Diaphyseal Shaft Research Articles

Is the Diagnosis of fifth Metatarsal Fracture Type Consistent? An Interobserver Reliability Study.

Treatment pathways of fifth metatarsal fractures are commonly directed based on fracture classification, with particular proximal fractures typically requiring closer observation and possibly more aggressive management. Our aim is to investigate the interobserver reliability of assessment of subtypes of fifth metatarsal fractures. We included all patients referred to our virtual fracture clinic with a suspected or confirmed fifth metatarsal fracture. Plain anteroposterior radiographs were reviewed by 2 novice observers, initially trained on the fifth metatarsal classification identification. Eight different zones were defined based on anatomical location. Patients were excluded from analysis if neither observer could identify a fracture. An interobserver reliability analysis using Cohen κ coefficient was carried out, and degree of observer agreement described using Landis and Koch's description. All data were analyzed using IBM SPSS, version 27. A total of 1360 patients who met the inclusion criteria were identified. The 2 observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and distal metaphysis (DM) fractures, which only achieved fair agreement (κ = 0.308 and 0.381 respectively). Zone 3 has slight agreement with zone 2 proximally, and there is an apparent difficulty with distal diaphyseal shaft (DS) fractures, resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; κ = .398, P < .001). Reliability of subcategorizing fifth metatarsal fractures using standardized instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow-up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration. Level III, retrospective cohort study.

IS THE DIAGNOSIS OF FIFTH METATARSAL FRACTURE SUBTYPE CONSISTENT? AN INTEROBSERVER RELIABILITY STUDY

IntroductionTreatment pathways of 5th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management.Primary objectiveTo investigate the reliability of assessment of subtypes of 5th metatarsal fractures by different observers.MethodsPatients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5th metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5th metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis &amp; Koch's description. All data was analysed using IBM SPSS v.27.Results878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively).ConclusionsReliability of sub-categorising 5th metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration.

Variability of the femoral mechanical-anatomical axis angle and its implications in primary and revision total knee arthroplasty.

Distal femoral resection in conventional total knee arthroplasty (TKA) utilizes an intramedullary guide to determine coronal alignment, commonly planned for 5° of valgus. However, a standard 5° resection angle may contribute to malalignment in patients with variability in the femoral anatomical and mechanical axis angle. The purpose of the study was to leverage deep learning (DL) to measure the femoral mechanical-anatomical axis angle (FMAA) in a heterogeneous cohort. Patients with full-limb radiographs from the Osteoarthritis Initiative were included. A DL workflow was created to measure the FMAA and validated against human measurements. To reflect potential intramedullary guide placement during manual TKA, two different FMAAs were calculated either using a line approximating the entire diaphyseal shaft, and a line connecting the apex of the femoral intercondylar sulcus to the centre of the diaphysis. The proportion of FMAAs outside a range of 5.0° (SD 2.0°) was calculated for both definitions, and FMAA was compared using univariate analyses across sex, BMI, knee alignment, and femur length. The algorithm measured 1,078 radiographs at a rate of 12.6 s/image (2,156 unique measurements in 3.8 hours). There was no significant difference or bias between reader and algorithm measurements for the FMAA (p = 0.130 to 0.563). The FMAA was 6.3° (SD 1.0°; 25% outside range of 5.0° (SD 2.0°)) using definition one and 4.6° (SD 1.3°; 13% outside range of 5.0° (SD 2.0°)) using definition two. Differences between males and females were observed using definition two (males more valgus; p < 0.001). We developed a rapid and accurate DL tool to quantify the FMAA. Considerable variation with different measurement approaches for the FMAA supports that patient-specific anatomy and surgeon-dependent technique must be accounted for when correcting for the FMAA using an intramedullary guide. The angle between the mechanical and anatomical axes of the femur fell outside the range of 5.0° (SD 2.0°) for nearly a quarter of patients.

Vitamin C Deficiency Deteriorates Bone Microarchitecture and Mineralization in a Sex-Specific Manner in Adult Mice.

Vitamin C (VitC) is essential for bone health, and low VitC serum levels increase the risk for skeletal fractures. If and how VitC affects bone mineralization is unclear. Using micro-computed tomography (μCT), histologic staining, as well as quantitative backscattered electron imaging (qBEI), we assessed the effects of VitC on femoral structure and microarchitecture, bone formation, and bone mineralization density distribution (BMDD) in the VitC incompetent Gulo-/- mouse model and wild-type mice. In particular, VitC-supplemented, 20-week-old mice were compared with age-matched counterparts where dietary VitC intake was excluded from week 15. VitC depletion in Gulo-/- mice severely reduced cortical thickness of the diaphyseal shaft and bone volume around the growth plate (eg, bone volume of the primary spongiosa -43%, p < 0.001). Loss of VitC also diminished the amount of newly formed bone tissue as visualized by histology and calcein labeling of the active mineralization front. BMDD analysis revealed a shift to higher calcium concentrations upon VitC supplementation, including higher average (~10% increase in female VitC deficient mice, p < 0.001) and peak calcium concentrations in the epiphyseal and metaphyseal spongiosa. These findings suggest higher bone tissue age. Importantly, loss of VitC had significantly more pronounced effects in female mice, indicating a higher sensitivity of their skeleton to VitC deficiency. Our results reveal that VitC plays a key role in bone formation rate, which directly affects mineralization. We propose that low VitC levels may contribute to the higher prevalence of bone-degenerative diseases in females and suggest leveraging this vitamin against these conditions. © 2023 American Society for Bone and Mineral Research (ASBMR).

Role of multimodality imaging for primary bone tumors among children: a case report

ABSTRACT Background: Bone lesions in children are very common and can be benign or malignant. Benign bone lesions, fortunately, are more common as compared to rare malignant neoplasms of bone. Osteosarcoma and Ewing sarcoma are the most common malignant bone tumors in younger age group. Multimodality imaging plays a major role in bridging the gap between clinical diagnosis and final diagnosis Case Presentation: We present here a case of 8-year-old male patient complained of progressive soft tissue swelling and pain in left thigh from 25-30 days. His X-ray of left femur showed a mixed density, predominantly sclerotic lesion involving mid-diaphysis. His contrast enhanced MRI of left thigh showed large, ill-defined, abnormal signal intensity medullary lesion seen in left femur involving mid to lower diaphyseal shaft, extending to metaphyseal region. His 99mTc MDP bone scintigraphy was done showing abnormal radiotracer uptake in lower half of left femur and adjoining soft tissue. Conclusion: Single modality imaging may not be enough in predicting the true extent of bone pathologies. Multimodality imaging plays a major role in characterizing the lesions to differentiate benign from malignant and bridging the gap between clinical diagnosis and final diagnosis. Keywords: Osteosarcoma, Ewing sarcoma, 99mTc MDP bone scintigraphy, case report

Is the Diagnosis of 5th Metatarsal Fracture Type Consistent? An Inter-Observer Reliability Study

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Treatment pathways of 5th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Our primary objective was to investigate the reliability of assessment of subtypes of 5th metatarsal fractures by different observers. Methods: Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5th metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5th metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. Patients were excluded from analysis if neither observer could identify a fracture or if one or more observers could not access the images. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis &amp; Koch's description. All data was analysed using IBM SPSS v.27. Results: 1360 patients who met the inclusion criteria were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from zone 1.2 and DM fractures, which only achieved 'fair' agreement (K=.308 and .381 respectively). Zones 1.1 (K=.538), 1.3 (K=.511), 2 (K=.515), 3 (K=.57), DS (K=.545) and Head (K=.558) all tended towards but did not achieve substantial agreement. Slight agreement with the next proximal and distal adjacent zones were found in Zones 1.1, 1.2 and 1.3. Slight agreement with the adjacent distal zone was found in Zone 2 and DM fractures. Zone 3 has slight agreement with Zone 2 proximally and there is an apparent difficulty with distal DS fractures resulting in a lot of crossover with DM, achieving a fair level of agreement (DS 312 vs 196; DM 120 vs 237; K=.398, p&lt;.001). Conclusion: Reliability of sub-categorising 5th metatarsal fractures using standardised instructions conveys moderate agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1-3 needs careful consideration.

Analysis of a Single Centre's Protocol of the Treatment of 5th Metatarsal Fractures. What Patients Need a Face-To-Face Fracture Clinic Review?

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: 5th metatarsal fractures are a common injury attending foot and ankle clinics in the UK. Within our department, we established a protocol to reduce the burden on fracture clinic of 5th metatarsal fractures by limiting face-to-face consultations to Zone 2 and 3. We sought to investigate whether our practice was consistent and the ultimate patient destination. Methods: Patients were identified from our database. We included all 5th metatarsal fractures referred to our virtual fracture clinic with a confirmed 5th metatarsal fracture. Data was collected on virtual fracture clinic (VFC) outcomes including telephone review, clinic reviews and requirement of surgery. Plain AP radiographs were reviewed for fracture morphology. Fractures were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. A binary linear regression analysis model was used. All data was analysed using IBM SPSS v.27. Results: 1360 patients met the inclusion criteria (mean age of 48.1; range 16-95, sd=19.1). 430 (31.6%) were planned for face-to- face review, however following telephone review, 542 (39.9%) were sent appointments (p&lt;.001 McNemar). On univariate analysis, only fractures in Zone 1.1 were associated with a plan to discharge from VFC (OR 2.851, p&lt;.001), with Zone 3 fractures associated with a plan for face-face review (p&lt;.001). Following telephone review, Zone 2 (OR 1.387, p=.034) and Zone 3 (OR 3.285, p&lt;.001) fractures were the only fractures significantly associated attending a face-to-face clinic appointment, with Zones 1.1 (OR 0.573, p=.008) and 1.2 (OR 0.642, p=.033) negatively associated. Zone 3 fractures were the only fractures that retained significance for attending &gt;1 appointment (OR 4.639, p&gt;.001) and requiring surgery (OR 3.895, p=.037). Only 15 patients (1.1%) required surgery, with 9 being for non-union and 5 being acute operations in younger patients (median age = 34 vs 51). Conclusion: There was a significant increase in patients requiring face-face review after telephone conversation. In addition to Zone 3 injuries and Zone 2 injuries had also required face-face reviews following telephone consultation. Based on these results, all Zone 2 and 3 fractures should be considered for at least one face-to-face fracture clinic review. Operative management is rare and usually secondary to non-union.

A case of bilateral humerus varus from the late antiquity Catacomb of Santa Mustiola (Chiusi, Italy)

ObjectiveTo report a case of bilateral humerus varus from a late antiquity archeological context in central Italy. MaterialsThe individual is a 25–40-year-old female, dated to the 4th cent. CE, from the catacomb of Santa Mustiola in Chiusi, Italy. MethodsThe bones were examined macroscopically and through CT scan imaging. ResultsBoth humeri show evident alterations in shape, including elongated, flattened and distally dislocated humeral heads, shortened anatomical necks, angulated upper diaphyseal shafts, and reduced overall lengths. The scapulae appear to have been mildly affected by this condition and show some bone loss and slight retroversion of the glenoid cavity. ConclusionsObservations are consistent with a diagnosis of humerus varus deformity likely caused by a traumatic event early in the individual's life. SignificanceVarus deformity of the proximal humerus is seldom reported in bioarcheological literature. The case presented provides insight into the etiology and effects of this condition and may serve as comparison for future studies. LimitationsEven though the absence of other skeletal deformities renders a systemic condition improbable, the traumatic etiology of the condition cannot be confirmed with certainty. Suggestions for further researchFuture publications of new cases may give a broader perspective of the etiology of this condition in the past.

Determining the ideal osteotomy for stemless total shoulder replacement: a cadaveric study.

We sought to determine the angle of osteotomy that produces a circular humeral cut surface. A total of 49 cadaveric shoulders, from 25 cadavers, underwent sequential humeral head osteotomy from 180° (vertical, in line with the humeral diaphyseal shaft), in 10° increments, until the rotator cuff insertion was encountered. At each stage, the anteroposterior (AP) and superoinferior (SI) distances were recorded. The data were analyzed for normality and then assessed to determine the optimum cut angle. The AP/SI ratio is an indication of roundness. Plotting values of 1 - AP/SI (ie, error) vs. cut angle allowed us to plot the likelihood of producing a circular cut surface using a third-order curve that created the best fit to the data set (R2 = 0.99). The results from this study suggest that the optimum osteotomy angle that produces a circular cut surface is 23° from the vertical. The cohort data illustrated that at this angle, the average roundness error was 1% with a 95% confidence limit of <1%. There was no significant difference (P > .05) between sexes. The humeral head shape changes from oval to circular and then to an oval cut surface as the osteotomy angle increases from the vertical toward the horizontal. The range of angles within which the cut surface is circular, within a 10% error margin, is 18°-27° from the vertical, which is much less than the traditional osteotomy angle of 45°.

Functional and Radiological Outcome in the Management of Diaphyseal Humeral Shaft Fracture Using the Minimally Invasive Percutaneous Plate Osteosynthesis (MIPO) Technique

Introduction: Minimally invasive percutaneous plate osteosynthesis (MIPO) is gaining preference nowadays compared to other treatment modalities for diaphyseal fracture of the humerus. We have evaluated the functional and radiological outcome of diaphyseal humeral shaft fracture with the MIPO technique.&#x0D; Methods: A hospital-based prospective study was conducted on 23 adult patients with diaphyseal fracture of the humerus and treated with the Minimally Invasive Percutaneous Plate Osteosynthesis (MIPO) technique. In all cases, 4.5mm locking compression plates were applied. Clinical and radiological evaluation was done at 6 weeks, 3 months, and 6 months.&#x0D; Results: Out of 23 patients, the mean age of patients was 40.3 years. The maximum number of cases were caused due to road traffic accidents 14 (60.9%). The left side was commonly affected with a maximum number of them being Type A fracture 13 (56%) as per AO/OTA classification. The mean operative time was 106 minutes and fracture union was achieved in all patients by the end of 20 weeks (mean 14.83 weeks). In the study group, 1 patient had superficial infection with no evidence of iatrogenic radial nerve injury or implant failure. Shoulder and elbow ROM was restored to normal range.&#x0D; Conclusion: MIPO is a safe and effective technique for the management of diaphyseal humerus fractures, with early fracture healing, less risk of complications such as superficial or deep infection, implant failure, and iatrogenic radial nerve injury, along with a cosmetically acceptable scar.

Distal Humeral Diaphyseal Open Fracture in a Child with Bone Loss

Distal diaphyseal humerus fracture is less common than supracondylar humeral fracture and its open fracture is even less. This is a case report of open distal humeral diaphyseal fracture on the left arm with bone loss in 10 years old male who sustained the injury from fall, diagnosed as Grade III open unstable distal diaphyseal shaft fracture of left humerus with bone loss without neurovascular deficit. We performed Open Reduction /Internal Fixation (OR/IF) and free bone fragment was flipped and fixed to the bone fragments and maximum possible contact was made and fixed with an external fixator. Range of motion was advised as early as possible. At final follow up the result was excellent as per Flynn's criteria. OR/IF (Open Reduction /Internal Fixation) of this fracture with posterior approach and flipping the bone to get more contact seems good and safe procedure. Further, external fixation provides reasonable fixation in these cases.

A comparative study of functional outcome in treatment of diaphyseal humerus fractures with open reduction and internal fixation by two different approaches, anterolateral and posterior

Introduction: The humerus diaphyseal fractures account for 3% all bone fractures. Humerus diaphyseal fractures occurs in young adults because of high velocity injuries like road traffic accidents, fall from height, assaults and heavy machinery injuries, humerus diaphyseal fractures occurs in old age patients because of simple falls due to osteoporotic bones. Methods: A retrospective review was conducted of patients with humerus diaphyseal fractures. In all 26 patients were enrolled in the study, of which 13(50%) were treated with anterolateral approaches and the 13(50%) with posterior approaches. In this study we treated diaphyseal humerus fractures with open reduction and internal fixation by two different approaches, anterolateral and posterior, and compared results and functional outcome. Results: Out of all the 26 patients with diaphyseal humerus fracture 13 patients were operated with open reduction and internal fixation by plate osteosynthesis by anterolateral approach 10(38.46%) patients had excellent result, 1(3.84%) patient had good result and 3(11.53%) patients had poor result. And Out of all the 26 patients with diaphyseal humerus fracture 13 patients operated with posterior approach 9(34.61%) patients had excellent result, 4(15.38%) patients had good result and none had poor result. Conclusion: in our study we conclude that both approaches are equally effective for diaphyseal humerus fractures treatment in terms of fracture union, functional outcome and complications. Posterior approach to shaft humerus fracture is beneficial because with mobilization of radial nerve 76% of humerus shaft is exposed. In preoperative radial nerve palsy with diaphyseal shaft fractures posterior approach is better choice for nerve exploration. And anterolateral approach is better option for upper third and middle third diaphyseal humerus fractures and posterior approach is better option for distal third diaphyseal humerus fractures

A prospective study of surgical management of diaphyseal shaft fracture of bones of forearm in adults with limited contact dynamic compression plate

Fracture of forearm bone are one of the most common injuries seen in day to day practice. The forearm, in combination with the proximal and distal radioulnar joints, allows pronation and supination movements that are important in the usual activities of daily living. The forearm serves an important role in upper extremity function. Decisive management is required after fractures of the shafts of the radius and ulna if function is to be restored. The Limited Contact Dynamic Compression Plate, was developed by Perren S. M. et to release the new concept of biological internal fixation. Grooves on the undersurface of the LC-DCP improved blood circulation. There is decreased damage to contact between plate and bone. It also allows for a small bone bridge beneath the plate at the most critical area, which is otherwise weak due to a stress concentration effect. This study is undertaken to assess the results of diaphyseal fractures of Bones of Forearm using LCDCP to study the advantages and its complications.Materials and Methods: Patients admitted to Cg Hospital and Bapuji Hospital between 2019 July to 2020 September were taken into the study after taking informed consent.Results: This study consists of 30 cases of fracture Both Bone Forearm Fractures. All cases were openly reduced and internally fixed with 3.5 mm LCDCP. Fracture was common in second and third decade. In our study, male preponderance was found with 73.3% males and 26.7% female patients. Side affected 24(80%) Left side and 6 patients (20%) right side. Mode of injury in the present study was RTA (33.3%) and fall (66.6%). An average time for union was around 5 months. Results were evaluated by Andersons scoring system. In present study, we had 24 patients (80%) with excellent results, 5 case (16.6%) as satisfactory and 1 case (2%) as unsatisfactory. No case needed refixation. In the present study there was 3 case (10%) of superficial infection, 1 case (3.3%) of Posterior Interosseous Nerve injury. Conclusion: LC-DCP can be considered the best mode of treatment for closed diaphyseal fractures of both bones forearm.

Variation in management of humeral and clavicular shaft fractures amongst fellowship trained orthopedic traumatologists

BackgroundThere exists a wide variety of opinions on the appropriate management of diaphyseal humeral and clavicular fractures amongst orthopedic surgeons.The purpose of this study is to determine if there is a preference amongst orthopedic traumatologists on treatment of diaphyseal humerus and clavicle fractures with respect to various patient populations.MethodsA 6-question survey was created using Surveymonkey.com and distributed via the Orthopedic Trauma Association (OTA) website to fellowship trained orthopedic surgery traumatologists to survey the preferred management of a simple oblique middle 1/3rd diaphyseal humerus fracture and a middle 1/3rd displaced diaphyseal clavicle fracture in the following 3 clinical settings: a healthy laborer, an older patient with co-morbidities, and if the surgeon themselves sustained the injury. The ratio of operative to non-operative management was calculated for all 6 questions. A chi-square value was performed to determine if the results are clinically significant based on the clinical scenario.ResultsThere was 56 responses to the survey that were included in the analysis. Overall, there was a statistically significant trend towards surgical management of the surgeon’s own diaphyseal humerus fractures (55%) compared to that of healthy patients (41%) and those with medical comorbidities (21%) (p = 0.02) A similar trend was noted for operative management for diaphyseal clavicle fractures by the surgeon on their own fractures (43%) compared to that of healthy patients (38%) and those with medical comorbidities (18%) (p = 0.02).ConclusionWhile there are an increasing number of relative indications for treatment of diaphyseal humerus shaft and clavicle fractures, the results of this survey indicate that fellow-ship-trained orthopedic trauma surgeons prefer surgical management of simple humerus and clavicular fractures in young, healthy patients as well as in themselves.

Low-profile double plating versus dorsal LCP in stabilization of the olecranon fractures

IntroductionProximal ulna fractures are common in orthopaedic surgery. Comminuted fractures require a high primary stability by the osteosynthesis, to allow an early functional rehabilitation as fast as possible, to reduce long-term limitations of range of motion. Classical dorsal plating is related to wound healing problems due to the prominence of the implant. New low-profile double plates are available addressing the soft tissue problems by positioning the plates at the medial and lateral side. This study analysed whether, under high loading conditions, these new double plates provide an equivalent stability as compared to the rigid olecranon locking compression plate (LCP).Materials and methodsIn Sawbones, Mayo Type IIB fractures were simulated and stabilized by plate osteosyntheses: In group one, two low-profile plates were placed. In group two, a single dorsal plate (LCP) was used. The bones was than cyclically loaded simulating flexion grades of 0°, 30°, 60° and 90° of the elbow joint with increasing tension forces (150 , 150 , 300 and 500 N). The displacement and fracture gap movement were recorded. In the end, in load-to-failure tests, load at failure and mode of failure were determined.ResultsNo significant differences were found for the displacement and fracture gap widening during cyclic loading. Under maximum loading, the double plates revealed a comparable load at failure like the single dorsal plate (LCP). The double plates failed with a proximal screw pull-out of the plate, whereas in the LCP group, in 10 out of 12 specimens the mode of failure was a diaphyseal shaft fracture at the distal plate peak.ConclusionBiomechanically, the double plates are a good alternative to the dorsal LCP providing a high stability under high loading conditions and, at the same, time reducing the soft tissue irritation by a lateral plate position.

Study between interlocking nail and dynamic compression plate in the management of diaphyseal fractures shaft humerus

Study between interlocking nail and dynamic compression plate in the management of diaphyseal fractures shaft humerus

Investigation of genicular neurotomy of the knee: MRI characterization of anatomy and implications for intervention

BackgroundGenicular nerve block and subsequent radiofrequency neurotomy (RFN) has emerged as a novel intervention and alternative for total knee arthroplasty in patients with refractory pain from knee osteoarthritis (OA). To our knowledge, there is no cited report correlating the accuracy of localizing the genicular nerves using bony landmarks on magnetic resonance imaging (MRI). ObjectivesTo quantify the proximity of superomedial genicular nerve (SMGN), superolateral genicular nerve (SLGN), and inferomedial genicular nerve (IMGN) from a target point. The target point was an intersection marked by a line parallel to the diaphysis and a separate line parallel to the metaphyseal flare along the cortical surfaces of both the femur and tibia. DesignRetrospective chart review. PatientsA total of 25 de-identified knee MRIs were reviewed. MethodsThe coronal proton density fat suppressed sequence was used for identification and localization of the SLGN, SMGN, and IMGN. The neurovascular bundles were traced from posterior location along their origin as they wrap around the distal diaphysis. The nerve locations were determined by consensus measurements performed by two board-certified radiologists with certificates of added qualification in neuroradiology and interventional radiology. The proximity of each respective genicular nerves was measured by drawing a perpendicular line from each genicular nerve to the height of the target point. All measurements were taken on the mid-coronal view at the point of maximal epiphyseal flare. Main outcome measurementsPositive values indicated the location of the neurovascular bundle to be superior to the target point. Negative values indicated the location of the neurovascular bundle to be inferior to the target point. ResultsThe distance between our target point and the inferior border of SLGN ranged from −3 mm to 6 mm. Twenty-three out of 25 (92%) SLGN lied exactly at or above our target intersection. The distance between our target point and the inferior border of SMGN ranged from −1 mm to 2 mm with twenty-two out of 25 (88%) SMGN lied exactly at or above our target point. The distance between our target point and the superior border of IMGN ranged from 0 mm to 3 mm with all (100%) IMGN lying exactly at or above the target point. ConclusionThe intersection of the femoral diaphyseal shaft to a line along the metaphyseal flare and the intersection of the tibial diaphyseal shaft to a line along the medial metaphyseal can be used as a target point to localize the genicular nerves with close proximity.

Treatment of Radius or Ulna Diaphysis Atrophic Non-Unions with Corticocancellous Autograft and Intramedullary Nailing

Objective: The purpose of this study was to present the functional and radiological results of tricortical cancellous iliac wing grafting and intramedullary nailing performed with the modified Nicoll’s method for the treatment of cases with radius or ulna atrophic non-union. Methods: The study which is a retrospective clinical study, included 12 patients (8 ulnas, 4 radiuses) with atrophic non-union as a result of plate-screw osteosynthesis applied for a radius or ulna diaphyseal shaft fractures. Fixation was made with tricorticocancellous autograft and intramedullary nailing with the modified Nicoll's method. In the functional and radiological evaluation, a visual analog scale, grip strengths, the Grace-Eversmann scale and the DASH score were used. Forearm pronation and supination and elbow flexion and extension angles were evaluated with goniometer. Results: The patients were comprised of 8 (66.7%) males and 4 (33.3%) females All the patients were followed up for mean 40.5 months (range, 12-84 months). Graft incorporation and remodeling was observed in all patients. According to the Grace-Eversmann scores, 9 patients were evaluated as excellent and 3 as good. Overall, the mean DASH score was 15.5 and the mean VAS score was 1.5. There were no complications about the donor site of the autogenous iliac graft. Conclusion: In cases of isolated radius and ulna non-union with a bone defect (gap) of

Three-dimensional orientation of the femoral curvature. How well does it match with the sagittal curvature of femoral implants?

BackgroundThe curvature of the femoral shaft is generally considered as residing in the sagittal plane. While many studies have measured the femur's radius of curvature, very few have studied the orientation of the plane in which it resides. The orientation of this plane may affect the rotation of intramedullary nails or revision stems with diaphyseal locking. This led us to conduct a three-dimensional (3D) anatomical study to: 1) analyze the 3D curvature of the femoral diaphysis by specifying the orientation of the plane in which it resides, 2) look for relationships between the curvature's orientation and anatomical parameters of the femur. HypothesisWe hypothesized that the femoral curvature resides in the anterolateral plane, not the sagittal plane. Materials and methodsA computed tomography scan was performed on 45 dry femur bones provided by a cadaver laboratory. The 3D reconstructions were analyzed to characterize the curvature of the diaphyseal shaft, radius of its various portions and to determine the plane in which it resides relative to the standard coronal reference plane defined by three points: posterior side of both condyles and the greater trochanter. The following parameters were measured: length, neck-shaft angle, femoral valgus (between anatomical and mechanical axis) and neck anteversion. ResultsThe largest curvature was in a plane oriented on average of 78.3°±14.9° (35.2° to 106.7°) anterolateral. The correlation between femoral curvature and neck-shaft angle (R=0.172), size (R=0.095), valgus (R=0.104) and overall curvature (R=0.60) was low. DiscussionImplants with diaphyseal fixation are designed such that the femoral curvature resides in a strict sagittal plane. Long revision stems with diaphyseal fixation may have a tendency to rotate laterally (externally) during insertion. Correcting this external rotation to prevent anteversion may result in a less than satisfactory press-fit. The femoral curvature must be taken into account when designing intramedullary implants. Level of evidenceIV, Cadaver study without control group.

Diaphyseal long bone nonunions - types, aetiology, economics, and treatment recommendations.

The intention of the current article is to review the epidemiology with related socioeconomic costs, pathophysiology, and treatment options for diaphyseal long bone delayed unions and nonunions. Diaphyseal nonunions in the tibia and in the femur are estimated to occur 4.6-8% after modern intramedullary nailing of closed fractures with an even much higher risk in open fractures. There is a high socioeconomic burden for long bone nonunions mainly driven by indirect costs, such as productivity losses due to long treatment duration. The classic classification of Weber and Cech of the 1970s is based on the underlying biological aspect of the nonunion differentiating between "vital" (hypertrophic) and "avital" (hypo-/atrophic) nonunions, and can still be considered to represent the basis for basic evaluation of nonunions. The "diamond concept" units biomechanical and biological aspects and provides the pre-requisites for successful bone healing in nonunions. For humeral diaphyseal shaft nonunions, excellent results for augmentation plating were reported. In atrophic humeral shaft nonunions, compression plating with stimulation of bone healing by bone grafting or BMPs seem to be the best option. For femoral and tibial diaphyseal shaft fractures, dynamization of the nail is an atraumatic, effective, and cheap surgical possibility to achieve bony consolidation, particularly in delayed nonunions before 24weeks after initial surgery. In established hypertrophic nonunions in the tibia and femur, biomechanical stability should be addressed by augmentation plating or exchange nailing. Hypotrophic or atrophic nonunions require additional biological stimulation of bone healing for augmentation plating.