Distal Fixation Research Articles

Management of severe femoral bone defect in revision total hip arthroplasty-A 236 hip, 6-14-year follow-up study

This study evaluated the clinical effect of impaction bone graft and distal press-fit fixation for the reconstruction of severe femoral bone defect in revision total hip arthroplasty. A total of 234 patients (involving 236 hips) with Paprosky III and IV femoral bone defects were treated with the revision total hip arthroplasty from June 1998 to Aug. 2006. Impaction bone graft technique was used for 112 hips, with allogeneic freeze-dried bone as bone graft and SPII as prosthesis. With 124 hips, modular distal press-fit fixation and tapered femoral stem (MP stem) were employed. After the operation, the subjects were followed up on regular basis and results were assessed by using the Harris Hip Score (HHS) and 12-item Short Form Health Survey (SF-12). Radiolucence, subsidence and loosening were observed and complications, including infection, fracture, dislocation etc. were recorded. A 6-14-year follow-up showed that prostheses failed, due to infection, in 4 patients of impaction bone graft group and that 6 patients in the press-fit fixation group experienced prosthesis failure, with the survival rates for the two techniques being 96.43% and 95.16%, respectively. One-way ANOVA showed that prosthesis survival was significantly associated with surgery-related complications (P<0.05) and was not related to the type of the bone defects (P>0.05). The rate of complications bore significant association with the type of bone defects in the two groups (P<0.05). Our study showed that the two revision methods could achieve satisfactory mid-term and long-term results for the reconstruction of severe bone defects. It is of great significance for attaining high prosthesis survival rate to select suitable operation on the basis of the type of bone defect. Careful operative manipulation and post-operative rehabilitation aimed at reducing complications are also important.

Gluteus Medius Repair With Double-Row Fixation

The merits of double-row tendon fixation have been well defined in the shoulder and may have greater applicability for gluteus medius tears in the hip, in which protection of the repair site can be even more of a challenge because the hip is a weight-bearing extremity. A detailed technique for double-row fixation with a reliable method and implants is highlighted in the accompanying stepwise-approach video. Standard laterally based peritrochanteric portals are used, including a viewing portal posterior to the vastus lateralis ridge and a working portal distal to the ridge, with anchors placed proximally, perpendicular to the cortex of the trochanter. Proximal fixation is accomplished with double-loaded Healicoil anchors (Smith & Nephew, Andover, MA) by use of sutures placed in a mattress fashion. Distal fixation is accomplished with a Footprint anchor (Smith & Nephew) paired to each Healicoil.

Effect of Distal Interlock Fixation in Stable Intertrochanteric Fractures

The objective of this study was to evaluate the torsion stiffness of locked and unlocked distal fixation of long cephalomedullary nail constructs, in both a fresh fracture and healed, stable intertrochanteric fracture model. Samples were tested in both internal and external rotation (0±3 Nm) for a duration of 10 cycles. Each femur was tested without instrumentation (intact femur), with instrumentation and no fracture (healed intertrochanteric fracture), and with instrumentation with an osteotomy creating a stable intertrochanteric fracture (fresh fracture). All specimens were instrumented with a long cephalomedullary nail. A distal interlock was placed in the dynamic position in 1 femur, and the other femur of the matched pair was left unlocked. Mean external (ER) and internal (IR) rotation stiffness for intact femurs without instrumentation (ER, 2.1±0.5 Nm/degree; IR, 2.2±0.5 Nm/degree) was statistically stiffer (P<.05 for all) compared with fresh fractured locked (ER, 1.1±0.2 Nm/degree; IR, 1.1±0.3 Nm/degree) and fresh fractured unlocked (ER, 0.9±0.3 Nm/degree; IR, 1.0±0.2 Nm/degree) samples. Similarly, healed locked (ER, 2.5±0.2 Nm/degree; IR, 2.8±0.1 Nm/degree) and healed unlocked (ER, 2.5±0.5 Nm/degree; IR, 2.4±0.3 Nm/degree) samples had statistically higher stiffness compared with fresh fractured treatments. These results suggest that the unlocked distal constructs provide similar torsional strength compared with locked fixation in these models.

Periprosthetic fractures of the hip. The role of revision arthroplasty

In periprosthetic fractures, an exchange of the prosthesis is necessary when the prosthesis is loose (Vancouver type B2 and B3 fractures). During revision, the prosthesis can be replaced by a cemented or by a cementless stem implant. The disadvantage of a cemented stem is that cement can be forced into the fracture site and so impede union and healing. Most cementless revision stems with distal fixation are preferred because the point of fixation lies outside the area of fracture, thus allowing the fracture itself to be bridged and to be osteosynthesised with cerclage wires or cables binding the fracture pieces to the prosthesis. The stems can be implanted in two different ways. The first technique involves initial reposition of the fragments and retention with cerclage wires and then the implantation of the stem. In the second procedure, first an opening of the proximal fragment is made using an extended trochanteric osteotomy to the tip of the fracture and separation of the proximal fragment, and then the fixation zone in the distal fragment is prepared with implantation of the stem and closure of the proximal fragment around the implanted stem with cerclages. In a prospective study, the last method for the treatment of Vancouver type B2 and B3 fractures leads to reproducibly very good results with respect to fixation of the prosthetic stem, and therefore subsidence, healing of the fracture and clinical outcome. The extension of the incision and division of the proximal fragment that is an integral part of the transfemoral approach does not impair healing of the fracture or the osteointegration of the stem. This technique enables the monitoring of the positioning of the stem fixation so that the surgeon can be certain that the stem or its distal component is firmly anchored distal to the fracture, by means of a press fit. Thus, we suggest that this technique is superior to the method involving repositioning of the fracture fragments and subsequent implantation of the prosthesis stem.

Tratamiento de las fracturas periprotésicas de fémur Vancouver B2 y B3

&lt;p&gt;&lt;strong&gt;Introducción:&lt;/strong&gt; Las fracturas periprotésicas femorales luego de un reemplazo total de cadera son cada vez más prevalentes. Cuando estas asientan sobre un tallo flojo (B2) o con déficit de capital óseo (B3), según la clasificación de Vancouver, el tratamiento es la revisión del tallo femoral.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales y métodos:&lt;/strong&gt; Se analizó retrospectivamente a 22 pacientes, 9 fracturas tipo B2 y 13 tipo B3 de la clasificación de Vancouver. El promedio del seguimiento fue de 48 meses. Se utilizaron tallos largos cementados junto con aloinjerto óseo impactado, tablas corticales, tallos largos no cementados de fijación distal y endoprótesis no convencionales, según el caso.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Resultados:&lt;/strong&gt; Se observó la curación y la remodelación de la fractura en todos los pacientes. Las complicaciones fueron 2 (9%) luxaciones, 1 (4,5%) infección, 1 (4,5%) fractura de calcar, 1 (4,5%) aflojamiento de cotilo y 2 (9%) decesos.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusiones:&lt;/strong&gt; Las fracturas posoperatorias periprotésicas de fémur tipo B2 y B3 requieren recambio del tallo femoral, si bien existe una tendencia actual a utilizar tallos no cementados, en esta serie, dada la superposición de tratamientos, según cada subtipo de fractura, no obtuvimos diferencias entre el uso de tallos cementados junto con injerto y tallos no cementados. En casos de grave déficit de capital óseo, las endoprótesis no convencionales ofrecen una opción terapéutica para pacientes con baja demanda funcional. La clasificación de Vancouver es un instrumento útil para evaluar y decidir el tratamiento.&lt;/p&gt;

Results of Monolithic and Modular Femoral Components Use at Total Hip Revision Arthroplasty

Results of 28 total hip revision arthroplasties using distal fixation stems were analyzed. In 18 operations revision stems Wagner SL (1 st group) and in 10 interventions modular revision stems Cerafit revision (2 nd group) were used. Mean follow up period made up 3 years. Course of operation and peculiarities of bone canal treatment prior to stem implantation were described in detail. In 1 st group excellent results were achieved in 2 (11.11%), good in 8 (44.44%) satisfactory in 4 (22.22%) and poor in 4 (22.22%) of patients. In 2 nd group in 2 (20%), 4 (40%), 3 (30%) and 1 (10%) patient, respectively. Poor treatment outcomes resulted from suppuration and distal migration offemoral component. Rate of intraoperative femur cracks and fractures for two study groups was not higher than at revision arthroplasty using other implants. Taking into account intraoperative advantages the use of modular femoral components in complicated cases is a good alternative to monolithic stems.

An Implantable Left Atrial Pressure Sensor Lead Designed for Percutaneous Extraction Using Standard Techniques

BackgroundAn implantable left atrial pressure (LAP) monitoring system for guiding the management of patients with advanced heart failure has the potential to require extraction, particularly in the setting of infection. The LAP sensor lead was designed to be suitable for ease of percutaneous extraction using standard techniques for extracting pacemaker and defibrillator leads. The clinical experience, to date, with percutaneous extraction of the LAP sensor lead is presented.MethodsA total of 82 patients underwent successful implantation of the LAP sensor lead using transseptal catheterization. Five patients of the 82 patients during a cumulative follow-up period of 267 patient-years (median of 2.9 years/patient) underwent percutaneous extraction using manual traction with a locking stylet and/or an excimer laser sheath to bore through adhesions. The distal fixation anchors of the LAP sensor lead are designed to fold forward during extraction so that the sensor module can easily separate from the interatrial septum.ResultsPercutaneous extraction of the LAP sensor lead was accomplished successfully in all five patients with no embolic events, vascular tears, perforations, or other complications requiring surgical intervention. Manual traction alone was sufficient to detach the LAP sensor lead from the interatrial septum in all cases. Use of the excimer laser sheath was needed in selected cases to bore through scar tissue within the venous insertion site, but not within the heart.ConclusionsThe extraction of the LAP sensor lead was accomplished safely using standard techniques and equipment for percutaneously extracting pacemaker and defibrillator leads.

Distal stem features improve the torsional resistance of long-stem cemented revision hip stems: An in vitro biomechanical study

When proximal bone stock is compromised at revision hip arthroplasty, distal fixation is often relied upon for stability of the femoral component. In such circumstances, torsional forces can result in debonding and loosening. This study compared the torsional behaviour of a cemented, polished and featureless (plain) stem with cemented, polished stems featuring fins or flutes. The finned stem construct was found to be significantly stiffer than the fluted stem. The maximum torque of the finned and fluted stems was significantly higher than the plain stem, with no difference between the finned and fluted stems. Distal stem features may provide a more reliable and greater resistance to torque in polished, cemented revision hip stems. Finned stem features may also increase the stiffness of the construct.

A Three-Dimensional Comparison of Intramedullary Nail Constructs for Osteopenic Supracondylar Femur Fractures

This study developed a new 6 degree-of-freedom, unconstrained biomechanical model that replicated the in vivo loading environment of femoral fractures. The objective of this study was to determine whether various distal fixation strategies alter failure mechanisms and/or offer mechanical advantages when performing retrograde intramedullary nail (IMN) stabilization of supracondylar femur fractures in osteoporotic bone. Forty fresh-frozen human femora were allocated into 2 groups of matched pairs: "locked" (fixed angle locking construct with both distal locking screws rigidly attached to the IMN) versus "unlocked" (conventional locking technique with 2 distal locking screws targeted through the distal locking screw holes of the IMN) and "locked" versus "washer" (fixed angle locking with the most distal screw exchanged for a bolt with condyle washers) distal fixation of a retrograde IM nails. A comminuted fracture (OTA 33-A3) was simulated with a wedge osteotomy. Bone density measurements were completed on all specimens before instrumentation. Instrumented femurs were loaded axially to failure, whereas 6 degree-of-freedom translations and angulations were measured using Roentgen stereophotogrammetric analysis. Mean (± SD) load born by "locked" specimens (1609 ± 667 N) at clinical failure was 38.1% greater (P = 0.09) than the corresponding mean load born by "unlocked" specimens (1165 ± 772 N). Clinical failure for the "washer" group (1738 ± 772 N) was 29.9% greater (P = 0.07) than the corresponding mean of the "locked" counterparts (1338 ± 822 N). Failure load was most clearly related to bone density in the "unlocked" fixation group. Predicting failure load based on bone density using a least squares estimate suggests that the washer construct provides superior fixation to other treatment techniques. The failure mechanism for a comminuted, supracondylar fracture cannot be analyzed accurately with a 1-dimensional measurement. The most common failure mechanism in this model was medial translation and varus angulation.

Utilización de tallos femorales largos cementados en revisiones de cadera.

&lt;p&gt;&lt;strong&gt;Resumen&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Introducción:&lt;/strong&gt; existen diferentes opciones de tratamiento para realizar una revisión (RRTC) de un reemplazo total de cadera (RTC) fallido. El uso de tallos femorales largos cementados asociados a la utilización de injerto óseo molido representa una de estas modalidades para los RTC con mala calidad y pérdida de capital óseo. El objetivo de este trabajo fue evaluar una serie de pacientes tratados mediante esta modalidad.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales y Método:&lt;/strong&gt; Analizamos retrospectivamente una serie de 33 RRTC, con un seguimiento promedio de 4 años. Las causas de la revisión fueron en 28 casos aflojamientos mecánicos, en 3 fracturas peri-protésicas y en 2 fallas de osteosíntesis. En todos los casos se utilizaron tallos largos cementados y en 30 (90%) casos se utilizo injerto óseo molido.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Resultados:&lt;/strong&gt; en cuanto al comportamiento de los tallos el hundimiento promedio fue de 4mm. Se observo osteintegración del injerto en 27 (90%) de los 30 casos, hubieron 3 fallas radiológicas donde los tallos se hundieron en 2 oportunidades 8mm y en el restante 12mm. Además hubieron 2 falsas vías (6%), 2 luxaciones (6%) y 2 pseudoartrosis de trocánter mayor (6%)&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusión:&lt;/strong&gt; la utilización de tallos largos femorales y cementados, asociados a injerto óseo molido e impactado, en los casos donde el fémur distal no es adecuado para recibir un tallo de fijación distal impresiona ser una técnica adecuada de reconstrucción para RRTC con déficit de capital óseo. Debe ser realizado en centros de referencia por manos experimentadas ya que es una técnica no exenta de complicaciones.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Palabras claves&lt;/strong&gt;: Tallos femorales largos cementados, injerto óseo molido, Ling, defecto óseo.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Abstract &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Introduction:&lt;/strong&gt; currently, there are different treatment options to perform a revision of a failed total hip arthroplasty (RTHA). The use of cemented long femoral stems associated with the use of morcelled bone graft is one of these modalities for the RTC with poor quality and loss of bone capital.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; we analyze retrospectively 33 RTHA, with an average follow-up of 4 years. The causes of the review were in 28 cases mechanical losing, 3 peri-prosthetic fractures and 2 failures of osteosynthesis. Long stems cups and 30 were used in all cases (90%) cases I use ground bone graft.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; with regard to the behaviour of the stems the average sinking was 4 mm. See the graft integration in 27(90%) of the 30 cases, had 3 radiological failures where the stems were sunk in two opportunities 8 mm and the remaining 12 mm. In addition there were 2 false tracks (6%), 2 dislocations (6%) and 2 pseudoarthrosis of major trochanter (6%)&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; the use of cemented long femoral stems associated with impacted bone graft in cases where the distal femur is not suitable to receive a uncemented stem of distal fixation impresses be a proper reconstruction technique for RTHA with bone capital deficit. It must be made in centers of reference by experienced hands that it is not free of complications.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Key words:&lt;/strong&gt; RTHA, impacted bone graft, bone loss, cemented long stem, Ling, uncemented long stem.&lt;/p&gt;

Three to seven year follow-up of a tapered modular femoral prosthesis in revision total hip arthroplasty

Modular femoral prostheses can provide independent distal fixation and intraoperative flexibility and are being used increasingly, especially in patients with proximal femoral bone defects. This retrospective clinical study evaluated whether modular prostheses were effective and reliable implants for femoral revision. This case series consisted of 58 patients who underwent hip revision with a tapered modular femoral prosthesis at our institution between 2004 and 2008. Mean patient age at surgery was 64 years (range 18-86 years). Femoral bone defects before revision surgery were evaluated using the Paprosky classification. All patients were followed for a minimum of 3 years (mean 4.3 years, range 3-7 years) with clinical and radiographic evaluation. Re-revisions and complications were also recorded. Two stems required re-revision, one each for recurrent deep infection and periprosthetic fracture. At last follow-up, the Harris Hip Score and Visual Analog Pain Scores had improved significantly, the median radiographic stem migration was 1.6 mm, leg length discrepancy was corrected in 64 % of the patients and osseointegration occurred in 90 %. Complications included intraoperative fracture in 10 (17 %) patients and hip dislocation in 2 (3 %). Modular femoral components can improve hip function, provide distal fixation, equalize leg length, and result in fewer complications when used to revise failed femoral components.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

PurposeThe aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. MethodsWe retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. ResultsAt the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DiscussionA destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. Level of evidenceLevel IV.

Pelvic fixation for adult scoliosis

Obtaining a fusion, especially to the sacrum for adult deformity correction remains a challenge. Prior to modern fixation techniques, the reported fusion rates for adult scoliotic deformities were low. However sacropelvic fixation techniques for adult deformity continue to evolve. As a result, modern day pelvic fixation techniques have improved fusion rates at the base of long constructs. The purpose of this article is to discuss the history, indications, and modern fixation techniques for pelvic fixation in the surgical management of adult scoliosis patients. We searched PUBMED using the search terms pelvic fixation, deformity, lumbopelvic, sacropelvic, and iliac fixation. Linkage or association studies published in English and available full-text were analyzed specifically regarding techniques and innovations in pelvic fixation. Sacropelvic fixation should be considered in any patient with a long construct ending in the sacrum, those patients with associated risk factors for loss of distal fixation or high risk for pseudarthrosis at L5-S1, and those undergoing three column osteotomies or vertebral body resections in the low lumbar spine. Current pelvic fixation techniques with iliac screws, multiple screw/rod constructs, and S2-alar-iliac screws are all viable techniques for achieving pelvic fixation. There is growing evidence that pelvic fixation may become the standard for obtaining long fusions in adult scoliosis. Although technically challenging, in selected cases the use of four pelvic screws and/or four rods across the lumbosacral pelvis can help address pseudarthroses, implant breakage, and screw pullout secondary to osteoporosis. Ultimately, indications and techniques should be individualized to the patient and based on surgeon preference and experience.

Distal radius fracture fixation with volar locking plates and additional bone augmentation in osteoporotic bone: a biomechanical study in a cadaveric model

Fractures of the distal radius represent the most common fractures in adults. Volar locked plating has become a popular method for treating these fractures, but has been subject to several shortcomings in osteoporotic bone, such as loss of reduction and screw purchase. In order to overcome these shortcomings, cement augmentation has been proposed. AO-type 23-A3.3 fractures were made in 8 pairs of fresh frozen osteoporotic cadaveric radial bones. All specimens were treated with volar plating, and divided into cement augmentation or non-augmentation groups (n = 8/group). Constructs were tested dynamically and load to failure, construct-stiffness, fracture gap movement and screw cutting distance were measured. Cement augmentation resulted in a significant increase in cycles and load to failure, as well as construct stiffness at loads higher than 325 N. When compared to the non-augmented group, fracture gap movement decreased significantly at this load and higher, as did screw cutting distance at the holes of the ulnar column. The cycles to failure depend on the BMD in the distal region of the radius. Cement augmentation improves biomechanical properties in volar plating of the distal radius.

Ilizarov Distraction and Vascularized Fibular Osteocutaneous Graft for Postosteomyelitis Skeletal Deformity of the Forearm

The reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. This paper reports on the treatment of bone defects caused by osteomyelitis of the radius using an Ilizarov distraction technique and a vascularized fibular graft. A 25-year-old man first presented with a right radial defect caused by osteomyelitis when he was 3 years old. His right forearm was shortened and angulated with a dislocation of the distal radio-ulnar joint. The defect in the radial shaft was noted on a radiograph. The reconstruction of his radial bone defect was performed in three separate operations. A two-stage Ilizarov application was performed. Ten months after this operation, the radial bone defect was reconstructed with a vascularized fibular osteocutaneous graft. The right radius was shortened by 10 mm due to the angulation in the distal fixation of the graft 14 years after surgery. Although limited motions of the right thumb extension and wrist supination were noted, other hand functions were adequately restored. The Ilizarov technique is an effective method for correcting distal radio-ulnar joint dislocations and shortened, angulated ulnar bones. The specific features of the vascularized fibular graft make it suitable for the bone reconstruction of large defects in the radius.

Innovative use of Proximal Humeral Interlocking System (PHILOS) plate for fixation of osteoporotic fibula fracture

Operative treatment of comminuted, osteoporotic distal fibula fractures is challenging due to poor bone stock. Conventional plates provide inadequate fixation. We describe treatment using the Proximal Humeral Interlocking System (PHILOS) plate (Synthes, Welwyn Garden City, UK). Following adequate exposure and reduction of the fracture, the PHILOS plate applied to the fibula in an inverted position. Proximal plate fixation using a compression screw is followed by distal fixation using locking screws. An image intensifier ensures satisfactory screw length. The PHILOS fixation is strong and provides angular stability. This technique has been used successfully in three patients with osteoporotic fibula fractures (Fig 1). The plate was not prominent and did not overlap with the distal fibula. Figure 1 Plain x-rays showing ankle 12 weeks following fixation of distal fibula using PHILOS plate

Successful Femoral Reconstruction with a Fluted and Tapered Modular Distal Fixation Stem in Revision Total Hip Arthroplasty

Early results of fluted and tapered distal fixation stems used in reconstruction of deficient femora in femoral revision arthroplasty have been successful in small series. We evaluated the survival of the LINK MP Reconstruction Hip Stem and factors associated with survival using data from a nation-wide arthroplasty register. 408 femoral revisions using LINK MP Reconstruction Hip Stem were performed during 1994 to 2007. The mean age of the patients was 72.5 (range: 36-93) years and 63% were performed in women. Kaplan-Meier analysis and the Cox regression model were used for the survival analysis. The effects of age, sex and diagnoses were also studied. The 9-year overall survivorship for the LINK MP Reconstruction Hip Stem was 75% (95% CI 70-80). Aseptic loosening was rare; the 9-year revision rate for aseptic loosening was only 3%, which coincides with earlier reports with shorter folllow-up. The most common reason for re-revision was dislocation of the prosthesis with or without malposition of the socket (67%). Indication for revision strongly affected the survival rate with revisions for dislocation having an over 3-fold and revisions for infection a 3-fold relative risk for re-revision compared to revisions for aseptic loosening. Increasing age slightly decreased the risk of re-revision but sex did not affect the survival. Based on our findings, we conclude LINK MP Reconstruction Hip Stem, as an example of a fluted and tapered distal fixation stem, appears to solve many problems with implant fixation in femoral revisions. High number of dislocations suggests that special attention should be paid to correct center of rotation, to correct implant positioning and to need of constrained implants in case of deficient abductor mechanism.

Commentary on ‘Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation’ by A.P. Riddick, B. Hickey, and S.P. White. J Hand Surg Eur. 2012, 37: 407-11

Commentary on ‘Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation’ by A.P. Riddick, B. Hickey, and S.P. White. J Hand Surg Eur. 2012, 37: 407-11

Arthroscopic refixation of a combined fracture of the greater and lesser tuberosity of the proximal humerus

Combined fractures of the greater and the lesser tuberosity are very rare injuries. This is a case report on arthroscopic treatment using suture anchors and one distal fixation screw. Clinical and radiographic follow-up showed recovery of active motion and consolidation of the fragments in anatomic positions. V.

Pediatric Distal Femur Fixation by Proximal Humeral Plate

Distal femoral metaphyseal fractures are common injuries in children. Multiple treatment options have been described for this type of injury. For older children with distal metaphyseal fracture, there is still no optimal method of fixation. We propose that the commonly used proximal humeral plate can provide good method of fixation for this fracture in adolescents. Two children (12 and 14 years old) with distal metaphyseal femoral fracture were treated with proximal humeral plate. We describe the surgical technique and postoperative management. The two children healed with good alignment and full range of motion of the knee. No external immobilization (other than knee immobilizer for the first 2 weeks) was used. We concluded that proximal humeral plate can provide adequate fixation for teenagers with distal femoral metaphyseal fracture. It is readily available; provide multiple options for screw fixation in the distal part of the fracture and fits easily on the distal part of the femur proximal to the physis.