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We aimed to summarize the radiographic and clinical outcomes in various conditions of tri-malleolar ankle fractures (TMFs) with posteromedial (PM) plafond involvement (TMF + PM) and determine the factors affecting their subjective clinical outcomes.Radiographic and clinical findings of 66 patients who underwent operative treatment for TMF + PM were retrospectively reviewed. The patients were classified into three groups according to the PM fracture line location. Type I fractures were defined when the PM fracture line extended medially beyond the PM corner of the distal tibia while type II fractures were those in which the PM fracture line was located laterally to the PM corner. Type III fractures were defined as medial malleolar avulsion fractures when the PM fracture integrated into the medial malleolus. Clinical outcomes were evaluated using a subjective rating scale (excellent, good, fair, poor, and bad). Satisfactory results were defined as excellent, good, and fair. Factors affecting satisfactory clinical outcomes were assessed using a binary logistic regression analysis. Independent variables included demographic, fracture-related, and operation-related factors and radiographic measurements at the final follow-up.Satisfactory clinical outcomes were observed in 74.2% of the total patients; of these patients, 75.7% (28/37), 76.5% (13/17), and 66.7% (8/12) had type I, type II, and type III fractures, respectively. The binary logistic regression analysis revealed that age at the time of operation, number of incarcerated fragments (IFs), type of IFs, and postoperative articular step-offs (mm) were related to subjective clinical outcomes (all P 0.05). A positive value for post-operative articular step-offs represented distal migration of the posterior malleolar fragments. The odds ratios for older age, increased numbers of IFs, rotated IFs, and positive articular step-offs were 0.936, 0.116, 0.020, and 0.295, respectively.Because TMF + PM is highly unstable, a delicate approach is needed according to each patient's fracture condition. Although it is best to reduce the fractured articular surface, a negative step-off, rather than a positive step-off, would be more likely recommended if accurate reduction is impossible. This could be applied to manage IFs, especially when the IFs are rotated. Dimpling of the articular surface induced by the removal of a small IF was not related to unsatisfactory clinical outcomes.

Purpose Adhesive capsulitis of the hip (ACH) is likely that this condition had been previously encountered, but easily unrecognised. We investigated the clinical features of patients with ACH, the efficacy of ultrasound-guided intra-articular hydrodilatation, and the patients’ prognosis. Methods We enrolled 84 patients (93 hips) who visited the outpatient clinic from August 2018 to November 2019. ACH was diagnosed by restricted range of motion and sharp pain when turning with the affected leg fixed on the ground. We evaluated patient demographics and associated intra-articular pathologies found on magnetic resonance angiography (MRA) images. Injections were performed twice at two week intervals with a mixture of 0.5% lidocaine (25 mL) and triamcinolone (40 mg; 1 mL) with capsular distension under ultrasound guidance. Patients were assessed before and after treatment using a visual analogue scale (VAS), hip disability and osteoarthritis outcome score (HOOS), hip range of motion (ROM), and distance from floor to knee (DFK) when sitting in the cross-legged position. Results On MRA, 18 patients had abnormal findings (eight labral tears, seven abductor tendinosis, three primary arthrosis). The mean VAS decreased from 7.1 ± 1.1 to 0.8 ± 0.9 after the last injection, and the HOOS improved in all subsets. The mean DFK decreased from 17.9 ± 4.8 to 9.7 ± 2.8 cm, and passive ROM showed improvement, especially in flexion and rotation. In seven patients, symptom recurrence was reported a mean of 4.1 months after the latest injection, but no independent risk factor for recurrence was identified. Conclusion Based on these current observations, patients with ACH may receive relief from hip joint pain and experience improved function with a timely diagnosis and effective treatment.

This study aimed to determine characteristics of acetabular fractures in the elderly by evaluating clinical course and computed tomography-based radiological features between low- and high-energy acetabular fractures.We reviewed 178 consecutive patients with acetabular fractures aged ≥60 years from six centers. Low-energy fractures (group 1) were identified in 23 (12.9%) patients and high-energy fractures (group 2) in 155 (87.1%) patients. We compared demographics, radiological findings, and clinical course between the groups.Average age (70.6 vs. 67.8 years, p = 0.046) and ratio of females (47.8% vs. 23.2%, p = 0.021) were significantly higher in group 1 than in group 2. The Charlson comorbidity index was also higher in group 1, but no other demographics showed difference. More patients in group 2 than in group 1 underwent surgery (91.6% vs. 73.9%); however, more in group 1 underwent minimally invasive surgery (17.4% vs 4.5%). Anterior column-associated fracture patterns occurred in 91.4% and 38.7% of cases in groups 1 and 2, respectively. Most fractures were displaced (2 mm); 68% of which were comminuted. Furthermore, 24.2% of the fractures had superior dome impaction, whereas 23.0% were associated with posterior wall impaction.Patients who sustained low-energy acetabular fractures were mostly women, were older, and had more comorbidities. Radiological findings of low-energy acetabular fractures showed anterior column involvement associated with injury to the quadrilateral surface. Additionally, it was observed to be commonly combined with comminution and impacted fragments.

A femoral shaft fracture is usually a high-energy injury and, thus, is likely to be accompanied by an injury of adjacent joints such as a knee ligament injury. However, these associated injuries are often neglected because of severe pain and deformity. The purpose of the current study is to evaluate the incidence, type and risk factors of ipsilateral knee injuries associated with femoral shaft fractures. A total of 429 femoral shaft fractures were included in this study from January 2010 to September 2015. There were 320 males and 109 females, with mean age of 40.7 years (range, 15-88). Exclusion criteria were skeletally immature patients and patients with metabolic bone disease such as osteoporosis, atypical femoral fractures, and pathologic fractures. The incidence and type of knee injury were identified, and the injury mechanisms, AO/OTA classification of the femoral shaft fractures, were analysed for assessment of risk factors for knee injuries combined with femoral shaft fractures. Knee injuries were found in 131 cases. Knee ligament injuries were identified in 87 cases. There were 20 posterior cruciate ligament injuries, 11 anterior cruciate ligament (ACL) injuries, 16 medial collateral ligament (MCL) injuries, 8 lateral collateral ligament (LCL) injuries, and 32 multi-ligament injuries. In 24 cases, ligament injuries were not detected before internal fixation of femoral shaft fractures. Average time of diagnosis for ligament injury after fixation in these neglected cases was about 10.6 weeks (range, 1-32). Fractures around the knee joint were identified in 69 cases; there were 32 patellar fractures, 14 distal femoral intra-articular fractures, 14 tibia plateau fractures, 3 proximal fibular fractures, and 6 combined fractures. Male sex, type C fracture of AO/OTA classification, and motor vehicle accidents were identified as risk factors for associated ipsilateral knee injuries in femoral shaft fractures. Knee injuries were identified in approximately 30% of femoral shaft fractures. About 30% of ligament injuries were not detected before internal fixation of femoral shaft fractures. Care should be taken since knee injuries can be accompanied by ipsilateral femoral shaft fractures.

Nonunion is the most frequent cause of reoperation and is associated with high morbidity after distal femur fracture (DFF). We examined the rates of nonunion requiring reoperation after fixation for DFF using a locking compression plate (LCP) or retrograde intramedullary nail (RIMN). We included four studies comparing LCP and RIMN and 38 single-cohort studies reporting LCP or RIMN. In total, 2156 femurs were included and 166 non-unions were detected. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the four comparative studies and a proportional meta-analysis on the 38 articles to estimate the nonunion rate. We performed sensitivity analysis by comparing studies using LCP with less invasive surgical systems (LISS) with those that used RIMN. The pairwise meta-analysis showed a similar nonunion rate between the groups [odds ratio: 1.02; 95% confidence interval (CI) 0.94–1.11, p = 0.633]. According to proportional meta-analysis, the pooled prevalence of nonunion was 5% (95% CI 4–7) totally, 6% (95% CI 4–8) in the LCP group, and 4% (95% CI 2–6) in the RIMN group (heterogeneity: p = 0.105). According to the sensitivity analysis, there was no difference in the union rate. The pooled prevalence of nonunion from sensitivity analysis was 4 % (95% CI, 3–5); it was 4% (95% CI, 3–6) in LCP with LISS and was 4% (95% CI, 2–6) in RIMN group (heterogeneity: p = 0.941). Approximately 5% of patients who underwent LCP or RIMN fixation developed nonunion. Therefore, LCP and RIMN are effective DFF techniques and mastering one of them is essential.

The purpose of this study was to demonstrate the effectiveness of controlled telescoping system for lateral hip pain caused by sliding of the blade following intramedullary nailing of trochanteric fractures.A retrospective cohort study was performed to compare the controlled telescoping system (Compression Hip Nail; CHN) with the conventional sliding system (Proximal Femoral Nail Antirotation; PFNA) for trochanteric fractures. 74 cases in the PFNA group and 77 cases in the CHN group were included from two university hospitals in this study. All patients had a minimum of 12-month follow up period. Lateral hip pain was evaluated and operation time and blood loss during the surgery were measured. The fracture classification was evaluated. The quality of postoperative reduction and other complications after surgery were also evaluated and tip-apex distance (TAD), telescoping and lateral protrusion of the blade and lag screw were measured.The mean age was 78.5 years in the PFNA group and 74.7 years in the CHN group (p=0.25). The mean telescoping was 19.2mm in the PFNA group and 10.7mm in the CHN group (p0.001). The mean length of lateral protrusion was 10.5mm in the PFNA group and 2.5mm in the CHN group (p0.001). Twenty-eight patients in the PFNA group complained of lateral hip pain, whereas 12 patients in the CHN group did (p=0.002). These four variables showed statistically significant differences between the PFNA and CHN groups (p0.05). The length of lateral protrusion was the only variable significantly related to lateral hip pain through multivariate logistic regression analysis (p=0.045).The degree of lateral protrusion was mainly related to lateral hip pain. Therefore, controlled telescoping would help to decrease lateral hip pain by decreasing the lateral protrusion beyond the lateral femoral cortex.

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

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

Aim Acute cholecystitis is a medical complication that can develop in the postoperative period after hip surgery. However, few studies have examined this complication in elderly patients. Our aim was therefore to evaluate the incidence and clinical manifestations of acute cholecystitis after hip fracture in elderly patients. Methods Medical records and radiological studies of patients aged older than 65 years who underwent hip surgery for femoral neck or intertrochanteric fractures at a single hospital from April 2003 to March 2013 were reviewed retrospectively. We analyzed the type of cholecystitis (acalculous or calculous), clinical manifestations, fracture type (neck or trochanteric fracture), age, sex, body mass index, type of surgery, time to surgery, time from surgery to onset of acute cholecystitis and the timing of ambulation in acute cholecystitis cases. Results There were nine confirmed acute cholecystitis cases among 1211 hip fractures; thus, the incidence of acute cholecystitis within 2 months after hip fracture surgery was 0.74%. Conclusions The incidence of acute cholecystitis was higher than we expected, and this condition can lead to more serious problems if overlooked. Acute cholecystitis as a medical complication after hip fracture was underestimated in previous studies. Furthermore, acute cholecystitis should be considered as a complication of hip fracture, not hip surgery, in the elderly. The present study does not imply that hip fracture causes acute cholecystitis, although elderly hip fracture patients are in an extremely debilitated state and are prone to developing acute cholecystitis. Geriatr Gerontol Int 2015; 16: 380–383.

Introduction Surgical treatment options for distal femur fractures include intramedullary nailing or plating using a lateral or lateral parapatellar approach. However, medial plating is required for additional stability in some fractures such as severely comminuted fractures and periprosthetic fractures, and in those for which use of a lateral plate or nail is not appropriate. This study aimed to explore the safe zone for medial minimally invasive plate osteosynthesis of the distal femur with computed tomography angiography. Material and methods In a series of 30 patients, the region of interest between the lesser trochanter (LT) to the adductor tubercle (AT) was divided into six levels (I to VI), and the distance from the femur to the femoral artery (FA) was measured. At each level, the medial half of the femur was divided into eight sections that were assigned ‘A to H’ from anteromedial to posteromedial, and the position of the FA and the deep femoral artery (DFA) was recorded. Results The average length from the LT to AT was 295.0 mm. The average distance to FA was 38.0 mm, 29.9 mm, 26.9 mm, 27.0 mm, 21.8 mm, and 12.2 mm from level I to VI, respectively. The FA was positioned posteromedially below level IV and positioned at C–H below level II, which was out of the anterior aspect of the femur. The DFA was in the same location as the FA between levels II and III. Conclusion The anteromedial aspect of the distal half of the femur is the safe zone, and a long plate can be positioned safely in this zone at the anterior aspect up to the level of 8 cm below the LT.

There is extension of the Kocher-Langenbeck approach using trochanteric osteotomy for posterior wall fracture extending to acetabular roof, but it exposes to complications such as nonunion, breakage, and heterotopic ossification. The current study introduces a submuscular sliding plate technique. We retrospectively analyzed 13 patients treated with this technique. It is based on conventional method for posterior wall fracture. After reduction of roof fragment with direct visualization, a pre-contoured plate was passed through a submuscular tunnel under the gluteus medius and minimus. A small split incision was performed on the muscles, and screws were inserted with a triple trocar complex safely under fluoroscopic imaging. All patients had fracture union without complications. X-rays results showed anatomical reduction in 10 cases and imperfect reduction in 3 cases. Our results were satisfactory, particularly without heterotopic ossifications despite no prophylactic regimen of NSAID was applied and no neurological complications, so we believe that this technique is a good option for posterior wall fractures extending to the acetabular roof.

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

In the treatment of nonunions of the distal femur, infection should be excluded. However, it is difficult to determine whether the nonunion is infected or not with negative history and signs of infection. The purpose of this study was to investigate indolent infection as a cause of presumptive aseptic distal femur nonunion. All presumptive aseptic distal femur nonunions treated from 1998 to 2008 were retrospectively reviewed. Any patient with suspected of having an infection clinically was excluded. Multiple tissue cultures were performed at the nonunion site. The main outcomes were to analyze the rate of positive cultures in presumptive aseptic distal femur nonunion and to compare the rate of secondary surgery in positive and negative culture groups. Of the 22 patients, 3 (13.6%) had positive culture results. The organisms cultured were Staphylococcus aureus, Staphylococcus epidermidis, and Enterobacter cloacae. The overall rate of infection was 9.1% (2/22), and one patient underwent a secondary procedure. In the open fracture group, 2 of 10 patients (20%) had positive cultures; all developed infection. In the closed fracture group, 1 of 12 patients (8.3%) had positive culture results, but Infection did not occur in the patient with a 3-week intravenous antibiotic treatment. The postoperative infection rate was 67% (2/3) in patients with positive intraoperative cultures, while 0% (0/18) in the group with negative intraoperative cultures (p

Purpose This prospective study aimed to evaluate radiographically, mechanical or hip–knee–ankle (HKA) axis in healthy, asymptomatic, Asian (Indian and Korean) adults between 20 and 40years of age to determine the incidence of inherent varus (mechanical limb alignment of >3° varus) and the factors influencing it. Methods Three hundred and eighty-eight lower limbs were evaluated using full length, standing hip-to-ankle radiographs in 198 healthy, asymptomatic, Asian (Indian and Korean) adults between 20 and 40years of age to assess the hip–knee–ankle (HKA) angle, medial proximal tibial angle (MPTA), femoral bowing and femoral neck–shaft angle to determine the incidence of inherent varus (mechanical limb alignment of >3° varus) and the factors influencing it. Results Overall, the mean HKA angle was 177.6°±2.6° with 34.5% of limbs in inherent varus (mean HKA angle 174.9°±1.8°). The incidence of inherent varus was significantly higher ( p =0.01) in males (40%) compared to females (28%) but similar among Indian (34%) and Korean subjects (35%). The hip–knee–ankle (HKA) angle showed significant positive correlation ( r =0.82, p Conclusions Inherent varus alignment of the lower limb is fairly common among asymptomatic, Asian adults. These results raise several pertinent questions regarding the role of inherent varus in the aetiopathogenesis of knee osteoarthritis and in lower limb realignment procedures.

Summary Background Accurate positioning of locking screws depends on accurate insertion of the drill sleeve into the locking compression plate (LCP). The purpose of the present study was to determine factors affecting accurate drill sleeve insertion. Hypothesis Tilting and shallow locking screw holes and combination-type holes make it difficult to insert the drill sleeve in the LCP. Materials and methods Twenty-seven 3.5 mm LCP metaphyseal insertion holes were selected (Philos®, LPHP®, DMTP®, low-band DMTP® [Synthes, Solothurn, Switzerland]). Two orthopedic surgeons checked the time taken for accurate insertion of the drill sleeve into the plate. Variables relating to LCP drill sleeve insertion time were analyzed. Results It took an average 6.6 seconds to insert the drill sleeve accurately in the holes. Insertion time increased with the tilt of the screw hole but not with shallowness. Insertion time in combination-type holes was longer (8.8 seconds) than in single locking holes (5.6 seconds). Discussion Tilted screw holes and combination-type holes affect the insertion of the drill sleeve into 3.5 mm LCPs. Level of evidence Level IV, experimental study.

Olecranon fractures are intra-articular injuries that require anatomic restoration of the articular surface. For most simple noncomminuted transverse olecranon fractures, tension band wire fixation can provide a stable construct to allow for early joint range of motion. However, in comminuted olecranon fractures, it is difficult to provide a sufficient buttress for impacted articular fragments using tension band wire fixation. Therefore, plate fixation is the standard fixation method, but wide skin exposure and symptomatic plate irritation on the skin are common complications. The authors’ technique uses tension band wire fixation with miniplate augmentation for patients with comminuted olecranon fractures.

The surgical goal for unstable pelvic injuries is to reduce and stabilize the anterior and posterior pelvic rings. Anatomical reduction and stable internal fixation of both the anterior and posterior rings can result in good radiologic and clinical outcomes. The surgical approach and fixation method used are based on the fracture classification, the amount of displacement, soft tissue condition, associated injuries, and overall hemodynamic status of the patient. Surgical fixation was focused on the posterior pelvic ring, which contributes about 60% of the overall pelvic ring stability, and then the anterior ring lesion is assessed for its need of fixation, if required. Matta and Tornetta1) have emphasized the importance of an accurate reduction and stable fixation for posterior ring injuries. Posterior pelvic ring fixation is traditionally associated with vertically unstable fractures. These injuries are associated with a substantial risk of retroperitoneal hemorrhage, presence of the Morel-Lavallee lesion, and 25% incidence of skin breakdown following internal fixation of these fractures. However, the visualization necessary for the reduction often requires significant soft tissue dissection and long operative times, which are problematic in unstable patients. There are various surgical options for anterior ring fixation, including external fixator, retrograde intrapubic screw, and plate. The most commonly used surgical approach is a Pfannenstiel-type incision for the symphyseal disruption and medial ramus fracture. For the plate fixation of a displaced lateral ramus fracture and anterior column, an ilioinguinal approach, described by Letournel,2) is widely used as the exposure of choice, which may require a long operation time, meticulous handling around the neurovascular bundle, and significant blood loss. Based on the current concept of minimally invasive surgery that emphasizes less tissue dissection, the modified Stoppa approach has gained in popularity. The Stoppa approach has been introduced for the treatment of pelvic-acetabular fractures, allowing the easy exposure of the pelvic brim, where bone quality is optimal for screw fixation.3,4,5,6) The purpose of our study was to investigate the surgical outcomes of unstable pelvic ring injuries treated using the Stoppa approach for stable anterior ring fixation.

Zinc oxide (ZnO) nanorods were grown on polyethersulfone substrates with a seed layer by hydrothermal synthesis. The effects of the growth temperature and duration on the structural and optical properties of the ZnO nanorods were investigated by X-ray diffraction, field emission scanning electron microscope and photoluminescence measurements. Improvement of the structural properties was confirmed when the ZnO nanorods were grown at a moderate thermal energy. Thermal energies that were too high or too low resulted in structural degradation: low thermal energies did not provide enough energy for the ZnO growth, and high thermal energies contributed to improper growth by creating an uncommon flake-like structure. Photoluminescence measurements showed that the near-band-edge emission to deep-level emission peak ratio increases with increasing growth temperature at growth duration of 5 h.

Arthroscopic transpatellar screw fixation with a cannulated screw and washer is a simple, effective, and safe technique providing stable fracture fixation to allow immediate mobilization with minimal loss of extension in type II and III tibial eminence fractures in adults.

†Background: Aseptic loosening of cemented hip prostheses is recognized as a long-term problem, and especially in males and younger patients. Much energy has been focused on developing new prostheses that are designed for cementless fixation. We evaluated the performance of and periprosthetic bone response to a tapered, titanium, hydroxyapatite (HA)-coated femoral hip prosthesis at a minimum of 7 years of follow-up after treatment with primary total hip arthroplasty. Methods: Seventy-eight patients and 86 hips were included in the study. There were 35 men and 43 women; the mean age at the time of the operation was 59 years (range, 41 to 81 years). We used a tapered, titanium (Ti6Al4V), HA-coated femoral implant. We evaluated the patients at a minimum of 7 years of follow-up after treatment with primary total hip arthroplasty. Clinical evaluation was performed using the scoring system and the hip scores were assigned according to the level of pain, the functional status and the range of motion. The patients who refused to return, but who did forward X-rays for review after being contacted were questioned by phone about the functional status of their hip. Radiographic follow-up was performed at six weeks, at three, six and twelve months and yearly thereafter. All the available radiographs were collected and assessed for implant stability, subsidence, osseointegration, osteolysis, stress shielding and evidence of periprosthetic lucency. Results: Eighty-six hips (78 patients) were available for review at follow-up of greater than 7 years. In 11 of the 86 cases, acetabular failure required revision of the acetabular component, but the femoral stem survived and it was available for long-term evaluation. The radiographs were obtained at 7-year follow-up for another 20 hips, but the patients would not come in for the 7-year clinical evaluation. Therefore, a phone interview was conducted to assess any change in the functional status at a minimum of 7 years. Conclusions: The mechanical fixation of a tapered, titanium, HA-coated femoral implant was excellent in this study. This femoral design provided reliable osseointegration that was durable at a mean of 7 years follow-up.

Osteosynthesis using compression or locking plate following indirect fracture reduction and using a minimally invasive technique has been recommended for the surgical treatment of Vancouver B1 and C periprosthetic femoral fractures. Recent advancements in fracture healing emphasize the significance of the type of mechanical stability depending on fracture patterns and the importance of the preservation of the blood supply around the fracture sites. We report two cases of mechanical failure after internal fixation of periprosthetic femoral fractures despite adherence to the principles of fracture care. Both patients were treated conservatively with a thigh cuff cast due to other concurrent issues. Bone healing was successfully achieved in both cases as a result of the preservation of the tissues and the biology around the fractures during the initial operations. We present our experiences of conservative management together with the preservation of the biology around the fracture site, as viable alternative options for difficult and traumatic revision surgery in cases of failed periprosthetic fracture fixation procedures.

Acute cholecystitis is a medical complication that can develop in the postoperative period after hip surgery. However, few studies have examined this complication in elderly patients. Our aim was therefore to evaluate the incidence and clinical manifestations of acute cholecystitis after hip fracture in elderly patients.Medical records and radiological studies of patients aged older than 65 years who underwent hip surgery for femoral neck or intertrochanteric fractures at a single hospital from April 2003 to March 2013 were reviewed retrospectively. We analyzed the type of cholecystitis (acalculous or calculous), clinical manifestations, fracture type (neck or trochanteric fracture), age, sex, body mass index, type of surgery, time to surgery, time from surgery to onset of acute cholecystitis and the timing of ambulation in acute cholecystitis cases.There were nine confirmed acute cholecystitis cases among 1211 hip fractures; thus, the incidence of acute cholecystitis within 2 months after hip fracture surgery was 0.74%.The incidence of acute cholecystitis was higher than we expected, and this condition can lead to more serious problems if overlooked. Acute cholecystitis as a medical complication after hip fracture was underestimated in previous studies. Furthermore, acute cholecystitis should be considered as a complication of hip fracture, not hip surgery, in the elderly. The present study does not imply that hip fracture causes acute cholecystitis, although elderly hip fracture patients are in an extremely debilitated state and are prone to developing acute cholecystitis.

The authors present clinical and radiographic results of minimal invasive plate osteosynthesis (MIPO) for three- or four-part fractures of the proximal humerus. Twenty-six patients with three- or four-part proximal humeral fractures treated with the MIPO technique through the deltoid splitting approach were clinically and radiographically evaluated at a minimum of 12 months with an average of 20.1 months. The valgus-impacted type of three-part fracture was excluded to verify the results of the MIPO with unstable multifragmentary fractures of the proximal humerus. Twenty female patients and six male patients were included (mean age 67 years; range 18–90 years). No cases of nonunion were seen. The mean forward flexion, abduction, and external rotation were 145°, 119°, and 48°, respectively. The mean visual analog scale (VAS) for pain was 1.47 points. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 14.5 points, and the mean UCLA score was 29.6 points. The mean neck-shaft angle was 134°. Twenty-three patients had adequate medial support, and three patients did not have adequate medial support on initial postoperative radiographs. Five shoulders (19 %) developed complicated results. Two cases of proximal malposition of the plate (7.7 %) and two intra-articular screw penetrations (7.7 %) were observed. One case of osteonecrosis of the humeral head was identified at the final follow-up (3.8 %). The MIPO technique provides reliable radiologic and functional outcomes for three- and four-part proximal humeral fractures. Our results might support the use of MIPO for treating unstable multi fragmentary fractures of proximal humerus such as three- or four-part fractures to decrease osteonecrosis of humeral head.

There are many various diseases in the bone and joint infections, and we tried to make antimicrobial treatment guidelines for common infectious diseases based on available data for microbiology and clinical trials. This guidelines focused on the treatment of osteomyelitis and septic arthritis, which can be experienced by physicians at diverse clinical settings. This guidelines is not applicable to diabetic foot infections, postoperative infections or post-traumatic infections which need special considerations. The guidelines for those conditions will be separately developed later. Surgical treatment of bone and joint infections, pediatric bone and joint infection, tuberculous bone and joint infection, and prophylactic antibiotic use were not included in this guideline.

The goal of this study was to determine the incidence of avascular necrosis of the femoral head (AVNFH) after intramedullary nailing of femoral shaft fractures and to identify risk factors for developing AVNFH. We retrospectively reviewed all patients with femoral shaft fractures treated with antegrade intramedullary nailing at 10 institutions. Among the 703 patients enrolled, 161 patients were excluded leaving 542 patients in the study. Average age was 42.1 years with average follow-up of 26.3 months. Patient characteristics and fracture patterns as well as entry point of femoral nails were identified and the incidence of AVNFH was investigated. Patients were divided into 2 groups according to open versus closed physis, open versus closed fractures, and age (

The popliteal artery is vulnerable to injury during surgeries performed around the knee joint. Pseudoaneurysm of the popliteal artery following a high tibial osteotomy is rare. Few case reports describe the development of this complication after a lateral closing wedge high tibial osteotomy. Our patient underwent an uneventful medial opening wedge high tibial osteotomy and autogenous bone grafting fixed with dual plating for medial osteoarthritis of the knee. The procedure was performed under tourniquet control, which was released only once after the wound closure. Postoperatively, the dressing was soaked, and a large volume of hemorrhagic collection was present in the suction drain. The patient experienced decreased sensation over the sole, which was successfully treated conservatively with medication. Other clinical parameters like motor function and distal pulses were normal. The patient was discharged after 2 weeks. Two days later, the patient presented with pain and numbness over the entire lower limb and a pulsatile swelling in the popliteal fossa. A femoral angiogram revealed a pseudoaneurysm arising from the popliteal artery just below the osteotomy site. Open vascular surgery with resection of the pseudoaneurysm and end-to-end anastomosis using contralateral saphenous vein interposition graft was performed. During the vascular surgery, a pinhead-sized tear was clearly identified on the anterior wall of the popliteal artery, which may have occurred while using the oscillating saw during opening wedge high tibial osteotomy. Careful placement of retractors around the osteotomy site during sawing and flexing the knee to displace the popliteal artery away are recommended to prevent this complication. To our knowledge, this is the first report of a popliteal artery pseudoaneurysm occurring after a medial opening wedge high tibial osteotomy.

Calcific tendinitis results from the deposition of calcium hydroxyapatite crystals in periarticular muscular attachments. It is a rare cause of knee pain commonly affecting patients aged 40 to 70 years. Although commonly seen in the shoulder, it should be kept in mind in nontraumatic cases, particularly when the pain is severe and localized to the lateral aspect of the knee. The exact mechanism of hydroxyapatite deposition is unclear, although genetic and metabolic factors have been suspected. A 45-year-old man presented with severe pain in the lateral aspect of his knee with local tenderness over the lateral epicondyle. Radiographs revealed multiple calcific deposits just below the lateral epicondyle of the femur. Magnetic resonance imaging showed multiple areas of low-signal present intra-articularly near the popliteus tendon that was suspected to be calcification. Erythrocyte sedimentation rate and C-reactive protein were slightly raised and other blood investigations including uric acid were within normal limits. Due to failure of conservative treatment, arthroscopy was performed through standard anteromedial and anterolateral portals. Arthroscopy revealed reddish synovial congestion in the lateral gutter. Partial synovectomy was performed with a shaver through a superolateral portal and the calcific deposit was found to lie between the popliteus tendon and the lateral collateral ligament. This was excised and sent for biopsy. Histopathological evaluation revealed the presence of hydroxyapatite crystals within degenerated tendon thereby confirming the diagnosis of calcific tendinitis. Immediate resolution of symptoms following excision allowed the patient to perform activities of daily living immediately postoperatively without pain.

최근 평균 수명의 연장과 골다공증이 동반된 노년층의 증가로 국 내 대퇴골 전자간 골절의 발생 빈도가 증가 추세에 있으며, 2010 년 기준으로 인구 100,000명당 26.8명(남 16.9명, 여 36.8명)의 발생 률이 보고되었다. 우리나라의 통계자료에 의하면 노인 인구의 증가는 매우 빠른 속도로 진행되고 있어 2026년에는 노인 인구가 20.8%로 ‘초고령 사회’에 도달할 것으로 보여 이에 대한 사회적 관심과 대책이 시급한 현실이다. 고령의 고관절부 골절의 치료 목표는 골절부의 안정적인 고정 으로 조기 거동 및 기능적 회복을 도모하여 가능한 수술 전 상태 로 회복하는 것이며, 오랜 기간의 침상 안정으로 인한 전신 합병 증의 발생을 최소화하는 데 있다. 최근 대퇴골 전자간 골절에 대 한 이해가 높아지면서 불안정성 골절에 대한 평가, 정복 방법, 내 고정물의 선택 및 수술 술기에 대한 연구로 이전과는 향상된 결 과들이 보고되고 있지만, 우리 나라의 경우 여전히 고관절 골절 에 의한 1년 내 사망률은 2007년 17.8%로 보고되고 있다. 고령의 대퇴골 전자간 골절 후의 높은 사망률과 더불어 고령 환자의 수 술 후 기능적 저하는 환자의 가정과 사회에 경제적으로 큰 부담 이 되고 있어 수술 후 방사선적 치료 결과뿐만 아니라 독립 거동 이 가능한 상태로 회복할 수 있도록 보다 많은 노력과 연구가 절 실하다. 이에 저자는 대퇴골 전자간 골절의 수술적 치료 시 내고정의 실패를 최소화하면서 안정적인 골유합을 얻을 수 있는 방법과 더 불어 기능적 회복을 위한 수술 전, 후 처치 및 고려 사항에 대하여 문헌 고찰을 통해 논의하고자 한다.

There is extension of the Kocher-Langenbeck approach using trochanteric osteotomy for posterior wall fracture extending to acetabular roof, but it exposes to complications such as non-union, breakage, and heterotopic ossification. The current study introduces a submuscular sliding plate technique. We retrospectively analyzed 13 patients treated with this technique. It is based on conventional method for posterior wall fracture. After reduction of roof fragment with direct visualization, a pre-contoured plate was passed through a submuscular tunnel under the gluteus medius and minimus. A small split incision was performed on the muscles, and screws were inserted with a triple trocar complex safely under fluoroscopic imaging. All patients had fracture union without complications. X-rays results showed anatomical reduction in 10 cases and imperfect reduction in three cases. Our results were satisfactory, particularly without heterotopic ossifications despite no prophylactic regimen of NSAID was applied and no neurological complications, so we believe that this technique is a good option for posterior wall fractures extending to the acetabular roof.

Summary Background Accurate positioning of locking screws depends on accurate insertion of the drill sleeve into the locking compression plate (LCP). The purpose of the present study was to determine factors affecting accurate drill sleeve insertion. Hypothesis Tilting and shallow locking screw holes and combination-type holes make it difficult to insert the drill sleeve in the LCP. Materials and methods Twenty-seven 3.5-mm LCP metaphysical insertion holes were selected (Philos ® , LPHP ® , DMTP ® , low-band DMTP ® [Synthes, Solothurn, Switzerland]). Two orthopedic surgeons checked the time taken for accurate insertion of the drill sleeve into the plate. Variables relating to LCP drill sleeve insertion time were analyzed. Results It took an average 6.6 seconds to insert the drill sleeve accurately in the holes. Insertion time increased with the tilt of the screw hole, but not with shallowness. Insertion time in combination-type holes was longer (8.8 seconds) than in single locking holes (5.6 seconds). Discussion Tilted screw holes and combination-type holes affect the insertion of the drill sleeve into 3.5-mm LCPs. Level of evidence Level IV. Experimental study.

140 통신저자:오 형 근 고양시 일산서구 주화로 170, 인제대학교 일산백병원 정형외과 Tel:031-910-7968ᆞFax:031-910-7967 E-mail:osd11@paik.ac.kr 접수: 2012. 10. 23 심사(수정): 1차 2012. 11. 22, 2차 2013. 1. 14 게재확정: 2013. 2. 12 Address reprint requests to:Hyoung-Keun Oh, M.D. Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 411-706, Korea Tel:82-31-910-7968ᆞFax:82-31-910-7967 E-mail:osd11@paik.ac.kr 대퇴골 중간 간부 골절에서 시행한 최소 침습적 금속판 고정술