Pathoanatomy of pertrochanteric fractures - a postmortem study.

BACKGROUND: Recent pathoanatomic studies based on 3D CT reconstructions have questioned validity of AO/OTA classification because it does not reflect the reality and requires revision. These 3D CT studies, however, do not allow analysis of all details. Therefore, we have exploited the possibility to analyze the pathoanatomy of pertrochanteric fractures on postmortem specimens. MATERIAL AND METHODS: From the collection of the Institute of Anatomy, the authors obtained 16 specimens of hip joints of individuals who had sustained a pertrochanteric fracture and died within 30 days of the injury, with anteroposterior radiographs of the injured hip available in all of them. The number of major fragments and their shape, and the courses of the main fracture lines were studied. RESULTS: Three major fragments (a proximal head and neck fragment, a distal diaphyseal fragment and a posterior flat fragment), separated by three types of fracture lines (primary, secondary and tertiary lines) were identified. The primary line separated the proximal fragment (head and neck) from the distal diaphyseal fragment. The secondary fracture line separated the posterior flat fragment from the distal diaphyseal fragment. The tertiary fracture line split the posterior fragment into two parts. A key factor for fracture instability is the defect of the posterior cortex, which depends on the size and shape of the posterior fragment. Avulsion of the lesser trochanter and the adjacent cortex results in an unstable configuration of fracture lines on the medial side, while on the lateral side a large posterior fragment weakens the lateral trochanteric wall. CONCLUSION: In agreement with recent CT studies, the findings of this pathoanatomical study change, in a number of aspects, the traditional view of the pathoanatomy and classification of pertrochanteric fractures, and introduces the concept of three, instead of the traditional four, main fragments.

Antithrombotic therapy of patients with atrial fibrillation discharged after major non-cardiac surgery. 1-year follow-up. Sub-analysis of PRAGUE 14 study.

BACKGROUND: The study investigated the discharge antithrombotic medication in patients with atrial fibrillation (AF) after major non-cardiac surgery and the impact on one-year outcomes. METHODS: A subgroup of 366 patients (mean age 75.9±10.5 years, women 42.3%, acute surgery 42.9%) undergoing major non-cardiac surgery and having any form of AF (30.6% of the total population enrolled in the PRAGUE-14 study) was followed for 1 year. RESULTS: Antithrombotics (interrupted due to surgery) were resumed until discharge in 51.8% of patients; less frequently in men (OR 0.6 (95% CI 0.95 to 0.35); p = 0.029), and in patients undergoing elective surgery (OR 0.6 (95% CI 0.91 to 0.33); p = 0.021). Dual antiplatelet therapy was resumed more often (91.7%) in comparison to aspirin monotherapy (57.3%; p = 0.047), and vitamin K antagonist (56.3%; p = 0.042). Patients with AF had significantly higher one-year mortality (22.1%) than patients without AF (14.1%, p = 0.001). The causes of death were: ischaemic events (32.6% of deaths), bleeding events (8.1%), others (N = 51; 59.3%, 20 of them died due to cancer). Non-reinstitution of aspirin until discharge was associated with higher one-year mortality (17.6% vs. 34.8%; p = 0.018). CONCLUSION: Preoperatively interrupted antithrombotics were re-administrated at discharge only in half of patients with AF, less likely in male patients and those undergoing elective surgery. The presence of AF was recognized as a predictor of one-year mortality, especially if aspirin therapy was not resumed until discharge. TRIAL REGISTRATION: ClinicalTrials.gov NCT01897220.

Distal tibiofibular synostosis after surgically resolved ankle fractures: An epidemiological, clinical and morphological evaluation of a patient sample.

INTRODUCTION: Ankle fractures comprise a highly morphologically and etiologically diverse group of injuries, which includes various degrees of impairment of bone and ligamentous structures. The complete synostosis and incomplete bony bridging of tibiofibular syndesmosis are among the local late complications after surgically treated ankle fractures. PATIENTS AND METHOD: 269 patients were evaluated, including 203 patients with Weber type-B fractures, and 66 patients with Weber type-C fractures. All patients underwent ankle radiography at standard intervals (post-operatively, 6 and 12 weeks, 6 and 12 months). The final assessment one year after osteosynthesis was performed. The study analyzed age, sex, fracture morphology, the location and morphology of ossification, functional outcomes and subjective evaluations of patient status. RESULTS: As risk factors there were found male sex, tibiotalar dislocation, syndesmotic screw fixation and Weber type-C fractures. The severity of subjective difficulties and objective status were not dependent on the size of distal tibiofibular synostosis. DISCUSSION AND CONCLUSION: Despite relatively extensive imaging findings of complete synostosis or incomplete bony bridging, they only limited functional outcomes to a minimal extent.

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

OBJECTIVES: The most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique. METHODS: We prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1+2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail. RESULTS: In total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p=0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p=0.028). CONCLUSION: Unlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.

The importance of intramedullary hip nail positioning during implantation for stable pertrochanteric fractures: biomechanical analysis.

PURPOSE: Proximal femoral fractures are among the most commonly sustained fractures. The current treatment of stable proximal femoral fractures located in trochanteric region primarily involves the use of two systems: extramedullary dynamic hip screws and intramedullary hip nails. Given that these fractures are mainly found in the elderly population, the necessity of a repeat, due to failure of the first, may jeopardize the patient's life. Decisive factors contributing to the healing of a fracture (or the failure thereof) include fracture pattern, technical implementation of the operation (i.e., position of the implant), implant's properties and its changes in relation to the surrounding bone tissue during loading. Each screw insertion variant results in damage to various load-bearing bone structures, which can be expected to influence healing quality and stability of newly formed bone. METHOD: With the aid of a numerical model and finite element methods, the authors analyzed several different positions of IMHN/PFH-nails in the proximal femur, with the objective of determining positions with an increased risk of failure. RESULTS AND CONCLUSION: In model situations, it has been shown that in stable fractures results do not depend on absolutely precise positioning and small deflections in the nails and neck screws positions do not significantly increase the risk of failure for the entire fixation. Damage to load-bearing structures relative to various implant placements does not impact the resultant overall fixation stability. Therefore, it is not necessary to re-introduce implants in the ideal position, which can lead to reduced patient radiation doses during surgery.

Subsequent contralateral hip fractures: can at-risk patients be identified? An observational study of 5,102 patients.

PURPOSE: The aim of this study was to evaluate a sample of patients who sustained hip fractures during the years 1997-2011 and identify risk factors for a subsequent contralateral hip fracture; one-year mortality rates were compared in both groups. METHODS: A total of 5,102 patients with hip fractures were prospectively studied to identify patients who had also suffered a subsequent, contralateral, hip fracture (SCHF). Those patients who had sustained a second fracture within 18 months of the initial fracture were then studied. All data were statistically processed. RESULTS: Within 18 months of the first fracture, a SCHF occurred in 105 patients (2.1 %). These patients were an average of three years older than those in the single fracture group. Risk factors for the development of a SCHF included: female gender, residing in a residential care facility, and limited mobility prior to injury. Trochanteric fractures did not represent a statistically significant risk factor for SCHF. More than three-quarters of patients with subsequent injuries suffered the same type of fractures on the opposite side. Patients with subsequent fractures had lower one-year mortality rates than patients with only one fracture. CONCLUSION: Patients at greatest risk for a SCHF were women with limited mobility who resided in nursing homes for the elderly. The lower mortality rate associated with second fractures shows that the prognosis for such patients is good. Since the at-risk group is so well defined, prophylactic measures for these patients should be utilized in order to minimize the risk of additional fractures.

Anatomist and the pioneer of radiology Étienne Destot--95th anniversary of his death.

Destot was a leading pioneer in radiology, a pupil of Ollier, an anatomist, and researcher who followed in the experimental medicine tradition of Claude Bérnard. This work is an extensive, in depth, look at the life and work of Étienne Destot. On February 5, 1896, he began performing X-ray examinations, less than two months after Roentgen's discovery! His pioneering work described a space bordered by the hamate, capitate, triquetrum, and lunate; this space is now known as Destot's space. Tanton stated that Destot was the first to reveal the mechanism of fractures of the posterior margin of the distal tibia and to emphasize their clinical relevance; in honor of this contribution, Tanton named such a fracture the "fracture of Destot." Moreover, Destot is credited with being the first physician to use the term "pilon" in the orthopedic literature. He first described fractures of the scaphoid in 1905. He also described superficial hematomas, Destot's sign, located above the inguinal ligament or in the scrotum or thigh. Such hematomas are indicative of pelvic fractures. Destot is credited with inventing or improving many pieces of medical equipment (e.g., Lambotte's screw plates, anastomotic boutons for the digestive tube, monopolar endocavital radiological tubes). He was also active in developing technical aspects of equipment (e.g., radioscopic examination of the heart, a prototype of the mobile radiological laboratory). Étienne Destot is best known as a radiologist; however, his influence extends well beyond this field. He was an anatomist and surgeon, the founder of radiology in Lyon, prosector, physician, electrician, researcher, and artist.

The correlation between muscles insertions and topography of break lines in pertrochanteric fractures: a comprehensive anatomical approach of complex proximal femur injuries.

PURPOSE: The purpose of our work was to verify the hypothesis that muscle insertions and ligament attachments have an impact on the course of typical break lines in the area of the trochanteric massif, i.e., to provide a more detailed description of the origins and insertions of the musculo-ligamentous apparatus on the surface of the proximal femur, and to find a potential morphological correlate between muscle insertions and ligament attachments to the proximal femur and the course of the break line in a typical pertrochanteric fracture. METHODS: A detailed dissection of areas of trochanter major et minor, linea et crista intertrochanterica was performed in 50 anatomical preparations of the proximal femur, and the insertions of the muscular-ligamentous structures were described. The set of 600 radiographs were used to obtain projections of typical break lines on the proximal femur, and corresponding areas of exposed bone surface were identified in the anatomical preparations based on the projections and on 15 real specimens of patients after the pertrochanteric fracture osteosynthesis. RESULTS AND CONCLUSION: Bone covered only with the periosteum, with no reinforcing elements of the origin or insertions of muscles or attachments of ligaments, represents the locus minoris resistentiae for beginning of fractures. Variability in the sizes and shapes of pertrochanteric fracture fragments also depends on variability of the locations and sizes of soft tissue attachment areas at specified sites on the proximal femur.

Pudendal nerve in pelvic bone fractures.

INTRODUCTION: Pelvic ring injuries rank among the most serious skeletal injuries. According to published data, pelvic fractures constitute 3-8% of all fractures. There has been a threefold increase in the number of these fractures over the last 10 years. A significant factor determining the choice of the therapeutic procedure, timing and sequence of individual steps, and also the prognosis of the patient with a fractured pelvis, are associated injuries defined as injuries to the organs and anatomical structures found in the pelvic region. Published data describes the incidence of injury to neurogenic structures as ranging between 9 and 21%, to the urogenital tract between 5 and 11%, to the gastrointestinal tract in 3-17% and to the gynecologic organs up to 1%. The pathway of the pudendal nerve may be affected in types B and C fractures where the root fibers emerge from the foramina sacralia and plexus sacralis is formed, on the one hand, and in types A, B and C fractures during the nerve's course alongside the inferior pubic ramus. MATERIALS AND METHODS: In order to determine the frequency of potential injury to the pudendal nerve, a set of 225 pelvic fractures treated between 2007 and 2009 was assessed; 38 fixed hemipelves were also used to study the length of the course of the pudendal nerve alongside the inferior pubic ramus, on the one hand, and the distances from the symphysis pubica at the crossing of the branches of the n. pudendus-n. dorsalis penis and the branches for the muscles of the diaphragma urogenitale on the other hand. CONCLUSION: The work elucidated the selected distances and discuss their possible clinical relevance for evaluation of the seriousness of pelvic fractures from the perspective of late sequelae in the region innervated by the pudendal nerve.

Operative treatment of avascular necrosis of the femoral head after proximal femur fractures in adolescents.

PURPOSE: Our aim was to assess operative treatment for post-traumatic avascular necrosis of the femoral head (ANFH) in adolescents. METHODS: Eleven patients with an average age of 17 (range 14-26) years were operated up on for ANFH after proximal femoral fractures. The average interval between injury and reconstructive surgery was four (range two to eight) years. The average follow-up of the entire cohort was 89 (range 48-132) months. Five patients with total ANFH were treated by total hip replacement (THR). Six patients with partial ANFH were treated with valgus intertrochanteric osteotomy (VITO). RESULTS: In all patients, operation improved hip function. The average preoperative Harris Hip Score (HHS) was 70 points and average postoperative HHS was 97 points. Comparison of magnetic resonance imaging (MRI) scans before and after VITO demonstrated resorption of the necrotic segment of the femoral head and its remodelling in all six patients with partial ANFH. A complication was encountered in one patient. CONCLUSION: Patients treated for ANFH had good medium-term outcomes after THR for total necrosis and also after VITO for partial necrosis.

Operative treatment of avascular necrosis of the femoral head after slipped capital femoral epiphysis.

PURPOSE: The aim of the study was assessment of the medium-term outcome of operative treatment of avascular necrosis of the femoral head (ANFH) after slipped capital femoral epiphysis (SCFE). MATERIALS AND METHODS: Five patients were treated with valgus-flexion intertrochanteric osteotomy (VFITO) for partial ANFH that developed after operative treatment. Their average age at the time of slip was 12.5 years (range, 10-14); at the time of the reconstructive operation 14 years (range, 12-16), the average interval between slip and the reconstructive operation was 14 months (range, 9-18). Partial ANFH was diagnosed between 6 and 8 months after the slip on the basis of radiographic examination. In all the patients, the anterolateral third up to half of the femoral head was always affected. The average follow-up period was 73 months (range, 60-84). RESULTS: Comparison of MRI scans before and after VFITO proved resorption of the necrotic segment of the femoral head and its remodeling in all the five patients. The average preoperative Harris hip score (HHS) was 86 points, the average postoperative HHS was 94 points. CONCLUSION: VFITO provides a good outcome at medium-term follow-up in adolescent patients with partial ANFH after SCFE.

Is distal locking with IMHN necessary in every pertrochanteric fracture?

Two groups of patients were treated for pertrochanteric fractures (AO/ASIF 31A1+A2) with an intramedullary hip nail. In the first group of 44 patients distal dynamic locking was used, and in the second group of 74 patients the nail was not distally locked. Comparison of the two groups of patients did not show any difference in terms of the period of fracture healing, radiological and functional results or frequency of complications. In the group with a distally locked nail the surgery took 40.4 minutes, while in the group without distal locking only 34.4 minutes. In total, we recorded only seven complications, none of which were caused by absence of distal locking of the nail. This study has shown that distal locking of IMHN is unnecessary in most pertrochanteric fractures (AO/ASIF 31A1+2). The only exceptions are comminution of the lateral wall of the greater trochanter, secondary diaphyseal fracture line, large posteromedial fragment extended distally below the level of the lesser trochanter and broad intramedullary canal.