Metaphyseal-diaphyseal Junction Research Articles

Application of external fixator combined with Kirschner wire fixation for oblique and comminuted distal humeral metaphyseal-diaphyseal junction fractures in children

To analyze the effectiveness of external fixator combined with Kirschner wire (EF-KW) fixation in the treatment of oblique and comminuted distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children. A clinical data of 22 children with DHMDJ fractures who met the selection criteria between April 2021 and December 2023 was retrospectively analyzed. All patients were treated with EF-KW fixation. There were 14 boys and 8 girls with an average age of 6.8 years (range, 1.5-12.0 years). The time from injury to operation was 14-38 hours (mean, 24.2 hours). There were 18 cases of comminuted fractures and 4 cases of oblique fractures; and 1 case of median nerve injury and 1 case of radial nerve injury before operation. The occurrence of postoperative complications was recorded. At last follow-up, the function of the affected elbow joint was evaluated according to the Mayo elbow joint function score, and the Baumann's angle (BA) and humero-capitellar angle (HCA) of the affected and healthy sides were recorded and compared. All fractures were successfully treated with closed reduction and no complications such as nerve injury occurred. Superficial infection occurred in 4 cases after operation and healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 9-24 months (mean, 13.8 months). At last follow-up, according to the Mayo elbow joint function score, the elbow joint function was rated as excellent in 15 cases, good in 6 cases, and fair in 1 case, with an excellent and good rate of 95.5%. The neurologic injury before operation recovered gradually. X-ray films reexamination showed that all fractures healed, and the healing time of fractures ranged from 29 to 61 days, with an average of 35.6 days. At last follow-up, there was no significant difference in BA and HCA between the healthy side and the affected side ( P>0.05). During follow-up, 1 case developed mild cubitus varus, while the other patients had no serious complications. EF-KW fixation for oblique and comminuted DHMDJ fractures in children has the advantages of less trauma, simple operation, easy reduction, good stability after reduction, low incidence of serious complications, and good elbow functional recovery.

Management of pediatric distal humerus metaphyseal-diaphyseal junction fracture: A systematic review and meta-analysis.

Fractures occurring at the metaphyseal-diaphyseal junction of the distal humerus in children are not commonly documented in the literature. Until this moment, there is no gold standard technique regarding its management and most surgeons treat it as a regular supracondylar humerus fracture by conventional pinning. This systematic review explores the relevant literature to assess the efficacy of different techniques. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our literature search encompassed several online databases, including PUBMED/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar. Data from articles that met our general inclusion criteria were extracted and categorized into treatment method groupings. Functional and cosmetic outcomes, demographic characteristics, and complications were the main parameters used to analyze the data. Ten retrospective studies met our inclusion criteria with a total of 178 participants of unilateral pediatric distal humerus metaphyseal-diaphyseal junction fractures. Most literature chose closed reduction and percutaneous pinning in seven articles, followed by elastic stable intramedullary nail technique used in three articles, then conservative treatment was chosen in two articles, while only one article used lateral miniplate and assisted K-wire and another article used combined closed reduction and percutaneous pinning and intramedullary K-wire. As regards the operation time; elastic stable intramedullary nails had the shortest time with a mean of 39.7 min (range: 37.5-41.9 min), while closed reduction and percutaneous pinning had the longest time with a mean of 75.47 min (range: 55.9-92.1 min). The shortest healing time was observed in miniplate with a mean of 7.2 weeks, while the most prolonged was in conservative management with a mean of 12 weeks and closed reduction and percutaneous pinning was a mean of 10 weeks. Regarding Flynn's criteria, all participants received excellent and good except in closed reduction and percutaneous pinning; 13 cases were fair and 2 cases were poor. Regarding complications, the most commonly observed complication after metaphyseal-diaphyseal junction fracture was cubitus varus, the highest incidence was in conservative management (33% of cases), followed by closed reduction and percutaneous pinning (10.9% of cases), the least incidence was observed in elastic stable intramedullary nails (3.77% of cases), and none of the cases treated with mini plate developed this complication. Other complications were observed only with closed reduction and percutaneous pinning; 8.5% of cases developed fixation loss, 6.2% of cases had a significantly reduced range of motion, and one case refractured. Pediatric distal humerus metaphyseal-diaphyseal junction fractures should be distinguished from the more prevalent supracondylar humerus fractures, as conventional pinning techniques are associated with a higher incidence of complications and increased both operative and healing times.Level of evidence: III.

Treatment of unstable forearm fractures at the metaphyseal-diaphyseal junction in children: antegrade ESIN vs. transepiphyseal intramedullary K-wire fixation.

Treatment of unstable forearm fractures in the metaphyseal-diaphyseal junction (MDJ) zone is still a matter of debate. Major drawbacks of all types of fixations include either invasiveness, technical impracticality, or lack of acceptance by patients. This study reports results after antegrade ESIN (a-ESIN) compared to transepiphyseal intramedullary K-wire (TIK) for unstable MDJ forearm fractures. The MDJ of the forearm was defined as the square over the joints of both forearm bones subtracted with the square over the metaphysis of the radius alone. The data of 40 consecutive patients < 16 years of age who were treated either by a-ESIN (later treatment period) or TIK (early treatment period) for an unstable MDJ forearm fracture at a single high-volume pediatric trauma center were retrospectively analyzed. The average age was slightly lower in the first group (TIK = 7.42 years; a-ESIN = 10.5 years). An additional ulna fracture was found in 50% of cases and was treated with a classic antegrade ESIN in 10/20 (TIK) and 6/20 cases (a-ESIN). Additional plaster cast immobilization was performed in all cases with TIK and in three cases with a-ESIN. After TIK, no complication, malalignment, or functional limitation occurred. After a-ESIN, 19/20 patients had an event-free course with stable retention and healing without axial malalignment. In one case, a temporary sensor dysfunction occurred. The same patient suffered a refracture two months after the original trauma, which required a closed reduction. Metal removal was performed after 84 days (TIK) and 150 days (a-ESIN). The outcome in all patients was good. Both a-ESIN and TIK are minimally invasive procedures that are technically easy to perform. Both methods are safe and lead to a complete restoration of the forearm's range of motion. The decisive advantage of a-ESIN is the possibility of postoperative immobilization-free rehabilitation.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study

BackgroundSeveral methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur.MethodsWe retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system.ResultsThirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment.ConclusionEF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment.Level of evidenceLevel III.

Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children

To summarize the research progress in the treatment of distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children and to provide reference for clinical practice. The characteristics and treatment methods of transverse and comminuted DHMDJ fractures in children were summarized and analyzed by referring to relevant literature at home and abroad. DHMDJ fractures in children are not uncommon clinically, with high fracture line position, multi-directional instability, difficult closed reduction in treatment, and easy to cause complications such as coronal and sagittal deformity of the elbow. The Kirschner wire technique was effective for DHMDJ fractures with the fracture line at the middle and low levels, but was prone to iatrogenic ulnar nerve injury. Elastic stable intramedullary nail is suitable for higher-position transverse DHMDJ fractures. However, this technique requires a second operation to remove the internal fixator, and may cause iatrogenic epiphysis plate injury in children. External fixator is a new way to treat DHMDJ fractures, and it can show satisfactory results for transverse and comminuted DHMDJ fractures. However, at present, there are few relevant studies, and most of them focus on biomechanical studies, and the efficacy lacks high-quality clinical research support. The ultimate goal of DHMDJ fracture treatment in children is to restore the anatomical alignment of the fracture and prevent the loss of reduction. The choice of internal fixator depends on the location of the fracture line and the shape of the fracture to provide personalized treatment.

Elastic stable intramedullary nail combined with Kirschner wire (E-K) technique for treating pediatric distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures.

Elastic stable intramedullary nail (ESIN) is a commonly used method for treating diaphyseal fractures of the tibia, but its application in Distal Tibial Diaphyseal Metaphyseal Junction (DTDMJ) fractures has been a subject of controversy. This study aims to evaluate the clinical efficacy of the Elastic stable intramedullary nail-Kirschner wire (E-K) technique in treating pediatric DTDMJ fractures, providing better clinical decision-making for clinicians in diagnosing and treating such fractures. We conducted a retrospective analysis of patients aged 3-9 years who received treatment at our hospital from January 2019-January 2021 for distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. Based on their surgical procedures, they were categorized into the Elastic Stable Intramedullary Nail-Kirschner wire group (E-K) and the ESIN group. Demographic data, surgical duration, clinical outcomes, complications, and imaging data were recorded. The study included a total of 57 patients, with 24 cases in the E-K group and 33 cases in the ESIN group. There were 30 males and 27 females. The average age was (6.25 ± 1.59) years in the E-K group and (6.27 ± 1.48) years in the ESIN group. There were no significant differences between the two groups in terms of gender, age, weight, time from injury to surgery, follow-up time, side of injury, associated injuries, nail site infection, deep infection, and nail removal time (P > 0.05). Neither group experienced nonunion or refracture. The E-K group exhibited significantly lower coronal and sagittal plane angular values at the final follow-up compared to the ESIN group (P < 0.001). In the E-K group, the final follow-up coronal plane angle was 2.67 (1.09)°, while in the ESIN group, it was 6.55 (2.05)°. The final follow-up sagittal plane angle was 3.12 (1.54)° in the E-K group and 7.58 (1.48)° in the ESIN group. Both groups showed good alignment in the initial postoperative x-rays, with no statistically significant differences. However, during clinical healing, the ESIN group exhibited significant displacement, whereas the E-K group had minimal displacement, demonstrating a significant statistical difference (P < 0.001). There was a statistically significant difference in the AOFAS joint function assessment between the two groups (P = 0.027). The E-K technique is a viable option for treating DTDMJ fractures in pediatric patients, with well-established clinical efficacy. Its advantages include a straightforward surgical procedure, safety, and a low incidence of severe complications.

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique

BackgroundSurgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation.Patients and methodsA retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up.ResultThere were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients.ConclusionIn the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.

Result of the pin fixation with mini-open technique for irreducible distal radius diaphyseal metaphyseal junction fractures in child

Aim: Although conservative treatment remains the preferred choice for distal radius fracture in children, reduction losses and failure to achieve reduction remain the main problems at diaphyseal metaphyseal junctional fractures. There is no consensus on the surgical treatment of displaced metaphyseal-diaphyseal distal radius fractures. This study aims to evaluate the result of the crossed pin fixation applied with the mini-open technique at pediatric metaphyseal-diaphyseal distal radius fractures. &#x0D; &#x0D; Methods: The radiological and clinical outcomes of pediatric distal metaphyseal diaphyseal distal radius fractures operated between 2018 and 2020 were retrospectively investigated. The clinical follow-ups of the patients were performed in the second, fourth, sixth weeks and the third month. Radiological recovery time, reduction losses during follow-up, complications, and forearm and wrist range of motion were examined. &#x0D; &#x0D; Result: There were 13 boys and 6 girls with an average age of 10.1 (8-12 years). Radiographs taken immediately after the operation showed less than 5% translation in the coronal plane and less than 10% translation in the sagittal plane. An average of 4 degrees of change was observed in the lateral radiographs, and an average of 3 changes was detected in the anterior to posterior (AP) radiographs at the last follow-up. No limitation in the range of motion was observed in the patients. &#x0D; &#x0D; Conclusion: Our data showed that the pin fixation with the mini-open technique was a suitable method to treat metaphyseal-diaphyseal distal radius fractures with a satisfactory alignment and achieving stable fixation.

Anterolateral Dual Plate Fixation for Distal Metaphyseal-Diaphyseal Junction Fractures of the Humerus: Biomechanical Finite Element Analysis with Clinical Results.

Distal metaphyseal-diaphyseal junction fractures of the humerus are a subset of injuries between humeral shaft fractures and distal intra-articular humerus fractures. A lack of space for distal fixation and the unique anatomy of concave curvature create difficulties during operative treatment. The closely lying radial nerve is another major concern. The aim of this study was to determine whether anterolateral dual plate fixation could be effective for a distal junctional fracture of the humerus both biomechanically and clinically. A right humerus 3-dimensional (3D) model was obtained based on plain radiographs and computed tomography data of patients. Two fractures, a spiral type and a spiral wedge type, were constructed. Three-dimensional models of locking compression plates and screws were constructed using materials provided by the manufacturer. The experiment was conducted by using COMSOL Multiphysics, a finite element analysis, solver, and simulation software package. For the clinical study, from July 2008 to March 2021, a total of 72 patients were included. Their medical records were retrospectively reviewed to obtain patient demographics, elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo Elbow Performance Scores (MEPS), and hand grip strength. No fracture fixation construct completely restored stiffness comparable to the intact model in torsion or compression. Combinations of the 7-hole and 5-hole plates and the 8-hole and 6-hole plates showed superior structural stiffness and stress than those with single lateral plates. At least 3 screws (6 cortices) should be inserted into the lateral plate to reduce the load effectively. For the anterior plate, it was sufficient to purchase only the near cortex. Regarding clinical results of the surgery, the range of motion showed satisfactory results in elbow flexion, elbow extension, and forearm rotation. The average DASH score was 4.3 and the average MEPS was 88.2. Anterolateral dual plate fixation was biomechanically superior to the single-plate method in the finite element analysis of a distal junctional fracture of the humerus model. Anterolateral dual plate fixation was also clinically effective in a large cohort of patients with distal junctional fractures of the humerus.

MRI as an aid to diagnosis of scurvy in absence of classic clinical and radiographic signs

Scurvy, a Vitamin C deficiency disorder leads to impaired synthesis of collagen, osteoid, and dentine, causing cutaneous, dental, and skeletal manifestations, respectively. The radiographic features of scurvy are very well established but the increasing use of magnetic resonance imaging (MRI) in limb pathologies warrants radiologists to be aware of its common as well as atypical magnetic resonance findings. Two children who presented with pain and swelling of the thigh and were proven to have scurvy were included in the study. The first child had cerebral palsy and MRI was performed as radiographs were suspicious for physeal subluxation. MRI confirmed physeal separation of the distal femur with subperiosteal collection. The second patient was developmentally normal and had non-traumatic painful thigh swelling. Radiographs showed a fracture at the distal metaphyseal–diaphyseal junction of the femur. Subperiosteal collection and surrounding muscle edema with heterogenous marrow signal were seen in both the patients on MRI. Inflammatory markers were normal. Follow-up with radiographs after treatment with vitamin C supplementation showed ossification of the subperiosteal hematomas and resolution of the symptoms. These two cases highlight the significance of MRI in reaching a diagnosis in atypical cases of scurvy which has excellent response to Vitamin C supplementation.

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal–diaphyseal junction fractures of the distal radius: a case-control study

BackgroundSeveral methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal–diaphyseal junction (MDJ) fractures of the pediatric distal radius.MethodsThe data of patients who were treated at a children’s hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.ResultsThe study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).ConclusionsK-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.Level of evidenceIII, a case-control study.

Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?

Fractures involving the distal radius metaphyseal-diaphyseal junction (MDJ) present a unique challenge for pediatric orthopedic surgeons. These fractures are too proximal for percutaneous K -wire fixation and too distal for retrograde flexible nailing. The purpose of this study was to: (1) determine the safety of a described antegrade approach from the posterior interosseous nerve (PIN); (2) assess the efficacy of antegrade nailing in cases of distal MDJ fractures; and (3) describe a standardized lateral approach to the proximal radius. A cadaveric study was performed using 10 adult forearms. Anterograde flexinail was introduced at the proximal radius based on the described "safe zone". Distal MDJ fractures were created using osteotomes. We evaluated the distance between the entry point to the PIN in addition to the quality of the reduction for the fracture. The average distance between the entry point and piercing instrument to the PIN was 5.4 cm (range: 4.7 to 6.0 cm). When grouped based on sex, the average distance was significantly further for males (5.8 cm, range: 5.2 to 6.0 cm) versus females (4.9 cm, range: 4.7 to 5.2 cm), P =0.004. Fracture reduction was not maintained after the introduction of the antegrade flexible nail across the fracture site. For all specimens, >25% displacement was seen on the anterior-posterior imaging. Our modified lateral approach to the starting point in the proximal radius is safe as long as the entry point for antegrade flexible nailing stays proximal to the radial tuberosity during the lateral approach to the proximal radius while the elbow is flexed and the forearm pronated.

A Novel Method for Treating Distal Radius Diaphyseal Metaphyseal Junction Fracture in Children.

BACKGROUND The treatment of distal radius diaphyseal metaphyseal junction (DMJ) fracture in children is a clinical problem; several treatments are available, but none are very effective. Therefore, this study aimed to report a novel method for treating this fracture using limited open reduction and transepiphyseal intramedullary fixation with Kirschner wire. MATERIAL AND METHODS From January 2018 to December 2019, a total of 15 children (13 boys and 2 girls) with distal radius DMJ fractures with a mean age of 10 years (range: 6-14 years) were included in the study. The operation time, incision length, and X-ray radiation exposure were precisely recorded. All children were followed up regularly. At the final follow-up, clinical outcomes were evaluated according to Price criteria, and complications were recorded. RESULTS The mean operation time of the 15 children was 21.4 min, and the mean incision length was 1.9 cm. The intraoperative X-ray was performed 3.7 times on average. The mean radiographic union of fracture was 4.7 weeks, and the mean time to remove the Kirschner wire was 4.8 weeks for radial instrumentation and 4.7 months for ulnar instrumentation. According to the Price grading evaluation system, clinical outcome was excellent in 14 cases and good in 1 case. Moreover, there were no major complications related to loss of reduction, malunion, nonunion, and physeal arrest of the distal radius. CONCLUSIONS Limited open reduction and transepiphyseal intramedullary fixation with Kirschner wire are effective for treating distal radius DMJ fracture in children, which has the advantages of simple surgical procedures, short operation time, small incision, and less radiation exposure, making it an excellent choice for treating this fracture.

External fixator as a safe method in the treatment of distal tibial fractures in children.

The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures. Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared. Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm). External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing. Level IV.

Short term outcome of treatment with percutaneous cross Kirschner wires in paediatric distal humeral metaphyseal diaphyseal junction fractures

Background: Soft tissue sarcomas (STS) are malignant tumours arising from mesenchymal tissue, comprising &lt;1% of all the tumours of the human body and represent the second most common type of solid tumours in children and adolescents. Surgical resection is considered the mainstay of treatment, supported by multimodal therapies including chemotherapy and radiotherapy. Resource-limited countries, like Pakistan, face additional challenges due to inadequate resources. This study presents the experience of management of soft tissue sarcomas presenting to a tertiary care hospital in Central Lahore.&#x0D; Patients and Methods: This was an observational study conducted in Surgical Unit I of Sir Ganga Ram Hospital Lahore from January 2017 till June 2022. American Joint Committee on Cancer (AJCC) staging system and Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) resection classification was applied. Surgical treatment including R0, R1 and R2 resections were carried out. SPSS 23 version was used for statistical analysis of collected data.&#x0D; Results: A total of 36 patients; 24 male (66.7%) and 12 females (33.3%) were included. Anatomical site involvement was observed as 23 (63.8%) limb sarcomas and 13 (36.1%) trunk sarcomas. Out of 36 patients, 20 (55.6%) patients were staged as stage II, 11 (30.5%) patients as stage III and 5 (13.9%) as stage I. Total 17 (47.2%) patients underwent wide excision, 13 (36.1%) patients underwent limited excision, 4 (11.1%) patients underwent compartmental excision and 2 (5.6%) patients underwent palliative excision. &#x0D; Conclusion: Thigh was the commonest site of involvement in extremity sarcomas. Retroperitoneal sarcomas were most frequent among trunk tumours. Leiomyosarcoma was the most common histopathological diagnosis followed by malignant peripheral nerve sheath tumours. Most of the patients presented with stage II disease.&#x0D; Keywords: Soft Tissue Sarcoma, Presentation, Resection, Histology, Outcome

Classifying Bone Loss in Failed Stemmed Total Knee Arthroplasty: Determining Reliability

BackgroundFailed stemmed total knee arthroplasty (TKA) components present with varying degrees of bone loss and technical challenges. A classification system has been proposed based upon metaphyseal bone loss and diaphyseal cortical integrity. A validation study was performed to determine interobserver and intraobserver reliability at multiple institutions and with different levels of training. MethodsAn online survey with digital anteroposterior and lateral radiographs was sent to 5 arthroplasty surgeons and 5 adult reconstruction fellows. The survey included 62 cases with stemmed femoral and tibial components, considered failures and pending revision, and scored by each reviewer independently using the classification system. Each case was scored in 2 separate sessions. Interobserver and intraobserver reliability was assessed using the intraclass correlation coefficient (ICC). ResultsInterobserver grading for both the femur (0.69) and tibia (0.72) showed strong reliability among the attendings and fellows, with slightly stronger reliability in tibia cases. The intraclass correlation coefficient (ICC) for attendings and fellows was similar overall, demonstrating consistency of the grading regardless of training level. Intraobserver comparisons showed a strong ICC for attendings and fellows in femoral cases, while fellows had near-perfect ICC in tibia cases. Across all reviewers there was on average 93% agreement within 1 grade per case with the majority of the discrepancy occurring at the metaphyseal-diaphyseal junction. ConclusionThis classification demonstrated overall strong interobserver and intraobserver reliability, with 93% agreement within 1 grade of bone loss. With further education, this classification system can ultimately be used to standardize the degree of bone loss in failed stemmed components and help with preoperative planning.

No Association Between Cavovarus Alignment and Risk of Non-Union or Delayed Union in Jones Fractures

Category: Midfoot/Forefoot; Other Introduction/Purpose: It has been well documented in the literature that fractures of the base of the fifth metatarsal are often associated with varus hindfoot alignment. Zone two fractures at the metaphyseal-diaphyseal junction, commonly referred to as Jones fractures, have specifically been noted to have a higher incidence of delayed union and nonunion. This has historically been attributed to the tenuous blood supply in this region. Although it is known that hindfoot varus may predispose to these fractures, there is little information on whether a cavovarus alignment may also contribute to the increased risk of nonunion. The purpose of this study is to determine whether cavovarus foot alignment is associated with delayed union or nonunion in Jones fractures. Methods: We identified patients who sustained a proximal fifth metatarsal fracture between the years 2016-2021 at a single academic institution. Weightbearing foot radiographs were then reviewed to identify zone 2 fractures. Talo-first metatarsal, talonavicular coverage, and talocalcaneal angles were then measured on the AP view and calcaneal pitch, talocalcaneal, and talo- first metatarsal angles were measured on the lateral view to assess foot alignment. The primary outcome measure was the presence of a nonunion or delayed union. T-tests, Mann Whitney U tests, and ANOVA analyses were conducted to assess for differences. Results: We identified a total of 117 patients with 118 zone 2 proximal fifth metatarsal fractures. Of those fractures, there were 23 of which were considered either delayed union (n=8) or nonunion (n=15). Similar rates of nonunion and delayed union were observed between patients undergoing nonoperative and operative management of their Jones fractures (p=0.514, p=0.200, respectively). For all patients with a nonunion or delayed union, no differences in anteroposterior (AP) talo-first metatarsal angle, AP talonavicular coverage angle, AP talocalcaneal angle, lateral calcaneal pitch, lateral talo-first metatarsal angle, or lateral talocalcaneal angle from those with expected healing were observed (p = 0.773, p = 0.084, p = 0.874, p = 0.751, p = 0.471, and p = 0.386 - respectively). Conclusion: Overall, no measured foot alignment values (talo-first metatarsal angle, talonavicular coverage, talocalcaneal angle, or calcaneal pitch) were statistically associated with increased risk of delayed union or non-union among patients with Jones fractures undergoing either operative or non-operative treatment. Furthermore, there was no measured difference in these foot alignment parameters between those patients undergoing operative treatment and those undergoing non-operative treatment. In conclusion, cavovarus alignment is not associated with an increased risk of non-union or delayed union in the operative or non-operative treatment of Jones fractures.

Poster 208: Changes in Posterior Tibial Slope Following "L" and "Inverse L" High Tibial Osteotomy: A Biomechanical Study

Objectives:High tibial osteotomy (HTO) is a well-established procedure for addressing varus deformity of the knee or offloading the medial compartment in cases of medial compartment osteoarthritis. Altering the weightbearing axis of the tibia through HTO may result in unintended changes to the posterior tibial slope (PTS) and thus the sagittal stability of the knee. In 2003, Lobenhoffer described a biplanar “L” shaped HTO with an ascending cut in the coronal plane, leaving the tibial tubercle on the distal side of the osteotomy. Since then, multiple techniques have been described, including an “Inverse L”, leaving the tibial tubercle on the proximal end of the osteotomy. We present a modified “flex” version to the plate fixation used in the “L” and “Inverse L” technique with the goal of minimizing changes in the PTS during HTO. To quantify the effect of osteotomy technique on PTS, “L” (n=5), “Inverse L” (n=5), “L with flex” (n=6), and “Inverse L with flex” (n=6) techniques were performed on cadaveric specimens following medial opening wedge HTO (Figure1). Pre- and post-osteotomy fluoroscopic images were taken and PTS measured to determine whether one technique was more effective at minimizing PTS change after medial HTO.Methods:The tibia from 22 fresh frozen cadaveric male specimen (11 pairs, mean age 46 + 14) were removed of all soft-tissue. Native anteroposterior and lateral radiographs were taken. Three independent observers measured the PTS angle using the circle method. Two 2.4mm Kirschner wires were placed through the medial cortex of the tibia at the metaphyseal-diaphyseal junction aimed towards the tip of the fibular head as a guide for the sagittal cut performed in the posterior four-fifths of the tibia. The oblique osteotomy stopped 10-15mm medial to the lateral tibial cortex and the joint line to avoid fracture. The osteotomy site was then medially opened 10mm. One specimen from each pair was randomized to receive the “L” shaped ascending HTO with the contralateral limb receiving the “Inverse L” shaped descending HTO. Vertical cuts on the coronal plane extending 3-4cm (proximally for the “L” and distally for “Inverse L”) were completed. 6 specimens from each group were subsequently fixed proximally with an anteriorly angled plate (15 degrees) which was forced posteriorly and fixed to the shaft (Figure 2). This plate “flex” technique was applied to purposefully correct PTS. All osteotomies were fixed using a standard locking AO Tomofix plate with 3 proximal screws and 4 distal screws. Pre- and post-HTO proximal tibia plateau orientations were collected using eight OptiTrack motion capture cameras as an adjunct to tibial slope measures completed through radiographic analysis. Three rigid body marker triads were used: distally along the anterior midline of tibia, medial superior articular surface, and the fixture frame. Post-HTO, the independent observers again measured PTS with the circle method. Change in tibial slope data was averaged among radiograph reviewers and compared to motion capture data. A one-way ANOVA statistical analysis was completed.Results:PTS as measured by reviewers before and after HTO using the “circle method” and the motion capture analysis of the change in orientation of the tibial plateau are reported in Table 1. For all specimens, the posterior tibial slope decreased by 1.77 degrees (+/- 3.2). There was no statistically significant difference in change of tibial slope amongst all techniques, measured by lateral radiographs or motion capture analysis.Conclusions:There was no statistical difference in the change in posterior tibial slope across treatment types. Reviewer calculations of tibial slope using the circle technique was not different from measures observed through high resolution motion capture. No difference in the change in PTS may allow surgeons to select the technique that they feel most comfortable using on their patient with less concern of causing changes in the PTS and sagittal instability during an HTO. Additionally, this may allow for versatility in the event that patient anatomical characteristics interfere or impede the use of a specific technique. Future studies incorporating pre- and post-CT data to quantify hinge fracture and further characterize slope are underway.Figure 1.Techniques used for fixation after medial opening wedge HTO. A) "L" B) "Inverse L" C) "L with Flex" D) "Inverse L with Flex" The green line describes the direction of the coronal cut defining the regular L from Inverse L technique.Figure 2."Flex" technique for maintaining posterior tibial slope in medial opening wedge high tibial osteotomy. Following osteotomy, the plate is secured proximal with the distal end purposefully positioned anterior along the tibial cortex (A). The plate is then reduced to the tibial shaft and secured, with obligatory asymmetric posterior gap relative to the anterior gap (B).Table 1.PTS angles pre- and post-HTO as measured by three independent reviewers. The table includes the change in slope as calculated from reviewer measures and the OptiTrack motion capture system. All angles are in degrees.

Analysis of the location and trajectory of the Kirschner wires in the fixation of extension-type supracondylar fracture of the humerus by 3D computational simulation.

Closed reduction and percutaneous pinning is still a preference for the treatment of supracondylar humerus fractures in children. However, no reports have shown the pin trajectory and the characteristics of the entry point so far. So we established a computational simulation model of the elbow to observe the trajectory of pinning for supracondylar humerus fractures. We reconstructed an adult elbow computationally and simulated pin placement through lateral and medial pinning. Pin trajectories were traced after placement and after the addition of the skin profile; the relative entry points of the pins were determined. We used the center of the dorsal olecranon inflection as an anatomic reference for the entry points of lateral pinning. Four quadrants were established based on the center of the dorsal olecranon inflection: upper medial quadrant, upper lateral quadrant, lower medial quadrant, and lower lateral quadrant (LLQ). The maximum angle of pinning through the lateral column was 64°±3°. The minimum angles of pinning through the lateral column and middle column were 37°±3° and 20°±2°, respectively. The range of safe angle pinning through the medial column was between 18°±2° and 57°±3° to avoid penetration of the olecranon fossa and the cortex of the medial column. The entry points of lateral pinning were within the lateral half of the LLQ, and the lateral one-third of the LLQ contained all entry points of the pins through the lateral column and minor points of the pins through the middle column. The exit points of the medial pinning were within the lateral fringe of the metaphyseal-diaphyseal junction region; entering from the inferior two-thirds of the medial epicondyle could lead to the exit points in the proximal half of the metaphyseal-diaphyseal junction region laterally. For lateral pinning, the entry points would be within the lateral half of the LLQ. For the pins through the lateral column, the entry points should be within the lateral one-third of the LLQ. For medial pinning, entering from the inferior two-thirds of the medial epicondyle would lead to a more proximal exit.

Limited Open Reduction and Transepiphyseal Intramedullary Kirschner Wire Fixation for Treatment of Irreducible Distal Radius Diaphyseal Metaphyseal Junction Fracture in Older Children.

ObjectiveThis study aimed to compare limited open reduction and transepiphyseal intramedullary fixation with Kirschner wire (LOR-TIKW) versus open reduction and internal fixation with plate and screw (ORIF-PS) for treatment of irreducible distal radius diaphyseal–metaphyseal junction (DMJ) fracture in older children.MethodsData of children (aged 10–14 years) treated in our hospital for distal radius DMJ fractures with LOR-TIKW or ORIF-PS from January 2018 to December 2019 were retrospectively analyzed. Follow-up was until radiographic union. Demographic, clinical, and radiographic data; treatment cost; healing time; functional outcome (by Price criteria); complications; and postoperative angulation and displacement were compared between children treated by the two methods. Statistical analysis was performed with alpha set at P < 0.05.ResultsA total of 26 children were included: 14 treated with LOR-TIKW and 12 with ORIF-PS. Operation time was less (22.1 min vs. 46.7 min, P < 0.0001), surgical incision smaller (2.43 cm vs. 5.00 cm, P < 0.0001), cost of internal fixation lower (US$, 40.6 vs. 2020, P < 0.0001), and healing time shorter (4.79 weeks vs. 5.64 weeks, P = 0.03) with LOR-TIKW; however, postoperative fracture angulation was slightly larger (1.07° vs. 0.83°, P = 0.85) and displacement slightly more (0.86 mm vs. 0.58 mm, P = 0.44) in the LOR-TIKW group. Rate of union, functional outcome, and complications were not significantly different between the groups.ConclusionFor irreducible DMJ fracture of distal radius in older children, LOR-TIKW appears to be a promising method with several advantages over ORIF-PS.