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2.  Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes 
Background
Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. In the majority of patients, fractures involve the distal fibula. The current standard in treating unstable fractures is through open reduction and internal fixation (ORIF) with plates and screws. Due to concerns with potentially devastating wound complications, minimally invasive strategies such as intramedullary fixation have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of intramedullary fixation of distal fibular fractures using either compression screws or nails.
Materials and methods
Numerous databases (MEDLINE, PubMed, Embase, Google Scholar) were searched, 17 studies consisting of 1,008 patients with distal fibular fractures treated with intramedullary fixation were found.
Results
Mean rate of union was 98.5 %, with functional outcome reported as being good or excellent in up to 91.3 % of patients. Regarding unlocked intramedullary nailing, the mean rate of union was 100 %, with up to 92 % of patients reporting good or excellent functional outcomes. Considering locked intramedullary nailing, the mean rate of union was 98 %, with the majority of patients reporting good or excellent functional outcomes. The mean complication rate across studies was 10.3 %, with issues such as implant-related problems requiring metalwork removal, fibular shortening and metalwork failure predominating.
Conclusion
Overall, intramedullary fixation of unstable distal fibular fractures can give excellent results that are comparable with modern plating techniques. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcome.
Level of evidence
Level IV evidence.
doi:10.1007/s10195-014-0320-0
PMCID: PMC4244552  PMID: 25304004
Fibular; Ankle; Fracture; Intramedullary
4.  External fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes 
Abstract
Background
The objective of the study was to compare the efficacy of external fixation and volar plating on the functional parameter of displaced intra-articular (Cooney’s type IV) distal end radius fractures using the Green and O’Brien scoring system.
Materials and methods
This prospective randomized study comprised 68 patients treated with external fixation and 42 patients treated with volar locking plates. The patients were followed up at 6 months and 1 year after surgery. The assessment of pain, range of motion, grip strength and activity were assessed at each follow-up visit and scored according to the Green and O’Brien scoring system.
Results
At 1 year after surgery, we observed that external fixation showed significantly better results than volar locking plates using the Green and O’Brien scores for range of motion (22.0 ± 4.77 vs 19.89 ± 5.05), grip strength (19.91 ± 5.4 vs 16.89 ± 4.4) and final outcome (87.36 ± 11.62 vs 81.55 ± 11.32). No difference was found in pain and activity between these two groups of patients. Patients aged <50 years treated with external fixation showed excellent results (final score (91.57 ± 9.01) at 1 year follow-up.
Conclusion
External fixation showed superiority over volar locked plating after 1 year of surgery.
Level of evidence
IV.
doi:10.1007/s10195-014-0317-8
PMCID: PMC4244555  PMID: 25193416
Distal end radius fracture; External fixation; Volar locking plate; Green and O’Brien score
6.  Complication rates and reduction potential of palmar versus dorsal locking plate osteosynthesis for the treatment of distal radius fractures 
Abstract
Background
The aim of this study was to evaluate the complication rates of volar versus dorsal locking plates and postoperative reduction potential after distal radius fractures.
Materials and methods
For this study 285 distal radius fractures (280 patients/59.4 % female) treated with locked plating were retrospectively evaluated. The mean age of the patients was 54.6 years (SD 17.4) and the mean follow-up was 33.2 months (SD 17.2). The palmar approach was used in 225 cases and the dorsal approach in 60 cases (95 % type C fractures).
Results
Adequate reduction was achieved with both approaches, regardless of fracture severity. In the dorsal group, the complications and implant removal rates were significantly higher and the operative time was also longer.
Conclusions
Based on these facts, we advocate the palmar locking plate for the vast majority of fractures. In cases of complex multifragmentary articular fractures where no compromise in reduction is acceptable, and with the biomechanical equality of palmar and dorsal plating remaining unproven, dorsal plating may still be considered.
Level of evidence
Therapeutic level IV.
doi:10.1007/s10195-014-0306-y
PMCID: PMC4244564  PMID: 25027735
Distal radius fracture; Locking plate; Approach; Complication
7.  Aseptic lysis L2–L3 as complication of abdominal aortic aneurysm repair 
Abstract
Osteolytic vertebral erosion is usually related to tumours, spondylitis or spondylodiscitis. Few reports in the literature describe lytic lesions of anterior lumbar vertebral bodies resulting from abdominal aortic aneurysm or false aneurysm. We report a case of abdominal aortic false aneurysm that caused lytic lesions of the second and third vertebral bodies in an 80-year-old man who underwent endovascular aneurysm repair. Fluoroscopy guided biopsy excluded infection or tumour. We performed a posterior spinal fusion and decompression because of bone loss of the second and third lumbar vertebral bodies and central stenosis. Postoperatively the patient showed satisfactory relief in low-back and thigh pain but, unfortunately, he died 1 month after surgery because of respiratory complications. This case suggests that when a lytic lesion of a lumbar vertebral body is discovered in a patient who has undergone endovascular aneurysm repair, an abdominal aortic false aneurysm may be the cause of the vertebral erosion even in cases without infective pathogenesis.
doi:10.1007/s10195-014-0308-9
PMCID: PMC4244547  PMID: 25017025
Contained aneurysm rupture; Vertebral erosion; False aneurysm; Endovascular repair
8.  Malunited extra-articular distal radius fractures: corrective osteotomies using volar locking plate 
Background
Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Volar fixed-angle plates have added a new concept to the treatment of distal radius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function.
Materials and methods
Between 2005 and 2012, 20 patients with symptomatic dorsally malunited extra-articular fractures of the distal radius underwent corrective osteotomy using a volar locking plate without additional bone graft. At a mean follow-up of 50 months, all the patients were clinically and functionally evaluated.
Results
All measurements of pain, final range of motion and grip strength significantly improved compared with preoperative measurements. The mean preoperative DASH score reduced from 54 points preoperatively to 25 postoperatively. Based on the modified Mayo wrist score, we obtained 14 excellent and six good results. Palmar tilt improved from an average of 23° to 11°. Radial inclination improved from an average of 29° to 22°, and ulnar variance decreased from an average of 3.6 mm to 0.9 mm. There were two cases of transient median neuroapraxia that resolved before the 6-week follow-up appointment. No other major complications, including non-union and infection, were observed.
Conclusion
The volar approach and locking plate, without necessarily the use of bone grafting, proved to be an effective approach for addressing symptomatic and even severe deformities of the distal radius.
Type of study/level of evidence
Therapeutic IV
doi:10.1007/s10195-014-0307-x
PMCID: PMC4244554  PMID: 25017024
Malunion; Fractures; Radius; Osteotomy; Volar; Angulated; Locking plate; Bone graft; DASH; Mayo
9.  A new volar plate made of carbon-fiber-reinforced polyetheretherketon for distal radius fracture: analysis of 40 cases 
Background
Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at 12-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon for the treatment of distal radius fractures.
Materials and methods
We included 40 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 21 fractures were type C1, 9 were type C2, 2 were type C3, 2 were type B1 and 6 were type B2.
Results
At a 12-month follow-up no cases of hardware breakage or loss of the surgically achieved fracture reduction were documented. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 6.0 points. The average grip strength, expressed as a percentage of the contralateral limb, was 92 %. Hardware removal was performed only in one case, for the occurrence of extensor tenosynovitis.
Conclusion
At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures.
Type of study/level of evidence
Therapeutic IV.
doi:10.1007/s10195-014-0311-1
PMCID: PMC4244565  PMID: 25017027
DiPHOS; Plate; Radius; Fracture; PEEK; Radiolucent; Carbon-fiber-reinforced
10.  Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases 
Background
Soft tissue defects over the mid- and distal third tibia, heel, dorsum and plantar aspect of the foot and over the medial, lateral and posterior aspect of the ankle are a common scenario in clinical orthopaedic practice. In this article, we describe the utility of the reverse sural fasciocutaneous flap with a cutaneous pedicle in 109 clinical cases with distal lower limb soft tissue defects.
Materials and methods
A total of 109 patients were operated on for moderate (5–15 cm) and large (more than 15 cm) soft tissue defects at various sites along the lower limb including foot, heel and sole with the reverse sural fasciocutaneous flap. The defects were secondary to trauma (61 cases), diabetic ulcers (12 cases), post-traumatic scar contracture (8 cases), venous ulcer (4 cases), wound dehiscence (10 cases), leprotic non-healing ulcer (1 case), post-infective wound (1 case), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (1 case), post-fibromatosis excision (1 case), post-dermatofibrosarcoma excision (1 case), post-heel melanoma excision (1 case) and actinomycosis foot (1 case). Patients were assessed for flap uptake and healing of defects.
Results
Among the 102 cases analysed, 81 were male and 21 female with an average age of 32.7 years. The average size of the flaps was 148.10 ± 59.54 cm2. The flap healed uneventfully in 89.21 % of patients. Edge necrosis occurred in 9 cases. Donor site regrafting was required in 7 patients.
Conclusion
The reverse sural fasciocutaneous flap with a cutaneous pedicle is a quick, versatile, easy and safe soft tissue defect coverage technique to cover most of the soft tissue defects of the lower limb in common orthopaedic practice and does not require any microvascular repair, though it may be cosmetically unappealing in a few cases.
Level of evidence
IV (Case series)
doi:10.1007/s10195-014-0304-0
PMCID: PMC4182622  PMID: 24957508
Distal; Defects; Flaps; Sural
11.  Variable-angle locking plate with or without double-tiered subchondral support procedure in the treatment of intra-articular distal radius fracture 
Background
Double-tiered subchondral support (DSS) procedure is two-row fixation in which proximal screws support the dorsal subchondral bone, whereas distal screws support the volar central subchondral bone, using the volar variable-angle locking plate to achieve better anatomical reduction. We examined whether DSS improves clinical outcome, complication rate, and loss of correction for dorsally displaced Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C3 distal radius fractures.
Materials and methods
We reviewed dorsally displaced intra-articular AO C3-type distal radius fractures treated at our institutions with a variable-angle volar locking plate. We assessed 49 patients (27 DSS; 22 non-DSS) treated with volar locking plates, with a mean age of 59.9 years and average follow-up of 20.2 months (range 12–56 months). We evaluated differences in functional outcome, complication rates, and loss of correction between groups using radiographic parameters.
Result
There were no differences in clinical outcome and complications. Final volar tilt and ulnar variance were better maintained in the DSS group (P = 0.01 and 0.03). Change in volar tilt of the non-DSS group was more than that of the DSS group (P = 0.00).
Conclusion
Though there were no significant differences in clinical outcomes, we identified a significant reduction in final volar tilt, ulnar variance, and change in volar tilt. DSS procedure is useful to avoid correction loss when treating unstable C3 distal radius fractures and thus would reduce posttraumatic arthrosis.
Level of evidence
Level IV.
doi:10.1007/s10195-014-0292-0
PMCID: PMC4244546  PMID: 24942842
Distal radius fracture; Locking plate; Double-tiered subchondral support
12.  Long term results after surgical management of posterior wall acetabular fractures 
Background
Posterior wall fractures are the most common of all acetabular fractures, and there is universal consensus that displaced fractures are best treated with anatomical reduction and stable internal fixation. Though early and mid term results for such studies are available, few shed light on long term results. This study was performed to evaluate long term functional and radiological outcomes in patients with posterior wall acetabular fractures and to determine factors that may contribute adversely to a satisfactory final outcome.
Materials and methods
We retrospectively analysed the hospital records for patients who underwent open reduction and internal fixation (ORIF) for posterior wall acetabular fractures. Twenty-five patients (20 men, five women), including one with bilateral posterior wall fracture, with a mean age of 41.28 ± 7.16 years (range 25–60 years) and a mean follow-up of 12.92 ± 6.36 years (range 5–22 years) who met the inclusion criteria formed the study cohort. Matta’s criteria were used to grade postoperative reduction and final radiological outcome. Functional outcome at final follow-up was assessed according to d’Aubigné and Postel score.
Results
Anatomic reduction was achieved in 22 hips, imperfect in four and poor in none. Radiological outcome at final follow-up revealed excellent results in ten hips, good in eight, fair in five and poor in three. The final d’Aubigné and Postel scores were excellent in 14 hips, good in six and fair and poor in three each. Patients with anatomical reduction had a favourable functional and radiological long term outcome. However, the presence of associated injuries in lower limbs and a body mass index (BMI) >25 adversely affected the final functional outcome. Osteonecrosis was seen in three patients, heterotopic ossification in two and Morel Lavallee lesion in one. One patient had postoperative sciatic nerve palsy, which recovered 6 weeks after surgery.
Conclusion
Anatomic postoperative reduction leads to optimal functional and radiological outcome on long term follow-up; however, the presence of associated lower-limb injuries and BMI >25 adversely affects a satisfactory final outcome in patients with posterior wall acetabular fractures.
Level of evidence
(Level 4) Retrospective case series.
doi:10.1007/s10195-014-0297-8
PMCID: PMC4182623  PMID: 24879360
Acetabular fracture; Posterior wall fracture of the acetabulum; Long term outcome
13.  Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures? 
Background
Clavicle fractures are common, accounting for 5–12 % of all fractures. Traditionally, displaced middle-third clavicle fractures have been managed non-operatively but the associated displacement often leads to mal-union with shortening, cosmetic deformity and occasionally non-union, with clinicians looking towards alternative operative methods such as intramedullary nailing (IMN). However, such methods have their own complications. In order to ascertain the effectiveness of IMN in the management of middle-third clavicle fractures compared with non-operative treatment, analysis of recent evidence is required and this review aims to achieve that, focusing on relevant, contemporary randomised-control trials.
Materials and methods
Essential search-terms identified from the research question were used to formulate a search strategy. A systematic search of multiple databases was then performed from 1966 until present and appropriate papers for appraisal identified.
Results
Thirteen papers were identified, with 10 excluded using appropriate eligibility criteria. The remaining papers were then critically appraised. With regards shoulder function, all papers demonstrated an association between IMN and a significantly (P < 0.05) superior shoulder function score, but no consensus with regards to complication rates. However, all have identified limitations; therefore, their overall findings must be considered conservatively.
Conclusions
Further, high-quality research, ideally in the form of well-designed, multi-centre RCTs is required to allow acceptable implementation of IMN of middle-third clavicle fractures into widespread practice. However, early results demonstrate that in young patients with displaced middle-third clavicle fractures, who are motivated to return to work, IMN provides superior functional results and should be considered. However, the importance of considering each patient individually as to their suitability for each management option, before coming to an informed decision with the patient rather than having a blanket approach to MTCF is essential.
Level of Evidence
Level 1.
doi:10.1007/s10195-014-0299-6
PMCID: PMC4182650  PMID: 24879361
Fracture; Clavicle; Nailing; Pinning; Intramedullary; Trauma
14.  Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating 
Background
This prospective comparative study was done to evaluate the effectiveness of implants of different design (titanium elastic intramedullary nail versus anatomical precontoured dynamic compression plate) in treatment of displaced midshaft clavicular fractures.
Materials and methods
Sixty-six patients between 18 and 65 years of age were included in this study. They were randomized in two groups to be treated with either elastic intramedullary nail (EIN) or plate. Clinical and radiological assessments were performed at regular intervals. Outcomes and complications of both groups over 2 years of follow-up time were compared.
Results
Length of incision, operation time, blood loss and duration of hospital stay were significantly less for the EIN group. American Shoulder and Elbow Surgeons (ASES) and Constant Shoulder scores were significantly higher (p < 0.05) in the plating group than the EIN group for the first 2 months but there was no significant difference found between the two groups regarding functional and radiological outcome at the 2-year follow-up. Significantly higher rates of refracture after implant removal (p = 0.045) in the plating group was observed. Infection and revision surgery rates were also higher in the plate group, but this difference was insignificant (p > 0.05).
Conclusions
EIN is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures.
Level of evidence
Level 2.
doi:10.1007/s10195-014-0298-7
PMCID: PMC4182648  PMID: 24859367
Displaced midshaft clavicle fractures; Elastic intramedullary nailing; Anatomical precontoured plating
15.  The pubic midline exposure for symphyseal open reduction and plate fixation 
Background
Open reduction and plate fixation of the disrupted symphysis pubis is commonly performed through a horizontal Pfannenstiel incision. Certain clinical situations that complicate the soft tissue conditions of the lower abdomen may make the Pfannenstiel incision a less appealing option. We report on the use of a vertical pubic area midline skin incision in a series of patients undergoing open reduction and plate fixation of their traumatically disrupted symphysis pubis.
Materials and methods
Institutional Review Board approval was obtained for a retrospective chart review of the charts of 25 patients treated between September 2011 and October 2012. Their charts were reviewed for patient age, gender, body mass index (BMI), pelvic injury type (as classified by Young and Burgess), mechanism of injury and associated traumatic injuries. The depth of the approach was estimated using the pelvic computed tomography (CT) scan. Details from the operative procedure were recorded, as was the length of follow-up and any perioperative complications.
Results
Twenty-five patients were eligible for inclusion during the defined study time period between September 2011 and October 2012. The patients’ average age was 55.8 years (range 25–91). All patients were males. The average BMI was 29.3 (range 18.8–43.8). The depth measured on the axial pelvic CT scan from skin to symphysis was 57.6 mm (range 35.2–90.2 mm). Five of 25 patients had an isolated pelvic ring injury without other associated injuries. The injury pattern was APC2 in 18, APC3 in 3, LC2 in 2, LC3 in 1 and VS in 1 patient(s) [anterior posterior compression (APC), lateral compression (LC), vertical shear (VS)]. Urologic procedures were performed in the same surgical setting in four patients. The average blood loss was 244 ml (range 150–400 ml). The average follow-up was 2.5 months (range 1–12 months). Perioperative issues were noted in two patients. One patient died within a month of surgery as a result of his associated traumatic injuries. One patient developed a deep infection.
Conclusion
The pubic midline skin exposure is a feasible alternative to the Pfannenstiel incision for open reduction and plate fixation of the pubic symphysis.
Level of evidence
IV, Retrospective case series
doi:10.1007/s10195-014-0296-9
PMCID: PMC4182616  PMID: 24804985
Pelvic ring; Pfannenstiel; Symphysis approach
16.  Non-operative treatment versus percutaneous fixation for minimally displaced scaphoid waist fractures in high demand young manual workers 
Background
Managing minimally displaced scaphoid fractures in young individuals doing physically demanding work remains an issue of debate due to duration of immobilisation and time required off work. Therefore, early diagnosis and appropriate treatment are important to avoid short- and long-term consequences. The literature lacks the exact definition of minimally displaced scaphoid waist fractures. The objective of this review article was to discuss nonoperative and minimally invasive treatment (percutaneous screw fixation) for minimally displaced scaphoid waist fractures and to systematically review the literature, focussing on young workers with physically demanding employment.
Materials and methods
We searched for articles through the most commonly used portals using appropriate terminologies to identify the most relevant articles in the English language comparing nonoperative and percutaneous fixation methods for these fractures in patients between 16 and 40 years of age. Strict inclusion and exclusion criteria were observed.
Results
Sixty relevant published articles were found. Twenty-one of these were considered valid for inclusion and comprised five randomised controlled trials, three prospective studies, four systematic reviews, three meta-analyses, and six retrospective studies. These studies provided a reasonable account of information on the managing undisplaced and minimally displaced scaphoid waist fractures, with satisfactory clinical and statistical analysis. However, it was difficult to assess the outcomes of minimally displaced fractures in isolation. Furthermore, few of these studies relied on plain radiographs for assessing union and did not report on patients’ work status.
Conclusion
Cast treatment has the disadvantages of longer immobilisation time, joint stiffness, reduced grip strength, and longer time to return to manual work. Percutaneous fixation is aimed at reducing damage to the blood supply and soft tissues, allowing early mobilisation of the wrist and early return to manual work. The best available evidence for percutaneous screw fixation versus cast treatment suggests that percutaneous fixation allows a faster time to union by 5 weeks and an earlier return to manual work by 7 weeks, with similar union rates. This systematic review indicates a potential requirement for a prospective randomised controlled trial to compare these two treatment modalities for minimally displaced scaphoid waist fractures in workers with physically demanding jobs in order to objectively assess functional outcomes, time to union and time to return to work.
Level of evidence
Level 3.
doi:10.1007/s10195-014-0293-z
PMCID: PMC4244556  PMID: 24781245
Minimally displaced scaphoid fractures; Percutaneous fixation; Cast treatment; Scaphoid waist fractures
17.  Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates 
Background
The aim of this retrospective study was to compare outcomes and complications of displaced fractures of the shaft of the humerus treated with limited-contact dynamic compression plates (LCDCPs) and locking compression plates (LCPs).
Materials and methods
Two hundred and twelve patients with displaced fractures of the shaft of the humerus, treated with plate osteosynthesis from January 2005 to December 2009 were reviewed. One hundred and two patients (group A) were treated with LCDCP osteosynthesis and 110 patients (group B) were treated with LCP osteosynthesis. Clinical and radiological assessments were made at monthly intervals for the first 6 months and then at 2-month intervals for the next 6 months. Primary outcome measures like operative time, duration of hospital stay, time to fracture union, union rate and secondary outcome measures (functional outcome and complications such as infection, malunion, delayed union, nonunion, implant failure and iatrogenic radial nerve palsy) were compared between both groups. The ULCA scoring system and Mayo elbow performance index (MEPI) were used to assess shoulder and elbow functions, respectively. Rodriguez-Merchan criteria were used to assess the functional outcomes of the fracture fixation.
Results
There was no significant difference found between the two groups in terms of primary outcome measures. According to Rodriguez-Merchan criteria, comparison of functional outcomes of both groups showed insignificant difference (p = 0.48). There was no significant difference found between the two groups regarding mean ULCA score (p = 0.34) and mean MEPI sore (p = 0.54). In terms of complications, no significant difference was found between the two groups.
Conclusion
This study concludes that the principle of fracture fixation was more important than plate selection in fractures of the shaft of the humerus.
Level of evidence
Level 3.
doi:10.1007/s10195-014-0290-2
PMCID: PMC4033817  PMID: 24687559
Limited contact dynamic compression plate; Locking compression plate; Fracture shaft of humerus; Dynamic compression
18.  Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail 
Background
The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN).
Materials and methods
The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group.
Results
There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649).
Conclusion
Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care.
Level of evidence
Level III, therapeutic study.
doi:10.1007/s10195-014-0287-x
PMCID: PMC4182644  PMID: 24687558
Periprosthetic fracture; Total knee arthroplasty; Femur plate system; Retrograde-inserted supracondylar nail
19.  Bone graft from greater trochanter in posterior wall fractures with impacted fragments 
Background
Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.
Materials and methods
Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.
Results
The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.
Conclusions
Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.
Level of evidence
Level IV.
doi:10.1007/s10195-014-0291-1
PMCID: PMC4182615  PMID: 24671489
Posterior wall fractures; Impacted fragment; Bone loss; Autograft; Hip dislocation; Intra-articular fragments
21.  Primary total hip arthroplasty versus internal fixation in displaced fracture of femoral neck in sexa- and septuagenarians 
Background
The optimal treatment of femoral neck fracture in the elderly patient is still under debate. In patients aged 60–80 years, the decision between internal fixation and arthroplasty remains controversial. The primary aim of the present study is to evaluate the functional outcome of patients aged 60–80 years with femoral neck fracture treated with total hip arthroplasty or closed reduction and internal fixation. The secondary aim is to evaluate the incidence of nonunion and avascular necrosis in femoral neck fracture in different age groups.
Materials and Methods
We studied 100 patients affected by displaced fracture of the femoral neck from May 2007 through June 2010. There were 60 men and 40 women with mean age of 66 years. Fifty patients were treated with closed reduction and internal fixation with cannulated screws (group A), and the other 50 patients with total hip arthroplasty (group B). Mean surgical time, blood loss, duration of hospital stay, Harris hip score, complications, and need for reoperation were recorded.
Results
Harris hip score was significantly higher in group B at 3-, 6-, 12-, and 18-month follow-up evaluation. The overall complication rate was 28 % in group A and 32 % in group B, which was not statistically significant. A statistically significant difference was found regarding patients who required reoperation in group A (20 %) compared with group B (no one). The average Harris hip score in the internal fixation group was 90.6 and in the total hip arthroplasty group was 93.7, which was statistically significant (p < 0.05). Our study showed an increased risk for intracapsular hip fracture developing nonunion with older age.
Conclusions
Primary total hip arthroplasty compared with internal fixation appears to be a reasonably safe method of treating displaced fracture of femoral neck in elderly patients. We also concluded that outcome regarding hip function is generally better after total hip arthroplasty compared with internal fixation.
Level of evidence
Level II-Prospective cohort study.
doi:10.1007/s10195-013-0278-3
PMCID: PMC4182619  PMID: 24385140
Avascular necrosis; Nonunion; Internal fixation; Arthroplasty
22.  A prospective randomized comparison of two skin closure techniques in acetabular fracture surgery 
Background
Recent publications have shown an infection rate of 5–7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods?
Materials and methods
In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51).
Results
Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure.
Conclusions
Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred.
Level of evidence
II.
doi:10.1007/s10195-013-0282-7
PMCID: PMC4182586  PMID: 24379118
Skin closure; Acetabular fracture; 2-Octyl cyanoacrylate
25.  Analysis on anatomical references to assess the coronal alignment of tibial and femoral cuts in mega prosthetic knee replacement 
Background
In megaprosthetic knee replacement, surgeons use cutting guides that depend on anatomLevel of evidence
ical references to determine the ideal cutting plane alignment. In this work, we investigated the accuracy of using femoral cortical surfaces and tibial canal portions as the references. The study aims to improve the design and use of the cutting guides.
Materials and methods
Sixty-one knee scanograms of 33 patients (mean age around 20 years) diagnosed with osteogenic sarcoma and undergoing distal femur megaprosthetic surgery were acquired. Angles between the selected anatomical references and axis perpendicular to the ideal cutting plane (anatomical axis for femur and mechanical axis for tibia) were measured for both femur and tibia, in coronal view. The smaller the magnitude of the angles, the better the anatomical reference is.
Results
At the central femoral region, on average, both lateral and medial cortical surfaces give accurate alignment of the ideal cutting plane (0.6° and 0.8°, respectively), with no significant difference (p > 0.01). At the distal region, the lateral cortical surface gives significantly better alignment compared to the medial cortical surface (p < 0.01), but not as accurate (1.4°) as in the central region. For tibia, the central tibial canal gives significantly accurate alignment of the ideal cutting plane (−0.3°) on average, compared to the proximal tibial canal (p < 0.01).
Conclusions
For a femoral cut, both lateral and medial cortical surfaces are the best anatomical references, but only at the central region. For a tibial cut, the central anatomical axis is the best reference.
Level of evidence
IV.
doi:10.1007/s10195-013-0277-4
PMCID: PMC4033827  PMID: 24363160
Knee replacement; Anatomical reference; Implant; Cutting alignment; Cutting guide

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