Offset nail fixation for intertrochanteric fractures improves reduction and lag screw position.

BACKGROUND: Surgery for intertrochanteric fractures using intramedullary hip nails (IHNs) is among the most common surgical procedures in the orthopedic field. Although IHNs provide good overall outcomes, they sometimes cause complications, such as loss of reduction and cut-out. Here, we investigated the usefulness of IHNs with an anterior offset (Best Fit Nail® [BFN]) in maintaining fragment reduction and ensuring proper lag screw position compared with conventional non-offset nails (Proximal Femoral Nail Antirotation® [PFNA]), using postoperative computed tomography (CT). METHODS: Fifty consecutive patients with intertrochanteric fractures who underwent surgery with BFNs (BFN group) and 50 patients who underwent surgery with PFNAs (PFNA group) were retrospectively analyzed. Indices evaluated by postoperative CT were displacement distance of proximal fragment relative to distal fragment, reduction status (intramedullary, anatomical, and extramedullary types), lag screw direction, and angle between lag screw and femoral neck axis (deviation angle). RESULTS: Median [interquartile range] displacement distance was significantly smaller in the BFN group (0 [0, 0] mm) compared with the PFNA group (5.2 [3.6, 7.1] mm) (p<0.001). Reduction status was significantly better in the BFN group (anatomical type, 40 cases; intramedullary type, in 9 cases, and extramedullary type in 1 case) than in the PFNA group (anatomical type, 6 cases; intramedullary type, 43 cases; extramedullary type, 1 case) (p<0.001). Deviation of lag screw direction was observed in significantly fewer cases in the BFN group (20 cases; 40%) compared with the PFNA group (36 cases; 72%). Lag screw deviation angle was significantly smaller in the BFN group (-0.71°±4.0°) compared with the PFNA group (6.9°±7.1°). No adverse events related to surgery were observed in either group. CONCLUSIONS: Intertrochanteric fracture surgery using offset BFNs exhibited significantly smaller displacement distance, better reduction status, and higher frequency of no deviation with central lag screw position, compared with surgery using non-offset PFNAs.

Double-bundle anatomic anterior cruciate ligament reconstruction using bone-hamstring-bone composite graft.

The bone-hamstring-bone (BHB) composite graft is a hybrid ligament reconstruction methodology that combines the advantages but eliminates the disadvantages of the bone-patellar tendon-bone (BPTB) and tendon of semitendinosus and gracilis muscle (STG) methods. We have developed an innovative modified BHB method involving anatomic anterior cruciate ligament (ACL) reconstruction. It takes into account the 2 bundles of the ACL: the anteromedial bundle and the posterolateral bundle. The composite graft was prepared by folding the gracilis and the semitendinosus tendons twice and flanking the ends by bone blocks obtained from the tibia. One tunnel of 11-mm diameter was made in the tibia and the femur, and the top of the graft was introduced into the femoral socket; the distal end of the graft was rotated 90 degrees in the counterclockwise direction for a right knee and 90 degrees in the clockwise direction for a left knee to apply a twist to the graft, giving rise to an anteromedial bundle and a posterolateral bundle. The bone blocks attached to the graft were fixed with 2 interference screws. Modified BHB technique allows free selection of the location of the bone plug, minimizes the intra-articular length of the graft, and maintains the double-bundle structure of the original ACL.