Long stem revision versus short stem revision with plate osteosynthesis for Vancouver type B2 periprosthetic femoral fracture: a comparative study of eighty five cases.

PURPOSE: Periprosthetic femoral fractures (PPFs) around the hip are challenging complications in orthopaedic surgery, particularly Vancouver type B2 (VTB2) fractures. The surgical management of these fractures is crucial and depends on various factors. Cementless short taper stem with plate osteosynthesis is an alternative surgical technique. This study aims to compare the outcomes of this surgical technique with revision arthroplasty (RA) with long stem in the treatment of VTB2 PPFs. METHODS: This retrospective study was conducted in a single medical institute from February 2010 to May 2019. Patients who had received either total hip arthroplasty or bipolar hemiarthroplasty and subsequently developed a VTB2 PPF were included; patients who sustained intra-operative fractures or received a cemented stem previously were excluded from the analysis. The patients were divided into two groups: group I received RA with cementless long stem, while group II underwent RA with cementless short taper stem with plate osteosynthesis. Demographic data, radiographic and functional outcomes, and complications were analyzed between the two groups. RESULTS: A total of 85 patients diagnosed with VTB2 PPFs were included in the study. There were no significant differences between the two groups in terms of demographic data, including age, gender, mean follow-up times, estimated blood loss, and operative times. The radiographic results showed that there was no significant difference in the incidence of subsidence and implant stability between the two groups. However, group II tended to have less subsidence and periprosthetic osteolysis. Patients in group II had significantly better functional scores (mean Harris hip score: post-operative: 60.2 in group I and 66.7 in group ii; last follow-up: 77.4 in group 1 and 83.2 in group II (both p < 0.05)). There were no significant differences in the overall complication rate, including infection, dislocation, re-fracture, and revision surgery, between the two groups. CONCLUSIONS: Both surgical techniques, cementless long stem and cementless short taper stem with plate osteosynthesis, are effective in the treatment of Vancouver B2 PPFs, with no significant differences in outcomes or complications. However, patients in cementless short taper stem with plate osteosynthesis had better functional scores at both post-operative and the last follow-up.

The role of postoperative piriformis fossa and greater trochanter tubercle distance to predict cutout failure after cephalomedullary nail fixation.

BACKGROUND: This study investigated the association between postoperative piriformis fossa and greater trochanter tubercle distance (distance from the deepest point of piriformis fossa to the most lateral greater trochanter tubercle [PG]) and cutout failure after cephalomedullary nail (CMN) osteosynthesis for intertrochanter fracture (ITF). A rotating femur model was designed to analyze PG variation during femur rotation. METHODS: From 2005 to 2010, 311 patients diagnosed of ITF (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] 31-A2 and A3) underwent CMN fixation at our institute were reviewed. Of these, 281 (90.3%) patients achieved union without complication, 21 (6.8%) had cutout failure, six (1.9%) had femoral head osteonecrosis, and three (1%) had nonunion during postoperative 2-year follow-up. The side difference of postoperative PG compared to contralateral uninjured hip (dPG) was analyzed between patients who had cutout failure and those who did not. In the rotating femur model, the PG was measured for every 2.5° increments of internal and external rotation from 0° to 50°. RESULTS: The dPG was significantly higher in the failure group (10.2 ± 4.2 vs 6.6 ± 3.5 mm, p <0.001). The odds ratio for lag screw cutout was 6.35 (95% CI, 1.10-11.6, p =0.003) for every 1 mm dPG increment. dPG exhibited high diagnostic performance in predicting cutout failure according to receiver operating characteristic curve analysis. The area under the curve was 0.774 (95% CI, 0.711-0.837). dPG yielded the greatest sensitivity (78.4%) and specificity (78.4%) to predict lag screw cutout when cutoff value being 8.65 mm. In rotating femur model, PG change from baseline demonstrated significant ( p <0.001) positive and negative correlation with increased external and internal rotation, respectively. CONCLUSION: Increased dPG is a risk factor of cutout failure for ITF osteosynthesis with CMN. In conjunction with tip-apex distance, fracture displacement, and reduction quality; dPG can help surgeons interpret postoperative radiograph and predict failure. However, it should be noticed that a proper and standard patient positioning is critical for accurate dPG measurement.

A comparative study of the hemodynamic and clinical effects of using or not tourniquet in total knee arthroplasty.

BACKGROUND: Pneumatic tourniquet is widely used in lower limb surgery to provide a bloodless operating field. Previous studies on total knee arthroplasty (TKA) in which tourniquets have been applied during surgery have reported some vascular and soft-tissue complications. Nevertheless, it is still not well known exactly how use of tourniquets contributes to hemodynamics of the lower limb and its clinical relevance following TKA. In this prospective study, we wished to determine whether tourniquet affects the hemodynamics and postoperative healing of the lower limb in the first few weeks and its clinical relevancies following TKA. METHODS: We prospectively collected consecutive 110 patients with advanced osteoarthritis of the knee. All the subjects were randomly assigned to one of two TKA procedures: TKA with (Group T) or without (Group O) tourniquets. The hemodynamics of each operated leg was assessed by Doppler, first before the operation, then postoperatively on days 2, 6, 14, and 28. The operative and postoperative managements were done the same as those described in the papers done by the author. Parameters during the operative and postoperative course, including, demography, pre- or postoperative knee score, tourniquet time, operation time, estimated blood loss, perioperative blood transfusion, hospital course, and complications will all be recorded and compared in detail. All patients were measured for all response variables, which included demographic variables, results of Doppler, and important surgical outcomes. Fisher's exact test was used to compare differences between the two groups for each discrete variable, and a Mann-Whitney Rank Sum Test was used to analyze each continuous variable. The p value was set for each test at 0.05 before analysis took place. In accordance with the repeated measures, the venous hemodynamic parameters were checked. If any significant differences appeared in the overall test, values were then compared in pairs using two sample t-tests for all statistical tests. The level of significance was set at p < 0.05. RESULTS: In our 110 patients (55 with tourniquet, 55 without), all checked clinical parameter were without significant difference except postoperative quadriceps muscle recovery. This implied tourniquet use influenced postoperative rehabilitation program. Blood loss amount were similar in both groups. There was only one DVT found. CONCLUSION: Tourniquet use in TKA must be managed very carefully. Not only because of immediate complication resulted from tourniquet but also influence on post-operational functional recovery, especially in quadriceps muscle function. According to this study, TKA without tourniquet use preserves better quadriceps muscle function to provide faster recovery and less transfusion need. It avoids complications from tourniquets as well.

Loss of radial height in extra-articular distal radial fracture following volar locking plate fixation.

BACKGROUND: Radial height is an important prognostic factor in treating distal radius fracture. However, does further collapse of radial height in distal radius fractures after with volar locking plate fixation have a great impact on the prognosis? The present study aimed to elucidate radial height loss and determine the associated risk factors after open reduction and internal fixation with volar locking plate in patients with extra-articular distal radius fractures. HYPOTHESIS: Patients with radial height collapse after fracture reduction and internal fixation with a volar locking plate may have poor outcomes. METHODS: Data of 87 patients (21 male) undergoing surgery for acute extra-articular distal radius fractures (AO: 23-A2 or 23-A3) between February 2014 and July 2016 were evaluated retrospectively. Patients were divided into two groups by radial height loss. Potential risk factors were tested by Pearson correlation coefficients. Stepwise multiple regression logistic analysis determined significant independent risk factors for extra-articular distal radius fractures. Clinical evaluation was performed by the same surgeon by determining wrist ROM. Grip strength was measured with a Jamar dynamometer and compared with non-affect wrist in percentage. In addition, all the patients were asked to grade modified Mayo wrist score and Visual Analogue Scale (VAS) score. These findings were recorded postoperative 1 year of follow-up. RESULTS: Mean radial height loss was 1.3±0.9mm. Age (ß=0.002, p=0.003), postoperative ulnar-positive deformity (ß=0.107, p<0.001), DEXA (ß=-0.015, p=0.008), and shortest diameter of distal fracture fragment in AP and lateral views (ß=-0.050, p=0.037; ß=-0.080, p=0.043) were significantly associated with radial height loss. As for the outcome of clinical prognosis, though radial height collapse group had poorer wrist range of motion, there was no statistical difference. Besides, there were no significant differences in grips strength and VAS score between these two groups. However, in regards of modified Mayo wrist score, the percentage of patients with poor outcomes is significant higher in radial height collapse group (p=0.039). Moreover, all patients with poor outcomes in radial height collapse groups were older than 65-year-old. DISCUSSION: Radial height loss is noted in patients undergoing open reduction and internal fixation with volar locking plate for extra-articular distal radius fractures. Risk factors for radial height collapse include advanced age, poor bone quality, shortest distance between fracture site and articular surface and postoperative ulnar-positive deformity. LEVEL OF EVIDENCE: IV; non-comparative prospective study.

Displaced isolated greater tuberosity fractures of elder adults treated with plate osteosynthesis.

BACKGROUND: We elucidated the effect of open reduction and internal fixation with locking plate for acute isolated displaced greater tuberosity fractures of humerus in elder adults (aged >60 years). METHODS: From 2009 to 2015, data from 32 patients, aged between 60 and 88 years, who had acute unilaterally displaced greater tuberosity fractures of humerus were collected and evaluated retrospectively. All the fractures were managed with open reduction and internal fixation with locking plate. The follow-up period was 50.8 months on an average (range 22-80 months). Finally, 25 patients were available for final evaluation of radiographic and functional results. RESULTS: All the 32 fractures had union with the average union time of 14 weeks (range 10-18 weeks) and with no complications. The average of preoperative Visual Analogue Scale (VAS) was 6.2 (range 4-8), ASES was 30.4 (range 13-45), and Constant score was 30.4 (range 20-45). At the last follow-up, the mean VAS was 1.3 (range 0-2.5), the mean ASES score was 90.1 (range 72-100), and the mean Constant score was 90.3 (range 80-100). There were statistically significant differences between preoperative and final follow-up in VAS, ASES, and Constant score. Hundred percent of patients had good or excellent results by Constant score, with excellent results (86-100) in 17 (68%) patients and good result (71-85) in 8 (32%). CONCLUSION: In conclusion, open reduction and internal fixation with locking plate is an effective treatment for acute displaced greater tuberosity fractures of humerus in elder adults.

Anterior release may not be necessary for idiopathic scoliosis with a large curve of more than 75° and a flexibility of less than 25.

BACKGROUND CONTEXT: To improve correction and fusion rates, an anterior release is often needed for the treatment of idiopathic scoliosis with a curve of more than 75° before posterior correction, instrumentation, and fusion. However, there are disadvantages to anterior release, and we are concerned about whether it is necessary for anterior-posterior spinal fusion in these patients. PURPOSE: The objective of this study was to compare the surgical results for idiopathic scoliosis with a curve of more than 75° and a flexibility of less than 25% between using posterior-only approach and combined anterior release followed by posterior correction with a hybrid construct (hooks and pedicle screws) and spinal fusion. STUDY DESIGN/SETTING: This was a retrospective cohort study. PATIENT SAMPLE: From 2000 to 2014, 388 consecutive patients with idiopathic scoliosis were treated surgically at our hospital. Of these patients, 53 whose primary curves were more than 75° with a flexibility of less than 25%, at an incidence of 13.6%, were included and divided into two groups. Thirty-one patients (mean age: 16.3 years old) who underwent anterior release followed by posterior correction, instrumentation, and fusion were included in the A+P group, and the remaining 22 patients (mean age: 17.3 years old) were designated as the P group for posterior procedure alone. OUTCOME MEASURES: The clinical outcomes were analyzed in terms of correction and loss of correction and by the Scoliosis Patient Questionnaire: Version 30 functional questionnaire. MATERIALS AND METHODS: In the A+P group, halo-femoral traction was applied for 1 week between the anterior release and the posterior procedure. Posterior instrumentation with a hybrid construct with hooks and pedicle screws was used for both groups. The radiological and functional outcomes were compared between the two groups. RESULTS: The average preoperative Cobb angle was 85.3° for the A+P group, with an average 17.4% flexibility, and 80° for the P group, with 15.3% flexibility. The postoperative Cobb angle was 53.1° for the A+P group and 45.6° for the P group. The Cobb angle at the final follow-up for the A+P group was 55.2° and that for the P group was 48°. The average correction rates of the A+P and P groups were 37% and 43.4%, respectively. There were no statistically significant differences between the groups in gender, age, number of levels fused, and flexibility of coronal curve. With a minimum 2-year follow-up, similar results were found between these two groups in terms of correction rate, loss of correction, and functional outcome. CONCLUSIONS: In this study, we found that a posterior-only approach with hybrid construct (hooks and pedicle screws) could provide a correction similar to that of an anterior-posterior approach. Also, the disadvantages of anterior release could be avoided by the posterior-only approach.