Type A3 Fractures Research Articles

How reliable is the distinction between thoracolumbar AO type A3 and A4 fractures? A systematic literature review.

The AOSpine classification divides thoracolumbar burst fractures into A3 and A4 fractures; nevertheless, past research has found inconsistent interobserver reliability in detecting those two fracture patterns. This systematic analysis aims to synthesize data on the reliability of discriminating between A3 and A4 fractures. We searched PubMed, Scopus, and the Web of Science for studies reporting the inter- and intra-observer reliability of detecting thoracolumbar AO A3 and A4 fractures using computed tomography (CT). The search spanned 2013 to 2023 and included both primarily reliability and observational comparative studies. We followed the PRISMA guidelines and used the modified COSMIN checklist to assess the studies' quality. Kappa coefficient (k) values were categorized according to Landis and Koch, from slight to excellent. Of the 396 identified studies, nine met the eligibilitycriteria; all were primarily reliability studies except one observational study. Interobserver k values for A3/A4 fracturesvaried widely among studies (0.19-86). The interobserver reliability was poor in two studies, fair in one study, moderate in four studies, and excellent in two studies. Only two studies reported intra-observer reliability, showing fair and excellent agreement. The included studies revealed significant heterogeneity in study design, sample size, and interpretation methods. Considerable variability exists in interobserver reliability for distinguishing A3 and A4 fractures from slight to excellent agreement. This variability might be attributed to methodological heterogeneity among studies, limitations of reliability analysis, or diagnostic pitfalls in differentiating between A3 and A4. Most observational studies comparing the outcome of A3 and A4 fractures do not report interobserver agreement, and this should be considered when interpreting their results.

Study on automatic and rapid diagnosis of distal radius fracture by X-ray

This article aims to combine deep learning with image analysis technology and propose an effective classification method for distal radius fracture types. Firstly, an extended U-Net three-layer cascaded segmentation network was used to accurately segment the most important joint surface and non joint surface areas for identifying fractures. Then, the images of the joint surface area and non joint surface area separately were classified and trained to distinguish fractures. Finally, based on the classification results of the two images, the normal or ABC fracture classification results could be comprehensively determined. The accuracy rates of normal, A-type, B-type, and C-type fracture on the test set were 0.99, 0.92, 0.91, and 0.82, respectively. For orthopedic medical experts, the average recognition accuracy rates were 0.98, 0.90, 0.87, and 0.81, respectively. The proposed automatic recognition method is generally better than experts, and can be used for preliminary auxiliary diagnosis of distal radius fractures in scenarios without expert participation.

ABORD ANTEROLATERAL DE LA CHARNIERE THORACO-LOMBAIRE : EXPERIENCE D’UN CAS AVEC CHYLOTHORAX PAR PLAIE IATROGENE DU CANAL THORACIQUE.

Despite its advantages, the anterolateral approach to the thoracolumbar spine can present several complications including chylothorax. We present a rare case of thoracic duct injury secondary to an anterolateral surgical approach to the thoracolumbar spine post-vertebromedullary trauma which was successfully treated non-surgically. Observation: This is a 35-year-old patient, hospitalized for the treatment of a spinal trauma whose radiological assessment revealed a type A3 fracture of the 12th thoracic vertebra according to the Ao-spine classification. He had benefited from a corpectomy of the same vertebra followed by the placement of an interbody implant via an anterolateral approach with thoraco-phrenotomy. The immediate aftermath of the operation was marked by the presence in the chest drain of a white lactescent liquid, the chemical study of which revealed the presence of chylomicrons by electrophoresis, lipoproteins and a triglyceride level of 80 g/l, confirming the diagnosis of chylothorax. Conservative medical treatment was instituted consisting of chest drainage for 3 weeks and parenteral nutrition which allowed complete recovery. Conclusion: Iatrogenic chylothorax represents a rare cause of pleural effusion. This case reflects a successful approach to the management of post-dorsal spine surgery lymph leak via anterolateral approach, using drainage and strict dietary changes, which precluded the need for thoracic duct repair surgery. Keywords: Anterolateral approach, Chylothorax, Conservative treatment,

Factors associated with loss of vertebral height and kyphosis correction after intermediate screws in short segment pedicular fixation for type-A fractures of the thoracolumbar spine: A retrospective study.

In this article, we attempted to identify risk factors affecting the loss of vertebral height and kyphosis correction on type A thoracolumbar fractures. Patients with type A thoracolumbar fractures who underwent short segments with intermediate screws at the fracture level management between 2017 and 2022 were included in this study. Clinical factors including patients' demographic characteristics (age, sex), history (smoking, hypertension and/or diabetes), value of height/kyphosis correction, the thoracolumbar injury classification and severity score (TLICS), the load sharing classification (LSC) scores and bone mineral density were collected. Correlation coefficient, simple linear regression analysis and multivariate regression analysis were performed to identify the clinical factors associated with the loss of vertebral height/kyphosis correction. Finally, 166 patients were included in this study. The mean height and kyphosis correction were 21.8% ± 7.5% and 9.9° ± 3.8°, respectively, the values of the loss were 6.5% ± 4.0% and 3.9° ± 1.9°, respectively. Simple linear regression analysis and multivariate regression analysis showed that age, value of height correction, LSC scores and bone mineral density were significantly associated with the loss of vertebral height and kyphosis correction (P < .01) We could draw the conclusion that patients with older age, lower bone mineral density, higher LSC scores and diabetes are at higher risk of vertebral height and kyphosis correction loss increase. For these patients, appropriate clinical measures such as long segment fixation, control of blood glucose, and increase of bone density must be taken to reduce the loss of correction.

Effect of Cold Isostatic Pressing and VC Grain Growth Inhibitor Addition on WC Grain Size and Mechanical Properties of WC-8Co Cemented Carbide

In this study, sub-micron WC-Co cemented carbides were fabricated by cold isostatic pressing using recycled WC powder, Co powder, and VC grain growth inhibitor as the initial composite powders. The raw WC-8Co and WC-8Co-0.3VC compositions were prepared according to conventional technology. After that, part of the green compacts was CIP-ed under pressure of 200 MPa. Sintering was carried out in an industrial vacuum sintering furnace at a temperature of 1420 ºC simultaneously for all samples. The microstructures and properties, including density, coercivity, transverse rupture strength, A-type Rockwell hardness and fracture toughness were investigated, characterized and compared systematically. The experimental results showed that the action of cold isostatic pressing in combination with grain growth inhibitor addition promoted ultrafine grains with the finest WC grain size of 0.68 μm and an increase in the fracture toughness up to 15.4 MPa·m1/2 ± 0.2 compared to rest cemented carbides, showing the techniquehas potential to fabricate cermets with both small average WC grain size and high fracture toughness, which is key in providing excellent performance.

EVALUATION OF SURGICAL TREATMENT RESULTS FOR FRACTURES IN THE TROCHANTERIC AREA USING LOCKING PLATES AT HA DONG GENERAL HOSPITAL

Objectives: To evaluate the results of surgery to treat adult fractures in the trochanteric area using locking plates at Ha Dong General Hospital. Methods: A retrospective, cross-sectional descriptive study on 30 patients with fractures in the trochanteric area who underwent surgery with locking plates, followed up, and re-examined at Ha Dong General Hospital from January 2018 to February 2022. Results: The main cause of injury was daily life accidents (63.3%). Classification according to AO: Type A1 fractures accounted for 13.3%, type A2 fractures were 56.7%, and type A3 fractures were 30%. The average hospital stay was 12.3 days. The anatomical correction results were 90% good and 10% not good. Bone healing results: Good bone healing was 96.7%; poor bone healing was 3.3%, with no cases of osteoarthritis or pseudoarthritis. The results of good and very good walking function were 86.7%, and poor walking function was 3.3%. Overall results: Very good and good accounted for 86.7%, average was 10%, and poor results was 3.3%. Conclusion: Fractures in the femoral trochanter area are mainly caused by daily life accidents. Bone union with locking plates is a good treatment method for patients with fractures in the trochanteric area helping to firmly fix fractures, allowing patients to exercise and practice early rehabilitation. It is convenient for patients to return to daily life, reducing the rate of complications encountered, thereby improving the quality of life for patients and reducing the burden on families and society.

Effectiveness of unilateral biportal endoscopy combined with percutaneous pedicle screw fixation in treatment of lumbar burst fractures with neurological symptoms

To evaluate the effectiveness of spinal canal decompression assisted by unilateral biportal endoscopy (UBE) and percutaneous uniplanar pedicle screw internal fixation in the treatment of lumbar burst fractures with neurological symptoms. Between June 2021 and December 2022, 10 patients with single level lumbar burst fracture with neurological symptoms were treated with spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw internal fixation. There were 7 males and 3 females with an average age of 43.1 years (range, 21-57 years). The injured vertebrae located at L 1 in 2 cases, L 2 in 4 cases, L 3 in 3 cases, and L 4 in 1 case. There were 7 cases of AO type A3 fractures and 3 cases of AO type A4 fractures. The total operation time, the time of operation under endoscopy, and complications were recorded. Pre- and post-operative visual analogue scale (VAS) score and American Spinal Injury Association (ASIA) scale (grading A-E corresponding to assigning 1-5 points for statistical analysis) were used to evaluate effectiveness. X-ray film and CT were performed to observe the fracture healing, and the ratio of anterior vertebral body height, Cobb angle, and rate of spinal canal invasion were measured to evaluate the reduction of fracture. All operations was successfully completed, and the spinal canal decompression and the bone fragment in spinal canal reduction completed under the endoscopy. Total operation time was 119 minutes on average (range, 95-150 minutes), and the time of operation under endoscopy was 46 minutes on average (range, 35-55 minutes). There was no complication such as dural sac, nerve root, or blood vessel injury during operation. All incisions healed by first intention. All patients were followed up 18.7 months on average (range, 10-28 months). The VAS score after operation significantly decreased when compared with that before operation ( P<0.05), and further improved at last follow-up ( P<0.05). The ASIA scale after operation significantly improved when compared with that before operation ( P<0.05), and there was no significant difference ( P>0.05) in the ASIA scale between at 1 week after operation and at last follow-up. The imaging examination showed that the screw position was good and the articular process joint was preserved. During follow-up, there was no loosening, fracture, or fixation failure of the internal fixation. The ratio of anterior vertebral body height and Cobb angle significantly improved, the rate of spinal canal invasion significantly decreased after operation ( P<0.05), and without significant loss of correction during the follow-up ( P>0.05). Spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw fixation is a feasible minimally invasive treatment for lumbar burst fractures with neurological symptoms, which can effectively restore the vertebral body sequence, as well as relieve the compression of spinal canal, and improve the neurological function.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views. Data from 340 female and 152 male patients ≥ 60years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis. Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure. Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Vertebral compression fractures managed with brace: risk factors for progression.

The aim of this study is to identify risk factors for vertebral compression fracture (VCF) progression in patients treated conservatively with a brace. Then, a case-control study was designed. All patients over 50years old with diagnosis of thoracic or lumbar VCF (T5 to L5) in absence of underlying oncological process, treated conservatively with brace, and consecutively attended at our department from January 2017 to June 2021 were retrospectively selected for analysis. Patients missed for follow-up or dead during the first 3months of follow-up were excluded. Five hundred and eighty-two consecutive patients were recorded. Incomplete follow-up excluded 74 patients and other 19 died in the first three months after diagnosis, so 489 cases were finally analyzed. Median follow-up was 21 (IQR 13;30) weeks. Increased collapse of the vertebral body was found in 29.9% of VCFs with a median time to progression of 9 (IQR 7;13) weeks. Male gender (OR 1.6), type A3 fracture of the AOSpine classification (OR 2.7), thoracolumbar junction location (OR 1.7), and incorrect use of the brace (OR 3.5) were identified as independent risk factors for progression after multivariable analysis. Male gender, type A3 fracture of the AOSpine classification, thoracolumbar junction location, and incorrect use of the brace were identified as independent risk factors for VCF progression, which resulted in worse pain control, when treated with brace. Thus, other treatments such as percutaneous vertebral augmentation could be considered to avoid progression in selected cases, since collapse rate has been demonstrated lower with these procedures.

The Incidence of Heterotopic Ossification in Surgically and Non-surgically Treated Elbow Fractures at a Municipal Hospital in Japan.

Background: Heterotopic ossification (HO) is a well-recognised complication of after elbow trauma. The prevalence and risk factors of HO have been previously reported. However, these reports were based on elbow trauma that had undergone surgical treatment and most of them were from Western countries. This study aimed to assess the incidence of HO in patients with elbow fractures who were treated surgically and non-surgically in Japan. Methods: We retrospectively identified consecutive patients who were treated of elbow fractures and fracture-dislocations at our institution in recent consecutive 3-year periods. We extracted patient demographics, injury mechanisms and treatment details from the medical records. Furthermore, we reviewed radiographs to classify the fracture pattern and identify the presence or absence of HO. Results: HO was identified in 6/97 (6%) patients. Fracture-dislocation was noted in 4/6 patients. The fracture types with HO included terrible triad injury (n = 2), isolated coronoid process fractures (n = 2), distal humerus A-type fractures (n = 1) and radial head fracture (n = 1). According to the Hastings and Graham classification, HO was classified as Class I in five patients and Class II B in one patient who underwent additional surgery for HO resection. Conclusions: The incidence of HO was relatively low in our patients. However, of the 20 conservatively treated elbows, one patient developed clinically relevant HO and required excision of HO. Even patients with elbow fractures treated conservatively should be informed of the potential risk of developing severe HO requiring surgical excision. In addition, surgeons in this region could use these data to inform patients about the risk of HO development after an elbow injury. Level of Evidence: Level IV (Therapeutic).

The trend in Management of Stable Burst Fracture of Thoracolumbar Spine with Intact Neurology among Members of the Association of Spine Surgeons of Nepal: A Survey

Background:The management of stable burst fracture of thoracolumbar spine with intact neurology is controversial. The radiological interpretation of such fractures differs among the surgeons and hence the treatment. So, this survey aims to study discrepancies in management of such fractures among the members of the Association of Spine Surgeons of Nepal (ASSN). Methods: Two representative cases of stable burst fracture with intact neurology (Case 1 AO type A3 and Case 2 AO type A4) were chosen by the authors. Questionnaire was formulated in Google form which also contained X-rays and CT scans of the cases. Google form was circulated among the members of ASSN. The response was recorded in excel and was analyzed. Results:Out of 67 members of ASSN, 55 (82.08%) responded the survey. 35 responders (63.63%) used both AO classification and TLICS. Majority of responders responded correctly as AO Type A3 and A4 burst fractures after looking at X-rays and CT scans of Case 1 and Case 2 respectively. Regardless of TLICS of 0-3 or 4 in both the cases, majority (81.81% in Case 1 and 78.18% in Case 2) chose surgical intervention. The degree of kyphosis for 48 respondents (87.27%), the level of fracture for 45 respondents (81.81%), bone quality for 41 respondents (74.54%), the severity of canal compromise for 40 respondents (72.72%) were some important factors in treatment decisions. Conclusion:The wide interobserver variability exists among members of ASSN in the management of stable burst fractures of the thoracolumbar spine with intact neurology. KeyWords: Intact neurology, Interobserver variability, Stable burst fracture, Trend in management

Usefulness of Percutaneous Pedicle Screw Fixation for Treatment of Lower Lumbar Burst (A3-A4) Fractures: Comparative Study with Thoracolumbar Junction Fractures.

Percutaneous pedicle screw fixation (PPSF) without fusion has been recently recommended in the treatment of thoracolumbar fracture to reduce the adverse effects associated with the conventional open approaches and to restore range of motion. However, those studies report on the thoracolumbar junction, and there is no report on lower lumbar fracture. To assess effectiveness of PPSF without fusion for treating lower lumbar burst (A3 and A4) fractures. A retrospective analysis was made to evaluate consecutive 50 patients with AO type A3 and A4 thoracolumbar fracture underwent PPSF. Patients were divided into a thoracolumbar junction (TLJ) group (T11-L2) and lower lumbar (LL) group (L3-5). The following items were measured and compared between the two groups. Vertebral height and consolidation, retropulsed fragment, sagittal curve and fixation failure were assessed with certain interval regularly. The average height at pre- and post-reduction were 56.2% (36.2-74.3), 95.3% (84.2-98.3) in TLJ group and 65.7% (45.7-86.2), 91% (73.1-100) in LL group. The average canal area occupancy rate at pre- and post-reduction were 46.1% (37.4%-67.5%), 38.1% (31.3%-40.8%) in TLJ group and 40.4% (15.0-65.7), 19.3% (9.4-26.6) in LL group. Consolidation was completed within 12months after surgery in both groups. There was no significant difference between two groups in clinical and radiographic parameters except cobb angle loss. Patients with lower lumbar fracture can be effectively managed with PPSF without fusion. PPSF following the implant removal can restore the movement of the lower lumbar spine, which is essential for daily life.

Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study.

Objective To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit. Methods Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up. Results Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p > 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p > 0.05), quality of life (EQ-5D), and return to work (DWS). Conclusion Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

A comparative study on efficacies of posterior microscopic mini-open and open technique for thoracolumbar burst fractures with severe traumatic spinal stenosis

PurposeThis study compares the efficacies of minimally invasive decompression by posterior microscopic mini-open technique combined with percutaneous pedicle fixation (hereafter MOT) to traditional open surgery in patients with severe traumatic spinal canal stenosis resulting from Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A3 or A4 thoracolumbar burst fractures and provides references for clinical treatment.MethodsIn total, 133 patients with severe traumatic spinal canal stenosis caused by AO type A3 or A4 thoracolumbar burst fractures who underwent MOT (group A) or traditional open surgery (group B) were retrospectively enrolled. The demographic and radiological data of the two groups were analyzed and compared.ResultsA total of 64 patients were finally recruited in this study. There were no significant differences in gender, age, follow-up time, injury mechanism, injury level, AO classification, American Spinal Injury Association (ASIA) score, visual analogue scale (VAS) score, and duration of hospital stay between the two groups (P > 0.05). After the procedures, the prevertebral height ratio (PHR), the Cobb angle, and the mid-sagittal canal diameter compression ratio (MSDCR) were significantly improved (P < 0.05) in both groups. However, group A demonstrated less intraoperative bleeding and a greater VAS score improvement postoperatively and at the last follow-up but involved a longer operation time (P < 0.05). The PHR and the Cobb angle in the two groups showed no significant difference postoperatively and at the last follow-up (P > 0.05). In contrast, a significant improvement in MSDCR was observed at the last follow-up when compared with the postoperative value (P < 0.05). However, the Cobb angle in group A was better maintained than in group B at the last follow-up (P < 0.05), while the MSDCR in group B demonstrated a greater improvement at the last follow-up than in group A (P < 0.05).ConclusionsBoth the MOT and traditional open surgery are effective treatment options for AO type A3 and A4 thoracolumbar burst fractures with severe traumatic spinal stenosis. The advantages of MOT include the minimally invasive procedure, extremely fine spinal canal decompression, less intraoperative bleeding, and significant pain relief. We suggest that MOT should be preferentially performed for AO type A3 or A4 thoracolumbar burst fractures with severe traumatic spinal stenosis.

Transpedicular decompression for painful AO Spine type A1 thoracic and lumbar compression fractures: case series study

Objective. To analyze dynamics of vertebrogenic pain syndrome and quality of life after transpedicular decompression in patients with depressed fractures of the thoracic and lumbar spine.Material and Methods. An observational prospective pilot study included 10 patients with AO Spine type A1 fractures of the thoracic and lumbar spine operated on in 2020–2021. All patients underwent transpedicular decompression. Severity of pain syndrome according to VAS, ODI score, and the magnitude of apical kyphosis were studied in the preoperative period and at 3 day, 1, 3, 6 and 12 month postoperative follow-up.Results. The age of patients was 35–70 years (median 46). The ratio of men and women was 1 : 4. By localization, the fractures were distributed as follows: T10 – 1 patient (10 %), T11 – 1 patient (10 %), L2 – 2 patients (20 %), T12 – 3 (30 %) and L1 – 3 patients (30 %). Statistically significant regression of pain syndrome according to VAS from 9.5 (7.3; 10.0) to 2 (1.0; 2.0) scores during the year (χ2 = 35.5, df 4, p &lt; 0.001) was observed. Noteworthy was a rapid regression of the pain syndrome 3 days after decompression from 9.5 (7.3; 10.0) to 4.5 (4.0; 6.0) and a decrease of ODI score and improvement in the quality of life of patients from 69.0 (58.5; 82.0) to 9.0 (4.8; 10.8): χ2 = 36.8, df4, p &lt; 0.001. During the follow-up period, an increase in the Cobb segmental angle from 5.3º°(4.1°; 6.7°) to 9.7°(8.4°; 12.5°) (p = 0.005) was observed in all patients. However, this did not affect the intensity of back pain or the quality of life of patients. Newly occurring fractures, Kümmel’s disease and postoperative complications were not identified. Instrumental diagnostics revealed spontaneous fusion at the fracture level during the first year after transpedicular decompression in all cases.Conclusion. Transpedicular decompression is an effective, safe and pathogenetically substantiated method of treating vertebrogenic pain syndrome associated with spinal fracture.

No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals.

The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Functional outcome of tibial pilon fractures treated with minimally invasive plate osteosynthesis in adults

Aim: The aim of the study is to assess the functional outcome of tibial pilon fractures treated with a minimally invasive plate osteosynthesis technique among adults. Materials & Methods: Patients who arrived at the orthopaedics department from 1st September 2018 to 30th September 2020 were considered for our study. Minimal Invasive Plate Osteosynthesis is the method adopted to treat pilon fractures. The mean follow-up time after surgery was six months to two years. Union time, complications, and AOFAS scores were evaluated. Results: According to AO/OTA classification, 7 patients were type A1 fractures, 4 were type A3, 2 were type A3, 3 were type B1, 1 was type B2, 1 was type C1 and 2 were type C3 fractures. The mean AOFAS score was 86.6. Minimal complications were noticed in patients. Conclusion: Minimal invasive plate osteosynthesis is a steadfast method of management for pilon fractures that delivers great fracture healing and a significant functional outcome with fewer complications.

Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1,2 intertrochanteric fractures treated with cephalomedullary nailing

Cephalomedullary nails are used widely today for pertrochanteric fractures, and intraoperative lateral wall fractures can cause adverse effects. Recently, a high incidence of coronal fragments in pertrochanteric fractures was reported when analyzed with 3D CT reconstructions. In this study, we analyzed the association between the type of coronal fragments and perioperative lateral wall fractures. Patients diagnosed with pertrochanteric fractures and treated by cephalomedullary nails at three university hospitals from September 2016 to December 2020 were examined. A total of 463 patients were included. We examined the coronal fragments and divided the patients into two groups according to the involvement of the posteromedial cortex. Postoperative X-rays were scanned for fracture lines at the blade entry site. Twenty-two patients among 463 patients had perioperative lateral wall fractures. The AO type A2 fractures, use of provisional pins, existence of coronal fragments, involvement of the posteromedial cortex, and the existence of anterior big neck fragments were significantly relevant to perioperative lateral wall fractures. 11 of 22 lateral wall fracture patients were delayed fracture patients, identified 4weeks after surgery. A coronal fragment combined by anterior big neck fragments had a 9.24 times higher risk of lateral wall fractures compared to fractures with only coronal fragments. Pertrochanteric fractures with large coronal fragments and anterior big neck fragments have a high risk of perioperative lateral wall fractures when treated by cephalomedullary nails. Surgeons should examine the width of the intact lateral wall, and take caution to preserve its integrity.

The Effect of Bone Morphology on Fracture Type and Treatment Result in Patients with Intertrochanteric Femur Fracture Aged over 65 year.

We aimed to investigate the effect of bone morphology on fracture type and treatment result in patient with inter-trochanteric fracture (IFF) treated with intramedullary nailing (IMN) aged over 65 years. Primary outcome of study was to investigate the relationship between fracture type (stable or unstable) and bone density. This was a retrospective cohort study conducted at single trauma center which included patients aged >65 years, minimum 3 months' control postoperatively, patients with simple fall by evaluating the patient data from 2010 to 2021. All fractures were classified based on the AO classification system. Proximal femoral nail anti-rotation was used between 2010 and 2016, while InterTAN was used after 2016 in our clinic practice. For the evaluation of the bone morphology, we measured the canal-to-calcar ratio (CCR) and cortical thickness index (CTI) and classified with Dorr morphology on anteroposterior (AP) hip radiograph of both the fracture side and contralateral sides. Complications were also evaluated on radiological view. Failures were defined as non-union or failure of fixation. Excessive collapse and screw/blade prominence also evaluated by hip radiograph on the 3rd month control visit. One hundred and fifty females and 59 males were included in this study. The average age was 81.6±8.8 years. One hundred and forty-four patients were treated with InterTAN and 65 patients with helical blade type IMN (PFN-A®). There were 78 patients with stable IFF type A1 fracture and 131 patients with unstable IFF (109 patients with A2 and 22 patients with A3 AO type fracture). The mean CTI was 0.469±0.09 and 0.510±0.09 in the fracture and unaffected side femurs, respectively (p<0.001), the CCR was 0.636±0.15 and 0.568±12 in the fracture and unaffected side femurs, respectively (p<0.001). There were 36 patients with Dorr type A, 115 patients with Dorr type B, and 48 patients with Dorr type C in fracture side and 65 patients with Dorr type A, 123 patients with Dorr type B, and 21 patients with Dorr type C in non-affected side (p<0.001). There were 29 (13.9%) patients with screw (n=14) and blade (n=15) prominence. Excessive collapse was seen 30 patients (14.4%) and 16 patients (7.7) evaluated as a failure. We found a significant difference in the failure rate between unstable group than stable group which higher in unstable group according to the AO classification. In addition, the mean CTI, CCR, and Dorr index were significant difference in fractured side than unaffected side which indicated lower bone quality at fracture side.

Can Vertical Laminar Fracture Further Discriminate Fracture Severity Between Thoracolumbar AO Type A3 and A4 Fractures?

To determine whether vertical laminar fracture (VLF) can distinguish between AO type A3 and A4 fractures. In a retrospective review of 111 consecutive acute thoracolumbar burst fractures, 5 reviewers independently analyzed computed tomography scans to classify fractures into A3 or A4 and to identify VLF. The following computed tomography parameters were measured: spinal canal stenosis >50%, anterior vertebral height ratio <50%, load sharing score >6, and local kyphosis >20°. We calculated the diagnostic performance of VLF in detecting A4 fracture. We compared the proportion of fractures with positive bony parameters, neurological deficit, dural tears, and surgical treatment between A3, A4 with VLF, and A4 without VLF. VLF was present in 62/75 (83%) A4 fractures and 2/36 (5.5%) A3 fractures (P < 0.0001). VLF yielded a high specificity of 94% (95% confidence interval 81%-99%) and moderately high sensitivity of 83% (95% CI 72%-91%) in detecting A4 fractures. A significantly higher proportion of A4 fractures with VLF had neurological deficit (24% vs. 0, P= 0.05), spinal canal stenosis >50% (25% vs. 0, P= 0.04), and anterior vertebral height ratio <50% (24% vs. 0, P=0.05) than A4 fractures with no VLF. Interrater and intrarater κ values for VLF and AO standard criterion were excellent (>0.85). We found VLF to be highly specific, sensitive, and reliable in detecting A4 fractures. A higher proportion of A4 fractures with VLF had radiographic parameters and neurological deficit than A4 fractures with no VLF. VLF could be used as a severity modifier to further discriminate A3 and A4 fractures regarding severity and potentially guide treatment decision making.