Short-Term Complications of Relative Femoral Neck Lengthening Combined with Extra-Articular Osteotomies of the Proximal Femur.

Purpose: Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO. Methods: All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1 week, 6 weeks, 3 months, 6 months, 12 months and 24 months. Results: Seventy two patients (31 males, 41 females, 6-52 years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union. Conclusion: RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections. Significance: The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.

How Safe is Antegrade Femoral Nailing in Ipsilateral Acetabulum Fractures Requiring Kocher-Langenbeck Approach? An Analysis of 23 Fractures.

Objective: The ipsilateral acetabulum and femur fracture (IAFF) is an uncommon entity. This combination challenges the surgeon in the optimal management of each injury component, fixation sequence, surgical approaches, implant choices and complications. Inappropriate approach for one fracture may affect the fixation of another or modify the overall outcome. In this perspective, we aim to analyze our results in patients who underwent acetabulum fixation with Kocher-Langenbeck (K-L) approach and antegrade femur nailing (AFN), emphasizing the incidence of infection, skin necrosis and heterotopic ossification (HO). Methods: During the five years, 22 patients with 23 IAFF (mean age of 36.5 years) were treated operatively. All the patients underwent K-L approach for acetabulum fixation and AFN for femur fracture. All the patients were treated under the supervision of a pelvi-acetabular trauma consultant. Demographic data, injury, surgical, and postoperative details were collected. The quality of acetabular reduction was evaluated using Matta's criteria. The radiological outcome, obtained at final follow-up, was graded according to Matta's criteria. Functional outcome was evaluated by Merle d'Aubigné and Postel system. HO was graded according to the Brooker system. Complications recorded were DVT, skin necrosis, infection, arthritis, HO, AVN and need for additional surgery. Results: Out of 23, 11 had posterior dislocation, 6 had quadrilateral plate injury with central protrusion and six without dislocation. Femur fractures include 9-midshaft, 4-proximal third, 3-distal third, 3-trochanteric fractures and 4-segmental fractures. There were 11 elementary and 12 associated acetabulum fractures. 21 fractures underwent staged-fixation. Single-stage fixation was done in 2. In all cases treated with staged-fixation, AFN was done first. The mean duration of follow-up was 28 months (16-57). All femur fractures united with a mean union time of 21.3 weeks (11-37). The radiological outcome was excellent in 13, good in 4, fair in 3 and poor in 3. The functional outcome was excellent in 3, good in 11, fair in 4 and poor in 4 patients. None had skin necrosis. Three patients had infection. 14 (60.8%) hips had HO, with clinically significant HO (grade 4) in 2(8.6%). Six (26%) patients had arthritic changes. Four (17.3%) hips had avascular necrosis. Conclusion: AFN is a viable option in IAFFs requiring a K-L approach under the supervision of a pelvi-acetabular surgeon. This combined approach per se does not demonstrate an increased risk of infection, wound healing problems or HO. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00544-w.

Pin Leverage Technique: A Simple Percutaneous Technique for Elevation of Posterolateral Tibial Plateau Fractures.

Depressed lateral tibial plateau fractures with a large central or posterior fragment can be seen in isolation or association with complex proximal tibia fractures. Conventionally elevation of the large depressed fragment is done by bone tamp through a medial metaphyseal window in isolated fractures, or the fractured window in associated complex fracture scenarios. Though various instruments have been devised for this purpose, reaching the posterior aspect of lateral condyle through the medial metaphyseal window is not always easy, considering the difficulty in aiming and trajectory. Excessive maneuvering can result in the widening of the medial metaphyseal window, leaves a large metaphyseal void, intraarticular penetration of elevating device, and comminution of the depressed fragment. Described herein is an alternate percutaneous technique for effective reduction of selected lateral tibial plateau depression fractures using Steinmann pin. Twenty- one patients with at least 1-year follow-up with successful outcomes have benefitted from this reduction technical tip thus far.

Morphology Specific Lateral Wall Reconstruction Techniques Using Cerclage Wires in Unstable Trochanteric Fractures.

Trochanteric lateral wall fracture (LWF) indicates instability and is found to be an important predictor of reoperations following trochanteric fracture fixation. A single unified technique for lateral wall reconstruction may not adequately stabilize all the fracture patterns. We have presented morphology specific lateral wall reconstruction techniques using cerclage wire around proximal femoral nails. Various LWF patterns have been simplified into three types. Type-specific lateral wall reconstruction techniques using cerclage wire were adopted in 49 consecutive unstable trochanteric fractures presented to our institute between 2016 and 2018. We analyzed the fracture pattern, fixation method used, union time, and complications. The functional outcome was analyzed using the Harris hip score (HSS). The mean follow-up period was 13 months (range 10-36 months). The mean age of the population was 66 years (range 36-91 years). There were 15 patients with type 1 LWF pattern, 26 patients with type 2, and 8 were of type 3 pattern. The mean operating time was 66 min. The mean union time was 14 weeks (10-24 weeks). HSS was excellent in 9 patients, good in 33 patients, fair in 4 patients, and poor in 5 patients. Complications include one patient with avascular necrosis (AVN) of the femoral head, varus collapse with non-union in one patient, screws back out in one patient, superficial infection in 4 patients, and distal screw breakage in one patient. Type 2 is the most common LWF type in our study. In unstable trochanteric fractures, morphology specific lateral wall reconstruction using cerclage wire loops around the proximal femoral nail is a simple technique with promising results with minimal complications.

Marginal impaction in complex posterior wall acetabular fractures: role of allograft and mid-term results.

OBJECTIVE: To evaluate the functional and radiological outcome of complex posterior wall acetabular fractures with marginal impaction treated with cancellous allograft and internal fixation. METHODS: A total of 16 patients with marginal impaction on pre-operative CT scan, who underwent internal fixation and allograft were analysed. Mean follow-up was 28 months (range 24-42). The mean age was 46.5 years (range 22-71). Out of 16 patients, 8 were AO A1.2- and 8 were AO A1.3-type fractures. Functional evaluation was performed using modified Merle d'Aubigné and Postel scores and radiological evaluation by Matta's criteria for quality of initial reduction and final outcome. RESULTS: The quality of reduction was anatomical in 12 patients (75%) and imperfect in 4 patients (25%). The radiological outcome at final follow-up was excellent in 9 (56.25%), good in 5 (31.25%) and fair in 2 patients (12.5%). None of the patients had a secondary loss of reduction at final follow-up. Functional outcome was excellent in 2 (12.5%), good in 8 (50%) and fair in 6 patients (37.5%). CONCLUSION: The use of cancellous allograft to fill the bone void provides good mechanical stability without any secondary loss of reduction. This surgical technique seems to be effective and safe in treating comminuted posterior wall fractures with marginal impaction without any donor site complications and other disadvantages of synthetic bone graft materials.

Impaction Bone Grafting and Valgus Osteotomy: A Technical Trick for the Treatment of Femoral Neck Nonunions.

Femoral neck nonunions in young adults is among the most challenging problems to treat. This is due to their inherent problems, such as neck resorption, increase in fracture gap, sclerosis of fracture margins, and avascular necrosis. Hip salvage in these cases, although challenging, is recommended in the Asian subcontinent where social and religious activities require squatting and sitting cross-legged. Muscle pedicle grafts and other vascularized bone grafting techniques are preferred treatment options, but they are technically demanding and require advanced microsurgical skills. Valgus osteotomy, although successful in certain cases, has a high failure rate in patients with poor bone stock. We present a simple technique of valgus subtrochanteric osteotomy, impaction bone grafting, and stabilization with a sliding hip screw. Here, we describe in detail about the surgical technique and present the clinical outcomes in 44 patients, with a mean follow-up of 3.4 years and a union rate of 95.5%.