Distal interlocking of intramedullary nails can be challenging if not done regularly and can be associated with a prolonged operating time and excessive radiation exposure. Multiple techniques have been developed to overcome these problems but all still rely on conventional distal locking methods. Between December 2011 and March 2013, 18 patients with diaphyseal femur fractures were treated with the shape memory nail (Orthofix, Verona, Italy). These nails use self-contained nitinol memory metal ‘wings’ at the distal aspect of the nail to provide rotational and longitudinal stability. We observed fracture union in all 18 cases with no non-unions, rotational malalignments or peri-prosthetic infections. Median theatre time was 35 (18–71) minutes and median total radiation time was 50 (20–209) seconds. The shape memory nail (Orthofix, Verona, Italy) is an attractive alternative to conventional interlocking femoral nails. It provides sufficient stability to allow fracture union while decreasing theater time and limiting radiation exposure.
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Edobor-Osula F, Wenokor C, Bloom T, Zhao C, Sabharwal S. Ipsilateral Osteochondritis Dissecans-like Distal Femoral Lesions in Children with Blount Disease: Prevalence and Associated Findings. 2019; 14 (3):121-125.
Purpose: Our goal was to assess the prevalence of ipsilateral distal femoral osteochondritis dissecans (OCD)-like lesions in children with Blount disease, including factors associated with this finding.
Materials and methods: Characteristics of patients with an OCD-like lesion on an imaging study [(X-ray and/or magnetic resonance imaging (MRI)] were compared with those without such a finding.
Results: Over a 12-year period, 6/63 (10%) skeletally immature patients (9/87 limbs) with Blount disease had an OCD-like lesion visible on plain radiographs. Based on available MRI, 7/37 (19%) patients or 10/53 (19%) limbs had an OCD-like distal femoral lesion. All lesions were noted in the posterior third of the weight-bearing portion of the medial femoral condyle with intact overlying articular cartilage. All patients with OCD-like lesions were followed for an average of 1.9 years (range: 1–2.6 years), and complete radiographic resolution of lesion was noted in 7/9 limbs (78%). There was no association of the presence of OCD-like lesion with early- vs late-onset disease, gender, age at imaging, laterality, magnitude of deformity [mean mechanical axis deviation (MAD) 63.3 vs 71.9 mm], mean mechanical lateral distal femoral angle (mLDFA; 91.3 vs 89.7°), and mean medial proximal tibial angle (MPTA; 71.7 vs 71.8°). Children with an OCD-like lesion tended to have a lower mean body mass index (BMI; 21 vs 36, p = 0.003).
Conclusion: The overall prevalence of OCD-like lesions in the medial femoral condyle in children with Blount disease lesions is 10% using plain radiographs and at least 19% on MRI. Based on the numbers available, we were unable to demonstrate any associations between the presence of such lesions and the patient\'s age, gender, or magnitude of varus deformity. Further research is needed to fully ascertain the aetiology and natural history of these benign appearing osteochondral imaging findings in children with Blount disease. Our current data support that these lesions do resolve with time and that no surgical intervention targeted at the femoral OCD-like lesion is warranted.
Level of evidence: Diagnostic study Level III.
Mehmet N Konya,
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Sargin S, Konya MN, Gulcu A, Aslan A. Effects of Zoledronic Acid Treatment on Fracture Healing, Morbidity and Mortality in Elderly Patients with Osteoporotic Hip Fractures. 2019; 14 (3):126-131.
Background: In this study, the effects of zoledronic acid (ZolA) administered at different times to patients undergoing surgical treatment for hip fracture were investigated.
Materials and methods: Ninety patients who underwent surgical treatment for osteoporotic (OP) hip fractures between February 2013 and September 2016 in our hospital were included in the study. After surgical treatment, patients were allocated into three groups: group I—patients who had osteosynthesis using proximal femoral nail (PFN) for an intertrochanteric fracture of the femur were given ZolA within 1 week after fracture and before discharge; group II—patients who had osteosynthesis using the PFN for an intertrochanteric fracture of the femur were given ZolA within 1 month after fracture post-discharge; group III—patients in the same age group who had a hemiarthroplasty (HA) for an intertrochanteric fracture of the femur were administered ZolA before discharge. In addition, all patients were given daily oral calcium and vitamin D3. The Radiographic Union Score for Hip (RUSH), Harris Hip Score (HHS), and bone mineral density (BMD) were used at the follow-up as evaluation criteria, and complications were noted.
Results: There were no significant differences between groups in terms of demographic data and laboratory outcomes (p > 0.05). Radiographic Union Score for Hip scores were similar between groups I and II (p > 0.05). Fracture union occurred by the sixth month in all patients whose results were evaluated. No statistically significant difference was found between three groups (p > 0.05). There was no difference between the three groups in the hip and vertebrae BMD and t scores (p > 0.05). When t and BMD scores before treatment were compared with those at 1 year after treatment, a benefit from ZolA treatment was observed in all three groups (p < 0.05).
Conclusion: This study shows that the timing of ZolA administration has no effect on fracture healing and complication incidence in elderly patients with hip fractures. In addition, ZolA was found to be beneficial in increasing BMD of both femur and vertebra in all groups, but there was no significant difference between the groups.
Clinical significance: The study demonstrated that ZolA may be used early in the treatment of osteoporotic hip fractures with PFN.
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Belthur MV, Jones S, Giles SN. Correction of Bowleg Deformity in Achondroplasia through Combined Bony Realignment and Lateral Collateral Ligament Tightening. 2019; 14 (3):132-138.
Introduction: Achondroplasia is one of the most common osteochondrodysplasias with an incidence of 1 in 26,000 live births. Bowing of lower limbs can cause significant morbidity in this population. The use of the Ilizarov external fixator to tighten collateral ligaments of the knee in children has not been reported in the literature. We report the technique and early results of lateral collateral ligament (LCL) tightening with correction of genu varum in children with achondroplasia.
Materials and methods: A retrospective review of children with achondroplasia presenting with bowleg deformity who were treated by corrective osteotomy and LCL tightening was conducted. Between 1998 and 2003, 12 patients (24 limb segments) underwent this procedure and were included in the study. All patients had grade III LCL laxity preoperatively. Pre- and postoperative anteroposterior standing mechanical axis radiographs were evaluated. The final outcome was graded using the grading system of Paley et al.
Results: All patients had bilateral corrections. The Ilizarov external fixator was used in 10 patients and the Orthofix limb reconstruction system in 2 patients. The bony realignment was achieved through monofocal or bifocal tibial osteotomies. The LCL was tightened in all limb segments using the Paley\'s type II strategy. The final result was graded as excellent in 20 limb segments and good in 4 limb segments. One patient developed transient common peroneal nerve palsy, four developed grade II pin site infections, and there was premature consolidation of the tibial regenerate in one patient.
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Lopes M, Nunes B, Couto A, Freitas J, Martins R, Coutinho J, Costa G. Electromagnetic Rod in Lower Limb Lengthening: A Technical Note for Shaft Osteotomy. 2019; 14 (3):139-141.
Purpose: Long bone lengthening procedures are paramount in the treatment of limb length discrepancies. We witnessed a revolution in the treatment paradigm of this pathology with the development of expandable intramedullary rods. Endomedular nailing might be technically demanding and some steps are critical for success. The aim of authors is to describe a technical note of the PRECICE system that may ease femoral nailing and fixation: the nail can be advanced through the femur and proximal and distal fixation performed previous to complete femoral osteotomy.
Materials and methods: The authors present a case series of XX patients in which the limb lengthening has been performed with partial osteotomy with Gigli saw, nail advancement, proximal and distal fixation, and osteotomy completion at the end of the procedure.
Results: After 18 consecutive limb (femoral) lengthening operations with this technical variation in PRECICE, nail patients presented no significant lower limb length discrepancy. There were no records of rotational deformities, nonunion, or infection. Material failure was not reported.
Conclusion: This technical note is another positive variable that can help to ease the procedure, minimise possible complications, and confirm magnetic expandable nails as the gold standard technique in limb lengthening procedures and it might be applied to other nailing systems for limb lengthening procedures.
Franz F Birkholtz,
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Naude J, Manjra M, Birkholtz FF, Barnard A, Glatt V, Tetsworth K, Hohmann E. Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. 2019; 14 (3):142-147.
Aim: The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators.
Material and methods: This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months’ follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the χ2 test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student\'s t tests.
Results: In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF (p = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) (p = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) (p = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) (p = 0.34 and 0.69).
Conclusion: The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients.
Level of evidence: Therapeutic level III
Background: We have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively.
Materials and methods: Thirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I—no bone defect, no or mild deformity; type II—no bone defect, severe deformity; type III—bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV—bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport.
Results: All patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one.
Conclusion: We have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases.
Aim: We present details of a surgical technique to create an intramedullary canal to allow intramedullary fracture fixation in patients with osteopetrosis. Clinical cases are used to facilitate the description.
Background: Osteopetrosis is a rare, hereditary condition characterised by hard, brittle, “marble bone;” primarily due to osteoclast dysfunction. Patients are prone to fractures and subsequently nonunions, periprosthetic fractures, and metal-ware failure are commonly seen. Due to the increased bone density, deformity, and obliteration of the medullary cavity, fracture fixation is also technically demanding.
Technique: Creation of a medullary canal allows the use of intramedullary fixation rather than plate and screws for long-bone fractures.
Key factors:• A new sharp drill bit should be used for each case as blunt drills are more likely to break.• Bone is drilled in a pulsatile fashion, with withdrawal every 2–4 seconds for bone swarf to be removed.• Constant cooling of the drill bit with saline to help prevent bone necrosis and drill breakage.• Regular exchanging of drill bit sizes to expand the canal. The smaller drills start the canal and are used to direct progress. Sequential expansion during canal creation is preferred.• Regular use of orthogonal radiographs to ensure correct canal positioning and prevent perforation.Conclusion: The creation of an intramedullary canal allows intramedullary fracture fixation. In our experience, this technique gives the orthopaedic surgeon a safe and effective method for treating long-bone fractures in patients with osteopetrosis.
Clinical relevance: Fractures and nonunions in patients with osteopetrosis are difficult to manage; and by detailing this technique, a further option is now available for surgeons when deciding upon fixation method.
Olecranon fractures and osteotomies are treated with either tension-band wiring or plate-screw fixation; however, these methods of fixation have high rates of symptomatic hardware, resulting in revision surgery. We describe the novel use of intramedullary noncannulated long screws to gain rigid internal fixation and allow early range of motion. Our procedure differs from traditional intramedullary olecranon fixation as the longer screws, which can commonly be found on many pelvic fixation sets, allow for endosteal purchase at the isthmus of the ulna, which increases the pull-out strength of the screw. This procedure can be done quickly and requires minimal exposure, which minimises anaesthetic exposure, blood loss, and tourniquet time. The construct is not palpable subcutaneously and therefore is less likely to result in symptomatic hardware and revision surgery.