Stable Fixation Research Articles

A Comparative Assessment of Right-Angle Screwdriver Versus Conventional Screwdriver for Orthognathic Surgeries.

Background Bilateral orthognathic surgery is one of the unique and challenging orthognathic surgeries that gained popularity after numerous modifications to the techniques. Using linear equipment inside the oral cavity might lead to malalignment or structural weakness due to incorrect placement, making the ramus osteotomy more difficult. By directly positioning the instrument perpendicularly over the mandibular ramus region, a right-angle drill can help promote a more ergonomic approach. Objectives The primary objective was to compare the efficacy of a right-angle screwdriver over a conventional screwdriver for orthognathic surgery using clinical parameters. The second objective was to assess the ease of fixation, the ease of osteotomy, and the time taken for the surgery in both groups. Methods This prospective observational study, comparing the effectiveness of conventional and right-angle screwdrivers for orthognathic surgery, was carried out on 12 patients. A split-mouth design was chosen. For the 12 patients, a right-angle screwdriver was used to secure the right mandibular plate and screw, while a traditional straight handpiece was used to fix the left plate and screw. Clinical parameters such as the ease of osteotomy, the ease of fixation, the time taken for fixation, and the postoperative angulation of the screw in relation to the bone with cone beam computed tomography were evaluated. The procedure was communicated to the patients, followed by obtaining written informed consent. Result Statistical analysis was done using descriptive and inferential statistics using an independent sample t-test and an unpaired t-test. IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, NY, USA), was used. The level of significance was set at a p-value of <0.05. Compared to a conventional screwdriver, the right-angle screwdriver made osteotomies and fixations easier for 12 patients and also required less surgical time. Statistically, it was shown that ease of fixation had a statistically significant difference among right-angled and conventional screwdrivers (p-value < 0.001), whereas time taken had an insignificant difference (p-value 0.13). The angulation of screw fixation with the right angle showed a consistent result of fixation perpendicular to the bone when compared with conventional screwdrivers providing stable fixation, which was statistically significant (p-value < 0.001). Conclusion Compared to the conventional screwdriver used in orthognathic procedures, the right-angle screwdriver ensures solid fixation and eliminates the challenges encountered while drilling and screwing posteriorly positioned screws.

Outcomes of a cementless onlay short stem reverse shoulder arthroplasty in elderly patients: a comprehensive analysis of clinical and radiological findings

ObjectiveThe objective of this study was to evaluate clinical and radiological outcomes of a short stem reverse shoulder prosthesis with metaphyseal fixation specifically in older patients.MethodsAll patients, older than 70 years, submitted to a Reverse Shoulder Arthroplasty (RSA) using a cementless onlay short stem (Aequalis Ascend™ Flex Convertible Shoulder System (Stryker®)) from January 2017 to December 2021, with a minimum follow-up of 2 years, were included. Postoperative radiographs were assessed for stem loosening, subsidence, and varus-valgus tilt. Range of motion, visual analogue scale for pain, constant score, complication rate and revision rate were also analysed.ResultsA total of 34 patients with a mean age of 75 years (range 71–83 years) were submitted to a cementless onlay short stem RSA with a Bone Increased Off-Set (BIO-RSA) construct. The mean follow-up period was 61 months (range 54–87). Significant improvements (p < 0.001) were observed for the constant score and range of motion from the preoperative state to final follow-up. One case exhibited a significant varus deviation (> 5˚) during the follow-up period. No case of stem loosening was identified. There was only one case of complication because of post-traumatic dislocation, but the stem didn’t need revision.ConclusionShort stem RSA, even in patients older than 70 years, can yield a stable fixation with a good clinical and radiological outcome at short-medium term follow-up.Level of EvidenceLevel III; Retrospective Study

IS THERE A ROLE FOR ANTIBIOTIC SUPPRESSION IN THE MANAGEMENT OF FRACTURE-RELATED INFECTION FOLLOWING INTRAMEDULLARY NAILING?

IntroductionThe management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection.Materials &amp; MethodsA retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union.ResultsThis approach was associated with successful treatment in 51/55 (93%) patients. Fracture union was achieved in 52/55 (95%) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98%) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13%) pathogens isolated from intra-operative samples demonstrated multi-drug resistance.ConclusionsInitial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93% of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature.

Extended Use of Proximal Humeral Locking Plates in Pediatric Femur Fractures and Osteotomies

Objective: To assess the extended use of proximal humeral locking plates in paediatric femur fractures and osteotomies. Background: Pediatric fractures and deformity correction pose unique challenges in orthopedic surgery. The utilization of the proximal humerus locking plates (PHLPs) in the pediatric population remains a relatively unexplored area. This manuscript presents a case-based analysis of the extended use of PHLP in pediatric femur fractures and osteotomies. Four distinct cases involving the use of PHLP are discussed, demonstrating its versatility and efficacy in addressing a variety of orthopedic conditions in the pediatric age group. Methods: We retrospectively reviewed the medical records of 4 pediatric patients who underwent surgical interventions utilizing PHLP at our institution. Case 1 involved a 9-year-old girl with a neglected neck of femur fracture, managed with in situ screw fixation and valgus osteotomy and stabilization using a PHLP. Case 2 featured a 10-year-old boy with a distal femur fracture, managed with a PHLP. Case 3 highlighted a 12-year-old girl with genu valgum, who underwent medial closing wedge osteotomy stabilized with a PHLP. Lastly, case 4 presented an 11-year-old boy with a subtrochanteric femur fracture, also managed using a PHLP. Surgical techniques, postoperative care, and outcomes were analyzed. Results: All 4 cases maintained satisfactory stability and alignment at final follow-up. All of them returned to preinjury status within 6 months. Conclusion: The extended use of proximal humeral locking plates in pediatric femur fractures and osteotomies presents a viable option for orthopedic surgeons. These cases illustrate the versatility and positive outcomes associated with PHLP in the pediatric population.

Optimizing bone fixation in vascularized fibula graft in the upper extremity

The free vascularized fibula transfer has become a widely utilized method in reconstructive surgery, with successful applications across various anatomical areas. The biological properties of the graft, including its ability to fuse with recipient bone, repair fractures, and remodel in new biomechanical environments, have been key to its efficacy. However, stable bone fixation is crucial for successful fusion and to prevent complications like non-union. While early approaches focused on minimally invasive techniques to preserve the fibula's vascular network, stable internal fixation has become favored in preventing complications. This article aims to systematically describe bone fixation options for vascularized fibula grafts in the upper limb based on extensive experience, recommending internal fixation over external methods, such as long plates for humerus reconstruction. Different osteotomy techniques are discussed, including intramedullary, transverse, and step cut, with considerations for biomechanics and patient demographics. The discussion emphasizes the importance of stable osteosynthesis for successful outcomes, particularly in early rehabilitation. Additionally, advancements in 3D printing offer personalized solutions in osteosynthesis device design, further enhancing surgical outcomes.

The Effect of Twisted Wire Configuration on the Stability of External Fixator: A Biomechanical Study

The Ilizarov fixator is a type of external fixator that is used to treat patients who have suffered injuries from accidents, bone shortening, or nonunion of the bone. The principle behind the Ilizarov fixator is that thin wires (called Kirschner wires) are used to support the bones and connect them to framed rings. Before being fastened to the rings, the wires are tensioned and drilled through the bones. This study suggests using a new parallel wires configuration at the same level on the same ring and two revised versions, which are divergent and convergent models, and compare them with standard wires, 60 angle wires model. All models were designed using SolidWorks, a computer-aided design (CAD) software, and then analyzed in four conditions (axial compression, medial bending, posterior bending, and torsion) with Finite Element Analysis (FEA) using Ansys Workbench 2020 R2. Mechanical testing was conducted to validate the FEA results, A simple model consisting of a single ring, two K-wires, and polylactic acid (PLA) cylinders was utilized in a tensile test. It has been concluded from the results that the parallel model and its improvement have higher stiffness to axial compression, medial bending, and torsion, but a lower posterior bending stiffness, except the divergent model with 8-hole separation which has a relatively acceptable stiffness for posterior bending.

Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series.

To review outcomes of spinopelvic dissociation treated with open lumbopelvic fixation. We reviewed all cases of spinopelvic dissociation treated at three Level-I trauma centers with open lumbopelvic fixation, including those with adjunctive percutaneous fixation. We collected demographic data, associated injuries, pre- and postoperative neurologic status, pre- and postoperative kyphosis, and Roy-Camille classification. Outcomes included presence of union, reoperation rates, and complications involving hardware or wound. From an initial cohort of 260 patients with spinopelvic dissociation, forty patients fulfilled inclusion criteria with a median follow-up of 351days. Ten patients (25%) had a combination of percutaneous iliosacral and open lumbopelvic repair. Average pre- and postoperative kyphosis was 30 degrees and 26 degrees, respectively. Twenty patients (50%) had neurologic deficit preoperatively, and eight (20%) were unknown or unable to be assessed. All patients presenting with bowel or bladder dysfunction (n = 12) underwent laminectomy at time of surgery, with 3 patients (25%) having continued dysfunction at final follow-up. Surgical site infection occurred in four cases (10%) and wound complications in two (5%). All cases (100%) went on to union and five patients (13%) required hardware removal. Open lumbopelvic fixation resulted in a high union rate in the treatment of spinopelvic dissociation. Approximately 1 in 6 patients had a wound complication, the majority of which were surgical site infections. Bowel and bladder dysfunction at presentation were common with the majority of cases resolving by final follow-up when spinopelvic dissociation had been treated with decompression and stable fixation.

Surgical treatment of coronal shear fractures of the distal humerus with an intact lateral epicondyle by the lateral combined approach

BackgroundCoronal shear fractures of the distal humerus are not only rare and prone to misdiagnosis, but their surgical treatment can be challenging. We aimed to investigate the feasibility of exposing distal humeral coronal shear fractures with a combined lateral approach that preserves the extensors and lateral ulnar collateral ligament (LUCL) and to analyze the clinical efficacy of open reduction and internal fixation (ORIF) in the treatment of these injuries. MethodsWe included 45 patients who sustained coronal shear fractures of the distal humerus with the lateral epicondyle intact and were treated with ORIF from January 2013 to August 2020. The fractures were exposed by the lateral combined approach in which the tendons involving the common extensor, the extensor carpi ulnaris (ECU), and the LUCL were preserved. Two observation windows were formed anterior to and posterior to these tendons and the LUCL was used to achieve fracture reduction. Countersunk screws, with or without a plate placed on the posterior lateral condyle, were used to fix the fragments. The functional outcomes of these patients were reviewed and assessed with physical and radiographic examinations, range of motion (ROM) measurements, and self-evaluation Mayo Elbow Performance Index (MEPI) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. ResultsIn total, 40 patients were followed up with for over 1 year and were included in the final analysis. The mean follow-up duration was 42±30 months (range, 12–107 months). The patients’ mean age was 42 years (range, 14–74 years). According to the Dubberley Classification, there were 15 type I, 17 type II, and 8 type III fractures. At the final follow-up, the mean flexion–extension arc was 131° (range, 65–150) and mean pronation and supination was 73° (range, 45–80) and 71° (range, 40–80), respectively. The mean MEPI score was 88 (range, 61–97) points; the results were excellent in 21, good in 13, fair in 4, and poor in 2 patients. The mean DASH score was 11 (range, 0–42) points. Neither functional score nor range of movement was associated with age, sex, fracture type, injury type, or surgical timing. ConclusionReduction and stable fixation with internal fixation for coronal shear fractures of the distal humerus can be achieved by the lateral combined approach. Early functional mobilization allows for satisfactory restoration of elbow function.

Improvement of coracoid process union rates: a comparative study of conventional open and arthroscopic-assisted Bristow procedures for treating anterior shoulder instability in rugby players

The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure. We retrospectively reviewed 104 rugby players (n=111 shoulders) who underwent an open (n=66 shoulders) or arthroscopy (AS)-assisted (n=45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3months, 6months, and 1year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed. The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3months, 6months, and 1year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3months, 6months, and 1year, respectively. Both groups showed significant improvement in the American Shoulder and Elbow Surgeons and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the 2 groups. The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

Severity of Disorganization of Retinal Layers and Visual Function Impairment in Diabetic Retinopathy

To evaluate best-corrected visual acuity (BCVA), retina sensitivity (RS), and fixation impairment by microperimetry (MP) due to the presence and severity of disorganization of retinal inner and outer layers (DRIL/DROL) and ischemia in OCT/OCT angiography (OCTA) in diabetic retinopathy (DR). Retrospective case-control study. Seventy-six eyes (65 patients) with DR were analyzed. Major exclusion criteria were: center-involving diabetic macular edema (DME), significant media opacity, nondiabetic macular pathology, and active proliferative DR. Patients with DRIL and DROL within central 3 mm were enrolled as cases. Patients with DR and no retina disorganization were considered as controls. A detailed grading of MP and OCT/OCTA images using Image J software, and specific Image Manipulation Program was applied to colocalize the presence of retina disorganization and RS. Best-corrected visual acuity and RS were correlated with the disorganization of retina layers' characteristics and grading (grade 1-DRIL; grade 2-DROL; grade 3-DROL plus, with involvement of the ellipsoid zone). The same procedure of colocalization was applied to the vascular layers on OCTA using MATLAB. Correlation between BCVA and MP parameters with disorganization of retina layers grading and OCTA parameters. Best-corrected visual acuity, mean RS within 1 mm and central 3 mm (overall RS [oRS]), perfusion density, vessel density, and geometric perfusion deficit in intermediate and deep capillary plexuses were lower in cases versus controls (P < 0.001). Mean RS within 1 mm (21.4 decibels [dB] ± 2.4 vs. 13.8 dB ± 5.4, P= 0.002), oRS (22.0 dB ± 2.1 vs. 14.4 dB ± 4.6, P < 0.001), and BCVA (76.1 ± 7.4 vs. 61.2 ± 20.4 ETDRS letters; P= 0.02), had a significant decrease from grade 1 to grade 3 retina disorganization. Choriocapillaris flow voids (CC-FVs) increased from grade 1 to grade 3 (DROL plus) (P= 0.004). Overall retina sensitivity and CC-FV were identified as significant predictors of retina disorganization grade with an adjusted coefficient of determination, R2= 0.45. Cases had more dense scotomas (P= 0.03) than controls with a positive correlation between the worsening of fixation stability and the severity of DRIL/DROL (P= 0.04). Microperimetry and BCVA documented a reduction in visual function in patients with DR and disorganization of retina layers at different grades, with greater functional impairment when outer retina layers and photoreceptors are involved. The severity of retina disorganization and the presence of ischemia could serve as a potential biomarker of functional impairment. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures.

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

Treatment of Ulnar Collateral Ligament Fracture-Avulsion of the Thumb: A Case Report

Ulnar collateral ligament (UCL) injuries of the thumb, often termed "gamekeeper's thumb," can result from falls or repetitive thumb abduction, predominantly affecting males. The severity ranges from stretching (grade I) to complete tearing (grade III), occasionally accompanied by avulsion fractures. Surgical intervention is advocated in some cases to restore joint stability and prevent osteoarthritis. The authors present a case report of a 51-year-old male with a displaced avulsion fracture at the UCL's distal attachment. Surgical treatment was performed. A lazy S dorsomedial approach over the first metacarpophalangeal joint was made, with careful protection of the dorsal cutaneous branches of the radial sensory nerve. An anatomic reduction of the fracture was achieved with the use of a suture passing k wire that was inserted through the avulsed fragment and then the phalanx and a non-absorbable suture (fiberwire) was passed. The free ends of the suture were securely tied on the distal radial side of the proximal phallanx, ensuring a stable fixation. Postoperative immobilization and rehabilitation led to a successful outcome, with the patient returning to work within 6 weeks, without complications. This case underscores the importance of surgical techniques in managing UCL injuries, emphasizing the restoration of joint stability to prevent long-term complications such as osteoarthritis, chronic pain and stiffness. The described method offers a viable option for treating UCL avulsion fractures, facilitating early recovery and preserving joint function.

Stable fixation using absorbable sutures in craniofacial surgery in patients over 24 months of age—a retrospective study

PurposeIn craniofacial surgery, the stable fixation of transposed bone segments is crucial in order to ensure good long-term results. The use of absorbable material in fixation avoids the need for a second surgery, which would otherwise be required to remove osteosynthesis material. The authors of the present manuscript have already demonstrated that absorbable sutures ensure the stable fixation of bone segments in patients up to 24 months of age. However, it has thus far remained unclear whether stable fixation is possible in older patients by using only absorbable sutures due to the slower bone remodelling and prolonged healing time in this cohort.MethodFor the present study, osteosynthesis was performed in 50 patients ranging from 25.7 to 192.1 months of age (mean, 61.4 ± 21.7 months) using solely absorbable sutures (PDS II®, Ethicon, Germany). Post-operative stability and possible restrictions—such as foreign body reactions—were evaluated within clinical and radiological routine follow-ups.ResultsAll children demonstrated clinically and radiologically stable osteosynthesis both directly post-operatively and in follow-ups. No significant foreign body reaction could be seen.ConclusionThe present study demonstrates—for the first time—that absorbable sutures with a longer absorption period are also very well suited for the fixation of bone segments in patients over 24 months of age. The sole use of absorbable sutures in children over 24 months of age is a safe procedure with nearly no foreign body reactions. The procedure enables stable and highly cost-effective osteosynthesis without altering the osteotomy design.

Efficacy and Outcomes of Gamma Nail Versus Proximal Femoral Nail in the Treatment of Stable Extracapsular Fractures of the Proximal Femur: A Comparative Study

Background: Stable extracapsular fractures of the proximal femur are a common and challenging injury in the elderly, with Gamma Nail and Proximal Femoral Nail (PFN) being the primary surgical options. This study aims to compare the efficacy and outcomes of these two methods.&#x0D; Methods: A prospective study was conducted on 50 patients with stable extracapsular fractures, randomly assigned to undergo CRIF with either Gamma Nail or PFN. Parameters such as operation time, blood loss, radiological outcomes, and postoperative recovery were analyzed.&#x0D; Results: The Gamma Nail group experienced shorter operation times (33±6.5 min) and less blood loss (28.08±32.80 ml) compared to the PFN group. Radiological outcomes showed no significant difference between the groups, with high success rates in achieving stable fixation. Both methods demonstrated effectiveness in managing these fractures, but Gamma Nail offered some technical advantages.&#x0D; Conclusion: Gamma Nail and PFN are both effective for treating stable extracapsular fractures of the proximal femur, with the choice of technique depending on various patient-specific factors.&#x0D; Keywords: Extracapsular fractures, proximal femur, Gamma Nail, Proximal Femoral Nail, orthopedic surgery, elderly.&#x0D;

Postoperative Intermaxillary Elastic Traction Contributes to the Stability of Absorbable Plates Fixation for Bilateral Mandibular Fracture.

The use of absorbable plates can be challenging for mandibular fractures involving bilateral dentition. Chewing and mouth opening movements may cause loosening or breakage of absorbable materials, leading to displacement of bone segments and resulting in malocclusion. The use of absorbable materials for bilateral mandibular fracture surgery itself raises concerns for surgeons. Timely intermaxillary elastic traction is essential for these patients after surgery to maintain correct occlusion. The surgical approaches were performed with intraoral mandibular sulcus incisions. During the surgery, intermaxillary fixation screws were implanted and steel wires were used for intermaxillary ligation and fixation to restore the occlusal. After the fractured segments were sequentially reduced, they were fixed with inion 2.0 absorbable plates. The patient underwent intermaxillary elastic traction for 1 week. Elastic mask was used to assist in stabilizing the position of the jawbone and maintaining occlusion. After discharge, the patient continued traction at home for 3 weeks before removing the intermaxillary fixation screws. The patient recovered well after surgery without any complications. The postoperative occlusal relationship is good. Postoperative CT showed good reduction of the fractured segments. For the case reported in this article, elastic traction was promptly implemented after surgery. We emphasize that restoring occlusion is always the treatment goal for jawbone fractures. We believe that keeping the intermaxillary fixation screws for a month is a wise choice to be prepared for unexpected needs.

Finite element analysis of the stability of retrograde intramedullary nail and plate-screw combinations for periprosthetic femoral fractures following total knee replacement.

Periprosthetic fractures following total knee replacement are rare but challenging. The goal of the treatment is to achieve the most stable fixation that allows early mobilization. Therefore, the aim of this study was to evaluate the biomechanical results of the use of different fixation systems in the treatment of distal femur periprosthetic fractures with finite element analysis. A total knee prosthesis was implanted in Sawbone femur models. A transverse fracture line was created in the supracondylar region and was fixed in four different groups. In group 1, fracture line fixation was fixed using retrograde intramedullary nailing. In group 2, fixation was applied using a lateral anatomic distal femoral. In group 3, in addition to the fixation made in group 1, a lateral anatomic distal femoral plate was used. In group 4, in addition to the fixation made in group 2, a 3.5 mm Limited Contact Dynamic Compression Plate (LC-DCP) was applied medially. Computed Tomography (CT) scans were taken of the created models and were converted to three-dimensional models. Axial and rotational loading forces were applied to all the created models. The least deformation with axial loading was observed in the double plate group. Group 3 was determined to be more advantageous against rotational forces. The greatest movement in the fracture line was found in group 2. The application of the medial plate was determined to reduce the tension on the lateral plate and increase stability in the fracture line. Combining a lateral anatomic plate with intramedullary nailing or a medial plate was seen to be biomechanically more advantageous than using a lateral plate or intramedullary nailing alone in the treatment of distal femoral periprosthetic fractures.

Modified Dunn Osteotomy for Moderate and Severe Slipped Capital Femoral Epiphysis

Background: Moderate to severe slipped capital femoral epiphysis is a condition that benefits from treatment with modified Dunn realignment osteotomy and fixation 1,2 . The results are acceptable when the procedure is performed by experienced surgeons 3,4 . Description: The patient is placed in the lateral decubitus position. Surgical hip dislocation is performed after a digastric trochanteric osteotomy. An extended retinacular flap is carefully prepared, and the epiphysis separated from the metaphysis, exposing the entirety of the femoral neck. Following this, an open reduction is performed by excising the posteromedial callus and trimming the femoral neck in order to allow capital realignment while avoiding tension on the retinacular vessels. Finally, the reduced slip is fixed with 6.5 or 7-mm cancellous screws and Kirschner wires. The femoral head is then repositioned in the acetabulum, and the trochanter is fixed distal to its original position with use of 3.5-mm self-tapping cortical screws. Closure is performed in layers after achieving adequate hemostasis. Alternatives: Operative alternatives to this technique include cuneiform osteotomy, compensatory osteotomy of the base of the neck or intertrochanteric osteotomy and controlled repositioning, and osteoplasty 5–7 . Osteotomies performed distally and away from the deformity can still lead to cam impingement, thereby failing to reduce the risk of future joint degeneration. In situ pinning has also been described for use in moderate to severe cases of slipped capital epiphysis, but the residual deformity leads to substantial femoroacetabular impingement and thus affects the prognosis of such a hip 8 . Rationale: This technique accounts for the complex anatomy of the hip joint, especially in terms of its precarious blood supply. Long-term studies have shown that corrective osteotomy performed near the physis can correct the alignment at the head-neck junction, thereby avoiding future femoroacetabular impingement. In the hands of experienced surgeons, results have been shown to be favorable 3,4 . Expected Outcomes: In a series of 30 consecutive hips, including 20 moderate and 10 severe slips, the slip angle improved significantly following the modified Dunn procedure (by 43.63° ± 8.42°; p &lt; 0.001). Osteonecrosis was observed in 2 hips (6.7%), and 1 hip had postoperative subluxation that required intervention 9 . In their series of 23 patients, Slongo et al. encountered 2 cases (9%) of osteoarthritis and osteonecrosis 10 . In their series of 40 patients from 2 different institutions, Ziebarth et al. reported no cases of chondrolysis or osteonecrosis 11 . Important Tips: The steps described need to be followed sequentially and meticulously in order to safely dislocate the hip while preserving the blood supply.The availability of an anterior pouch in draping, to deliver the leg during dislocation, will reduce the dependence on an assistant and maintain sterilityThe trochanteric osteotomy should be started with the help of a saw, completed with an osteotomy and must be about 1 to 1.5 cm thick in order to achieve good, stable fixation following relocation of the femoral head and to achieve good abductor function post-relocation.The use of curved, stout, thick scissors (“episiotomy scissors”) can help to ease the step of cutting the ligamentum teres during dislocation.The retinacular flap should be widely exposed along with removal of the posterior callus so that no tension remains on the blood supply. Acronyms and Abbreviations: SCFE = slipped capital femoral epiphysisFAI = femoroacetabular impingementMDP = modified Dunn procedureAVN = avascular necrosisTHR = total hip replacementFAER = flexion, abduction and internal rotationCT = computed tomographyMRI = magnetic resonance imagingAP = anteroposterior

Stability of Proximal Femoral Osteotomies in Pediatric Bone Models Fixed with Flexible Intramedullary Nails and Evaluated by the Finite Element Method.

Objective To evaluate the stability of osteotomies created in the subtrochanteric and trochanteric regions in a pediatric femur model fixed by flexible intramedullary rods. Method Tomographic sections were obtained from a pediatric femur model with two elastic titanium rods and converted to a three-dimensional model. This model created a mesh with tetrahedral elements according to the finite element method. Three virtual models were obtained, and osteotomies were performed in different regions: mediodiaphyseal, subtrochanteric, and trochanteric. A vertical load of 85N was applied to the top of the femoral head, obtaining the displacements, the maximum and minimum main stress, and the equivalent Von Mises stress on the implant. Results With the applied load, displacements were observed at the osteotomy site of 0.04 mm in the diaphyseal group, 0.5 mm in the subtrochanteric group, and 0.06 mm in the trochanteric group. The maximum stress in the diaphyseal, subtrochanteric, and trochanteric groups was 10.4 Pa, 7.52 Pa, and 26.4 Pa, respectively. That is around 40% higher in the trochanteric group in regards to the diaphyseal (control). The minimum stress of the bone was located in the inner cortical of the femur. The equivalent Von Mises stress on the implants occurred at osteotomy, with a maximum value of 27.6 Pa in the trochanteric group. Conclusion In both trochanteric and subtrochanteric osteotomies, fixation stability was often lower than in the diaphyseal model, suggesting that flexible intramedullary nails are not suitable implants for proximal femoral fixations.

Intramedullary nailing for irreducible spiral subtrochanteric fractures: A comparison of cerclage and non-cerclage wiring

PurposeIntramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages. However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment. This study is performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures. MethodsPatients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed. The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group. The patients' clinical data, including the operative time, intraoperative blood loss, hospital stay, reoperation rate, fracture union time, and Harris hip score, were compared between these 2 groups. Categorical variables were compared using Chi-square or Fisher's exact test. Continuous variables with normal distribution were presented as mean ± standard deviation and analyzed with Student's t-test. Non-normally distributed variables were expressed as median (Q1, Q3) and assessed using the Mann-Whitney test. A p < 0.05 was considered significant. ResultsIn total, 69 patients were included in the study (35 patients in the non-cerclage group and 34 patients in the cerclage group). The baseline data of the 2 groups were comparable. There were no significant difference in the length of hospital stay (z = -0.391, p = 0.696), operative time (z = -1.289, p = 0.197), or intraoperative blood loss (z = -1.321, p = 0.186). However, compared with non-cerclage group, the fracture union time was shorter (z = -5.587, p < 0.001), the rate of nonunion was lower (χ2 = 6.030, p = 0.03), the anatomical reduction rate was higher (χ2 = 5.449, p = 0.03), and the Harris hip score was higher (z = -2.99, p = 0.003) in the cerclage group, all with statistically significant differences. ConclusionsIntramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures. This technique can improve the reduction effect, increase the stability of fracture fixation, shorten the fracture union time, reduce the occurrence of nonunion, and contribute to the recovery of hip joint function.

Revision total hip arthroplasty using a modular fluted, tapered revision femoral component and interlocking screws in Vancouver B3 periprosthetic fractures with insufficient bone at the isthmus.

Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients. A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm. One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively. The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes.