Varus Displacement Research Articles

Biomechanical investigation of positive reduction in the femoral neck fracture: a finite element analysis.

Gotfried positive reduction offers an alternative strategy for femoral neck fracture (FNF) when achieving anatomical reduction is challenging. However, the biomechanical consequences of positive reduction remain unclear. The purpose of this study was to investigate the biomechanical behavior of positive reduction across different Pauwels classification, providing a reference for quantifying positive reduction in clinical practice. Three-dimensional (3D) models of FNF were established and categorized according to the Pauwels classifications (Pauwels I, II, and III), each of them contained seven models with different reduction qualities, including an anatomical reduction model, two negative reduction models, and four positive reduction models, all of which were stabilized with dynamic hip screws (DHS) and cannulated screws (CS). We investigated the maximal von-Mises stress of internal fixation and proximal femoral, femoral fragment displacement, and maximal von-Mises strain at the proximal fragment fracture site when a 2100N load was applied to the femoral head. The maximum von-Mises stress on the internal fixators in each Pauwels group was lowest in the anatomical reduction model. In the Pauwels I group, positive reduction exceeding 3mm resulted in the maximum von-Mises stress on the internal fixators surpassing that of the negative reduction model. For the Pauwels II group, positive reduction beyond 2mm led to the maximum von-Mises stress on the internal fixators exceeding that of the negative reduction model. In the Pauwels III group, positive reduction beyond 1mm caused the maximum von-Mises stress on the internal fixators to be higher than that of the negative reduction model. The maximum von-Mises strain at the fracture site of proximal femur fragment increased with positive reduction. Varus displacement increased in positive reduction models as the Pauwels angle rose, potentially exacerbating rotation deformity in Pauwels III group. Excessive positive reduction may increase the risk of FNF failure after internal fixation. From a biomechanical stability perspective, positive reduction should be limited to 3mm or below in the Pauwels I group, restricted to not exceed 2mm in the Pauwels II group, and should not exceed 1mm in the Pauwels III group. Negative reduction should be avoided in all Pauwels groups.

Minimally Invasive Chevron Akin Osteotomy: Preoperative Planning Using the Radiographic First-Ray Squeeze Test.

Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic first-ray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure. A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic first-ray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively. Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001). The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure.Level of Evidence: Level III, prospective cohort study.

Effect of the Initial Deformity in the Coronal Plane on Postoperative Outcome of Proximal Humeral Fractures.

There is currently no consensus on proximal humerus fractures with an initial deformity in the coronal plane who are better off with plates or nails, so we designed this study. To compare the effect of the initial deformity in the coronal plane of proximal humerus fractures on postoperative outcomes, we compare the maintenance of reduction in procedures utilizing plates and nails, and analyzed the subsequent occurrence of complications to explore whether the initial deformity should dictate the fixation approach. The clinical data of patients with proximal humerus fractures who were hospitalized and underwent surgical treatment in our hospital from January 2016 to December 2020 were reviewed. Postoperative functional scores (American Shoulder and Elbow Surgeons, ASES; Constant-Murley Score, CMS), Neck-shaft angle (NSA), Quality of fracture reduction, Deltoid Tuberosity Index (DTI), and complications were compared among cases with initial varus, normal, or valgus deformities. We included 131 patients, 56 males and 75 females, with a mean age of 60.89 ± 5.53 years (range 50-76) and a mean follow-up duration of 16.63 ± 6.78months (range 12-48). Of these, 29 cases had initial varus displacement, 71 had a normal NSA, and 31 had initial valgus displacement. Seventy-five were treated with a locking plate and 56 with a nail. After open reduction and internal fixation, the NSA was restored to normal (-135°) in all patients in all groups (P > 0.05). There was a significant difference in NSA changes at the last follow-up; 2.93° ± 2.12° in the varus group, 1.77° ± 1.18° in the normal group, and 2.32° ± 1.64° in the valgus group, with the highest change occurring in the varus group. There was no significant difference in the range of motion or functional scores including ASES and CMS among the three groups (P > 0.05). The complication rate of 20.7% in the varus group was significantly higher than the complication rates of 12.7% in the normal and 12.9% in the valgus groups (P < 0.05). While proximal humerus fractures with initial coronal displacement (varus, normal, and valgus) show similar postoperative functional outcomes, varus fractures have a higher rate of complications. The nail provides better maintenance of reduction than the locking plate, especially in varus fractures.

It Is Always the Same—A Complication Classification following Angular Stable Plating of Proximal Humeral Fractures

The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2-4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.

Morphological Analysis of Fractures of the Proximal Humerus by the Fracture Mapping Technique.

Fractures of different parts of the proximal humerus may lead to different postoperative functional deficits, but there are few studies on the morphology and related functions of the proximal humerus. The purpose of this study was to analyze the fracture pattern of the proximal humerus by the three-dimensional (3-D) fracture mapping technique and to further evaluate its clinical utility. Patients with proximal humeral fractures admitted to Pudong Hospital, Fudan University, from January 2018 to December 2020, were analyzed. Three surgeons divided the fractures into groups according to the 3-D CT imaging technique and mapped the fractures on a 3-D template according to the fracture line of each fracture. Finally, the humeral head inversion angle and the functional score were recorded in different fracture types. A total of 312 cases of humeral fractures were included. Among them, there were 90 patients (28.8%) in the simple greater tuberosity + lesser tuberosity + medial cortex group, with typical fracture features of surgical neck fractures of the humerus + greater tuberosity fractures. Eighty-seven patients (27.9%) in the greater tuberosity + isolated fragment lesser tuberosity + medial cortex group had typical "four-part fractures." There were 45 patients (14.4%) in the greater tuberosity + lesser tuberosity + medial isolated fragment group. Moreover, more patients in this group had medial comminution due to varus displacement of the femoral head. There were 66 patients (21.1%) in the isolated greater tuberosity group, 21 patients (6.7%) in the greater tuberosity + lesser tuberosity group, and three patients (1.0%) in the greater tuberosity + medial cortex group. In addition, the humeral head inversion angle and other statistical differences were observed in the greater tuberosity + lesser tuberosity + medial isolated fragment group. This morphological study helps to further identify the characteristics of proximal humerus fracture patterns, which may be closely related to different clinical outcomes. Further relevant studies are needed to verify the reliability of their clinical application and the potential value in surgical planning and postoperative functional rehabilitation.

Clinical and Radiological Outcome of Dual Plating for Proximal Humerus Fractures.

Introduction Proximal humerus fractures account for approximately 4%-5% of all fractures. It accounts for approximately 45% of all humeral fractures. Proximal humerus fractures which are mostly stable or minimally displaced fractures are usually managed non-operatively with good outcomes. Displaced or unstable fractures may require reduction and stabilization. For proximal humerus fractures, conservative treatments often result in stiffness and malunion of the shoulder. In comminuted proximal humerus fracturesthe use of a proximal humeral internal locking system (PHILOS) only does not provide the required stable fixation which usually leads to complications such as varus collapse,malunion, anterior-posterior angulation, screw cutout, metal failure and nonunionand thusopen reduction and internal fixation with dual plating are recommended for proximal humerus fractures. Material and methods The Institutional Ethics Committee of Dr. D. Y. Patil Vidyapeeth in Pune approved this prospective study. We included a sample size of 52 patients and conducted a study on these patients who were admitted under the Orthopedics department at Dr. D. Y. Patil Medical College and Hospital, Pune. Results In this study, 52 patients were treated with dual plating for proximal humerus fracture, an additional plate is used along with PHILOS. In our study, the majority of the study population belonged to > 50 years (34.6%), followed by 41-50 years (26.9%), 31-40 years (23.1%), and 21-30 years (15.4%). The mean age of the patient was 53.7 years including 33 male and 19 female patients. The majority of the patient in the study included was with RTA 40 patients and 12 patients with a history of falls from height. The fracture was classified using Neers classification, Neer type 2 fracture (23.1%), Neer type 3 fracture (46.2%), and Neer type 4 fracture (30.7%). In the current study, the mean DASH score at Baseline was 58.88±6.29, at three months was 36.23±5.05 and at six months was 31.85±4.16. The mean DASH score decreased significantly from baseline to three months to 6 months. As per the Paavolainen method, it was good among 40 (76.9%) and fair among 10 (19.2%), and poor among two (3.8%) cases. Out of 52 patients, we found varus collapse in immediate postop x-ray in two patient and screw protrusion in the glenohumeral joint in one patient. Conclusion Satisfactory clinical and radiological outcomes were noted. This dual mechanism prevents varus displacement of the proximal fragment, and as a result, it provides a good functional outcome with dual plates in proximal humerus fractures.

Comparative study of the management of inter-trochanteric fractures in the elderly: Trochantric femoral nail vs dynamic hip screw

Introduction: Trochanteric fractures are among the most common injuries necessitating hospital admission. Regardless the type of fracture, trochanteric fractures can lead to substantial morbidity and mortality, especially in elderly patients. Surgery has been the mainstay of the treatment for these fractures to allow early mobilization of the patient. Among the surgical treatment, dynamic hip screw (DHS) as extramedullary power transmission system and trochanteric fixation nail (TFN) as the means of intramedullary stabilization are the established and standard in the treatment of trochanteric femoral fractures, particulary in elderly patients. AIM: The present study was designed to compare the results of TFN and DHS in treatment of intertrochanteric fracture femur. Material and methods: After fulfilling the mentioned criteria, patients were screened for medical fitness and then further randomized in group I and II. Group I-Patients treated with TFN (n=30). Group II-Patients treated with DHS (n=30). The clinical assessment was done according to the “Salvati and Wilson Function Score (SWS Score)”. Blood loss measurement and complications were also studied and compared. Results: Thirty patients were included in the study in each group. Salvati and Wilson Function Score (SWS) Score was used to evaluate the results at follow up. Mean ± SD of SWS at 16 weeks & 24 weeks was 18.93±3.34 & 28.80±5.33 respectively in group I whereas in group II, the value was 15.13±2.18 & 21.67±5.14 respectively. P-value was significant (< .01) Complications were observed in follow ups and the most frequent was varus displacement. It was observed that out of 30 subjects of Group 2, maximum i.e. 8 (26.67%) subjects had varus deformity whereas out of 30 subjects of group 1, only 1 (3.33%) subject had varus deformity Other complications include Non Union and Implant failure. Conclusion: We conclude that the advantage with Trochanteric fixation nail is that a smaller exposure is required than for a sliding screw, it may therefore be associated with lesser blood loss, shorter operating time and less morbidity.

The effectiveness of fixation of hydroxyapatite-coated helical blade in preventing of the cut-out observed in treatment with proximal femoral nail of fractures of the femur intertrochanteric in elderly.

This study aimed to retrospectively evaluate the effectiveness of hydroxyapatite-coated (HA-coated) implants and other caput-collum implants in preventing cut-out observed in treatment with proximal femoral nail (PFN) of intertrochanteric femur fractures in elderly patients. A total of 98 consecutive patients (56 males and 42 females; mean age: 79.42 (61-115) years) treated with three differ-ent PFNs for intertrochanteric femoral fractures were retrospectively examined. The mean of the follow-up period was 7.87 (4-48) months. It was used a threaded lag screw in 40 patients, an HA-coated helical blade in 28 patients and a non-coated helical blade in 30 patients for PFN. The reduction quality, fracture type, and radiological outcomes among all groups were evaluated. Unstable type was seen in 50 (52.1%) patients according to AO Foundation/Orthopedic Trauma Association fracture classi-fication. An acceptable-good reduction quality was seen in 87 (88.8%) of all patients. The average of tip-apex distance (TAD) value was 27.61 mm, calcar-referenced TAD (CalTAD) value was 28.72 mm, caput-collum diaphyseal angle was 128,° Parker's anteroposterior ratio was 46.36%, and Parker's lateral ratio was 46.82%. The best suitable implant position was observed in 49 (50%) patients. Cut-out was observed in 7 (7.14%) patients, and secondary varus displacement of more than 10° was observed in 12 (12.24%) patients. Correlation analysis and multivariate logistic regression analysis showed a significant difference between HA-coated and other implants in cut-out. Furthermore, implant type was the strongest predictive factor for cut-out complications in the multivariate logistic regression analysis. HA-coated implants may reduce the long-term cut-out risk due to increased osteointegration and bone ingrowth in elderly patients with intertrochanteric femoral fractures with poor bone quality. However, this alone is not enough; a suitable screw position, optimal TAD values, and excellent reduction quality are other important factors.

Are The Lateral Wall Reduction And Ideal Tip-Apex Distance Important In Reverse Oblique And Transverse Intertrochanteric Femoral Fractures (31-A3) Treated With Gamma Nail?

Purpose: Reverse oblique and transverse intertrochanteric femoral fractures (31A3 AO/OTA classification) have their own mechanical and anatomical properties. The aim of our study is to verify whether the reduction of the lateral femoral wall and ideal tip-apex distance are important predictive factors in the future of these fractures treated by gamma nails in terms of healing and complication rates. Methods: The radiological and clinical outcomes of 35 fractures of this type treated by short and long gamma nail from June 2014 to April 2021 were retrospectively reviewed. The elements considered were the quality of the lateral femoral wall reduction, the tip-apex distance (TAD), the lag screw position and overall quality reduction using the Baumgaertner criteria. Union, nonunion, cutout, screw sliding, nail or screw breakage were also radiographically evaluated during follow-up. Results: The union rate was 97%. A significant association was not observed between the state of reduction of the lateral wall and the three types of complications considered (cutout: p=0.31; sliding screw: p=1.00; varus displacement: p=0.30), and the linear regression model obtained indicates that in subjects with a non-reduction of the lateral wall, the consolidation time is increased on average by approximately 3 months (β= 2.99; 95%CI: 1.79-4.20, p&lt;0.001). No significant association was found between TAD and complications (cut-out: p=1.00; sliding screw: p=1.00; varus displacement: p=0.13). Conclusion: Anatomic reduction of the lateral wall and an ideal TAD ≤ 25mm might not be as significant for 31A3 fractures treated with gamma nails. Acceptable reduction of the lateral wall and stable internal fixation are sufficient elements to achieve fracture healing and functional recovery.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery.

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8–11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8–13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11–0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

IntroductionA stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. Patients and methodsRetrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. ResultsAfter a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DiscussionArthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

Impact on periosteal vasculature after dual plating of the distal femur: a cadaveric study.

Objectives:Although dual plating of distal femur fractures has been described for injuries at risk of varus displacement, the vascular insult to the medial distal femur utilizing this technique is unknown. The aim of this study was to evaluate the perfusion of the medial distal femoral periosteal arteries after supplemental medial plating of the distal femur.Methods:Fifteen human fresh-frozen cadaveric femora were thawed and randomized to lateral locked plating alone or with supplemental medial plate fixation. Conventional submuscular medial plating was performed using a 12-hole small fragment plate and multiple cortical screws. The superficial femoral artery was injected with latex dye. Specimens were dissected. The patency of the medial distal femoral periosteal vessels was evaluated.Results:Four vessels were consistently observed traversing the distal medial femur: the transverse and descending (d-MMPA) branches of the medial metaphyseal periosteal artery, and the transverse and longitudinal branches of the descending geniculate artery. The anterior longitudinal arch (ALA) was present in 13 of 15 specimens and was fed by the d-MMPA. The median number of periosteal arteries occluded by the medial plate was 2 (6 out of 8 specimens). The d-MMPA was occluded in 6 of 8 medially plated femurs, resulting in a complete lack of perfusion of the ALA.Conclusions:Submuscular medial plating of the distal femur compressed the d-MMPA in the majority of specimens. This vessel gives rise to the ALA, which lacked perfusion in these specimens. This vascular insult could affect the healing of metaphyseal distal femur fractures treated with dual plating.

Fluoroscopic landmarks to recognize iatrogenic varus displacement (wedge effect) during cephalomedullary nailing of intertrochanteric fractures

Iatrogenic varus malreduction after intramedullary nailing of intertrochanteric fractures (wedge effect) may be more common than previously reported. The aim of study is to determine its incidence and to define easy fluoroscopic landmarks to recognize it intraoperatively. We included surgical procedures with residual varus malreduction and sufficient intraoperative fluoroscopy images to assess an intraoperative anatomical reduction at the beginning of the procedure. Two intraoperative fluoroscopic landmarks were defined to assess varus in the anteroposterior view: the position of the greater trochanter (GT) related to the femoral shaft (medialized GT sign), and the position (superior, centre or inferior) of the guide wire in both the neck and the head of the femur (cross wire sign). We describe our current method of treatment to avoid this complication. A total of 369 extracapsular hip fractures were treated using PFNA and Gamma 3 systems. We found 55 (14.9%) fractures with a varus malreduction. Six were underreduced and fixed in varus. Thirty-five (9.48%) were well reduced by closed reduction but suffered a iatrogenic varus displacement when introducing the nail. 31 were female; mean age was 86.6 (range 70-97). Mean postoperative head-shaft angle was 119,2° range (113°-123°). Mean TAD was 24,37 range (14-36 mm). Wedge effect (iatrogenic varus displacement of a well reduced intertrochanteric fracture when introducing the nail) could occur in at least 10% of intertrochanteric fractures. The medialized GT and the "crossing wire sign" seem to be good predictors of iatrogenic varus malalignement.

The First Experience of Using the Developed Modified Allogenic Bone Grafts in the Surgical Treatment of Patients With Severe Fractures of the Surgical Neck of the Humerus

BACKGROUND Fractures of the proximal humerus are more common in older adults. Two options for surgical treatment of the same fractures are routinely performed — primary arthroplasty and osteosynthesis with metal fixators. Both methods are most effective in elderly patients for augmentation of the proximal humerus. For this purpose, methyl methacrylate cement or bone allo-/autografts are used. However, the incidence of unsatisfactory functional results after surgery remains high.AIM OF STUDY To develop allogeneic graft to strengthen the proximal humerus in the osteosynthesis of a comminuted fracture with a lack of bone tissue which has osteoconductive properties and capable of being a carrier of biologically active substances.MATERIAl AND METHODS The head, neck and portion of diaphysis of a fibula of a cadaver were used for a graft. The graft 6–8 cm long was formed and saturated with a collagen solution. Ten patients with 4-fragment fractures of the proximal humerus underwent surgery. X-rays and computed tomography of the operated joint were performed the day after surgery, and then, 6 weeks, 6 months, and one year after the surgery. The follow-up period ranged from 6 to 18 months.RESUlTS When evaluating osteoconductive effect in cell culture during saturation with collagen, the content cells on the surface of bone was 5–8 thousand/cm2 and 16–18 thousand/cm2 on the sample, saturated with plasma and growth factors. The studied bone grafts were biocompatible and non-toxic for fibroblast culture. On the surface of the bone graft without collagen adhesion of minimum number of cells occurred. After saturation of the graft with collagen, the adhesive activity of cells on the bone matrix increased, which indicated the presence of an osteoconductive effect. The addition of plasma saturated with growth factors promoted an increase in the number of adhered cells; therefore, the graft can be used as a carrier of biologically active substances. Postoperative X-ray didn’t reveal secondary varus displacement of the head in any patient (except for ununiformed fracture case).CONClUSION The developed graft is non-toxic, does not possess immunogenicity, has more pronounced osteoconductive properties in comparison with native bone allografts, which contributes to its colonization with cells. The use of such a graft in clinical practice makes it possible to achieve healing of the fracture and prevent secondary displacement of fragments.

Clinical Results of Dual SC Screw: A Mini-Sliding Hip Screw with an Anti-rotating Screw for Femoral Neck Fractures.

BackgroudDual SC screw (DSCS) is a unique concept internal fixation device consisting of a sliding screw and barrel assembly that enables compression force to be applied to the femoral neck fracture side. There are two types of barrels: a thread barrel and a plate barrel that has a one-holed side plate to prevent varus deformity. We report clinical results of the application of a DSCS with combined use of a thread barrel screw as an anti-rotational screw and a plate barrel screw as a compression hip screw.MethodsWe used DSCS for femoral neck fractures in 196 hip joints of 190 patients between November 2005 and June 2017. Among them, 70 hips in 66 patients (13 men and 53 women; mean age, 73.2 years) were followed up for at least 24 months. There were 53 nondisplaced fractures (Garden's classification stage 1 or 2) and 17 displaced fractures (stage 3 or 4). We evaluated the postoperative walking ability of the patients who were followed up for at least 24 months and examined details of all complications.ResultsThe mean follow-up period was 37.4 months (range, 24–144 months). Forty-two (64%) out of the 66 patients who were followed up for at least 2 years were able to walk independently with or without a cane. The incidence of complications was 11.5% in nondisplaced fractures and 17.5% in displaced fractures, and arthroplasty was required in 5.8% and 5.0%, respectively. The most frequent complication was secondary displacement including cutout and shortening of the femoral neck, but no implants showed varus displacement.ConclusionsThe application of DSCS for the treatment of femoral neck fractures had satisfactory results. The complication rate was low, and there was no postoperative varus displacement of DSCS in either displaced or nondisplaced fractures. We suggest DSCS is a reliable option for both displaced and nondisplaced femoral neck fractures.

Sub-Classification of AO/OTA-2018 Pertrochanteric Fractures Is Associated With Clinical Outcomes After Fixation of Intramedullary Nails.

BackgroundThe new edited AO/OTA-2018 classification of pertrochanteric fractures was revised and no longer based on the status of lesser trochanter. This paper aimed to explore the clinical and technical outcomes among the subgroups (31A1 and 31A2) of the new classification treated with cephalomedullary nails.MethodsA retrospective research of 154 patients diagnosed with pertrochanteric fractures (AO/OTA-2018 31A1.2/3 and 31A2.1/2/3) treated with intramedullary nails was conducted. The baseline data and outcomes were compared among the subgroups. The outcomes included tip-apex distance (TAD), Cal-TAD, Parker ratio, neck shaft angle (NSA), blood loss, varus displacement, and over lateral sliding rate of the blade.ResultsThere were 154 cases involving 48 males and 106 females. The average age was higher in the sub-classifications of A2.2 and A2.3 than A1.2. Furthermore, the subgroups of A2.2 and A2.3 presented inferior outcomes with regard to blood loss and reduction quality score than A1.2 and A1.3. The subgroup of A2.3 was further poor with respect to calcar fracture gapping in the anteroposterior view and excessive lateral migration occurrence rate than A1.2.ConclusionsComplex pertrochanteric fractures indicated inferior outcomes compared to simple sub-classifications, which might lead by the incompetent of lateral wall and instability of the fracture. The newly proposed AO/OTA-2018 classification was conductive to forecast the prognosis.

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108). Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. Level 3, retrospective cohort.

Varus malposition relates to functional outcomes following open reduction and internal fixation for proximal humeral fractures: A retrospective comparative cohort study with minimum 2 years follow-up

Background: The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures.Methods: Data of 685 patients with a mean age of 67±15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or <10° of varus or valgus malposition, group B: 10–20° of varus malposition and group C: >20° varus malposition, while anatomic head-shaft-angle was defined 135° The groups were compared with regards to functional outcomes by means of the Constant Score (CS).Results: In 565 patients with anatomic to minor <10° varus or valgus malposition (Group A), the mean CS was 72.5 ± 18.8 points. The %CS to the uninjured side was 87.2 ± 24.1 and the age and gender normalized nCS was 84.7 ± 21.7. In comparison, in group B (10–20° varus) the mean CS was 64.7 ± 16.9, the mean %CS was 84.5 ± 18.3 and the mean nCS was 76.2 ± 20.6. In group C (>20° varus) the mean CS was 54.1 ± 19.5, the mean was %CS: 72.3 ± 26.4 and the mean nCS was 64.8 ± 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25).Conclusion: Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe >20° of varus malposition, revision surgery should be considered.

Comparison of Locked Plating of Varus Displaced Proximal Humeral Fractures With and Without Fibula Allograft Augmentation.

To compare the clinical and radiographic outcomes between patients treated with fibula allograft-augmented locking compression fixation and patients treated with locking compression fixation alone for 2- and 3-part proximal humeral fractures with varus displacement. Retrospective review. Level 1 trauma center. One hundred two patients treated with locking plate fixation ± fibular allograft augmentation confirmed intraoperatively by visual inspection to have varus-angulated, 2- and 3-part proximal humerus fractures with at least 45 degrees of varus angulation at the neck/shaft and at least 1 cm of displacement. Proximal humerus locking plate (PHILOS; Synthes, Paoli, PA) with or without fibula allograft augmentation. Statistical analysis to determine the differences between fractures treated with locking compression fixation ± fibula allograft augmentation regarding complications, shoulder reported outcome measures, and patient ROMs (Visual Analog Score (VAS), Disabilities of the Arm, Shoulder and Hand, and Simple Shoulder Test scores). Medical comorbidities as potential risk factors for complication from surgery were also evaluated. Of 102 surgical cases, 27 were augmented with fibula allograft and 75 were not. Postoperatively, there were 16 noncatastrophic varus collapses of the fracture, 6 catastrophic varus collapses, and 5 deaths. Addition of fibula allograft did not significantly affect postoperative varus collapse, shoulder ROM, pain, or PROMs. Addition of fibula allograft to patients sustaining varus-angulated, 2- and 3-part proximal humeral fractures conferred no benefit to patient outcomes at our institution. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: a retrospective assessment

BackgroundScrew-tip augmentation in angular stable plating offers new possibilities for the treatment of complex proximal humerus fractures. This retrospective analysis was performed to evaluate the radiological outcome of proximal humerus fractures treated with angular stable plates and additional screw-tip cement augmentation in patients over the age of 60.Materials and methodsA retrospective single centre analysis was conducted from June 2013 to December 2016. The minimum follow-up time was set to 6 months after surgery. Anatomical reduction and fixation were evaluated in respect to reattached tuberosities to the head fragment and the adequate restoration of the calcar area not showing any valgus or varus malalignment. Complete fracture healing was determined 3 months after surgery. Any failures such as secondary displacement, primary screw perforation, intraarticular cement leakage and avascular necrosis of the humeral head with concomitant screw cut-out were assessed.ResultsIn total, 24 patients (21 females; 3 males) at a median age of 77.5 (62–96) years were included. Five 2-part, twelve 3-part and seven 4-part fractures were detected. The measured median BMD value of 23 patients was 78.4 mg/cm3 (38.8–136.9 mg/cm3). Anatomical reduction was achieved in 50% of the patients. In most cases, the A level screws and the B1 screw were augmented with bone cement by a median of 7 (5–9) head screws used. Postoperative varus displacement was not detected in any of the patients. One patient (4.2%) sustained an early secondary displacement. Intraarticular cement leakage was detected in 3 patients (2 head-split fractures). Avascular necrosis of the humeral head was observed in 4 patients (16.7%). Revision surgery was necessary in four cases, using hemiarthroplasty twice and reverse shoulder arthroplasty the other two times.ConclusionScrew-tip augmentation in angular stable plating for proximal humerus fracture treatment showed a low secondary displacement rate of 4.2% in patients suffering from poor bone quality. Nevertheless, the occurrence of avascular necrosis of the humeral head with mainly severe fracture patterns observed in this study was higher compared to previously reported results in the literature. Cement augmentation in head-split fractures is not recommended, considering the high risk of an intraarticular cement leakage.