Osteosynthesis of unstable intracapsular femoral neck fracture by dynamic locking plate or screw fixation: early results.

OBJECTIVES: The purpose of this study was to compare the postoperative radiologic and clinical outcomes of telescopic femur neck screws and small locking plate device (Targon FN) (group 1) with multiple cancellous screws (group 2) for displaced intracapsular femoral neck fractures. DESIGN: Comparison of a prospective collected data to a historical control group (retrospective). SETTING: One community teaching hospital. PATIENTS: Seventy-eight patients (group 1, 31; group 2, 47) underwent reduction and internal fixation of displaced intracapsular femoral neck fractures with either Targon FN device or multiple cancellous screws from March 2000 to July 2010. Their mean age was 53.7 years (SD: 16.4), and the mean follow-up period was 28.6 months. MAIN OUTCOME MEASURES: Treatment failure was considered to be either a nonunion, osteonecrosis, or revision surgery of any type. Treatment was regarded as successful in patients who did not show failure and had at least 1-year follow-up. RESULTS: One patient in group 1 (3.2%) and 22 (46.8%) in group 2 had a nonunion (P = 0.0001). Four (12.9%) group 1 patients and 16 (34.0%) group 2 patients underwent revision surgery (P = 0.036). Four (12.9%) patients in group 1 and 4 (8.5%) group 2 patients had osteonecrosis of the femoral head (P = 0.531). Multivariate logistic regression showed that internal fixation by the fixed-angle fixation device decreased the odds ratio for overall complication by a factor of 0.23, for example, by 77% (P = 0.018). CONCLUSIONS: Performing internal fixation by a fixed-angle fixation device decreased nonunion rates and revision rates. It did not affect the rate of osteonecrosis. LEVEL OF EVIDENCE: Therapeutic level III. See instructions for authors for a complete description of levels of evidence.

Delay in diagnosis of femoral hematogenous osteomyelitis in adults: an elusive disease with poor outcome.

BACKGROUND: Hematogenous osteomyelitis of long bone is rare in adults, especially in the immune competent host. Only a few cases have been described to date. OBJECTIVES: To present a case series of femoral hematogenous osteomyelitis in adults, a rare condition that is difficult to diagnose and may cause major morbidity and mortality. METHODS: We reviewed three cases of femoral hematogenous osteomyelitis that occurred between 2007 and 2009. The course of the disease, physical findings, imaging modalities, laboratory analysis, culture results and functional outcomes were recorded. RESULTS: In all cases the diagnosis was delayed after symptoms were first attributed to radicular-like pain or lateral thigh pain due to an inflammatory non-infectious source. In all cases infection was caused by an unusual or fastidious bacterium. The pathogen was Haemophilus aphrophilus in one case, and Streptococcus specimens were found in the other two. Pathological fracture occurred in two of the cases despite culture-specific antibiotic treatment and a non-weight bearing treatment protocol. It took five surgical interventions on average to reach full recovery from infection, but residual disability was still noted at the last follow-up. CONCLUSIONS: Clinicians should be aware that although femoral hematogenous osteomyelitis is a rare condition in adults, its ability to mimic other pathologies can result in delayed diagnosis and major morbidity. In our series the pathogen was different in each case and was cultured only from the infected site. Pathological fracture is a devastating complication but we do not recommend prophylactic stabilization at this point.

[Atypical femoral fractures in long-term osteoporotic treatment with bisphosphonates].

Recently, atypical femoral fractures, especially at the proximal part, were reported in the literature. Most of the reports discussed the relationship between those atypical fractures and chronic use of bisphosphonate drugs as prophylactic treatment for osteoporosis. As a result, the FDA (US Food and Drug Administration) published a statement on October 2010, which was the conclusion of a multidisciplinary working group. The FDA decided to add warnings for every bisphosphonate drug which was given as prophylactic treatment for osteoporosis in the USA. In this review, we will present the bisphosphonate drugs, the presenting symptoms of patients who suffer from the pathologic fracture, the radiologic characteristics and the surgical treatment. We will present the work of a Task Force of the American Society for Bone and Mineral Research and the FDA statements.

Digital image enhancement improves diagnosis of nondisplaced proximal femur fractures.

UNLABELLED: Today most emergency room radiographs are computerized, making digital image enhancement a natural advancement to improve fracture diagnosis. We compared the diagnosis of nondisplaced proximal femur fractures using four different image enhancement methods using standard DICOM (Digital Imaging and Communications in Medicine) after window-leveling optimization. Twenty-nine orthopaedic residents and specialists reviewed 28 pelvic images consisting of 25 occult proximal femur fractures and three images with no fracture, using four different image filters and the original DICOM image. For intertrochanteric fractures, the Retinex filter outperforms the other filters and the original image with a correct fracture type diagnosis rate of 50.6%. The Retinex filter also performs well for diagnosis of other fracture types. The Retinex filter had an interobserver agreement index of 53.5%, higher than the other filters. Sensitivity of fracture diagnosis increased to 85.2% when the Retinex filter was combined with the standard DICOM image. Correct fracture type diagnosis per minute for the Retinex filter was 1.43, outperforming the other filters. The Retinex filter may become a valuable tool in clinical settings for diagnosing fractures. LEVEL OF EVIDENCE: Level I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Percutaneous Achilles tendon repair combined with real-time sonography.

BACKGROUND: When encountering complaints of pain in the area of Achilles tendon with a suspected lesion, the clinician seldom reaches a precise diagnosis based only on X-ray and clinical examination. Ultrasonography is useful for evaluating the pathology and treatment. OBJECTIVES: To assess the relative contribution of real-time intraoperative ultrasound examination and immediate postoperative ultrasound in patients with acute rupture of the Achilles tendon treated by percutaneous suture method. The combination of both procedures provides a unique advantage that could facilitate better results. METHODS: Ultrasound examination was used in 20 patients with acute rupture of the Achilles tendon who were treated surgically. Intraoperative as well as postoperative ultrasound examinations were performed in 5 patients while 15 patients underwent an immediate postoperative ultrasound. RESULTS: Ultrasound pathologies were found in all patients. Percutaneous surgical correction of ruptured Achilles tendon with accurate positioning of the foot using real-time sonography was successful in all the patients. CONCLUSION: As in many other soft tissue lesions, ultrasonography is a useful tool for evaluating the pathology and for planning the surgical correction of ruptures in the Achilles tendon.

Ultrasonography as a diagnostic modality in acromioclavicular joint pathologies.

BACKGROUND: Ultrasound is useful in detecting acromioclavicular pathologies in cases of trauma, inflammations and degenerative changes. OBJECTIVES: To describe the sonographic findings of acromioclavicular joint pathology in patients with anterior shoulder pain. METHODS: Sonographic examination of the ACJ was used to examine 30 adults with anterior shoulder pain. As a control group we studied 30 asymptomatic patients and compared the findings to plain radiographs of the symptomatic group. RESULTS: The pathologic findings consisted of swelling of the joints, bone irregularities, widening and/or narrowing of the ACJ, soft tissue cyst formation, excessive fluid collection, and calcification. All these signs represent degenerative changes compatible with early osteoarthritis. We encountered one case of septic arthritis that required joint aspiration and antibiotic treatment. CONCLUSIONS: It is our belief that ultrasonography should be used routinely in cases of anterior shoulder pain since it demonstrates various pathologies undetected by plain radiographs.

Colchicine inhibits heterotopic ossification: experimental study in rabbits.

BACKGROUND: Heterotopic ossification is a common complication of hip surgery and musculoskeletal or brain trauma. OBJECTIVES: To confirm by in vivo study that colchicine inhibits osteoblast cell proliferation with marked decrease in tissue mineralization. METHODS: Heterotopic ossification was induced in three groups of New Zealand white rabbits (females, 6 months old, weight 3-3.5 kg) by injecting 2 ml bone marrow drawn from the iliac crest into their right thigh muscle. To prevent heterotopic ossification, colchicine (0.25 mg/ day) was administered orally for 4 weeks to two groups of adult rabbits: group A (preload group)--1 week preceding bone marrow injection; group B--on day of injection; and group C--control group. RESULTS: After 4 weeks the rabbits were evaluated by radiographs and ultrasound for evidence of heterotopic ossification. At the end of the study histologic samples were taken from all the thighs. Imaging and histologic studies showed, with statistical significance, almost complete prevention of heterotopic ossification formation in group A (preload) and a marked decrease in group B, when compared with the controls where large new bone had formed at the injection site. These results indicated the inhibitory effects of colchicine on a bone-forming process in soft tissue such as heterotopic ossification. CONCLUSIONS: The role of colchicine in preventing heterotopic ossification in other bone-forming conditions, such as hip arthroplasty or pelvic trauma, and after brain trauma, remains to be evaluated in a clinical setting.

Total hip arthroplasty after avascular necrosis of the femoral head: does etiology affect the results?

INTRODUCTION: The aim of the study was to evaluate the results of total hip arthroplasty (THA) due to avascular necrosis (AVN) of the femoral head and to establish whether the cause of AVN affects the results. MATERIAL AND METHODS: A group of 68 patients, 17-82 years of age (mean: 49.9 years) underwent 84 total hip arthroplasties due to AVN. The patients were divided into subgroups according to the etiology of AVN of the hip joint. The results of each group were evaluated by the Harris Hip score (HHS) at 3-18 years (mean: 6.2 years). The complication rate was also assessed. RESULTS: The mean preoperative HHS was 28.5+/-4.5 as opposed to a postoperative HHS of 86+/-10. The revision rate was 16.7%. Etiology does not affect the final outcome, but less favorable long-term results were found in the steroid-induced AVN patients. CONCLUSIONS: Despite the previously reported, less favorable results, THA is a good option for the younger population, even with AVN, especially in bilateral disease. Etiology did not affect the final outcome. However, patients with steroid-induced AVN should be informed that although their final functional results will equal those of other groups, the longevity of the implants is limited.