and strength of both the injured and contralateral upper extremity. A radiograph of the operated shoulder was obtained at the time of final follow up to measure the head-neck angle as well as to determine the presence or absence of post traumatic arthritis and avascular necrosis (AVN) in the humeral head. Results: The mean age of our patients at the time of surgery was 66.8 years (40.5 to 85.4). There were no intra-operative complications. Mean estimated blood loss (EBL) was 109 ml (10 to 300) and the mean operative time was 119 min (70 to 236). All patients were able to return to their pre-injury level of activity and all were satisfied with their result. The mean follow-up time was 5.9 years (1 to 13.5). The mean external rotation of the injured versus uninjured shoulder was 49 deg (25 to 85) vs. 59 deg (20 to 90) p1⁄40.003, internal rotation was to T10 (L5 to T6) vs. T9 (L1 to T4) p1⁄40.65, forward flexion was 143 deg (90 to 180) vs. 158 deg (110 to 180) p1⁄40.019, and abduction was 113 deg (60 to 180) vs. 120 deg (85 to 180) p1⁄40.07. The mean ASES score was 88.2 (33 to 100), DASH score 13.9 (0 to 73.3), and Constant score 68.9 (37.9 to 86.3). The mean head-neck angle was 129 deg (106-140). Post-operative complications included one case of subacromial impingement, 2 cases of avascular necrosis, one of which involved less than twenty-five percent of the articular segment with no collapse, and one with articular collapse that required revision to hemiarthroplasty. There was one case of capsular contracture requiring manipulation under anesthesia and arthroscopic capsular release 38 months after the index procedure. There were two cases of heterotopic ossification of which one required excision 5 months after the index procedure. There was one pin tract infection that resolved with oral antibiotics. Conclusion: The use of coral as a strut allograft is a simple, safe, and effective technique for the surgical treatment of 3 and 4-part valgus-impacted proximal humerus fractures leading to consistently high patient satisfaction.

Classifications in Brief: The Hawkins Classification for Talus Fractures.

As reported by Coltart [5], Fabricius von Hilden first described talus injuries in 1608, and in 1919, Anderson et al. [1] reported a series of talus fracture dislocations in which they emphasized dorsiflexion as the mechanism of injury and coined the term ‘‘aviator’s astragalus’’ (astragalus being another term for talus) because of the impressive frequency with which the mechanism—aircraft accidents— was associated with the injury in question. In 1952, Coltart [5] reported on 228 talus injuries treated by surgeons in the British Royal Air Force in an attempt to describe the variety of injuries that occur to the talus and surrounding joints. He described various talus fracture patterns, fracture-dislocation combinations, and isolated peritalar dislocations [5]. Others have presented case series of talus injuries and associated rarely used classification schemes [15, 19], but all have noted high complication rates with injuries to the talus [5, 11, 15, 19]. In 1970, proposed treatment strategies for vertical fractures of the talar neck ranged from nonoperative management to urgent open reduction internal fixation, bone graft augmentation, fusion of the dorsal talus to the distal tibia, and even complete talectomy [11]. Although the importance of early, anatomic reduction of these injuries was noted at that time, the incidence of avascular necrosis (AVN) was not. In 1970 Hawkins [11] described injury patterns and AVN rates in a series of 57 vertical talar neck fractures in 55 patients from three different institutions. All 55 patients sustained forced dorsiflexion injuries, similar to the mechanism described by Anderson et al. [1] in pilots.

The Result of Open Reduction and Mini-Plate Fixation for Displaced Talar Neck Fracture

Purpose: We evaluated the complications, radiological and clinical results after operative treatment using a mini-plate for fixation of displaced talar neck fractures. Materials and Methods: There were 20 cases of displaced talar neck fractures from May 2006 to December 2011; we performed a retrospective chart review of 15 patients treated by open reduction and internal fixation using a mini-plate who had more than 2 years of follow-up. According to Hawkin’s classification, there were 7 cases of type II fractures and 8 cases of type III fractures. During postoperative 12-16 weeks we checked magnetic resonance imaging. The assessment of clinical results was based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. Results: Mean union period was 11.6 weeks (10-15 weeks). Nonunion and malunion did not occur in all cases. The mean AOFAS score was 88.2 points (80-97 points). There were 5 cases of avascular necrosis. Of these, there were 3 cases of body collapse and 4 cases of post-traumatic arthritis. In the statistical analysis, there was no correlation between the elements including gender, Hawkin’s classification and union rates and clinical results. Conclusion: Mini-plate fixation of a displaced talar neck fracture is thought to be a good technique, with a low rate of malunion and also showed satisfactory results in radiological and clinical assessment.

Rapid magnetic resonance imaging protocol for detecting femoral head avascular necrosis: A case series-it′s utility in the general population in developing countries

Introduction: Osteonecrosis of the femoral head is an increasing cause of musculoskeletal disability, common among the younger population, between the third and fifth decade of life, affecting mainly men, thereby requiring prompt diagnosis and early intervention. Aims and Objectives: The aim was to formulate a limited magnetic resonance imaging (MRI) examination protocol for detection of avascular necrosis (AVN) in clinically suspected cases that can be performed rapidly and will be inexpensive. Materials and Methods: Forty-five patients suspected clinically and or on conventional radiography for AVN of the femoral head were referred for MRI hip. MRI hip was done on 1.5 T Siemens Avanto. Of 45, 36 were detected to have AVN (total 58 hips), whereas 9 did not have AVN on MRI. Initially, coronal T1-weighted image (T1WI) sequence was obtained as limited MRI protocol, followed by complete MRI examination. Results: Maximum patients belonged to age group 31-40 (30.5%). 32 (88.88%) patients were males and 4 (11.11%) were females. Bilateral AVN was detected in 44 (61.1%) and unilateral in 14 patients (38.8%). Pre collapsed stage (Stages I and II) was detected in 18 hips (31.03%), collapsed stage (Stages III and IV) was detected in 40 hips (68.9%). Peripheral low-intensity rim was seen on T1WI in all 58 cases of AVN. Double line sign on T2-weighted image was seen in 33/58 (56.8%). Conclusion: Our study concluded that coronal T1W sequence is an easy, rapid and cost-effective method of detecting unilateral or bilateral AVN.

The Role of Capital Realignment Versus In Situ Stabilization for the Treatment of Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) can be treated by a variety of methods with the traditional method of in situ pin fixation being most commonly used. More recently, the Modified Dunn (Mod. Dunn) procedure consisting of capital realignment has been popularized as a treatment method for SCFE, particularly for more severe cases. Over the last 5 years, our institution has selectively used this method for more complex cases. The purpose of this article is to evaluate the differences between these 2 treatment methods in terms of avascular necrosis (AVN) rate, reoperation rate, and complication rate. Eighty-eight hips that were surgically treated for SCFE between July 2004 and June 2012 met our inclusion criteria. The in situ fixation group included 71 hips, whereas 17 hips were anatomically reduced with the Mod. Dunn procedure. Loder classification, severity, acuity, complication rate, and reoperation rate were determined for the 2 cohorts. The χ analysis was performed to evaluate the relationship between the treatment method and outcome. As expected, stable slips did well with in situ pinning with no cases of AVN, even in more severe slips. Ten stable slips were treated with the Mod. Dunn approach and 2 (20%) developed AVN. Unstable slips were more difficult to treat with 3 of the 7 hips stabilized in situ developing AVN (43%). Two of the 7 unstable slips treated by the Mod. Dunn procedure developed AVN (29%). The other outcomes studied (reoperation rate and complication rate) were not significantly related to the surgical treatment method (P = 0.732 and 0.261, respectively). In situ pinning remains a safe and predictable method for treatment of stable SCFE with no AVN noted, even in severe slips. Attempts to anatomically reduce stable slips led to severe AVN in 20% of cases, thus this treatment approach should be considered with caution. Treatment of unstable slips remains problematic with high AVN rates noted whether treated by in situ fixation or capital realignment (Mod. Dunn). Level III retrospective comparative study.

Prevalence, incidence, and associated factors of avascular necrosis in Korean patients with systemic lupus erythematosus: a nationwide epidemiologic study.

Avascular necrosis (AVN) is one of the most frequent types of organ damage in systemic lupus erythematosus (SLE). However, little is currently known about the epidemiology of AVN in SLE patients. The aim of this study was to estimate the prevalence and incidence of AVN in Korean patients with SLE based on National Health Insurance (NHI) claims data and to determine the risk factors for AVN among SLE patients. This study was conducted using the 2006-2010 data of 25,358 SLE patients from the NHI program. AVN cases were defined as those with at least one diagnosis of AVN. The prevalence was calculated by dividing the number of AVN cases by the number of SLE cases in the same year. The annual incidence was calculated by dividing the number of incident AVN cases by the number of SLE-prevalent cases not previously diagnosed with AVN. Patients who developed AVN in 2008-2010 were compared with SLE patients who did not develop AVN to identify any risk factors. The prevalence of AVN among SLE patients (2006-2010) was 31.5-34.2 per 1,000 persons and was similar in all the years studied. The incidence per 1,000 persons of AVN among SLE patients was 8.6 [95 % confidence interval (95 % CI) 6.9-10.3] in 2008, 9.8 (95 % CI 8.0-11.6) in 2009, and 8.4 (95 % CI 6.8-10.0) in 2010. Regression analysis indicated that taking an oral corticosteroid [odds ratio (OR) 2.12, 95 % CI 1.39-3.23] or an intravenous corticosteroid (OR 1.5, 95 % CI 1.2-1.89) was significantly associated with AVN. In addition, AVN was associated with use of immunosuppressive agents (OR 2.12, 95 % CI 1.66-2.72), hydroxychloroquine (OR 1.4, 95 % CI 1.09-1.81), and lipid-lowering agents (OR 1.78, 95 % CI 1.24-2.57) among the prescribed medications, and with hypertension (OR 1.39, 95 % CI 1.08-1.79) among the comorbidities. The prevalence and incidence of AVN among SLE patients, which were 31.5-34.2 and 8.4-9.8 per 1,000 persons, respectively, may be representative of the entire population of symptomatic AVN patients with SLE in Korea. AVN is associated with the use of corticosteroids, immunosuppressants, hydroxychloroquine, lipid-lowering agents, and with hypertension. Studies of large, prospective cohorts are needed to confirm these results.

The clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in elderly patients.

The purpose of the present study was to evaluate the clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in patients aged 65 years and older. The records of consecutive patients who underwent surgery for undisplaced femoral neck fractures between 1999 and 2011 were retrospectively reviewed. The patients underwent the surgery as early as possible, and allowed early full weight-bearing. The interval between initial injury and surgery, time to admission and operation, operation time, decrease in hemoglobin, the postoperative day starting to walk, postoperative walking status, and the incidence of any secondary procedures were evaluated. The average patient age was 77.5 years and the average duration of postoperative follow-up was 46.8 months. The patients were divided to two groups to determine the effect of early operation: the early operation group within 24 h on admission, and the late operation group done 24 h after admission. Eighty-six percent of surgeries were performed within 48 h of admission. The average operation time was 46 min (range 20-95 min). Transfusions were performed in 6.9 % (4/58) of patients. The mortality rate was 6.9 %, and the rate of complications was 9.3 % (5/54): four cases of avascular necrosis (AVN) and one case of fixation failure. The rate of secondary procedures was 7.4 % (4/54). Seventy-two percent (39/54) of patients recovered their postoperative walking ability to pre-injury levels. This study demonstrated that early internal fixation of undisplaced femoral neck fractures in elderly patients produced satisfactory clinical outcomes.

Percutaneous Screw Fixation Promotes Healing of Lateral Condyle Nonunion in Children

This retrospective study examined whether pediatric lateral condyle nonunions could be successfully managed by percutaneous screw fixation. We report the outcome of this minimally invasive technique avoiding open reduction and bone grafting associated with the risk of avascular necrosis (AVN), infection, and stiffness. The hospital radiology database was searched between 1998 and 2008. This identified 16 consecutive patients aged 2 to 10 years, with lateral condyle nonunions treated with percutaneous screw fixation. We assessed clinical and radiographic outcomes from presentation to final follow-up. Potential risk factors for recalcitrant nonunion were identified. Categorical variables are presented as proportions and percentages. Continuous variables were assessed for normality with the d'Agostino-Pearson test. Normally distributed variables are presented as means with 1 SD. Non-normally distributed data are presented as medians with interquartile range. Outcome was defined as successful if radiologic and clinical union was achieved. Twelve patients (75%) united after surgery, at a mean of 16.2 weeks (±6.74). Four (25%) failed to unite. The failures presented with nonunion later (median of 225.5 wk from initial injury). This was significantly different (P=0.039) from presentation in the successful group (median time 15.7 wk).Median age at injury was 5.1 years (range, 3.2 to 7.2) in the successful and 2.8 years (range, 2.1 to 4.7) in the unsuccessful group (P=0.18). Overall, mean time from nonunion diagnosis to percutaneous surgery was 5.2 weeks (±4.11). Forty-four percent had implant removal once union was achieved and no cases of AVN were reported. We demonstrate this technique to be successful in nonunions addressed within 16 weeks from initial injury to diagnosis. Our 4 failures occurred in nonunions diagnosed >31 weeks from the injury (31, 68, 383, 427 wk). All had been managed nonoperatively as their primary treatment plan.Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed after a greater delay. There was a trend toward successfully treated patients being younger. There were no cases of AVN, infection, or elbow stiffness. Level 4.

Internal Splinting with a Balloon-Shaped Allogenic Cancellous Bone Graft for Proximal Humerus Comminuted Fracture

Background/Purpose: Mechanical support of the inferomedial region of the proximal humerus is important for maintaining fracture reduction in comminuted fracture of the proximal humerus. We use the balloon shape of allograft cancellous bone to provide medial column support and summarize the result. Patients and methods: We included 25 patients (12 men and 13 women with a mean age of 55 years) with 3-and 4-part humerus fractures, who underwent internal splinting from July 2008 to September 2012, in our study. We used a T-plate with internal splinting (balloon shaped allogenic cancellous bone) to fix the proximal humerus fracture. Radiographs were periodically checked half, 1, 2, 4, 6, 12 and 24 months months after surgery. The shoulder function was evaluated with Constant-Murley score one year after surgery. Results: Eighteen (72%) of humerus fractures healed after 12 months. The following complications were observed:2 case of screws pull out (8%), 1 case of nonunion (4%), 2 cases of avascular necrosis (8%), and 2 cases of varus collapse (8%). There were no cases of infection or nerve injury. The median Constant-Murley score at one year was 70 points. Discussion and conclusion: Medial support is important to provide stability after proximal humerus fractures.. We used a balloon-shaped allogenic cancellous bone graft to provide (1) a more balanced medial support, (2) material for screw purchase, and (3) a biologic effect for bone healing. It should be another treatment option for patients with comminuted proximal humerus fractures.

A Stepwise Algorithm for Surgical Treatment of Type II Displaced Pediatric Phalangeal Neck Fractures

To evaluate a stepwise reduction algorithm including closed, percutaneous, and open reduction techniques followed by percutaneous pin fixation for displaced pediatric phalangeal neck fractures. Sixty-one consecutive children (mean age, 9.4 y; range, 2-18 y) presenting with closed, type II displaced phalangeal neck fractures were treated using the following algorithm. If satisfactory reduction was achieved with closed reduction, percutaneous pinning (CRPP) was performed. If not achieved, then percutaneous reduction and pinning (PRPP) was performed using a temporary intrafocal joystick for reduction and for osteoclasis as needed. If percutaneous reduction failed, open reduction and percutaneous pinning (ORPP) was performed. Using the Al-Qattan system, radiographic and clinical outcomes were retrospectively graded for union, deformity, range of motion, and function. Satisfactory alignment was achieved in all 61 fractures, by CRPP in 49 and PRPP in 12. No fracture required open reduction. Mean number of days from injury to surgery was 8 days for CRPP and 17 days for PRPP. All fractures treated after 13 days required percutaneous pinning. Fifty-three patients were followed for at least 1 year or until full functional recovery was achieved, with 45 excellent, 4 good, 1 fair, and 3 poor results. Four complications accounted for the fair and poor results, including 1 flexion contracture, 1 nonunion following pin track infection, and 1 case of avascular necrosis following a severe crush injury in the CRPP group and 1 flexion contracture following PRPP. Our stepwise algorithm for surgical treatment of closed, type II displaced pediatric phalangeal neck fractures produced 92% good to excellent results while minimizing the need for open reduction even in late-presenting fractures. Therapeutic IV.