To investigate whether helical blade implant systems have advantages in terms of tip apex distance (TAD) and cut-out rate in comparison to conventional lag screws for intertrochanteric fractures in a ...geriatric population. Methods: Relevant articles were sourced from the MEDLINE, Embase, Ovid and Cochrane Library databases from inception through March 2015. All randomized controlled trials (RCTs) comparing outcomes between helical blade and lag screw implant systems were selected. Mean TAD values and reported cut-out complications were noted. Each author independently assessed the relevance of the enrolled studies and the quality of the extracted data. Data were analyzed using R software.
Ten studies including 1831 patients were eligible for this review, seven of which were included in a combined analysis of dichotomous outcomes and five in a combined analysis of continuous outcomes. The results revealed that, compared with lag screw implantations, the use of helical blades led to a lower rate of cut-out complications (95 % CI: 0.28–0.96, P = 0.036). Patients who experienced cut-out complications had a significantly greater tip apex distance (95 % CI: 0.68–1.34, P < 0.001). However, the actual tip apex distances were similar between the screw group and blade group (95 % CI: −0.44–0.79, P = 0.58).
No difference in TAD values was found between blades and screws. In addition, the cut-out risk in the blade-design group was lower than that of the screw group. Therefore, TAD is not an accurate predictor of cut-out risk.
Background:
InterTAN is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to ...tighten the preloaded setscrew to allow or not allow secondary sliding in InterTan nail is controversial in clinical practice.
Methods:
We retrospectively collected 4 nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further secondary sliding and femoral neck shortening.
Results:
After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage.
Conclusions:
As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in standard-obliquity pertrochanteric hip fractures (AO/OTA-31A1 and A2).
Objective
Fracture classification evolves dynamically with new and enhanced imaging modalities. This paper aims to introduce a novel hypothesis of a sophisticated fracture classification system for ...the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images and accommodate the clinical requirement of the worldwide outbreak of geriatric hip fractures with large amounts of surgical operations.
Methods
In the current practice of widely preoperative 3D-CT application and cephalomedullary nailing, we attempt to propose a new comprehensive classification system to describe the fracture characteristics in a more detailed and sophisticated architecture, and pay the most important concern to the parameters that contribute to fracture stability reconstruction in osteosynthesis.
Results
The new four-by-four comprehensive classification system, followed the structure of the AO/OTA system, incorporates many fracture characteristics as dividing indexes into multiple grade levels, such as fracture line direction, the number of fragments, the lesser trochanter fragment and its distal extension (>2 cm), the posterior coronal fragment and its anterior expansion (to the entry portal of head–neck implant at the lateral cortex), the lateral wall and anterior cortex fracture, and the anteromedial inferior corner comminution. From a panoramic perspective, there are four types and each type has four subtypes. A1 is simple two-part fractures (20%), A2 is characterized by lesser trochanter fragment and posterior coronal fractures (62.5%), A3 is reverse obliquity and transverse fractures with complete lateral wall broken (15.5%), and A4 is medial wall comminution which further lacks anteromedial cortex transmission of compression force (2%). For subtypes, A2.2 is with a banana-like posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior expansion of the posterior coronal fragment(s) to the entry portal of head–neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region.
Conclusion
Classification represents diversity under consistency. The four-by-four sophisticated classification system delineates fracture characteristics in more detail. It is applicable in the time of rapid outbreak of trochanteric fractures in the older population, the large amounts of surgical operations, and incorporates various rare and/or more complicated subtypes which is unclassifiable before.
Schatzker type IV medial tibial plateau fractures have an unfavorable prognosis, likely due to the mechanism of injury (fracture-dislocation/subluxation type) and possibly due to the involvement of ...the posterolateral plateau, which is different from previously thought. The aim of this study was to propose a new subclassification of Schatzker type IV fracture patterns based on 2-dimensional (2-D) computed tomography and three-dimensional (3-D) reconstruction. The authors defined Schatzker type IV medial tibial plateau fractures as AO/OTA 41 type B fractures (partial articular), with partial or total medial plateau involvement, leaving at least the anterolateral quadrant intact. The images of 42 fractures (42 patients) were evaluated. The fractures were further anatomically divided into 2 groups: Group 1 were classic medial unicondylar fractures and Group 2 were more complicated variants involving both condyles, characterized by medial condyle fractures with lateral plateau extension, usually with articular impaction of the centroposterior lateral plateau. Twelve (29%) cases involved only the medial condyle, and 30 (71%) involved both the medial and lateral condyles. Twenty-nine (69%) cases demonstrated posterior coronal fractures. The most common patterns were bicondylar posteromedial plateau fractures with posterolateral quadrant depression (bicondylar posterior fractures: 14 cases, 33%) and total/subtotal medial condyle fractures with posterolateral quadrant depression (13 cases, 31%). The isolated unicondylar posteromedial split fracture was uncommon (2 cases, 5%). Computed tomography-based reconstruction enhances the understanding of fracture anatomy and the relationships between fracture fragments. In Schatzker type IV medial tibial plateau fractures, the involvement of posterolateral quadrants is common.
The inverted triangle configuration of the three cannulated screws is the classic fixation method most commonly performed for undisplaced femoral neck fractures in young and geriatric patients. ...However, the posterosuperior screw has a high incidence of cortical breach, known as an in-out-in (IOI) screw. In this study, we present a novel posterosuperior screw placement strategy to prevent the screw from becoming IOI.
Using computed tomography data and image-processing software, 91 undisplaced femoral neck fractures were reconstructed. The anteroposterior (AP), lateral, and axial radiographs were simulated. To simulate the intraoperative screw placement process, participants used three screw insertion angles (0°, 10°, and 20°) to place the screw on the AP and lateral views of the radiograph according to the three established strategies. On the AP radiograph, a screw was placed abutting (strategy 1), 3.25 mm away from (strategy 2), or 6.5 mm away from (strategy 3) the superior border of the femoral neck. On the lateral radiograph, all the screws were placed abutting the posterior border of the femoral neck. Axial radiographs were used to evaluate the screw position.
In strategy 1, all the placed screws were IOI regardless of the screw insertion angle. In strategy 2, 48.3% (44/91) of IOI screws occurred at a 0° screw insertion angle, 41.7% (38/91) of IOI screws occurred at a 10° screw insertion angle, and 42.9% (39/91) of IOI screws occurred at a 20° screw insertion angle situation. In strategy 3, no IOI screw occurred, and the screw insertion angles did not affect the safety and accuracy of screw placement.
Screws placed according to strategy 3 are safe. The reliability of this screw placement strategy is unaffected by a screw insertion angle of less than 20 degrees.
Background
The 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.
Methods
A 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.
Results
There 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.
Conclusions
Complex 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.
The objective of this prospective study was to test whether the treatment of Lisfranc injuries with open reduction and dorsal plate fixation would have the same or better functional outcomes as ...treatment with standard trans-articular screw fixation.
Sixty patients with primarily isolated Lisfranc joint injury were treated by open reduction and dorsal plate fixation or standard screw fixation. The patients were followed on average for 31 months. Evaluation was performed with patients' chief complaint, clinical examination, radiography, and AOFAS Midfoot Scale.
Thirty two patients were treated with open reduction and dorsal plate fixation, and twenty eight patients were treated with open reduction and screw fixation. After two years follow-up, the mean AOFAS Midfoot score was 83.1 points in the dorsal plate fixation group and 78.5 points in the screw fixation group (p<0.01). Of the dorsal plate fixation group, radiographic analysis revealed anatomic reduction in twenty-nine patients (90.6%, 29/32) and nonanatomic reduction in three patients. Of the screw fixation group, radiographic analysis revealed anatomic reduction in twenty-three patients and nonanatomic reduction in five patients (82.1%, 23/28).
Open reduction and dorsal plate fixation for a dislocated Lisfranc injury do have better short and median term outcome and a lower reoperation rate than standard screw ORIF. In our experience, we recommend using dorsal plate in ORIF on dislocated Lisfranc injuries. Level of Evidence II, Prospective Comparative Study.
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