Screw Cut-out Research Articles

Factors affecting the functional outcome and implant failure of proximal femoral nail (PFN) for treatment of intertrochanteric fractures

Background: Various implants have been developed to stabilize intertrochanteric fractures from the earlier days. Recent techniques of closed reduction and internal fixation by intramedullary device are more popular and have given favorable results, as these devices are bio-mechanically more stable, cause less trauma to the soft tissues and also preserve the fracture hematoma. This study was conducted to know the functional outcome, technical complications, and factors predicting the failure of the implant by treating intertrochanteric fractures by proximal femoral nailing (PFN). Methods: From October 2017 to December 2019 we treated 60 patients with stable and unstable intertrochanteric fractures with PFN. Mean age of the study population was 64.10 years. Those who had bilateral hip fractures, patients with pathological fractures, who underwent previous hip surgery for the same or opposite side are excluded from the study. Results: 81.7% patients had excellent and good outcome and 18.3% patients had fair and poor outcome at the end of 1-year follow-up. Fair and poor results were observed in patients who belonged to higher age group (p=0.001), associated with co-morbid conditions (p=0.01) and who had complications.4 patients developed complications related to the implant (3 –proximal screw cut-out and 1 z-effect). Complications were observed in patients in whom fractures were fixed with high values of tip apex distance (TAD), calcar referenced tip apex distance (CalTAD), Parker’s ratio index (p

Proximal humeral fractures treated with an intramedullary cage and plate: clinical and radiographic outcomes at a minimum of 1 year postoperatively

Proximal humeral fractures are common injuries. Although certain fracture types may benefit from surgery including open reduction-internal fixation (ORIF), the optimal method for fixation is unclear. Newer implant designs that improve healing by minimizing hardware failure and recurrent fracture displacement may optimize clinical outcomes. Over a 27-month period, 37 consecutive patients with proximal humeral fractures were treated by a single surgeon with a lateral humeral plate through which an intramedullary nitinol cage was inserted. Additional screws were placed through the tuberosities and cage as required. Fractures were classified by both the Neer classification and angulation or displacement in the coronal plane. At most recent follow-up, radiographic results, patient-reported outcome measurements, range of motion, complications, and reoperations were recorded. Thirty-one patients had a minimum of 1 year of clinical and radiographic follow-up. The average follow-up period was 91 weeks. By use of the Neer classification, there were 4 two-part, 21 three-part, and 6 four-part fractures. Twenty-one fractures were displaced in valgus and 10 in varus. Outcome measurements at most recent follow-up demonstrated an average American Shoulder and Elbow Surgeons score of 68; Single Assessment Numeric Evaluation score of 70; Quick Disabilities of the Arm, Shoulder and Hand score of 27; Veterans RAND-12 Physical Component Score of 37 and Mental Component Score of 51; Constant score of 55; Patient-Reported Outcomes Measurement Information System score of 29; and Oxford Shoulder Score of 23. Average active range of motion showed forward elevation of 134°, abduction of 91°, external rotation with the arm at the side of 30° (range, -10° to 60°), and internal rotation with the arm at the side to L1 (range, T6-S4). There were 11 complications (35%), including 2 cases of axillary nerve neurapraxia that resolved and 4 cases of avascular necrosis (13%). Unplanned reoperations were performed in 6 patients (19%). One patient underwent revision for loose hardware removal, 1 patient underwent revision ORIF after a fall, and 4 patients required component removal and revision to shoulder arthroplasty. No screw cutout or varus head collapse occurred. The management of proximal humeral fractures remains challenging. Our results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. At 1 year of follow-up, there were low rates of recurrent fracture displacement and screw cutout. There was a higher-than-expected rate of avascular necrosis as compared with other studies using a similar fixation construct. Larger studies and longer follow-up may demonstrate decreased rates of revision surgery and superior outcomes. Additional studies may determine whether this fixation method is superior to others for proximal humeral fractures.

LONG VERSUS SHORT PROXIMAL FEMORAL NAIL IN THE MANAGEMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES IN ELDERLY POPULATION

INTRODUCTION: Intertrochanteric fractures constitute a vast majority of geriatric orthopedic trauma having highest postoperative morbidity and mortality of surgically treated fractures. Use of cephalomedullary nails for treatment of highly unstable intertrochanteric fractures is now more common as plate xation is associated with higher risk of implant breakage and screw cutout. However, choice of length of these nails remains surgeon dependent. AIM: to compare the functional outcome and complications associated with the use of Long and Short PFN for the treatment of unstable intertrochanteric fractures (AO/OTAtype 31A1 and 31A2) in elderly population. METHOD: A prospective interventional study comprising of 58 patients distributed in two groups in which one group (n=25) was treated with long PFN while other group (n=33) was operated with short PFN. Parameters compared between these two groups included demographic data, intraoperative blood loss and surgical duration as well as analysis of radiological and clinical progression of union and postoperative complications in the form of hip pain, anterior thigh pain and failure rate. Functional assessment was done using Harris hip score. RESULT:This study included only AO/OTAtype 31A1 and 31A2 fracture types in elderly patients above 60 years of age. We found no statistically signicant difference with regard to age, sex as well as fracture type among two groups. Long PFN group had a shorter union time (11.4 weeks) and was associated with lesser postoperative complication and failure rate as compared to short PFN. Also, functional outcome evaluated using Harris hip score shown better scores in long PFN group. However, intraoperative blood loss and surgical duration was found to be signicantly lesser in short PFN group. CONCLUSION: use of cephalomedullary nails either short or long for xation of unstable intertrochanteric fractures particularly AO/OTA type 31A1 and 31A2 provides good results. However, longer nails should be preferred over short nails as these are associated with less postoperative complication such as hip pain or anterior thigh pain owing to excessive curvature of femur in Indian population with lesser union time and better functional outcome as compared to short PFN. Shorter nails may be used in cases of sick and polytrauma patients where shorter operative time with minimal blood loss is desirable

Gamma 3 Long Nail for Complex Sub-Trochanteric Fractures: A Ten-Year Retrospective Study

Cephalomedullary nailing is considered the treatment of choice for trochanteric and subtrochanteric femoral fractures. The aim of this study was to report postoperative outcomes of one of the widely used trochanteric nail device, the Gamma 3 long nail. We retrospectively assessed 405 patients treated with Gamma 3 long nail in a single Level One Trauma Centre between 2010 and 2018. We finally included 261 ambulant patients with 65 years or older, a lowenergy trauma and a closed trochanteric or subtrochanteric femoral fracture. Clinical outcomes were evaluated using the Hip Fracture Functional Recovery Score (FRS), while radiological complications and failures were assessed on postoperative x-rays. More than two-thirds of patients had completed fracture consolidation within 4 months after surgery. Immediate full weight bearing was allowed postoperatively in 64.0% of patients. We reported a mortality of 24.5% at one year postoperatively. The leading clinical postoperative complication was anemia (69.3%), followed by deep venous thrombosis (7.7%). Coxa vara was observed in 73 patients (28%), followed by malreduction in flexion-external rotation of the proximal femoral fragment (26.8%). No case of lag screw cutout was reported. Our study indicated that last generation of Long Gamma nail is a reliable implant for trochanteric and subtrochanteric femoral fractures in the elderly patients, leading to high rate of bone union and reduced incidence of related complications. An excellent fracture reduction and prevention of postoperative varus malalignment are the main factors that can avoid the major postoperative complications and failures after Gamma 3 long nailing.

No difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis.

Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur fractures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fellowship training. A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers (January 1st, 1985-May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria. Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were included and graded by MINOR and Newcastle-Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI). There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR: 1.03; 95% CI: 0.25-4.23). Pooled data analysis revealed TAD > 25mm (n = 310) was associated with higher odds of increased cut-out rate relative to TAD < 25mm (n = 730) (OR: 3.72; 95% CI: 2.06-6.72). Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25mm is a reliable predictor of implant cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out. Level III.

Conversion total hip arthroplasty for early failure following unstable intertrochanteric hip fracture: what can patients expect?

To report surgical outcomes in patients treated with conversion total hip arthroplasty (CTHA) for early failure of cephalomedullary nails (CMNs). A retrospective review was conducted of CTHA for treatment of failed CMN within 1year of initial surgery for intertrochanteric (IT) hip fractures. The cohort was matched 1:5 to patients who underwent elective primary THA (PTHA). Patient demographics, mechanism of CMN failure, surgical outcomes, and complication rates were assessed. 22 patients met criteria with a mean time to failure of 145days. Modes of failure included: lag screw cut-out with superior migration (9, 40.9%), or medialization (8, 36.4%), and aseptic nonunion with implant failure (2, 9.0%) and without implant failure (3, 13.6%). Fourteen of the patients (63.6%) had acetabular-sided damage secondary to lag screw penetration, all in the screw cut-out groups. Patient demographics were similar between cohorts. Compared to PTHA, CTHA patients had increased operative time, blood loss, LOS, and readmission rates. After IMN failure, the operative leg was shorter than the contralateral leg in all cases. CTHA restored leg lengths to < = 10mm in 15 (68.1%) of patients, with an average leg length discrepancy after CTHA of 6.7mm. CTHA patients had increased rates of overall surgical complications and medical complications, specifically anemia (all p < 0.01). Tranexamic acid was used less often in the CTHA group (p < 0.01). Rate of periprosthetic joint infection (PJI), dislocation, and revision were all higher in the CTHA, though did not reach statistical significance. The majority (77.3%) of CMN implant failure for nonunion within 1year was due to screw cut-out. CTHA is a salvage option for early failed IT hip fracture repair, but expected surgical outcomes are more similar to revision THA than primary THA, with increased risk of readmission, longer surgery and LOS, increased blood loss, and higher complication rates. III, Retrospective comparative study.

Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly

IntroductionSurgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA).Materials and MethodsAll patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score.ResultsA cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal.ConclusionsReversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

Enhanced interfragmentary stability and improved clinical prognosis with use of the off-axis screw technique to treat vertical femoral neck fractures in nongeriatric patients

BackgroundThe optimal internal fixation strategy for vertical femoral neck fractures (VFNFs) in nongeriatric patients remains uncertain. Therefore, the purpose of this study was to compare the clinical prognoses and underlying mechanical characteristics of a novel off-axis screw technique with dynamic hip screws (DHSs) and three traditional parallel screws.MethodsThis study included a clinical investigation and a patient-specific finite element analysis (FEA). In the clinical investigation, VFNF patients were grouped by fixation type: (1) use of three parallel screws (G-TRI); (2) augmentation with an off-axis screw (G-ALP); and (3) DHS with an anti-rotational screw (G-DHS). Fixation failures (nonunion, femoral neck shortening (FNS), varus deformation, screw cut-out) and avascular necrosis (AVN) consequent to the three types of fixations were compared. In the FEA, twenty-four fixation models with the three fixation types were created based on the data of eight healthy volunteers. Models were assessed under walking conditions. Stiffness, interfragmentary motion (IFM), and implant stress were evaluated.ResultsIn the clinical investigation, the fixation failure rate was significantly (p < 0.05) lower in G-ALP (18.5%) than in G-DHS (37.5%) and G-TRI (39.3%). No significant difference in AVN was observed among the three fixation groups. In the FEA, stiffness and implant stress in the G-DHS models were significantly (p < 0.05) higher, and the IFM of G-ALP was significantly (p < 0.05) lower among the groups.ConclusionsAmong fixation types for VFNFs, the off-axis screw technique exhibited better interfragmentary stability (lowest IFM) and a lower fixation failure rate (especially FNS). Analyzing interfragmentary stability in biomechanical experiments is more consistent with clinical prognosis than construct stability for VFNFs, suggesting that internal fixations should aim for this outcome.

Outcome Analysis of Osteosynthesis Versus Hemiarthroplasty for the Treatment of Displaced Femoral Neck Fracture in Young Elderly Patient

This study was designed to compare the osteosynthesis and hemiarthroplasty treatment among the elderly population and evaluate the postoperative functional performance of these two recommended treatments of a displaced femoral neck fracture.&#x0D; Methodology: This retrospective study was conducted in Bone Care trauma center Heerabad Hospital Hyderabad Pakistan from March 2019 to March 2020. A total of 74 patients of age between 60 to 70 years were selected. All the selected patients were diagnosed with femoral neck fractures (Garden’s III and IV). Harris's hip score was used to evaluate the clinical status of patients with pain, whereas we used Palmer and Parker's mobility to access mobility. Implant breakage, screw cut, and nonunion were considered as parameters of osteosynthesis failure. At the same time, hemiarthroplasty failure was defined as two or more recurrent dislocation, aseptic loosening, periprosthetic fracture, and infection.&#x0D; Results: In the first three postoperative months, the mean score of the hemiarthroplasty group was reported as 74.44±8.480, which was comparatively high than the osteosynthesis group (66.44±8.520). After six months, this score reached 80.12±7.005 in the hemiarthroplasty group and reached its maximum of 92.14±7.125. After the first three months, the increment ratio was relatively slow with six ratios, but in the last visit, we observed a sudden increase in score in both groups. Regarding Palmer and Parker's mobility score, the hemiarthroplasty group reflected better outcomes than the osteosynthesis group.&#x0D; Conclusion: Our study concluded that management of displaced femoral neck fracture with osteosynthesis revealed a high probability of nonunion, screw cutout complications and enhanced the risk of reoperation. Patients treated with osteosynthesis showed delay rehabilitation.

Tip-neck distance ratio as a novel predictor for failure in cephalomedullary nailing of unstable trochanteric fractures (UTF).

Intertrochanteric femur fractures (ITFF) are frequently fixed with proximal femoral nailing (PFN), and a common cause of fixation failure is cut-out of the lag screws. In the literature, many factors have been defined to determine the failure risk, including the tip-apex distance (TAD), calcar-referenced tip-apex distance (CalTAD), the Cleveland zone and Parker's ratio. In this study, a novel technique is described which favors infero-posterior placement of the lag screw and predicts failure risk for PFN. The purpose of this study was to evaluate the tip-neck distance ratio as a factor for the prediction of cut-out after PFN of ITFF. A retrospective evaluation was made of the data of 125 patients applied with PFN for ITFF between October 2016 and September 2019. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anaesthesiologists classification, fracture classification, reduction quality, bone quality, Cleveland zone, Parker's ratio, TAD, CalTAD and the TNDR. A total of 125 patients, including 16 with mechanical complications, were suitable for full analysis. In the univariate analysis, reduction quality (p = 0.003), the TAD (p = 0.048) and the TNDR (p = 0.030) were statistically associated with mechanical complications (p < 0.05). In the multivariate analysis, good quality of reduction reduced risk of mechanical failure (p = 0.011) and the TNDR (p < 0.001) indicated that these were two independent factors affecting mechanical complications. The results of this study provide clinical evidence that the TNDR is a predictor for cut-out risk. Placement of the lag screw posterior and inferior reduces the risk of mechanical complications. Level 3.

RESULTS OF TFN AND SHORT PFNA-II IN UNSTABLE TROCHANTERIC FRACTURES: A RETROSPECTIVE COMPARATIVE STUDY

Background: Advancements in modern medicine have given people the opportunity to live longer. The resultant increase in the elderly population has led to a higher incidence of peri-trochanteric fractures of the femur. The preferred implant for the comminuted unstable variety has been intramedullary nails with one or two head/neck compression screws, which are known to have high rate of complications like screw cut-out, back out, Z-effect, varus collapse and rotational instability, especially in the osteoporotic patients leading to the development of helical blade systems. Here we have compared the results of trochanteric xation nail (TFN) and short proximal femoral nail antirotation (PFNA)-II. Methods: It was a retrospective, comparative study in seventy-ve patients with comminuted unstable trochanteric fractures (AO classication31A2) treated using TFN in 34 and short PFNA-II in 41 patients with a minimum follow up period of six months. Results: Most of the data were comparable between the two groups except: signicantly higher operation time and implant-related complications in the TFN group. No signicant differences in the functional outcome between the two groups were noted as indicated by Harris Hip Score at six months. Conclusion: Short PFNA-II should be used in preference to TFN for comminuted unstable trochanteric fractures with no sub-trochanteric extension in the elderly osteoporotic patients in view of the shorter operative time, easier insertion and lower complications rate.

A biomechanical comparison of steel screws versus PLLA and magnesium screws for the Latarjet procedure

IntroductionThe fixation of the coracoid process onto the glenoid is an important step of the Latarjet procedure, and implant-associated complications are a relevant and severe problem. This study compares the fixation strength and failure mode of two biodegradable materials with stainless-steel screws.Methods24 Fresh-frozen cadaveric scapulae were divided into three groups of equal size and received a coracoid transfer. Cadavers were matched according to their bone mineral density (BMD). In group 1, small-fragment screws made of stainless steel were used. In the second group, magnesium screws were used, and in the third group, screws consisted of polylactic acid (PLLA). A continuously increasing sinusoidal cyclic compression force was applied until failure occurred, which was defined as graft displacement relative to its initial position of more than 5 mm.ResultsAt 5-mm displacement, the axial force values showed a mean of 374 ± 92 N (range 219–479 N) in group 1 (steel). The force values in group 2 (magnesium) had a mean of 299 ± 57 N (range 190–357 N). In group 3 (PLLA), failure occurred at 231 ± 83 N (range 109–355 N). The difference between group 1 (steel) and group 2 (magnesium) was not statistically significant (P = 0.212), while the difference between group 1 (steel) and group 3 (PLLA) was significant (P = 0.005).ConclusionStainless-Steel screws showed the highest stability. However, all three screw types showed axial force values of more than 200 N. Stainless steel screws and PLLA screws showed screw cut-out as the most common failure mode, while magnesium screws showed screw breakage in the majority of cases.EvidenceControlled laboratory study.

L’effet du remplissage médullaire sur le déplacement en varus d’une fracture intertrochantérienne AO 31A3 (obliquité inverse) traitée avec des clous céphalomédullaires

ObjectiveCephalomedullary nails are tools commonly used for surgical fixation in proximal femoral fractures. The most common complications in their use are varus collapse and screw cutout of the femoral head. The objective of this study is to examine the effects of intramedullary nail movement on varus collapse and screw cutout. Materials and MethodsThe study was conducted on 70 composite femur models treated with PFNA. We divided the femurs into 4 groups based on the differences in nail diameter, fracture type and filling of the distal intramedullary area. All femurs were exposed to axial cyclic loading. Each femur was examined in terms of intramedullary nail movement and amount of erosions in femoral medulla (amount of erosion in femoral head (FT distance), amount of erosion in femoral neck (FB distance), amount of erosion in trochanteric major (TB distance) and expansion of trochanter tip (TT distance)). ResultsWe found that degree of nail movement in the intramedullary region was inversely correlated with nail diameter and directly correlated with instability of fracture. One of the parameters used to evaluate varus development, FB distance, was affected by the degree of intramedullary nail movement and fracture type. TB distance was affected by nail diameter. ConclusionsNail diameter and fracture type are effective in intramedullary nail movement. Varus collapse progress is accelerated by the increase in nail movement in the intramedullary region. Thus, we conclude that it is important to strengthen diaphyseal adherence, which decreases intramedullary movement of the nail. Level of evidenceIII; well-design case control study.

Double plating is associated with higher fixation strength than single plating in osteoporotic fractures of the scapular spine: a biomechanical study

IntroductionThe number of atraumatic stress fractures of the scapular spine associated with reverse shoulder arthroplasty is increasing. At present, there is no consensus regarding the optimal treatment strategy. Due to the already weakened bone, fractures of the scapular spine require a high fixation stability. Higher fixation strength may be achieved by double plating. The aim of this study was to evaluate the biomechanical principles of double plating in comparison to single plating for scapular spine fractures.MethodsIn this study, eight pairs (n = 16) of human shoulders were randomised pairwise into two groups. After an osteotomy at the level of the spinoglenoid notch, one side of each pair received fracture fixation with a single 3.5 LCP (Locking Compression Plate) plate. The contralateral scapular spine was fixed with a 3.5 LCP and an additional 2.7 LCP plate in 90–90 configuration.The biomechanical test protocol consisted of 700 cycles of dynamic loading and a load-to-failure test with a servohydraulic testing machine. Failure was defined as macroscopic catastrophic failure (screw cut-out, plate breakage). The focus was set on the results of specimens with osteoporotic bone quality.ResultsIn specimens with an osteoporotic bone mineral density (BMD; n = 12), the mean failure load was significantly higher for the double plate group compared to single plating (471 N vs. 328 N; p = 0.029). Analysis of all specimens (n = 16) including four specimens without osteoporotic BMD revealed no significant differences regarding stiffness and failure load (p > 0.05).ConclusionDouble plating may provide higher fixation strength in osteoporotic bone in comparison to a single plate alone. This finding is of particular relevance for fixation of scapular spine fractures following reverse shoulder arthroplasty.Level of evidenceControlled laboratory study.

Surgical treatment of proximal humerus fractures with intramedullary nail

Introduction. Proximal humerus fracture is the most common fracture of the shoulder gir- dle, accounting for approximately 4-7% of all fractures. The aim of this study is to provide surgeons safe and effective surgical solutions, minimizing the risk of complications.Materials and methods. We retrospectively analyzed all 3-fragment proximal humerus frac- tures, treated between January 2017 and December 2018 with the Diphos® short intramedullary nail (Lima Corporate®, San Daniele del Friuli, Italy). 33 patients, 19 men (57.6%) and 14 women (42.4%), were included; average age was 68.4 years (min. 63 - max. 78, SD 3.67).Results. Hospitalization was 6.27 ± 2.87 days (3.6 days before undergo surgery, 2.7 days after). Mean surgical time was 27.36 ± 8.49 minutes. On average, patients healed after 78.36 days. We registered 10 complications: 4 malunion (12.1%), 2 screw-cut outs (6.1%), 1 delayedunion (3.0%), 1 cuff lesion (3.0%), 1 loss of reduction (3.0%), and 1 intraoperative fracture(3.0%). Overall re-operation rate was 6.1%.Conclusions. During surgery, it is crucial to choose the right entry point when placing the nail. Failing at this level can lead to intraoperative and postoperative complications, in addi- tion to worse clinical outcomes.

Factors associated with the development of screw cut-out after the fixation of intertrochanteric femoral fractures with a proximal femoral nail

Objective: To reveal the factors associated with screw cut-out in the fixation of proximal femur intertrochanteric fractures with a proximal femoral nail (PFN).&#x0D; Material and Method: Patients who were diagnosed with proximal femoral intertrochanteric fractures and were being treated and followed up in our hospital between January 2014 and January 2019 were retrospectively analyzed. The hip fracture types of the patients were determined according to the American Foundation/American Orthopedic Trauma Association (AO/OTA) classification. AO/OTA 31-A1, A2 and A3 type fractures were included in the study. Twenty-seven patients with PFN fixation failure and screw cut-out (cut-out group, 11.4%) were compared with 208 patients who had successful osteosynthesis without cut-out (non-cut-out group, 88.6%). Age, gender, affected side, follow-up time, PFN design, tip-apex distance (TAD), calcar-referenced TAD, fracture type, reduction quality, posteromedial support loss, lag screw position, Singh index, and collo-diaphyseal angle (CDA) were compared between the two groups.&#x0D; Results: The two groups significantly differed in terms of TAD and calcar-referenced TAD (p = 0.002 and 0.001, respectively). In the evaluation of reduction quality according to the Baumgaertner scale and the Garden alignment index, a significant difference was found between the two groups (p = 0.021 and 0.002, respectively). A significant difference was also observed between the two groups in terms of screw position and posteromedial cortex continuity (p = 0.009 and 0.037, respectively). However, there was no significant difference in relation to age, gender, affected side, CDA, PFN design, and osteoporosis severity.&#x0D; Conclusion: Fracture type, poor reduction quality, loss of posteromedial support, TAD, calcar-referenced TAD, and lag screw position were found to be associated factors in the development of screw cut-out. Apart from the type of fracture, these factors that are under the control of the surgeon generally show the importance of anatomical reduction and accurate screw placement.

Clinical outcomes of an all-arthroscopic glenoid reconstruction using iliac crest bone graft with a double cannulated screw fixation technique

IntroductionSignificant glenoid bone loss contributes to recurrent anterior shoulder instability. Reconstruction using an iliac crest bone graft provides an anatomic restoration of the glenohumeral arc. We present a case series of an all-arthroscopic glenoid bone reconstruction using iliac crest bone graft (ICBG) with a double cannulated screw fixation technique. Materials and methodsThis is a retrospective study from 2012 to 2017. Patient selection was based on Instability Severity Index Score (ISIS) of greater than 3 points and the presence of glenoid bone defect of more than 20% surface area. The ICBG was harvested from the ipsilateral hip and delivered arthroscopically to the deficient glenoid. The bone graft was then fixed with two cannulated screws. All patients were evaluated at 0, 6, 12 and 24 months for range of motion, isometric strength, pain score, and functional outcome scores: Constant-Murley Score (CMSO), Oxford Shoulder Score (OSS), and UCLA Shoulder Score. Results7 patients (6 males, 1 female) with the mean age of 40.2 years and mean glenoid bone loss of 41.8% were included. At 24 months, the mean active flexion improved from 119 to 143° (p = 0.128) and active abduction improved from 112 to 138° (p = 0.063). Isometric strength increased from 14.7 to 17.6lbs (p = 0.345). All functional scores showed significant improvement (p < 0.05), where CMSO increased from 66.9 to 81.4; OSS 17.4 to 31.4, and UCLA score 23.5 to 32.1. Pain score improved from 4 to 0.5. Bone graft incorporation was confirmed for all the cases and none had recurrent instability. One patient required screw removal for screw cutout. ConclusionOur mid-term results for an all-arthroscopic glenoid reconstruction using ICBG demonstrated good clinical result with minimal complications.

Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures – a biomechanical analysis

Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter. Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p<0.05. Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 o±2.6o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1o±8.7o vs. 8.2o±1.7o respectively, p=0.267). The narrow canal unlocked group (13.7o±2.4o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94o±2.13o and 10.2o±1.7o respectively, than in the narrow or wide canal locked specimens, 2.4o±0.2o and 4.2o±0.5o respectively (p<0.05) CONCLUSION: Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

Low Implant Failure Rate of Percutaneous Fixation for Spinal Metastases: A Multicenter Retrospective Study

To evaluate incidence and types of implant failure observed in a series of patients with spinal metastases (SM) treated with minimally invasive stabilization surgery without fusion. In this multicenter, retrospective, observational study, we reviewed the files of patients >18 years old who underwent surgery for SM using percutaneous spinal stabilization without fusion with a minimum 3-month follow-up. The following variables were included: demographics, clinical findings, prior radiation history, SM location, epidural spinal cord compression scale, Spinal Instability Neoplastic Scale, neurological examination, and surgery-related data. Primary outcome measure was implant failure rate, as observed in patients' last computed tomography scan. Multivariable analysis was performed to identify baseline factors and factors associated with implant failure. Analysis included 72 patients. Mean age of patients was 62 years, 39 patients were men, and 75% of patients had an intermediate Spinal Instability Neoplastic Scale score. Tumor separation surgery was performed in 48.6% of patients. Short instrumentation was indicated in 54.2% of patients. Three patients (4.2%) experienced implant failure (2 screw loosening, 1 screw cut-out); none of them required revision surgery. In 73.6% of cases, survival was >6 months. No significant predictors of failure were identified in the multivariate analysis. A low implant failure rate was observed over the short and medium term, even when short instrumentations without fusion were performed. These findings suggest that minimally invasive stabilization surgery without fusion may be an effective and safe way to treat complicated SM.

The effect of medullary fill on varus collapse in AO 31A3 intertrochanteric (reverse obliquity) fracture treated with cephalomedullary nails

ObjectiveCephalomedullary nails are tools commonly used for surgical fixation in proximal femoral fractures. The most common complications in their use are varus collapse and screw cutout of the femoral head. The objective of this study is to examine the effects of intramedullary nail movement on varus collapse and screw cutout. Materials and methodsThe study was conducted on 70 composite femur models treated with PFNA. We divided the femurs into 4 groups based on the differences in nail diameter, fracture type and filling of the distal intramedullary area. All femurs were exposed to axial cyclic loading. Each femur was examined in terms of intramedullary nail movement and amount of erosions in femoral medulla [amount of erosion in femoral head (FT distance), amount of erosion in femoral neck (FB distance), amount of erosion in trochanteric major (TB distance) and expansion of trochanter tip (TT distance)]. ResultsWe found that degree of nail movement in the intramedullary region was inversely correlated with nail diameter and directly correlated with instability of fracture. One of the parameters used to evaluate varus development, FB distance, was affected by the degree of intramedullary nail movement and fracture type. TB distance was affected by nail diameter. ConclusionsNail diameter and fracture type are effective in intramedullary nail movement. Varus collapse progress is accelerated by the increase in nail movement in the intramedullary region. Thus, we conclude that it is important to strengthen diaphyseal adherence, which decreases intramedullary movement of the nail. Level of evidenceIII; well-design case control study.