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1.  Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study 
This study is a randomized prospective study comparing two fracture fixation implants, the extramedullary sliding hip screw (SHS) and the dual lag screw cephalomedullary nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and sixty-five patients with low-energy intertrochanteric fractures, classified as AO/OTA 31A, were prospectively included during a 2-year period (2005–2006). Patients were randomized into two groups: group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails. Delay to surgery, duration of surgery, time of fluoroscopy, total hospital stay, implant-related complications, transfusion requirements, re-operation details, functional recovery, and mortality were recorded. The mean follow-up was 36 months (24–56 months). The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred. There was no statistically significant difference in the functional recovery score, reoperation, and mortality rates between the 2 groups. A new type of complication, the so-called Z-effect phenomenon, was noticed in the cephalomedullary nail group. There are no statistically significant differences between the two techniques in terms of type and rate of complications, functional outcome, reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures. Our data do not support recommendations for the use of one implant over the other.
doi:10.1007/s11751-012-0146-3
PMCID: PMC3482439  PMID: 23086659
Dual lag screw intramedullary nail; Sliding hip screw; Intertrochanteric fractures
2.  Exposure of the surgeon to radiation during surgery 
International Orthopaedics  1998;22(3):153-156.
Summary.
Exposure to radiation over many years increases the incidence of cataracts and promotes the development of carcinoma of the thyroid gland. A prospective study of 24 operative procedures involving minimal invasive techniques and fluoroscopic guidance was undertaken in order to measure the radiation exposure to the primary surgeon. The study was conducted during 8 K-wire osteosyntheses in fractures of the distal radius, 8 closed interlocking intramedullary nailings in fractures of the femur and 8 internal fixator procedures, with or without posterior autogenic transpedicular bone grafting, in fractures of the lumbar spine. Radiation was monitored with the use of high sensitive thermoluminescent dosimeters. Fluoroscopy was necessary during the procedures, with exposure times ranging from 55 s to 12 min 35 s. The radiation dose received per procedure ranged from 0.6–259.3 μSv and was well within the dose limits set by German law.
doi:10.1007/s002640050230
PMCID: PMC3619589  PMID: 9728306
3.  Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip 
International Orthopaedics  2012;36(9):1803-1806.
Purpose
The purpose of the study was to quantify patient exposure to ionising radiation during fluoroscopic-assisted arthroscopic surgery of the hip, establish a risk profile of this exposure, and reassure patients of radiation safety during the procedure.
Methods
We retrospectively analysed the dose area products for 50 consecutive patients undergoing arthroscopic hip surgery by an experienced hip arthroscopic surgeon. The effective dose and organ dose were derived using a Monte Carlo program.
Results
The mean total fluoroscopy time was 1.10 minutes and the mean dose area product value was 297.2 cGycm2. We calculated the entrance skin dose to be 52 mGy to the area where the beam was targeted (81 cm2). The mean effective dose for intra-operative fluoroscopy was 0.33 mSv, with a SD of 0.90 Sv.
Conclusion
This study confirms that fluoroscopic-assisted arthroscopic surgery of the hip is safe with a low maximum radiation dose and supports its continued use in preference to alternative imaging modalities.
doi:10.1007/s00264-012-1557-y
PMCID: PMC3427451  PMID: 22588691
4.  Hip fracture fixation in a patient with below-knee amputation presents a surgical dilemma: a case report 
Introduction
Hip fracture fixation surgery in patients with below-knee amputations poses a challenging problem to the surgeon in terms of obtaining traction for reduction of the fracture. The absence of the foot and part of the leg in these patients makes positioning on the fracture table difficult. We highlight this difficult problem and suggest techniques to overcome it.
Case presentation
A 73-year-old man with bilateral below-knee amputations presented with a history of fall. Radiographs revealed an inter-trochanteric fracture of the femur. A dynamic hip screw fixation was planned for the fracture but the dilemma was on how to position the patient on the fracture table for the surgery. Special attention was needed in positioning the patient and in surgical fixation of the fracture.
Conclusion
Hip fracture fixation in patients with below-knee amputations poses a special problem in positioning for fracture reduction and fixation. In this case report, we share our experience and suggest techniques to use when encountering this difficult problem.
doi:10.1186/1752-1947-2-296
PMCID: PMC2542403  PMID: 18782438
5.  Fixation of Intertrochanteric Fractures: Dynamic Hip Screw versus Locking Compression Plate 
Trauma Monthly  2013;18(2):67-70.
Background
According to the existing literature, the Dynamic Hip Screw (DHS) is the preferred standard for the treatment of intertrochanteric fractures. However, some surgeons use other devices such as the Locking Compression Plate (LCP).
Objectives
In this study, we compared the outcome of using DHS or LCP in intertrochanteric fractures.
Materials and Methods
This cross-sectional study was carried out on 104 patients who were referred to Pursina Hospital in Rasht, Iran with intertrochanteric fractures of the femur treated with either the DHS or LCP devices. Demographic features, existence or nonexistence of stability and operating time were obtained from questionnaires. During a 6-month follow-up after surgery, patients were interviewed to record variables such as Harris Hip Scores and complications. The patients were also interviewed on their final visit (between 9 and 31 postoperative months). The collected data was analyzed using SPSS.
Results
We discovered that the number of incidences of limb shortening and device failure was higher for patients treated with the LCP device (P = 0.048 and P = 0.014). Patients treated with the DHS device had higher Harris Hip scores for both the 6-month postoperative and the final evaluation visits (P = 0.01 and P = 0.018).
Conclusions
Despite the complications of fixation with the DHS device, it remains the most successful for treatment of intertrochanteric fractures.
doi:10.5812/traumamon.10436
PMCID: PMC3860680  PMID: 24350155
Hip Fractures; Infection; Joint; Fracture Fixation
6.  Total hip arthroplasty following failed fixation of proximal hip fractures 
Indian Journal of Orthopaedics  2008;42(3):279-286.
Background:
Most proximal femoral fractures are successfully treated with internal fixation but a failed surgery can be very distressing for the patient due to pain and disability. For the treating surgeon it can be a challenge to perform salvage operations. The purpose of this study was to evaluate the short-term functional outcome and complications of total hip arthroplasty (THA) following failed fixation of proximal hip fracture.
Materials and Methods:
In a retrospective study, 21 hips in 20 patients (13 females and seven males) with complications of operated hip fractures as indicated by either established nonunion or fracture collapse with hardware failure were analysed. Mean age of the patients was 62 years (range 38 years to 85 years). Nine patients were treated for femoral neck fracture, 10 for intertrochanteric (I/T) fracture and two for subtrochanteric (S/T) fracture of the hip. Uncemented THA was done in 11 cases, cemented THA in eight hip joints and hybrid THA in two patients.
Results:
The average duration of follow-up was four years (2-13 years). The mean duration of surgery was 125 min and blood loss was 1300 ml. There were three dislocations postoperatively. Two were managed conservatively and one was operated. There was one superficial infection and one deep infection. Only one patient required a walker while four required walking stick for ambulation. The mean Harris Hip score increased from 32 preoperatively to 79 postoperatively at one year interval.
Conclusion:
Total hip arthroplasty is an effective salvage procedure after failed osteosynthesis of hip fractures. Most patients have good pain relief and functional improvements inspite of technical difficulties and high complication rates than primary arthroplasty.
doi:10.4103/0019-5413.41851
PMCID: PMC2739465  PMID: 19753153
Failed internal fixation; hip arthroplasty; hip fractures; THA
7.  Intertrochanteric fracture under an arthrodesed hip 
Patient:
Female, 30
Primary Diagnosis:
Intertrochanteric fracture under an arthrodesed hip
Co-existing Diseases:
Developmental dysplasia of the hip
Medication:
Pain • inability to walk
Clinical Procedure:
Open reduction and internal fixation
Specialty:
Orthopedics and traumatology
Objective:
Rare disease, Unusual setting of medical care
Background:
An intertrochanteric fracture among elderly people is common, but it is rare to see such a fracture under a longstanding hip arthrodesis. Its surgical management represents a real challenge to orthopedic surgeons.
Case Report:
A 30-year-old female teacher with long-standing hip arthrodesis was involved in a traffic accident. Clinical and radiological examination revealed the presence of a displaced intertrochanteric fracture under an arthrodesed hip and high neck shaft angle.
Before embarking on surgery, we have to consider many factors such as patient personality (a young active and ambitious woman) and the mature of the fracture (a displaced fracture, coxa valga, and atrophied muscles). After a deep discussion and evaluation of the available devices, we selected a heavy duty locked plate and cannulated screws to fix the fracture.
Conclusions:
Because of the rarity of intertrochanteric fracture under an arthrodesis hip, the proper surgical treatment is controversial. Nevertheless, we were fortunate in successfully treating this unusual fracture using a locked plate and cannulated screws, which are implants that can be useful in treatment of such fractures.
doi:10.12659/AJCR.883909
PMCID: PMC3700455  PMID: 23826454
hip; arthrodesis; intertrochanteric fracture
8.  Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation 
Background
Fixation of unstable ankle fractures, including fixation of posterior malleolus fracture fragments with the attached, intact posteroinferior tibiofibular ligament (PITFL), reportedly provides more stable fixation than transsyndesmotic screws.
Questions/Purposes
To confirm this observation we compared the Foot and Ankle Outcome Score (FAOS) and radiographic maintenance of fixation for fractures treated through direct posterior malleolar fixation versus syndesmotic screw fixation.
Methods
We prospectively followed 31 one patients with unstable ankle fractures treated with (1) open posterior malleolus fixation whenever the posterior malleolus was fractured, regardless of fragment size (PM group; n = 9); (2) locked syndesmotic screws in the absence of a posterior malleolar fracture (S group; n = 14); or (3) combined fixation in fracture-dislocations and more severe soft tissue injury (C group; n = 8). All patients had preoperative MRI confirming syndesmotic injury and an intact PITFL; postoperative and followup radiographs were evaluated for syndesmotic congruence. The minimum followup was 12 months (mean, 15 months; range, 12–31 months).
Results
Postoperative and followup FAOS scores were similar in the three groups. The tibiofibular clear space was greater in the S versus the PM group, but we found no other differences in the postoperative versus followup measurements between the PM, S, and C groups.
Conclusions
Syndesmotic fixation through the posterior malleolus and PITFL is maintained at followup, and these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation.
Level of Evidence
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1111-4
PMCID: PMC2835618  PMID: 19798540
9.  Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement? 
We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.
Level of Evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-0959-7
PMCID: PMC2835619  PMID: 19582527
10.  Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement? 
We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.
Level of Evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-0959-7
PMCID: PMC2835619  PMID: 19582527
11.  Is a Sliding Hip Screw or IM Nail the Preferred Implant for Intertrochanteric Fracture Fixation? 
This study was performed to determine whether patients who sustain an intertrochanteric fracture have better outcomes when stabilized using a sliding hip screw or an intramedullary nail. A 20% sample of Part A and B entitled Medicare beneficiaries 65 years or older was used to generate a cohort of patients who sustained intertrochanteric femur fractures between 1999 and 2001. Two fracture implant groups, intramedullary nail and sliding hip screw, were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. The cohort consisted of 43,659 patients. Patients treated with an intramedullary nail had higher rates of revision surgery during the first year than those treated with a sliding hip screw (7.2% intramedullary nail versus 5.5% sliding hip screw). Mortality rates at 30 days (14.2% intramedullary nail versus 15.8% sliding hip screw) and 1 year (30.7% intramedullary nail versus 32.5% sliding hip screw) were similar. Adjusted secondary outcome measures showed significant increases in the intramedullary nail group relative to the sliding hip screw group for index hospital length of stay, days of rehabilitation services in the first 6 months after discharge, and total expenditures for doctor and hospital services.
Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0285-5
PMCID: PMC2565060  PMID: 18465180
12.  Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures 
Introduction
Treatment of ankle fractures is often based on fracture type and surgeon’s individual judgment. Literature concerning the treatment options and outcome are dated and frequently contradicting. The aim of this study was to determine the clinical and functional outcome after AO-Weber B-type ankle fractures in operatively and conservatively treated patients and to determine which factors influenced outcome.
Patients and methods
A retrospective cohort study in patients with a AO-Weber B-type ankle fracture. Patient, fracture and treatment characteristics were recorded. Clinical and functional outcome was measured using the Olerud–Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS) and a Visual Analog Score (VAS) for overall satisfaction (range 0–10).
Results
Eighty-two patients were treated conservatively and 103 underwent operative treatment. The majority was female. Most conservatively treated fractures were AO-Weber B1.1 type fractures. Fractures with fibular displacement (mainly AO type B1.2 and Lauge-Hansen type SER-4) were predominantly treated operatively. The outcome scores in the non-operative group were OMAS 93, AOFAS 98, and VAS 8. Outcome in this group was independently negatively affected by age, affected side, BMI, fibular displacement, and duration of plaster immobilization. In the surgically treated group, the OMAS, AOFAS, and VAS scores were 90, 97, and 8, respectively, with outcome negatively influenced by duration of plaster immobilization.
Conclusion
Treatment selection based upon stability and surgeon’s judgment led to overall good clinical outcome in both treatment groups. Reducing the cast immobilization period may further improve outcome.
doi:10.1007/s00402-011-1397-z
PMCID: PMC3261401  PMID: 21959696
Ankle; Fracture; Outcome; Operative; Non-operative
13.  Simultaneous Use of Cannulated Reamer and Schanz Screw for Closed Intramedullary Femoral Nailing 
ISRN Surgery  2011;2011:502408.
Introduction. Closed reduction is a critical component of the intramedullary nailing and at times can be difficult and technically challenging resulting in increased operative time. Fluoroscopy is used extensively to achieve closed reduction which increases the intra-operative radiation exposure. Materials and Methods. Sixty patients with femoral diaphyseal fractures treated by locked intramedullary nailing were randomized in two groups. In group I, fracture reduction was performed under fluoroscopy with a cannulated reamer in the proximal fragment or with simultaneous use of a cannulated reamer in the proximal fragment and a Schanz screw in the distal fragment. Patients in group II had fracture reduction under fluoroscopy alone. Results. Closed reduction was achieved in 29 patients in group I and 25 patients in group II. The guide wire insertion time, time for nail insertion and its distal locking, total operative time, and total fluoroscopic time were 26.57, 27.93, 68.03, and 0.19 minutes in group I, compared with 30.87, 27.83, 69.93, and 0.24 minutes in group II, respectively. The average number of images taken to achieve guide wire insertion, for nail insertion and its locking and for the complete procedure in group I, respectively, was 12.33, 25.27, and 37.6 compared with 22.1, 26.17, and 48.27, respectively, in group II. Conclusion. The use of cannulated reamer in proximal fragment as intramedullary joystick and Schanz screw and in the distal fragment as percutaneous joystick facilitates closed reduction of the fracture during closed intramedullary femoral nailing with statistically significant reduction in guide wire insertion time and radiation exposure.
doi:10.5402/2011/502408
PMCID: PMC3200078  PMID: 22084760
14.  Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods 
Background
No consensus exists regarding the optimal treatment of ipsilateral femoral neck and shaft fractures. The three major issues related to these fractures are the optimal timing of surgery, which fracture to stabilize first, and the optimal implant to use. In an effort to find answers to these three key issues, we report our experience of managing 27 patients with ipsilateral femoral neck and shaft fractures by using two different treatment methods, i.e., reconstruction-type intramedullary nailing and various plate combinations.
Materials and methods
We divided patients into two groups. Group I included 15 patients (13 males and 2 females) who were operated with cancellous lag screws or dynamic hip screws (DHS) for fractured neck and compression plate fixation for fractured shaft of the femur. Group II included 12 patients (11 males and 1 female) who were operated with reconstruction-type intramedullary nailing.
Results
Mean age was 33.2 and 37.9 years in group I and II, respectively. Mean delay in surgery was 5.9 and 5.4 days in group I and II, respectively. Average union time for femoral neck fracture in groups I and II were 15.2 and 17.1 weeks, respectively; and for shaft fracture these times were 20.3 and 22.8 weeks, respectively. There were 13 (86.6%) good, 1 (6.7%) fair and 1 (6.7%) poor functional results in group I. There were 10 (83.3%) good, 1 (8.3%) fair and 1 (8.3%) poor functional results in group II.
Conclusions
Both of the treatment methods used in the present study achieved satisfactory functional outcome in these complex fractures. Fixation with plate for shaft and screws or DHS for hip is easy from a technical point of view. Choice of the treatment method should be dictated primarily by the type of femoral neck fracture and the surgeon’s familiarity with the treatment method chosen. The femoral neck fracture should preferably be stabilized first, and a delay of 5–6 days does not affect the ultimate functional outcome.
doi:10.1007/s10195-008-0025-3
PMCID: PMC2656981  PMID: 19384610
Reconstruction nailing; Plating; Ipsilateral femoral neck and shaft fracture; Dynamic hip screw; Lag screw
15.  A simple technique to position patients with bilateral above-knee amputations for operative fixation of intertrochanteric fractures of the femur: a case report 
Introduction
Intertrochanteric fractures of the femur are common fractures in the elderly, and management includes operative fixation after patient positioning on the fracture table. Patients with bilateral above-knee amputations are challenging in terms of positioning on the table. We describe a simple technique to overcome this special problem.
Case presentation
A 75-year-old wheelchair-bound Caucasian man with bilateral above-knee amputations presented to our hospital after a fall. Plain radiographs showed an intertrochanteric fracture of the femur, and operative fixation with a dynamic hip screw was planned. His positioning on the table posed a particular problem, and therefore we developed a technique to overcome this problem.
Conclusion
Positioning of patients for fixation of intertrochanteric fractures of the femur poses a particular problem that can be solved by using our simple technique.
doi:10.1186/1752-1947-4-390
PMCID: PMC3012042  PMID: 21118535
16.  Postoperative radiographs or thermal prints after internal fixation of fractures? A study of DHS fixation of hip fractures. 
Immediate postoperative radiographs confirm the quality of reduction and fixation of fractures. This information is already available from the image intensifier and can be saved as hard copy thermal prints. If thermal prints give the surgeon the necessary patient and clinical information them immediate postoperative radiography should not be required. In this retrospective study of 20 hip fractures treated by dynamic hip screw (DHS) fixation, plain radiographs and thermal prints were compared for the patient and clinical information they contained. Thermal prints were found to be deficient in some areas but, nevertheless, can potentially replace postoperative radiographs in many orthopaedic procedures saving time, money and radiation exposure.
PMCID: PMC2502858  PMID: 8943634
17.  Clinical outcome after undisplaced femoral neck fractures 
Acta Orthopaedica  2011;82(3):268-274.
Background and purpose
Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.
Methods
Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.
Results
The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.
Interpretation
Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.
doi:10.3109/17453674.2011.588857
PMCID: PMC3235303  PMID: 21619501
18.  Survey of terminology used for the intraoperative direction of C-arm fluoroscopy 
Canadian Journal of Surgery  2013;56(2):109-112.
Background
Orthopedic surgeons depend on the intraoperative use of fluoroscopy to facilitate procedures across all subspecialties. The versatility of the C-arm fluoroscope allows acquisition of nearly any radiographic view. This versatility, however, creates the opportunity for difficulty in communication between surgeon and radiation technologist. Poor communication leads to delays, frustration and increased exposure to ionizing radiation. There is currently no standard terminology employed by surgeons and technologists with regards to direction of the fluoroscope.
Methods
The investigation consisted of a web-based survey in 2 parts. Part 1 was administered to the membership of the Canadian Orthopedic Association, part 2 to the membership of the Canadian Association of Medical Radiation Technologists. The survey consisted of open-ended or multiple-choice questions examining experience with the C-arm fluoroscope and the terminology preferred by both orthopedic surgeons and radiation technologists.
Results
The survey revealed tremendous inconsistency in language used by orthopedic surgeons and radiation technologists. It also revealed that many radiation technologists were inexperienced in operating the fluoroscope.
Conclusion
Adoption of a common language has been demonstrated to increase efficiency in performing defined tasks with the fluoroscope. We offer a potential system to facilitate communication based on current terminology used among Canadian orthopedic surgeons and radiation technologists.
doi:10.1503/cjs.015311
PMCID: PMC3617115  PMID: 23351496
19.  Anterior dislocation of the hip associated with intertrochanteric fracture of the femur-Case presentation- 
Journal of Medicine and Life  2013;6(3):336-339.
Dislocations of the hip usually occur following high energy trauma, the coxo-femoral joint being inherently stable, and can be associated with acetabular fractures or fractures of the head, neck or shaft of femur. However, the combination between the anterior hip dislocation and the ipsilateral intertrochanteric fracture is extremely rare, the literature offering only scarce information.
We present the case of a patient, aged 44, victim of a trauma by precipitation from height (12m), diagnosed with left hip anterior dislocation and intertrochanteric fracture of the ipsilateral femur. An emergency surgical treatment was applied in less than 3 hours after trauma. The hip dislocation was reduced under general anesthesia and the intertrochanteric fracture was also reduced and internally fixed with a dynamic hip screw. Radiological and functional evaluation at 6 months after surgery, using the modified Merle D’Aubigne hip score was good.
The clinical outcome of such a case depends on the quick evaluation and treatment. Providing a stable reduction of the dislocation and a stable internal fixation of the fracture as soon as possible (within the first 6 hours) will allow an early physical rehabilitation and decrease the risk of complications.
PMCID: PMC3786497  PMID: 24146697
hip dislocation; intertrochanteric fracture; high energy trauma
20.  Does a Multidisciplinary Team Decrease Complications in Male Patients With Hip Fractures? 
Background
Men with hip fractures are more likely to experience postoperative complications than women. The Medical Orthopaedic Trauma Service program at New York Presbyterian Hospital utilizes a multidisciplinary team approach to care for patients with hip fractures. The service is comanaged by an attending hospitalist and orthopaedic surgeon, with daily walking rounds attended by the hospitalist, orthopaedic resident, physical therapist, social worker, and a dedicated Medical Orthopaedic Trauma Service physician assistant.
Questions/purposes
We asked whether a multidisciplinary service for patients with hip fracture decreases (1) the incidence of inpatient complications in men, (2) the length of hospitalization, and (3) 90-day and 1-year mortality.
Patients and Methods
We retrospectively reviewed the charts of 74 men who had surgery for a nonperiprosthetic femoral neck, intertrochanteric, or subtrochanteric fracture for two 7-month periods before and after implementation of the Medical Orthopaedic Trauma Service. Age, ethnicity, comorbidity status, time to surgery, and postoperative complication data were collected. Regression modeling was used to evaluate the likelihood of postoperative complications, length of hospitalization, and 90-day and 1-year mortality while controlling for age, Charlson Comorbidity Index score, fracture type, and time from admission to surgery.
Results
We observed a decrease in the likelihood of experiencing at least one inpatient complication in male patients after implementation of the Medical Orthopaedic Trauma Service (odds ratio = 0.264). There was no difference in length of hospitalization, 90-day mortality, or 1-year mortality.
Conclusions
Multidisciplinary collaboration for patients with hip fractures can decrease the likelihood of experiencing inpatient complications in male patients.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-1825-y
PMCID: PMC3111804  PMID: 21350887
21.  Femoral head fractures 
Femoral head fractures may present in various patterns with or without associated fractures around the hip. As a result, the treating orthopaedic surgeon must understand not only the fracture pattern, but also patient-related fractures and the relevant operative exposures and reconstructive options to achieve the best functional outcome while minimizing complications. Treatment options range from non-operative treatment to fracture fragment excision or fracture fixation using various surgical exposures and implants. This article reviews the current literature on the treatment options for femoral head fractures and presents modern operative techniques that have improved exposure of the fracture while minimizing associated risks such as avascular necrosis, heterotopic ossification, and neurovascular compromise. A sound understanding of the anatomy and these newer techniques can enable the surgeon to provide improved expectations and clinical outcomes.
doi:10.1007/s12178-012-9129-8
PMCID: PMC3535084  PMID: 22628176
Femoral head fracture; Hip; Surgical dislocation; Hip dislocation; Trauma
22.  Fracture Surgery of the extremities with the intra-operative use of 3D-RX: A randomized multicenter trial (EF3X-trial) 
Background
Posttraumatic osteoarthritis can develop after an intra-articular extremity fracture, leading to pain and loss of function. According to international guidelines, anatomical reduction and fixation are the basis for an optimal functional result. In order to achieve this during fracture surgery, an optimal view on the position of the bone fragments and fixation material is a necessity. The currently used 2D-fluoroscopy does not provide sufficient insight, in particular in cases with complex anatomy or subtle injury, and even an 18-26% suboptimal fracture reduction is reported for the ankle and foot. More intra-operative information is therefore needed.
Recently the 3D-RX-system was developed, which provides conventional 2D-fluoroscopic images as well as a 3D-reconstruction of bony structures. This modality provides more information, which consequently leads to extra corrections in 18-30% of the fracture operations. However, the effect of the extra corrections on the quality of the anatomical fracture reduction and fixation as well as on patient relevant outcomes has never been investigated.
The objective of this study protocol is to investigate the effectiveness of the intra-operative use of the 3D-RX-system as compared to the conventional 2D-fluoroscopy in patients with traumatic intra-articular fractures of the wrist, ankle and calcaneus. The effectiveness will be assessed in two different areas: 1) the quality of fracture reduction and fixation, based on the current golden standard, Computed Tomography. 2) The patient-relevant outcomes like functional outcome range of motion and pain. In addition, the diagnostic accuracy of the 3D-RX-scan will be determined in a clinical setting and a cost-effectiveness as well as a cost-utility analysis will be performed.
Methods/design
In this protocol for an international multicenter randomized clinical trial, adult patients (age > 17 years) with a traumatic intra-articular fracture of the wrist, ankle or calcaneus eligible for surgery will be subjected to additional intra-operative 3D-RX. In half of the patients the surgeon will be blinded to these results, in the other half the surgeon may use the 3D-RX results to further optimize fracture reduction. In both randomization groups a CT-scan will be performed postoperatively. Based on these CT-scans the quality of fracture reduction and fixation will be determined. During the follow-up visits after hospital discharge at 6 and 12 weeks and 1 year postoperatively the patient relevant outcomes will be determined by joint specific, health economic and quality of life questionnaires. In addition a follow up study will be performed to determine the patient relevant outcomes and prevalence of posttraumatic osteoarthritis at 2 and 5 years postoperatively.
Discussion
The results of the study will provide more information on the effectiveness of the intra-operative use of 3D-imaging during surgical treatment of intra-articular fractures of the wrist, ankle and calcaneus. A randomized design in which patients will be allocated to a treatment arm during surgery will be used because of its high methodological quality and the ability to detect incongruences in the reduction and/or fixation that occur intra-operatively in the blinded arm of the 3D-RX. An alternative, pragmatic design could be to randomize before the start of the surgery, then two surgical strategies would be compared. This resembles clinical practice better, but introduces more bias and does not allow the assessment of incongruences that would have been detected by 3D-RX in the blinded arm.
Trial registration
Dutch Trial Register NTR 1902
doi:10.1186/1471-2474-12-151
PMCID: PMC3152540  PMID: 21733185
Fracture; Wrist; Ankle; Calcaneus; Intra-operative imaging; 2D-fluoroscopy; 3D-imaging; Conebeam-CT; 3D-RX
23.  Extensively coated revision stems in proximally deficient femur: Early results in 15 patients 
Indian Journal of Orthopaedics  2008;42(3):287-293.
Background:
Hip replacement following failed internal fixation (dynamic hip screw for intertrochanteric fractures) or previous hip arthroplasty presents a major surgical challenge. Proximal fitting revision stems do not achieve adequate fixation. Distal fixation with long-stemmed extensively coated cementless implants (like the Solution™ system) affords a suitable solution. We present our early results of 15 patients treated with extensively coated cementless revision stems.
Materials and Methods:
Fifteen patients with severely compromised proximal femora following either failed hip arthroplasty or failed internal fixation (dynamic hip screw fixation for intertrochanteric fractures) were operated by the senior author over a two-year period. Eight patients had aseptic loosening of their femoral stems following cemented hip replacements, with severe thinning of their proximal cortices and impending stress fractures. Seven had secondary hip arthritis following failure of long implants for comminuted intertrochanteric or subtrochanteric femoral fractures. All patients were treated by removal of implant (cemented stems/DHS implants) and insertion of long-stemmed extensively coated cementless revision (‘Solution™ DePuy, Warsaw (IN), US’) stems along with press-fit acetabular component (Duraloc Cup, DePuy, Warsaw (IN), US). All eight hip revisions needed extended trochanteric osteotomies.
Results:
All patients were primarily kept in bed on physiotherapy for six weeks and then gradually progressed to weight-bearing walking over the next six to eight weeks. The Harris Hip Scores and patient satisfaction were used for final evaluation. We achieved good results in the short term studied. In our first three patients (all following failed cemented total hip replacements), we resorted to cerclage wiring to hold osteotomised segments (done to facilitate stem removal). The subsequent 12 proceeded without the need for cerclage wiring. One patient had a intraoperative severe comminuted fracture extending into the supracondylar region while hammering in the stem. Post cerclage wiring, she was put on a long knee brace and her mobilization was delayed to 12 weeks.
Conclusions:
The extensively coated cementless (‘Solution™’) femoral stem provides a reasonable ‘solution’ to the deficient femur in hip revision. The proximal femoral deficiences can be relatively easily bypassed and distal fixation can be achieved with this stem. Extreme care needs to be taken to avoid fractures and penetration of the femoral shaft, which can, however, be managed by cerclage wiring. Principles of a successful outcome include preservation of the functional continuity of the abduction apparatus, care to recognize and prevent distal extension of fracture while inserting the stem (preemptive cerclage wiring) and supervised rehabilitation.
doi:10.4103/0019-5413.39554
PMCID: PMC2739478  PMID: 19753154
Cementless fixation; extensively coated; proximally deficient femur
24.  Minimally invasive percutaneous transpedicular screw fixation: increased accuracy and reduced radiation exposure by means of a novel electromagnetic navigation system 
Acta Neurochirurgica  2010;153(3):589-596.
Background
Minimally invasive percutaneous pedicle screw instrumentation methods may increase the need for intraoperative fluoroscopy, resulting in excessive radiation exposure for the patient, surgeon, and support staff. Electromagnetic field (EMF)-based navigation may aid more accurate placement of percutaneous pedicle screws while reducing fluoroscopic exposure. We compared the accuracy, time of insertion, and radiation exposure of EMF with traditional fluoroscopic percutaneous pedicle screw placement.
Methods
Minimally invasive pedicle screw placement in T8 to S1 pedicles of eight fresh-frozen human cadaveric torsos was guided with EMF or standard fluoroscopy. Set-up, insertion, and fluoroscopic times and radiation exposure and accuracy (measured with post-procedural computed tomography) were analyzed in each group.
Results
Sixty-two pedicle screws were placed under fluoroscopic guidance and 60 under EMF guidance. Ideal trajectories were achieved more frequently with EMF over all segments (62.7% vs. 40%; p = 0.01). Greatest EMF accuracy was achieved in the lumbar spine, with significant improvements in both ideal trajectory and reduction of pedicle breaches over fluoroscopically guided placement (64.9% vs. 40%, p = 0.03, and 16.2% vs. 42.5%, p = 0.01, respectively). Fluoroscopy time was reduced 77% with the use of EMF (22 s vs. 5 s per level; p < 0.0001) over all spinal segments. Radiation exposure at the hand and body was reduced 60% (p = 0.058) and 32% (p = 0.073), respectively. Time for insertion did not vary between the two techniques.
Conclusions
Minimally invasive pedicle screw placement with the aid of EMF image guidance reduces fluoroscopy time and increases placement accuracy when compared with traditional fluoroscopic guidance while adding no additional time to the procedure.
doi:10.1007/s00701-010-0882-4
PMCID: PMC3040822  PMID: 21153669
Minimally invasive; Electromagnetic field navigation; Pedicle screw; Fluoroscopy; Accuracy
25.  Rotational Fluoroscopy Assists in Detection of Intra-Articular Screw Penetration During Volar Plating of the Distal Radius 
The Journal of hand surgery  2010;35(4):619-627.
Purpose
Intra-articular screw penetration is one complication of volar plate fixation of distal radius fractures. This study was designed to determine the most utilized imaging techniques and views during volar plating of distal radius fractures and to evaluate surgeons’ ability to detect intra-articular screw placement on static fluoroscopic images and rotational fluoroscopy.
Methods
Active members of The American Society for Surgery of the Hand were polled regarding preferred imaging techniques (fluoroscopic versus cassette radiographs) and views (rotational fluoroscopy, static orthogonal/anatomic tilt/semi-pronated imaging) during volar plating of distal radius fractures. Following the survey, volar locking plates were applied to 30 cadaveric distal radii. A single screw intentionally penetrated the radiocarpal joint in half of the specimens (15 arms) and intentionally did not penetrate the radiocarpal joint in the other half. Imaging (standard posterior-anterior (PA) and lateral views, 11° tilt PA and 22° tilt lateral views, and two 360° fluoroscopy movies) was performed utilizing a custom jig. Five blinded surgeons reviewed randomized image sets evaluating for intra-articular screw placement. Receiver operating characteristic curves were constructed to compare the reliability of each fluoroscopic projection/movie.
Results
Among 696 survey respondents, 88% exclusively utilized fluoroscopic imaging (without cassette radiographs) and nearly 66% preferred either tilt images or rotational fluoroscopy to detect intra-articular screw penetration. In our cadaveric model, rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration. Rotational fluoroscopy was significantly more reliable (p<0.01) than most images (standard lateral, 11° PA, 22° lateral, paired PA/lateral) and trended strongly toward better reliability for all remaining images (standard PA [p=0.07], paired 11° PA/22° lateral [p=0.08], 22° tilt fluoroscopy movie [p=0.11]).
Conclusions
Rotational fluoroscopy improves the surgeon’s ability to detect intra-articular screw penetration during volar plating of the distal radius. No combination of imaging allowed detection of all intra-articular screws. A high level of suspicion for intra-articular screw penetration should be maintained during volar plating of distal radial fractures.
Level of evidence
Unable to be determined according to guidelines
doi:10.1016/j.jhsa.2009.12.033
PMCID: PMC2854080  PMID: 20202762
complication; distal radius; fracture; fluoroscopy; volar plate

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