Rate Of Cut-out Research Articles

Short-term and long-term results of odontoid screw fixation in patients with Type II and rostral Type III dens fractures

ObjectivesTo evaluate both the short-term and long-term outcomes of odontoid screw fixation (OSF), identifying potential risk factors for implant-related complications in patients with odontoid fractures. MethodsThis is a retrospective observational cohort study. Inclusion criteria were as follows: 1) Type II fractures and rostral Type III fractures, according to the Anderson and D’Alonzo classification; 2) patients older than 15 years. Exclusion criteria were: 1) other Type III injuries; 2) osteoporosis confirmed by densitometry or a CT bone density score below 100 Hounsfield units; 3) odontoid fractures related to tumors or aneurysmal bone cysts. ResultsIn total, 56 patients were considered for the analysis of short-term results, and 26 patients were evaluated for long-term outcomes. No significant differences were observed in the preoperative imaging data and intraoperative features of OSF between patients with Type II and rostral Type III fractures. The mean operative duration was 63.9 ± 20.9 min, and the mean intraoperative blood loss was 22.1 ± 22.9 ml.Screw cut-out was identified in four patients with rostral Type III fractures (p = 0.04). The rate of screw cut-out was found to correlate with the degree of dens fragment displacement. The bone fusion rate was 95.7%. CT scans identified stable pseudarthrosis in two cases. We observed C2–C3 ankylosis in all cases following partial disc resection. One third of patients with screws placed through the anterior lip of C2 showed no C2–C3 ankylosis. A strong trend towards lateral joint ankylosis formation in patients with a median lateral mass dislocation of 11.9 mm was observed. Most SF-36 scores either matched or exceeded the corresponding normal median values in the published reference database. ConclusionsOSF is a reliable treatment method of Type II and rostral Type III odontoid fractures with fragment displacement of 4 mm or less. The minimally invasive OSF through the anterior-inferior lip of C2, using monocortical screw placement and cannulated instruments, without rigid intraoperative head immobilization, is sufficient to achieve favorable clinical and fusion results. This technique reduces the risk of ankylosis in the C2–C3 segment. OSF restore the quality of life for patients with odontoid fractures to levels comparable to those of the general population norm.

Short-term and long-term results of odontoid screw fixation in patients with Type II and rostral Type III dens fractures

ObjectivesTo evaluate both the short-term and long-term outcomes of odontoid screw fixation (OSF), identifying potential risk factors for implant-related complications in patients with odontoid fractures. MethodsThis is a retrospective observational cohort study. Inclusion criteria were as follows: 1) Type II fractures and rostral Type III fractures, according to the Anderson and D’Alonzo classification; 2) patients older than 15 years. Exclusion criteria were: 1) other Type III injuries; 2) osteoporosis confirmed by densitometry or a CT bone density score below 100 Hounsfield units; 3) odontoid fractures related to tumors or aneurysmal bone cysts. ResultsIn total, 56 patients were considered for the analysis of short-term results, and 26 patients were evaluated for long-term outcomes. No significant differences were observed in the preoperative imaging data and intraoperative features of OSF between patients with Type II and rostral Type III fractures. The mean operative duration was 63.9 ± 20.9 min, and the mean intraoperative blood loss was 22.1 ± 22.9 ml.Screw cut-out was identified in four patients with rostral Type III fractures (p = 0.04). The rate of screw cut-out was found to correlate with the degree of dens fragment displacement. The bone fusion rate was 95.7%. CT scans identified stable pseudarthrosis in two cases. We observed C2–C3 ankylosis in all cases following partial disc resection. One third of patients with screws placed through the anterior lip of C2 showed no C2–C3 ankylosis. A strong trend towards lateral joint ankylosis formation in patients with a median lateral mass dislocation of 11.9 mm was observed. Most SF-36 scores either matched or exceeded the corresponding normal median values in the published reference database. ConclusionsOSF is a reliable treatment method of Type II and rostral Type III odontoid fractures with fragment displacement of 4 mm or less. The minimally invasive OSF through the anterior-inferior lip of C2, using monocortical screw placement and cannulated instruments, without rigid intraoperative head immobilization, is sufficient to achieve favorable clinical and fusion results. This technique reduces the risk of ankylosis in the C2–C3 segment. OSF restore the quality of life for patients with odontoid fractures to levels comparable to those of the general population norm.

Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined with Percutaneous Reduction Techniques is Safe and Results in a Low Rate of Cut-out.

To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. Retrospective cohort study. Level-1 trauma center. Two-hundred twenty consecutive patients with intertrochanteric fractures. Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. Radiographic outcome including union, cut-out and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. Mechanical complications (nonunion, cut-out and varus collapse) occurred in 8.8% of patients at one year. Eleven of 13 patients that developed these complications had either sub-optimal implant placement (tip-to-apex distance > 25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, p=0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and one patient (0.7%) that did not have an accessory incision developed a postoperative infection. The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracturereduction and optimal implant placement and not hesitate to utilize an accessory incision to assist with fracture reduction. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictive value of the deltoid tuberosity index for assessing the risk of screw cut-out

Abstract Background Reconstruction of the proximal humerus with a locking plate is often the first surgical approach for proximal humerus fractures. Screw cut-out is a common complication and is relevant in osteoporotic bone of older adults. The Deltoid Tuberosity Index (DTI) is an indirect measure for assessing local bone quality and failure rate before surgery, providing important information for surgical planning. This was the first independent, large-sample retrospective analysis of the correlation between local bone density, indirectly measured through the DTI, and screw cut-out. Methods In total, 306 cases of proximal humerus fractures treated with the PHILOS plate (DePuy Synthes, Oberdorf, Switzerland) were retrospectively analyzed. The DTI was measured on anteroposterior x‑rays. The primary endpoint was screw cut-out defined as the intra-articular position of at least one screw associated with a reduction loss after surgery. Results The mean clinical follow-up was 935 days. The DTI varied from 1.10 to 2.28 (average: 1.45). Screw cut-out occurred on average in 8% of the cases and was positively correlated with a DTI of ≤ 1.44 (p = 0.003). However, the rate of cut-out and correlation with DTI varied widely according to age group: for ages 65–80 years, a DTI of ≤ 1.44 increased the cut-out rate from 0% to 17% (p = 0.02); in younger ages (< 65 years) the DTI did not correlate with cut-out and in the oldest group (> 80 years) cut-out rates were high (17–20%) independently of the DTI. Conclusion We confirm the correlation between a DTI of ≤ 1.44 and screw cut-out. High-risk groups for screw cut-out are patients over 65 years with a DTI of ≤ 1.44 or any patient older than 80 years. Applying the DTI in the age group of 65–80 years offers relevant information for surgical planning in the trauma setting via a fast, cheap, and easy-to-use tool. Level of Evidence: Level 3, Retrospective Cohort Study.

Use of the Heracles straight blade in the treatment of intertrochanteric hip fractures: a prospective study with a 1-year follow-up.

The treatment of intertrochanteric fractures in the elderly remains challenging for orthopedic surgeons, due to aging, comorbidities, and poor bone quality. The Heracles straight blade has proven a lower rate of cut-out and femoral head displacement in biomechanical studies; however, there are currently no published clinical studies using this nail. To analyze the clinical and radiological results of the Heracles nail with the straight cephalic Heracles blade as a device to treat osteoporotic intertrochanteric fractures of the proximal femur. A total of 136 patients with trochanteric hip fractures were operated on by the same surgeon, using the Heracles nail with a straight cephalic blade. However, only 86 patients completed the 1-year follow-up both clinically and radiologically. According to the Association of Osteosynthesis classification, 38 patients (44.1%) had 31-A1, 36 patients (41.6%) had 31-A2, and 12 patients (14.1%) had 31-A3. Functional outcomes were assessed according to the Katz and Barthel scores, finding that 58% of patients recovered their original functional level, According to Barthel score, a mean loss of 11.8 points was found. The mean hospital stay was 8.22 days (mean preoperative stay of 2.71 days). The mean tip-apex distance was 15.2 mm. During the follow-up, 6 complications (6.96%) were detected: 4 cut-out, 1 cut-in, and 1 nail breakage. According to the Katz score, 58% of the patients recovered their previous functional status and 20.58% needed an additional walking aid. The mean loss in the Barthel score was 11.8 points. The Heracles nail using a cephalic straight blade has proven to be a valid treatment of trochanteric fractures, due to the functional recovery of the patients and low level of complications.

Blade Augmentation in Nailing Proximal Femur Fractures-An Advantage despite Higher Costs?

Proximal femoral fractures occur with increasing incidence, especially in the elderly. Commonly used implants for surgical treatment are cephalomedullary nails. To increase stability, a perforated femoral neck blade can be augmented with cement. The study investigated whether this results in a relevant clinical advantage and justifies the higher cost. This is a single-center retrospective study of 620 patients with proximal femur fractures treated with cephalomedullary nailing. Between January 2016 and December 2020, 207 male and 413 female patients were surgically treated with a proximal femur nail (DePuy Synthes) using a perforated blade and cement augmentation in cases with severe osteoporosis. Primary outcome measures were the rate of cut-out, tip apex distance and the positioning of the blade in the femoral head. Secondary outcome measures were the implant costs and operating times. Of the 620 femoral neck blades, 299 were augmented with cement. A total of six cut-outs were seen in the first 3 months after the operation. There were three in the cement-augmented group (CAB = cement-augmented blade) and three in the conventional group (NCAB = non-cement-augmented blade). There was a significant positive correlation between age and augmentation, with a mean difference of 11 years between the two groups (CAB 85.7 ± 7.9 vs. NCAB 75.3 ± 15.1; p < 0.05). There was no difference in the tip-apex distance (CAB 15.97 vs. 15.69; p = 0.64) or rate of optimal blade positions between the groups (CAB 81.6% vs. NCAB 83.2%; p = 0.341). Operation times were significantly longer in the cemented group (CAB 62.6 21.2 min vs. NCAB 54.1 7.7 min; p < 0.05), and the implant cost nearly doubled due to augmentation. When the principles of anatomic fracture reduction, optimal tip-apex distance and optimal blade position are combined with cement augmentation in cases of severe osteoporosis, a cut-out rate of less than 1% can be achieved. Nevertheless, it should be noted that augmentation remains expensive and prolongs surgery time without definite proof of mechanical superiority.

Eccentric distance zone analysis system: New regional evaluation of cephalic fixator tip location for predicting cut-out in geriatric intertrochanteric fractures with internal fixation.

The aim of this study was to investigate an eccentric distance (ED) zone analysis system for regional evaluation of the cephalic fixator tip based on the ED of the cephalic fixator tip referenced to the radius of its own femoral head to predict cut-out in intertrochanteric fractures (ITF) with internal fixation. First, we assumed all the femoral heads were regular spheres with the radius (R FD) of "3" for a complete match of the Cleveland zone system and calculated the ED of the cephalic fixator tip by measuring the distances from the cephalic fixator tip to the geometric central axis in the femoral neck and head on both anteroposterior (AP) view and lateral view radiographs. Second, we defined the maximum transverse section of the femoral head into three zones named ED Zone A with ED less than "1," Zone B with ED ranging in "1-2," and Zone C with ED ranging in "2-3" in turns by concentric circles (circles A, B, and C) with the radius of 1/3, 2/3, and 3/3 times of R FD, respectively. Third, we evaluated the ED zones according to the ED and location of the cephalic fixator tip in the eligible 123 ITF patients with single-screw cephalomedullary nail (SCMN) fixation and then analyzed the correlation between the cut-out rate and the ED zones. The cut-out rates in ED Zones A, B, and C were 4.17%, 38.46%, and 100%, respectively. Multivariate logistic regression indicated that ED Zone A had at least a 14 times lower rate of cut-out compared with ED Zone B. The cephalic fixator tip located in ED Zone A has a lower cut-out rate than that in Cleveland Zone 5. The cut-out rate in ED Zone A is significantly lower than that in the region inside Cleveland Zone 5 but outside ED Zone A. ED zone analysis system is a reliable regional evaluation of the cephalic fixator tip position for predicting cut-out in geriatric ITF patients with SCMN fixations and potentially an artificial intelligence measurement during surgery. For decreasing the cut-out rate, the cephalic fixator tip should be located in ED Zone A.

Clinical evaluation of suture materials for transtibial pullout repair of medial meniscus posterior root tear

BackgroundThere are no recommendations for specific suture materials in transtibial pullout repair of medial meniscus posterior root tears. This study aimed to evaluate the clinical outcomes of transtibial pullout repair of medial meniscus posterior root tears using ultrahigh-molecular-weight polyethylene sutures and suture tape.MethodsWe retrospectively reviewed the data of 36 patients (27 women and 9 men, mean age 64.1 years) who had undergone transtibial pullout repair of medial meniscus posterior root tears between November 2018 and December 2019. Two groups of 18 patients each received either two different cord-like sutures or suture tape. Clinical parameters were assessed preoperatively and on second-look arthroscopy (mean postoperative period 12 months). The meniscal healing status was assessed using a previously published scoring system (ranging from 0 to 10), and the incidence rate of suture cut-out was assessed on second-look arthroscopy.ResultsAll clinical scores significantly improved in both groups, with no significant between-group differences on second-look arthroscopy. The arthroscopic meniscal healing scores significantly differed between sutures (mean 6.7 points) and suture tape (mean 7.4 points; p = 0.044). No significant between-group difference in the suture cut-out rate was observed.ConclusionsThis study found no significant differences in the clinical outcomes between ultrahigh-molecular-weight polyethylene sutures and suture tape. Favorable clinical outcomes were obtained using both types of suture; however, the usefulness of suture tape appears to be limited.

Risk Factor of Proximal Lag Screw Cut-Out After Cephalomedullary Nail Fixation in Trochanteric Femoral Fractures: A Retrospective Analytic Study

Objective: A cephalomedullary nail is the treatment of choice for trochanteric fractures; however, a lag screw cutout is one of the most devastating complications. The lag screw cut-out rate was reported to be around 2.5%–8.3%. This study aimed to evaluate the prevalence of lag screw cut-outs and identify the associated risk factors.Materials and Methods: A retrospective review of 267 trochanteric fracture patients treated with cephalomedullary nail fixation from January 2007 to December 2017 was conducted. The demographic variables were documented, comprising age, gender, fracture pattern, and AO/OTA classification. Immediate postoperative radiographs were assessed for quality of reduction and implant position. Lag screw cut-outs or radiographic union were determined using the final follow-up radiograph. Prognostic factors associated with lag screw cut-out were determined using univariate and multivariate logistic regression analyses.Results: Of the 175 patients, 154 were successfully treated, and 21 had a lag screw cut-out. There were no significant differences in mean ages or genders of the union and cut-out groups. No lag screw cut-outs were observed in patients with AO/OTA 31-A1. Patients with AO/OTA 31-B2.1 had a higher rate of screw cut-out (OR 10.5, [3.22, 34.25] p &lt; .001). The disintegration of basicervical fragments was significantly associated with lag screw cut-out (OR 5.51, [2.01, 15.12] p = .001). The highest cut-out rate was found in the superoanterior and superoposterior positions of the lag screw. However, the screw position did not reach the significance level in a multivariate analysis (p = .094).Conclusion: The prevalence of lag screw cut-out after cephalomedullary nail fixation for trochanteric fractures was 12%. A simple, two-part, basicervical trochanteric fracture hads a significantly higher risk of lag screw cut-out.

THE COMPARISON OF FIXATION AND CUT-OUT OF PROXIMAL INTRAMEDULLARY NAIL AND DYNAMIC HIP SCREW THERAPY IN THE TREATMENT OF STABLE INTERTROCHANTERIC FRACTURES OF THE FEMUR: A RETROSPECTIVE STUDY

Introduction: Intertrochanteric fractures, among the osteoporotic fractures, have higher mortality and important complications, and are more prevalent among the elderly. There are several methods for fixing these fractures that have different advantages and disadvantages. The purpose of this study was to compare the proximal intramedullary nail (PIN) and dynamic hip screw (DHS) treatments. Material and Methods: This retrospective study, investigated the cases of 300 between 2015 and 2018 patients who complained of intertrochanteric fracture were referred to Kowsar Medical Center clinic of Semnan, Iran or admitted to orthopedic section of this center have been treated either PIN or DHS method. Patients were divided into two groups of 150 and after examining the age and sex of the patients, the rate of cut-out and fixation was compared between the two groups. Results: The mean age of the patients was 640.8 years in the PIN group and 631.1 years in the DHS group, respectively. The rate of cut-out and implant fixation in this study were 2% and 98% in patients treated with PIN and 6.66% and 93.4% in patients treated with DHS, respectively. As well as in terms of gender in implant cut-out in PIN and DHS group 66.66% and 70% of them were women, 33.33% and 30% men, respectively. Conclusion: According to the results of this study, proximal intramedullary nail treatment in comparison to dynamic hip screw treatment, in the treatment of intertrochanteric fractures, has more fixation and less cut-out.

Which implant is better for beginners to learn to treat geriatric intertrochanteric femur fractures: A randomised controlled trial of surgeons, metalwork, and patients

BackgroundWe wondered whether the third-generation gamma nail-3 (GN-3) was better for junior surgeons to learn to treat geriatric intertrochanteric femur fractures than proximal femoral nail antirotation-II (PFNA-II). MethodsThis is a prospective randomised study of 350 patients who underwent GN-3 fixation and PFNA-II carried out by junior orthopaedic trauma surgeons from January 2011 February 2017. We compared nail positioning, complication rates, operative and fluoroscopy time, blood transfused, time to mobilisation, hospital stay, fracture union, mismatch, mortality and postoperative outcomes. The minimum follow-up was 12 months (mean, 27.2 months; range, 12–42 months). ResultsThe recovery rate of the GN-3 group was higher than that of the PFNA-II group significantly. Compared with the PFNA-II group, the GN-3 group was superior in fracture gap, while operative time, fluoroscopy time, blood transfused, time to mobilisation, hospital stay, Harris Hip Score, reoperation, mortality and so on had no significant difference between two groups. There were five cases with cutout through the femoral neck in the GN-3 group, whereas in the PFNA-II group, we only had two cases with significant difference. The area of match in the GN-3 group conformed to that of the femur of Asian population better than that in the PFNA-II group. ConclusionsPFNA-II and GN-3 internal fixation are both effective methods for junior orthopaedic trauma surgeons to treat femoral intertrochanteric fracture. But our study reveals better results of the GN-3 group over the PFNA-II group on recovery rate. There is a high rate of cutout in patients treated with the GN-3, especially for those with bone defect or serious osteoporosis. The translational potential of this articleThe results of this work have the potential to improve the cognition of geriatric intertrochanteric femur fractures for junior surgeons, supplying the theoretical basis for the selection and comparison of Intramedullary nail. Such a guidance will allow better healing, fewer complications, and ultimately improved outcomes.

PFNA and DHS for AO/OTA 31-A2 fractures: radiographic measurements, morbidity and mortality.

For this retrospective cohort study, we assessed pertrochanteric fracture types AO/OTA 31-A2. PFNA and DHS were the devices used. We determined both devices in relation to peri-operative variables, postoperative radiographic measurements, implant-related complications and mortality up to 2years. The null hypothesis was no effect between the two devices. This single-centre study was conducted based on our computerized data. The treatment period ranged from 2006 to 2015. Only patients with type AO/OTA 31-A2 fractures and an age ≥ 65years were included. Apart from descriptive variables, the following measurements were assessed: (1) duration of surgery, (2) blood loss, (3) transfusion, (4) hospitalization, (5) tip-apex distance (TAD), (6) fracture reduction, (7) screw position, (8) implant-related complications, and (9) mortality. The follow-up was 2years for each living patient. Missing data were evaluated by telephone call. A total of 375 consecutive patients were enrolled into three groups: (1) 75 patients treated with DHS and antirotation screw (ARS); (2); 100 patients treated with DHS + ARS + TSP (trochanteric stabilization plate); and (3) 200 patients treated with PFNA. Apart from dementia, the descriptive data (e.g., age and BMI) demonstrated no effects between the three groups. Compared to PFNA, DHS with or without TSP was adversely affected by a longer operation time, higher blood loss, increase in transfusion, and more implant-related complications including cut-out, infection and failure. The rate of cut-out was significantly higher in TAD ≥ 25mm (p = 0.005), and PFNA demonstrated significantly better TAD measurements (p = 0.001), better fracture reduction (0.002), more central-central screw positions (p = 0.014), and less poor screw placement (p = 0.001). The mortality rate was without effect between the three groups (log rank 0.698). DHS with or without TSP was associated with significantly higher rates of implant-related complications based on inferior radiographic measurements. Therefore, we only recommend PFNA for the treatment of proximal type AO/OTA 31-A2 femoral fractures. Therapeutic level III.

The rebar repair for radial meniscus tears: a biomechanical comparison of a reinforced suture repair versus parallel and cross-stitch techniques

BackgroundRadial meniscus tears can cause the meniscus to be completely incompetent. This serious type of meniscus tear can be difficult to repair. Techniques have been developed that juxtapose the meniscus tear edges and are able to withstand high loads. The purpose of this study was to determine the load to failure of a reinforced suture bar repair (Rebar Repair) for radial meniscus tear and compare it to the parallel suture technique and cross-stitch technique and to compare mode of failure among all three groups. The hypothesis was that the Rebar Repair will have a higher load to failure than both the parallel technique and the cross-stitch technique and that the Rebar Repair would have a lower rate of suture cutting through the meniscus.MethodsForty-eight menisci were tested from 24 human knee specimens, with 16 menisci in each group evenly distributed between medial and lateral menisci. Radial mid body meniscal tears were recreated and repaired with one of three inside-out techniques: the 2-parallel suture technique, 2 cross-stitch sutures, and the Rebar Repair. The specimens were cycled between 5 N to 30 N and axially loaded to failure perpendicularly across the repair site.ResultsThe average load to failure of the parallel group, cross-stitch group and Rebar Repair was 85.5 N ± 22.0, 76.2 N ± 28.8 and 124.1 N ± 27.1 respectively. The Rebar Repair had a higher load to failure than the parallel group (p < 0.01) and cross-stitch group (p < 0.01). There was no difference in the load to failure between the cross-stitch and parallel group (p = 0.49). The failure mechanism was different when comparing the 3 groups (p < 0.01). The predominant mode of failure for both the parallel and cross-stitch group was suture cutout through the meniscus (88% and 94% respectively). The Rebar Repair failed due to suture rupture in 50% and suture cutout through the meniscus in 50%.ConclusionThe Rebar Repair for radial meniscus tear has a higher load to failure and a lower rate of suture cutout through the meniscus than the parallel technique and cross-stitch technique.Clinical relevanceRadial meniscus tears lead to decreased hoop stresses of the meniscus and effectively a non-functional meniscus. Newer techniques may have a higher load to failure leading to more successful repairs.

What’s New in Orthopaedic Trauma

What’s New in Orthopaedic Trauma

Epithelial tissue cut-out following needle insertion into a joint: a potential complication during arthroscopy.

Knee arthroscopy is a common orthopaedic procedure and often involves insertion of a needle through skin into a joint. This needle insertion can create epithelial tissue cut-outs possibly containing commensal bacteria that can be flushed into the joint, and potentially lead to post-arthroscopy septic arthritis. This study aims to assess the frequency of epithelial tissue cut-out creation on insertion of different needle sizes at different angles to the skin. Using an ex-vivo porcine limb tissue model, needles of various gauge (14-23G) were inserted at angles of 90, 60, 45 and 30° to the skin surface. Ten passes were undertaken at each angle. Needle lumen contents were then examined for solid tissue cut-out. Two hundred and eighty needle passes were performed resulting in 70 tissue cut-outs (25%) containing solid material. This was more common amongst lower gauge needles. 8 of the 70 (11.4%) tissue cut-outs contained macroscopic evidence of epithelium. The overall rate of epithelial tissue cut-out was 2.9%. The 23G needle had the lowest rate of tissue cut-out creation, occurring twice out of 40 passes (P = 0.002). Neither of these contained macroscopic epithelial tissue. Hypodermic needle insertion through skin into a joint can create epithelial tissue cut-out. Epithelial tissue cut-out occurs more frequently with use of lower gauge needles. This study suggests use of a 23G needle during arthroscopy, inserted either at 60 or 90° to the skin, to reduce epithelial tissue cut-out and any potential contribution to post-arthroscopy septic arthritis.

Implant cut-out following cephalomedullary nailing of intertrochanteric femur fractures: Are helical blades to blame?

IntroductionImplant cut-out remains a common cause of cephalomedullary nail (CMN) failure and patient morbidity following surgical treatment of intertrochanteric femur fractures. Recent studies have suggested an increased rate of CMN cut-out with helical blades as opposed to lag screws. We compared rates of overall cut-out between helical blades and lag screws and used bivariate and multivariate analysis to determine the role of proximal fixation method among other variables on risk for cut-out. Subgroup analysis was performed on the basis of failure mechanism; superior migration (Fig. 2) versus medial perforation (Fig. 3). MethodsThree-hundred and thirteen patient charts were retrospectively reviewed over an 8-year period; 245 patients were treated with helical blades and 68 with lag screws. Radiographs were reviewed for fracture pattern, Tip-Apex Distance (TAD), Parker’s Ratio (PR) and reduction quality. Rate of implant cut-out was compared between groups and multiple logistic regression was used to analyze the ability of several independent variables to predict implant cut-out. ResultsTwenty cut-outs occurred; 15 with helical blades and 5 with lag screws. No difference in the rate of cut-out was observed between the two groups (p = 0.45). Poor fracture reduction was found to be a significant predictor of implant failure via bivariate and multiple logistic regression analysis (p = <0.01, OR 23.573). Helical blade fixation, fracture instability, TAD ≥ 25, and PR ≥ 0.45 were not predictive of implant cut-out during multivariate analysis. Similarly, patient smoking status and surgeon trauma fellowship training did not significantly increase the odds of implant cut-out. Failure by medial perforation occurred in 12 instances, all involving helical blades. Failure by superior migration occurred at a significantly higher rate with lag screws than helical blades (p = 0.02). ConclusionCMN cutout is likely multifactorial. A direct association between helical blade fixation and implant cut-out was not observed in our study. Amongst modifiable risk factors for implant failure, poorer fracture reduction was predictive of failure by cut-out. Subgroup analysis highlights differing modes of failure between lag screws and helical blades which warrants further investigation. Ideal TAD during helical blade fixation remains unknown.

Interest of navigation for the treatment of pertrochanteric fractures with the Gamma 3 nail

Introduction Per trochanteric fractures are frequent among the geriatric population and their number is increasing. Intra-medullary nailing of these fractures is a safe and reliable procedure, the main postoperative complication being the cut-out of the cervical screw through the femoral head estimated around 2% in previous studies. Baumgartner et al. previously demonstrated the relation between the odds of a cut-out and a Tip-Apex distance superior to 25 mm. The aim of our study was to evaluate the use of a navigation system (Adapt System, Stryker) in improving the TAD and subsequently reducing the rate of postoperative cut-out. Material and methods From May 2015 to April 2016, we included all the adult patients with a per trochanteric fracture who accepted to participate in this randomized, monocentric, prospective study. People were allocated in the conventional or “navigation” group with the help of dedicated software. The first group was operated with a standard fluoroscopy and the second one with the Stryker Adapt System, also known as the FluoroMap, allowing a 3D reconstruction of the proximal femur from the standard 2D images of the fluoroscopy. Patients were operated either by senior residents or head surgeons. The post-operative TAD was measured on the first radiographs, before patient's discharge. At 6 weeks, 3, 6 and 12 months and the TAD was measured independently by 2 different examiners on digital AP and axial radiographs. Results Fourteen men and 61 women were included in the study and randomized in one of the two study groups. The groups were similar in age (83.4 vs. 85.9 y.o), sex (82 vs. 80% of women) and death ratio (15 vs 14.3%) and the TAD was measured at each endpoint on digital radiographs independently by two examiners. A significant difference was observed in favor of the FluoroMap group with a mean TAD of 16.75 mm (95% CI: 15,33–18.17) versus 20,75 mm (95% CI: 19.36–22.15) in the standard group. Two cut-outs were observed in the standard group versus none with the FluoroMap but this was not statistically significant. Discussion As it was previously demonstrated in a cadaveric study, the FluoroMap helps surgeons to reduce the intra-operative TAD by offering better tri-dimensional visualization of the femoral head surface. Conclusion The use of the FluoroMap seems to help surgeons in achieving the best cervical screw placement.

Evaluation of Partial Cut-out of Sacroiliac Screws From the Sacral Ala Slope via Pelvic Inlet and Outlet View.

An anatomic and radiographic study of placement of sacroiliac screws. The aim of this study was to quantitatively assess the risk of partial cut-out of sacroiliac screws from the sacral ala slope via inlet and outlet view. The partial cut-out of sacroiliac screws from the superior surface of sacral ala can jeopardize the L5 nerve root, which is difficult to identify on the pelvic inlet and outlet views. Computed tomography images of 60 patients without pelvic ring deformity or injury were used to measure the width (on inlet view) and height (on outlet view) of the sacral ala. The angle of the sacral ala slope was measured on lateral view. According to the measured parameters, the theoretical safe trajectories of screw placement were calculated using inverse trigonometric functions. Under fluoroscopic guidance, a sacroiliac screw was placed close to the midline on both inlet and outlet views, including posterosuperior, posteroinferior, anterosuperior, and anteroinferior regions to the midline. The incidence of screw partial cut-out from the superior surface of sacral ala was identified. The measured widths and heights of the sacral alas were 28.1 ± 2.8 and 29.8 ± 3.1 mm, respectively. The average angle between the superior aspect of the S1 vertebral body and the superior aspect of the sacral ala was 37.2 ± 2.5 degrees. The rate of partial cut-out of the screws from the superior surface of sacral ala slope was 12.5% (5/40) in posterosuperior, 0% (0/40) in posteroinferior, 70% (28/40) in anterosuperior, and 20% (8/40) in anteroinferior. To avoid the risk of partial cut-out from sacroiliac screw placement, more precise description should be added to the conventional description: the sacroiliac screws should be placed at the inferior half portion on outlet view and at the posterior half portion on inlet view. 4.

Accuracy of the surgeon's eye: Use of the tip–apex distance in clinical practice

Tip–apex distance is a well described method for assessment of screw placement in dynamic hip screw fixation of proximal femoral fracture. A distance of <25mm is associated with a significantly lower rate of cut out of the fixation device. Measurement is frequently performed retrospectively, although there has been no demonstration as to what accuracy the surgeon has of estimating tip–apex distance from image intensifier images, whilst scrubbed in theatre.Thirty-one clinicians working within orthopaedic departments were tested in their ability to identify adequacy of tip–apex distance on a series of image intensifier images. Level of seniority, awareness of the concept of tip–apex distance and use of the concept in clinical practice were each assessed.The accuracy in identifying the correct TAD was 82.5% in consultants, 83.8% in registrars and 71.1% in Senior house officers (SHO). The method was used in clinical practice by 50% of consultants, 89% of registrars and none of the SHOs.

Accuracy of the lesser trochanter for guiding lag screw insertion in hip fracture management.

The goal of this study was to evaluate the accuracy of the lesser trochanter for entry of lag screw placement in the fixation of hip fractures. Radiographs of the pelvis with both hips in 50 Chinese patients were analyzed to determine the accuracy of using the lesser trochanter as a reference landmark for inserting lag screws. The femoral neck was divided into 4 parts, and the second distal part was classified as the safe zone. Cobb angles of 125° and 130° were used as representative lag screw insertion angles, referencing the lateral cortex of the lesser trochanter for measurement, and insertion tracks were drawn on the neck of the femur. The accuracy of lag screw placement in the defined safe zone was evaluated. Accuracy of placement in the safe zone for entry points at the superior tip, apex, and inferior tip of the lesser trochanter were 78%, 39%, and 0%, respectively, for the 125° Cobb angle. Rates for the superior tip, apex, and inferior tip of the lesser trochanter were 31%, 74%, and 6%, respectively, for the 130° Cobb angle. The entry point at the level of the inferior tip of the lesser trochanter had incidence rates of 95% and 71% for cutout for 125° and 130° screws, respectively. The authors found that the superior tip of the lesser trochanter was a good reference point for 125° lag screw insertion and that the apex of the lesser trochanter was a good reference point for 130° lag screw insertion. Entry at the level of the inferior tip of the lesser trochanter has a very high rate of cutout and should be avoided.