Kyu Hyun Yang

Pseudoaneurysm of the Superficial Femoral Artery After Closed Hip Nailing With a Gamma Nail : Report of a Case

Pseudoaneurysm of the femoral artery after internal fixation of a trochanteric fracture is caused primarily by overpenetration of the drill bit or screws. We report a case of pseudoaneurysm of the superficial femoral artery after insertion of a Gamma nail. A probable cause for this injury is adduction and internal rotation of the involved limb. During the distal interlocking procedure, this maneuver endangers the superficial femoral artery by abutment of the femoral vessels to the femur. It is recommended that the limb be placed in a neutral position during preparation of the interlocking hole.

Fracture of the ipsilateral neck of the femur in shaft nailing: THE ROLE OF CT IN DIAGNOSIS

We report retrospective and prospective studies to identify the causes of fracture of the femoral neck associated with femoral shaft nailing on the same side. Of a total of 14 neck fractures in a series of 152 shaft nailings, eight were not visible on the initial pelvic radiographs. We used CT scans before and after operation, and fluoroscopy during the procedure in our prospective series, and reviewed abdominal CT scans retrospectively with the window set to bone level. Six of the eight undisplaced fractures were shown to have been present before operation, but two were iatrogenic. We recommend the preoperative use of CT scans of the femoral neck in high-risk patients such as those with associated fractures of the acetabulum, the distal femur or the patella. Early diagnosis will allow better general management and early fixation of the neck fracture.

The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail.

BACKGROUND Reverse obliquity intertrochanteric fractures have been recognized as having unique anatomic and mechanical characteristics. Even though some clinical reports regarding intramedullary hip nailing for reverse obliquity intertrochanteric fracture show favorable results, there has been no clinical report of intramedullary hip nailing regarding the clinical significance of the lesser trochanteric fragment which differentiates Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31-A3.3 from A3.1 and A3.2. METHODS We retrospectively reviewed the clinical results of 46 cases of reverse obliquity or transverse intertrochanteric fracture treated with intramedullary hip nails. Twenty-five fractures were fixed with proximal femoral nail (PFN), and 21 fractures were fixed with intertrochanteric subtrochanteric nail. RESULTS Among 40 patients, followed up for more than 6 months, 22 31-A3.3 fractures (84.6%) out of 26 and all 14 A3.1 or A3.2 fractures were healed after the first operation. The complications were four cases of fixation failure and one case of femoral shaft fracture after fall. They occurred in the A3.3 type fracture, which were fixed with the PFN. The mean union time was longer in the A3.3 group (5.98 months, range 3-17 months) compared with that in the A3.1 or A3.2 group (4.65 months, range 3-9 months) (p = 0.048). Two cases of reciprocal migration of two screws (Z-effect) required exchange of the femoral neck screw to a shorter one in the PFN group. The amount of sliding of the femoral neck screw of the PFN (6.8 mm, range 0.3 mm-16.5 mm) was greater than that of the intertrochanteric subtrochanteric nail lag screw (1.89 mm, range: 0.2 mm-4.6 mm) (p = 0.012). Statistical analysis showed that the type of implant PFN, fracture subtype (31-A3.3), and old ages (more than 65 years old) significantly prolonged the union time (p < 0.05). CONCLUSION The lesser trochanteric fragment and posteromedial defect in 31-A3.3 fracture seems to play an important role in the stability after intramedullary hip nailing. The causes of fixation failure in the PFN group were associated with excessive sliding of femoral neck screw, which was aggravated by toggling motion in the 31-A3.3 fractures.

Tibial Lengthening Over an Intramedullary Nail with Use of the Ilizarov External Fixator for Idiopathic Short Stature

BACKGROUND The details regarding bone formation and complication rates associated with tibial lengthening over an intramedullary nail with use of the Ilizarov external fixator have not been reported, to our knowledge. The purpose of this study was to review our experiences with this procedure, performed in individuals with idiopathic short stature. In addition, we compared the results of lengthening over a nail, in terms of the observed bone formation and the complications, with those of the conventional Ilizarov method. METHODS Eighty-eight tibiae in forty-four individuals with a mean preoperative height (and standard deviation) of 153.7 +/- 7.2 cm were included in the study. Thirty-two tibial lengthening procedures were performed with the conventional method and fifty-six, with a nail. The increase in the length of the tibia, the external fixation index, the healing index, and complications were assessed. Three specific concerns, including mobility during the lengthening procedure, the time interval before the patient could return to previous activities after completion of the lengthening, and physical activities at the time of final follow-up, were also assessed. RESULTS The mean final height was 160.1 +/- 7.0 cm, and the mean gain in tibial length was 6.2 cm (20.0%). There was no difference in the mean gain in tibial length or the healing index between the groups; however, the external fixation index was lower and there were fewer complications per tibia in the group treated with the lengthening over a nail. The individuals treated with lengthening over a nail coped better with outdoor activities during the treatment period than the individuals treated with the conventional Ilizarov method; however, there was no difference in the time until the individual returned to previous activities or in the ability to carry out physical activities at the time of final follow-up between the groups. CONCLUSIONS Tibial lengthening with use of the Ilizarov external fixator over an intramedullary nail results in new bone formation of a quality equal to that obtained with the conventional Ilizarov method; however, it reduces the duration of external fixation and the rate of complications.

The Treatment of Nonisthmal Femoral Shaft Nonunions With IM Nail Exchange Versus Augmentation Plating

Objectives: The purpose of this study was to compare the results between exchange nailing (EN) and augmentation plating (AP) with a nail left in situ for nonisthmal femoral shaft nonunion after femoral nailing. Design: Retrospective data analysis, November 1996-March 2006. Setting: A level I trauma center. Patients: Eighteen patients with 18 nonisthmal femoral nonunions. Intervention: Seven patients with 7 fractures treated for nonisthmal femoral shaft nonunions after femoral nailing with EN and 11 patients with 11 fractures treated for nonisthmal femoral shaft nonunions after nailing with AP combined with bone grafting. Main Outcome Measure: Union and complications. Results: Five nonunions in the EN group failed to achieve union (72% failure rate), whereas all 11 pseudarthroses in the AP group obtained osseous union. Fisher exact test showed a higher nonunion rate of EN compared with AP for nonisthmal femoral shaft nonunion (odds ratio, 6.5; P = 0.002). Conclusions: AP with autogenous bone grafting may be a better option than EN for nonisthmal femoral nonunions.

Removal of a broken intramedullary nail with a narrow hollow

This report describes a technique for removal of a broken interlocking intramedullary nail with a small diameter and narrow hollow using a modified smooth guide wire.

Nonisthmal femoral shaft nonunion as a risk factor for exchange nailing failure.

Background: Although nail exchange with a larger diameter nail after additional reaming is typically considered the gold standard for failed femoral nailing, some reports question the role of exchange nailing. The purpose of this study was to evaluate the risk factors affecting the outcome of exchange nailing for femoral shaft nonunion after initial nailing. Methods: Forty-one consecutive patients treated with exchange nailing between November 1996 and March 2010 for femoral shaft nonunion that was initially managed with an intramedullary nailing were retrospectively reviewed. Possible risk factors and outcome (bony union) of exchange nailing were evaluated. Results: Of the 41 femoral shaft nonunions treated with exchange nailing, 9 (22%) failed to achieve bony union. The union rate for isthmal nonunions was 87% (27 of 31 cases) and for nonisthmal nonunions was 50% (5 of 10 cases). Univariate and multivariate logistic regression analyses demonstrated that the anatomic site (isthmal vs. nonisthmal) was a significant risk factor for exchange nailing failure (univariate, p = 0.021; multivariate, p = 0.016). Conclusions: Although exchange nailing is an excellent choice for aseptic isthmal femoral shaft nonunion occurring after the initial nailing, other treatment options such as augmentative plating should be considered for nonisthmal femoral shaft nonunions.

Detection of Prefracture Hip Lesions in Atypical Subtrochanteric Fracture with Dual-Energy X-ray Absorptiometry Images

PURPOSE To retrospectively assess how often and how early hip dual-energy x-ray absorptiometry (DXA) images show prefracture lesions in patients with atypical subtrochanteric fracture (ASF) and determine whether DXA images with assessment of prodromal symptoms could be used for early ASF prediction. MATERIALS AND METHODS The retrospective research protocol complied with HIPAA and was institutional review board approved, with waiver of informed consent. Among 62 women with ASF, nine without hip DXA images and seven without clear documentation of prodromal symptoms were excluded. Serial DXA images of 52 hips in 46 patients were included. Among them, 33 hips were assessed with ipsilateral DXA. For this ipsilateral group, each hip was assessed for prodromal symptoms and focal cortical changes in the lateral subtrochanteric femur cortex at DXA. Overall and cumulative detection rates for prodromal symptoms, DXA, and DXA with prodromal symptoms were measured and compared with a general linear model for overall detection rate and Cox proportional hazard models for cumulative detection rate. Thirty-three representative ipsilateral images and 199 images from subjects without fractures were reviewed in random order for prefracture lesions by three musculoskeletal radiologists independently, and the performance of DXA in ASF prediction was assessed. RESULTS Overall detection rates for DXA, prodromal symptoms, and DXA with prodromal symptoms were 61% (20 of 33), 42% (14 of 33), and 73% (24 of 33), respectively, in the ipsilateral group. Overall detection rate comparisons showed that DXA with prodromal symptoms was superior to prodromal symptoms alone (P = .0377). The cumulative detection rate curve for DXA with prodromal symptoms was also superior to that of prodromal symptoms alone (P = .0018). Sensitivity and specificity of DXA in ASF prediction ranged from 52% (17 of 33) to 58% (19 of 33) and 99% (197 of 199) to 100% (199 of 199), respectively. CONCLUSION Assessment of hip DXA images combined with conventional assessment of prodromal symptoms enables detection of more ASFs earlier than assessment based on prodromal symptoms alone.

Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research

Osteoporotic fractures are one of the most common causes of disability and a major contributor to medical care costs worldwide. Prior osteoporotic fracture at any site is one of the strongest risk factors for a new fracture, which occurs very soon after the first fracture. Bone mineral density (BMD) scan, a conventional diagnostic tool for osteoporosis, has clear limitations in diagnosing osteoporotic fractures and identifying the risk of subsequent fractures. Therefore, early and accurate diagnosis of osteoporotic fractures using the clinical definition which is applicable practically and independent of BMD, is essential for preventing subsequent fractures and reducing the socioeconomic burden of these fractures. Fractures caused by low-level trauma equivalent to a fall from a standing height or less at major (hip, spine, distal radius, and proximal humerus) or minor (pelvis, sacrum, ribs, distal femur and humerus, and ankle) sites in adults over age 50, should be first regarded as osteoporotic. In addition, if osteoporotic fractures are strongly suspected on history and physical examination even though there are no positive findings on conventional X-rays, more advanced imaging techniques such as computed tomography, bone scan, and magnetic resonance imaging are necessary as soon as possible.

Indications and outcomes of augmentation plating with decortication and autogenous bone grafting for femoral shaft nonunions.

INTRODUCTION Though augmentation plating (AP) with decortication and bone grafting (BG) reportedly has excellent outcomes for femoral shaft nonunions, there are no established indications of AP with decortication and BG. The purpose of this study was to evaluate the results of AP with decortication and autogenous BG for femoral shaft nonunions, focussing on the indications of AP with decortication and BG. METHODS Thirty-nine patients treated with AP combined with decortication and BG for femoral shaft nonunions after femoral nail failure between November 1996 and October 2010 were retrospectively reviewed. Indications of AP with decortication and BG at the time of surgery and outcomes (bony union) were evaluated. RESULTS The mean follow-up duration was 24.8 months (range 12-81 months). Thirty-eight (97%) of 39 femoral shaft nonunions achieved bony union. One incompliant patient showed screw breakage, which was healed uneventfully with subsequent cast application. The mean time to union was 6.1 months (range 3-16 months). Primary indications at the time of surgery were nonisthmal femoral nonunions in 17 patients, isthmal nonunions in 10 patients (cortical bone defect in five and widened canal in five), failed exchange nail in seven patients, nonunions with malrotation in two patients and difficult removal in three patients. CONCLUSIONS AP with decortication and autogenous BG is a good option for nonisthmal femoral shaft nonunions, such as supra-isthmal and infra-isthmal nonunions. In addition, this option is useful for selected cases of isthmal femoral shaft nonunions in which failure of exchange nailing is expected due to lack of a tight fit between the new larger nail and femoral cortices.