Subtrochanteric femur nonunion - Chasing the elusive an analysis of two techniques to achieve union: Nail-plate fixation and plate-structural fibula graft fixation.

INTRODUCTION: The subtrochanteric region is known for its unique biomechanical properties that contribute to challenges in fracture reduction. To ensure optimal fracture healing, achieving robust mechanical stability is essential. There are very few studies in the literature describing the treatment of subtrochanteric fracture nonunion. PURPOSE: To analyze the outcomes of two techniques of revision fixation of nonunion in subtrochanteric femur fracture, namely, nail-plate fixation and plate-structural fibula graft fixation. METHODS: This was a retrospective analysis of subtrochanteric femur nonunion between January 2011 and December 2019. The demographic details, details of the index surgery, details of the revision surgery and the time to final union were collected. The nonunion was divided based on the level of the fracture into high subtrochanteric and low subtrochanteric. Two revision techniques were used: plate-structural fibula graft for high subtrochanteric and nail-plate construct for low subtrochanteric femur fractures RESULTS: Out of the 54 patients that were included, there was malalignment in 53.70 %, medial comminution in 46.3 %, distraction at the fracture site in 44.4 %, lateral trochanteric wall break in 37.03 % and implant failure in 70.37 % of the patients. There were 20 high subtrochanteric and 34 low subtrochanteric fractures. Union was achieved in 53 patients (98.14 %). The mean LEFS score was 71.4 in the nail-plate group and 66.2 in the plate-structural fibula graft group (p 0.003). CONCLUSION: The treatment of subtrochanteric femur fracture nonunion can be a daunting task. The goal is to correct the varus and restore the medial support which will prevent the occurrence of collapse and another failure. We were able to achieve this with both the nail-plate and the plate- structural fibula graft revision methods.

Can the rate of mortality and neurological recovery be predicted from the time of onset of symptoms and MRI grade in patients with cerebral fat embolism? : a study of 34 patients.

AIMS: The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. METHODS: The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination. RESULTS: In all, seven who had early-onset CFES (< 24 hours), and a severe Takahashi grade on MRI, died. There was a significant association between the time of onset of neurological signs and mortality (p = 0.035). Mortality was also significantly associated with a severe Takahashi grade (p < 0.001). Among the 27 surviving patients, 26 (96.3%) recovered completely. One (3.7%) had a cognitive deficit. The mean time to recovery was 4.7 weeks (2 to 13), with late recovery aftereight eight weeks being recorded in three patients. CONCLUSION: There was a significantly increased rate of mortality in patients with CFES who had an early onset of symptoms and a severe grade on MRI. Complete neurological recovery can be expected in most patients with CFES who survive. Cite this article: Bone Joint J 2022;104-B(1):142-149.

Posterior Stabilization of Unstable Sacral Fractures: A Single-Center Experience of Percutaneous Sacroiliac Screw and Lumbopelvic Fixation in 67 Cases

Methods@#Out of the 67 patients, 40 and 27 were in the SI and LPF groups, respectively. The electronic medical record for each patient was reviewed, including patient demographic data, mode of trauma, coexisting injuries, neurological status (Gibbon’s four-grade system), Injury Severity Score, time from admission to operative stabilization, type of surgical stabilization, complications, return to the operating room, and treatment outcome measures using Majeed’s functional grading system and Matta’s radiological criteria. The minimum follow-up period was 2 years. @*Results@#Noncomminuted longitudinal injuries with normal neurology and acceptable closed reduction have undergone SI screw fixation (n=40). Irreducible, comminuted, or high transverse fractures associated with dysmorphic anatomy or neurodeficit were managed by LPF (n=27). Excellent and good Majeed and Matta scores at 86.57% and 92.54% of the patients, respectively, were postoperatively achieved. @*Conclusions@#Unstable sacral fractures can be effectively managed with percutaneous SI screw including vertically unstable injuries by paying strict attention to preoperative patient selection whereas LPF can be reserved for comminuted fractures, unacceptable closed reduction, associated neurodeficit, lumbosacral dysmorphism, and high transverse fractures.

Management of acute 'pink pulseless' hand in pediatric supracondylar fractures of the humerus.

The management of a persistent pink pulseless hand after a satisfactory closed reduction in a pediatric supracondylar fracture of the humerus is controversial. Several recent publications have recommended vascular exploration in contrast to a more conservative approach accepted traditionally. We report the results of seven patients with a mean follow-up of 36.6 months with a persistent pulseless, but well-perfused hand postreduction. All patients were managed conservatively without vascular exploration. A palpable return of the radial pulse was seen in six patients at 3 weeks and at 6 weeks follow-up in the other patient with no long-term dysfunction. We believe that the management of a persistent pink pulseless hand remains a 'watchful expectancy'. Surgical exploration should be recommended only if there is either severe pain in the forearm persisting for more than 12 h after the injury or if there are signs of a deteriorating neurological function.

Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries.

STUDY DESIGN: Randomized clinical trial (level I evidence). OBJECTIVE: To compare the accuracy of non-navigation and Iso-C based navigation in pedicle screw fixation in thoracic spine deformities. SUMMARY OF BACKGROUND DATA: Thoracic pedicle screw insertion for spinal deformity correction can be associated with increased pedicle breaches. Iso-C based navigation has been reported to improve the accuracy of pedicle screw placement, but its use in the presence of deformity has not been reported. METHODS: Twenty-seven patients with scoliosis and 6 patients with kyphosis had a total of 478 thoracic pedicle screws. The average Cobb angle was 58.4 degrees +/- 8 degrees (range 50 degrees -80 degrees), and the mean kyphotic angle was 54.6 degrees +/- 4 degrees (range 51 degrees -76 degrees). By random allocation, 17 patients had screw insertion under navigation (242 screws) and 16 under fluoroscopic control (236 screws). The 2 groups were compared for accuracy of screw placement, time for screw insertion, and the number of times the C-arm had to be brought into the field. Two independent blinded observers determined accuracy using postoperative computed tomography assessments. RESULTS: There were 54 (23%) pedicle breaches in the non-navigation group as compared to only 5 (2%) in the navigation group (P < 0.001). Thirty-eight screws (16%) in the non-navigation group had penetrated the anterior or lateral cortex compared to 2 screws (0.8%) in the navigation group. Average screw insertion time in the non-navigation group was 4.61 +/- 1.05 minutes (range 1.8-6.5) compared to 2.37 +/- 0.72 minutes (range 1.16-4.5) in navigation group (P < 0.01). The C-arm had to be moved into the operation field on an average of 1.5 +/- 0.25 times (range 1-3) per screw. With single screening data, an average of 11.4 pedicles (range 9-14) could be visualized without necessity to bring the C-arm into operating field again. CONCLUSIONS: Iso-C navigation increases accuracy, and reduces surgical time and radiation in thoracic deformity correction surgeries.