Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients.

INTRODUCTION: The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS: We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS: Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS: Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Morel-Lavallee lesion: report of two cases of a rare extensive closed soft-tissue injury / Morel-Lavallée-laesio: egy ritka, kiterjedt, zárt lágyrész-sérülés. Két eset ismertetése

Morel-Lavallee lesion is an extensive, decollement-like closed degloving soft-tissue injury. It occurs most commonly in the thigh, pelvis or lumbar region, primarily due to traffic accidents or sports injuries. The injury is often associated with pelvic or femoral fractures and polytrauma but it may occur separately. Early diagnosis and specific treatment are critically important to achieve adequate therapy in which the operative approach is preferred. If not treated properly, complaints may progress and the condition can become chronic. It should be highlighted that a considerable number of patients suffering from this condition may not present in central institutions but in minor hospitals or outpatient units with separately occurring, chronic or painful injury. Morel-Lavallee lesion is rarely mentioned in the Hungarian literature. The authors aim to present the most important knowledge about the injury in accordance with the case presentation of two patients with lumbar complaints they treated in a non-central institution.

Maximal Axial Vertebral Rotation in Adolescent Idiopathic Scoliosis: Is the Apical Vertebra the Most Rotated?

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVES: It is generally believed that the apical vertebra has the largest axial rotation in adolescent idiopathic scoliosis. We investigated the relationship between apical axial vertebral rotation (apicalAVR) and maximal axial vertebral rotation (maxAVR) in both major and minor curves using biplanar stereo-imaging. METHODS: EOS 2D/3D biplanar radiograph images were collected from 332 patients with adolescent idiopathic scoliosis (Cobb angle range 10°-122°, mean age 14.7 years). Based on the X-ray images, with the help of 3D full spine reconstructions Cobb angle, curvature level, apicalAVR and maxAVR were determined. These parameters were also determined for minor curves in Lenke 2, 3, 4, 6 type patients. Maximal thoracic rotation and maximal thoracolumbar/lumbar rotation were calculated. Statistical analysis was performed with descriptive statistics, Shapiro-Wilk test, and Wilcoxon signed-rank test. RESULTS: The apical vertebrae were the most rotated vertebra in only 40.4% of the major curves, and 31.7% in minor curves. MaxAVR significantly exceeded apicalAVR values in the major curves (P < .001) as well as in minor curves (P < .001). The 2 parameters differed significantly in each severity group and Lenke type. CONCLUSIONS: The apical vertebrae were not the most rotated vertebra in more than half of cases investigated indicating that apicalAVR and maxAVR should be considered as 2 distinct parameters, of which maxAVR fully describes the axial dimension of scoliosis. Furthermore, the substitution of maxAVR for the apicalAVR should be especially avoided in double and triple curves, as the apical vertebra was even less commonly the most rotated in minor curves.

The treatment of pediatric tibial fractures ­ from conservative therapy to a Hungarian innovation / A gyermekkori tibiatörések kezelése - a konzervatív terápiától a hazai innovációig.

Összefoglaló. A tibiatörés a gyermekkorban eloforduló leggyakoribb csontsérülések egyike. Felosztása során elsodlegesen elkülönítendok a növekedési zóna közeli, az azt érinto, illetve a diaphysisre lokalizált sérülések. A gyermekkor jelentette speciális adottságoknak - mint a jó gyógy- és regenerációs hajlam - köszönhetoen a tibiatörések kezelése az esetek többségében konzervatív módon kituno eredményekkel végezheto. A kezelési lehetoségek fejlodésével, illetve a sérülteknek a mielobbi funkcionális felépüléshez való megnövekedett igénye miatt az elmúlt idoszakban a mutétes beavatkozások aránya egyértelmu emelkedést mutatott. Ez kifejezetten igaz a lábszártestet érinto törésekre. A mutétes beavatkozások során elsodleges szempont a minimális invazivitásra való törekvés, kitüntetett figyelmet fordítva a növekedési zónák iatrogén károsításának elkerülésére. A megfelelo terápiás módszer megválasztása során azonban a sérülés lokalizációja és típusa mellett szem elott kell tartani a sérült gyermek életkorát, fizikális állapotát és személyes igényeit is. A jelen közlemény célja egy átfogó kép adása a gyermekkorban eloforduló, a lábszárat érinto töréses sérülésekrol, különös tekintettel azok kezelési lehetoségeire. A sérülések átfogó ismertetésén túl a szerzok kiemelt célja volt a diaphysist érinto serdülokori törések behatóbb értékelése, kihangsúlyozva ezzel az említett csoport kezelésében az elmúlt idoszakban megfigyelheto stratégiai változásokat, valamint azok operatív terápiájával kapcsolatosan a szerzok nevéhez kötheto újfajta mutéti lehetoséget. Orv Hetil. 2021; 162(52): 2079-2088. Summary. Tibial fractures are among the most common fracture types in children. Their classification is primarily based on the affected part of the tibia which can be close to the epiphyseal plate, involving the epiphyseal plate or diaphyseal. Owing to the special characteristics of childhood, such as excellent tendency for healing and recovery, the first-line treatment of tibial fractures should be conservative, which has a favorable outcome in most cases. However, the rate of operative management has risen recently due to the improvement of treatment options and the patients' increasing demand for a quick functional recovery, especially in the treatment of diaphyseal fractures. Pursuing a minimally invasive method is an essential aspect of operative management, while special attention is paid to avoid further iatrogenic damage to the physes. When selecting the adequate method for treatment, the age, physical condition, and personal needs of the injured child should also be considered along with fracture type and localization. This review aims to provide a comprehensive summary about pediatric tibial fractures, especially the available therapeutic approaches. A strong emphasis is placed on the treatment of adolescent diaphyseal fractures, highlighting the recent changes in strategy and the authors' innovation in the operative management of adolescent diaphyseal fractures. Orv Hetil. 2021; 162(52): 2079-2088.

Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures.

INTRODUCTION: The first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. MATERIALS AND METHODS: Between January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. RESULTS: Good functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. DISCUSSION: The treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures.

Analysis of Proximal Femoral Parameters in Adolescent Idiopathic Scoliosis.

BACKGROUND: Assessment of the proximal femoral parameters in adolescent idiopathic scoliosis using three-dimensional radiological image reconstructions may allow better characterization than conventional techniques. METHODS: EOS 3D reconstructions of spines and femurs of 320 scoliotic patients (10-18 years old) and 350 control children lacking spinal abnormality were performed and 6 proximal femoral parameters measured. RESULTS: Individuals with adolescent idiopathic scoliosis showed a small but statistically significant decrease in neck shaft angle (average difference=2.58°) and a higher (0.22°) femoral mechanical axis-femoral shaft angle. When the two sides were compared based on curve direction, greater changes in the neck shaft angle and femoral mechanical axis-femoral shaft angle were found on the side of the convexity. CONCLUSIONS: Patients with adolescent idiopathic scoliosis were found to have a small but significantly lower neck shaft angle and higher femoral mechanical axis-femoral shaft angle, which related to the curve direction. This is postulated to be due to mechanical compensation for altered balance and centre of gravity associated with a scoliosis deformity, although the observed difference likely has negligible clinical effect.

Sagittal plane assessment of spino-pelvic complex in a Central European population with adolescent idiopathic scoliosis: a case control study.

BACKGROUND: Scoliosis is a complex three-dimensional deformity. While the frontal profile is well understood, increasing attention has turned to balance in the sagittal plane. The present study evaluated changes in sagittal spino-pelvic parameters in a large Hungarian population with adolescent idiopathic scoliosis. METHODS: EOS 2D/3D images of 458 scoliotic and 69 control cases were analyzed. After performing 3D reconstructions, the sagittal parameters were assessed as a whole and by curve type using independent sample t test and linear regression analysis. RESULTS: Patients with scoliosis had significantly decreased thoracic kyphosis (p < 0.001) with values T1-T12, 34.1 ± 17.1o vs. 43.4 ± 12.7o in control; T4-T12, 27.1 ± 18.8o vs. 37.7 ± 15.1o in control; and T5-T12, 24.9 ± 15.8o vs. 32.9 ± 15.0o in control. Changes in thoracic kyphosis correlated with magnitude of the Cobb angle (p < 0.001). No significant change was found in lumbar lordosis and the pelvic parameters. After substratification according to the Lenke classification and individually evaluating subgroups, results were similar with a significant decrease in only the thoracic kyphosis. A strong correlation was seen between sacral slope, pelvic incidence, and lumbar lordosis, and between pelvic version and thoracic kyphosis in control and scoliotic groups, whereas pelvic incidence was also seen to be correlated with thoracic kyphosis in scoliosis patients. CONCLUSION: Adolescent idiopathic scoliosis patients showed a significant decrease in thoracic kyphosis, and the magnitude of the decrease was directly related to the Cobb angle. Changes in pelvic incidence were minimal but were also significantly correlated with thoracic changes. Changes were similar though not identical to those seen in other Caucasian studies and differed from those in other ethnicities. Scoliotic curves and their effect on pelvic balance must still be regarded as individual to each patient, necessitating individual assessment, although changes perhaps can be predicted by patient ethnicity.

The effect of coronal decompensation on the biomechanical parameters in lower limbs in adolescent idiopathic scoliosis.

STUDY HYPOTHESIS: We hypothesized that altered coronal balance in adolescent scoliosis leads to asymmetric stress on the lower limbs, with subsequent effects on bone maturation and later morphology. We aimed to assess the correlation between the biomechanical parameters of the lower limbs and coronal balance in idiopathic scoliosis. MATERIALS AND METHODS: In this study, EOS images of 280 patients and 56 controls were randomly selected from our clinics' database. The average age of AIS patients was 14.5years and average Cobb angle 33.48°. Three D reconstructions of the pelvis and lower limbs were performed and coronal balance assessed. Reliability of measurements was ensured by intra- and inter-observer agreement. During statistical analysis the Kolmogorov-Smirnov test, t-test and linear regression analysis were performed. A p value <0.05 was considered significant. RESULTS: Of the 15 examined lower limb parameters, a significant difference between sides was found in those with AIS for femur length, total length, collodiaphyseal angle, angle between the femoral mechanical and anatomical axis and tibial torsion. In addition, the tibial length and the mechanical tibiofemoral angle were significantly higher than those of the controls. The coronal balance was found to be the strongest predictive factor showing a significant correlation with all of the previous parameters, except tibial torsion. With patients grouped based on coronal balance (compensated, right and left decompensated) the paired t-test also supported these findings. CONCLUSION: The biomechanical parameters of the lower limbs are affected in cases of scoliosis with an altered coronal balance. It was thought that a shift in balance in the coronal plane accounted for the small but significant changes seen in our study, with the lower limb on the side of decompensation becoming shorter in comparison to its' counterpart, with a lower collodiaphyseal angle and increased varus at the knee joint. LEVEL OF EVIDENCE: III, case-control study.

Axial plane dissimilarities of two identical Lenke-type 6C scoliosis cases visualized and analyzed by vertebral vectors.

PURPOSE: The global appearance of scoliosis in the horizontal plane is not really known. Therefore, the aims of this study were to analyze scoliosis in the horizontal plane using vertebral vectors in two patients classified with the same Lenke group, and to highlight the importance of the information obtained from these vertebral vector-based top-view images in clinical practice. METHODS: Two identical cases of scoliosis were selected, based on preoperative full-body standing anteroposterior and lateral radiographs obtained by the EOS™ 2D/3D system. Three-dimensional (3D) surface reconstructions of the spinal curves were performed by using sterEOS™ 3D software before and after surgery. In both patients, we also determined the vertebral vectors and horizontal plane coordinates for analyzing the curves mathematically before and after surgery. RESULTS: Despite the identical appearance of spinal curves in the frontal and sagittal planes, the horizontal views seemed to be significantly different. The vertebral vectors in the horizontal plane provided different types of parameters regarding scoliosis and the impact of surgical treatment: reducing lateral deviations, achieving harmony of the curves in the sagittal plane, and reducing rotations in the horizontal plane. CONCLUSIONS: Vertebral vectors allow the evolution of scoliosis curve projections in the horizontal plane before and after surgical treatment, along with representation of the entire spine. The top view in the horizontal plane is essential to completely evaluate the scoliosis curves, because, despite the similar representations in the frontal and sagittal planes, the occurrence of scoliosis in the horizontal plane can be completely different. These slides can be retrieved under Electronic Supplementary Material.

[Assessment of sacroiliacal joint mobility in patients with low back pain]. / A keresztcsonti ízület mobilitásának vizsgálata derékpanaszos betegcsoportban.

INTRODUCTION: Sagittal alignment of the pelvis is typically characterized using three fundamental parameters. Among these, pelvic incidence is traditionally considered to be anatomically 'constant'. AIM: We aimed to analyze the pelvic parameters of low back pain patients with suspected sacroiliac joint laxity. METHOD: Pelvic parameters were assessed in standing and seated EOS 2D/3D radiographs of 48 cases of persistent low back pain, and compared to upper body position using cluster analysis and t-test. RESULTS: Median pelvic incidence did not differ statistically between standing and sitting (47.8°-47.7°). However, in individual analysis 7 cases (15%) exhibited a forward tilt in their upper body with an increased pelvic incidence, and 7 cases (15%) showed a backward upper body tilt. No change was found in 34 cases. CONCLUSION: Our results indicate the pelvis should not be regarded as a rigid unit, as in some cases significant appreciable sacroiliac joint laxity can occur. Orv Hetil. 2017; 158(52): 2079-2085.

The horizontal plane appearances of scoliosis: what information can be obtained from top-view images?

PURPOSE: A posterior-anterior vertebral vector is proposed to facilitate visualization and understanding of scoliosis. The aim of this study was to highlight the interest of using vertebral vectors, especially in the horizontal plane, in clinical practice. METHODS: We used an EOS two-/three-dimensional (2D/3D) system and its sterEOS 3D software for 3D reconstruction of 139 normal and 814 scoliotic spines-of which 95 cases were analyzed pre-operatively and post-operatively, as well. Vertebral vectors were generated for each case. Vertebral vectors have starting points in the middle of the interpedicular segment, while they are parallel to the upper plate, ending in the middle of the segment joining the anterior end plates points, thus defining the posterior-anterior axis of vertebrae. To illustrate what information could be obtained from vertebral vector-based top-view images, representative cases of a normal spine and a thoracic scoliosis are presented. RESULTS: For a normal spine, vector projections in the transverse plane are aligned with the posterior-anterior anatomical axis. For a scoliotic spine, vector projections in the horizontal plane provide information on the lateral decompensation of the spine and the lateral displacement of vertebrae. In the horizontal plane view, vertebral rotation and projections of the sagittal curves can also be analyzed simultaneously. CONCLUSIONS: The use of posterior-anterior vertebral vector facilitates the understanding of the 3D nature of scoliosis. The approach used is simple. These results are sufficient for a first visual analysis furnishing significant clinical information in all three anatomical planes. This visualization represents a reasonable compromise between mathematical purity and practical use.