Pavel Douša

Valgus intertrochanteric osteotomy for malunion and nonunion of trochanteric fractures

Objective To evaluate the results of valgus intertrochanteric osteotomy for varus nonunion and malunion of trochanteric fractures. Setting University hospital. Design Retrospective clinical study. Patients Fifteen patients (age range 29–84 years) with varus malunion (11 cases) or varus nonunion (4 cases). Indication for surgery was nonunion or varus malunion with limb shortening greater than 2 cm associated with limp, abductor muscle insufficiency, hip pain, and back pain. Intervention The patients were treated by a valgus intertrochanteric osteotomy fixed with a 120° double-angled blade plate. Results Average follow-up was 5.5 years (range 2–10 years). Fourteen patients healed without complications: 12 patients within 4 months; 2 delayed unions within 6 months. One patient required revision surgery for a loss of fixation due to a fall 6 weeks after surgery. This osteotomy also healed. Average lengthening achieved by osteotomy was 2 cm (range 1–5 cm). In all patients, the resulting range of flexion in the hip joint was greater than 90°, Harris hip score before surgery was 73 points (range 61–83), and after surgery 92 points (range 76–98). Osteoarthritis or avascular necrosis of the femoral head did not develop in any of the cases. Conclusion Valgus intertrochanteric osteotomy is an effective procedure that reliably restores hip function in trochanteric malunion or nonunion.

Avascular necrosis of the femoral head in pertrochanteric fractures: a report of 8 cases and a review of the literature.

Objective: To evaluate patients with pertrochanteric fractures (Type 31A1 + 2 ASIF/OTA classification) treated surgically and who subsequently developed avascular necrosis of the femoral head (ANFH). Setting: University hospital. Design: Retrospective clinical study and analysis of the literature. Patients: From 1995 to 2003 the authors operated on 1,373 patients with pertrochanteric fractures. Eight patients with a mean age of 69 years (range, 52-78 years) subsequently developed ANFH. Intervention: Five patients were treated with a dynamic hip screw (DHS), and 3 were treated with an intramedullary hip nail (IMHN). Results: All fractures in these 8 patients healed without complications in 3 to 4 months. Avascular necrosis of the femoral head developed 4 months to 4 years after the operation. Detailed analysis of these cases did not reveal any risk factors or errors in surgical technique to account for the ANFH. Results of a literature review of 41 cases in addition to our 8 cases give us reason to believe the etiology of postoperative AFNH following surgical treatment of pertrochanteric fractures is probable injury to the deep branch of the medial circumflex artery at time of fracture. Other possible risk factors include high-energy trauma, comminution, displacement of the fragments, and atypical fracture line. Conclusions: ANFH develops in approximately 0.5-1% of all pertrochanteric fractures, mostly within 4 years after the injury and predominantly in patients older than 50 years of age. The diagnosis should be considered in patients who have undergone an operation previously and have symptoms that are unclear. Prevention of ANFH in these fractures includes an early reduction, stable fixation, and correct surgical technique.

Ipsilateral fractures of the femoral neck, shaft and distal end: long-term outcome of five cases

Out of 52 cases of ipsilateral femoral fractures treated at a level I trauma centre between June 1994 and March 2008, the diaphyseal fracture was accompanied by a intracapsular neck fracture in only 20 cases. In the rest of the cases, the diaphyseal fracture was combined with either an extracapsular or pertrochanteric fracture. Five of these patients also had fractures of the distal femur. In three of those patients we began treatment with osteosynthesis of the femoral neck and shaft, using a reconstruction nail, then stabilized the distal fracture with a 95° blade plate or with lag screws. In the other two cases, initial treatment dealt with the distal femoral fracture, stabilizing it with a 95° blade plate, which was also used for stabilization of the diaphyseal fracture. In these patients, the proximal fracture was treated using dynamic hip screws (DHS). All fractures healed, two after initial treatment, while the other three needed one reoperation. The follow-up period was 2–13 years after the injury. The order in which fractures are treated is best left to the discretion of the physician and the circumstances. In our experience, two implants are sufficient for osteosynthesis, one for stabilizing one end of the femur together with the shaft, and the other is used for treating the other end of the femur.

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

OBJECTIVES The most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique. METHODS We prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1+2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail. RESULTS In total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p=0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p=0.028). CONCLUSION Unlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.

Anatomist and the pioneer of radiology Étienne Destot--95th anniversary of his death.

Destot was a leading pioneer in radiology, a pupil of Ollier, an anatomist, and researcher who followed in the experimental medicine tradition of Claude Bérnard. This work is an extensive, in depth, look at the life and work of Étienne Destot. On February 5, 1896, he began performing X‐ray examinations, less than two months after Roentgens discovery! His pioneering work described a space bordered by the hamate, capitate, triquetrum, and lunate; this space is now known as Destots space. Tanton stated that Destot was the first to reveal the mechanism of fractures of the posterior margin of the distal tibia and to emphasize their clinical relevance; in honor of this contribution, Tanton named such a fracture the “fracture of Destot.” Moreover, Destot is credited with being the first physician to use the term “pilon” in the orthopedic literature. He first described fractures of the scaphoid in 1905. He also described superficial hematomas, Destots sign, located above the inguinal ligament or in the scrotum or thigh. Such hematomas are indicative of pelvic fractures. Destot is credited with inventing or improving many pieces of medical equipment (e.g., Lambottes screw plates, anastomotic boutons for the digestive tube, monopolar endocavital radiological tubes). He was also active in developing technical aspects of equipment (e.g., radioscopic examination of the heart, a prototype of the mobile radiological laboratory). Étienne Destot is best known as a radiologist; however, his influence extends well beyond this field. He was an anatomist and surgeon, the founder of radiology in Lyon, prosector, physician, electrician, researcher, and artist. Clin. Anat. 27:282–285, 2014.