Outcomes of Angular Stable Locking System in Femoral Diaphyseal Fractures of Elderly Patients:A Multicenter Comparative Study

Background@#The angular stable locking system (ASLS) was developed to provide additional stability to the distal interlocking screw of the intramedullary (IM) nail. Effects of ASLS on the treatment of femoral diaphyseal fractures in the elderly remain unknown. The aim of this study was to compare radiological outcomes of IM nailing using ASLS screws to IM nails with conventional interlocking screws in elderly patients with femoral shaft fractures. @*Methods@#A multicenter retrospective review of 129 patients (average age, 73.5 years; 98 women and 31 men) aged 65 years or older who underwent IM nail fixation for femoral diaphyseal fractures (AO/Orthopaedic Trauma Association [OTA] classification 32) was conducted. Demographic information of patients, fracture site (subtrochanteric or shaft), fracture type (traumatic or atypical), and AO/OTA fracture classification were investigated. Reduction status was evaluated by postoperative plain radiography. Presence of union and time to union were evaluated through serial plain radiograph follow-up. Reoperation due to nonunion or implant failure was also evaluated. @*Results@#ASLS was used in 65 patients (50.3%). A total of 118 patients (91.5%) achieved union without additional surgery and the mean union time was 31.8 ± 13.0 weeks. In terms of reduction status, angulation was greater in the group using ASLS. There were no statistically significant differences of union rate, time to union, and reoperation rate according to the use of ASLS (p > 0.05). There was no difference in the outcomes according to the use of ASLS even when the analysis was divided in terms of fracture site or fracture type (p > 0.05). In further subgroup analysis, only the traumatic subtrochanteric area group showed statistically significantly shorter time to union when ASLS was used (p = 0.038). @*Conclusions@#In geriatric patients with femoral diaphyseal fractures, the use of ASLS was not considered to have a significant effect on fracture healing. Fracture healing seemed to be more affected by surgical techniques such as minimizing the gap and fracture characteristics such as atypical femoral fractures, rather than implants.

Corrigendum: Outcomes following Treatment of Geriatric Distal Femur Fractures with Analyzing Risk Factors for the Nonunion

The approval number of Institutional Review Board (IRB) was wrong in the article. The IRB approval number should be corrected.

Sclerotherapy Using Abnobaviscum for the Extensive Recurrent Chronic Morel-Lavallée Lesions - A Case Report -

The Morel-Lavallée lesion (MLL) is a closed soft-tissue degloving injury, resulting in characteristic hemo-lymphatic fluid collection between the fascia and subcutaneous layers. The MLL was managed routinely with drainage and compression bandages, but sclerotherapy can be used in patients with chronic lesions refractory to first-line therapy. This paper presents a case of extensive recurrent chronic MLL treated with sclerotherapy using Abnobaviscum, which has been used to treat adhesion in malignant pleural effusion.

Rare Experience of Bilateral Femoral Neck and Shaft Fractures - A Case Report -

Ipsilateral fractures of the femoral neck and shaft are relatively common injuries and accompany 2% to 9% of all femoral shaft fractures. On the other hand, it is extremely rare for these injuries to occur bilaterally. This paper reports the authors’ experience of a case with bilateral femoral neck and shaft fractures. The patient sustained multiple injuries, including liver laceration with hemoperitoneum, bilateral open fractures of the tibia, and bilateral femoral neck, and shaft fractures caused by a high-speed motor vehicle accident. Under the circumstances, damage-control orthopedic principles were applied, and external fixators were initially placed. After the patient’s general condition showed improvement, both femurs were fixed with a reconstruction nail. Fracture healing was achieved without complications, such as avascular necrosis of the femoral head. Despite the rare occurrence, this paper describes this case because these injuries must be managed with meticulous attention.

Outcomes following Treatment of Geriatric Distal Femur Fractures with Analyzing Risk Factors for the Nonunion

PURPOSE: Many international journals have published studies on the results of distal femoral fractures in elderly people, but only a few studies have been conducted on the Korean population. The aim of this study was to determine the factors that are associated with the outcomes and prognosis of fixation of distal femur fractures using the minimally invasive plate osteosynthesis (MIPO) technique in elderly patients (age≥60) and to determine the risk factors related witht he occurrence of nonunion. MATERIALS AND METHODS: This study is a retrospective study. From January 2008 to June 2018, distal femur fracture (AO/OTA 33) patients who underwent surgical treatment (MIPO) were analyzed. A total of 52 patients were included in the study after removing 121 patients that met with the exclusion criteria. Medical records, including surgical records, were reviewed to evaluate the patients' underlying disease, bone mineral density, the number of days delayed from surgery, complications and mortality. In addition, follow-up radiographs were used to determine bone union, delayed union and nonunion. RESULTS: The average time to achieve bone union was 19.95 weeks, the rate of nonunion was 20.0% (10/50) and the overall mortality was 3.8% (2/52). There were no significant differences in the clinical and radiological results of those patients with or without periprosthetic fracture. On the univariate analysis, which compared the union group vs. the nonunion group, no factors were identified as significant risk factors for nonunion. On the multiple logistic regression analysis, medical history of cancer was identified as a significant risk factor for nonunion (p=0.045). CONCLUSION: The rate of nonunion is high in the Korean population of elderly people suffering from distal femur fracture, but the mortality rate appears to be low. A medical history of cancer is a significant risk factor for nonunion. Further prospective studies are required to determine other associated factors.

Englerin A-sensing charged residues for transient receptor potential canonical 5 channel activation

The transient receptor potential canonical (TRPC) 5 channel, known as a nonselective cation channel, has a crucial role in calcium influx. TRPC5 has been reported to be activated by muscarinic receptor activation and extracellular pH change and inhibited by the protein kinase C pathway. Recent studies have also suggested that TRPC5 is extracellularly activated by englerin A (EA), but the mechanism remains unclear. The purpose of this study is to identify the EA-interaction sites in TRPC5 and thereby clarify the mechanism of TRPC5 activation. TRPC5 channels are over-expressed in human embryonic kidney (HEK293) cells. TRPC5 mutants were generated by site-directed mutagenesis. The whole-cell patch-clamp configuration was used to record TRPC5 currents. Western analysis was also performed to observe the expression of TRPC5 mutants. To identify the EA-interaction site in TRPC5, we first generated pore mutants. When screening the mutants with EA, we observed the EA-induced current increases of TRPC5 abolished in K554N, H594N, and E598Q mutants. The current increases of other mutants were reduced in different levels. We also examined the functional intactness of the mutants that had no effect by EA with TRPC5 agonists, such as carbachol or GTPγS. Our results suggest that the three residues, Lys-554, His-594, and Glu-598, in TRPC5 might be responsible for direct interaction with EA, inducing the channel activation. We also suggest that although other pore residues are not critical, they could partly contribute to the EA-induced channel activation.

The Current Concepts in the Management of Open Fractures / 대한정형외과학회잡지

Open fractures require infection prevention, injured soft tissue management, and fracture fixation. Moreover, it should be treated according to the emergency surgery. The main goals of treatment are life preservation, limb preservation, infection prevention, and functional restoration. Treatment procedure is carried out in the following order. Early diagnosis and management in the emergency room, appropriate antibiotic treatment, adequate irrigation and thorough debridement, fracture fixation and wound restoration (temporary stabilization of the fracture and covering of the wound, definite fixation of the fracture and soft tissue coverage). Herein, we discuss the current trends in each treatment phase to be helpful to other clinicians regarding the applicability of these steps in clinical practice.

Apophyseal Avulsion Fracture of Ischial Tuberosity during Soccer: A Case Report and Literature Review / 대한스포츠의학회지

The incidence of avulsion fracture of ischial tuberosity is reported to present in 1.4%–4% of hamstring injuries. The injury mechanism is known to be caused by a sudden forceful hip flexion in the extended knee with eccentric load to the hamstrings. Although the majority of hamstring injuries are strains of the muscle, avulsion fracture of ischial tuberosity occurs rarely. In this report, a 13-year-old boy with avulsion fracture of ischial tuberosity is presented. Successful clinical outcome was achieved with careful conservative management. Previous literatures including operative indications are reviewed.

Osteotomy Selection: Advantages, Disadvantages, and Indication

Malunion causes not only cosmetic problems, but also degenerative osteoarthritis due to changes in the anatomical and mechanical axes. Corrective osteotomy may be required in some cases to prevent these complications. The corrective osteotomy is divided into two types: Straight and dome. The straight type is divided into open and closed wedge, in accordance with the correction method. Surgeons should understand the indication, surgical procedure, as well as the advantages and disadvantages of each osteotomy method. Deciding on the method of corrective osteotomy depends on the degree of angulation, soft tissue condition, approximate with joint, implant type, and the experience of the surgeon.

A Interventional Study in a Real Life Setting to Assess the Clinical Efficacy and Effect on Fracture in the 1 Year after Injection of Zoledronic Acid in Osteoporotic Patients with Long Bone or Spine, Pelvic Fractures / 대한정형외과학회잡지

PURPOSE: We studied the improvement of back pain in vertebral fracture and fracture healing in non-vertebral fracture after treatment with zoledronate in postmenopausal patients. MATERIALS AND METHODS: Postmenopausal women with bone mineral density (BMD) T-score of -2.5 or less and existing vertebral fractures or non-vertebral fractures between January 2011 and June 2012 were included. Patients received a single intravenous infusion of zoledronate within 3 days after diagnosis of fractures. The primary outcome was BMD and secondary outcomes were visual analogue scale (VAS) for back pain, fracture healing, and new clinical fracture. RESULTS: T-score increased significantly in the vertebral fracture group (n=97) and non-vertebral fracture group (n=31) at 1 year (p<0.05). The average VAS for back pain decreased significantly in the vertebral fracture group (p<0.05) and there was no delayed union, nonunion in the non-vertebral fracture group. There was no re-fracture and 3 new clinical fractures (2.34%) occurred during the follow-up period. CONCLUSION: Zoledronate, as treatment in postmenopausal osteoporosis patients can improve BMD, reduce back pain in vertebral fracture, and has no negative effect on bone healing after fracture in non-vertebral fracture.

Cerclage Clamping Using Cerclage Passer for Reduction of Anterior and Posterior Column Fracture / 대한정형외과학회잡지

PURPOSE: Both column and T-shaped acetabular fractures are frequently presented with difficulty in reduction. Incomplete reduction may cause traumatic arthritis in the hip joint, resulting in inferior clinical outcomes. The purpose of this study is to introduce our wiring technique and to report the clinical and radiological outcomes of such technique. MATERIALS AND METHODS: Eight patients who underwent our proposed technique for having acetabular fracture with displaced quadrilateral plate between March 2013 and December 2014 were enrolled. All patients were followed-up more than 1 year. The wire passer was set up from an anterolateral aspect of the iliac crest to the greater sciatic notch, between the abductor muscle and the periosteum. The quadrilateral plate of acetabular fracture was reduced with wiring. Internal fixation was added to the pelvic brim. An analysis of the clinical and radiological outcomes was performed. RESULTS: Reduction was performed within the 3 mm intra-articular step-off in all patients. The mean duration of union was 11.8 weeks (9-15 weeks). Five patients (62.5%) showed excellent results, and radiologically, three patients (37.5%) showed good results, and seven patients (87.5%) showed better than good results. CONCLUSION: The cerclage wiring fixation technique using a large cerclage passer instrument can be a useful and safe reduction method in some cases of acetabular fractures.

Mangled Extremity: Salvage versus Amputation

No abstract available.

Analysis of Missed Fractures in Polytrauma Patients

PURPOSE: The purpose of this study is to determine the frequency of missed fractures in severe multiple trauma patients and to analyze any differences in treatment plan, after whole body bone scan. MATERIALS AND METHODS: From September 2012 to December 2013, 49 patients were confirmed to have multiple trauma with an injury severity score (ISS) of 16 or higher. Whole body bone scan was performed at an average of 15.7 days (7-25) after injury. Missed fractures were diagnosed according to physical examination and additional radiologic reports. Locations and patterns of missed fractures were analyzed. We evaluated any differences in treatment plan after the diagnosis of missed fractures. RESULTS: Missed fractures were diagnosed in 14 patients (16 cases) on the whole body bone scan. The most frequent location was the knee (three cases), followed by rib, clavicle, carpal bone, and foot. Seven cases were occult fractures, five cases were undisplaced fractures and four cases were displaced fractures. Conservative treatment was administered in 15 patients and surgery was necessary in one patient. CONCLUSION: Delayed or missed diagnosis of fractures occurred frequently in patients of multiple trauma with a high ISS. Whole body bone scan appears to be effective in finding missed fractures in the whole body. Definitive assessment should be supplemented after initial trauma care in order to reduce the rate of missed fractures.

Osteoporotic Spinal Compression Fracture and Degree of Vitamin D Deficiency

PURPOSE: The aim of the present study was to evaluate the degree of serum vitamin D deficiency in patients with osteoporotic spinal compression fracture and correlation of serum vitamin D level with several variables. MATERIALS AND METHODS: The medical records of 134 patients with osteoporotic spinal compression fracture, diagnosed at our hospital between October 2008 and June 2011, were reviewed. Serum 25(OH)vitamin D3 was used to evaluate the status of vitamin D level. Serum 25(OH)vitamin D3 level was compared and analyzed according to sex, the number of fractured vertebral body, living environment, and the season of injury. The correlation between vitamin D level and age, bone mineral density, and bone turnover marker were evaluated. RESULTS: In the serum 25(OH)vitamin D3, 87 patients (65%) associated with osteoporotic spinal compression fracture had an insufficient level. Vitamin D level was the lowest in winter, the highest in summer, and significantly higher in the living home than nursing home. Vitamin D level was negatively correlated with age (r=-0.201, p=0.02) and positively correlated with bone mineral density (r=0.217, p=0.012). CONCLUSION: Evaluation of vitamin D level in osteoporotic vertebral compression fracture patients may be helpful in planning the treatment of the patients. For insufficient vitamin D level, the adequate sun exposure and supplement of vitamin D may be used.

Augmentative Locking Plate Fixation for the Treatment of Femoral Nonunion after Intramedullary Nailing

PURPOSE: To evaluate the efficacy of the augmentative locking compression plate fixation in the treatment of femoral shaft nonunion occurring after intramedullary nailing. MATERIALS AND METHODS: Between July 2004 and September 2012, a total of 17 patients (twelve men, five women, average age 52.5 years) who had femoral nonunions after primary intramedullary nailing for femoral shaft fractures were reviewed. The mean period of nonunion after primary nailing was 18.5 months. Leaving the nail in situ, an augmentative locking plate was applied to the nonunion site with simultaneous autogenous bone grafting, except for five hypertrophic nonunions. We followed up all patients with plain radiograph and evaluated clinical status to determine bone union. RESULTS: All patients demonstrated evidence of fracture union with an average follow-up time of 5.0 (range 2 to 9) months. The time of operation was an average of 115 (range 45 to 160) minutes, and mean blood loss was 345.9 (range 150 to 700) ml. Two patients noted discomfort at the distal portion of plate, and one noted discomfort of donor site, but functional limitation was not observed in all patients. CONCLUSION: Augmentative locking plate fixation for diaphyseal femoral nonunion after intramedullary nailing is a reasonable treatment option with increased stability.

Reduction and Stabilization of Pelvic Ring Injury

No abstract available.

Treatment of Unstable Sacral Fractures Related to Spino-Pelvic Dissociations

PURPOSE: To evaluate the outcomes of surgical treatment modality in unstable sacral fractures combined with spinal and pelvic ring injury depending on the presence of spino-pelvic dissociations. MATERIALS AND METHODS: The subjects were 16 patients, with unstable sacral fractures combined with spinal and pelvic ring injuries, were operated from July 2004 to January 2011. The patients were divided into 2 groups depending on the presence of spino-pelvic dissociations: those with dissociations were group 1, and those without dissociations were group 2. Group 1 was treated with spino-pelvic fixations using iliac screw, while group 2 was treated with percutaneous iliosacral screw fixations. The availability of the radiological bony union with its application periods, and clinical results using visual analogue scale (VAS) and oswestry disability index (ODI) were evaluated, retrospectively. RESULTS: Out of 16 patients, 8 patients in group 1 were treated with spino-pelvic fixation using iliac screw, and 8 patients in group 2 were treated with percutaneous iliosacral screw fixation. The mean bony union period was 17.4 weeks in group 1, and 19.6 weeks in group 2. The Mean VAS and ODI scores on the last follow-up were 2.5 points and 15.6 points in group 1, 2 points and 18.8 points in group 2, respectively. Both groups had favorable clinical results at the last follow-up. CONCLUSION: For surgical treatments of unstable sacral fractures, spino-pelvic fixation using iliac screws is advised for cases with combined spino-pelvic dissociation, while percutaneous iliosacral screw fixation is advised for cases without combined dissociation.

Efficacy of Percutaneous Cerclage Wiring in Intramedullary Nailing of Subtrochanteric Femur Fracture: Technical Note

The subtrochanteric fractures of femur have high rates of delayed union or nonunion due to less-dense cancellous bone, insufficient cortical blood flow and high stress concentration. Anatomical reduction and rigid internal fixation are important in this region; however, an open reduction might damage the biological environment at the fracture site as well as increase the risk of nonunion. We present our experience with nine cases of subtrochanteric femur fractures surgically fixated with intramedullary nailing after percutaneous cerclage wiring through minimal incision.

Treatment of Distal Femur Fracture with Minimally Invasive Locking Compression Plate Osteosynthesis

PURPOSE: To analyze the result of distal femur fracture treatment with minimally invasive plate osteosynthesis (MIPO) using a locking compression plate (LCP). MATERIALS AND METHODS: From December 2004 to April 2010, 33 patients with distal femur fractures were treated by MIPO with a locking compression plate. The reduction state and bone union time was checked radiologically. The clinical outcome was evaluated by the Schatzker and Lambert criteria. RESULTS: The mean bone union time was 16.3 weeks (10~22 weeks). There were 3 nonunions, 2 broken plates, 1 superficial infection, 7degrees of valgus angulation in 1 case, and 1.5 cm limb shortening in 1 case. Except for the 3 nonunion cases, according to the Schatzker and Lambert criteria, results were graded as excellent in 11 cases, good in 14 cases, and moderate in 5 cases. CONCLUSION: The treatment of distal femoral fracture by MIPO with a locking compression plate resulted in good functional and radiological outcomes, but it has problems, such as broken plates and nonunion. Accurate surgical technique and appropriate treatment will be needed according to fracture type.

Delayed Soft Tissue Coverage after Negative Pressure Wound Therapy in Open Fractures of Lower Extremities / 대한정형외과학회잡지

PURPOSE: To evaluate the delayed soft tissue coverage after previous negative wound therapy in treating wounds associated with open lower extremity fracture. MATERIALS AND METHODS: Between June 2007 and February 2011, delayed soft tissue coverage of open lower extremity fractures after previous use of a negative pressure vacuum device, were performed in 15 consecutive patients. Patients included 13 male and 2 female, and their mean age was 39.0 (7-65) years old. Information on the time from injury to definitive wound coverage, type of coverage, functional result, bone union, and complications such as infection were collected. RESULTS: The vacuum-assisted closure devices was applied for an average of 29.3 (9-50) days, and the mean time from injury to definitive wound was 36.1 (21-60) days. Skin graft coverage was performed in 5 cases, free flap in 8 cases, and local flap in 3 cases. The mean time to radiographic union was 5.2 (3-8) months and delayed union occurred in 2 cases. CONCLUSION: Delayed soft tissue coverage after previous negative wound therapy was considered an alternative treatment method in open lower extremity fractures associated with severe concomitant injury.