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The present study examined the effect of rehabilitation exercises with BFR in improving muscle strength, thigh muscle hypertrophy, and knee joint flexibility for those with double fractures in the lower body. Methods: 6 volunteer subjects (average age 44 (40-50) years) were randomized into one group that trained in restriction of blood flow period eight weeks. Participants were familiar with all testing and exercise protocols before starting the study. Rehabilitation exercises with BFR were done before and after--form for each player to record the sequence measurements. Quadriceps circumference measurement (cm), the range of motion of the knee joint, and Quadriceps muscle strength measurement were performed on the participants. Independent samples t-test was used to compare the scores obtained from the measurements according to categorical variables. The significance level was determined as P 0.05. Results: Thigh circumference (cm) There was a significant increase in thigh circumference from before the experiment (41.17 cm) to after the investigation (45.33 cm) (p<0,001). There's a remarkable development in post-test measurements (13.97 kg), (p<0,000) compared to pre-test measurements (8.83 kg), indicating an improvement in quadriceps strength. Hamstring strength (kg) in the post-test measurement (10.17 kg) demonstrated a remarkable development compared to the pre-test measurement (7.5 kg) (p<0,003). The post-test measurement (24.5 degrees) showed significant development compared to the pre-test measurement (60.83 degrees) (p<0,000), suggesting an improvement in the range of motion of the flexed knee joint. In conclusion, it shows that blood flow restriction is a safe and effective treatment for people with multiple fractures. [ABSTRACT FROM AUTHOR]

Background: Posterolateral corner (PLC) knee injuries associated with different injury mechanisms are not well known. Purpose/Hypothesis: This study sought to assess the patterns of associated injuries in the setting of PLC injury. The hypothesis was that there are recognizable injury patterns in PLC injuries that may correlate with injury mechanism. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients who sustained a multiligament knee injury were retrospectively reviewed. Patients who sustained an acute grade 3 PLC injury and underwent surgery were enrolled in this study. A description of the PLC injury (location of the injury of the fibular collateral ligament [FCL], popliteus tendon, and/or popliteofibular ligament) and reported concomitant injuries (biceps femoris tendon or meniscal tears, cartilage pathology and/or peroneal nerve palsy, or bone bruises) were collected and classified based on intraoperative and magnetic resonance imaging (MRI) findings. Results: Of 135 patients reviewed, 83 did not have PLC involvement and 13 were excluded due to insufficient MRI scans available. Thus, 39 patients were included in this study. For both the anterior cruciate ligament (ACL)–PLC and ACL–posterior cruciate ligament–PLC injury patterns, the most frequent injury pattern entailed a bone bruise of the anteromedial (AM) femur and tibia, an FCL tear from the fibular head, the popliteus tendon avulsed off the femur, a biceps femoris tendon torn off the fibular head, and a common peroneal nerve palsy. Conversely, when no bone bruise occurred on the AM femur and tibia, the FCL was injured on the femoral side and the popliteus tendon, biceps femoris, and peroneal nerve were not injured. Conclusion: AM bone bruise was associated with a peroneal nerve injury in almost half of the patients, and peroneal nerve injury was not seen if there was no AM bone bruise. [ABSTRACT FROM AUTHOR]

Background: In Austria around 100 trams are involved in accidents with pedestrians every year. Since the service lives of trams are very high, the probabilities are also high that each tram on the network will be involved in an accident of this kind at least once, highlighting the need of protective designs of tram fronts. However, due to lack of studies in this area, this is still a challenging task. Purpose: The aim of this study is to show the applicability and the usability of virtual testing involving HBMs in tram front design studies to improve passive safety in general. Methodology: In this study, the impact of pedestrians with a tram was investigated using a generic tram front model in a basic version and a conceptually improved version, respectively, and detailed finite element human body models (HBM). To consider gender-differences and to avoid designs that unintentionally favour only particular groups of the population, the study simulations were carried out with a male and a female 50th percentile finite element human body model (VIVA+). The risk for head, chest, femur and tibia injuries were analysed as the simulation result, since these body areas were identified based on field data to be most relevant in accidents involving pedestrians and trams. Collision scenarios are evaluated for a wide parameter variation in impact location and speed, respectively. Findings: The results show a reduction in head injury risk for both the female and the male HBM at different speeds and impact locations for impact with the enhanced version of the tram front. Depending on the gender of the HBM, the considered improvement shows different effects for each body region, with a greater reduction in the likelihood of head injury for the female model, and a greater reduction in the likelihood of thoracic injury for the male model. These differences are due to the considered anthropomorphic variations. A reduction for the risk of femur injuries can be achieved in all cases using the modified tram front. The study showcases the application of detailed human body models for tram pedestrian impact analyses in the context of pedestrian safety and in particular for tram front improvements. It was shown that even a minor modification of the tram front with softer front skirt attachments leads to remarkable benefits with respect to injury criteria in all investigated crash scenarios. The presented research goes beyond current technical recommendations and shows the benefit of virtual testing including HBMs and considering a wide variety of impact speeds, anthropometries and injury assessments, respectively. [ABSTRACT FROM AUTHOR]

Introduction: With rapid industrialization and modernization rate of road traffic accidents has also increased concomitantly which has inadverantly increased rate of musculoskeletal injuries. In all these injuries supracondylar femur fracture contributes 1% of all the fractures and 3-6% of all femur fractures. In young patients the main reason is due to high energy trauma whereas in elderly this occurs due to trivial trauma attributed to osteopenia. Despite of various treatment modalities these fractures still possess a great challenge in front of orthopaedics surgeons. Method & Material: we conducted the study from March 2021 to Feb 2022 on 25 patients arrived at M.Y hospital emergency room with 13 of them treated with RN, while 12 are treated with locking plate. Patients were followed up for 6 months. Muller classification system was used to classify this fracture with only type A1-3 were taken into consideration. Results: KOOS scoring system was used to evaluate final outcome at the end of 6 months follow up which demonstrated that in RN group 3 cases were excellent, 7 were good, 2 were fair while 1 was poor. In LP group 2 were excellent, 4 were good, 4 were fair while 2 were poor. Over 90% fracture healed before 6 months with average time of union for RN and LP group being 17 weeks and 21 weeks respectively. Conclusion: Retrograde nailing and plating both provide an excellent means of treating such fracture. Early fracture healing, less intraop blood loss, less operative time were some advantages beared by RN group but it was also associated with more incidence of anterior knee pain. Both the method allows fracture healing with statistical significance. However, this difference was seen in both the group can be explained as more complex/communited fractures were treated with plating. At last, both the procedure requires proper planning and execution so as to get desirable result. [ABSTRACT FROM AUTHOR]

Background: Pertrochanteric fractures are a common problem with an increasing incidence specially among old age groups. Objectives: Accurate realignment, rigid fixation, decreasing comorbidities during surgical intervention is the main goal during treatment of these fractures as well as early mobilization Evaluation the results of Gamma nail in treatment unstable trochanteric fracture . Patients & Methods: This is a prospective study included 18 patients with ages ranged from (53 to 78 years with mean (65.11 years) with closed unstable trochanteric fractures managed between September 2017 and February 2019 at Zigzag university hospital and Zliten teaching hospital fixed with gamma nail. Results: This study that Gamma nail provides a good choice of treatment of per trochanteric fractures. Younger patients recover better than older patients72.2% were satisfactory (good & excellent) and 27.8% were unsatisfactory (poor& fair) results according to Harris hip score at last postoperative follow up, Conclusions: Gamma nail provides a biomechanically stable construct, proved by minimal or negligible incidence of implant-related failures. [ABSTRACT FROM AUTHOR]

Open wounds pose major infection and mortality risks in animals. 1,2 To reduce these risks, many animal species apply antimicrobial compounds on their wounds. 1,2,3,4 Ant societies use antimicrobial secretions from the metapleural gland to combat pathogens, 5,6,7,8,9,10 but this gland has been lost over evolutionary time in several genera, including Camponotus. 11 To understand how infected wounds are handled without the use of antimicrobial secretions from the metapleural gland, we conducted behavioral and microbiological experiments in Camponotus floridanus. When we experimentally injured a worker's leg at the femur, nestmates amputated the injured limb by biting the base (trochanter) of the leg until it was severed, thereby significantly increasing survival compared to ants that did not receive amputations. However, when the experimental injury was more distal (at the tibia), nestmates did not amputate the leg and instead directed more wound care to the injury site. Experimental amputations also failed to improve survival in ants with infected tibia injuries unless the leg was amputated immediately after pathogen exposure. Micro-CT scans revealed that the muscles likely responsible for leg hemolymph circulation are predominantly in the femur. Thus, it is likely that femur injuries, by attenuating hemolymph flow, provide sufficient time for workers to perform amputations before pathogen spread. Overall, this study provides the first example of the use of amputations to treat infected individuals in a non-human animal and demonstrates that ants can adapt their type of treatment depending on the location of wounds. • Ants amputate injured legs of nestmates to improve their survival • Amputations increase survival for femur injuries but not tibia injuries • Pathogen spread is slower in femur injuries than the more distal tibia injuries • Ants are capable of differentiating wound type and adapt their treatment accordingly Frank et al. provide the first example of the use of amputations to treat infected leg wounds in a non-human animal. The findings demonstrate that ants can adapt their treatment modality depending on wound location. [ABSTRACT FROM AUTHOR]

A recent study conducted by biologist Erik Frank and his colleagues at the University of Würzburg has discovered that Florida carpenter ants have a unique way of responding to injury. Unlike most ant species that coat the injured limb of a comrade with an antimicrobial substance, these ants amputate the limb entirely. This surprising tactic is believed to prevent the spread of bacterial infections within the colony. The researchers found that ants who underwent this "surgery" had a significantly higher survival rate compared to those who were left alone. The study suggests that ants have evolved sophisticated behaviors similar to humans, challenging the perception of ants as disposable soldiers. [Extracted from the article]

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Purpose: This study aimed to conduct arthroscopic evaluation of cartilage electromechanical properties and establish their correlation with International Cartilage Repair Society (ICRS) grading scores., Methods: In 18 patients, quantitative parameter (QP) measurements were taken on the weight-bearing surface of the medial femoral condyle. Adjacently, the same site was graded using ICRS scores (0-4). Electromechanical QPs for ICRS grades 0 to 3 were obtained during arthroscopy, while complete grade 4 injuries were assessed using femur cartilage-bone blocks from knee arthroplasty. The QP values for ICRS grades 0 to 2 were compared with grades 3 and 4 using Welch t test. The corresponding QP values were assigned to ICRS grades 0 to 4 and compared using Welch ANOVA (analysis of variance). Pearson's coefficient evaluated QP-ICRS grade relationship., Results: Healthy grade 0 cartilage displayed a mean QP value of 10.5 (±2.8 SD, n = 4). The ICRS grade 1 and grade 2 injuries were associated with QP values of 12 (±0.7, n = 2) and 13.25 (±1.77, n = 2), respectively. The grade 3 defects had QP values of 20.43 (±4.84, n = 4), whereas complete grade 4 defects showed electromechanical values of 30.17 (±2.19, n = 6). Significant differences in QP values were observed between ICRS grades 0 to 2 (mean QP 11.56 ± 2.3, n = 8) and grades 3 and 4 (26.27 ± 6, n = 10; P < 0.0001). Pearson's correlation coefficient of 0.9 indicated a strong association between higher ICRS cartilage injury grades and elevated QP values ( P < 0.0001)., Conclusion: Arthroscopic electromechanical QP assessment robustly correlates with ICRS scores. The QP values for ICRS grades 0 to 2 are significantly lower, compared with grades 3 and 4., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Proximal femoral fracture segmentation in computed tomography (CT) is essential in the preoperative planning of orthopedic surgeons. Recently, numerous deep learning-based approaches have been proposed for segmenting various structures within CT scans. Nevertheless, distinguishing various attributes between fracture fragments and soft tissue regions in CT scans frequently poses challenges, which have received comparatively limited research attention. Besides, the cornerstone of contemporary deep learning methodologies is the availability of annotated data, while detailed CT annotations remain scarce. To address the challenge, we propose a novel weakly-supervised framework, namely Rough Turbo Net (RT-Net), for the segmentation of proximal femoral fractures. We emphasize the utilization of human resources to produce rough annotations on a substantial scale, as opposed to relying on limited fine-grained annotations that demand a substantial time to create. In RT-Net, rough annotations pose fractured-region constraints, which have demonstrated significant efficacy in enhancing the accuracy of the network. Conversely, the fine annotations can provide more details for recognizing edges and soft tissues. Besides, we design a spatial adaptive attention module (SAAM) that adapts to the spatial distribution of the fracture regions and align feature in each decoder. Moreover, we propose a fine-edge loss which is applied through an edge discrimination network to penalize the absence or imprecision edge features. Extensive quantitative and qualitative experiments demonstrate the superiority of RT-Net to state-of-the-art approaches. Furthermore, additional experiments show that RT-Net has the capability to produce pseudo labels for raw CT images that can further improve fracture segmentation performance and has the potential to improve segmentation performance on public datasets. The code is available at: https://github.com/zyairelu/RT-Net.

Objective: To compare the clinical efficacy of the posterior hemipelvectomy of the greater trochanter approach with the standard Kocher-Langenbeck(K-L) approach in the treatment of posterior acetabulum wall fractures and to explore a more optimal approach for the treatment of posterior acetabulum wall fractures., Methods: Total of 26 patients with posterior acetabulum wall fractures were retrospectively analysed and divided into two groups:the posterior hemipelvectomy of the greater trochanter group (test group) and the standard K-L approach group (control group). In the test group, there were 24 patients including 16 males and 8 females with an average age of (42.00±4.52) years old, the time of injury to surgery was (6.75±1.15) d. In the control group, there were 23 patients including 16 males and 7 females with an average age of (41.00±5.82) years old, the time of injury to surgery was (7.09±1.20) days. The total hospital stay, length of incision, operation time, intraoperative bleeding, postoperative drainage, discharge, fracture reduction quality (Matta criteria), hip abduction muscle strength, hip function (Merle d'Aubigne-Postel score), postoperative complications and the incidence of ectopic ossification were compared., Results: All cases were followed up for 6 months. There was no significant difference in incision length, intraoperative bleeding and postoperative drainage between two groups( P >0.05). However, the operation time of the test group was shorter than that of the control group ( P <0.05). There was no statistically significant difference in fracture reduction and hip function between two groups ( P >0.05). The hip abduction muscle strength of test group was better than that of control group( P <0.05). In addition, there was no significant difference in the incidence of postoperative complications and heterotopic ossification between two groups( P >0.05)., Conclusion: Compared with the standard K-L approach, the posterior hemipelvectomy of the greater trochanter approach can shorten the operative time, has better recovery of the postoperative hip abduction muscle strength, exposes the view of the fracture involving the more comminuted posterior acetabulum wall or the fracture of the roof of the socket, improved the rate of fracture anatomical repositioning, provides a new idea for the clinical treatment of posterior acetabulum wall fractures, and allows patients to perform functional exercises at an early stage.

Purpose: To develop and assess three-dimensional models of physeal fractures in dog femurs (3D MPFDF) using radiographic imaging., Methods: The study was conducted in three phases: development of 3D MPFDF; radiographic examination of the 3D MPFDF; and comparative analysis of the anatomical and radiographic features of the 3D MPFDF., Results: The base model and the 3D MPFDF achieved high fidelity in replicating the bone structures, accurately maintaining the morphological characteristics and dimensions such as length, width, and thickness, closely resembling natural bone. The radiographs of the 3D MPFDF displayed distinct radiopaque and radiolucent areas, enabling clear visualization of the various anatomical structures of the femur. However, in these radiographs, it was challenging to distinguish between the cortical and medullary regions due to the use of 99% internal padding in the printing process. Despite this limitation, the radiographs successfully demonstrated the representation of the Salter-Harris classification., Conclusions: This paper presents a pioneering project focused on technological advancement aimed at developing a method for the rapid and cost-effective production of three-printed models and radiographs of physeal fractures in dogs.

Background: Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established., Purpose: To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures., Study Design: Cross-sectional study; Level of evidence, 2., Methods: A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions., Results: A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence ( P = .17) or grade ( P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations ( P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001)., Conclusion: This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.W.G. has received consulting fees from Arthrex, intellectual property royalties from Arthrex and Pega Medical, and speaking fees from Synthes. B.E.H. has received support for education from Arthrex, Kairos Surgical, and Pylant Medical, and owns stock options in Imagen Technologies. J.M.B. has received consulting fees from Miach Orthopaedics, compensation for services other than consulting from Smith+Nephew, and support for education from Arthrex and Steelhead Surgical. S.N.P. has received consulting fees from Pfizer, support for education from CDC Medical, and compensation for serving as a faculty member or speaker from Synthes. B.E.S.S. has received consulting fees from Arthrex and research support from ConMed; her spouse has received consulting fees and royalties from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Dismemberment and subsequent burning are common methods employed in an attempt to conceal or destroy evidence. While kerf characteristics can be utilised to identify tool(s) used for dismemberment, further research is necessary to assess the effect of burning on these characteristics. In this study, a back (tenon) saw (13 teeth per inch) was used to manually inflict trauma on Ovis aries de-fleshed femur bones (n = 18). Three different cut marks (shallow false start, incomplete cut and complete transection) were made on the mid-shaft of each bone. Subsequently, the bones were burned for 20 minutes in a muffle furnace. Three burn temperatures were assessed: 400 °C, 600 °C and 800 °C. Saw mark characteristics of each cut type were assessed and compared pre- and post-burning. All pre-existing trauma was recognisable post-burning; however, metric and morphological alterations were apparent. An increase in kerf width was observed at 600 °C in false start lesions and 800 °C in incomplete cuts. Breakaway spur thickness decreased post-burning (at 400 °C and 800 °C) but length was not significantly affected. Mean inter-striation distance decreased post burning at all temperature groups. Saw marks were distinguishable from heat-related fractures across all temperature groups. One false start lesion was obliterated at 800 °C. Exit chipping, pull-out striae as well as striation regularity appeared to be more enhanced after heat exposure. These alterations indicate a temperature-dependent impact on these characteristics. Further research is necessary to assess the role of burn duration., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: This study aimed to assess the efficacy of adipose-derived mesenchymal stem cell exosomes (ASCs exosome) and platelet-rich fibrin (PRF) in treating critical long bone defects in Sprague-Dawley rats. Critical long bone defects, defined as exceeding 2 cm or 50% of the bone diameter, often pose a healing challenge. While autologous bone grafts have been considered, they have shown unreliable results and donor-site complications, necessitating alternative treatments., Methods: The research followed a quasi-experimental post-test only control group design involving 30 male Sprague-Dawley rats. The rats were divided into five groups and subjected to femur bone defect creation, internally fixed with a 1.4 mm K-wire, and treated with various combinations of hydroxyapatite (HA), bone graft (BG), ASCs exosome, and PRF. Histomorphometry and BMP-2 gene expression analysis were performed to evaluate bone healing., Results and Discussion: The results indicated that the group treated with HA + BG + ASCs exosome (group IV) exhibited the highest BMP-2 gene expression, while group III (HA + BG + ASCs exosome + PRF) had the highest chordin level. Overall, groups receiving ASCs exosome or PRF intervention showed elevated BMP-2 expression compared to the control group. The use of ASCs exosome and PRF showed comparable outcomes compared to bone graft administration in terms of histomorphometry analysis., Conclusion: The administration of adipose tissue derived mesenchymal stem cells and PRF has a comparable outcome with the use of bone graft in terms of osseus area and expression of BMP-2 in critical bone defect., (© 2024. The Author(s).)

Distal femur physeal arrest due to physeal bar formation with progressive deformities is an unwanted complication following injury to the femur. Various techniques of physeal bar resection, either using open techniques or endoscopic methods, have been described in the available literature. The associated angular deformities could be addressed either with osteotomy in acute correction or gradual correction with an external fixator or guided growth principle. We would like to recommend the use of fat tissues from the surgical wound used for the guided growth and evaluation of the recurrence of the physeal bar via computed tomography in our case. To our knowledge there is no previous reports using similar approach. We shall share case of a severely comminuted distal femoral physeal injury Salter-Harris IV complicated with central physeal bar causing growth disturbance and angular knee deformity treated via endoscopic resection surgery and simultaneous 8-plate insertion for which has shown a good radiological and functional outcome. [ABSTRACT FROM AUTHOR]

Lower extremity injuries in AIS2+ were the most costly injuries through the statistical analysis of traffic accidents. This study aimed to investigate the response characteristics of the lower limb with different contact stiffness, in which knee cushion and foot cushion were applied. First, a model with a human body and a car was established, and the muscle function was activated in lower extremity of human model. Second, the deceleration pulse with a peak of 186 m/s² was applied to the car to simulate the frontal crash. Then, four sets of simulations with different contact stiffness are conducted to obtain the lower limb responses. Results indicate that the maximum loading of the left and right legs during the impact was 1.29 and 1.22 kN, respectively. Meanwhile, the maximum moment were 28.82 and 52.17 Nm, respectively. The maximum stress of lower extremity was 87.35 MPa, and the maximum tibia index was 0.230. It was demonstrated that the injury risk of the femur in the groups with equipment of knee cushion and foot cushion was low, but the injury risk of the tibia increased at the same time. This study could provide a reference to the study of lower limb injury in a frontal impact. [ABSTRACT FROM AUTHOR]

This study aimed at investigating the femur injury mechanisms and femur injury tolerance limit in combined axial force and bending moment. A finite element (FE) model of the lower extremity in sitting posture was developed and validated against femur three-point bending dynamic test and axial impact test of knee-thigh (KT) complex. Following, the femur fractures in combined compression–bending load were analysed via using an analytical model of the curved beam. At last, six virtual simulation tests were conducted by using the developed femur FE model. Moreover, the femur fracture mechanism was analysed in terms of the fracture location and the calculated failure bending moments from both the analytical and FE models. The results revealed that with the increasing of preload bending moment from 0 to 676 Nm, the femur fracture location transferred from the femoral neck region to the femoral shaft region. In the two simulation tests of femur fractures in femoral neck regions, the peak value of femur bending moment were 285 and 296 Nm, respectively. In the other four tests with femur fractures occurred in shaft region, the fracture femur moment varied from 381 to 443 Nm. The results demonstrated that the occupant femur fracture location and femur fracture tolerance limit were affected by both bending moment and axial compression loads. This study can provides an explanation for the phenomenon that the high prevalence of femoral shaft fractures occurs in real-world car frontal impacts when the axial loads lower than that used in the current injury tolerance of femur. [ABSTRACT FROM AUTHOR]

Purpose: Proximal femoral bone stress injuries (BSI), especially those involving the femoral neck (FNBSI), pose a risk to military medical readiness. There is currently no optimal physical examination technique or test item cluster that substantially influences the clinical diagnosis of FNBSI. Consequently, a lower threshold to order diagnostic imaging is employed by clinicians who manage military populations at risk for FNBSI. A viable physical examination technique or cluster of techniques is needed to better inform this clinical decision process and reduce the associated diagnostic imaging burden. This project assessed the perceived clinical utility of several novel physical examination techniques intended to identify proximal femoral bone stress injuries. Methods: Thirteen FNBSI-specific physical examination techniques were evaluated using standardized grading criteria, evaluating safety, reliability, and credibility. Based on group consensus, two weight-bearing techniques-- forward lunge and tap (FLT), rear lunge reach and tap (RLRT)--and three non-weight-bearing technique--proximal femoral shear test, 45-degree compress and percuss, and the side-lying scissor test--were each determined to possess a parsimonious cluster of desirable examination properties. A one-hour, multimedia presentation accompanied by live demonstrations was presented to 13 clinicians. Each clinician rated the physical examination techniques based on the following five criteria: patient safety, likely to identify only bone pathology, accuracy regardless of symptom duration or acuity, performed in the mid-range of available motion, and reliability. These criteria were individually weighted from 1 (strongly disagree) to 5 (strongly agree), yielding a possible maximum score of 25. Each physical examination technique was also given a yes or no rating for overall credibility. The minimum acceptable value was set a priori at 80% yes votes. Results: All clinicians in attendance were physical therapists with an average of 5.9 (SD: 4.4) years of experience managing patients with FNBSI. All attendees either agreed or strongly agreed all techniques would be safe to use with patients suspected of having a FNBSI. The highest overall scoring test based on the five criteria was the FLT with a score of 21. The only two tests to exceed the 80% benchmark for overall credibility were the FLT (92.3%) and the RLRT (83.3%). There were no overall statistically significant differences within each individual criterion except for the safety criterion. However, post hoc pairwise comparisons revealed no statistically significant differences. Conclusions: A minimum of two of the novel physical examination techniques (FLT, RLRT) appear to have sufficient credibility to warrant further evaluation based on voting results from an experienced group of clinicians. A concurrent criterion validity study to assess the diagnostic accuracy properties associated with these techniques is now indicated. Clinical Relevance: This line of research may assist future clinicians to determine the need for diagnostic imaging procedures in patients with a suspected FNBSI. [ABSTRACT FROM AUTHOR]

Intramedullary (IM) nailing is the standard of care for adult lower extremity long bone fracture stabilisation. Key to this procedure is obtaining the correct entry point and trajectory for initial guide pin insertion. This work presents the Femoral Antegrade Starting Tool (FAST), a surgical tool that addresses the lack of connectivity in utilising sequential 2D fluoroscopic images to achieve 3D alignment of femoral guide pin placement. The user centred design and development of FAST is introduced and the performance of this device evaluated during guide pin insertion for femoral IM nailing in a series of sawbones and cadaveric models leading to a first in human clinical cohort study. The results demonstrated the potential of FAST to improve time and consistency of the guide pin insertion for femoral IM nailing for less experienced surgeons and trainees. Overall, FAST was found to be easy to use with a high degree of clinical interest (particularly for use in large patients) and acceptance motivating continued development of this new technology. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY The intertrochanteric femur fractures seen in the elderly population are usually treated surgically. Mechanical failure of this treatment is a serious complication and to prevent this, many assessment factors have been described such as tip-apex distance, reduction quality etc. The aim of this study is to evaluate the intra- and inter-observer reliability of modifiable factors evaluated after the treatment of intertrochanteric fractures. MATERIAL AND METHODS The early post-operative radiographs of sixty-two patients treated with PFN-A were evaluated. Six observers with 8 to 27 years of experience in hip trauma surgery were asked to measure tip apex distance (TAD), calcar referenced TAD (calTAD), collo-diaphyseal angle (CDA) and evaluate the position of helical blade and also fracture reductions according to Baumgaertner and Chang criteria on these radiographs. Fleiss kappa and intra-class correlation coefficient (ICC) values were calculated for inter-observer and intra-observer reliability assessment, respectively. RESULTS Inter-observer reliability values for both evaluations were moderate (fleiss κ: 0.417–0.455) for TAD measurements, moderate (fleiss κ: 0.418–0.458) for calTAD measurements, fair (fleiss κ: 0.302–0.288) for CDA measurements, substantial (fleiss κ: 0.606–0.631) for antero-posterior zone evaluation, moderate (fleiss κ: 0.550–0.546) for lateral zone assessment, fair-moderate (fleiss κ: 0.353–0.453) for Baumgaertner reduction quality assessment, and fair-moderate (fleiss κ: 0.365– 0.456) for Chang reduction quality assessment. Intra-observer reliabilities were found to be moderate to good for TAD and calTAD measurements, moderate for CDA measurements, good to excellent for AP and lateral zone and Baumgaertner reduction quality criteria assessments and good for Chang reduction quality criteria assessment. DISCUSSION There is no large data on the subject of the present study in the literature. There is a single article evaluating the reliability of more than one evaluation criteria in which only two observers’ findings were evaluated in the literature. As in our study, more accurate inferences can be made with the increase in the number of observers. Unlike the literature, the inter-observer reliabilities of TAD and calTAD which have a very important place in the postoperative evaluation of these fractures were found as “moderate’’ instead of “excellent’’ in our study, CONCLUSIONS It was determined that only the inter-observer reliability of antero-posterior zone evaluation was substantial. The inter-observer reliability of all other measurements and evaluations were fair to moderate. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY Exploring the therapeutic potential of pathological fractures treatment of the proximal femur in childhood with LCP paediatric hip plate system according to the principles of AO. MATERIAL AND METHODS Six children with pathological fractures of the proximal femur and with an unicameral bone cyst have undergone surgery in our institution, in the period between June 2018 up until December 2020. All patients were young boys with a mean age of 11.83 ± 3.43 years. According to the classification of Delbet-Colonna, three of the fractures were Type IV – intertrochanteric fractures and three were Type III – basocervical fractures. ccording to the AO Trauma classification, one of the fractures was complete transtrochanteric multifragmentary (31–M/3.2.III), two were complete transtrochanteric simple (31-M/3.1.III), one was Complete basocervical multifragmentary (31-M/3.2.II) and two were complete basicervical simple (31-M/3.1.II). All patients have undergone open reposition and osteosynthesis with a 130° LCP pediatric hip plate system (DePuy Synthes Pediatric LCP Plate System). In four of the patients, one or two of the proximal locking screws pass through the growth plate, to ensure more stability. The anatomical correction of the proximal femur has been measured through the cervico-diaphyseal angle, consolidation of the fracture, the spontaneous reparation of the cyst according to the Capanna classification and cystic index, presence of avascular necrosis of the epiphysis, shortening of the extremity, and functional grading by the Musculoskeletal Tumor Society (MSTS) staging system. The Mann-Whitney (Wilcoxon W) test was used for data processing. RESULTS The mean timing of the follow-up after the surgery was 22 months (range 6–32). A radiographically supported consolidation of the fracture has occurred at an average timing of 4.8 months (range 3–6) in all patients. There is no clinical or radiological evidence of postoperative avascular necrosis in any of the patients. According to the classification of Capanna, in five of the six patients a spontaneous reparation of the cyst has occurred. In one of the cases, the reparation is classified as grade II with a pathological cystic index of 2.27. A postoperative correction of the varus fracture deformity of the proximal femur has been achieved in all children. The cervical-diaphysary angle of 112.50° preoperatively has been corrected to 137.17° (p=0.002). The achieved correction is lasting and the average value of the CDS at the final follow-up is 138.17° (p=0.794). Intraoperative correction, statistically equal to the CDA of the healthy side (p=0.942) is achieved with this operative technique. Data from the MSTS show functional correction on the third postoperative month with 38.33% of the norm (p=0.002) and 85% on the final follow-up (p=0.002). A contralateral distal femoral surgical epiphysiodesis by the method of Métaizeau has been used for the correction of the difference in the length of the extremities (with an average of 2.9 cm). CONCLUSIONS Osteosynthesis with an LCP paediatric hip plate system gives the opportunity for anatomical correction of the proximal femur with a low risk of avascular necrosis and achieving optimal functional results in pathological basocervical and intertrochanteric fractures in childhood. The use of 5mm plates and penetration of the proximal screw through the growth plate holds an increased risk of growth disruption. [ABSTRACT FROM AUTHOR]

Introduction: Distal femur fractures are a common fracture seen in both high and low-energy traumas in young and elderly patients. The standard of care in healthy, mobile, younger patients remains open reduction and internal fixation (ORIF) through various fixation devices. However, the standard of care for comorbid and elderly patients remains unclear. In these patients, rates of nonunion vary between 6% and 20%, requiring revision surgery. Our study sought to identify patients who have gone endoprosthesis conversion to a distal femur replacement following failed ORIF. Methods: This descriptive study includes a total of eight patients who underwent a revision distal femoral replacement (DFR) following failure of primary distal femur ORIF and data were gathered through chart review. Patient comorbidities, demographic characteristics, hospital disposition, complications, and mortality were collected and described. Results: The average age of this cohort was 52.1 years, with 6 being female, and with a follow-up mean of 3.02 years. The most common medical comorbidities present in these patients at the time of ORIF were diabetes, hypertension, obesity, smoking, and renal insufficiency. 87.5% of patients were able to tolerate weight bearing following DFR conversion, compared to 62.5% tolerating weight bearing before revision. Complications requiring revision surgery occurred in 3/8 patients, which included: aseptic loosening, prosthetic joint infection, and patellar maltracking. Conclusion: DFR in a revision setting following acute distal femur ORIF can be an acceptable treatment options with outcomes similar to primary DFR. Further investigation is warranted to determine optimal timing and indications for primary DFR in a fracture setting. [ABSTRACT FROM AUTHOR]

When delivering cells on a scaffold to treat a bone defect, the cell seeding technique determines the number and distribution of cells within a scaffold, however the optimal technique has not been established. This study investigated if human adipose-derived stem cells (ASCs) transduced with a lentiviral vector to overexpress bone morphogenetic protein 2 (BMP-2) and loaded on a scaffold using dynamic orbital shaker could reduce the total cell dose required to heal a critical sized bone defect when compared with static seeding. Human ASCs were loaded onto a collagen/biphasic ceramic scaffold using static loading and dynamic orbital shaker techniques, compared with our labs standard loading technique, and implanted into femoral defects of nude rats. Both a low dose and standard dose of transduced cells were evaluated. Outcomes investigated included BMP-2 production, radiographic healing, micro-computerized tomography, histologic assessment, and biomechanical torsional testing. BMP-2 production was higher in the orbital shaker cohort compared with the static seeding cohort. No statistically significant differences were noted in radiographic, histomorphometric, and biomechanical outcomes between the low-dose static and dynamic seeding groups, however the standard-dose static seeding cohort had superior biomechanical properties. The standard-dose 5 million cell dose standard loading cohort had superior maximum torque and torsional stiffness on biomechanical testing. The use of orbital shaker technique was labor intensive and did not provide equivalent biomechanical results with the use of fewer cells., (© 2024 Wiley Periodicals LLC.)

Background: The negative impact of cigarette smoking on bone union has been well documented. However, the impact of heated tobacco product (HTP) use on bone fracture-healing remains unclear. The present study investigated the effect of HTPs on preosteoblast viability, osteoblastic differentiation, and fracture-healing and compared the effects with those of conventional combustible cigarettes.Methods: Cigarette smoke extracts (CSEs) were generated from combustible cigarettes (cCSE) and HTPs (hCSE). CSE concentrations were standardized by assessing optical density. Preosteoblast (MC3T3-E1) cells were incubated with normal medium, cCSE, or hCSE. The cell viability was assessed via MTT assay. After osteoblastic differentiation of CSE-exposed cells, alkaline phosphatase (ALP) activity was assessed. To assess the in vivo effects of CSEs, a femoral midshaft osteotomy was performed in a rat model; thereafter, saline solution, cCSE, or hCSE was injected intraperitoneally, and bone union was assessed on the basis of micro-computed tomography (μCT) and biomechanical analysis 4 weeks later.Results: MC3T3-E1 cell viability was reduced in a time and concentration-dependent manner when treated with either cCSE or hCSE. ALP activity after osteoblastic differentiation of cCSE-treated cells was significantly lower than that of both untreated and hCSE-treated cells (mean and standard deviation, 452.4 ± 48.8 [untreated], 326.2 ± 26.2 [cCSE-treated], and 389.9 ± 26.6 [hCSE-treated] mol/L/min; p = 0.002). Moreover, the levels of osteoblastic differentiation in untreated and hCSE-treated cells differed significantly (p < 0.05). In vivo assessment of the femoral midshaft cortical region revealed that both cCSE and hCSE administration significantly decreased bone mineral content 4 weeks after surgery compared with levels observed in untreated animals (107.0 ± 11.9 [untreated], 94.5 ± 13.0 [cCSE-treated], and 89.0 ± 10.1 mg/cm3 [hCSE-treated]; p = 0.049). Additionally, cCSE and hCSE-exposed femora had significantly lower bone volumes than unexposed femora. Biomechanical analyses showed that both cCSE and hCSE administration significantly decreased femoral maximum load and elastic modulus (p = 0.015 and 0.019).Conclusions: HTP use impairs cell viability, osteoblastic differentiation, and bone fracture-healing at levels comparable with those associated with combustible cigarette use.Clinical Relevance: HTP use negatively affects bone fracture-healing to a degree similar to that of combustible cigarettes. Orthopaedic surgeons should recommend HTP smoking cessation to improve bone union. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia is commonly used for orthopedic surgeries. The most important issue to improve outcome is patient cooperation to have a proper position for reducing pain during spinal anesthesia procedure. However, any change in position is painful which leads to sympathetic activation, tachycardia and hypertension, which may put patients with ischemic heart disease at risk. Peripheral nerve block is a safe and reliable alternative to systemic analgesia. Using the ultrasound-guided method reduces local anesthetics’ amount and side effects. Methods: In this study, 53 patients who came to the operating room with femoral fracture as candidates for spinal anesthesia were enrolled and received ultrasound-guided Femoral Nerve Block (FNB) (10 ml Lidocaine 1.5%). Before and after receiving the nerve block, the patients were asked about the severity of their pain using the Numerical Rating Scale (NRS). Both groups of patients and physicians were asked about their satisfaction according to a 5-point Likert scale. Results: Mean pain intensity in the NRS score at the time of admission to the operating room was 7.6±0.8, which was reduced to 1.8±1.5 after blockade. In this study, 39 (73.5%) patients were very satisfied (Likert scale 5), 10 (18.8%) were satisfied (Likert scale 4), 2 (3.7%) had no opinion (Likert scale 3), 2 (3.7%) were not satisfied (Likert scale 2), and no one was very dissatisfied (Likert scale 1). There was significant difference in physician’s satisfaction. Conclusion: Ultrasound-guided nerve block is a safe and effective method to be used for positioning during spinal anesthesia procedure. [ABSTRACT FROM AUTHOR]

A 27-year-old U.S. military active duty male sustained an accidental, self-inflicted left knee gunshot injury with an unsalvageable medial femoral condyle injury. The patient underwent bulk osteochondral allograft transplantation. Nine months post-operation, the patient was fit for full military duties with no reported functional limitations and remained on active duty. Severe knee medial femoral condyle bone loss after accidental firearm injury is uncommon. Bulk knee osteochondral allograft transplantation to the medial femoral condyle provided a successful treatment option for an active duty U.S. military member with multicompartment osteochondral defects and severe medial femoral condyle bone loss due to a gunshot injury., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To assess the efficacy of a bioregenerative scaffold derived from bone marrow aspirate, cancellous bone autograft, platelet-rich plasma and autologous fibrin in treating supracondylar femur nonunions. Methods & materials: Three patients with nonunions following multiple surgical failures underwent bone stabilization and the application of a novel bioregenerative scaffold. x-rays and subjective scales were collected before surgery and at 6, 12 and 24 months post-surgery. Results: All nonunions exhibited healing with sufficient callus formation, as confirmed radiologically. After 6 months, all patients resumed full weight-bearing walking without pain. Statistical analysis showed improvements in all scales compared with pre-surgical values. Conclusion: This method presents itself as an option for treating supracondylar femur nonunions following multiple surgical failures.

Purpose: The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD. Methods: A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD. Results: Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (β-0.4, confidence-interval − 0.5 to − 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment. Conclusion: These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Background: The relationship between perioperative red blood cell (RBC) infusion and deep vein thrombosis (DVT) has not been determined. Objectives: To analyze the time-event relationship between perioperative RBC infusion and DVT in patients with femoral and pelvic fractures after adjusting for confounding factors and to provide reference for optimizing DVT risk factors. Methods: The clinical data of 569 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to December 2019 were retrospectively analyzed. Propensity score matching (PSM) was performed on 20 covariates of DVT. With the formation or progression of DVT after RBC infusion as the end point, the time-event relationship between perioperative RBC infusion and DVT in patients was analyzed by binary logistic regression. Results: After 1:1 PSM of 569 patients included in this study, 126 patients were in the transfusion group and the non-transfusion group, respectively. Before PSM (P = 0.023, OR = 1.496 [95% CI, 1.058-2.115]), perioperative RBC infusion was associated with DVT formation for femoral and pelvic fractures. This conclusion was still obtained after PSM (P = 0.038, OR = 1.728, 95% CI = (1.031, 2.896)). The risk of DVT in patients with RBC infusion of 2-4U and > 4U is 1.833 and 2.667 times that of ≤ 2U, respectively. After excluding patients who received preoperative RBC infusion and had DVT formation or progression prior to RBC infusion, perioperative RBC infusion was still associated with the formation of DVT in femoral and pelvic fractures (P = 0.037, OR = 2.231 [95% CI, 1.049-4.745]). Conclusion: Perioperative RBC infusion is one of the causes of DVT in patients with femoral and pelvic fractures, and the risk of DVT is positively correlated with the amount of RBC infusion. [ABSTRACT FROM AUTHOR]

Introduction: Delayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome. Materials and Methods: This retrospective study was designed to evaluate the outcome and complications of 138 patients with femoral head fracture dislocation treated by a single surgeon over a period of 22 years. Only seven patients presented within 24 h of injury and remaining all presented late. The hip joints could be reduced by closed manoeuvre in 105 patients, and 33 patients needed open reduction. The patients were managed conservatively or surgically. The mean follow-up period was 3.57 years (1–18 years). Results: There were 119 males and 19 females. The mean age was 35.71 years (range, 18–70 years). Forty-two patients were managed conservatively, and 96 patients needed surgical treatment. The Kocher-Langenbeck approach was used in 40 patients, the trochanteric flip osteotomy in 14 patients, the Smith-Peterson approach in 31 patients, and the Watson-Jones approach in one patient. The femoral head fragment was fixed in 47.82% patients and excised in 11.59% patients. Primary total hip replacement (THR) was performed in 7.24% of patients through the posterior approach. 24.63% of patients developed complications with 14.49% of hip osteonecrosis, 2.89% posttraumatic osteoarthritis and 2.17% femoral head resorption. 55% of patients who developed osteonecrosis were operated through the posterior approach. Secondary procedures were needed in 14.48% of patients. The clinical outcome, as evaluated using the modified Harris Hip Score, was good to excellent in 52.89% of patients and poor to fair in 47.11% of patients. Conclusion: The incidences of osteonecrosis and secondary procedures are increased in delayed and neglected femoral head fracture dislocation. Osteonecrosis is commonly seen in Brumback 2A injuries and posterior-based approaches. All Brumback 3B fractures in such delayed cases should be treated with THR. Osteosynthesis or conservative treatment should be reserved for other types of injuries. A careful selection of treatment plan in such delayed cases can result in a comparable functional outcome as reported in the literature. [ABSTRACT FROM AUTHOR]

Introduction: Distal femur fractures make up < 1% of all fractures and 3–6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other. Methods: Systematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria. Results: Forty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment. Conclusion: Compiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures. [ABSTRACT FROM AUTHOR]

An editorial is presented on the Intertrochanteric (IT) fractures in the elderly which is a challenging surgery. The article discusses that the bones are osteoporotic with implants having less hold as well as the co morbidities associated in these elderly leads to almost one-third mortality by the end of one year, which is a major global economic burden; and the worldwide problem at present stands at over 2 million fractures and it is bound to triple by the next 50 years.

Introduction: Osteomalacia is a hitherto common orthopaedic condition and is commonly coexists with osteoporosis. However, the identification of osteomalacia always slips under the radar and more emphasis is given to diagnosis and management of osteoporosis. Identification of osteomalacia is equally relevant as management of the osteoporotic fractures is different with or without osteomalacia Methods: This was a prospective study design that included patients 50 years or above of either sex presented with proximal femur fractures. Osteoporosis was identified by DEXA scan of hip and lumbar spine. Metabolic tests including serum calcium, phosphorus, ALP and vitamin D levels were done. Histopathological diagnosis of osteomalacia was performed on bony tissues that were taken during surgery from a site adjacent to the fracture and histological examination was performed on non-decalcified paraffin sections using special stains. Results: A total of 45 patients was included in study. Mean age was 68.7 years (53–85 years). Abnormal values of serum calcium, phosphorus, ALP, vitamin D were noted in 44.4%, 22.2%, 53.3% and 48.9% patients, respectively. On histopathology, 73.17% patients showed osteomalacia. No significant correlation was found between serum biochemical markers and histopathology except with serum Vitamin D (p value − 0.004). Conclusion: The majority of patients with osteoporotic hip fractures had coexisting osteomalacia. Abnormal biochemical values were not significantly associated with osteomalacia. Hence, histopathology remains the gold standard for the diagnosis of osteomalacia. Further research is needed to identify a biomarker that may enable the clinician to diagnosis and treat osteomalacia well in time. [ABSTRACT FROM AUTHOR]

Purpose: The role of increased femoral antetorsion (femAT) as a contributor to patellofemoral (PF) osteoarthritis (OA) is unknown. The purpose of this study was to investigate whether increased femAT was associated with advanced cartilage degeneration in the lateral PF joint.Methods: Patients who underwent complete radiographic workup for surgical intervention due to OA in any knee joint compartment were included. Cartilage morphology according to the International Cartilage Repair Society (ICRS) cartilage lesion classification system in the PF joint, femoral and tibial torsion, frontal leg axis, and tibial tuberosity-trochlear groove (TT-TG) distance were assessed. Increased femAT was defined as  > 20° according to previous reports.Results: A total of 144 patients were included. Ninety-seven patients had a femAT of  < 20° and 45 of  > 20°. A significant odds ratio (OR) was found for lateral retropatellar (OR 3.5; p = 0.02) ICRS grade 3 and 4 cartilage degeneration and increased femAT  ≥ 20°. In the medial PF compartment, increased femAT had an inverse effect (OR 0.16; p = 0.01). No significant ORs were found for TT-TG distance, tibial torsion, or leg axis. The lateral retropatellar ICRS grade showed a linear correlation to increased femAT values. In valgus knees, isolated lateral PF OA had an even more pronounced correlation to increased femAT (p = 0.004).Conclusion: Increased femAT showed higher grades of lateral retropatellar cartilage degeneration, which was even more pronounced in valgus knees.Level Of Evidence: Cohort study: Level III. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to measure the femoral intercondylar notch volume using a truncated-pyramid shape simulation and compare this volume between anterior cruciate ligament (ACL) injured and intact subjects. Methods: Forty-seven subjects diagnosed with ACL tear by MRI (22 male and 25 female: median age 26: range 15–49), and 41 subjects in which knee MRI was performed and no ACL injury detected (20 males and 21 females: median age 27: range 16–49), were included in this study. Using three-dimensional computed tomography (3D-CT), the axial femoral intercondylar notch area was measured in the slice containing the most proximal (S1) and most distal (S2) level of Blumensaat's line. Femoral condyle height (h) was measured using a sagittal view of knees in 3D-CT. The truncated-pyramid shape simulation was calculated as: Volume = h (S 1 + S 2 + s 1 s 2 ) / 3 . Statistical analysis was performed to compare S1, S2, notch height, and notch volume between the ACL-injured and intact groups. Results: The measured S1, S2, and the notch height of the ACL-injured and intact groups were 201 ± 64 and 214 ± 50mm2, 370 ± 91 and 461 ± 94mm2, and 31 ± 3 and 30 ± 4mm, respectively. The calculated femoral intercondylar notch volume of the ACL-injured and intact groups was 8.6 ± 2.2 and 9.9 ± 2.6cm3, respectively. The ACL intact group showed significantly larger S2 and notch volume when compared with the ACL-injured group. Conclusion: For clinical relevance, notch volume and most distal axial notch area parameters were significantly larger in ACL intact subjects. The truncated-pyramid shape simulation is an easy and cost-effective method to evaluate intercondylar notch volume. In knees with small femoral intercondylar notch volume, attention is needed to prevent ACL injury. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: Preoperative posterior tilt is a risk factor for fixation failure in femoral neck fractures. This study aimed to evaluate the configuration of anterior positioning screw in proximal femoral plating in the treatment of retroverted femoral neck fractures in terms of resisting posterior tilt. Methods: We retrospectively analyzed patients with retroverted femoral neck fractures who were fixed by proximal femoral plating from January 2014 to August 2019. All patients were divided into two groups according to screw configuration: anterior long-threaded screw (ALTS, n = 36) and normally short-threaded screws (NTS, n = 46). Baseline characteristics were reviewed and radiological and clinical outcomes were analyzed. Logistic regression analysis was used to identify risk factors for developing posterior tilt. Results: Age, gender, Garden classification, posterior comminution, and reduction quality showed no significant difference between the groups. Increased posterior tilt was lower in the ALTS group (3.2°, 2.1–4.3°) than that in the NTS group (5.3°, 4.2–8.3°) (p < 0.001), and the percentage of people with > 5° of posterior tilt was also lower in the ALTS group (5, 13.9% vs. 24, 52.2%; p < 0.001). Femoral neck shortening (FNS) was lower in the ALTS group (3.1 (2.1–4.7) mm vs. 4.3 (3.1–6.3) mm, p = 0.003), though not statistically significant when using 5 mm as the cut-off value. Harris Hip Score in the ALTS group was higher than that in the NTS group (87.0, 84.0–90.0 vs. 82.0, 76.0–84.5; p < 0.001). Postoperative complications including delayed union, nonunion, and avascular necrosis were comparable between the groups. Multivariable analysis identified posterior comminution (OR 15.9, 95% CI 3.6–70.3, p < 0.001), suboptimal reduction quality (OR 12.0, 95% CI 2.6–56.1, p = 0.002), and NTS configuration (reference: ALTS configuration) (OR 21.9, 95% CI 4.1–116.4, p < 0.001) as risk factors for developing posterior tilt. Conclusions: Configuration of anterior positioning screw in proximal femoral plating provides better resistance against posterior tilt in the fixation of retroverted femoral neck fractures. Also, posterior comminution, suboptimal reduction, and NTS configuration (reference: ALTS) are risk factors for developing posterior tilt. Trial registration: The trial registration number was ChiCTR2000039482. [ABSTRACT FROM AUTHOR]

Introduction: Femoral head fractures with associated acetabular fractures are uncommon injuries usually resulting from high-energy mechanisms such as motor vehicle collisions. Outcomes of Pipkin type IV fractures have been historically poor, with high rates of osteonecrosis, post-traumatic arthritis, and heterotopic ossification. The objective of this study was to define the outcomes of operatively treated Pipkin type IV fractures In addition, we reviewed the available literature of this uncommon injury pattern. Methods: A retrospective chart review at a single level 1 trauma center from 2007 to 2016 identified 10 patients with Pipkin IV femoral head fractures. Demographic information, fracture type, associated injuries, operative details, and complications were evaluated. Clinical and radiological outcomes were assessed at latest follow-up including conversion to total hip arthroplasty. Results: Six of the seven patients were treated with open reduction and internal fixation of the femoral head fracture and acetabular fracture through a Kocher–Langenbeck approach aided by a trochanteric flip and one had fragment excision. Six patients (87.5%) developed post-traumatic arthritis. Four (57.1%) later underwent conversion to total hip arthroplasty (THA) a mean of 20.5 months after index procedure. Conclusion: Our study shows a rate of osteonecrosis and osteoarthritis that is even higher than the previously reported studies. The former may relate to longer-term follow-up and the latter possibly due to associated comminuted posterior wall fracture. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. Methods: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. Results: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15–35%), female gender (77% vs. 64%, D 13%, CI 3–22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2–23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6–108). Conclusion: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. Level of evidence: Level 3, retrospective cohort. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY In this study we aimed to investigate the clinical and radiographic results of AO/OTA 31 A3 fractures operated on with either a proximal femoral lateral locking plate or short cephalomedullary nails. MATERIAL AND METHODS/RESULTS Medical data of patients treated with either implant were evaluated retrospectively. Patients > 55 years old sustaining an AO 31 A3 type fracture with a minimum follow-up of one year from two institutions were included in the study. RESULTS In all, 22 patients in the plate group and 30 patients in the nail group were included. All patients achieved union excluding the patients with failure. No significant differences in the mean duration of surgery, pre- and postoperative hemoglobin levels, duration of union time, or need for an open reduction or revision surgery were observed between the two groups. Reduction quality was better in the nail group. Failure of fixation was detected in three patients in the plate group and in four patients in the nail group. The duration of hospital stay was longer in the plate group than the nail group (p = 0.007). Time to independent mobilization was significantly shorter in the nail group than the plate group (p = 0.027). The Harris hip score results were similar between the groups after one year (p = 0.479). CONCLUSIONS Both implants had similar radiographic and clinical outcomes treat 31 A3 intertrochanteric fractures if the lateral wall of the proximal fragment was intact and anatomical medial-posteromedial restoration of the fracture is performed. Although complication rates were similar between the two groups, nails enabled early mobilization of patients. [ABSTRACT FROM AUTHOR]

Background: To investigate the clinical efficacy of locking compression plate fixation for the treatment of femoral intertrochanteric fractures in patients with preexisting proximal femoral deformity. Methods: A retrospective analysis was conducted on 37 patients with femoral intertrochanteric fractures combined with preexisting proximal femoral deformity between January 2013 and July 2019. The patients included 24 males and 13 females aged from 23 to 69 years old, with an average age of 47.5 years. The preexisting proximal femoral deformities resulted from poliomyelitis sequela, proximal femoral fibrous dysplasia, malunion and implant failure combined with coxa vara after intramedullary nailing fixation. There were 6 cases of 31-A2.1, 6 cases of 31-A2.2, 20 cases of 31-A3.1, and 5 cases of 31-A3.2, determined based on the AO classification of intertrochanteric fractures. All fractures were managed through open reduction and locking plate fixation. The hip disability and osteoarthritis outcome score (HOOS) was used to assess hip function before injury and at the last postoperative follow-up. The short form 36 (SF-36) Health Survey Questionnaire was used to assess quality of life. Results: Thirty-seven patients were followed up for 12 to 27 months (average, 20.7 months). All patients achieved bone healing within 5.1 months on average (range, 3 to 6 months). Postoperative complications included deep vein thrombosis in three patients, bedsores in one and delayed union in one patient. No other complications, such as surgical site infection, fat embolism, nonunion and re-fracture, were presented. There was no significant difference in the HOOS scores and the SF-36 Health Questionnaire outcomes at pre-injury and at the last postoperative follow-up (p > 0.05). Conclusions: It is difficult to perform intramedullary fixation of femoral intertrochanteric fractures in patients with preexisting proximal femoral deformity, while locking compression plate fixation is a simple and effective method of treatment. [ABSTRACT FROM AUTHOR]

Background: Hemophilic pseudotumor (HPT)-related fracture is a rare but severe complication in patients with HPTs. These fractures often occur in femurs. There is no consensus on the standard surgical protocol for HPT-related femoral fracture. The present retrospective study evaluated the outcomes of these patients treated with surgical interventions. Methods: Ten patients with HPT-related femoral fractures who were treated with 14 surgical procedures due to 11 fractures in our hospital from January 2014 to April 2020 were evaluated retrospectively. Demographic data, fracture location, complications after surgery, and follow-up outcomes were recorded and analyzed. The mean follow-up period was 39.7 months. Results: The mean age at surgery was 31 years. Closed reduction external fixation (CREF) was originally performed in 2 patients, open reduction internal fixation (ORIF) was performed in 4 patients, screw fixation alone was performed in 1 patient, brace immobilization was performed in 1 patient, and amputation was performed in 3 patients. Bone union was observed in 5 patients, and an adequate callus was visible in 2 patients. Both patients with CREF had pin infections. Nonunion combined with external fixation (EF) failure occurred in 1 patient, and the plate was broken after ORIF. Three patients underwent autogenous or allogeneic cortical strut grafting. Three patients had HPT recurrence. Conclusions: It is necessary to perform surgery in patients with HPT-related femoral fractures. Surgical treatments must consider fracture stabilization and HPT resection. Internal fixation is preferable, and EF should only be used for temporary fixation. If the HPT erodes more than one third of the bone diameter, strut grafts are necessary for mechanical stability. Amputation is an appropriate curative method in certain situations. [ABSTRACT FROM AUTHOR]

Purpose. Poller screws may serve as an adjunctive reduction tool and aid fracture reduction while augmented with intramedullary (IM) nailing for treating diaphyseal or metaphyseal fractures of the femur and tibia. However, there is no consistent conclusion about whether the method of using IM nailing augmented with poller screws is more advantageous than using IM nailing alone. Methods. A total of 96 patients who received IM nailing with or without supportive poller screw for treating long-bone fractures in lower limbs and who experienced difficulties in performing reduction or IM insertion during the surgical process were included in this retrospective cohort study (33 patients with poller screws in group A versus 63 patients without poller screws in group B). Patient demographics including age, gender, and body mass index; injury-related data including fracture location, classification, and injury mechanism; operation-related data including American Society of Anesthesiologists, duration of operation, poller screw time, method of anesthesia, and volume of intraoperative hemorrhage; outcomes including fracture healing time; and incidence of outcomes of nonunion, malunion, infection, and secondary surgical procedures were evaluated. Results. Fracture healing time of patients in group A was significantly shorter than that of group B (18.3 ± 4.8 weeks versus 24.3 ± 3.0 weeks, p = 0.023). Union rate was higher (100.0% versus 87.3%, p = 0.048), and malunion rate and secondary surgical procedure rate were lower (both are 3.0% versus 19.0%, p = 0.031) in group A than that of group B. Conclusion. Poller screw augmentation of IM nailing is a favourable option to shorten fracture healing time and to reduce complication rates in terms of nonunion, malunion, and secondary surgical procedure in the treatment of both diaphyseal/metaphyseal fractures of the femur or tibia while compare with those treated by IM nailing alone. [ABSTRACT FROM AUTHOR]

Case: We present 2 case reports: the first, a diaphyseal fracture of the humerus treated with a Marchetti nail resulting in a nonunion in 2017. The second, a fracture of the femur treated with a Kuntscher nail in 1989. A gunshot injury to that femur in 2014 evolved in nonunion and displacement. In both cases, the old nails were removed by using pieces of the Ilizarov apparatus. Conclusions: In case of complications, the versatility of the Ilizarov apparatus allows us to connect the intramedullary element to the universal extraction system; it proves itself to be an excellent cost-effective extraction system. [ABSTRACT FROM AUTHOR]

Introduction: The standard anteroposterior and lateral fluoroscopic projections used during femoral neck fracture fixation provide a two-dimensional representation of the cephalocaudal and anteroposterior extents of the femoral neck. The radiographic representation differs from the actual extent of the femoral neck. The anterosuperior (AS) and posterosuperior (PS) surfaces of the femoral neck are at risk of bony breach by the fixation screws and that may get easily missed with standard fluoroscopic views. The current study aims at investigating the special fluoroscopy views, based on the orientation of the AS and PS surface of the femoral neck, that can help in the safe placement of screws near these surfaces without bony breach. Method: A computed tomography-based analysis of fifty intact proximal femora was performed. The longitudinal axis of the proximal femoral shaft and the center of the femoral head were aligned along a common horizontal plane. The cephalocaudally constricted zone of the femoral neck was identified along its axis. The surface inclinations of the AS surface and the PS surface at the constricted zone of the femoral neck were measured in relation to the horizontal plane. The mean, standard deviation, overall range, interquartile ranges and gender-based variation of each of the two surface inclinations were measured. Results: The mean surface inclinations of the AS surface and the PS surface with reference to the horizontal plane were 55° ± 7.76° and 123.32° ± 7.88°, respectively. There were no significant side to side and male to female differences. Conclusions: The modified radiographic views based on the surface inclinations of the AS and the PS surfaces can help in the localization of the critical zones of these surfaces which are at risk of bony breach with screw placement close to the surface. A prior fluoroscopic evaluation of these surfaces before guidewire placement can help in preventing the surface violation. [ABSTRACT FROM AUTHOR]

Background and purpose — Proximal femoral osteotomy (PFO) is commonly performed to treat children with developmental dysplasia of the hip (DDH). Implant-related femoral fractures after osteotomy are sometimes reported, but the potential risk factors for these fractures remain unclear. We investigated the association of implant-related fractures with PFO and potential risk factors for these fractures. Patients and methods — We retrospectively reviewed 1,385 children undergoing PFO for DDH in our institution from 2009 to 2016 after obtaining institutional review board (IRB) approval and identified 27 children (28 hips, fracture group) with implant-related femoral fractures after PFO. We selected 137 children (218 hips, control group) without fractures who matched the children in the fracture group by age, weight, surgeon, and surgical period. Relevant clinical data were collected and compared between the 2 groups. Multiple analyses of risk factors for implant-related fractures were conducted by logistic regression with the stepwise regression method. Results — The occurrence rate of implant-related fractures was 1.9% (27/1,385). Compared with the control group, the fracture group more commonly exhibited bilateral involvement (74% vs. 53%, p = 0.04), used a spica orthosis for immobilization after osteotomy (43% vs 21%, p = 0.01) and exhibited mild remodeling at the osteotomy site (46% vs. 19%, p = 0.003), and less commonly required capsulotomy during osteotomy (61% vs. 79%, p = 0.03). According to the multiple regression analysis, the only factor identified as an independent risk factor for implant-related fractures was mild remodeling at the osteotomy site (OR = 3.2, 95% CI 1.4–7.5). Remodeling at the osteotomy site was significantly associated with varus osteotomy (coefficient = 1.4, CI 1.03–1.8). The fracture occurred at a mean of 12 months (2.2–25) after osteotomy or 3.3 months (0–12) after implant removal. In children undergoing implant removal, the fractures mostly occurred at the osteotomy site (n = 13/15), while in those with the implant remaining, the fractures mostly occurred in the screw hole (n = 8/13). Interpretation — The type of PFO performed is not associated with implant-related fractures in children with DDH. Children with mild remodeling at the osteotomy site should be closely followed up, regardless of whether the hardware is removed, and high-intensity activity should not be permitted until moderate or extensive remodeling is confirmed. After PFO, the implants should be removed when solid union is achieved at the osteotomy site. [ABSTRACT FROM AUTHOR]

Background and Objectives: The Israeli National Program for Quality Indicators (INPQ) sets as its primary goal to promote high-quality health care within selected core areas in the Israeli health system. Surgical site infection is one of the most common types of acquired infections. The INPQ supports 3 distinct indicators concerning suitable antibiotic treatment in colorectal surgery, cesarean sections, and surgery for femoral neck fractures. Methods: We measured the number of patients who received prophylactic antibiotics, beginning an hour before the first cut and stopping after 24 hours in 1 of the 3 operations, according to the International Classification of Diseases, Ninth Revision (ICD-9) codes. Goals for success have been established annually according to the results of the previous year. Data computed for each operation included socioeconomic status, dates of hospitalization and release, date of death, date of birth, gender, date of operation, time of beginning and end of the operation, and time of beginning and end of anesthesia. Results: Within 3 to 5 years, we achieved a significant increase in appropriate prophylactic antibiotic use from 78% to 85%, 78% to 95%, and 66% to 88% for colorectal surgery (n = 9404), cesarean sections (n = 141 362), and femoral joint operations (n = 30 728), respectively. The mortality rate was lower, 1.85% versus 0.55% in patients who received proper antibiotic therapy (odds ratio [OR] = 3.141; 95% confidence interval [CI], 1.829-5.394, P< .0001), 0.031% versus 0.006% (OR = 6.741; 95% CI, 1.879-21.187; P= .003), and 5.59% versus 4.51% (OR = 1.253; 95% CI, 1.091-1.439; P= .001), respectively. Conclusion: Prophylactic antibiotic treatment is strongly recommended by medical guidelines. The experience of the INPQ supports this approach. We demonstrate a significant lower mortality rate in patients who have been properly treated. [ABSTRACT FROM AUTHOR]