Ji Wan Kim

A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis.

Objectives: To compare the clinical and radiologic results of conventional open plating (COP) and minimally invasive plate osteosynthesis (MIPO) in the treatment of noncomminuted humeral shaft fractures. Design: Randomized prospective study. Setting: Five level 1 trauma centers. Patients: Sixty-eight consecutive patients were randomized into 2 study groups: those treated by COP (COP group; n = 32) and those treated by MIPO (MIPO group; n = 36). Intervention: Simple humeral shaft fractures (AO/OTA classification types A and B) were reduced by open reduction or closed reduction and fixed with a narrow 4.5/5.0 locking compression plate, metaphyseal locking compression plate, or proximal humeral internal locking system plate to the anterior lateral aspect of the humerus. Main Outcome Measurements: Fracture healing time, operative time, radiation exposure time, and intraoperative nerve injury. To assess shoulder and elbow function, we used the University of California, Los Angeles (UCLA) scoring system and the Mayo elbow performance index, including the range of motion and pain. Radiographic measurements included fracture alignment, delayed union, and nonunion. Results: Thirty-one fractures (97%) healed in the COP group within 16 weeks, whereas 36 fractures (100%) were healed in the MIPO group by 15 weeks. No significant difference was observed in the operative time or complication rates. In both groups, all fractures achieved union without malunion and with excellent functional outcomes by definition of the Mayo elbow performance index and UCLA scoring system. Conclusions: This study confirmed a high overall rate of union and excellent functional outcomes in both MIPO and COP groups. MIPO is equivalent to COP as a safe and effective method for simple types of humeral shaft fractures when surgery is indicated, and the surgeon is experienced in the technique. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Custom-made antibiotic cement nails: A comparative study of different fabrication techniques

INTRODUCTION The management of intramedullary long bone infections remains a challenge. Placement of antibiotic cement nails is a useful adjuvant to the antibiotic treatment of osteomyelitis. However, fabrication of antibiotic cement nails can be arduous. The purpose of this article is to introduce an easy and reproducible technique for the fabrication of antibiotics cement nails. MATERIALS AND METHODS We compared the time required to peel the chest tube off the 6 antibiotic cement nail using 2 different cement-cooling techniques and the addition of mineral oil in the chest tube. Additionally, we evaluated the optimal time to cut the chest tube (before and after cement hardening), consistency of nails diameter, and the roughness of its surface. Cooling and peeling times were measured and failure was defined as a working time (from cement mixing to have a usable antibiotic cement nail) that exceeded 1 h. RESULTS When the antibiotic cement nail was left to cool by convection (i.e. air-cooling), we failed to peel the plastic off the cement nail. When the chest tube was cut after conductive cooling (i.e. cold water-cooled), the cooling time was 10 min and the peeling time was 30 min without the use of mineral oil; the addition of mineral oil reduced peeling time to 7.5 min. Following peeling, residual adherent plastic pieces were found along the entire surface of the nail when no mineral oil was used. This was rarely seen when mineral oil was utilized to coat the inner layer of the chest tube. CONCLUSION Conductively cooling of the cement nail (in cold water) and pre-lubricating the chest tube with mineral oil are 2 tricks that render fabrication of antibiotic nail more efficient, reliable, and practical.

Current Role and Application of Teriparatide in Fracture Healing of Osteoporotic Patients: A Systematic Review

Background The use of osteoanabolic agents to facilitate fracture healing has been of heightened interest to the field of orthopaedic trauma. This study aimed to evaluate the evidence of teriparatide for fracture healing and functional recovery in osteoporotic patients. Methods We performed a literature search in PubMed, EMBASE, Web of Science, and the Cochrane Library using terms including “Fracture” [tiab] AND “Teriparatide [tiab] OR “PTH” [tiab]. Results This systematic review included 6 randomized clinical trials, 4 well-controlled retrospective studies, and 1 retrospective post hoc subgroup analysis. Fracture location was 2 in pelvis, 3 in proximal femur, 1 in distal femur, 1 in shoulder, 2 in wrist and 2 in spine. The use of teriparatide yielded positive effects on radiographic bone healing in 6 studies, but was not associated with better radiographic outcome in 3. In terms of functional recovery, teriparatide injection was related with decrease in pain or shorter time to mobilization in 6 studies, but not related with pain numerical scale and mobility in 3. Conclusions Our findings suggest that teriparatide provide selective advantages to fracture healing or functional recovery in the management of osteoporotic fractures. A better understanding of the role of teriparatide on osteoporotic fractures requires greater evidences from large volume prospective trials.

Challenge to treat hypertrophic nonunion of the femoral shaft: the Poller screw augmentation technique

The management of a femoral nonunion after intramedullary nailing is challenging. Exchange nailing or plate augmentation has been used to treat hypertrophic nonunions previously. The Poller screw augmentation technique is a simple procedure that can be performed in the outpatient surgery. In this study, we highlight the method of hypertrophic nonunion management according to the specific indication including our Poller screw augmentation technique.

Factors affecting fracture location in atypical femoral fractures: A cross-sectional study with 147 patients

INTRODUCTION Many studies have tried to determine the characteristics of atypical femoral fractures (AFFs) through age-, sex-, and ethnicity-matched comparison with non-AFFs. However, we hypothesized that diaphyseal AFFs would have characteristics different from those of subtrochanteric AFFs. The aim of this study was to evaluate the clinical features of diaphyseal/subtrochanteric AFFs and determine the factors related to fracture location. PATIENTS AND METHODS One hundred forty-seven patients with AFF were enrolled, 114 patients (78%) had a history of bisphosphonate use. Forty-nine patients (33%) had bilateral lesion, and 35% of patients had thigh pain. Patients were divided into two groups according to fracture location: 52 patients (35.4%) with subtrochanteric AFF and 95 patients (64.6%) with diaphyseal AFF. The patient demographics and fracture characteristics of the two groups were compared. Multivariate logistic regression analysis was used to adjust for variables related to fracture location. RESULTS The patients in the diaphyseal AFFs group were older and had lower BMI, lower BMD, and larger lateral and anterior bowing. Multivariate analysis revealed that age greater than 65 years and low BMD were related with diaphyseal location. With greater lateral bowing angle, the AFF location was moved from the subtrochanteric area to the diaphyseal area. CONCLUSION This study demonstrated that patients with diaphyseal AFFs had different characteristics compared with those with subtrochanteric AFFs.

Internal fixation of displaced inferior pole of the patella fractures using vertical wiring augmented with Krachow suturing

BACKGROUND We present the surgical technique of separate vertical wiring for displaced inferior pole fractures of the patella combined with Krachow suture and report the surgical outcomes. MATERIALS AND METHODS Between September 2007 to May 2012, 11 consecutive patients (mean age, 54.6 years) with inferior pole fractures of the patella (AO/OTA 34-A1) were retrospectively enrolled in this study. Through longitudinal incision, all patients underwent open reduction and internal fixation by separate vertical wiring combined with Krackow suture. The range of motion, loss of fixation, and Bostman score were primary outcome measures. RESULTS The union time was 10 weeks after surgery on average (range: 8-12). No patient had nonunion, loss of reduction and wire breakage. There was no case of wound problem and irritation from the implant. At final follow-up, the average range of motion arc was 129.4° (range: 120-140). The mean Bostman score at last follow-up was 29.6 points (range: 28-30) and graded excellent in all cases. CONCLUSION Separate vertical wiring combined with Krackow suture for inferior pole fractures of the patella is a useful technique that is easy to perform and can provide stable fixation with excellent results in knee function.

Does the OTA Open Fracture Classification Predict the Need for Limb Amputation? A Retrospective Observational Cohort Study on 512 Patients.

Background: Few studies have examined the utility of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) compared to the traditional Gustilo-Anderson classification for prediction of treatment outcomes in patients with open fractures. Questions/Objectives: (1) How do the Gustilo-Anderson classification and OTA-OFC systems compare in accuracy of predicting limb amputation, infection, and need for soft tissue coverage? (2) Is there an OTA-OFC summative threshold score that may guide the discussion and decision-making with regard to limb salvage or amputation? Design: Retrospective observational cohort study; Level IV evidence. Setting: Level I trauma center and urban safety-net institution. Patients/Participants: Consecutive adult patients with open long bone fractures who underwent operative treatment between January 1, 2007 and December 31, 2012. Main Outcome and Measurements: Postoperative complications of infection, early limb amputation, and requirement for soft-tissue procedures. Results: The study cohort comprised 512 patients with mean age 49.6 ± 14.9 years. Nineteen patients (3.7%) underwent amputation. The Gustilo-Anderson classification demonstrated no correlations with any of the primary outcome measures, while OTA-OFC summative scores significantly varied between all outcome comparison groups. The skin injury component of the OTA-OFC was an independent predictor of limb amputation (OR, 5.44; 95% CI, 2.37–12.47), and an OTA-OFC summative score of ≥10 best correlated with need for amputation (P < 0.001). Sensitivity and specificity of the reported model were 79% and 94%, respectively. Conclusions: Our results should be interpreted with caution due to the retrospective nature of our study. Based on our data, the OTA-OFC is superior to the Gustilo-Anderson classification system for prediction of postoperative complications and treatment outcomes in patients with open long bone fractures. A summative threshold score of 10 seems to identify increased odds of successful limb salvage.

Incidence of Avascular Necrosis of the Femoral Head After Intramedullary Nailing of Femoral Shaft Fractures: A Multicenter Retrospective Analysis of 542 Cases.

Abstract The goal of this study was to determine the incidence of avascular necrosis of the femoral head (AVNFH) after intramedullary nailing of femoral shaft fractures and to identify risk factors for developing AVNFH. We retrospectively reviewed all patients with femoral shaft fractures treated with antegrade intramedullary nailing at 10 institutions. Among the 703 patients enrolled, 161 patients were excluded leaving 542 patients in the study. Average age was 42.1 years with average follow-up of 26.3 months. Patient characteristics and fracture patterns as well as entry point of femoral nails were identified and the incidence of AVNFH was investigated. Patients were divided into 2 groups according to open versus closed physis, open versus closed fractures, and age (<20 versus ≥20 years). Overall incidence of AVNFH was 0.2% (1 of 542): the patient was 15-year-old boy. Of 25 patients with open physis, the incidence of AVNFH was 4%, whereas none of 517 patients with closed physis developed AVNFH (P < 0.001). The incidence of AVNFH in patients aged < 20 versus ≥20 years was 1.1% (1 of 93) and 0.0% (0 of 449), respectively (P = 0.172), which meant that the incidence of AVNFH was 0% in adult with femur shaft fracture. Of 61 patients with open fractures, the incidence of AVNFH was 0%. The number of cases with entry point at the trochanteric fossa or tip of the greater trochanter (GT) was 324 and 218, respectively, and the incidence of AVNFH was 0.3% and 0.0%, respectively (P = 0.412). In patients aged ≥20 years with isolated femoral shaft fracture, there was no case of AVNFH following antegrade intramedullary nailing regardless of the entry point. Therefore, our findings suggest that the risk of AVNFH following antegrade femoral nailing is extremely low in adult patients.

Fluoroscopic Views for a More Accurate Placement of Iliosacral Screws: An Experimental Study.

Objectives: Misperception on the fluoroscopic image showing a well-placed iliosacral (IS) screw can occur, when the screw is in reality misplaced. The purpose of this study was to demonstrate and highlight examples of misperception and suggest alternative inlet and outlet views to confirm adequate IS screw placement. Methods: We used 9 different pelvic plastic models. In 8 of those models, IS screws were purposely misplaced: exiting anterior at the midportion of the S1 body, exiting at the lateral aspect of the anterior S1 body, abutting posterior to S1 body, exiting posterior to the S1 body, exiting superior to the far-side of the sacral ala, exiting superior to the S1 body, exiting partially in the S1 foramen, exiting completely in the S1 foramen. One model was used as control with correct screw placement. Different outlet and inlet views were tested to accurately detect important anatomic landmarks and avoid fake phenomenon (FP) using 3 different angles. Results: Misperception occurred in 3 models: (1) penetration at the midportion of the anterior border of S1, (2) penetration of the superior sacrum ala, and (3) partial penetration of S1 foramen. In the first situation, misperception could be avoided when the “anterior inlet view” was obtained. In the other 2 situations, misperception could be avoided using specific outlet views herein described. Conclusions: Our findings highlight that misperception can occur using standard inlet and outlet views. We suggest using 2 variations of the inlet views and 3 variations of the outlet views to avoid misperception in clinical practice.

Pseudoaneurysm of the deep femoral artery caused by a guide wire following femur intertrochanteric fracture with a hip nail: A case report

An 85-year-old woman developed severe swelling and pain in the proximal thigh after internal fixation of an intertrochanteric fracture of the femur with a hip nail. In order to identify the causes and determine the effective treatment, angiography was performed. The results of the angiography revealed a pseudoaneurysm of a branch of deep femoral artery. Endovascular embolization was used to treat the pseudoaneurysm. After reviewing all possible causes, we found a mistake in insertion of a guide wire for hip nail. Using intraoperative fluoroscopic images, we found the mal-positioned guide wire located posterior to trochanter on lateral view of hip. This case study reminds us that pseudoaneurysm can occur in a guide wire during hip nailing. Surgeons can avoid this complication with confirmation of lateral and anteroposterior view of hip.