Description of new sign of integral (∫) for rotational deformity of distal femur.

PURPOSE: Femur shaft fractures commonly occur due to high velocity trauma and most of them are fixed with nailing. Malrotation is common after fixation. A rotational malalignment more than 30° is a deformity which requires correction. Various techniques described for rotational deformities are: the 'cable techniques' for the determination of varus-valgus malalignment; the 'hyperextension test', 'radiographic recurvatum sign', 'tibial plateau sign', and 'meterstick technique' for length analysis; and the 'hip rotation test', 'lesser trochanter shape sign', 'cortical step sign', and 'diameter difference sign' for rotational analysis. We describe integration sign at the medial or lateral aspect of notch of femur in fixed internal or external rotation due to condensation of trabeculae. METHODS: This is a prospective observational study. Informed consent was taken, and this study was approved by institutional review board. C arm imaging study of 50 knees was done at our institution in which rotational profile of distal femur was analyzed In 3 different views -AP , Internal and external rotation views. The rotation views were taken sequentially and each observer was asked to identify the sign at its appearance and at rotation when it was best seen. All the observers were asked to draw the sign on linear line diagram of distal femur. The data was analysed statistically. RESULTS: Sign of integral (∫) for rotational deformity was seen at Mean external rotation of  22±1.71 with a range of 19 degree to 25 degree and  Mean internal rotation of 15.78±1.21 with a range of 14 degree to 18 degree. CONCLUSION: The integration sign can be used as intraoperative C arm sign to understand the rotational deformity of distal fragment of femur. This helps the surgeon to understand the alignment and revise if needed intraoperatively. If combined with position of lesser trochanter, this will give alignment for both proximal as well as distal fragment of femur.

Tibia Nailing Using Modular Stand: A Technical Note.

Interlocking nailing is a well-established procedure for managing unstable tibial shaft fractures. Closed reduction and internal fixation of the tibial shaft fractures require ease of intraoperative positioning, maneuvering, and biplane imaging. We describe the use of an innovative modular tibia-nailing stand, which greatly enhances the ergonomics of the tibia nailing procedure.

Description of new "epsilon sign" and its significance in reduction in highly unstable variant of intertrochanteric fracture.

BACKGROUND: Intertrochanteric fractures are commonly encountered in day-to-day trauma practice having various fracture patterns. Adequate reduction and appropriate fixation methodology is required for optimum results. However, failure rates are very high in unstable fractures. Here we describe a unique unstable variant of intertrochanteric fracture characterized by a long spike of proximal fragment, irreducibility of fracture with standard traction and internal rotation and soft tissue interposition. This appears as typical figure of 3 signs on right side and epsilon ε sign on left side on AP X-ray of pelvis with both hips. MATERIALS AND METHODS: In retrospective review of 924 intertrochanteric fractures treated at our institution from June 2005 to January 2017, twenty patients with this typical highly unstable fracture pattern (epsilon sign/figure of 3 at fracture site) were operated at our institution, which included 18 males and two females with average age of 43.5 years (range 30-60 years). All patients required open reduction with specific maneuver and dynamic hip screw fixation. RESULTS: All patients had good reduction at the end of surgery, and all patients had good signs of clinico-radiological union at follow-up. None of the patients had implant loosening or screw back out. CONCLUSION: The typical radiological pattern seen on X-ray will guide the surgeon to predict this unstable variant of IT fracture preoperatively and will suggest toward requirement of open reduction with specific maneuver and internal fixation with dynamic hip screw.

A proposed radiological classification system of Hoffa's fracture based on fracture configuration and consequent optimal treatment strategy along with the review of literature.

BACKGROUND: Coronal fractures of distal end femur, referred as Hoffa's fracture are not uncommon, yet easily missed injuries lacking proper classification system and consensus for ideal treatment. While most trauma surgeons adopt different strategies based on the fracture configuration and their own experience, there are no set ways to classify these based on the most appropriate treatment strategy. METHODS: Thirty cases of Hoffa fracture from tertiary care centres were studied for the fracture pattern, fragment size, comminution and possible variations to formulate a radiological classification and treatment guidelines. Additionally, a literature search was used to analyze 77 case studies based on Hoffa fracture to find out the common fracture patterns and treatment modalities adopted for varying fracture patterns in these studies. Six independent observers participated in testing the inter-observer reliability of the proposed classification. RESULTS: A new proposed radiological classification for Hoffa fracture consists of four main types. Type 1 is with fracture fragment >2.5 cm, Type 2 with fragment <2.5 cm, Type 3 is comminuted fracture, Type 4 are subdivided as Type 4a - Anterior, Type 4b - Bicondylar, Type 4c - Osteochondral type and Type 4d - With supracondylar extension. Optimum treatment modality depends on the type of Hoffa's fracture and has been suggested in the study. Interobserver reliability demonstrated that overall agreement was 0.907692 with a fixed marginal Kappa of 0.881067 and free Marginal Kappa at 0.892308. Intra-observer reliability test for the classification system showed a strong Kappa value of +1.0. CONCLUSION: The new suggested classification helps identify different types of Hoffa's fracture. This is likely to help decide optimal surgical treatment depending on the nature of the injury. The classification system has high inter and intra-observer reliability that enables its universal applicability.