Sub-Classification of AO/OTA-2018 Pertrochanteric Fractures Is Associated With Clinical Outcomes After Fixation of Intramedullary Nails

Background The new edited AO/OTA-2018 classification of pertrochanteric fractures was revised and no longer based on the status of lesser trochanter. This paper aimed to explore the clinical and technical outcomes among the subgroups (31A1 and 31A2) of the new classification treated with cephalomedullary nails. Methods A retrospective research of 154 patients diagnosed with pertrochanteric fractures (AO/OTA-2018 31A1.2/3 and 31A2.1/2/3) treated with intramedullary nails was conducted. The baseline data and outcomes were compared among the subgroups. The outcomes included tip-apex distance (TAD), Cal-TAD, Parker ratio, neck shaft angle (NSA), blood loss, varus displacement, and over lateral sliding rate of the blade. Results There were 154 cases involving 48 males and 106 females. The average age was higher in the sub-classifications of A2.2 and A2.3 than A1.2. Furthermore, the subgroups of A2.2 and A2.3 presented inferior outcomes with regard to blood loss and reduction quality score than A1.2 and A1.3. The subgroup of A2.3 was further poor with respect to calcar fracture gapping in the anteroposterior view and excessive lateral migration occurrence rate than A1.2. Conclusions Complex pertrochanteric fractures indicated inferior outcomes compared to simple sub-classifications, which might lead by the incompetent of lateral wall and instability of the fracture. The newly proposed AO/OTA-2018 classification was conductive to forecast the prognosis.

Functional outcome of intertrochanteric fractures in elderly patients with proximal femoral nail: retrospective study

<p class="abstract"><strong>Background:</strong> Intertrochanteric fractures are disabling injuries in elderly population and they are the most frequently operated fracture type which has the highest postoperative fatality rate of all surgically treated fractures. The objective of the study was to evaluate the functional outcomes of intertrochanteric fractures treated with proximal femoral nail (PFN) in elderly patients.</p><p class="abstract"><strong>Methods:</strong> A retrospective study of 24 patients, all above 60 years treated with PFN between March 2016 to April 2018. Data collected include age, sex, mechanism of injury, type of fracture pattern according to Boyd and Griffin’s classification. Patients were followed up at intervals of 6, 12, 18 and 24 weeks and final results were evaluated using Kyle’s criteria at the end of 24^th week. All patients had a minimum follow up of one year.<strong></strong></p><p class="abstract"><strong>Results:</strong> The study included 24 patients, 10 males, 14 females with mean age of 75.77 years (range: 60-82 years). The fracture union rate was 96% and average union time was 14.2 weeks. Our results were excellent (80%), good (8%), fair (8%) and poor (4%). Our complications include thigh pain (20%) shortening (20%), varus displacement (8%), knee and hip stiffness (8%), z effect (4%) and non-union (4%).</p><p class="abstract"><strong>Conclusions:</strong> PFN is a reliable fixation in intertrochanteric fractures only after good intraoperative reduction leading to high rate of bone union and with reduced rate of implant failure or complications.</p>

Biomechanical comparison of screw-based zones of a spatial subchondral support plate for proximal humerus fractures

Stabilisation of proximal humerus fractures remains a surgical challenge. Spatial subchondral support (S3) plate promises to overcome common complications associated with conventional proximal humerus plates. This study compared the biomechanical performance of S3 plate with a fixed-angle hybrid blade (Equinoxe Fx) plate and a conventional fixed-angle locking plate (PHILOS). The effects of removal of different S3 plate screws on the humeral stability were also investigated. A total of 20 synthetic left humeri were osteotomised transversely at the surgical neck to simulate a two-part fracture and were each treated with an S3 plate. Head screws were divided into three zones based on their distance from the fracture site. Specimens were divided into four equal groups where one group acted as a control with all screws and three groups had one of the screw zones missing. With humeral head fixed, humeral shaft was first displaced 5 mm in extension, flexion, valgus and varus direction (elastic testing) and then until 30 mm varus displacement (plastic testing). Load–displacement data were recorded to determine construct stiffness in elastic tests and assess specimens’ varus stability under plastic testing. Removal of the screw nearest to the fracture site led to a 20.71% drop in mean elastic varus bending stiffness. Removal of the two inferomedial screw above it resulted in a larger drop. The proximal screw pair had the largest contribution to extension and flexion bending stiffness. Varus stiffness of S3 plate constructs was higher than PHILOS and Fx plate constructs. Stability of humeri treated with S3 plate depends on screws’ number, orientation and location. Varus stiffness of S3 plate construct (10.54 N/mm) was higher than that of PHILOS (6.61 N/mm) and Fx (7.59 N/mm) plate constructs. We attribute this to S3 plates’ thicker cross section, the 135° inclination of its screws with respect to the humeral shaft and the availability of pegs for subchondral support.

Proximal fragment intermetatarsal angle (PFIA) increases after SCARF osteotomy

Category: Bunion Introduction/Purpose: Instability of the joint between the medial cuneiform and the first metatarsal is considered as one of the progression factors of Hallux valgus and its recurrence in some cases. We believe that we must increase the intermetatarsal angle of the proximal fragment during the correction by the SCARF osteotomy, seeking the greater degree of instability of this joint. Doing that, we can prevent further varus displacement, as we have reached the greater degree of instability. The purpose of this study was to evaluate if the SCARF osteotomy is able to increase the varus position of the base of the first metatarsal. Methods: This is a retrospective study with 32 patients with mild, moderate and severe hallux valgus, who were submitted to surgical treatment by the SCARF technique. All patients were operated by the same surgeon. Anteroposterior radiographs of the loaded foot were analyzed in the pre and postoperative (3 months) moments. We developed two measures to evaluate the position of the base of the first metatarsal: The Proximal Fragment Intermetatarsal Angle (PFIA), and the distance between the lateral cortex of the first metatarsal and the medial cortex of the second metatarsal (3 cm from the base of the first metatarsal). All measurements were made with a virtual ruler on magnified digital images and rounded to the nearest 0.1 mm. A 95% confidence interval was considered for statistical significant results (p<0,05). Results: The mean age of the sample was 44 years, with a predominance of females (62%). The mean pre-operative intermetatarsal angle was 14.9°, while in the postoperative period it was 5.2°, showing that there was correction of the metatarsal positioning. However, the PFIA increased to 17.8° at the post-operative period (p<0,05), showing a greater instability of the first metatarsal cuneiform joint, as the base of the first metatarsal was positioned in a more varus condition. In addition, we observed that there was an increase in the distance between the base of the first metatarsus and the second metatarsus after the surgical procedure, from 13.7 to 16 millimeters (p<0,05). Conclusion: We concluded that the SCARF osteotomy is able to increase the varus position of the base of the first metatarsal, leading to more instability at the first metatarsal cuneiform joint, and, in our opinion, less chance of recurrence in the long-term. A prospective and long-term is needed to prove this statement.

Altered Knee and Ankle Kinematics During Squatting in Those With Limited Weight-Bearing–Lunge Ankle-Dorsiflexion Range of Motion

Context: Ankle-dorsiflexion (DF) range of motion (ROM) may influence movement variables that are known to affect anterior cruciate ligament loading, such as knee valgus and knee flexion. To our knowledge, researchers have not studied individuals with limited or normal ankle DF-ROM to investigate the relationship between those factors and the lower extremity movement patterns associated with anterior cruciate ligament injury. Objective: To determine, using 2 different measurement techniques, whether knee- and ankle-joint kinematics differ between participants with limited and normal ankle DF-ROM. Design: Cross-sectional study. Setting: Sports medicine research laboratory. Patients or Other Participants: Forty physically active adults (20 with limited ankle DF-ROM, 20 with normal ankle DF-ROM). Main Outcome Measure(s): Ankle DF-ROM was assessed using 2 techniques: (1) nonweight-bearing ankle DF-ROM with the knee straight, and (2) weight-bearing lunge (WBL). Knee flexion, knee valgus-varus, knee internal-external rotation, and ankle DF displacements were assessed during the overhead-squat, single-legged squat, and jump-landing tasks. Separate 1-way analyses of variance were performed to determine whether differences in knee- and ankle-joint kinematics existed between the normal and limited groups for each assessment. Results: We observed no differences between the normal and limited groups when classifying groups based on nonweight-bearing passive-ankle DF-ROM. However, individuals with greater ankle DF-ROM during the WBL displayed greater knee-flexion and ankle-DF displacement and peak knee flexion during the overhead-squat and single-legged squat tasks. In addition, those individuals also demonstrated greater knee-varus displacement during the single-legged squat. Conclusions: Greater ankle DF-ROM assessed during the WBL was associated with greater knee-flexion and ankle-DF displacement during both squatting tasks as well as greater knee-varus displacement during the single-legged squat. Assessment of ankle DF-ROM using the WBL provided important insight into compensatory movement patterns during squatting, whereas nonweight-bearing passive ankle DF-ROM did not. Improving ankle DF-ROM during the WBL may be an important intervention for altering high-risk movement patterns commonly associated with noncontact anterior cruciate ligament injury.

Action of the Peroneus Longus Tendon on the First Metatarsal Against Metatarsus Primus Varus Force

A medially directed force was applied to the first metatarsal in 10 cadaver feet. The peroneus longus tendon was subjected to a pull of 5 pounds. The soft tissues between the first and second metatarsals were cut sequentially, starting with the skin on the dorsal and plantar aspect, followed by the intermetatarsal ligament and adductor hallucis tendon, and, finally, the peroneus longus tendon at its distal insertion. Dorsoplantar radiographs while weightbearing were taken after each sectioning. A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal.