Management of periprosthetic femoral fractures following total knee arthroplasties using locking plates or intramedullary nailing. Comparative study of 567 cases.

INTRODUCTION: Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable. MATERIALS AND METHODS: The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal. RESULTS: The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)]. DISCUSSION AND CONCLUSION: The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups. LEVEL OF EVIDENCE: IV; comparative retrospective study.

The comparative efficacy of nerve transfer versus tendon transfer in the management of radial palsy: A systematic review and meta-analysis.

Background: There is no clear census as to which operative technique provides better recovery for radial nerve injuries. Therefore, in this systematic review, we examined the functional recovery, patient-reported outcomes, and complications of tendon transfer (TT) and nerve transfer (NT). Methods: Five electronic databases were searched for studies (>10 cases per study) comparing NT and TT regardless of the study design (observational or experimental). Manual search was also conducted. The quality was assessed by the NIH tool. Outcomes included functional recovery, patient-reported outcomes (DASH score, satisfaction, and inability to return to work), and complications. The prevalence was pooled across studies using STATA software, and then, a subgroup analysis based on the intervention type. Results: Twenty-one studies (542 patients) were analyzed. Excellent recovery, assessed by the Bincaz scale, was higher in the TT group (29 % vs. 11 %) as well as failure to extend the fingers (49 % vs. 9 %). No significant difference was noted between both groups regarding DASH score (mean difference = -2.76; 95 % CI: -12.66: 6.93). Satisfaction was great in the TT group (89 %) with a limited proportion of patients unable to return to work (7 %). Complications were slightly higher in the TT group (8 % vs. 7 %) while 18 % of patients undergoing TT requiring revision surgery. Radial deviation was encountered in 18 % of patients in the TT group and 0 % in the NT group. The quality was good, fair, and poor in 2, 13, and 6, respectively. Conclusions: In radial nerve injuries, although tendon transfer may seem to provide better functional motor recovery than nerve transfer, it is associated with a higher rate of failure to extend the finger. Given the large confidence interval, the accuracy of this finding is questioned. However, a great proportion of those patients require revision surgery afterward. Additionally, tendon transfer is associated with a greater complication rate than nerve transfer, particularly radial deviation.

Floating-Variant Medial Elbow Dislocation: A New Classification System.

Floating-variant elbow dislocation is a newly updated term used to describe several associations of fractures around the elbow and elbow dislocation that are still not adequately classified due to their rarity. Being extremely rare, only a handful of case reports are found in the literature describing this condition. Most of these papers described cases associated with the posterior or posterolateral direction of elbow dislocation, wherein each author has treated the fracture differently. The decision of surgical treatment, the order of fixation, the material used, and the need for ligamentous repair are all questions that are yet to be answered. We present herein a unique new variant of floating medial elbow dislocation in a 13-year-old female that was successfully treated by closed reduction of the elbow, open reduction of the distal humerus fracture, and orthopedic treatment of the radial shaft fracture.

Belt and suspender technique for bipolar bone loss in shoulder instability.

Bipolar glenohumeral bone loss is a challenging condition to address in patients with recurrent anterior shoulder instability. In this category of patients, most isolated soft-tissue procedures such as remplissage or infraspinatus capsulotenodesis are associated with high risk of failure and instability recurrence. Even bony procedures such as Latarjet may fail to provide absolute stability, and instability may eventually recur. For a better understanding of the cause of failure in this particular type of patient, we may refer to the glenoid track concept which has been described as a useful tool for surgical planning. In fact, Latarjet procedure alone may leave a place for engagement of the Hill-Sachs defect on the anterior glenoid resulting in an off-track situation and secondary glenohumeral instability. In this technical note, we present the combination of arthroscopic remplissage and an open Latarjet procedure to treat patients with bipolar glenohumeral bone loss with good results at 31-month follow-up. Our aim is to propose these techniques as a possible rescue procedure for highly unstable shoulders combining engaged Hill-Sachs lesion and glenoid bone loss of more than 25%. We believe this technique would be a good option for patients who present other risk factors of recurrence such as past medical history of epilepsy, laxity, and psychiatric illnesses.

Isolated Acromial Fracture in a Cyclist: A Case Report and Review of the Literature.

CASE: An isolated acromial fracture was diagnosed in a 45-year-old subject, recreational athlete, during a cycling fall on the shoulder. Clinical examination combined with x-ray and computerized tomography scan confirmed the isolated injury. Open reduction and osteosynthesis using a tension band technique was performed. The patient was immobilized in a sling for 6 weeks, and fixation hardware was removed after 6 months. At the 1-year follow-up, patient had returned to his preinjury level of athletic activity. CONCLUSION: Isolated acromial fracture is an uncommon sports-related injury. Although several treatment modalities exist, nonoperative, immobilization treatment is typically effective if fracture is not displaced. Osteosynthesis should be considered if there is subacromial impingement or fracture displacement >10 mm.

Isopropanol Dehydration on Amorphous Silica-Alumina: Synergy of Brønsted and Lewis Acidities at Pseudo-Bridging Silanols.

The mechanism of isopropanol dehydration on amorphous silica-alumina (ASA) was unraveled by a combination of experimental kinetic measurements and periodic density functional theory (DFT) calculations. We show that pseudo-bridging silanols (PBS-Al) are the most likely active sites owing to the synergy between the Brønsted and Lewis acidic properties of these sites, which facilitates the activation of alcohol hydroxy groups as leaving groups. Isopropanol dehydration was used to specifically investigate these PBS-Al sites, whose density was estimated to be about 10-1  site nm-2 on the silica-doped alumina surface under investigation, by combining information from experiments and theoretical calculations.