Narrow Medullary Canal Research Articles

Challenges in the Surgical Orthopedic Treatment of Long Bone Fracture in a Rare Case of Pycnodysostosis

Pycnodysostosis is a rare autosomal recessive disorder caused by an inactivating mutation in cathepsin K (CTSK) and characterized by dysmorphic facial features, a short stature, acro-osteolysis, osteosclerosis with increased bone fragility, and delayed closure of cranial sutures. Although the satisfying healing potential, many issues exist in managing fractures in pycnodysostosis patients. In this paper, we report the challenges faced in managing a fracture of the femoral shaft in a 14-year-old boy coming from a low-income family. The patient was administered to the Paediatric Surgical Emergency Department of the Children's Hospital in Rabat for the management of a closed fracture of the left femur. Despite being of small stature with dysmorphic facial features, a prominent forehead, and brachydactyly, he never had a medical consultation before. The patient then underwent a surgical reduction. We attempted titanium elastic nail fixation, but metaphyseal drilling was not feasible due to the high bone density, and the narrow medullary canal eliminated this option. Therefore we opted for the palate fixation. Sclerotic bone made drilling extremely difficult. The postoperative fracture was successfully healed.

Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures.

Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal. Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail. In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a10º varus deformity present after surgery in one case. Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.

Surgical strategy of the treatment of atypical femoral fractures.

The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.

FUNCTIONAL OUTCOME OF ANTEGRADE AND RETROGRADE INTRAMEDULLARY INTERLOCKING NAIL FOR THE TREATMENT OF SHAFT OF HUMERUS FRACTURE - A PROSPECTIVE COMPARATIVE STUDY

Background: Antegrade or retrograde locked intramedullary nailing are both effective treatments for humeral shaft fractures; however, these two techniques have not been sufciently compared. In this study, mid humeral shaft fractures treated with these two strategies using the identical locking nails were evaluated for efcacy and potential risks. 50 fractures in 50 Methodology: patients with humerus mid-shaft fractures were randomly assigned to get either antegrade or retrograde locked nailing using sealed-envelope method in this prospective comparative research. Clinical outcomes including fracture healing time, complications, functional recovery of the elbow and shoulder, and time for functional recovery were evaluated. There was no statistically signicant difference in the time of union i Results: n this trial, with an average of 13.6 weeks in the Antegrade group and 14 weeks in the Retrograde group. The two treatment groups in the current research were similar in terms of demographics, fracture patterns, surgical indications, and treatment. The antegrade nailing patients regained functional recovery faster while comparing to retrograde nailing patients. Antegrade nailing is advised for patients with proxima Conclusion: l fractures, young age and patients with tiny medullary canal whereas retrograde nailing is advised for fractures which are distal with broad medullary canal or prior shoulder issues. Due to less complications of elbow stiffness , shortened surgery duration, early functional recovery and since humerus generally tends to have narrow medullary canal we conclude that antegrade nailing is favoured over retrograde nailing for patients with humerus shaft fractures.

Uncemented hemiarthroplasty in a case of post-polio residual paralysis patient with transcervical femur fracture with dysplastic femur: A surgical technical challenge

Introduction: Technical difficulties in managing a case of transcervical femur fracture in post-polio residual paralysis patient with dysplastic femur. Case Report: We present a case of a 66 year male with Post-Polio residual Paralysis walking with Hand to knee gait who sustained a transcervical Femur fracture. The difficulties faced in this case were narrow medullary canal, coxa valgus, dysplastic greater trochanter, hypoplastic lesser trochanter, Shallow acetabulum, inability to compare the length after insertion of trial implant with the opposite limb due to underdeveloped and shortened affected limb.Conclusion: We try to emphasise on the preoperative preparations that need to be done in terms of CT scan with pre operative estimation of canal diameter, keeping a back-up of an array of implants including CDH hip stems, technique of measuring the vertical and horizontal offset before neck osteotomy and extraction of the head and recreating the offset after implantation, increased anteversion of the hip to prevent dislocation due to shallow acetabulum, and proper closure of the capsule.

The Three-Dimensional Morphology of Femoral Medullary Cavity in the Developmental Dysplasia of the Hip.

ObjectiveThis study aimed to assess the morphology of the femoral medullary canal in subjects with developmental dysplasia of the hip (DDH) with the intent of improving the design of femoral stems in total hip arthroplasty.MethodsComputed tomography images of 56 DDH hips, which were classified into Crowe I to Crowe IV, and 30 normal hips were collected and used to reconstruct three-dimensional morphology of the femoral medullary cavity. Images of twenty-one cross sections were taken from 20 mm above the apex of the lesser trochanter to the isthmus. The morphology of femoral cavity was evaluated on each cross section for the longest canal diameter, the femoral medullary torsion angle (FMTA), and the femoral medullary roundness index (FMRI).ResultsThe Crowe IV group displayed the narrowest medullary canal in the region superior to the end of the lesser trochanter, but then gradually aligned with the medullary diameter of the other groups down to the isthmus. The FMTA along the femoral cavity increased with the severity of DDH, but the rate of variation of FMTA along the femoral canal was consistent in the DDH groups. The DDH hips generally showed a larger FMRI than the normal hips, indicating more elliptical shapes.ConclusionA femoral stem with a cone shape in the proximal femur and a cylindrical shape for the remainder down to the isthmus may benefit the subjects with severe DDH. This design could protect bone, recover excessive femoral anteversion and facilitate the implantation in the narrow medullary canal.

A controlled diaphyseal expansion osteotomy for the implantation of a wagner cone prosthesis in a stenotic femoral canal encountered in a polio limb: a case report of the technique

<p class="Default">Dysplastic hips pose a significant technical challenge to arthroplasty surgeons. Such deformed hips might be encountered either in congenital and developmental conditions or as sequel of neuromuscular disorders (like poliomyelitis), following infections, or after childhood surgical procedures of the hip. The scientific literature, focussing on total hip arthroplasty (THA), for coxarthrosis in patients with residual poliomyelitis, is relatively rare. Several anatomical distortions seen in dysplastic femurs are described, one of which includes an undersized diaphysis with a stenotic medullary canal. We present a case of a 28 years old male with residual poliomyelitis who underwent a cementless THA for a non united transcervical neck of femur fracture. The patient had an extremely narrow medullary canal which posed a formidable difficulty in the procedure. This was overcome by a novel diaphyseal expansion osteotomy, which enabled the implantation of Wagner Cone prosthesis. This technique, which has hitherto not been described in the literature, can significantly facilitate the implantation of an appropriately sized stem in an undersized femur while at the same time ensuring a good long-term result.</p>

Atypical Femoral Fracture in McCune-Albright Syndrome

McCune-Albright Syndrome (MAS) is characterized by endocrinopathies, café-au-lait spots, and fibrous dysplasia. Bisphosphonates are the most prescribed treatment for reducing the pain but their long-term use has been associated with atypical fractures of cortical bones like femur in patients. We present a 23-year-old girl diagnosed with MAS. She had an atypical mid-shaft left femoral fracture that happened during simple walking. She also had a history of long-term use of alendronate. Because of the narrow medullary canal, we used 14 holes hybrid locking plate for the lateral aspect of the thigh to fix the fracture and 5 holes dynamic compression plate (instead of the intramedullary nail) in the anterior surface to double fix it, reducing the probability of device failure. With double plate fixation and discontinuation of alendronate, the complete union was achieved five months after surgery

A prospective study of management of subtrochanteric femur fracture using proximal femoral nail

<p class="abstract"><strong>Background:</strong> Proximal femur fractures present considerable challenge in management. They are due to high velocity trauma, with or without soft tissue injury and usually with a metaphyseal and diaphyseal involvement. The surgeon has to face many challenges like identifying the entry, reduction the fracture, and difficulty due to a narrow medullary canal and comminution. The present study was conducted to assess the utility and effectiveness of Proximal Femoral Nail for subtrochanteric fractures of femur.</p><p class="abstract"><strong>Methods:</strong> In this study a total of 30 patients with Sub trochanteric femur fracture admitted to MGM medical college and hospital from June 2015 to July 2017 were selected for treatment with proximal femur nail.<strong></strong></p><p class="abstract"><strong>Results:</strong> 30 patients were included in this study with subtrochanteric fractures of femur treated with Proximal femoral nail. Maximum 21(70%) of patients were below 61 yrs of age. Mean age was 47.9 years. There was 21 male and 9 females in the study. There were 6 patients with local complications. Final result of our study, we had 26.7% excellent, 46.6% good, 20% fair and 6.7 % poor results according to Harris hip score.</p><p class="abstract"><strong>Conclusions:</strong> In our study, looking at the results we found that Proximal femoral Nail proves to be a good implant in management of subtrochanteric fractures of femur. However, it is a small study to conclude anything definitely.</p>

Interlocking nailing of femoral shaft fractures with an extremely narrow medullary canal is associated with iatrogenic fractures

IntroductionControversy exists regarding the use of reamed interlocking nailing in femoral shafts with extremely narrow medullary canals (diameter ≤ 9 mm). The aims of this study were to (1) investigate the association of age and sex on femoral canal diameter in patients with a simple femoral shaft fracture and (2) compare the outcomes and complications of interlocking nailing between wide and extremely narrow intramedullary canals. Patients and methodsFor the purposes of this retrospective cohort study, consecutive patients with simple femoral shaft fractures were recruited between January 2009 and December 2016. The patient demographic data were analyzed. Then, fractures treated with interlocking nailing were divided into the wide group (canal diameter > 9 mm) and narrow group. The primary outcome was union rate, and the secondary outcomes were complications such as thermal necrosis, fat embolism syndrome, iatrogenic fracture, and implant failure. ResultsThis study included 340 femoral shaft fractures. The average canal diameter was 9.97 ± 1.79 mm, with significantly wider canals in men than in women. Overall, 289 of the patients had undergone interlocking nail fixation, and a similar union rate and complications were noted between the wide canal and narrow canal groups, with the exception of the incidence of iatrogenic fracture. ConclusionsFemoral shaft fractures associated with extremely narrow medullary canals are more common in women than in men. There was a similar union rate found when using interlocking nailing in a femoral shaft fracture in cases with extremely narrow and wider canals. Iatrogenic fracture is the only significant risk when using interlocking nailing in femoral shafts with extremely narrow canals.

Elastic intramedullary nailing of the femur fracture in patients affected by osteogenesis imperfecta type 3: Indications, limits and pitfalls

IntroductionPatients with Osteogenesis Imperfecta (OI) Type 3 may exhibit both primitive deformities and secondary fracture malunions on a femoral level. The orthopaedic surgeon’s objective is to cure the deformities in order to prevent fractures and to treat the fractures in order to prevent deformities, by using telescopic nails as the gold standard method of fixation. However, the titanium elastic nail (TEN) is indicated as a possible alternative in certain selected cases. Materials and methodsThe Centre for Congenital Osteodystrophy of the Sapienza University of Rome follows 485 patients with osteogenesis imperfecta. For the purpose of this study, we selected 36 patients with OI type 3 (15 females and 21 males), aged between 2 and 10 years old, who were surgically treated for femur fractures with Titanium Elastic Nail (TEN) from January 2007 to December 2009. In 12 cases a single TEN was implanted, while 24 of the cases were treated by implanting 2 TENs with the Sliding Nail (SN) technique. A retrospective evaluation was carried out by analysing the data from the medical charts and dossiers related to pain symptoms, knee and hip Range of Motion (ROM), any possible complications that could cause implant revisions (infections, nail slide failure, nail migration, traumatic events following surgery, delayed consolidation, epiphysiodesis). ResultsAt the 60th post-surgical month, the revision rate was 75%, mostly due to migration, osteolysis, nail slide failure and nail fracture. The Kaplan-Meier's survival curve analysis showed a coefficient of 0.25–60 months (confidence interval −0.31 and 0.81). DiscussionThe percentage of complications and the high rate of revisions recorded in our sample confirm that telescopic nail is the gold standard in the treatment of femoral fractures in patients with OI type 3. ConclusionsIn patients under the age of 4, with narrow medullary canals, low life expectancy, few to nil rehabilitative prospectives or severe comorbidities, the use of TEN may be considered as a less invasive approach compared to telescopic nail surgery, however only temporarily, as it will still most probably require a surgical revision a few years down the line.

Simplified internal fixation of fifth metacarpal neck fractures.

Fifth metacarpal neck fractures (boxer's fractures) are common injuries that contribute 20% of all hand fractures. Divergent percutaneous pinning (bouquet fixation) as described by Foucher has gained popularity but is challenging and at times arduous, as it requires the insertion of several slender K-wires into a narrow medullary canal. Here, we report on a simplified technique in which a single thick K-wire is inserted. An 18/10 K-wire is bent at one end then mounted on a drill chuck. The incision is performed and the entry hole created using the K-wire, which is then advanced along the medullary canal. After reduction of the metacarpal head using the Jahss manoeuvre, the K-wire is inserted across the fracture site into the subchondral bone. Any persistent rotational malalignment is corrected by rotating the metacarpal around the K-wire. Immobilisation is by buddy taping covered by a resin guard. We collected follow-up data for 30patients treated using our technique, at a mean age of 32years. 90 days after surgery, the fracture was healed in all patients. No patients had rotational malalignment. Mean operative time was 14minutes. No complications were recorded. The use of a single thick K-wire proved simple, effective, reproducible, and rapid. No rotational malalignment occurred. This technique is faster and easier to perform than divergent pinning with multiple K-wires. This technique can be used to treat fifth metacarpal neck fractures.

Study of clinical and functional outcome of fractures of long bones with locking compression plates

The study was done to observe the role of locking compression plate as a fixation device in the management of fracture of long bones. Locking compression plate is an economical, safe and sound fixation system for the treatment of fracture of any part of the long bones. It is the implant of choice in case of pathological fractures comminuted fracture periarticular fractures, periprosthetic fractures and very wide or very narrow medullary canal in fractured bone. LCP is an alternative choice of implants for conventional plating and intramedullary nailing. It takes minimal time and less blood loss when used as a MIPO technique. The fixation of the long bone fracture by LCP allowed rapid mobilization and early weight bearing and does not interfere with functional use of limb during treatment or healing of fracture. A total of 40 patients were included in this study, but only 35 patients was evaluated and followed up at 1 week, 3 weeks, 6 weeks, 9 weeks, 12 weeks and 24 weeks.

Developmental hip dysplasia treated by total hip arthroplasty using a cementless Wagner cone stem in young adult patients with a small physique

BackgroundDevelopmental hip dysplasia (DDH) may lead to severe acetabular and femoral abnormalities that can render total hip arthroplasty (THA) challenging, especially in DDH patients with a small physique. Most conventional cemented or cementless femoral components are often difficult to implant in the narrow femoral canal and require slight version correction during surgery. The aim of this study was to present the mid-term results of THA in the treatment of DDH patients with a small physique using a cementless Wagner cone prosthesis (Zimmer®, US).MethodsBetween January 2006 and March 2010, we retrospectively reviewed 50 patients who were treated at our center. A total of 50 patients (52 hips; 45 women, five men; mean age 32.5 years; range 27 to 38 years) who underwent THA were observed. The mean femoral medullary canal dimension at the isthmus was 7.6 mm (range 6.0 to 8.7). According to the Crowe classification, 19 hips presented dysplasia of grade I, while 33 presented dysplasia of grade II. All patients were treated with THA using a cementless Wagner cone prosthesis. Clinical and radiologic evaluations were performed on all patients.ResultsThe mean duration of follow-up was 7.7 years (range 5.4 to 10.5). The Harris hip score (HHS) improved from 63 ± 9 (range 55 to 70) pre-operatively to 92 ± 8 (range 88 to 100) at the last follow-up. The HHS at the most recent follow-up was excellent in 66% of patients (34 hips), good in 26% (14 hips), fair in 6% (3 hips), and poor in 2% (1 hip). Radiographic evaluation demonstrated excellent osteointegration of the implants. Stem subsidence was present in three stems, and the range of stem subsidence was 2 mm in two stems (3.9%) and 3 mm in one stem (1.9%). Femoral osteolysis was observed in nine hips (18%) in the proximal zones, and no distal osteolysis was noted. Heterotopic ossification was observed in three hips (5.8%); of these, two were classified as Brooker’s grade 1, and one was classified as Brooker’s grade 2 at the most recent follow-up. None of the implants were revised.ConclusionsBased on the tapered shape and free setting of anteversion, the Wagner cone femoral stem facilitates its implantation in dysplastic hips. Therefore, this series of short stems with a smaller diameter can ensure safe implantation in narrow medullary canals, especially in young DDH patients with a small physique.Trial registrationRegistration Number: ChiCTR-ORC-17011181.Reg Date: 2017-04-19 00:44:59Retrospective registration

Tibial Lengthening Using a Fixator-Assisted Lengthening Plate: A New Technique.

BackgroundThere are many techniques that are used for limb lengthening. Lengthening a limb over a plate is an alternative choice used in children or when using an intramedullary nail is difficult.ObjectivesIn this study, we presented a new technique for tibial lengthening using a monolateral external fixator over a lengthening plate.Materials and MethodsFor tibial lengthening, a monolateral external fixator was attached to the composite bone model medially. After a corticotomy was performed, the lengthening plate was placed laterally. Three locking screws were inserted proximally, and two cortical screws were inserted into a lengthening hole that was 1 cm below the osteotomy site. We avoided contact between the screws of the lengthening plate and the pins of the external fixator. During bone lengthening with the monolateral external fixator, the screws at the lengthening hole were able to slide distally with the distal segment of the tibia to allow for tibial elongation. Two locking screws were fixed at the distal locking holes of the plate when the bone elongation was complete. The external fixator was then removed.ResultsThe fixator-assisted lengthening plate allowed bone lengthening without malalignment. There were no mechanical problems associated with the external fixator during the lengthening process. Plate osteosynthesis was stable after the fixator was removed. There was no contact between the screws of plate and the Schanz pins of the external fixator under C-arm fluoroscopy.ConclusionsThe fixator-assisted lengthening plate technique helps to maintain the stability and alignment at both sides of an osteotomy during tibial elongation. It allows the early removal of the external fixator immediately after lengthening is completed. This technique can be applied in children with open physes and in patients with a narrow medullary canal who are unsuitable for limb lengthening over an intramedullary nail.

Femoral lengthening and deformity correction using the Fitbone motorized lengthening nail.

BackgroundThis study reports our results with retrograde Fitbone insertion in patients with femoral shortening and deformity. We also present our experience regarding the benefits, complications, and factors associated with complications of the Fitbone technique.MethodsTwelve males and ten females had femoral shortening and deformities treated using the retrograde Fitbone technique between 2009 and 2012. The etiologies were post-traumatic in 12 patients, poliomyelitis in four, cosmetic in two, congenital hypoplasia in two, achondroplasia in one, and Perthes sequela in one.ResultsThe follow-up time was 30.8 months. The mean lengthening was 5.8 (range 2–14) cm. The degree of acute angular correction was 9° (5–22°) in nine cases. The time to full weight-bearing was 5.9 months. The consolidation index was 1.07 (0.75–1.62) months/cm. Complete consolidation was obtained in all cases except two. Running back was observed in two cases.ConclusionsThe Fitbone technique allows accurate deformity correction. The rigid reamers allow the surgeon to use the Fitbone even in patients with a narrow medullary canal. As this might result in poor bone regeneration, thinner lengthening nails should be considered.

Morphometric analysis of septal aperture of humerus

Introduction: Lower end of humerus shows olecranon and coronoid fossae separated by a thin bony septum, sometimes it may deficient and shows foramen which communicates both the fossae called Septal aperture, which is commonly referred as supratrochlear foramen (STF). Materials & Methods: We have studied 260 humeri (126 right side and 134 left side), measurements were taken by using vernier caliper, translucency septum was observed by keeping the lower end of humerus against the x-ray lobby. Results: A clear cut STF was observed in 19.2% bones, translucency septum was observed in 99 (91.6%) humeri on the right side and 95 (93.1%) humeri on the left sides respectively (Table – 1). Clinical significance: The presence of STF is always associated with the narrow medullary canal at the lower end of humerus, Supracondylar fracture of humerus is most common in paediatric age group, medullary nailing is done to treat the fractures in those cases the knowledge about the STF is very important for treating the fractures. It has been observed in x-ray of lower end of the humerus the STF is comparatively radiolucent, it is commonly seen as a type of ‘pseudolesions’ in an x-ray of the lower end of humerus and it may mistake for an osteolytic or cystic lesions. Conclusion: The present study can add data into anthropology and anatomy text books regarding STF and it gives knowledge of understanding anatomical variation of distal end of the humerus, which is significant for anthropologists, orthopaedic surgeons and radiologists in habitual clinical practice.

Letter to the Editor: Mid-America Orthopaedic Association Physician in Training Award: Surgical Technique: Pediatric Supracondylar Humerus Fractures: A Technique to Aid Closed Reduction

To the Editor: We read the article by Herzog et al. [1] with great interest. We found the study interesting because the technique described by the authors is similar to our previously published article [2], referred by the authors in the Introduction and Discussion sections of their study. Although their “novel” technique is very similar to ours with the idea of controlling the external rotation, coronal tilt, and translation of the proximal fragment by using the “joystick” K-wire, there are some slight modifications in the technique, which we cannot clearly understand. First, we would like to comment on a point raised by the study authors regarding the location and direction of the Schanz pin. In our original paper, we placed a K-wire below the deltoid muscle insertion from lateral to medial direction. Our purpose in chosing this anatomical landmark was to expose the patient to the least risk of iatrogenic harm and minimal injury to muscular tissues. We think that a Schanz pin placed from posterior to anterior has the potential risk of damaging triceps muscle function, which should be avoided. Of course, a more distally placed joystick has the advantage of better control of the proximal fragment owing to the proximity of the pin to the fracture line, but in this age group there is no need to exert tremendous effort in controlling the fragment; we believe it is quite easy. The second point we would like to comment on is the size of the Schanz pin used in the paper by Herzog and colleagues. In Table 1 of their study, we can see that the average age of the patients was 6.1 years with a range of 1.1 to 12.1 years. In our original paper, the mean age of the patients was 6.7 years (range; 4 to 10 years). We used a K-wire at the appropriate size depending on the age of the patient — usually 3.0 mm for the older children and 2.0 mm for the younger children. The authors, however, used a percutaneously placed 2.5 mm Schanz pin in every age group. If we understand the work correctly, this means that they used a 2.5 mm Scahnz pin in a 1.1 year-old patient whose humerus most likely had a very narrow medullary canal. We wonder if they observed any iatrogenic humerus shaft fracture intra- or postoperatively; if not, it seems to us that using such a large pin would put a small humerus at risk for later fracture. We also would like to find out the number of patients younger than 2 years of age at the time of the study. After performing our original technique for nearly 20 years, we hardly ever needed to use the joystick technique in this age group. The authors stated that the study included 143 patients who were divided into two groups depending on whether treatment occurred before (Group 1, 90 fractures) or after (Group 2, 53 fractures) implementation of the Schanz pin technique (to aid in closed reduction). However, in the Results section, the authors stated that one fracture treated with open reduction in Group 2 did not undergo the Schanz pin method before conversion to open reduction. We wonder why this patient was included in the study? Even so, we think this Level-III research paper is an important contribution to the literature proving the reproducibility and safety of our Joystick method [2], which was published earlier as a case series. We therefore would like to thank the authors for their interest in our work.

Indications for treatment of femoral trochanteric fractures with reversed less invasive stabilization system (LISS)

Objective To discuss outcomes of and indications for treatment of femoral trochanteric fractures with reversed less invasive stabilization system (LISS).Methods A retrospective study was performed for 72 consecutive patients with femoral trochanteric fracture who had been treated with reversed LISS at our institution between June 2005 and June 2011.They were 33 men and 39 women,with a mean age of 73.4 years (range,45 to 87 years).The operation time,intraoperative blood loss,intra-hospital complications and internal fixation-related complications at the last follow-up were analyzed.The fracture union was assessed by follow-up radiographs and hip functional recovery by Harris hip scoring.Results The operation time averaged 141.4 minutes and the intraoperative blood loss averaged 138.1 mL.The intra-hospital complications included deep venous thrombosis in 3 cases,pneumonia in one,gastrointestinal bleeding in one,postoperative delirium in one,and a death resulting from multiple organ failure.Sixty-five patients (90.3％) obtained a mean follow-up of 22.1 months (range,18 to 46 months).The fracture union was achieved after an average of 4.2 months (range,3 to 8 months).The mean Harris score at the last follow-up was 73.7 points (range,20 to 100 points).Eight patients were excellent,19 good,25 fair and 13 poor,giving an excellent to good rate of 41.5％.The internal fixation-related complications at the last follow-up were observed in 10 out of the 65 patients (15.4％),including 6 cases of screw breakage,one of nonunion,one of plate breakage,one of screw loosening and one of malunion.Conclusions Reversed LISS should not be a routine treatment for femoral trochanteric fractures because of its high rate of complications.We recommend its indications include fractures more complex than AO type 31A2.2,those with a narrow medullary canal,those with a severely bowed or deformed femur,pathologic and periprosthetic ones and those with multiple traumas and a priority of immediate trauma control. Key words: Hip fractures; Fracture fixation, internal; Bone plates; Surgical procedures,minimally invasive; Indication

Aperture in coronoid-olecranon septum: A radiological evaluation

Background:The humerus bone with coronoid-olecranon septal aperture have very narrow medullary canal and extreme anterolateral bowing proximally and/or extreme anterolateral compressed surface at distal part. Septal perforation might make nailing through a retrograde technique more difficult or possibly with an increased risk of iatrogenic fracture at the site of insertion. Coronoid-olecranon perforation might be very important in preoperative planning for successful nailing. Since the data available has been obtained from the ancient studies using the skeletal material, the present study is aimed at investigating originally the presence of the coronoid-olecranon septum perforation in the living subjects, using a radiographic method.Materials and Methods:The study was performed on direct radiograms and computed tomography of the elbow obtained from the 709 volunteers (367 males, 342 females).Results:The incidence of the perforation was found to be 8.6 %. Bilateral occurrence was found to be more common significantly. The highest incidence occurred in second decade.Conclusion:The present study suggests female prepronounced and left asymmetry in case of septal perforation. Bilateral occurrence from our study might be peculiar to the clinician.