Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis.

BACKGROUND: In this study we describe the morphology of the posteromedial fragment in pertrochanteric fractures using 3D CT scans and answer two questions 1) Do differences exist between the 3D CT appearances of posteromedial fragments and the depictions made in the AO classification 2) Does the posteromedial fragment affect stability in pertrochanteric fractures, in terms of fracture collapse? METHODS: Preoperative CT scans of eight 31-A1 and fifty 31-A2 fractures were analysed. The presence of PM fragment, its fragmentation, greater trochanter (GT) involvement, lesser trochanter (LT) fragment size (in terms of its posterior and medial extent as well as LT length), LT fragment displacement (in terms of medial displacement and rotation) were determined. All fractures were treated with a DHS. Fracture collapse was determined on postoperative radiographs. The relationship between fracture collapse and patient factors including age, gender, fracture type (A1 versus A2), characteristics of the posteromedial fragment, and the presence of a lateral wall fracture were determined. RESULTS: Three out of eight 31-A1 fractures demonstrated a separate GT fragment (three part fracture). Out of the 50 31-A2 fractures, 12 had a single PM fragment, which included the LT and GT in continuity. The more common four part fractures seem to form by further fragmentation of this basic form. In A2 fractures, the GT was almost always broken and the broken fragment comprised a mean 56% of normal GT. The LT fragment involved an average of 74% of the posterior wall, and an average of 36% of the medial wall of the proximal femur. Larger LT fragments were less displaced as compared to smaller fragments. Univariate regression analyses revealed that fracture collapse was significantly correlated with fracture type (A1 versus A2, p 0.036), GT size (p 0.002) and the presence of a lateral wall fracture (p<0.001). CONCLUSIONS: This study revealed some important differences between the 3D CT appearances and AO classification of pertrochanteric fractures. Further, neither fragmentation of the posteromedial fragment, nor the size of the lesser trochanter fragment was found to predict stability in pertrochanteric fractures. A perioperative lateral wall fracture is the main determinant of stability in these fractures.

Which AO/OTA 31-A2 pertrochanteric fractures can be treated with a dynamic hip screw without developing a lateral wall fracture? A CT-based study.

PURPOSE: To determine whether radiographic measurements derived from standard computed tomography (CT) evaluation can be used to predict likelihood of a peri-operative lateral femoral wall fracture in AO/OTA 31-A2 pertrochanteric fractures treated with a dynamic hip screw (DHS). METHODS: Fifty-one patients with AO/OTA 31-A2 classified pertrochanteric fractures were evaluated using a pre-operative CT scan of the pelvis with both hips. Dimensions of the lateral wall were calculated for each patient using four parameters: (1) height of the lateral wall above the vastus ridge; (2) circumference of the lateral wall 2 cm below the vastus ridge at an angle of 135°; this circumference was further divided into an anterior, lateral and posterior component; (3) cortical thickness at the centre of the lateral component of the lateral wall; and (4) cortical index. All patients were treated with a 135° DHS. Postoperative radiographs were assessed for lateral femoral wall fracture. RESULTS: Patients with a lateral wall fracture (17/51) had a smaller circumference (4.47 cm vs 5.44 cm p value <0.001) as well as a lower height of the lateral femoral wall (1.37 cm vs 2.21 p value < 0.001). Analysis of the three components of the circumference revealed a significant difference for the anterior component only and not for the lateral and posterior components. There was no statistical difference in the cortical thickness or cortical index in the two groups. The cutoff values for height of the lateral wall and anterior component were calculated using ROC curves and found to be 1.68 cm (AUC 0.918) and 2.10 cm (AUC 0.851) respectively. CONCLUSION: AO/OTA 31-A2 pertrochanteric fractures with a lateral wall height of > 1.68 cm and an anterior component of > 2.10 cm in circumference are not likely to sustain a lateral wall fracture when treated with a DHS.

On-table reconstruction and fixation of Mason type III radial head fractures.

PURPOSE: To evaluate the functional and radiological outcome of comminuted radial head fractures, which were not amenable for classical open reduction with internal fixation, treated by on-table reconstruction and fixation using low profile plates. METHODS: We reviewed 6 patients of Mason type III radial head fractures treated by on-table reconstruction technique between 2011 and 2013. There were 5 men and 1 woman with a mean age of 35 years (range 25-46 years). All surgeries were carried out at our tertiary care level 1 trauma centre within a mean of 3 days (range 1-8 days) from date of injury using on-table reconstruction technique. The functional outcome was measured using elbow functional rating index described by Broberg and Morrey and the patient-based Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. RESULTS: The mean follow-up period was 25 months. The average elbow flexion was 135°(range 125°-140°) and theaverage flexion contracture was 5°(range 0-10°). The average supination and pronation was 75°(range 70°-80°) and 70°(range 65°-82°) respectively. According to Broberg and Morrey scoring system, the average score was 90 points (range 75-100). The mean DASH score was 2.49 points. CONCLUSION: On-table reconstruction and fixation of comminuted radial head fractures using low profile plates is a reasonable option. The reconstructed radial head acts as spacer and provides reasonably good results and no surgical intervention is required for asymptomatic nonunion of these fractures regardless of the radiological findings.

Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility.

PURPOSE: To define the unique radiographic features, operative treatment, and complications of pertrochanteric fractures (AO/OTA 31-A1 and A2) which are not amenable to the usual closed reduction manoeuvres. METHODS: During a 2-year period (from August 2011 until December 2013), 212 patients with pertrochanteric fractures were treated at our level I trauma centre. A retrospective review was undertaken to determine which of these fractures were not reducible via the routine closed reduction manoeuvres and required some form of open reduction. These fractures were assessed for radiographic markers of irreducibility, surgical findings, reduction techniques, and perioperative complications. RESULTS: Twenty-four patients had fractures, which were not amenable to closed reduction and underwent open reduction. These fractures could be grouped into four patterns. A preoperative CT scan was available for at least two cases of each pattern, which provided further insights into the cause of irreducibility by closed means. These included a variant where the proximal fragment is locked underneath the shaft fragment (3 cases), bisected lesser trochanter with a locked proximal fragment (3 cases), irreducibility due to entrapped posteromedial fragment at the fracture site (6 cases) and a variant where the proximal fragment is flexed passively by the underlying lesser trochanter (12 cases). CONCLUSIONS: Pertrochanteric fractures, which are not amenable to closed reduction, are uncommon, but are heralded by unique radiographic features. These patients warrant special consideration in terms of recognition and management. The specific radiographic markers should alert the surgeon to this injury pattern and its related difficulty encountered during closed reduction. Once reduction is achieved, however, these fractures follow an uneventful course.

Acute femoral artery pseudoaneurysm due to lesser trochanter fragment: an unusual complication of an intertrochanteric fracture.

False aneurysm of the femoral artery is a rare complication of intertrochanteric fracture. Most of these situations are due to iatrogenic trauma or the trauma itself and are rarely caused by dislocated bone fragments. Here we report a case of a 72-year-old man who presented acutely with a pseudoaneurysm of the superficial femoral artery from the spike of a lesser trochanter fragment. Percutaneous endovascular treatment of the pseudoaneurysm with a covered stent was undertaken on an urgent basis. Five days later, the patient was operated upon and the lesser trochanter fragment was excised through an anterior incision and the intertrochanteric fracture was fixed using dynamic hip screws. The fracture was united at 10 weeks. At one-year's follow-up, there were no graft-related complications. This case illustrates that an intertrochanteric fracture with a displaced lesser trochanter fragment can present acutely with bleeding and a pseudoaneurysm of the femoral artery.

Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System: mid term to long term follow-up.

Patients older than 55 years presenting with acetabular fractures fulfilling the criteria for acute total hip arthroplasty (THA) were included. Cementless THA was done using the Octopus System and autologous bone grafting. 15 patients were available for latest follow up. The average follow-up was 81.5 months (62-122 months). Mean Harris Hip Score was 91.1. 10 patients were walking without any support while 5 were using a cane. There were no cases of acetabular or femoral component loosening. This method of treatment is promising in the older population as there is deficiency of bone stock which may lead to fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly.

Transplantation of free tibial periosteal grafts for the repair of articular cartilage defect: An experimental study.

BACKGROUND: Articular chondrocytes have got a long lifespan but rarely divides after maturity. Thus, an articular cartilage has a limited capacity for repair. Periosteal grafts have chondrogenic potential and have been used to repair defects in the articular cartilage. The purpose of the present study is to investigate the differentiation of free periosteal grafts in the patellofemoral joint where the cambium layer faces the subchondral bone and to investigate the applicability of periosteal grafts in the reconstruction of articular surfaces. MATERIALS AND METHODS: The study was carried out over a period of 1 year on 25 adult, male Indian rabbits after obtaining permission from the institutional animal ethical committee. A full-thickness osteochondral defect was created by shaving off the whole articular cartilage of the patella of the left knee. The defect thus created was grafted with free periosteal graft. The patella of the right knee was taken as a control where no grafting was done after shaving off the articular cartilage. The first animal was used to study the normal histology of the patellar articular cartilage and periosteum obtained from the medial surface of tibial condyle. Rest 24 animals were subjected to patellectomy, 4 each at serial intervals of 2, 4, 8, 16, 32 and 48 weeks and the patellar articular surfaces were examined macroscopically and histologically. RESULTS: The grafts got adherent to the underlying patellar articular surface at the end of 4 weeks. Microscopically, graft incorporation could be appreciated at 4 weeks. Mesenchymal cells of the cambium layer were seen differentiating into chondrocytes by the end of 4 weeks in four grafts (100%) and they were arranged in a haphazard manner. Till the end of 8 weeks, the cellular arrangement was mostly wooly. At 16 weeks, one graft (25%) had wooly arrangement of chondrocytes and three grafts (75%) had columnar formation of cells. Same percentage was maintained at 32 weeks. Four grafts (100%) at 48 weeks showed columnar orientation. The control side showed no changes over the shaved off articular surface in all the rabbits. One rabbit at 4 weeks had a dislocation of the patella on the control side. None of the rabbits developed any infection or wound dehiscence. CONCLUSION: Autologous periosteal graft transplantation can be a promising substitute for articular cartilaginous defects.