Je-Hyun Yoo

Overlapping intramedullary nailing after failed minimally invasive locked plating for osteoporotic distal femur fractures - Report of 2 cases

Minimally invasive plate osteosynthesis (MIPO) using a locking plate has been widely used for distal femur fractures in the elderly with osteoporosis and yielded favourable results. However, implant failure and subsequent periplate fracture have still occurred owing to the controversy of concepts regarding locked plating. The treatment after failed MIPO in elderly patients is very challenging and has been not yet addressed definitely in the literature, although several options can be considered. We report the successful outcomes of two cases treated with overlapping intramedullary (IM) nailing for implant failure and periplate fracture after MIPO for osteoporotic distal femur fracture, along with simple tips of distal interlocking of IM nail.

Management of traumatic labral tear in acetabular fractures with posterior wall component

BACKGROUNDnPosterior labral tear is frequently encountered in acetabular fractures with posterior wall component (AFPWC). However, there has been very little information in the literature on the type and management of traumatic labral tears in AFPWC.nnnHYPOTHESISnTraumatic labral tear is a constant intracapsular injury in AFPWC and can be repaired using adequate methods according to its type and size.nnnMATERIALS AND METHODSnA retrospective study of 14 patients (mean age 38 years [16-58]) who underwent open surgery for AFPWC was conducted using prospectively collected data. The types of posterior labral tear were investigated at intraoperative examination through the ruptured joint capsule or its extension, and were concomitantly managed. Surgical outcomes were clinically assessed using Merle dAubigné (PMA) score and Visual Analog Scale (VAS), and radiologically evaluated at final follow-up.nnnRESULTSnPosterior labral tears were present in all 14 patients. The types of labral tear were osseous avulsion and posterior root avulsion tear (n=9), longitudinal peripheral tear and posterior root avulsion tear (n=2), longitudinal peripheral tear (n=2), and osseous avulsion tear (n=1). All unstable labra in 12 patients (86%) were repaired. All avulsion tears of the posterior root were repaired using a suture anchor, longitudinal peripheral tears using suture fixation or/and suture anchors, and osseous avulsion tears using a spring plate. The mean PMA score and VAS were 16.4 (14-18) and 1.7 (0-3) at final follow-up, respectively. The radiologic grades at last follow-up were good or excellent in all patients.nnnDISCUSSIONnAll AFPWC in this study consistently revealed posterior labral tear. Posterior root avulsion tears accompanied with osseous avulsion was the most common type. Torn labra should be repaired as much as possible if unstable, considering the important functions of a normal labrum; fixation using a suture anchor may be useful for an avulsion tear of the posterior root.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

A modified rat tibia osteotomy model with proximal interlocked intramedullary nailing

The purpose of this study was to develop a rat tibia osteotomy model capable of providing more stability on osteotomy site using proximal interlocking intramedullary (IM) nailing with a modified Kirschner’s wire (K-wire). In group I, a standardized conventional osteotomy rat with 3-mm defect was fixed with 0.89-mm K-wire, while in group II we used pre-bended 0.89-mm K-wire which had a proximal hole for fixation with an interlocking pin. All 30 rats survived during experiment without sacrifices and group I had abrupt reduction of osteotomy gap on postoperative radiographs of day after surgery and maintained during rest first week after surgery. While sagittal angulation and gap reduction were progressed until postoperative 6 weeks in group I, most rats of group II showed consistent gap throughout the experiment period after surgery with statistical significance (p = 0.028). Initial sagittal angulation was excellent in group I (mean, 2.6 ± degrees) but it was not maintained until 6 weeks (mean, 26.73 ± degrees) but in group II initial sagittal angulation was severe than group I (18.27 degrees, p < 0.05) but angulation of group II was not progressed (23.6 degrees, p = 0.456). In conclusion, our modified rat tibia osteotomy model provide firm stability compared to previous models and it is inexpensive and reproducible without custom-made device or technical difficulty.

Indirect reduction of posterior wall fragment using a suture anchor in acetabular posterior wall fracture with posterior labral root tear

Posterior wall fractures, which are the most common type of acetabulum fracture, are frequently accompanied with an avulsion tear of the posterior labral root as well as hip dislocation due to the injury mechanism. In the treatment of these fractures with an avulsed posterior labral root attached to posterior wall fragment, the use of a suture anchor can induce indirect reduction of a posterior wall fragment as well as direct repair of a labral root tear simultaneously. We describe the simple and efficient technique using a suture anchor in posterior wall acetabular fractures and surgical outcomes of two cases treated with this technique.

Early postoperative delirium after hemiarthroplasty in elderly patients aged over 70 years with displaced femoral neck fracture

Purpose Postoperative delirium is a risk factor for worse outcome after hip fracture surgery in elderly patients. Postoperative delirium is associated with anesthesia, postoperative pain, and patient factors. We investigated the incidence, predictors, and prognostic implications of post-operative delirium after hemiarthroplasty (HA) in elderly patients with femoral neck fracture. Patients and methods A total of 356 consecutive patients aged >70 years who underwent HA for femoral neck fracture were enrolled. Diagnosis of delirium was made by a psychiatrist based on patient status and an objective scoring system. The patients were divided into 2 categories according to the HA onset time (immediate [≤24 h after surgery] vs delayed delirium [>24 h after surgery]) and its incidence, predictors and mortality were evaluated. Results Postoperative delirium was diagnosed in 110 patients (30.9%) during hospitalization. Immediate and delayed delirium occurred in 59 (53.6%), and 51 (46.4%) patients, respectively. The independent predictors of immediate delirium included age (odds ratio [OR] 1.47, 95% CI 0.98–2.23, p=0.066), and general anesthesia (OR 2.25, 95% CI 1.17–4.43, p=0.015). The independent predictors of delayed delirium were parkinsonism (OR 5.75, 95% CI 1.66–19.96, p=0.006), intensive care unit stay (OR 1.85, 95% CI 0.97–3.56, p=0.064), and higher American Society of Anesthesiologists grade (OR 2.33, 95% CI 0.90–6.07, p=0.083). On Kaplan–Meier survival analysis, the 2-year survival rate was significantly lower in the immediate delirium group than those in the delayed and control groups (71.0% vs 83.6% vs 87.8%, respectively; p=0.031). Conclusion Immediate and delayed delirium after HA for femoral neck fracture had different predictors and immediate delirium was associated with worse prognosis.

Dual mobility hip arthroplasty provides better outcomes compared to hemiarthroplasty for displaced femoral neck fractures: a retrospective comparative clinical study

PurposeTotal hip arthroplasty with a dual mobility cup (DMC) is a proposed alternative to the widely performed bipolar hemiarthroplasty (BHA) for treating displaced intracapsular femoral neck fractures (DFNF) in the elderly. However, the comparison between the two modalities has not been extensively conducted thus far.MethodsA retrospective cohort study was conducted with DFNF patients aged over 65xa0years who were treated either by BHA or DMC. After propensity matching each group comprised 84 patients (168 patients in total) and was analyzed using peri-operative and post-operative parameters.ResultsMean follow-up durations were 22.1 and 21.7xa0months in the BHA and DMC groups, respectively. The BHA group demonstrated significantly less intra-operative blood loss (pu2009=u20090.001) and a shorter length of operation (pu2009<u20090.001). However, there was no difference in one-year mortality (pu2009=u20090.773). The Harris hip score (HHS) was significantly higher (pu2009=u20090.018) in the DMC group. The dislocation rate was not different between the two groups (pu2009=u20091.000).ConclusionIn DFNF patients aged over 65xa0years, short-term observation showed DMC to be the preferred treatment over BHA with better clinical outcome, without disadvantages in mortality or dislocation rate. Further long-term investigations are recommended to strengthen these results.

Cortical erosion after elastic stable intramedullary nail fixation for pediatric long bone fractures: Case series according to the site

BACKGROUNDnElastic stable intramedullary nail (ESIN) is widely used for treatment of long bone fractures in children. However, migration of the nail or cortical bone erosion in children has been reported. This study was conducted to investigate the incidence of cortical erosion according to the site and cortical erosion type.nnnMATERIALS AND METHODSnA total of 221 normally developing children (223 fractures) who were treated with ESIN for fractures of the long bones without cortical breakage at immediate postoperative radiography and with the ESIN in position for more than 6 months were included. Two pediatric orthopaedic surgeons reviewed all the radiographs. Cortical bone erosion was defined when the two investigators agreed that there was cortical breakage by the ESIN.nnnRESULTSnPenetration of nails through the bone cortex was observed in 25 patients (11.2%). Fifteen patients (6.7%) showed cortical erosion at the diaphysis and ten patients (4.5%) showed protrusion of the tip of the ESIN at the metaphysis-diaphysis junction. The average time for hardware removal in patients with cortical erosion was 14.2 months.nnnCONCLUSIONnCortical bone erosion by ESIN could occur in pediatric long bones without any iatrogenic problem or disease related to the bony structure. Erosion at diaphysis was more common than at metaphysis-diaphysis junction. Cortical erosion should be considered in children who retain their ESIN for a long time.

Does preoperative mechanical prophylaxis have additional effectiveness in preventing postoperative venous thromboembolism in elderly patients with hip fracture?-Retrospective case-control study.

Background Elderly patients undergoing hip fracture surgery (HFS) are at increased risk of postoperative venous thromboembolism (VTE). To reduce this risk, combined postoperative mechanical and chemical thromboprophylaxis has been routinely performed after HFS in these patients. This retrospective case-control study was conducted to evaluate the additional effectiveness of preoperative mechanical thromboprophylaxis for the prevention of VTE following HFS in elderly patients. Methods Of 539 consecutive patients aged 70 years or older undergoing HFS, 404 (control group) did not receive preoperative mechanical thromboprophylaxis, while 135 (study group) received mechanical thromboprophylaxis using an intermittent pneumatic compression device and graduated compression stockings from the time of admission until surgery. All patients received combined postoperative mechanical and chemical thromboprophylaxis following HFS in accordance with the same protocol. The incidence of symptomatic VTE confirmed based on clinical symptoms and 3-dimensional CT angiography within one month of surgery was investigated in both groups. Results The American Society of Anesthesiologists grade was higher (p = 0.016) in the study group and more patients in this group had concomitant cardiovascular and neurologic diseases (p = 0.005 and p = 0.009, respectively). In addition, more patients in the study group had received anticoagulant medication preinjury owing to comorbidities (39% vs 28%, p = 0.025). The overall incidences of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) were 7.4% and 3.7%, and 2.2% and 1.5% in the control and study groups, respectively. According to multiple logistic regression, symptomatic DVT significantly reduced in the study group (OR 0.28, p = 0.042), while there was no significant difference in the incidence of symptomatic PE between the two groups (p = 0.223). Conclusions Preoperative mechanical thromboprophylaxis may confer an additional benefit by preventing postoperative VTE without adding more risk of perioperative bleeding in elderly patients with hip fracture.

Postoperative fever after hemiarthroplasty in elderly patients over 70 years of age with displaced femoral neck fracture: Necessity of routine workup?

OBJECTIVESnDisplaced femoral neck fracture in elderly patients has been treated with hemiarthroplasty as the treatment of choice. Fever following HA is common in these elderly patients. The aim of this study was to determine which post-HA fever workup could be beneficial in this group of patients.nnnMETHODSnA total of 272 consecutive patients aged ≥70 years undergoing HA for displaced femoral neck fracture were retrospectively investigated. Postoperative fever (POF) was defined as any recorded body temperature ≥38°C in the early postoperative period. POF in each patient was characterized by the maximum temperature, the day of the first fever, and frequency of fever, stratified as either single or multiple fever spikes. Medical records were reviewed to identify positive fever workups and febrile complications.nnnRESULTSnOf 272 patients, 135 (49.6%) developed POF. A total of 428 routine diagnostic tests were performed in all patients with POF, of which only 57 tests (13.3%) were positive. Urinalysis showed the highest positive rate (21.9%), followed by urine culture (14.3%), chest x-ray (12.6%), and blood culture (1.1%). The most common febrile complication was pneumonia (12.6%), followed by urinary tract infection (8.1%). On multivariate logistic regression for positive workups, only fever after postoperative day (POD) 2 was a risk factor for positive chest x-ray (OR 3.86, p=0.016) and urine culture (OR 5.04, p=0.019). Moreover, fever after POD 2 (OR 6.93, p<0.0001) and multiple fever spikes (OR 2.92, p=0.026) were independent predictors of infectious febrile complications.nnnCONCLUSIONSnRoutine workup for POF following hemiarthroplasty in elderly patients with displaced femoral neck fracture is not warranted. However, for fever after POD 2 and multiple fever spikes, chest x-ray and urinalysis would be necessary to rule out the two most common febrile complications such as pneumonia and urinary tract infection.