Femoral head fractures resulting from hip dislocations are rare injuries resulting from high-velocity trauma. Garrett Pipkin, in 1957, classified these fractures into four types. All varieties are associated with hip dislocations, which are attended to as emergencies. Few cases of isolated femoral head fractures without hip dislocation have been published in the literature; we describe one such atypical variant. A 38-year-old male presented with a history of pain and swelling in his right knee following a traffic accident. After 48 hours of bed rest on ambulating, the patient had mild right hip discomfort, but hip examination was essentially normal. Radiology was repeated with plain radiographs and non-contrast computed tomography (NCCT), followed by contrast-enhanced magnetic resonance imaging (MRI) pelvis with bilateral hips. He had a fracture of the head of the femur and acetabular lip with concentric joint. Without hip dislocation, this was an unusual presentation of Pipkin Type IV fracture of the femoral head & posterior acetabular lip. It was managed with open reduction and lag screw fixation of supra-foveal femoral head fracture approaching through the acetabular bony rim avulsion, which was later fixed with lag screw and spring plates. The patient recovered well. This was an unusual presentation of Pipkin type IV fracture without hip dislocation and can be missed due to a subtle presentation, not yet described in the literature. A high degree of suspicion and advanced radiology helped in the appropriate management of the case.

IntroductionThe optimal treatment for complex acetabular fracture involving the posterior wall and column remains controversial. To address this issue, a novel anatomically integrated acetabular plate (AIP) was developed, designed to integrate the biomechanical advantages of both reconstruction and T-shaped plates. This biomechanical study aimed to evaluate the mechanical performance of the AIP in comparison with conventional fixation methods.MethodsAcetabular fractures involving the posterior wall and column were created in 18 fresh-frozen pelvis specimens and assigned to three fixation groups: (1) an anatomically integrated plate (AIP), (2) two reconstruction plates with a T-plate (RPTP), and (3) two reconstruction plates with two lag screws (RPLS). A standing position was simulated, and a Zwick Z100 testing machine applied an axial load from 0 to 1400 N. A load-displacement sensor and digital dial gauge were used to measure overall displacement, stiffness, and displacement of the posterior wall and column to evaluate the mechanical stability of each fixation construct.ResultsUnder increasing axial loading, all three groups of model specimens exhibited a linear trend in axial displacement without sudden load drops. Among the groups, the AIP group demonstrated the smallest overall displacement (1.87 ± 1.09 mm), followed by the RPTP (2.29 ± 1.12 mm) and RPLS groups (2.63 ± 1.21 mm). No significant difference in displacement was observed between the AIP and RPTP groups under loads of 0–1000 N (P > 0.05), whereas a significant difference emerged at higher loads of 1200–1400 N (P < 0.05). Under a peak load of 1400 N, the axial stiffness followed the trend: Normal (NOR) group > AIP group > RPTP group > RPLS group, with mean stiffness values of 356.10 ± 12.33 N/mm, 339.87 ± 21.86 N/mm, 302.04 ± 13.69 N/mm, and 266.32 ± 9.16 N/mm, respectively. The AIP group exhibited significantly higher stiffness than both the RPTP and RPLS groups (P < 0.05), with no significant difference between the AIP and NOR groups (P > 0.05). Furthermore, the AIP group showed significantly lower displacement of the acetabular posterior wall and column compared to the RPTP and RPLS groups (P < 0.05). Notably, two specimens in the RPLS group showed posterior wall displacements exceeding 2 mm, which met the criteria for internal fixation failure.ConclusionOverall, the AIP group provided the best biomechanical performance in terms of minimizing displacement and maximizing stiffness, followed by RPTP and RPLS group, indicating its potential superiority for the stabilization of acetabular fractures involving the posterior wall and column.

IOFix™ with plate construct is similar to locking plate construct for Lapidus bunionectomy procedure outcomes.

Surgical treatment of displaced intraarticular pediatric condyle fractures.

One of the surgical treatment options for advanced ankle joint destruction with various etiologies is the total joint replacement. Its significant upside is the preservation of range of motion of the ankle joint and less stress on forefoot joints compared to ankle arthrodesis. Since 2022, we have been using the Zimmer Trabecular Metal Total Ankle inserted via a lateral transfibular approach. This study aims to evaluate the initial outcomes and experience with this implant. Between 2022 and 2024, 65 total ankle replacements were performed in 63 patients using the lateral transfibular approach. Long oblique osteotomy is newly performed in the frontal plane, replacing the original type of osteotomy in the sagittal plane. After releasing and removing the distal fragment of the fibula distally and dorsally, the lower limb and ankle are placed in an alignment frame, which is fixed with Steinmann pins to the calcaneus, anterior border of the tibia, and the talus bone. The centre of rotation of the ankle is identified using the side bars anchored in the frame. Using the burs, guided by Cutting Guides that are locked to the frame, the talus and distal tibia are removed. After testing, rail holes are drilled in the resected surfaces for the original implants. After releasing the tourniquet, the original components are inserted and osteosynthesis of the fibula is performed. During the study, the previously performed fibula osteosynthesis with LCP was replaced by lag screws. Postoperatively, the ankle is supported with a brace for the period of 5 weeks, after which the patient is permitted to fully weight-bear. A total of 63 patients (32 women and 31 men) were followed, in whom 65 total ankle replacements were performed. The mean age of the patient was 56 years (age range 30 to 80 years). The mean follow-up period was 14.6 ± 9.3 months (3 to 38 months). The most frequent indication was post-traumatic ankle arthritis, namely in 46 cases (70.8%). Furthermore, there were 5 patients (7.7%) with post-traumatic ankle ankylosis, 9 patients (13.8%) with primary osteoarthritis, and in 5 patients (7.7%) the indication was the damage caused by rheumatoid arthritis. Deep bacterial infection of the prosthesis requiring revision was reported in 3 cases (4.6%). Superficial infection of the surgical wound was seen in 4 other cases (6.2%), which did not require hospitalization. Plate osteosynthesis of the fibula was removed in 7 cases (13.8%), 5 times due to infection and 2 times due to soft tissue irritation. One case of asymptomatic non-union of fibula was observed. The benefit of total ankle replacement is the preservation of motion of the operated joint, whereas the complication rate is twice as high as in arthrodesis. Contraindications for ankle replacement include significant varus and valgus deformities of the ankle, ankle instability, necrosis of the talus, severe diabetes mellitus, and severe limb ischemia. The advantage of the transfibular approach is the ability to partly correct deformities of the ankle joint and the position of varus or valgus. It provides a better view of the dorsal structures of the ankle and allows accurate identification of the centre of rotation. Another advantage is the low thickness of the components, requiring minimal bone resection. The main disadvantage is the longer operative time and longer learning curve. Other disadvantages include the complications associated with osteosynthesis and fibula healing, such as non-union or soft tissue irritation by plate. The incidence of superficial and deep infection is also slightly higher compared to the anterior approach. The Zimmer Trabecular Metal Total Ankle system is one of the treatment options for ankle joint destruction provided it is correctly indicated. However, the surgical procedure is a challenge and requires an experienced surgeon. When the indication is correct, the system brings very good short-term outcomes. Nonetheless, longer follow-up period is necessary since the incidence of complications will certainly increase over time.

Salvage options following failed surgical hip fracture repair: Part II, extracapsular proximal femoral fractures.

Hangman's fracture, caused by high-energy hyperextension with axial loading trauma, remains challenging to manage. Unstable types (IIa and III) can be treated by a variety of surgical options. Lag-screw fixation has recently gained attention owing to its compatibility with navigation, minimally invasive instrumentation, and lower surgical morbidity. A systematic review and meta-analysis of surgical efficacy and safety of lag screw fixation was undertaken. Nine studies, which included a total of 128 patients, assessed outcomes of lag screw fixation, including neck range of motion, intervertebral angle (C2-C3), postoperative pain (visual analog scale), intraoperative parameters, and complications. Significant improvements were observed in pooled range of motion (extension: 6.28°, flexion: 5.13°) and correction of the C2 to C3 angle by -3.54° (P < 0.001) vs baseline. Pain decreased across early and late timepoints, although heterogeneity reflects variable follow-up and unreported analgesic/analgesia protocols. Reported complications were low in the included series. C2 transpedicular lag-screw fixation restores alignment and preserves motion with low reported complications in available case series. Larger comparative trials are needed to define its role relative to fusion techniques. Direct osteosynthesis of unstable hangman's fractures via lag-screw fixation offers a viable motion-preserving alternative to C2-C3 fusion. By avoiding fusion, this technique maintains physiological cervical biomechanics and reduces the risk of adjacent segment disease. However, clinicians must carefully weigh these benefits against the technical demands of screw placement and the current lack of high-level comparative evidence.

Background and Objectives: Screw cut-out is the most common mechanical complication after intertrochanteric fracture fixation with proximal femoral nails (PFNs). While the traditional tip–apex distance (TAD) is widely used, the calcar-referenced TAD (CalTAD) may better represent inferomedial cortical support. This study aimed to identify radiographic predictors of cut-out in dual-screw PFN fixations and establish a clinically relevant threshold for inferior-screw-based CalTAD. Materials and Methods: A retrospective cohort of patients treated with a dual cephalic screw PFN between 2017 and 2024 was analyzed. The implant uses two equal-diameter screws. Radiographic parameters included TAD, inferior-screw CalTAD, reduction quality, lateral wall thickness (LWT), collodiaphyseal angle (CDA), and Cleveland zone positioning. Logistic regression analyses were used to identify independent predictors of mechanical failure. Results: Both TAD and CalTAD values were significantly higher in patients who experienced screw cut-out. ROC analysis identified an inferior-screw-referenced CalTAD cutoff with strong predictive accuracy (AUC = 0.84). Optimal screw positioning, particularly avoiding superior placement on AP radiographs, was associated with reduced cut-out risk, while anterior positioning on the lateral view demonstrated only a borderline effect. Reduction quality showed borderline significance in univariate testing but remained independently predictive in multivariate modeling, while LWT and CDA were not significantly different between groups. Conclusions: Ensuring the inferior lag screw is positioned close to the calcar and achieving a low CalTAD, together with proper Cleveland zone alignment, appear to be key technical goals for minimizing mechanical cut-out in dual-screw PFN fixations. These findings support the use of inferior-screw–referenced CalTAD as a reliable and reproducible parameter for surgical optimization.

Independent Risk Factors for Lag Screw Cut-Out: The Role of Open Reduction in Intertrochanteric Fracture Fixation With the Proximal Femoral Nail

A Biomechanical Cadaveric Comparison of Three Fixation Methods for Bennett Fractures.

Rotational instability is a key factor in fixation failure of extracapsular hip fractures. The U-Blade (RC) lag screw was designed to improve rotational stability. This study aimed to compare mechanical complication rates between Gamma3 and Gamma3 RC nails in elderly patients with rotationally unstable extracapsular fractures. We conducted a prospective, single-center randomized controlled trial including 316 patients aged ≥ 65 years with rotationally unstable extracapsular fractures. Patients were randomized to treatment with a Gamma3 nail (n = 169) or a Gamma3 RC nail (n = 147). Mechanical complications were classified as major (rotation and migration of the implant, cut-out, non-union) or minor (back-out, cervicodiaphyseal angle change, excessive sliding). The overall rate of major complications was 2.9 per 10,000 person-days, being the most frequent the cut out (2.2%), with no significant difference between Gamma3 and Gamma3 RC groups (RR = 1.0; 95% CI: 0.4-2.7). TAD > 25mm increased the risk of major complications (RT = 3.7; 95% CI: 1.2-11.2), as did superior screw placement (Cleveland zones 1-3: RT = 7.5; 95% CI: 2.7-20.8) and postoperative diastasis (RT = 4.7; 95% CI: 1.4-16.2). Similarly, implant type was not significantly associated with minor complications that were observed in 85 patients (26.9%), most frequently back-out (14.6%). The U-Blade (RC) lag screw did not reduce mechanical complication rates compared with the standard Gamma3. Radiographic parameters, particularly TAD, reduction quality, screw position, and postoperative diastasis, were the main predictors of fixation failure.

Helical Blade or Lag Screw? It Doesn't Matter as Much as We Thought: Commentary on an article by Kanu Okike, MD, MPH, et al.: "Helical Blade Versus Lag Screw Fixation in the Cephalomedullary Nailing of Geriatric Hip Fractures".

Fix the phalanx: A meta-analysis comparing intramedullary screws, pinning, plates, and lag screws for closed extra-articular proximal phalanx fractures.

Relationship between anterior fracture line location and rotational instability during inserting lag screw of cephalomedullary nail in intertrochanteric femoral fracture.

Complex tibial plateau fractures continue to challenge orthopaedic surgeons because of the difficulty in obtaining an anatomic reduction of the joint, axial alignment of the articular segment, while avoiding complications. Despite overall good results, significant complications persist with internal fixation, particularly in cases with compromised soft tissues, open fractures, bone loss, extensive comminution, compartment syndrome, extensor mechanism disruption, or significant osteopenia. Circular external fixation offers advantages in these situations because of its unique biomechanics, adaptability, and percutaneous techniques. The method limits incisions to only those needed to optimize reduction. Fixation of the articular surface and metaphyseal region is by a combination of small-diameter lag screws and olive wires ± half pins. Fixation of the shaft is with half pins from 1 or 2 rings. The articular fixation block can be connected to the distal ring block by threaded rods, trauma struts, or hexapod struts. Extension of the frame across the knee is useful in selected cases to protect injured soft tissue or extensor mechanism, provide distraction, and prevent a flexion contracture. Excellent results have been achieved with this technique and may have a lower complication rate than internal fixation in complex injuries.

Lateral epicondyle osteotomy for panoramic exposure of comminuted radial head fractures- a surgical technique guide.

Background/Objectives: Femoral intertrochanteric fractures (ITFs) in older adults are associated with a substantial risk of mechanical failure after fixation, which can lead to persistent pain, delayed mobilization, and increased mortality. Injectable calcium composite bone substitute (ICCBS) augmentation has been proposed as a strategy to enhance construct stability and promote bone healing, but clinical evidence remains limited. The purpose of this study was to evaluate the efficacy of ICCBS in the management of osteoporotic ITFs. Methods: We conducted a multicenter, prospective, non-randomized controlled study of patients undergoing surgical fixation for osteoporotic ITFs using proximal femoral nails. Patients who consented to augmentation received ICCBS, while the control group underwent standard fixation alone. Demographic and injury-related variables were documented, and outcome data were prospectively collected. The primary outcome was time to radiographic bone union, while secondary outcomes included functional recovery (pain and ambulatory status) and complications, including fixation failure. Results: The mean time to radiographic bone union did not differ significantly between groups (p = 0.28). However, patients receiving ICCBS augmentation reported significantly lower postoperative pain scores up to 6 weeks and demonstrated reduced lag screw sliding and varus collapse at the time of bone union. There were no significant differences in complication rates, fixation failure, or ambulatory status at last follow-up between the two groups. Conclusions: ICCBS augmentation may improve early postoperative pain, construct stability, and functional recovery in patients with osteoporotic ITFs, although its effect on fracture healing and long-term outcomes remains uncertain. Further high-quality randomized trials are warranted to confirm these findings.

Introduction: In the current climate of cost containment and fiscal responsibility, high-value implant alternatives offer a substantial opportunity for savings in the treatment of orthopedic trauma patients. As patents have expired on many commonly used trauma implants, high-value alternatives have become available. The purpose of this study was to examine the clinical and economic impact of a cost containment program utilizing high-value, single lag screw cephalomedullary hip nail implants for treating intertrochanteric femur fractures. Design: Retrospective comparative cohort study. Setting: Level II trauma center Patients/Participants: 885 patients (347 Males and 538 Females) with intertrochanteric femur fractures. Intervention: Patients treated with high-value single lag screw cephalomedullary implants were compared to those treated with conventional implants during the same period. Main Outcome Measurements: Operative records were reviewed to identify intraoperative complications, operative time, and estimated blood loss. Cases involving infection, malunion, nonunion, or the need for repeat surgery were documented. Hospital financial records were evaluated to determine implant costs. Results: 443 patients were treated with the high-value implant, while 442 patients received conventional single lag screw cephalomedullary implants over the same period. No difference was observed in intraoperative complications or estimated blood loss. Operative time was significantly shorter in the high-value implant group (p=2.3E-10). There was no increase in postoperative infection rates, implant complications, malunion, or nonunion. Overall, the hospital saved a total of $512,994 on implant costs. Conclusions: Implant costs decreased significantly without an increase in complication rates or changes in radiographic outcomes. These savings were essential to our success in the Bundled Payment for Care Improvement (BPCI) initiative. Additionally, the savings can be reinvested into the trauma program in alignment with OTA/AAOS position statements and guidelines, as well as to support gainsharing and co-management initiatives. Level of Evidence: Level III - Retrospective comparative cohort study Keywords: Cephalomedullary nail, Hip fracture, High-value implants, Cost containment, Orthopaedic trauma.

Introduction:Intertrochanteric fractures are common in elderly patients and can lead to significant malunion and varus deformities if untreated. While the dynamic hip screw has been the gold standard, there is a continuous effort to evaluate newer fixation devices. This study assesses the functional and radiological outcomes of intertrochanteric femur fractures treated with the Halifax nail, aiming to provide a contemporary comparison to existing methods.Materials and Methods:This prospective study was conducted at our institution from January 2019 to December 2024. We included patients with intertrochanteric fractures, excluding those with open fractures, pathological fractures, pre-operative neurovascular deficits, or polytrauma with head injuries. All patients underwent surgery under spinal anesthesia on a fracture table. Closed reduction was attempted under C-arm guidance; if unsuccessful, open reduction was performed. The Halifax nail was inserted after a tensor fascia lata and gluteus medius split. This was followed by lag screw insertion with tri-wire guidance, end cap application, and distal locking.Results:The study included 57 patients (31 male and 26 female). Fracture classifications were 11 AO type A1, 23 AO type A2, and 23 AO type A3. The average surgery duration was 65 min, with an average blood loss of about 200 mL. Patients achieved an average time to union of 11.7 weeks, and the functional outcome, measured by the average Harris Hip score, was 91.Conclusion:The findings suggest that the Halifax nail provides favorable functional and radiological outcomes for intertrochanteric femur fractures. Its use resulted in good union rates and high patient function, indicating that it is a viable and effective treatment option. Further comparative studies are needed to confirm its role in orthopedic practice.

To present and evaluate the safety and efficacy of our new procedure for treating thoracolumbar burst-split fractures without neurological injury. Our new surgical technique for the treatment of thoracolumbar burst-split fractures (AO type A4, Magerl classification A3.2.1) involving (1) posterior reduction and bisegmental instrumention, (2) anterior screw fixation of the caudal sagittal split, (3) anterior one-level fusion of the cranial segment, and (4) interval posterior implant removal was presented. In an initial cohort of patients, demographic information, surgical specifics and imaging data were evaluated. Twenty-one patients (mean age 29.5 ± 11.8 years, 38% male, mean follow-up 36 ± 14 months) were included. Anterior column reconstruction involving sagittal split lag screw and monosegmental fusion was performed at a mean of 2.9 ± 2 days after posterior instrumentation. All fractures healed. There were no occurrences of implant failures or migrations. None of the patients required revision surgery. The removal of the temporary posterior instrumentation was performed at a mean of 8.4 ± 1.8 months after the initial surgery. Bisegmental, superior monosegmental, and inferior monosegmental kyphosis angle did not significantly change from six months to 12 months postoperatively after removal of the posterior instrumentation (p > 0.9). No listhesis or change in bisegmental scoliosis angle were observed. The inferior monosegmental angle was significantly greater in flexion (1.2° ± 5.8°) compared to extension (-3.3° ± 6°) at 12 months postoperatively indicating motion in the inferior, non-fused segment after removal of the posterior instrumentation (p = 0.0001). The intervertebral disc height at the temporarily fused segment decreased significantly from six (9.2 ± 2.2) to 12 months postoperatively (8.3 ± 2.2; p < 0.0101). Thoracolumbar burst-split fractures can be safely and successfully treated through a treatment protocol that includes (1) posterior reduction and bisegmental instrumention, (2) anterior screw fixation of the caudal sagittal split, (3) anterior one-level fusion of the cranial segment, and (4) interval posterior implant removal. This new surgical technique promotes reliable fracture healing, kyphosis correction and preserves the physiological motion at the caudal segment.