A minimally invasive cerclage of the tibia in a modified Goetze technique: operative technique and first clinical results

Introduction In spiral fractures of the tibia, the stability of an osteosynthesis may be significantly increased by additive cerclages and, according to biomechanical studies, be brought into a state that allows immediate full weight bearing. As early as 1933, Goetze described a minimally invasive technique for classic steel cerclages. This technique was modified, so that it can be used for modern cable cerclages in a soft part saving way. Method After closed reduction, an 8 Fr redon drain is first inserted in a minimally invasive manner, strictly along the bone and placed around the tibia via 1 cm incisions on the anterolateral and dorsomedial tibial edges using a curette and a tissue protection sleeve. Via this drain, a 1.7 mm cable cerclage can be inserted. The fracture is then anatomically reduced while simultaneously tightening the cerclage. Subsequently, a nail or a minimally invasive plate osteosynthesis is executed using the standard technique. Using the hospital documentation system, data of patients that were treated with additional cerclages for tibial fractures between 01/01/2014 and 06/30/2020 were subjected to a retrospective analysis for postoperative complications (wound-healing problems, infections and neurovascular injury). Inclusion criteria were: operatively treated tibial fractures, at least one minimally invasive additive cerclage, and age of 18 years or older. Exclusion criteria were: periprosthetic or pathological fractures and the primary need of reconstructive plastic surgery. SPSS was used for statistical analysis. Results 96 tibial shaft spiral fractures were treated with a total of 113 additive cerclages. The foregoing resulted in 10 (10.4%) postoperative wound infections, 7 of which did not involve the cerclage. One lesion of the profundal peroneal nerve was detected, which largely declined after cerclage removal. In 3 cases, local irritation from the cerclage occurred and required removal of material. Conclusion In the described technique, cerclages may be inserted additively at the tibia in a minimally invasive manner and with a few complications, thus significantly increasing the stability of an osteosynthesis. How this ultimately affects fracture healing is the subject of an ongoing study.

Influence of Timing of Postoperative Weight-Bearing on Implant Failure Rate Among Older Patients With Intertrochanteric Hip Fractures: A Propensity Score Matching Cohort Study

Introduction: The purpose of this study was to determine whether immediate weight-bearing as tolerated increased the risk of implant failure and decreased functional outcomes compared with restricted weight-bearing.Methods: From January 2010 to December 2018, 1,125 consecutive patients (≥65 years) with intertrochanteric fractures were identified. Of them, 130 patients were excluded, resulting in 995 patients in final cohort (563 receiving immediate weight-bearing and 432 receiving restricted weight-bearing). Propensity score (PS) matching yielded 403 patient pairs. Primary outcome was implant failure at 12 months. Secondary outcomes were implant failure at 3 months, functional outcomes at 12 months, and time to full weight-bearing.Results: Among 806 patients who were matched by PS, the mean age was 77.8 years (SD, 7.6), and 603 patients (74.8%) were women. After matching, there was no significant difference between immediate (10.0% [39/389]) and restricted (9.1%, [35/385]) weight-bearing for implant failure at 12 months (absolute risk difference, 0.93% [95% CI, −3.26 to 5.13%]; RR, 1.11 [95% CI, 0.69 to 1.80]; p = 0.66). Additionally, no significant difference was seen for implant failure at 3 months and functional outcomes at 12 months. Patients with immediate weight-bearing had shorter time to full weight-bearing (mean [SD], 87.6 days [7.5] vs. 121.3 days [11.0]; mean difference, −33.7 [95% CI, −35.0 to −32.3]; p < 0.001).Conclusions: Among older patients with intertrochanteric fractures, receipt of immediate weight-bearing as tolerated did not increase risks of implant failure or worsen functional outcomes compared with receipt of restricted weight-bearing. However, patients receiving immediate weight-bearing had a shorter time to full weight-bearing.

The effects of full weight-bearing mobilization on clinical outcomes and subsidence in cemented and uncemented hemiarthroplasty in osteoporotic patients: A retrospective single-center study

BACKGROUND: Early full weight-bearing mobilization is controversial in osteoporotic patients who have undergone uncemented hemiarthroplasty (CH). OBJECTIVES: The aim of the study was to compare the results of early full weight-bearing mobilization in CH and uncemented hemiarthroplasty (UCH). The effect of subsidence on the results was also evaluated. METHODS: Fifty-nine patients who underwent CH and UCH were evaluated. The mean age was 79.8 years (10 females, 15 males) for CH and 75.5 years (10 females, 24 males) for UCH. All patients started immediate full weight-bearing mobilization and weight-bearing exercises. RESULTS: There was no difference between the groups according to the Harris Hip Score. Both groups were evaluated in subgroups according to whether there is varus in the femoral stem. There was no difference between subgroups according to the Harris Hip Score. The femoral subsidence was not determined in CH group. In the UCH group, the subsidence was 1.13 ± 1.03 mm in varus femoral stem subgroup and 0.81 ± 0.85 mm in without femoral stem varus subgroup. There was no difference in subsidence between femoral stem with varus and without varus. The subsidence did not affect the Harris Hip Score. CONCLUSION: Full weight-bearing mobilization could be safely preferred in UCH, as in CH. Femoral stem varus below 5 degrees does not affect the results and subsidence.

Short-term results of a novel management of supracondylar fracture with coexisting osteoarthritis with bifold fixation and total knee arthroplasty

Purpose Presence of supracondylar and periarticular femoral fracture with associated arthritis of knee poses a challenging situation to the orthopaedic surgeon. The results of fixation of fracture in osteoporosis are not very satisfactory and have complications. With fixation alone, they still cannot bear weight on affected leg due to severe disability of osteoarthritis. To make patient walk, conventionally three surgeries in the form of fracture fixation, removal of implant and total knee arthroplasty (TKA) needs to be done in staged manner. We propose a novel management in form of bifold fixation and simultaneous TKA. Methods Eight cases (6 females, 2 males) of supracondylar femoral fractures with severe osteoarthritis of the knee and osteoporosis were primarily fixed with bifold fixation using SIGN nail (www.signfracturecare.org) and locking plate together with simultaneous total knee arthroplasty. There were five cases (2 males and 3 females) of grade 4 (Kellgren-Lawrence grading) osteoarthritis (OA) and three cases (all females) of severe rheumatoid arthritis (RA). Results The mean age was 68 years and average time for full weight bearing was 6 days. Radiographic evidence of fracture union was achieved in 16.25 weeks. The mean Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 26 months was 83.13 and 22.13 respectively. Conclusions Single stage combined bifold osteosynthesis with interlocking nail and locking plate together with total knee arthroplasty helps in one time management of these difficult injuries. It is a cost-effective and economically sound option and gives excellent results with good patient satisfaction.

Reconstruction of a Neglected, Extensor Hallucis Longus Tendon Rupture Using Interposed Scar Tissue: A Case Report and Literature Review

Injury of the extensor hallucis longus (EHL) tendon is relatively rare, but surgical repair is necessary to prevent deformity and gait disturbance. Primary suturing is possible if the condition is acute, but not when it is chronic. The scar tissue between the ruptured ends is a proliferative tissue composed of fibroblasts and collagen fibers. Given the histological similarity to normal tendons, several studies have reported tendon reconstruction using scar tissue. Here, we report a reconstruction of a neglected EHL rupture using interposed scar tissue. A 54-year-old female visited our clinic with a weak extension of a big toe. She had dropped a knife on her foot a month prior, but did not go to hospital. The wound had healed, but she noted dysfunctional extension of the toe and increasing pain. Magnetic resonance imaging (MRI) revealed that EHL continuity was lost and that the proximal tendon stump was displaced toward the midfoot. Scar tissue running in the direction of the original ligament was observed between the ruptured ends. In the surgical field, the scar tissue formed a shape similar to the extensor tendon. Therefore, we performed tendon reconstruction using the interposed scar tissue. For the first 2 postoperative weeks, the ankle and foot were immobilized to protect the repair. Six weeks after surgery, the patient commenced full weight-bearing. At the 3-month follow-up, active extension of the hallux was possible, with a full range of motion. The patient did not feel any discomfort during daily life. Postoperative MRI performed at 1 year revealed that the reconstructed EHL exhibited homogeneously low signal intensity, and was continuous. The AOFAS Hallux Metatarsophalangeal-Interphalangeal scale improved from 57 to 90 points and the FAAM scores improved from 74% to 95% (the Activities of Daily Living subscale) and from 64% to 94% (the Sports subscale). Scar tissue reconstruction is as effective as tendon autografting or allografting, eliminates the risk of donor site morbidity and infection, and requires only a small incision and a short operative time.

Ankle arthrodesis using a retrograde intramedullary rod with fins for highly destructive joints in elderly patients with rheumatoid arthritis: A report of two cases

Here we present two cases in older adult patients with highly destructive changes in ankle joints (Larsen Grade IV) and who underwent retrograde intramedullary nail fixation with fins. In both patients, bony union was achieved, full weight-bearing was attained 3 months after surgery and good functional outcome was acquired.

Double-Level Osteotomy in Severe Varus Malalignment to Optimize Knee Joint Restoration

Background: Lower extremity alignment-correcting procedures for unicompartmental osteoarthritis are experiencing a rapid rise. Medial open-wedge high tibial osteotomy (MOW-HTO) thereby represents the most common technique among osteotomies but is limited in cases of severe malalignment. Some cases make a double-level osteotomy necessary. Indications: If planning of malalignment correction using a MOW-HTO results in a mechanical medial proximal tibial angle (mMPTA) of more than 93° (causing an oblique joint line), double-level osteotomy is indicated to avoid nonphysiological knee kinematics. Technique Description: After clinical examination and detailed analysis of malalignment (full-weight-bearing long-leg radiograph: hip-knee-angle [HKA], mMPTA, mechanical lateral distal femoral angle [mLDFA], joint line convergence angle [JLCA]), as well as individualized planning of the correction, the surgical procedure starts with an arthroscopy to evaluate the cartilage conditions and eventually treat intraarticular pathologies. Then, the femoral supracondylar correction is performed (closed wedge, biplanar osteotomy [ to increase bony healing]) according to the presurgical planning by resecting the osteotomy wedge with the measured length. K-wires are placed to check the correction. An angle-stable plate is used for osteosynthesis. The wedge taken out will be used as bone stock for the MOW-HTO afterward. The biplanar open-wedge tibial osteotomy is then performed subsequently using a medial tibial approach and an angle-stable plate. Opening of the osteotomy is then performed and double checked with intraoperative fluoroscopy using an alignment rod. Postoperative partial weight bearing for 6 weeks is recommended. Results: In recent literature, only few publications report on results of double-level osteotomies. Babis et al reports that it is a valuable procedure for patients with large varus deformity. Nakayama et al noted a significant improvement in patient-registered clinical outcomes in early postoperative evaluation of 20 patients. Schröter et al reports on 37 knees and findings include good clinical results, despite progressive osteoarthritis. Discussion/Conclusion: In cases of severe malalignment, adequate axis correction may require a double-level osteotomy. Exact preoperative planning is essential. Results reported in recent publications are promising. By splitting 1 large correction into 2 smaller ones, complications like hinge fracture and delayed bone healing are lowered.

A study on clinical outcomes of complex subtrochanteric femoral fractures with cephalomedullary nail

<p class="abstract"><strong>Background:</strong> The aim of the study was to evaluate the clinical outcomes of complex subtrochanteric fractures treated by using cephalomedulary nail.</p><p class="abstract"><strong>Methods:</strong> This is a prospective observational study of 30 cases of complex subtrochanteric femoral fractures admitted to our hospital from January 2018 to June 2019. Cases were taken according to the inclusion and exclusion criteria i.e. type IV, type V Seinsheimer’s classification, above 18 years and those who are willing to participate in the study has been included and pathological fractures, open fractures were excluded. All the patients are followed up on 2 post-operative day, after 4 weeks, 8 weeks, 12 weeks and 6months. X-ray hip with thigh anteroposterior (AP) and lateral view taken during each follow up. Out comes was assessed using modified Harris hip score.<strong></strong></p><p class="abstract"><strong>Results:</strong> In our study of 30 cases there are 22 males and 8 females and the mean age of 43.7 years. 73.3% patients are due to Road traffic accidents predominance of right side. In our study 66% had type 4 Seinsheimers and 34% cases had type 5 Seinsheimers fracture. The mean duration of hospital stay was 17 days. Mean time for full weight bearing is 12 weeks. Good to excellent results are seen in 80% of type 4 subtrochanteric fractures and 75% of cases of type 5 subtrochanteric fractures. 4 cases had surgical site infection, 3 cases had varus, 1 case had developed implant failure, and 1 case had reverse Z effect.</p><p class="abstract"><strong>Conclusions:</strong> From this study, we conclude that proximal femoral nail is an excellent implant in the treatment of complex subtrochanteric femoral fractures the terms of successful outcome include a good understanding of fracture biomechanics, good preoperative planning and accurate instrumentation.</p>

Gamma 3 Long Nail for Complex Sub-Trochanteric Fractures: A Ten-Year Retrospective Study

Cephalomedullary nailing is considered the treatment of choice for trochanteric and subtrochanteric femoral fractures. The aim of this study was to report postoperative outcomes of one of the widely used trochanteric nail device, the Gamma 3 long nail. We retrospectively assessed 405 patients treated with Gamma 3 long nail in a single Level One Trauma Centre between 2010 and 2018. We finally included 261 ambulant patients with 65 years or older, a lowenergy trauma and a closed trochanteric or subtrochanteric femoral fracture. Clinical outcomes were evaluated using the Hip Fracture Functional Recovery Score (FRS), while radiological complications and failures were assessed on postoperative x-rays. More than two-thirds of patients had completed fracture consolidation within 4 months after surgery. Immediate full weight bearing was allowed postoperatively in 64.0% of patients. We reported a mortality of 24.5% at one year postoperatively. The leading clinical postoperative complication was anemia (69.3%), followed by deep venous thrombosis (7.7%). Coxa vara was observed in 73 patients (28%), followed by malreduction in flexion-external rotation of the proximal femoral fragment (26.8%). No case of lag screw cutout was reported. Our study indicated that last generation of Long Gamma nail is a reliable implant for trochanteric and subtrochanteric femoral fractures in the elderly patients, leading to high rate of bone union and reduced incidence of related complications. An excellent fracture reduction and prevention of postoperative varus malalignment are the main factors that can avoid the major postoperative complications and failures after Gamma 3 long nailing.

A review of pediatric femoral fracture patterns, surgical managements, and outcomes

<p class="abstract"><strong>Background: </strong>Femoral fractures are the most common pediatric orthopedic fractures that require hospitalization. The non-accidental injury should be suspected in early infancy and non-ambulatory children. Treatment of pediatric femoral fractures is widely variable and depends on intrinsic and extrinsic factors. This study presents pediatric femoral fracture epidemiology and outcomes and reviews the literature regarding best practices in pediatric femoral fractures.</p><p class="abstract"><strong>Methods:</strong> This retrospective study reviewed the clinical and radiological records of forty-sevens femur fractures in the pediatric age group from September 2020 until June 2021 in Prince Rashid bin AL Hassan Military Hospital in Jordan.</p><p class="abstract"><strong>Results:</strong> Males form 80.9% of patients. The mean age for the patients was equal to 6.70 years (±3.91). Falling is responsible for the majority of the injury. The middle femur shaft was fractured in 46.8%, and the pathological fracture was found in 17% of patients. Non-operative treatment by cast represents 42.6%. All fractures were healed at 7.90 weeks (±2.37).</p><p class="abstract"><strong>Conclusions: </strong>Pediatric femur fracture lacks standardized treatment. Nevertheless, most fractures healed with satisfactory results. Younger age groups are more likely to be treated non-operatively. Non-surgical treatment is more prone to shortening, angulation, and later return to weight-bearing and activity. Children older than eight years treated by plating demonstrated faster healing, return to full weight-bearing, and lower complication rate. </p>