Risk of periprosthetic fracture after anterior femoral notching.

BACKGROUND: Notching of the anterior femoral cortex in distal femoral fractures following TKR has been observed clinically and studied biomechanically. It has been hypothesized that femoral notching weakens the cortex of the femur, which can predispose to femoral fractures in the early postoperative period. We examined the relationship between notching of the anterior femoral cortex during total knee replacement (TKR) and supracondylar fracture. PATIENTS AND METHODS: Postoperative lateral radiographs of 200 TKRs were reviewed at an average of 9 (6-15) years postoperatively. 72 knees (41%) showed notching of the anterior femoral cortex. Notches were classified into 4 grades using the Tayside classification as follows. Grade I: violation of the outer table of the anterior femoral cortex; grade II: violation of the outer and the inner table of the anterior femoral cortex; grade III: violation up to 25% of the medullary canal (from the inner table to the center of the medullary canal); grade IV: violation up to 50% of the medullary canal (from the inner table to the center of the medullary canal) and unclassifiable. RESULTS: The interobserver variability of the classification system using Cohen's Kappa score was found to be substantially reliable. 3 of the 200 TKRs sustained later supracondylar fractures. One of these patients had grade II femoral notching and the other 2 showed no notching. The patient with femoral notching sustained a supracondylar fracture of the femur following a simple fall at home 9 years after TKR. INTERPRETATION: There is no relationship between minimal anterior femoral notching and supracondylar fracture of the femur in TKR.

Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures.

PURPOSE. To compare functional outcomes, union and complication rates in patients treated with locked intramedullary nailing or dynamic compression plating for humeral shaft fractures. METHODS. 32 men and 2 women with humeral shaft fractures were randomised to undergo locked antegrade intramedullary nailing (IMN, n=16) or dynamic compression plating (DCP, n=18). Patients with pathological fractures, grade-III open fractures, neurovascular injury, or fractures for more than 2 weeks were excluded. Fractures were classified according to the AO classification system (one in A1, 6 in A2, 12 in A3, 6 in B1, and 9 in B2). 28 were injured in road traffic accidents. The functional outcome (according to the American Shoulder and Elbow Surgeons [ASES] score) and rates of union and complication of the 2 groups were compared. RESULTS. All patients were followed up for a minimum of 24 months. In the respective IMN and DCP groups, the mean ASES scores were 45.2 and 45.1 (p=0.69), the complication rates were 50% and 17% (p=0.038), and the non-union rates were 0% and 6% (p=0.15). In the IMN group, 2 sustained iatrogenic fractures during nail insertion; 2 had transient radial nerve palsies; one underwent nail removal for shoulder impingement; and 3 had adhesive capsulitis. In the DCP group, one underwent re-operation for implant failure; one had a superficial infection; and one developed adhesive capsulitis. CONCLUSION. The complication rate was higher in the IMN group, whereas functional outcomes were good with both modalities.