Union Rate Research Articles

Comparative Efficacy and Safety of Robot-Assisted vs. Freehand Screw Placement in Femoral Neck Fractures: An Updated Systematic Review and Meta-Analysis.

Background: Femoral neck fractures pose significant surgical challenges with high morbidity and mortality. Traditional freehand screw placement often yields variable outcomes. Recent robotic advancements offer a promising alternative with enhanced precision. Methods: This systematic review compares the efficacy and safety of robot-assisted versus freehand techniques. A comprehensive literature search across multiple databases up to July 2024 included studies comparing both techniques. Primary outcomes were the union rate and time, functional outcomes, operative time, intraoperative parameters, and complication rates. Meta-regression analyses identified treatment response determinants. Results: Twenty-four studies (1437 patients) were included. Robot-assisted screw placement significantly improved the union rate, reduced the union time, and showed superior functional outcomes. Additionally, it resulted in shorter operative times, less intraoperative blood loss, and fewer instances of fluoroscopy and guide pin insertion. The risk of femoral neck necrosis was notably lower with robotic assistance. Meta-regression highlighted the robot type, patient age, and sample size as significant factors. Conclusions: Despite the promise of robot-assisted screw placement, limitations exist. The evidence being mainly from China raises concerns about generalizability. The lack of long-term follow-up data hinders assessment of technique durability. Unreported surgeon expertise levels and learning curves affect result validity. High initial costs and steep learning curves of robotic systems also present barriers to widespread adoption.

Arthrodesis using Iliac Crest autograft in revision surgery of the first metatarsophalangeal joint total arthroplasty for the treatment of Hallux Rigidus: a retrospective study

PurposeThe treatments for hallux rigidus (HR) encompass a wide spectrum, including conservative methods and surgical approaches such as arthroplasty and arthrodesis. This study aims to evaluate the outcomes of revision with arthrodesis following the failure of the first metatarsophalangeal joint total arthroplasty (MTPJ1TA).Materials and methodsPatients who had surgery at two advanced orthopedic centers between January 1, 2020, and January 1, 2024, were reviewed. Those with at least 6 months of postoperative follow-up were assessed for demographics (gender, age, side), reoperation rates, complications, Visual Analogue Scale (VAS) scores, Foot and Ankle Disability Index (FADI) scores, and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal and Interphalangeal Scale (AOFAS-HMI) scores. Radiological evaluations included hallux valgus angle (HVA), intermetatarsal angle (IMA), dorsiflexion angle (DFA), and first ray length (FRL) in anteroposterior and lateral views.ResultsOf 27 patients, 4 were male (15%) and 23 female (85%), with an average age of 56.18 ± 7.49 years (range 41–72). Arthrodesis was performed in 26 patients, with one requiring reoperation due to implant failure. Average VAS scores were 7.14 preoperatively and 3.55 postoperatively (p < 0.05). Average FADI scores were 50.51 preoperatively and 71.51 postoperatively (p < 0.05). Average AOFAS-HMI scores were 51.22 preoperatively and 70.59 postoperatively (p < 0.05). Average HVA was 19.7° preoperatively and 6.29° postoperatively (p < 0.05). Average IMA was 10.66° preoperatively and 11.37° postoperatively (p = 0.406). Average DFA was 34.14° preoperatively and 22.33° postoperatively (p < 0.05). Average anteroposterior FRL was 10.17 cm preoperatively and 10.77 cm postoperatively (p < 0.05). Average lateral FRL was 10.12 cm preoperatively and 10.42 cm postoperatively (p < 0.05). None of the patients in the study exhibited postoperative donor site complications or transfer metatarsalgia, while a 100% rate of bone union was observed.ConclusionWe think that revision of MTPJ1TA with arthrodesis is a safe treatment option. Additionally, the use of an iliac crest autograft can be a viable option to restore bone stock and create a biological environment conducive to fusion. This study evaluates revision surgery with arthrodesis in the largest patient group with failed MTPJ1TA, highlighting its significance in the field. However, further studies are needed to determine the ideal surgical procedure.

The Ilizarov Technique: A Dynamic Solution for Orthopaedic Challenges.

The Ilizarov technique is one of the most important tools that is currently employed in bone reconstruction surgeries. Its inception dates back to the mid-20th century and involves various bone reconstruction methodologies implemented using a circular external fixator system devised by G. A. Ilizarov. The key advantages of this approach include the generation of viable new bone via distraction osteogenesis, high union rates, and the functional utilization of the limb during the treatment process. The exploration of distraction osteogenesis phenomenon triggered by tensile stress with the Ilizarov device served as a catalyst for progress in bone reconstruction surgery. Subsequently, the original technique has been utilized alongside several adaptations resulting from the introduction of novel fixation tools and methods of their application, such as hexapod external fixators and motorized intramedullary lengthening nails. It is crucial to possess a precise comprehension of the Ilizarov principles of deformity correction in order to effectively utilize this fixation system. In this article, we will discuss the history of Ilizarov frame, the basic sciences behind it, the mechanical principles governing its use, and the clinical application of the fixation system in our daily practice.

Ilizarov Distraction for Congenital Pseudoarthrosis of the Tibia in Adults.

The clinical evidence on the management for congenital pseudoarthrosis of the tibia (CPT) in adults is limited. The aim of this study is to assess the functional and radiological outcomes of Ilizarov distraction for treating CPT in adults. A retrospective analysis was conducted. Between 2013 and 2022, an Ilizarov distraction technique was performed on 14 adults (14 limbs) with CPT in our limb deformity center. There were seven females and seven males with a mean age of 33.7 (range, 18 ~ 53) years. The diagnosis of NF-1 was confirmed in seven (50.0%) patients. Eight patients had a history of previous surgical failure. The pseudoarthrosis occurred in the middle and lower tibia in all limbs (six left and eight right). The CPT was classified by Crawford classification and Paley classification. The surgical procedures, external fixation time (EFT), and all outcomes and complications were recorded. The Kolmogorov-Smirnov test was performed to test the normality of the data. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score at the preoperative and final follow-up was compared by using the Wilcoxon's signed-rank test. The limb-length discrepancy (LLD) and a self-made exercise capacity score at the preoperative and final follow-up were compared by using the student's t-test. The clinical and radiological outcomes were assessed by the Inan scale. The mean EFT of Ilizarov fixator was 19.5 months (range, 7.3 ~ 39.1). At a median follow-up of 26.8 months (IQR, 20.2 ~ 34.3), bone union of the pseudarthrosis and consolidation of the distraction zone were achieved in all patients. The mean LLD was decreased from 11.3 cm (range, 3.4 ~ 17.3) preoperatively to 1.1 cm (range, 0.3 ~ 3.7) (p < 0.05). The mean or median AOFAS ankle-hindfoot score was improved from 53.5 (IQR, 26.5 ~ 60.5) preoperatively to 63.9 (range, 53 to 73) at final follow-up (p < 0.05). The mean score for exercise capacity were improved from 4.9 (range, 1 to 8) preoperatively to 9.6 (range, 7 ~ 12) at final follow-up (p < 0.05). According to the criteria described by Inan et al., the clinical results were classified as good in 10 and fair in 4, while the radiological results were classified as excellent in three, good in 8, and fair in 2. The success rate was 92.9%, as refracture was defined as treatment failure and occurred in one patient. Ilizarov distraction provided a suitable treatment option for the CPT in adults, as it could achieve a high rate of bone union, a good correction of secondary deformity, a low risk of refracture, and consequently restore a relatively functional limb.

The Gradual Correction of Rigid Pes Cavus Using Midfoot Osteotomy Combined with Ilizarov Methods.

Midfoot osteotomy combined with Ilizarov methods of correction is a rarely reported treatment that is particularly well-suited for severe rigid pes cavus. The study aimed to assess the radiological and clinical results of patients who had been treated for rigid pes cavus using this method. The study retrospectively analyzed the clinical and radiological data of 15 pes cavus in 12 patients who were corrected by midfoot osteotomy with Ilizarov external frame in our department from March 2020 to September 2022. Radiologic outcomes were measured using the Meary angle (MA), talus-first metatarsal angle (TM1A), calcaneal varus angle (CVA) and foot length with weight-bearing radiographs. Functional assessments were evaluated in terms of pain, function, and quality of life by using the visual analogue scale (VAS), the American Orthopedic Foot and Ankle Society hindfoot scale score (AOFAS), and 36-item Short Form Health Survey (SF-36). Additionally, the postoperative satisfaction of patients was investigated by a questionnaire. The clinical and radiological results were evaluated by a paired t-test. All patients received plantigrade feet and pain relief. The mean follow-up was 33.1 ± 5.0 months (range from 25 to 41 months). The etiology included poliomyelitis (4), idiopathic (3), trauma (2), spina bifida (2) and tethered cord syndrome (1). The duration of gradual correction was 30.4 ± 10.6 days, and the external fixation time was 116.3 ± 33.3 days. The bony union rate was 100%. The VAS, AOFAS, and SF-36 scores significantly improved (p < 0.05). The MA, TM1A, and CVA were close to or reached the normal range postoperative (p < 0.01). The length of each foot was well preserved, which was increased more than 0.8 cm than preoperative. No major complications were reported except two cases of mildly hindfoot varus deformity. The results of the questionnaire showed that patients' satisfaction was 92% (11/12). Midfoot osteotomy combined with Ilizarov external frame proved to be a reasonable procedure with satisfying mid-term results for the gradual correction of rigid pes cavus.

Clinical and radiographic outcome of tension band suture fixation for displaced olecranon fractures

BackgroundTension band wire fixation (TBW) is a well-described method for treating displaced olecranon fractures. Further surgery is often needed due to wound breakdown or prominent hardware. An all-suture technique has recently been described as an alternative to TBW but radiographic and clinical outcome are not well established. The aim of this single-center retrospective cohort study was to evaluate outcome after treatment with all-suture technique for simple displaced olecranon fractures.MethodsA retrospective review of olecranon fractures in patients (> 18 years) treated for displaced olecranon fractures with tension band suture fixation (TBSF) between February and August 2019 was performed in our facility. Primary outcome was revision surgery, which was assessed four years after surgery. Clinical and radiographical follow-up was performed at two weeks, six weeks, three months and six months to assess union rate, fracture displacement, range of motion (ROM), Quick-DASH and Oxford Elbow Score.ResultsA total of 24 patients were included. Median age was 64 years [IQR:39–73], 9 patients were male and median ASA score was 2 [IQR:1–2]. 15 fractures were Mayo type 2 A and 9 type 2B with minor comminution. At four-year follow-up, three patients had died. None of the remaining 21 patients had undergone revision surgery. At six months, the median Quick-DASH and Oxford Elbow Score were 2.3 [IQR:0-4.5] and 47 [IQR:46–48], respectively. Median elbow extension and flexion deficits were 0° [IQR:0-2.25] and 0° [IQR:0–0], respectively. Radiographic union was achieved in all patients. In two cases radiographic loss of reduction and malunion was observed but both patients were asymptomatic and had no functional deficits. One patient refractured the elbow due to a second trauma and was reoperated.ConclusionsTBSF is a promising technique for Mayo type 2 A and 2B fractures with minor comminution. There were no revision surgeries within the first four years. We found good functional outcomes and a high union rate.

Unionization rates, inequality, and poverty in Canadian provinces 2000–2020

Unions can increase the power of workers through both collective bargaining and political avenues, potentially creating less income inequality and poverty. However, this potential may not be realized. Drawing on power resource theory, this study uses panel data to investigate the connection between unionization and two measures of after-tax inequality – the income share of the top 1% and the Gini coefficient – and three measures of poverty – the percentage of the population below the low-income cut-off, the average income of the bottom decile, and the percent of the population below the low-income measure – between Canadian provinces from 2000 to 2020. We find that unionization is negatively associated with income inequality in Canada. This relationship is statistically significant. However, we do not find evidence of any statistical association between unionization and poverty in Canada.

TROCHANTERIC OSTEOTOMY AND TRANSFER DURING TOTAL HIP ARTHROPLASTY IN PATIENTS WITH DISLOCATED DYSPLASTIC HIPS: UNION RATE USING MONOFILAMENT TRANSVERSE WIRE CERCLAGE

Securing the osteotomized greater trochanter (GT) during total hip arthroplasty (THA) for dislocated dysplastic hips (DDH) poses a significant challenge. This study evaluates the union rate and effectiveness of a 2-strand transverse wiring technique utilizing the lesser trochanter for wire anchorage and tensioning.A digastric anterior slide trochanteric osteotomy was performed in 106 patients (118 hips) undergoing THA for DDH. Following uncemented stem insertion, the GT was transferred and fixed to the lateral cortex of the proximal femur using monofilament stainless steel wires. In 72 out of 106 patients (80 hips), the GT was fixed with 2 transverse wire cerclages threaded through 2 drill holes in the base of the lesser trochanter, spaced vertically 5–10 millimeters apart. The wires were wrapped transversely over the GT and tightened, avoiding contact with its tendinous attachments. Patients were regularly monitored, and GT union was assessed clinically and radiographically.Patient ages ranged from 20 to 57 years (mean 35.5), with a follow-up period ranging from 1.5 to 12 years (mean 6.2). The mean union time was 3.3 months (range 2–7). Among all hips, two developed stable nonunion and single wire breakage, but no fragment displacement (2.5%). Two hips exhibited delayed union, eventually healing at 6 and 7 months after surgery.Reattachment of the greater trochanter utilizing a 2-strand transverse wire cerclage anchored at the base of the lesser trochanter demonstrated a high rate of union (97.5%) following THA in dislocated DDH cases.

Addressing the challenges of complex type III odontoid fractures: Clinical and radiological outcomes of various treatment modalities

BackgroundUnlike simple fractures, complex Type III odontoid fractures—characterized by intricate morphology and pathomechanics—pose significant management challenges. This study aims to evaluate the clinical and radiological outcomes of conservative and surgical treatment modalities for these complex fractures, with a focus on assessing factors influencing fracture union. MethodsFollowing approval of our institutional review board, this retrospective observational cohort study was conducted. All Patients with complex Type III odontoid fractures who were managed at our center from June 2016 to December 2022 were assessed for eligibility. The primary outcome was union status. Secondary outcomes included the ASIA impairment scale, neck disability index (NDI), and complications. Logistic regression analysis was conducted to identify risk factors for adverse union outcomes. ResultsA total of 39 patients were included in the final analysis, with a mean age of 36.10 years. Nine patients were managed conservatively, 12 patients underwent anterior odontoid screw (AOS) fixation, and 18 patients received posterior fusion (PF). The rate of bony union varied significantly across the treatment groups, 100 % in the PF group, 58 % in the AOS group and 22 % in the conservative group (p = 0.0012). The NDI revealed superior functional outcomes in the PF group compared to the other groups (p = 0.0436). Failure of primary treatment was observed in seven patients (three from the conservative group and four from the AOS), necessitating secondary treatment with PF. Lateral mass gap >2 mm, coronal tilt >5°, and atlantoaxial instability >50 % were identified as significant risk factors for adverse union outcomes. ConclusionsSurgical treatment, particularly PF, offers superior outcomes in terms of union rates and functional recovery for complex Type III odontoid fractures. The identification of specific radiological measurements as significant risk factors for non-union underscores the need for detailed imaging and careful patient selection for conservative versus surgical management.

Rigid Thoracolumbar Orthosis Does Not Improve Outcomes of Acute Adolescent Spondylolysis as Compared with Placebo. Bony Union Predicts Improved Health-Related Quality of Life Outcomes at 2-year Follow-Up.

A prospective, comparative study on clinical, radiographic, and health-related quality of life (HRQoL) outcomes in adolescents with acute spondylolysis treated with a rigid thoracolumbar orthosis (Boston brace) or with a placebo (elastic lumbar support) with a 2-year follow-up time. To compare outcomes of acute adolescent spondylolysis treated with a rigid thoracolumbar orthosis or a placebo with a 2-year follow-up time. The benefits of the use of rigid orthosis for treatment of spondylolysis and achieving bony union of spondylolysis remains unclear. Sixty consecutive patients with acute spondylolysis were prospectively enrolled. Three patients were excluded from analysis as they did not fulfill inclusion criteria. First 14 patients were randomized and the remaining 46 chose treatment method themselves. Treatment time was four months and follow-up time was two years. HRQoL was measured using Scoliosis Research Society-24 (SRS-24) outcome questionnaire. The primary outcome was the HRQoL at 24 months and whether treatment type, bony union of the spondylolysis or development of spondylolisthesis affected it. Thirty (30/57) patients were treated with a Boston brace and twenty-seven (27/57) patients with a placebo. The bony union rate of spondylolysis did not differ between study groups (20/30 vs 17/27, respectively, P=0.789). The HRQoL did not differ between treatment groups in the SRS-24 domains through follow-up (P>0.05 for all). Five patients (5/57) developed spondylolisthesis (mean slip 4.2mm) during two-year follow-up time. Non-union of the spondylolysis predicted development of spondylolisthesis (P=0.005), but treatment type did not affect it (P>0.05). Two years after treatment patients who had bony union had higher SRS-24 total (P=0.005) and satisfaction domain (P<0.001) compared to patients with non-union. A rigid brace is not necessary for treatment of acute spondylolysis. Achieving bony union of adolescent spondylolysis is desirable as their HRQoL is higher at two years. II.

Free vascularized medial femoral condyle periosteal flaps in the ankle and foot region: A narrative review.

The objective of this study was to determine the role and reliability of the free medial femoral condyle (MFC) flap (MFCF) in demanding foot and ankle reconstruction procedures. A search of the MEDLINE, PubMed, and Embase electronic databases was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines between January 2008 and September 2023. Articles concerning free MFC bone flaps for reconstruction of the foot and ankle regions were included. Outcomes of interest included flap failure, complications, union rate, time to union, and functional scores. Twenty studies involving 131 patients met the inclusion criteria. The most common clinical indications for the free MFCF were nonunion, avascular necrosis, and osteomyelitis. The most common sites of nonunion were tibiotalar arthrodesis (50%) and subtalar arthrodesis (33%). Overall, the bony union rate was 93.1%, with a mean time to union of 14.6±0.1 weeks. There were no flap failures reported. Postoperative complications were observed in 39 (29.7%) cases (e.g., delayed donor site wound healing, flap debulking, medial condyle osteonecrosis, and donor site numbness), with 21 (16%) patients requiring further operative intervention. No major donor or recipient site morbidity occurred, except for one case. Free MFCFs offer a versatile and dependable choice for cases of foot and ankle reconstruction, displaying favorable rates of bone fusion and acceptable complication rates. Existing literature indicates that MFC reconstruction in the foot and ankle is not associated with significant morbidity at the donor or recipient sites. The pooled data demonstrated a 93% success rate in achieving bone fusion in the foot and ankle region, supporting the view that it can be considered another option of treatment.

Risk factors for delayed bone union in opening wedge high tibial osteotomy.

The purpose of this study was to investigate the relationship between patient demographics and potential intraoperative factors and delayed bone union in opening wedge high tibial osteotomy (OWHTO). A retrospective review of 65 patients (37 females, 28 males; mean age: 60.1±10.1 years; range, 44 to 77 years) who underwent OWHTO using an angle-stable implant with beta-tricalcium phosphate gap filling between September 2016 and October 2019 was conducted. The osteotomy site was divided into five zones from the lateral hinge on anteroposterior radiographs, and we defined the zone in which bone healing was observed. The bone union area was assessed according to this definition at three, six, nine, and 12 months after surgery, and bone union was defined as union at the fourth zone or greater. A generalized estimating equations approach was employed to investigate longitudinal data pertaining to bone union area as a dependent variable. In addition, the association of bone union at six months postoperatively and predictors were evaluated using cross-sectional statistical methods. The categorical predictors included in the models were smoking, diabetes, hinge fracture, and autologous osteophyte grafting. The continuous variables included in the models were age, body mass index, opening gap width, and plate position. Smoking (odds ratio [OR]=0.478, p<0.01), large opening gap width (OR=0.941, p=0.014), and anterior plate placement (OR=0.971, p<0.01) were significantly associated with decreased bone union area. Union rate at six months in smokers was significantly lower compared to nonsmokers (16.6% and 67.8%, respectively; OR=0.10, p=0.023). Area under the curve in the receiver operating characteristic analysis for bone union at six months was 0.60 for gap width and 0.63 for plate placement. Smoking, large opening gap width, and anterior plate placement are risk factors for delayed bone union after OWHTO. Surgeons should avoid anterior placement of the plate and carefully consider other options for smokers and those who require a large correction.

Assessment of functional and radiological outcomes of suprapatellar and infrapatellar approaches of tibial nailing in patients with tibial shaft fracture: A randomized control study

BackgroundThe study aimed to assess functional and radiological outcomes of the suprapatellar approach (SPA) and infrapatellar approaches (IPA) of tibial nailing in patients with closed tibia shaft fractures. MethodAfter Institutional Ethical Committee (IEC) and Clinical Trials Registry- India (CTRI) approval, patients with Orthopaedic Trauma Association (OTA) fracture type 42 were enrolled from August 2021 and August 2022 at a level I trauma centre and randomized to SPA and IPA with informed consent. Demographics, American Society of Anaesthesiologists (ASA) physical grading, intraoperative fluoroscopy time, operative duration, bleeding, postoperative radiographic alignment, and union were compared among both approaches. Functional parameters like Lysholm knee score, Anterior knee pain (AKP), Visual Analog Scale (VAS) Score upon kneeling, Knee Injury and Osteoarthritis outcome score (KOOS), KOOS Patellofemoral score (KOOS PF), EuroQol (EQ5D5L), Forgotten joint score (FJS), Range of motion (ROM) of knee and any complications were assessed at 3,6 and 12 months postoperatively. ResultsPer protocol analysis of 50 patients (25 SPA, 25 IPA) done at the end of the study. SPA group had significantly lesser fluoroscopy time (91.28 ± 12.40s vs. 105.36 ± 9.23s, p < 0.001) and operative duration (mins) (123.80 ± 24.25 vs. 130.00 ± 18.20, p < 0.001) than IPA. No significant differences were noted in Lysholm knee score at three months (p = 0.094), six months (p = 0.406), and 12 months (p = 0.071). The SPA group showed significantly lower VAS Score upon kneeling at six months (p < 0.0001). Similarly, KOOS (p < 0.001), KOOS PF (p = 0.01), and EQ 5D5L (p = 0.03) were significantly better in the SPA group at six months postoperatively. Lower Coronal translation was found in SPA [0 (0–1.8) vs. 1.4 (0.9–1.8), p = 0.010]. Whereas, IPA had higher range of flexion at 3 months [130.0 (129.0–135.0) vs 123.1 (120.0–130.5), p = 0.047]. However, no significant differences were noted in blood loss, AKP, FJS, EQ-VAS, coronal angulation, sagittal malalignment, time to union, return to work and postoperative complications among the groups. ConclusionSPA has lesser surgery time, more straightforward anatomic fracture reduction, better fracture alignment, lesser radiation exposure for both patients and surgeons, quicker recovery time, and promotes early kneeling activities with similar long-term functional outcomes and union rates, and can be considered in routine clinical practice than conventional IPA.

Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures.

Angular deformities of the tibia and femur lead to mechanical axis deviation (MAD) of the lower limb and malorientation of the joints adjacent to the deformity. The current study analyses the outcomes of using a medial closing wedge high tibial osteotomy (MCWHTO) for the management of genu valgum with high medial proximal tibial angle (MPTA), and combined MCWHTO with lateral opening-wedge distal femoral osteotomy (LOWDFO) in the setting of concomitant genu varum with low lateral distal femoral angle (LDFA). There were 18 high tibial osteotomy (HTO)-only and 13 combined HTO + distal femoral osteotomy (DFO) procedures performed. The primary radiographic outcome variables included postoperative MPTA and MAD (in mm). The accuracy of MAD correction was expressed as a percentage. The postoperative posterior proximal tibial angle (PPTA) and limb length discrepancy (LLD) were also measured as secondary radiographic outcome variables. The clinical outcome variables included intraoperative surgical complications (e.g., hinge fracture), all-causes for revision, union rate, time to union, and postoperative knee range of motion. Functional outcomes used included the LDSRS, PROMIS, and EuroQOL scores. The mean preoperative MPTA was 92.9° (SD = 1.81, range: 88-96). After surgical correction, the mean MPTA was 86.0° (SD = 1.80, range: 83-90) (p < 0.0001). The mean preoperative MAD was 32.5 mm (SD = 20.16, range: 10-77) lateral to the centre of the knee joint. The mean postoperative MAD was 2.44 mm medial to the centre of the joint (SD = 7.13, range: 13 medial - 15 lateral) (p < 0.0001). The mean change in MAD achieved through surgical correction was 38.16 mm (SD = 17.94, range: 13-77). The accuracy of MAD correction was 96.1% (SD = 0.06%, range: 81.25-100%). The time to unassisted WB was a mean of 75 days (SD = 44.5, range: 44-242).There was a single stable hinge fracture and one case of chronic regional pain syndrome diagnosed. There were no cases of non-union and no indications for revision surgery in any case. Medial closing wedge high tibial osteotomy is an effective surgical procedure for the management of genu valgum deformity. The MPTA, LDFA, and MAD can be accurately corrected without significantly altering PPTA or limb length. It may be combined with open lateral distal femoral osteotomy for cases with femoral and tibial contributions to deformity without significantly impacting clinical outcomes. Functional outcomes, specifically relating to self-image are significantly improved after the MCWHTO has been performed. Sheridan GA, Page BJ, Greenstein MD, et al. Medial Closing Wedge High Tibial Osteotomy Accurately Corrects Genu Valgum without Iatrogenic Deformity or Complications: A Consecutive Series of Thirty-one Procedures. Strategies Trauma Limb Reconstr 2024;19(2):82-86.

Clinical and Radiographic results of a Retrograde Nail - Washer Combination Versus Lateral Locked Plating for Distal Femur Fractures.

The objective of this study was to report outcomes of the Retrograde Femoral Nail-Advanced with Lateral Attachment Washer (RFNA-LAW) (Synthes; Paoli, PA) compared to laterally locked plates (LLP) when treating AO/OTA type 33 distal femoral fractures. Design: Retrospective chart review. Single, academic, Level-1 Trauma Center. All adult patients who had fixation of an AO/OTA type 33 distal femoral fracture with the RFNA-LAW combination or LLP from 2018-2023 with follow-up to union or a minimum of one year. immediately post-operatively and at final follow-up. The main outcome measure was union. Secondary outcomes included implant failure, infection, and alignment immediately post-operatively and at final follow-up. Patients were followed for a minimum of 1-year or to skeletal healing. Forty-eight patients (19 female) with a mean age of 56 years (range 19-94 years) were in the RFNA-LAW group. Fifty-three patients (29 female) with a mean age of 66 years (24-91 years) were in the LLP group. There were no significant differences when comparing Body Mass Index, diabetes, smoking status, mechanism of injury, or fracture classification between groups (p>0.05). There was no difference in immediate, post-operative alignment (p = 0.49). When comparing aLDFA measurements at final follow-up, there was significantly more malalignment in the LLP group (p = 0.005). There were 8 implant failures (15%) in the LLP group compared to 1 in the RFNA-LAW group (2%) (p = 0.02). There were 14 reoperations (26%) in the LLP group compared to 4 (8%) in the RFNA-LAW group (p = 0.02). The Retrograde Nail Advanced - Lateral Attachment Washer combination demonstrated a high union rate when treating complex fractures of the distal femur. When compared to lateral locked plating, this implant combination demonstrated significantly lower rates of nonunion and reoperation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of clinical and radiographic outcomes of bilateral versus unilateral ramus fixation in straddle fractures with posterior pelvic ring injury.

Superior and inferior ramus fractures, termed straddle fractures, are high-energy fractures often accompanied by unstable pelvic ring injuries. However, consensus is lacking regarding indications for surgical treatment or fixation methods. We aimed to compare clinical and radiological outcomes of unilateral ramus fixation (URF) and bilateral ramus fixation (BRF) for straddle fractures with unilateral posterior pelvic ring injuries. We enrolled 118 patients (73 males, 45 females; mean age, 47 years) diagnosed with straddle fractures between March 2015 and December 2021 with > 1 year of follow-up. Patients were divided into URF (n = 60) and BRF (n = 58) groups based on the anterior pelvic ring fixation method. Preoperative factors including body mass index, diabetes, smoking, injury mechanism, injury severity score, American Society of Anesthesiologists classification system, Tile classification, and Young and Burgess classification were compared. Intraoperative blood loss, operation time, postoperative bone union rate, complications, and the need for additional surgeries were analyzed. There were no statistically significant preoperative differences between the two groups. However, the URF group showed a significantly lower mean operative time and blood transfusion requirement (63min and 2 units, respectively) than the BRF group (104min and 3 units, respectively) (both p < 0.001). Postoperatively, bone union was achieved in 57 (95.0%) and 56 (96.6%) patients in the URF and BRF groups, respectively. Complications occurred in 17 (28.3%) and 14 (24.1%) patients in the URF and BRF groups, respectively, with additional surgeries needed in 3 (5.0%) patients in the URF group and 2 (3.4%) patients in the BRF group. Unilateral anterior fixation can provide sufficient stability and clinical effectiveness in the surgical treatment of straddle fractures in areas with posterior pelvic ring injuries. Compared with bilateral anterior fixation, unilateral fixation significantly reduces operation time and blood loss, making it a viable fixation method for straddle fractures.

Pilot study of three novel implants–GSK triangular system, locking hip screw and controlled sliding dynamic hip screw, for fixation of fracture of the neck of femur

Background and objectiveIntra capsular fracture of the neck of femur (FNF) treated traditionally with a dynamic hip screw (DHS) or three cancellous screws (3CS) has a high incidence of complications with reoperation rates between 20 % and 45 %. We hypothesized that FNF unites by primary healing. Therefore, intra-operative compression and absolute stability post-operatively until healing are essential. We postulated that FNF requires 2 types of implants- those which provide absolute stability for young patients with good bone stock and another with sliding mechanism for elderly patients with osteoporosis. We developed three novel fixation systems at our research institute in India using a modified DHS. In patients with good bone stock, locking DHS, called LHS and GSK triangular system (GSKT) provided intra-operative compression and absolute stability during the post-operative period. In those with poor bone stock, the controlled sliding DHS (CSDHS)was used as a locking implant might penetrate the hip joint. Materials and method42 patients of FNF <55 years of age were studied. Among 39 patients with good bone stock, LHS was used in five patients and GSKT system was used in 34 patients. CSDHS was used in three patients with poor bone stock or communition. The patients were followed up for a minimum of eight months up to a maximum of two years, with the average follow up duration of 14 months. Results32 out of 34 fractures treated by GSKT system united. Five cases managed by LHS and three by CSDHS, all united. The union rate was 95.2 %. Of the two failed cases, one patient had nonunion (NU), the other had deep infection. Avascular necrosis of the head (AVN) was detected in three patients treated with GSKT system in the second year following surgery. Two of them had hip pain while one was asymptomatic. Eight cases of FNF Pauwels type III underwent a primary valgus osteotomy. All of them united without complications. ConclusionIn patients with good bone stock, LHS and GSKT system allowed intra-operative compression and absolute post-operative stability without sliding of head fragment as the triangle construct is biomechanically the strongest. When bones are osteoporotic, a CSDHS provided controlled sliding (1 to 5 mm only). This pilot study showed a promising success rate of 95.2 %. We propose that the GSKT system may be used to treat intertrochanteric and other metaphyseal fractures as well. Further biomechanical studies are underway to strenghten the evidence needed for the widespread use of these implants.

Graft choice for managing scaphoid non-union: umbrella review

IntroductionSince the introduction of the non-vascularized bone graft by Matti and Russe, followed by vascularized grafts and more recently by free vascularized bone grafts, the choice of technique in scaphoid non-union has been controversial. The purpose of the present study was to address the following questions in an umbrella review: Do union rates differ between techniques? Is there any evidence that one technique is superior to another? MethodsAn umbrella review conducted during September 2023 month included systematic reviews and meta-analyses. The primary criterion was mean union rate according to technique. The secondary criterion was indication according to type of non-union. The PubMed, Cochrane, and MEDLINE databases were searched using a predefined methodology according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA version 2020). The quality of the systematic reviews included was evaluated by the “Assessing the Methodological Quality of Systematic Reviews” instrument (AMSTAR 2). ResultsNine studies (systematic reviews or meta-analyses) were included. Quality ranged between low and high. A Table was constructed to summarize the qualitative findings of each article. There was no significant difference in union rates between vascularized and non-vascularized bone grafts in 8 of the 9 studies: vascularized bone graft, 84–92%; non-vascularized bone graft, 80–88%. One study found higher union rates with vascularized bone graft (RR 1.1; 95% CI 1.0–1.2; P = 0.02), but no significant difference in functional results. However, vascularized bone graft was more effective in case of avascular necrosis of the proximal pole (74–88% union for vascularized bone graft vs. 47–62% for non-vascularized bone graft) and in revision cases, while non-vascularized bone graft showed fewer failures in case of humpback deformity and/or dorsal intercalated segment instability (IRR 0.7 ± 0.09; P = 0.01). ConclusionsThis umbrella review provides an overview for management of scaphoid non-union. There were no significant global differences between techniques. Thus, various factors need to be considered when selecting the appropriate technique.

Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty?

This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. A retrospective review was conducted of patients > 50years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8weeks, p = 0.005). Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. : Level III, Retrospective Comparative Study.

Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center.

The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures. A prospectively maintained database was retrospectively interrogated. Single major trauma center in the United Kingdom. All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors. The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases. Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%). Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.